Tuning our hrt support as we age

After all of the work we have gone through to find our best hrt and correct dose, it would be understandable if we thought our job were done. Unfortunately, that's not the case. Sooner or later, we'll need to re-evaluate where we are with our dose and whether it's still appropriate for us.

Sometimes it's a matter of our doctors freaking out and going "You've been taking hrt for HOW long? OMG you have to quit immediately!" That's not a response guided by the major specialist practice guidelines, but it is a response to popular media coverage of hrt issues, especially the cancellation of the Women's Health Initiative Study, and their sense of legal liability.

What happened was that after five years of studying several kinds of hrt use, the WHI found that in (only) one arm of the study breast cancer incidence rose a small amount that was nonetheless enough to trip the study limit guidelines and force shutdown of the program after it had gone on for five years. In the popular media, of course, the headline was "HRT kills!" And in medical literature, doctors solemnly agreed that they could prescribe hrts for five years of safe use, but one day after that five years, it was unacceptably deadly.

That's a nearly nonsensical reading of the study results. And in fact, over time and re-analysis of the results of the WHI, recommendations have come to reflect this. Most current guidelines repeat the mantra: as little as possible for as short a time as possible. Which, to phrase it more constructively, can be construed as the minimum amount that meets our needs for no longer than we require it to meet our needs.

See what they've done there? There is no calendar attached to that statement other than that provided by our own bodies and our own health goals. Aside from major and incompatible health problems, our doctors have no justification for demanding we quit and we should feel no obligation to stop using hrt at some arbitrary deadline.

Why we do need to revisit our hrt dose

Nonetheless, we do need to be sure we're paying attention to the least/shortest guideline because that does speak to our best current understanding of the risks of hrt use.

Here's the thing: as we age, our hormone needs decline. We can't freeze ourselves at one age by thinking we're supporting that by our hrt. That's an old fallacy and a dangerous one. Instead, our goal is to support our needs as they are in each moment with just enough hrt to feel right.

The problem is that we tend to go along unquestioning and tiny bit by tiny bit our hrt fits us less well. We don't really notice, even, because excess tends to be a lot less dramatic than deficiency. But we may have fewer hot flashes (especially those lingering ones at 5 am) or our breasts may feel fuller or we don't seem to need our local vaginal hrt quite as frequently. It's nothing we might notice as a trend, but that's what it is.

Because of its subtlety, though, waiting until we notice it isn't the best of strategies. Instead, we will more accurately shave that important line of least risk by regularly challenging our dose. How regularly? Oh, every three to five years seems to be the sort of interval that produces useful results, although a case could be made for deliberately asking this question about a year after our surgeries as well.

So how does this work? 

We're glad you asked.

When it comes time for a dose challenge, we need to look at our hrt and determine a reasonable amount to try as a decrease. For some hrts, we're limited by the doses it's sold in because we can't break the delivery form. For others, it's very easy to make a tweak.

We're looking to decrease our dose by no more than 10-15%. That amount is enough to notice but shouldn't be enough to really ignite transitional fireworks. If we have no other choice, a 25% reduction is something we might pull off without too much uproar, but beyond that it's unlikely we'll not experience some deficiency if we weren't in significant excess earlier. In other words: we're looking to eliminate that invisible creep of dose above needs, and if it were more than about 25%, we'd probably have already felt the need for change. On the other hand, if you've been taking hrt for 20 years without ever adjusting your dose, you might be there.

So we try out our new reduced dose. We can do this at any time, although it may be more successfully done in the summer (which of course means winter if you're in the southern hemisphere). That's because the withdrawal of that amount of support from our brain chemistry in particular is most smoothly adjusted to when we have other things to help out with it, things like outdoor exercise and sunshine. Women who reduce their dose in the winter (by which we mean the dark time of year), particularly when they live in higher latitudes, may find seasonal blues too overwhelming when they are decreasing their hormonal support at the same time. Remember: even when we're moving toward a better dose, we're still going to need to make adjustments to that new dose.

If we are going to be dramatically unsuccessful in our challenge, we're likely to know this within a week or two. Transitional symptoms, in which our bodies respond to any change, generally settle within three to seven days, and only after that is the adequacy of the background dose revealed. Journaling through this period, even if we haven't done it for years, can be very helpful in revealing things in retrospect that were too slight to recognize at the time.

If we are experiencing unpleasant symptoms of deficiency, then, we can determine that our dose most likely needed to be where it was. We resume our previous dose and figure okay, good for another few years.

If things seem to be going okay once the transitional symptoms taper off, however, we might as well carry on with the new dose. Which doesn't yet mean our challenge is a total success. Sometimes a dose drop can leave us with such a very tiny deficiency that it takes a long time, months even, to decide that nope, this isn't really meeting our needs the way we want. Symptoms may be very subtle with this kind of a mismatch: maybe we notice one day that we're getting creakier or we just don't feel the joy in life the way we did last year. We make these kinds of evaluations based upon what we have previously learned about how our own body demonstrates deficiency; if we develop new problems, we cannot automatically assume they're about the hrt because we are getting older all the time.

If we experience this kind of slow deficit, the answer is still to go back up a bit in dose: there's no time limit on this. If we have the option, going up less than the full increment we decreased by would make sense; if not, we can go back to the old dose with the assurance that we're as closely tuned as that particular hrt makes possible to our present level of need.

And when our doctors ask at our annual checkup about whether we've thought about still needing hrt? Being able to say "yeah, last year I tried cutting back a bit and found that within a month I was running noticeably low and I feel a lot better now that I'm back on my current dose" is going to go a long way toward convincing them that we're using hrt responsibly in accordance with the current medical practice guidelines.

So in summary:
  • there is no calendar date that defines safe vs unsafe duration of hrt use;
  • our needs for hormone supplementation do decline slowly with age;
  • we should challenge our dose every 3-5 years to make sure we're using the least dose that meets our needs; and
  • our doctors should be impressed that we're taking care of this for ourselves.