How to Adjusting to a HRT Regimen During Perimenopause


It used to be that a standard HRT prescription included a uniform number of milligrams of estrogen and synthetic progestin or natural progesterone. But we know now that dosages need to be tailored much more precisely to meet a woman’s individual needs. You’ll notice that I suggested changing only one thing at a time about Laura’s HRT regimen. That would allow Laura and her health care provider to isolate which change provided the most benefit. The same step-by-step change was made for Rhonda, who had been stable on an HRT regimen of oral estrogen and natural progesterone for months, only to experience a sudden recurrence of her headaches and hot flashes. She recently had had a gastrointestinal upset, and together with her health provider, we concluded that this episode might have temporarily affected her ability to absorb the oral hormones. She switched to the estrogen patch for one -cycle and felt the difference almost immediately¡ªher symptoms were greatly alleviated.

HRT Perimenopause

“How much estrogen or progesterone do I need? What dosage should I be taking?” Women who are considering HRT are often confused about dosages, and understandably so. Most often, they worry that taking too much estrogen, even when combined with natural progesterone or a synthetic progestin will raise their risk of breast or uterine cancer. We often tend to believe that one prescription, whether it’s for perimenopausal symptoms or anything else, is the final word¡ªnow we should feel better. We hope the medication will take care of whatever is bothering us, and we’re disappointed if it does not. But there’s no pat answer to questions about HRT dosages, or at least no way to say that x mg is always appropriate. Arriving at the most appropriate HRT prescription may take some work and perseverance on the part of both you and your health care provider. I’m not talking about an extended trial-and-error experiment while your symptoms continue unabated, but a careful evaluation of what you need.

Many perimenopausal women choose to begin with the lowest possible dosages of HRT, adjusting them upward as needed to provide symptom relief. A conservative, low-dose approach is often adequate for perimenopausal women who are still producing some hormones. The lower dosages can offer symptom relief without exposing them to hormone levels that are too high.

While you are taking HRT, it’s important to assess your hormone levels through blood or saliva testing to be sure that the amount circulating in the body closely approximates the amount that would be there if your body were still producing all that it needs. The amount of medication required to achieve these levels varies from woman to woman.

In general, circulating estradiol levels of 50 to 60 pg/ml (in blood) are the minimum necessary to avoid bone loss and changes in sexual function. To maintain energy and avoid changes in mood, memory, and sleep patterns, target estradiol levels need to be within the 90 to 200 pg/ml range when measured in blood. These ranges are general goals. The HRT prescription that one woman needs in order to maintain these target ranges and to relieve her symptoms may be different from her friend’s or her sister’s, and the differences could be in types of hormones prescribed, forms of administration, or in dosage amounts.

If a particular medication isn’t working, we often hesitate to report it to the doctor, fearing that we’ll be thought of as a pest, a bother, or a hypochondriac. Unfortunately, health care providers sometimes seem less than interested in working with us in partnership, which sometimes intimidates us. This was the case with Genevieve, who came to me not long ago to talk over the perimenopausal symptoms she was experiencing and her options for managing them. After we went through her symptoms and family history, she decided that she wanted to try a low dose of HRT that would include natural progesterone and estriol. But when she raised this issue with her health care provider, she heard nothing about the pros and cons of HRT and nothing about taking care of herself. Instead, she was subjected to a lecture during which her physician told her, with practiced condescension, that he “disapproved of doctor shopping.”

In Genevieve’s situation, one professional’s insecurities got in the way of recommending what was best for her. I mention her experience because although many excellent health care providers are willing to take a team approach, some still believe that theirs is the final word. Fortunately, fewer and fewer health care providers adopt a dictatorial style, and fewer patients are willing to accept it when they do. My advice? If you want more than one opinion about your HRT options, give yourself permission to get the information you need. And should you find yourself in a situation like Genevieve’s, run¡ªdon’t walk¡ªout the door.

HRT Perimenopause

When Cynthia, a preschool teacher, and her health care provider were attempting to find the best HRT combination for her, she came up with a good analogy for her situation. She had begun on a dosage of 0.25 mg of Estrace twice a day and 200 mg of natural progesterone daily, a combination that relieved her hot flashes and sleeplessness but didn’t improve her teary, anxious state of mind. “This reminds me of toddlers” she said. “You think you have everything figured out about their habits and behavior when they’re three. Then they turn three and a half, and all bets are off!” The flexibility she adopted in her preschool classes helped her to monitor her symptoms while her HRT was being adjusted and made her unhesitant to let her health care provider know what was going on. Her provider increased her natural progesterone dosage to 300 mg daily, and she found herself in tears much less often

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About the Author: Andrew Reinert is a health care professional who loves to share different tips on health and personal care. He is a regular contributor to MegaHowTo and lives in Canada.

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