Got a question about HRT doses? Find out what you need to know
I’ve started taking HRT. How will I know how much of each hormone I need?
HRT dosage, regimen and duration should be individualised. Doses are prescribed according to symptoms, and some women have more symptomatic improvement with higher doses than other women. Prescribing HRT at the right dose improves symptoms and reduces future risk of heart disease, osteoporosis, clinical depression and type 2 diabetes.
It is really important to take into account how you feel and if your symptoms have changed since taking your hormones. Monitor your symptoms regularly, every 3-6 months, by using this app.
Hormone blood tests are not usually needed to make a diagnosis of perimenopause or menopause, as they are unreliable, especially as the levels fluctuate so much during perimenopause. However, hormone blood tests can be useful to monitor the absorption of estradiol and testosterone through your skin, as absorption can really vary between women. Estradiol levels are not usually accurate if you take estrogen as a tablet, as the estrogen becomes metabolised into different types of estrogen when it is digested.
RELATED: Understanding hormone levels in your blood
How will I know if I need to change my dose?
Information about your symptoms and blood tests will usually be considered to help decide if you need a change in your dose or type of hormone treatment. However, the dose of estrogen needed to relieve the symptoms of perimenopause and menopause can really vary between women. Studies have shown that younger women experiencing symptoms of perimenopause or menopause often tend to need higher levels of oestradiol (and therefore usually higher doses of HRT) than older women do.
Note: If you are having symptoms despite taking HRT, then it may be that there are other causes for your symptoms so it is important to discuss any symptoms with a healthcare professional.
RELATED: How often should I review my HRT?
What estradiol blood level do I need?
Generally, to offer the health benefits of estradiol replacement, estradiol blood levels need to be over 250pmol/l. Few women need to have a level above 1,000pmol/l. (In comparison, during pregnancy levels of estrogen can be around 65,000pmol/l.) Levels can alter rapidly during perimenopause and it can be common for women to transiently have higher levels, so a one-off high level should be interpreted with caution and usually it is repeated. Sometimes using the gel on your arms the morning of your blood test can lead to a falsely high estradiol level.
A Newson Research study of 1,508 women found that almost one in three women using licensed doses had low blood estradiol levels, including around one in four who were using the highest licensed dose [1]. These findings suggest that up to one in four women may need higher doses or a change in estradiol formulations (eg from patch to gel) to achieve blood levels needed for optimal health.
It is important to have adequate estradiol to improve symptoms as well as to improve future health. If amounts of hormones in your body are too low, then it is likely you will experience symptoms and the health risks of low hormones (such as increased risk of heart disease, osteoporosis, clinical depression and dementia) will still be present.
RELATED: Understanding the benefits and risks of HRT: downloadable visual aids
Are progesterone doses linked to estradiol doses?
The dose of progesterone needed to thin your womb lining and ensure unexpected bleeding does not depend on your dose of estradiol. There is no good quality evidence that if you are prescribed a higher dose of estradiol that you also require a higher dose of progesterone.
The dose of progesterone may increase if you are experiencing bleeding, regardless of your estradiol dose. Some women find using progesterone as a pessary, especially at higher doses, has more benefits to their symptoms as the pessary is absorbed directly into your body as progesterone, whereas when it is taken orally it is metabolised into different types of progesterone. Progesterone as pessaries can be really beneficial for women with PMS, PMDD and postnatal depression.
If you are experiencing bleeding when you shouldn’t be bleeding, regardless of your dose of hormones, you should discuss this with your healthcare provider to see if any other investigations are needed. Bleeding commonly occurs in the first 3-6 months after starting or altering the dose of HRT and can occur with both higher and lower doses of estradiol. Sometimes a higher dose of progesterone is recommended to reduce any bleeding.
A recent study by Newson Research found that there is no correlation between estradiol or progesterone dose and the thickness of the lining of the womb [2].
RELATED: Body identical hormone dose is not linked to womb lining thickness
How will I know if my testosterone dose needs adjusting?
Generally, after 3-6 months from starting testosterone treatment (usually as a daily gel or cream), a blood test is done to check the level of testosterone and often also your sex hormone binding globulin (SHBG) to determine your Free Androgen Index (FAI). If your levels are low despite treatment with testosterone and you are still experiencing symptoms of testosterone deficiency (such as reduced libido, low energy, reduced motivation), then you may be recommended to increase the amount of testosterone gel or cream you are using and then repeat the blood test again after a few months. Side effects due to testosterone are very rare if levels of testosterone and Free Androgen Index remain in the female range.
RELATED: Testosterone gel and cream: what you need to know
My friend is on a lower dose than I am. Does that mean my dose is too high?
Our skin types and thickness are all different and so estradiol and testosterone can be absorbed through our skin differently. Some women need higher doses of estradiol and testosterone than other women to absorb the same amounts. For example, some people find they absorb estradiol much more effectively through gels rather than patches, whereas for other women they find they absorb more effectively using patches compared to gels. Some women absorb testosterone better as a gel rather than the cream and for some women it is the other way around - they absorb better from the gel. Other people find they absorb some brands of gels or patches better than others, despite them all containing the same type and dose of estradiol. Because of this, to achieve a specific estradiol level, some women may only need a very low dose and some may need a higher dose.
RELATED: HRT easy prescribing guide
Is it safe to use a higher than licensed dose of estradiol or testosterone?
While many women will respond well to lower doses of estradiol, some will require higher doses such as 200mcg or 300mcg of estradiol patches to absorb enough estradiol to provide adequate symptom control. The higher doses are prescribed to lead to adequate absorption rather than using higher doses for high levels of estradiol in our bodies. This is the same for testosterone - absorption can really vary between women.
RELATED: High dose HRT unlikely to increase the risk of clot
Why do some people absorb female hormones differently to others?
There are so many reasons why you may absorb hormones through your skin differently to others. There are many tiny blood vessels, called capillaries, which supply blood and nutrients to our skin and absorb the hormones from the patches, gels or creams. The depth and numbers of these capillaries varies between women [3]. Other factors that affect absorption of hormones through our skin into our body will be the thickness of the layers of our skin, how well hydrated it is and the temperature of our skin. The fact our skin works as a barrier is relevant too and some people’s barriers will be better than others even to hormones in patches and gels that are designed to penetrate our skin [4].
In addition, there are many proteins and enzymes that help make up the five layers of our skin. These enzymes can affect the amounts of hormones that are available in our bodies (bio-availability) from the patches and gels and there is evidence this composition of proteins and enzymes alters with time too [5]. Some studies have found that your ethnicity can affect how much of a drug is absorbed through your skin. One study found people from a Hispanic background had the best absorption rate, followed by White people, Asian people and people from an Afro-Caribbean background [6].
In summary, there are many different factors that affect the dose of HRT you need to ensure you have adequate hormones to improve both your symptoms and your future health. You should talk to a healthcare professional if you feel your dose or type of hormone treatment needs changing.
RELATED: ‘Specialists agree I need higher dose estrogen, so why has it been such a fight?’
