This article is based on a question from a reader. I will call her Katy. In fact, it was so interesting and enlightening that we did a podcast about it (TheProgressYourHealth podcast).
The question hits home that HRT really needs to be individualized to the patient.
I know, I know, I preach this all the time. But I get so many questions from women all over the world who are concerned (and confused) with their HRT dosing.
Every dose of HRT needs to be tailored to the person. What works for one person may not work for another.
A lot of these HRT dosing questions are from women who really want to be on HRT but are having trouble finding the right dose for them.
Of course, working with an experienced provider/practitioner who is an expert in HRT would be the best course of action.
However, not all women have access to an HRT specialist, whether due to cost or availability.
Unfortunately, this is where it gets a little murky. When dosing HRT, you want to keep the patient safe, but you also want to ensure that you are addressing their hormone goals.
And there is a lot, I mean A LOT of information online about hormones. So I get a lot of reader/listener questions from women who are frustrated, not feeling well, worried about safety, and genuinely confused about HRT.
We get questions all the time asking:
- How long can one take HRT?
- Is it safe for me?
- How much is too much?
- How much is even enough to protect my bones, heart, and brain?
- I'm not feeling well on my HRT, and my doctor doesn't know what to do.
So that is why this particular question hit many HRT hot buttons.
Below is the question. We called her Katy because we changed any personal information for privacy. Katy's question really does represent other women, and I am sure others can relate to what she is going through with her HRT.
From Katy:
Hi, I've been on BHRT for at least 14 years. I'm 61. I went through menopause with absolutely zero symptoms. My issue is I am going to a regular physician now who will prescribe me pill form but doesn't really know much about BHRT. It definitely saves me a lot of money versus the cream. At the end of the month, though, when I'm off the three days from my estradiol and am off the 14 days for my progesterone, emotionally, I can barely keep it together. Do I have to skip three days a month on Estradiol and 14 days on progesterone? Should maybe I start back on my progesterone when I'm off my estradiol to keep my mood stable? I'm so happy I come across your post. Hopefully, you can help me with this question.
There are some really great key points here about HRT.
This is Not Cycling:
The way Katy is taking the hormones might be 'called' cycling. But it is not.
She takes estradiol daily and skips three days out of the month.
She takes progesterone for 14 days out of the month (same dose).
Some theories and thoughts suggest that taking progesterone for half a month is comparable to a pre-menopausal female. It is not.
In a menstruating, cycling female, the hormones are changing throughout the month.
Let me quickly (promise not to bore you) tell you about the female 28-day cycle.
Female 28 Day Cycle:
Day1-4: This is your period, when the estrogen and progesterone are very low. The low estrogen and progesterone levels are what signal the uterus to slough its linging causing bleeding/period.
Day 5-11: The estrogen levels are starting to rise and rise. There are low to no progesterone levels at this time. This is where there are many follicles (about 20-25) in the ovary coming to fruition in hope of becoming the mature ovum (egg). By the time ovulation occurs, there is one main mature egg and all the other follicles regress and are absorbed.
Days 12-13: There is a big spike in the estrogen levels. This spike in estrogen is what causes the main eggs to leave the ovary.
Day 14: Ovulation. The mature egg has left the ovary and is on its way to travel down the fallopian tube and hang out at the top of the uterus in hopes of fertilization.
Where the egg has left the ovary is a small spot called the Corpus Luteum.
Day 15: The corpus luteum starts to secrete progesterone.
Day 21: Progesterone is at the highest level in the cycle.
From ovulation to the period (day one), the estrogen levels will level off and start to drop.
Day 28: If there is no fertilization of the egg. The estrogen and progesterone levels drop, and you are back to day one, a period.
In Katy's case, there is a thought that if progesterone is only present for 14 days, then HRT progesterone should only be taken for 14 days. And as you can see from the 28 day cycle, the first few days of the cycle have low hormones (period). Again, in Katy's case, she is being told to not take any estrogen for 3 days.
While this might sound like a good idea, it really is not. The female hormonal cycle does not involve abrupt hormone changes, as seen in Katy's case. The hormones are changing daily.
In a pre-menopausal woman, the progesterone levels at day 14 are much different from those at day 21 and day 27.
The same goes for estradiol/estrogen. The estrogen from day 5 is much different from day 12 to day 21.
The hormones have beautiful spikes and undulations throughout the entire 28 days.
There is a way to cycle the hormones, or what we call Rhythmic Dosing HRT. Rhythmic dosing is where a woman takes her hormones in a way that exactly mimics a 28-day cycle. The hormones need to be changed frequently to copy the hormone cycle of that of a healthy 28-30 year female.
The way Katy is taking her hormones, no wonder she feels good when she is on the estradiol and progesterone, but terrible when she is not.
Progesterone and Estradiol:
Progesterone is a beautiful hormone. It can help stimulate the GABA, which helps us feel at peace and relaxed. It can help with sleep and especially with mood. When Shari is not taking the progesterone, she must be having trouble sleeping and feel really cranky, irritable, even anxious and down. And when she is not taking the estradiol, she could be having hot flashes, night sweats, and feel very moody.
Static dosing:
I really think for Katy's case, she would do really well on static dosing. Static dosing is different from rhythmic dosing. Static dosing is taking hormones every day with no changes to dosing. She already mentioned that she feels good when she is on estradiol and progesterone, but feels terrible when she has to stop one. So there would be no issue if she took the progesterone nightly and the estradiol daily.
Plus, she has been post-menopausal for at least 14 years. Generally, rhythmic dosing can be a bit trying on a woman who has not truly cycled for many years.
Estradiol orally or cream?
Estradiol orally is really hard on the liver. This is why we often use estrogen creams. Cream can bypass the digestion and take the burden off the liver that the oral forms cause. Katy mentions that she likes the oral because it is helpful for her pocketbook. And I understand that. But it needs to be managed properly to keep her safe. It is essential to monitor estrogen metabolites, liver function tests, enzymes, and other health indicators when taking estradiol orally.
Progesterone orally?
Progesterone is effective when taken orally and as a cream. Taking progesterone orally will not have a burden on the liver like estradiol does. Orally, it seems to help the relaxing feeling of well-being and is more helpful for sleep than the cream. But they are both good. Caveat here: if you're on estradiol and have a uterus, you must take oral progesterone to protect your uterus. A thickened uterine lining is a risk for endometrial/uterine cancer.
Uterus or No Uterus:
I know Katy didn't say, but I am pretty sure (99.9999999%) that she doesn't have a uterus. She must have had a hysterectomy at some point. The reason I am saying that is because if she has a uterus, takes estradiol, and takes progesterone for 14 days of the month, she would start bleeding.
You do not want a woman on static HRT to bleed. Unless she is on a specialized rhythmic dosing as mentioned above. Rhythmic dosing is intended to follow the pattern of a young 28-30-year-old female's cycle. That means purposely thickening up the lining and causing a period on day one. This is safe and meant to happen.
If Katy had a uterus, and took her progesterone part of the cycle but the biest is static the entire month, at some point, she would have spotting and bleeding. And as she mentioned, her GP that is prescribing this, does not have any knowledge in HRT. Her GP would get very worried and upset if a 61-year-old woman started bleeding. And most likely would send her for a lot of testing (transvaginal ultrasounds, uterine biopsy, see gynecologist) and stop prescribing the hormones.
As a post-menopausal woman, Katy's protocol of hormones should not have uterine bleeding. As I mentioned above, a woman on estradiol and has a uterus must take oral progesterone to protect that lining from thickening and protect the uterus.
One aspect (really the most important) of Katy's dilemma is that she does not feel well. She says she can barely keep it together emotionally and wants to keep her mood stable. Having your hormones out of balance can truly affect moods.
Now hormones are not an excuse for bad behavior. But feeling emotional and having a hard time controlling your emotions is a terrible feeling. I have had many patients come see me with this exact issue. I have had women come in with their partners so they can describe how they are feeling, because the family is concerned.
Please never suppress or stuff your emotions. Have a voice, if something is not right or bothering you, speak up and voice your concerns. We do not always have to be perfectly happy, agreeable ladies.
But what I am saying is that sinking feeling we have when we explode at the people we love. When we react to something relatively benign, like the sky is falling. When we get irritable and salty at even inanimate objects. Just because that pen is out of ink does not mean it needs to be thrown at the wall.
HRT might seem like the fountain of youth. But it needs to be dosed properly for that particular individual, or you might have the opposite of what you are looking for. I am sure Katy's general practitioner means well. She/he is trying to help her out, so she can save some money. But as Katy says, '…when I'm off the three days from my estradiol and am off the 14 days for my progesterone, emotionally, I can barely keep it together.' She is saying, for 17 days of the month, emotionally she can 'barely keep it together.'
When you break it down, over 50% of the month, Katy feels awful. She can barely keep it together. Is it really worth saving money when you feel terrible for over half of the month? That is 50% of your life. I understand that her financial situation and circumstances may limit her ability to pay more than she is currently paying.
Soapbox here, which is why HRT needs to be more accessible to the masses. But compounding pharmacies have a lot of overhead and costs, so it is not on their shoulders. Honestly, I don't know whose shoulders these burdens fall on, but women need easier access to HRT and knowledgeable HRT specialists.
Needless to say, Katy's dose needs to be changed. A static dose would work perfectly in her case. Along with regular blood work to ensure that the levels are in a safe range (which is an entirely different article/blog/podcast).
Like I mentioned above, Katy is not alone. Many women have the same concerns about not feeling well and not knowing how to tweak their hormones to help. So if you are resonating with Katy, please reach out and tell me about it.
DrValorie
→ Subscribe to the full version of the newsletter to read the rest.
