Can't I just have some instructions on how to do this, please?

It happens all the time: a woman comes to our discussion list to say:
This is all too hard! I don't want to learn to be a doctor! Just tell me what works for you all so I can get the same thing and be rid of these symptoms that are driving me crazy.

This same question applies to searching for hormone balance once we're launched into the process:
if I have bothersome symptoms that I attribute to hormone imbalance, is there a way to go about replacing hormones knowledgably, or is it just a shot in the dark?

Sadly, there isn't just one good answer, one best hrt that will make any woman feel the way she wants to. All of our bodies are different; our lifestyles are different; our family/genetic histories are different. How any given hrt will function in a woman's body depends upon all of those little details where those differences lie. Beyond that, medical science does not yet have enough insight into how our ovarian hormones and menopause actually function in our bodies in order to predict any of this. There is no lab test that says this hrt, this is the one that will make you feel the best.

While we cannot predict how we'll respond to any hrt or hrt change, there is indeed a series of systematic steps that we can bring to the process of trying different hrts and dosages on to see which fits us best. It's not a firm rule by any means, but we've developed a rough decision tree that seems to work for covering the essentials.

It's also, we need to add, very very useful to journal symptoms carefully during the process, because each decision point is driven by how our bodies respond. While lab tests can tell us if we're terrifically off base, they can't tell us when we feel good or if we could feel better by making this or that adjustment. Only our bodies can do that, so we need to learn to listen very attentively and remember what we've heard, preferably by keeping good notes. If you're unclear on how to get going with a journal, we've created a rough draft spreadsheet workbook (note that there are additional pages beyond the one that opens). Feel free to save a copy and modify it to suit your own needs, either on your computer or by printing it out. While there are no limits to the format that suits this purpose, reading through our version might help you get a better feel for what you want to be recording.

As you read through these steps, first read them straight through. Each section contains links to either supporting documents or much more detailed information on those topics that is found elsewhere on this site. When you're ready to explore a section in detail, by all means go follow those links. But for overview purposes, we've tried to keep this discussion focused on the process, not the content. Ready?

Step 1: Which hormones?

We begin our consideration of our hormone supplementation needs by deciding where we will begin: what hormones we will work with. While women taking therapeutic hrts to treat or help control a specific disease condition (like endometriosis or cancer) will often need to work with multiple hormones at once, most other women may be better advised to begin with just estrogen, planning to achieve its best possible balance before adding to the complexity of the process by adding additional hormones to meet specific objectives.

We didn't just make this up (and we offer this knowing full well that many sales pitches will tell you just the opposite). This is the basic premise of the specialist statement, American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Menopause (free signup required to read). They are, if you are unfamiliar with the term "endocrinologist," the specialists in dealing with hormones. We find their reasoning compelling: because other hormones can be converted to estrogen if that hormone is deficient in supply, we really can't get a picture of other hormone needs until that estrogen need is satisfied. Until that time—and this is a critically important concept—we're just using those other hormones to prop up a suboptimal estrogen situation. Only when our estrogen needs are well met can other hormones fall back into their own roles such that we tell whether or not their supply is adequate.

Step 2: What type of hormones?

A useful way of categorizing hrts is by type: synthetic or human-identical. If you're not sure what "human-identical" means, we are increasingly switching to the use of this term because compounding pharmacists have taken over "bioidentical" as a marketing term for a specific hrt-and-testing scheme, making it confusing to determine whether the word is being used in a generic or proprietary sense. In this instance, then, we're simply distinguishing between those hormones that are chemically identical in structure to our own from those that are not, once in our systems.

This, as all decisions at the top of the tree, will be in part guided by preference and in part by personal health considerations.

What would consitute such a preference or risk? Some vegetarians might eschew an hrt from animal origins. Some women have ethical objections to the way some hrts are manufactured. Some women are tailoring their hrt to help treat or control hormone-sensitive disease states like cancer or endometriosis and may need an hrt that cannot be converted to any other substance or that has a metabolic pathway possessing certain characteristics. Some women may see hrts as split between overly pharmaceutical and more "natural" according to chemical structure. These are all perfectly reasonable preferences to hold and your doctor should certainly be willing and able to work within them.

Do you have to decide this right away? Nope. This is just one criterion by which you can winnow the whole field down to a reasonable number of candidates. If you prefer to skip this step, fine: you'll just have a wider selection to work with.

Step 3: Delivery by which route?

Next we'll further narrow our choices by looking at route. Each route has specific benefits and risks, and lifestyle factors will come into this decision as well.

We may make a route decision based upon therapeutic needs: a woman taking thyroid hormone might opt for a non-oral hrt so that the two supplements don't conflict with each other. Some route choices may relate to health situations: a woman with digestive issues might eschew an oral, while a woman with a skin disorder might not feel comfortable with transdermals other than transbuccal or vaginal. Women who work outdoors in a very hot climate might find that patch hrts will be fighting an uphill battle for adhesion. Women with infants may not care to use an hrt like a gel, which remains on the skin for a prolonged period and can be transferred to others. We all have unique factors in our lives and health situations that may make one or more routes either undesirable or sound like just the right combination of convenience and plausibility.

Step 4: At last we get to the specific hrts

Having thus lopped whole chunks of the list off as being unsuitable for one reason or another, we should now have a shorter list of hrts that meet our initial criteria.

We next examine the specific hrts, all listed on the estrogen pages (US, UK) of the hrts section of this site. We need to review the discussion of them in these listings as well as the supplementary information, usually the prescribing information pamphlet, linked to for each one. This may further help us determine where we feel our best starting place may be.

For example, a woman wanting a transdermal estrogen but concerned about transferring hormones to her small children might opt for a cream, with rapid skin penetration, or a patch, which is covered by the backing, over a gel, which forms a reservoir of hormones on top of the skin. These kinds of details are in that discussion and can have a great deal of bearing on what specific hrts within a general route-related family will best suit our preferences.

If you're getting confused and losing track of all of these various criteria and how they apply across the estrogen hrts list, we've made an Estrogen Selection Matrix for both US and UK estrogen-only hrts. Print a copy or copy/paste it into a spreadsheet program, and just start crossing out the lines with characteristics that you don't want. Eventually you'll come down to those you are ready to read more detail about (because sometimes a choice will come down to specific details not covered in the matrix).

It takes some time to go through all of these steps, but by gradually narrowing the available options in this way, we can eventually arrive at a reasonable number of choices that represent hrts that actually interest us out of the overwhelming number that the market offers. And by having thought through this process of justifying our choices to ourselves, we're well prepared to pitch exactly those reasons to our doctors in support of our argument that we want to try these particular hrts rather than whatever default he routinely gives to all of his patients or whichever one he happens to have just gotten a hot pitch on from the latest drug rep to visit his office.

Step 5: What dose?

Once a woman has made a choice of hrt, then, it's often simplest to start at the "usual starting dose" unless she has specific criteria to meet that would indicate otherwise. What would those be? Perhaps she distrusts hrts or doesn't really believe she needs one, and so she wants to to take only the barest minimum to see what happens. Perhaps she has previous experience to suggest that she responds strongly to hormonal preparations. Perhaps she's unusually large or small in body mass compared to the general population.

It's generally not a hugely successful idea to assume that our requirements will be higher than usual, especially when we come to a new hrt, just because our last one delivered ineffectively. Why? Because an hrt that didn't get into our systems well didn't really get a chance to show how it stacked up against our personal level of need. Similarly, if our previous experience was with oral contraceptive pills taken preoperatively, we need to recognize that this was a different blend of hormonal agents at a different dosing level, addressing a whole different situation and one that really doesn't predict our menopausal, post-fertile needs for estrogen.

If we do overestimate, it's harder to recognize excess than it is to identify symptoms suggestive of shortfall. Additionally, that recognition delay represents a period of enhanced risk, as well as taking a longer process to clear than it requires to recognize deficiency and ramp dosing upward.

This may be where some women come into conflict with their doctors, because it's way more cost effective for them to hit things right on the first try (and impresses women with their doctor's abilities). That's great when it works, but when it doesn't, then a woman has to dig back out of that hole and it's not.... fun. So if we keep in mind that this is an orderly process and not a leap to the finish, it can be easier to have patience with this part and be more gentle with our bodies. "Start low and go slow" is not a particularly exciting sounding rule, but in fact many women have found that excitement tends not to be what they're looking for in hormone balancing and that it ends up being well worth taking the slower approach rather than unsnarling themselves after an over-hasty miscalculation.

There's also a popular myth that women who are younger than menopausal age will need very high doses of hrt because they must match their premenopausal levels. While they may indeed start a little bit higher than an older woman just to let themselves down a little bit more gently, in fact they are no longer fertile and most of that higher level of hormones was going to support fertility. A post-fertile woman will still need hormones appropriate to her age, but they are much, much lower in quantity than when she was fertile because her uses for them are lower. We've seen young women start at several times the usual maximum dose on this mistaken premise and rapidly find themselves in miserable excess. There's no reason to put our bodies through this: the usual starting dose will generally support us enough not to be in dismal shape and we can more gently feel our own way from there. Really.

Step 6: Do it!

Okay, so we begin taking the usual starting dose of our chosen hrt.

Then we wait. And journal.

It takes 6-8 weeks for full adjustment to a change in hormone support to be carried out throughout our bodies, whether we are starting hrt or simply changing some aspect of the hrt we've been on. We don't need to wait that entire long time, however, to have a sense of whether this is an hrt that is going to work for us or not.

Step 7: Is this hrt working for me?

In the early stages of a trial of a new hrt, the decision tree is first of all: working (delivering) or not. Symptoms that our hrt is not delivering are going to present as soon as our previous hrt (or pre-op hormone supply) is leaving our system and the new can be presumed to have entered it.

The amount of time this takes to show up varies with types of hrt. Patches are the most rapid and a switch from one patch brand to another should be virtually instantaneous unless there were a situation of hormone excess as well. Something like Premarin, that has a long buildup and elimination period, will take longer to judge, especially since the elimination period grows longer the longer this hrt is taken. And for all of us, it will generally take a woman some months after surgery to stabilize on hrt and really get a sense that her preop hormone support is no longer having any effect.

The general rule of thumb we've seen in women's discussions of hrt is that it takes a week or sometimes two to have a sense of general delivery, but that will need to be modified somewhat for specific hrts. As a general rule, patches provide the fastest turnover; orals and daily-dosed transdermals are middling; Premarin and long-dosed forms (pellets, shots) take the longest to get out of our systems—sometimes months.

And of course the other major part of this turnover is the uptake/buildup efficacy of the new hrt. Again, patches work very quickly; daily-dosed transdermals are pretty close behind; orals, pellets and shots may take a few days longer and Premarin is somewhat beyond that into the weeks scale.

So when we look at what we've been journaling, we're looking for whether this is an hrt that's not delivering at all (big dramatic symptoms, usually) or one that's delivering and just needs some work to get into better step with our level of needs.

This time period of our first trial of a new hrt also gives us a chance to decide how well this hrt fits into our lifestyle and overall health. If the patch gives us hives under it or simply fails to adhere, ever, then dose isn't an issue: that patch isn't going to work well for us. If we're allergic to an ingredient, we're never going to have a chance to see if it is otherwise a good hrt for us. If we have wicked heartburn or nausea after taking an oral hrt, we're not likely to want to continue even if the hormone support is good. So there are quite a few factors that come into that early decision of "is this hrt working for me?"

And if the answer is: No

If the answer at that point is no, it's not working for whatever various reason (or none that we can determine and it just...isn't), then we pull out of that trial and select another candidate based upon the nature of the problem with the one we've just tried.

If it's rash under a patch but we really really like the patch otherwise, then changing brand addresses that issue and points out the next direction we might take. If we just can't stomach an oral, we might move back to route considerations and work through our options again. In other words, we need to decide where the failure point might have been and return to that level of our previous decision tree and take a different turning there. If we don't really know what went wrong, then we can reverse the tree and work back up it from the bottom, trying our next favorite that changes that level's characteristic.
While our doctors will often counsel us to wait up to two to three months, even when we find after a couple weeks that our hrt is making no appreciable difference or we're encountering insoluble problems trying to use it, women's actual experience has shown that a massive negative result from a particular hrt is most unlikely to entirely reverse itself over time. Sure, there is an adjustment curve and small niggling irritations may ease away over time, but just flat-out reversing a major negative experience tends not to actually happen.

Your doctor will probably be most sympathetic and willing to change your prescription after you've waited your three months in misery, but why should you have to earn that change that way? Your hot flashes and teary meltdowns aren't keeping him awake at night. You have the right to make this call, to say "no, I'm not doing this any more; I don't like this one and I want something else." And that is the conversation in which you also have your next choice already identified with a pitch you're prepared to make in support of why you think it'll be better. Take notes with you and support them with data from your journal: specific data helps your doctor's scientific mind accept the validity of your experience rather than just brushing you off as a silly hysterical woman who's not accepting her changed circumstances and is doing too much reading on the internet.

And if the answer is: Yes

If the answer is yes to the question of whether or not our hrt is delivering, however, then we move into the realm of tuning that hrt for best possible support of our needs.

Most typically, the major issue with an hrt that is "delivering okay but" is dose. Here the question is whether or not we're experiencing symptoms that suggest the dose is either too high or too low to meet our needs. While it may be tempting to address this issue in a big jump, aiming at a one-stop answer, that impatience can cloud the process and ultimately prolong it, especially if we jump right past our needed dose.

Each large dose change we make induces fluctuations in our hormone levels that themselves add to symptoms we're experiencing. We need to wait for the symptoms due to the change to abate before we can judge the actual adequacy of the dose we changed to. This is a critically important element of hrt tweaking, and one many women regretfully fail to take into consideration as they make rapid, large, multiple changes in their hrt while they flail about looking for something, anything that will make them feel better RIGHT NOW.

But smaller dose changes, ones that are small enough that our body barely registers that change has occurred, allow us to minimize that disruption from fluctuation and slowly, gently home in towards that best dose. Obviously, some hrts can only be adjusted in fixed increments while others are infinitely adjustable. We have to work within the limits of the specific hrt we've chosen... but lack of adjustability may, at some point, actually cause us to set that hrt aside and look for a new one because it just cannot conveniently be adjusted to our actual dose need. At this point, we do the best we can, and this is where "best" = small = gentle.

At some point in this dose-adjustment process, even if we are trying to sneak up on our best dose level, we may overshoot and ease into symptoms of excess. The smaller the increment of excessive supply, the longer it can take to be apparent that we're taking too much. That's another good reason for patience, of course. But a sharp dose drop for a short period will let us clear a relatively small excess and we can then take our last incremental dose increase off the top and return to the next previous dose level to restabilize. In that way, we actually narrow in on our best dose by bracketing it, a concept well known to photographers who do the same thing with exposure settings.

Beyond estrogen

Okay, so we've tweaked that dose up and down, maybe auditioned a couple different brands or types of hrt for optimal fit, and found where we feel best on our estrogen hrt.

But wait, we don't actually feel as "best" as we were hoping to be.

If we've fully explored our estrogen hrts, feel we're on the best hrt and dose we can find, and still don't feel that we've gotten where we want to be, then we're ready to explore other hormones and drugs. We choose these according to which hormone specifically has the actions we're hoping to add or which drugs might cover aspects of our hrt that we are missing. And then we go through the same entire process with that hormone or drug while keeping our estrogen stable. We may end up needing to tweak our estrogen in the final stages of tweaking the new hrt to take relative balance into account, but we need to get pretty close first or we'll just be setting up a state of confusion we'll end up chasing until we're dizzy.

We're not going to go through all of the different other hrts and drugs and factors like the needed nutrients for metabolizing hrts (that make a huge difference in how we experience those hrts' effectiveness). You can explore more of these topics on this website using our Table of Contents to find more detail on these, and you are welcome to join our discussion forums to help troubleshoot this step. Basically, once a woman has achieved some reasonable degree of stability by meeting her basic estrogen needs, some of the pressure is off and she can take the time to learn more, to explore more options. And the work she's done in learning to listen to her body and work through the process will provide her important tools to continue her refining work on her own.

Okay, now you try it

That's a general outline of the process. Yes, it's rather loose and a whole lot of this is left up to you. That may seem overwhelming, but you should keep in mind that you are the expert on your body; no one else can sense what works best for you. There is no formal process—your doctor will do much this same thing for you if you simply place it in his hands and wait passively. Unfortunately, if you're not participating, that means those decisions will be based upon that doctor's preferences and they may not speak to your own concerns at all.

Remember too, that every change we make, whether it's the whole move to a new hrt or just the tiniest incremental dose adjustment, can always be rolled back. If we're at a maybe okay place now and just wonder if X might make things better, we can always try X out with the knowledge that if it turns out not to be our answer, we can go back to its sort-of-okay predecessor, regroup, and reconsider further attempts. It's not as though each try erases all previous situations. Keeping this firmly in mind provides a safety net that does allow us to experiment with a little greater daring.

Want a little backup? We're there on our forums to help a woman cut through to the issues and look at where she might turn to make the next iteration of adjustments. We can't tell exactly what any given woman should do, but we can often as a group ask some questions that will help her make her own decision of what to adjust next.