Surgical menopause, hrts, and headaches

Headaches aren't special to menopause or even the surgical variety, but for those prone to them, hrt can involve some special concerns.

Headaches due to low estrogen

This may be one of the earliest symptoms to hit us after we have a hysterectomy—once the headache from not being able to have coffee before surgery wears off! Some folks develop a lingering, grinding headache that they just can't shake until their hrt is properly adjusted to their needs. For them, headaches become a tuning symptom, something we know has a specific meaning for our own body.

If we've not immediately gone onto hrt after surgery, doctors are sometimes worried that a headache during the recovery period means we're having or are at high risk for a stroke and shouldn't have hrt. While there is validity to ruling stroke out, especially when we've just had surgery, and while there is a slightly higher risk of stroke in the first year of using an oral hrt, some women are left with their doctors' refusal to prescribe just because they are still afraid of that risk. That says something rather sad about their faith in their own diagnostic capabilities and it says something terrible about a woman being able to get the care she needs. Shopping for a new doctor can, sadly, be about the only way out of this trap.

Generally speaking, headaches due to low estrogen tend to abate pretty well once our estrogen levels are meeting our needs.

Headaches from high estrogen

Yes, this happens too.

Decreasing the dose is the right answer for risk and for this kind of headache. How can we tell which is which, high vs low? By the other symptoms that appear with the headaches, just as with any other aspect of hrt tuning.

In general, the tactic of adding a diuretic (water pill) to hrt with the goal of reducing fluid retention from excessive estrogen is not an effective strategy for dealing with this kind of headache, let alone the risks posed by excessive estrogen exposure. It's a common medical response, however, to see each new symptom of imbalance as a separate disease that requires separate medication. We need to be alert to the state of our hrt balance and, if our doctor wants to prescribe diuretics when we think we're in hormone overload, we should be prepared to advocate for our own preferences. Suggesting a trial of dose reduction before adding a new drug is not an inappropriate proposal and a doctor willing to work with us should prove amenable to this kind of trial.

If going down in dose of an hrt doesn't cover our overall hormone needs but that previous dose being the next increment up presents excess, then we can understand that to mean that this isn't the best hrt for our bodies and that we could make more progress by moving along to a new hrt. While we always advocate adjusting dose before giving up on an hrt that appears to be delivering, there's only so far we can adjust things. If we're bracketing our needs without being able to find an acceptable middle ground, we're there. Moving along is likely to be more satisfying sooner.

Headaches upon taking an HRT dose

Some of us don't consider ourselves prone to headaches but then when we begin taking hrt, BLAM. These are often those who had semi-regular headaches during their former menstrual cycle, and if so, that's a great clue we can use in tuning our hrt.

In the situation of menstrual cycle headaches or right-after-taking-hrt headaches, the culprit often seems to be the rapid rise of estrogen levels; once a woman is a few hours or days into a dose, it abates. Because every dose of hrt takes us from a lower level to a higher one, especially early in our adjustment period, we're simply recreating the hormonal setting of those earlier cyclical headaches.

For these women, the key seems to be getting onto a stable level of hormonal support and a dependable delivery, so that they're not swinging up and down with each dose. While there will always be an uptake curve at one end of an hrt dose and a wash-out curve at the other end, once we stack several days' doses on top of each other, we reach a background level of hormonal supply that keeps us supported between doses. Some women, alas, take this sort of situation to mean they need to overlap their hrt doses or take them in tiny increments under the impression that a perfectly even and continuous delivery is necessary. In fact, however, this is something our bodies can sort out for themselves if those doses are adequate to permit us that background leveling between doses. While it's still the case that some hrts will be more comfortable than others for a woman sensitive to this dynamic, there's no single answer as to which those hrts will be.

Headaches with HRT

This is a bit different from the above situation in that a person on a poorly-fitting hrt may have frequent headaches as part of a picture of poor coverage: jangly nerves, anxiety, poor sleep, mood instability, and a general sense that they're walking a knife edge of disaster, not at ease in their skin. This situation tends to persist through dose adjustments up and down and even with a change of hrts. Often, these folks come to our forums summarizing their experience as "I can't tolerate hrt."

But frequently that's not the full story. Often these users, even when they've explored dose adjustments, have pretty much stuck to the estradiol hrts. And that's understandable because most of the hrts on the market today are estradiol hrts. We tend to divide the hrt market into human-identical estradiol and Premarin, and Premarin's reputation is a difficult one for many women to embrace. Routinely, more doctors seem to be offering estradiol than Premarin (or the other conjugated estrogens), and people are choosing estradiol hrts on their own.

But estradiol is the active form of estrogen and it seems that some of us don't want that much activity dumped into our system at once. These users seem to do better whwith an hrt that is comprised of some or all estrone rather than 100% estradiol. Estrone is a much less active form of estrogen, even a storage form, and it can be much gentler in its impact.

It feels, watching what the surgical menopause community is discussing, as though this problem is showing up more today than it did, say, a decade or two ago. But that was when we more freely used progesterone to take the edge off of a poorly-fitting estrogen hrt (a practice that's waning today due to better understanding of progestogens' risks) and that was when there were more estrone hrts on the market. These have mostly disappeared, now, and we think that this has left those who prefer them more adrift in what seems to be an all-estradiol world.

If an individual has tried various routes of estradiol hrt and still doesn't feel comfortable, they may want to explore the remaining non-estradiol hrts. These include:

• compounded hrts with all estrone or a blend of just a bit of estradiol with mostly estrone;
• Menest, which contains mostly estrone with a bit of equilin estrone (synthetic horse estrogen, similar to some of the compounds in Premarin);
• Enjuvia or Cenestin or a generic for them, which contain various blends of synthetic estrogenic compounds that are mostly estrone-ish in action plus a few that are estradiol-ish (no longer on the market); or
• Premarin, which contains a blend of synthetic estrogenic, androgenic and progestogenic compounds that are mostly estrone-ish in action.

With the exception of the compounded hrts, these are all oral deliveries, which may not be our first choice these days. Those who experience this particular problem often find, however, that they are willing to accept that profile in the interests of a better hrt fit. It really can make an astounding difference from the impact of estradiol hrts.

Migraine headaches and HRT

Migraines are a miserable affliction and for those who hoped that removal of their ovaries would put an end to a monthly brain implosion, they, disappointingly, can continue right on thanks to the efforts of our menopausal hrts.

The primary migraine triggers seem to be much like the general headache causes: hormonal fluctuations and the type of estrogen used (by which we mean, the activity of the form of estrogen the hrt contains). So when troubleshooting hrts around migraines, those are some of the considerations to work with.

Sadly, hrt alone isn't always enough to control migraines, and some women end up finding that a combination of hrt plus other drugs that are specific to migraines ends up working the best for them. Still, these hrt adjustments do give us a place to begin that can be more helpful than simply being told we can't take hrt if we get migraines.

What's the best way to get a perfectly even hormone delivery?

You can't.

No, really. It's a myth. Yes, we know the notion that this will solve all of our hormonal ills is a very popular, very prevalent theme in hrt discussions online. But it's really neither possible nor necessarily desirable.

Shocking, no? Yes, we do understand that the ups and downs of the various delivery routes can be problematic, causing all sorts of unpleasant symptoms. But that doesn't mean that the attempt to do away with them by taking ever more frequent ever tinier doses is going to work. That's right: even if we were to walk around with a constant IV drip of estrogen, we still wouldn't eliminate fluctuation.

That doesn't mean that we can't smooth things out, but it does mean that we need to look into the situation a little more intently to determine what exactly it is that needs to be fixed.

Life isn't a perfectly stable system

To begin with, nothing around us is perfectly stable. Today we are stressed by a deadline at work; tomorrow we will have a cold; the day after that is our birthday and we'll have that surprise party even though you know how we feel about surprises. Everything around us changes and our bodies are built to cope with that. We need that ability to cope, because there will always be something out there, a stress good or bad, or even the relief of stress.

Our interactions with the world affect our hormone supplies as well as the demands upon them. We eat foods that contain estrogens, either as plant estrogens or as hormones given to commercial meats or as estrogenic pesticides applied to plants and coating them or eaten by the animals we then go on to eat. We drink water supplies into which every day vast quantities of drugs and pesticides are flushed and, because their content is not legislated, we never see test results to show us how very many things are still in our "clean" water. Every molecule of the hormonally-active compounds we consume becomes a part of our hormone reservoir, a reservoir that changes from moment to moment, hour to hour, day to day.

Neither is our body

Our endocrine system (that portion of our physiology to do with hormonal regulation of various functions) is itself not a static system.

First, our bodies need to be able to keep things running in that ever-changing world we live in. We need reserves to allow us to cope, to ramp things up when we're facing stress and to ramp things down when stress eases off.

And we need to maintain cycles of our own. We may have been accustomed to the cycles of fertility, but there are many more cycles in our bodies. One of the most important is our daily cycle of sleep and waking, the latter encompassing various stages of alertness and, well, not so much.

Our estrogen is a critical component of our daily cycle. Our levels naturally are highest in the morning, fall gradually during the day and evening, and reach their lowest point around 4 or 5 am. This cycle keys in with with many other hormone cycles, including that of melatonin, another hormone that helps regulate our sleep cycle. It also interacts with thyroid hormone as part of our metabolic regulation. If estrogen levels were completely static, our whole system would come adrift from this important regulatory relationship. And if our hrt were absolutely continuously stable, we'd spend most of our time with either too much or too little to meet our bodies' demands during our daily cycle.

Change, then, is both an inescapable part of both internal and external hormonal regulation and response. But that doesn't mean that it doesn't pose challenges when we do it to ourselves with our hrts.

But the ups and downs are killing me!

The problem is that our body wants to regulate things so we stay on a fairly even keel amidst all of these changes. We work hard, all the time, to do so. When that doesn't happen, of course, the resulting temporary imbalance and the shifts of it coming and going all cause symptoms that can range from annoying to devastating. And it's a feature of our response to change that the greater the fluctuation, the greater the response to it will be.

The most comfortable hrt, then, is going to be one that eases into our bodies with the least disruption, is taken at a dose that lasts long enough that its falling effectiveness meets the rise of the next dose without either great troughs or peaks, and provides a reservoir of hormonal potential to get us through the times of day when we must respond to a need for greater hormonal activity. And as it turns out, none of that actually requires anything like a completely continuous supply.

Minimizing the ups and downs due to uptake

There are two important facets of getting hrts into our bodies. First, they have to physically get into our systems and, second, they need to impact our circulation in a fairly tolerable manner. Both of these factors can present us with problems when hrt characteristics are a mismatch for our personal capabilities.

In dealing with the first problem, we need a delivery method that our bodies can absorb smoothly and reliably. A patch that is stuck now and flapping later isn't going to do that; instead, it will provide us with a roller coaster of ups and downs. Oral deliveries may not work reliably for all women. A gel might be sweat off on the days we go to the gym. All hrt delivery routes have ways they can fail to work smoothly, and so when we're not happy with how a dose is taken up by our bodies, we need to take a close look at just what kinds of interference we might be experiencing at this very basic level of delivery.

But it's not enough to get those hormones into our bodies effectively. We also have to weather the rise in circulating hormone levels. Each hrt will create a slightly different uptake curve if you plot out the amount of hormone in our blood over time. A patch will start delivering fairly rapidly, but if the previous patch was exhausted and our hormone support from it had dropped, even the small dose delivered by a patch will be seen as a sharp uptick by our bodies. Some individuals find that the rapid absorption of a whole day's transbuccal dose doesn't dissipate rapidly enough to prevent being hit by something of a slam.

Each hrt has its own time and type of uptake. When we are troubleshooting these, we can look at alternatives that might perform differently. For example, if a cream transdermal dose seems to provide too abrupt an uptake to be comfortable, perhaps the slower uptake of a gel would be more gentle while still otherwise providing a transdermal profile of effects.

But an often-neglected aspect of uptake has to do not so much with delivery route but what specific hormone we're delivering. When we're taking estradiol, we're using the active form of the hormone. If we dump a day's estradiol into our systems at once, we may have trouble moving quickly enough to convert the portion of it that we don't need to have active at that exact moment into the inactive reserve form, estrone. If this is the case, our dose might give us a fierce headache or palpitations or excessive jumpy nervousness.

For those who experience this problem, it’s possible to get around this effect somewhat by switching to an hrt that contains some or all estrone. That way, the net total hormone support delivered in a dose cycle is still provided, but the initial slam of excessive activity can be dodged. Not all of us experience this problem, but for those who do, this can be a highly productive direction to explore. This is especially true for those who suffer from migraines when they take estradiol, perhaps because the two estrogen versions affect somewhat different areas of the brain.

Minimizing the ups and downs due to duration

If the dose of hrt we take doesn't last until the next dose is taken, our hormone support will taper down far enough that both its decline and the rise of the next dose's uptake will cause uncomfortable fluctuations. While users often address this gap by trying to take smaller doses more frequently, that often doesn't provide a fully satisfactory coverage, not to mention becoming increasingly impractical.

A common misunderstanding of the concept of "half life" often drives this attempted solution. "Half life" in medical terms is simply how long it takes for half of a dose to be metabolized. The fact that a dose is half gone, however, doesn't mean that another full dose is needed; it only means that the body has taken its normal steps to process our hormone supply as it's used to meet our present needs.

If a dose interval is meant to be a full day, then, it's appropriate that the half life be 12 hours. That means we'll have used up most of yesterday's dose by the time we add today's. Yes, that's some up and down, but our body can handle a fair amount of variability through its own storage and retrieval mechanisms if we're not shorting ourselves down too far between doses. The other direction, taking a new dose before we've used up most of the last, only takes us into excess...and excessive risks. In fact, many individuals tune their dose exactly so that they do feel a bit short as the next dose comes due or so that they do have a hot flash or at least warm spell at that 5am low point in their daily hormone cycle, just so that they know they're skimming along the edge of "lowest effective dose."

So in practical terms, if an individual feels as though they're running out far too soon, they might do more good by re-examining their total dose amount and consider whether taking more would make it last longer and round out that dose period. Taking it more frequently only speeds up the cycle of ups and downs and doesn't really improve its coverage.

Minimizing the ups and downs due to reservoir

There's another factor, beyond simply how long the dose lasts, and that is the form in which it lasts.

Yes, the measured amount of our total hrt-provided intake goes up and then down, but focusing on that alone misses the fact that our overall hormone capacity is not represented by just one form. When is taking estradiol, an individual's body will normally move quickly to convert any excess beyond momentary need into estrone, which will exercise less activity. In the course of the subsequent dose interval, that estrone will gradually be converted back to active estradiol as current demand requires, throughout this period, to do more estrogen work.

We’re not sure of the physiology behind this, but some women seem more comfortable when they have a considerable reservoir on board. Now, that’s not an excess we’re talking about; we only mean the sort of buffer that a day’s dose provides. Those for whom this is the case often feel edgy and stressed, never quite comfortable in their bodies, on trickle-dosed hrts (patches, pellets, even gels), as though something isn’t right even though they may have lab tests that put them in an ostensibly normal hormone level range. Unfortunately, this is often the sort of situation in which they move to trying to manage their hrt levels even more closely—something that is actually moving in the wrong direction. Switching to daily dosing, which allows their bodies to regain and manage a reservoir to meet their fluctuating needs in a more natural process can help alleviate that problem and provide a better fit between hrt and how their body best functions.

This is vague. Also, confusing.

Yes, we know. We’re getting into the more subtle aspects of hrt “fit” here and there are no real rules, no body of research knowledge. By standard medical thinking, all pharmaceutical hrts must work exactly alike and if there’s a problem, it’s somehow with the patient.

But in the decades we’ve been watching hrt use and talking with women about what they’ve tried and experienced, these seem to be common trends and the strategies that seem to have good, durable results for dealing with them.

These aren’t recipes, however. We need to think about the ways our current hrt can be ill-suiting us and we need to know enough about hrts to know which ones hold different characteristics. This is way more subtle than the situation where if we try one patch at one dose and aren’t happy, our only option is whatever oral hrt our doctor most often prescribes. Our hrt pages here can help you with some of this (they're arranged by hormone, so check the Table of Contents for links). If nothing else, we hope that this will help keep you from wasting a lot of time and effort adding and subtracting bits of patch every hour during the day (yes, we’ve actually read accounts of women so desperate to get that impossibly even hormone state that they’ve tried this). And encourage you that there are some fairly subtle things that can be done to manipulate our hrts’ effects to make them fit better.

As ever, we’re more than happy to discuss this in greater detail on our forums. While we can’t provide answers for everyone, we can often ask questions to help them discover their own best answers.

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

It happens all the time: a new member 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 each individual feel just the way they want to. All of our bodies are different; our lifestyles are different; our family/genetic histories are different. How any given hrt will function in any one person'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 our own body 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, listed across the bottom, 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 individuals taking therapeutic hrts to treat or help control a specific disease condition (like endometriosis or cancer risk) will often need to work with multiple hormones at once, most others 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 medical 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 sales program, 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 constitute such a preference or risk? Some vegetarians might eschew an hrt from animal origins. Others have ethical objections to the way some hrts are manufactured. Some individuals 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. Yet others 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 choose between.

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: someone 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 different individual with digestive issues might eschew an oral, while another with a skin disorder might not feel comfortable with transdermals other than transbuccal or vaginal. Those who work outdoors in a very hot climate might find that patch hrts will be fighting an uphill battle for adhesion. Others caring for infants may not choose 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.

Now we can 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 person wanting a transdermal estrogen but concerned about transferring hormones to 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 and easily shared. 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.

Finally, don't forget to make sure that your health insurance coverage will cover the brand (or similar generic) or that you are able to pick up the cost yourself. Some basic hrts like Estrace are available so cheaply that it becomes more sensible to pay cash than to involve drug insurance deductibles and coverage. GoodRx can help if you want to research price deals.

Step 5: What dose?

Once we've made a choice of hrt, then, it's often simplest to start at the "usual starting dose" unless we have specific criteria to meet that would indicate otherwise. What would those be? Perhaps you distrust hrts or don't really believe you needs one, and so you want to to take only the barest minimum to see what happens. Perhaps you have previous experience to suggest that you respond strongly to hormonal preparations. Perhaps you're 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 rubric, but in fact many of us have found that excitement tends not to be what we're looking for in hormone balancing and that it ends up being well worth taking the slower approach rather than unsnarling ourselves after an over-hasty miscalculation.

There's also a popular myth that anyone who is younger than the typical menopausal age of 50 will need very high doses of hrt because they must match their premenopausal levels. While they may indeed start a little bit higher than the 50-year-old 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 and uterine needs. We've seen younger individuals 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  first-pass 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 us some months after surgery to stabilize on hrt and really get a sense that our preop hormone support is no longer having any effect.

The general rule of thumb we've seen in 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, many individuals' 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  who's not accepting their 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 people 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 someone has achieved some reasonable degree of stability by meeting their basic estrogen needs, some of the pressure is off and they can take the time to learn more, to explore more options. And the work they've done in learning to listen to their body and work through the process will provide them important tools to continue their refining work on their 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 you cut through to the issues and look at where you might turn to make the next iteration of adjustments. We can't tell exactly what any given individual should do, but we can often as a group ask some questions that will help then make their own decision of what to adjust next.

Vaginal delivery of systemic estrogen HRT

We've been following discussions of this topic for some time now in a number of locations on the internet and it's come up on our forums as well.

There is, of course, one vaginal-delivery systemic estrogen hrt on the market already, Femring. But we're also seeing some individuals report exploring the use of Estrace and its generics (micronized estradiol) vaginally for systemic support. And that raises some distinct concerns.

Vaginal micronized estradiol: will it work?

First of all, yes, absorption through vaginal tissues will function as a delivery route for this hrt. Oral mucosa is very similar to vaginal and it is indeed permeable to this molecular form of estrogen. In fact, it's been quite some years now since we first heard of using a tiny bit of the dust leftover from cutting tabs for transbuccal or oral use for local vaginal supplementation. We had some concerns initially that either the colorant or the base might prove problematic since neither are designed for the vaginal environment, but that has not been the case for those who've shared their experiences with us. We've also run this past a few doctors who have said there doesn't seem to be any obvious peril beyond the issue of making sure the dose is appropriate. So that seems to be both effective and reasonable as a means of local supplementation. But that's not the same thing as using this delivery for systemic support.

Risks: concentration in pelvic circulation

Our greatest concern with using this route for systemic vaginal dosing, however, is where that estrogen goes immediately after it is absorbed.

With transbuccal use, many users see distinct local effects according to where in their mouths the tablet is placed. Those seem primarily to do with fluid retention (such as sinus stuffiness, ear fullness or transient headache) and we have speculated that they represent higher local concentrations in the part of the circulation to which they are initially delivered, before they are well-diluted. Most of those reporting this effect have had success in switching to other locations in the mouth where this is less problematic, although the non-problematic location varies (of course it does) from individual to individual.

Looking at that same aspect in terms of vaginal delivery, then, we have a concentration of estradiol—which is the active form of estrogen—delivered to local pelvic circulation. We know from research done with vaginal progesterone that this kind of concentration in the pelvic area does happen with vaginal delivery of that hormone supplement and there is no reason at all to expect that estradiol could escape a similar distribution pattern.

Now, when that happens with progesterone, that represents a desirable situation in terms of delivering a therapeutic concentration of that hormone to pelvic organs without causing a corresponding systemic concentration—and heightened systemic effects. But with estrogen, there's no real reason that this concentration would be desirable and in many situations, we're quite concerned that it isn't. Anyone with endometriosis, for example, would hardly want higher estrogen concentrations flowing directly to their endo implants. Anyone with a risk of ovarian cancer retains that risk even when their ovaries are removed because there is a (low but present) risk that before oophorectomy, micro-tumors may have escaped their ovaries to later be stimulated by that higher level of estrogen in the circulation that feeds them. This is recognized in the specific warnings for current vaginal systemic hrt, that caution high risk users about precisely this.

We know from users of the systemic vaginal ring that some find this route of supplementation to be highly uncomfortable, citing symptoms of pelvic bloating or congestion as well as stimulation of irritable bowel syndrome or bowel cramping. There is also a mixed body of evidence suggesting that higher levels of estrogen may add to incontinence. So not only do we have the progesterone model to shape our expectations but we have experience with vaginal delivery and pelvic symptoms to suggest that it most certainly does happen and we have FDA concurrence that this represents an undesirable level of risk for at least some users.

It is worth noting that Femring, the vaginally-delivered systemic hrt, uses a form of estradiol that, although human-identical, is inactive until it has been further processed in the bloodstream. This means that it is well on its way to being diluted and distributed before it becomes fully active as estrogen. It seems likely that this is deliberately done to reduce estradiol activity exposure at systemic levels to those pelvic tissues. In other words, there may be significant negative concerns with vaginal delivery of systemic estrogen that led the pharmaceutical companies to put additional funding into working around that problem rather than, more economically, just repurposing an existing product they already had on the shelf. While we may not know what led them to do so, the simple fact that they spent money on this raises the warning flag that it was probably not done without substantive reason.

Risks: estrogen activity and vaginal tissue health

Were an individual to elect to try vaginal estradiol systemic hrt notwithstanding the above risks, we would also think that a regular, detailed and careful exam of vaginal tissues by a knowledgeable practioner would be important. While the low-dose vaginal hrts are documented to have a fairly light effect on the tissues they directly contact, all that systemic-dose estrogen going through a relatively small location (even though the tab breaks up quickly, it's still not going to be distributed over a wide area of mucosa in the fairly static vagina) may have disturbing effects upon the mucosal cells in that area.

This is a concern raised by some doctors when users discuss transbuccal use, based upon similar issues seen with some sublingual and nasal drugs. Those using this route need to be careful to switch locations around frequently, visually check their oral mucosa regularly, and also ask their dentists and oral hygienists to do so as a backup. We see no reason why similar precautions with vaginal use would not be a good idea (only, of course, probably not asking your dentist to be the one do it) to make sure that we are not stimulating some sort of cellular changes that could become problematic. Remember: the reason why estrogen is carcinogenic is that it fosters growth of tumors, and that's not something we want going on out of sight in our vaginas.

Would this work with any of the oral estrones?

That's a good thought that came from our discussion of vaginal systemics on our discussion forums. We don't really know, but it seems as though since there was an Ogen vaginal cream made for local use, the oral estrones Ogen or Ortho-Est would seem to be usable transbuccally or vaginally since they contain the same compounds.

That said, many of the same concerns with respect to vaginal systemic dosing would still apply. Although estrone is an inactive form of estrogen, the conversion of estrone to estradiol occurs in cells throughout the body. A higher-than-normal local concentration of estrone might well still result in higher-than-desirable estradiol exposure to vaginal and pelvic tissues. We certainly don't see any reason why switching out estrone for estradiol would moderate risk adequately that those with specific risk factors such as endo or ovarian cancer could be confident that this would safer for them, however much the systemic impact might be gentler than all-estradiol dosing.

So should we use oral hrts vaginally or not?

We have really mixed feelings about this whole premise. That it would work to deliver estrogen to our systems, there is little doubt. It is likely that in reaching the circulation through pelvic rather than head/upper body dilution, the specific local effects that are problematic for some women with transbuccal use might be avoided.

We can't, however, see that it in any way alters the way the dose is processed by the body other than that initial concentrated absorption uptick, so the premise that it somehow is delivered more evenly than transbuccal is likely a subjective impression that is not supported by physiology. It may be different from other transdermal (general body skin) deliveries, just as transbuccal is, because it represents a different uptake dynamic and the skin/fat reservoir and transmission effects are taken out of the mix. Like the transdermals, however, it also represents a risk of transfer to a partner than is unquantifed but certainly real.

We've taken up elsewhere the issues of whether not estradiol needs to be dosed multiple times per day and whether "even" is ever a state that can be achieved (spoiler: no, it's a myth), so we won't reference those concerns here other than to say that there is nothing in pelvic delivery that would lead us to feel they are not applicable here as well. Anyone whose body is not capable of using a daily dose via this route, as with any other, is not utilizing that particular hrt well. Whether or not other hrts would better suit them is the issue here, not just the route and timing; multiple-dose dosing is a stopgap measure to try to force a fit with a deficient hrt, not a good or sustainable strategy in itself (although it's true that in some instances where trying other things is truly not feasible, stopgaps may be the best thing we have within our reach). The ability to divide a vaginal dose into micro-doses given at extremely short intervals is thus not a compelling argument that in any way offsets the risks, let alone makes this route somehow unique.

So the bottom line on this is that there's just no reason to be really comfortable with the risks that this concentration provides in this location. That doesn't mean it mightn't be the more practical option for some women, but it would require special precautions that make it nothing to be taken lightly. One of the dangers of discussion forums that focus on support rather than information is that women can advocate for use of a particular hrt strategy without any corresponding exploration—or even awareness—of the risks it poses.

We do think this notional hrt use is worthy of exploration, but that exploration should be done knowledgeably and with great care to monitor for negative outcomes. Given the widespread lack of understanding of hrt and hormone effects, though, we're afraid that users will be injured by and later regret decisions made without fully understanding those risks. Individuals with hormonal concerns may distrust their doctors because that relationship is so formulaic, paternalistic, and illness-based, ill-suiting their menopausal health needs. Yet when they engage in risks without that backup of medically sophisticated knowledge, they've lost an important safety net. Maybe it looks as though we're being too conservative in this case, but with things we can't get back from without great cost, yeah, conservative does have positive benefits.

But then what about compounded hrt to be used this way?

Are compounded vaginal estrogen hrts being prepared for systemic use? What are compounders doing about these issues? We're not seeing direct-to-consumer advertising of this type of hrt, so we don't really know if this market niche currently exists and we haven't yet encountered anyone who does.

Because there is no substantive difference between retail human-identical and compounded bioidentical hrts in terms of this risk situation, our concerns would definitely extend to those hrts as well. While doctors in theory vet the prescriptions suggested by compounders, in practice many of them tend to just pass them on as suggested by a fully qualified professional and happily pocket their share of the business income so generated. So there's a questionable safety net right there.

In fact, if they are doing so, this would be exactly where we tend to think that the FDA has a reasonable ground to be critical of compounding. This would be a major departure from what is known and tested and generalizable from other tested and licensed retail hrts. This is where their current practice model might indeed overstep their training and licensure and, of course, constitute the legal vulnerability that is being exploited by the pharmaceutical companies in response to what is actually a perceived marketing threat rather than the nominal concern for patient safety in which it is couched.

So we're going to hand this part of the question back to you. What do compounding pharmacists you are working with have to say about direct systemic vaginal estradiol hrts? And estrone used that way? Are they making and selling it? What precautionary screenings are they doing or what counseling are they doing on risks specific to this delivery? We'd be very interested to know what the compounders' take on this is. If you have any information, please do share the results of your inquiry with us.

This is an idea we need to explore just because there are indeed individuals out there claiming to be using this route and promoting it on discussion forums. The more concrete the information we have, the more useful it becomes to us, whether it's to give us the go-ahead to experiment more freely or to convince us that it's really not such a good idea after all. We're not at all opposed to exploring and pushing the envelope in search of alternative ways to use the available hrts, but we're always going to be taking a firm hard look at the risks along the way.

Gleanings from an article on contraceptive patches

Since we're always interested in expanding our understanding of patches and transdermal hormone delivery, we recently clicked through on "Transdermal Contraceptive Patches: Current Status and Future Potential" (free signup required to read) just to see if it had anything to offer that also seemed applicable to hrts.

Delivery from alternative patch placement locations

We've known for some time that butt and belly application differs by 17-25% in the quantity of hormones absorbed from the same patch. This is in the official US FDA patch data sheets. Users have also reported using upper arm and upper back and thighs for patch placement for years, but we're never had any guide other than experimentation to determine the approximate dose equivalency for those locations. This current article, however, lists some of these locations and reports on their delivery:

The patch is designed to be placed on one of four sites: the lower abdomen, upper arm, buttock or upper torso (excluding on the breasts). Two consecutive patches should not be placed over the exact same area. Hormonal absorption from the lower abdomen is approximately 20% lower than that observed from the other three sites

There's no reason at all to suppose that this would not hold true for hrt-sized doses as it does for the higher contraceptive-sized doses referenced in the article. That means that we don't especially need to anticipate making huge changes to our patch dose if we choose to spread our use out over more alternative locations.

What's underneath still matters

This doesn't, of course, guarantee that even the sites with roughly the same statistical deliverability can be trusted to work that way on an individual basis--we still have to contend with individuality of fat-vs-muscle underlayment of the skin to which the patch is applied. That's also supported by this statement from the article:

cautioned that women with body weight in excess of 90 kg may be at higher risk for pregnancy compared with lighter women

In other words, individuals with a thicker fat layer the hormone must traverse to enter circulation may have an overall lower delivery to systemic circulation. For well-padded users, then, a patch may not be an optimal delivery if transmission through thicker fat layers prevents good uptake. Beyond this, though, it supports the notion that underlaying tissue type is pertinent to patch delivery for all users, something that may help in troubleshooting variations in patch performance that result from using multiple locations.

Environmental impact of patch disposal

Also of broader interest is this reminder of the environmental impact of undelivered hormones:

As there is still a considerable amount of hormone left in the patch at the end of its 7-day use, it is recommended that patches not be flushed down toilets, but disposed of folded in half via solid waste collection systems. In some countries, it is recommended that the used patches are returned to pharmacies.

While users in menopause tend to come closer to exhausting the hormone content of their much lower dose patches by the end of the nominal delivery life, we should keep in mind that there may still be enough in them to have impact on others. Our water supplies are growing increasingly contaminated by hormones and drugs, none of which are typically measured (in the US) by EPA-mandated water supply testing. This contamination is increasingly pointed to as a potential factor in the earlier sexual maturity of children and the higher incidence of hormone-mediated disorders we may suffer as adults.

We might be especially concerned about patches discarded prematurely—say, that one that got caught on our underwear on day 1 and peeled up and had to be replaced. But any patch, really, should be disposed of with some care as to where its leftover content might end up, given that it's unfilterable and untested once in our water supplies. Even their suggestion that it go into solid waste disposal would be ineffective in safely sequestering it some places, such as New York City, where much solid waste is simply barged out to sea and dumped. Responsible disposal of our hrts is something to think about for the sake of our children and grandchildren.

Transdermal delivery and the risk of blood clots

The main issue that this article is addressing is risks of blood clots. In general, we know from a growing body of evidence that oral hrts (as compared to transdermal) seem to be associated with a higher incidence of clots, generally attributed to the way that the liver is more heavily involved in oral dose processing. The article reviews that situation:

Estrogen increases VTE risks by altering hepatic production of extrinsic clotting factors, and antithrombin III. With oral contraceptives, hepatic exposure to estrogen is much higher than is reflected by serum estrogen measurements. This is because much of the estrogen absorbed through the intestine into the liver is conjugated and excreted through the gallbladder back into the intestine without ever entering the bloodstream. However, with transdermal systems, all the estrogen to which the liver may be exposed is reflected in the serum levels.

Oral processing is also generally believed to boost inflammatory factors (such as C-reactive protein), which has been suggested as a reason why cancer rates may be higher with orals than other delivery. This is also considered to be a factor in the cardiovascular disease development issue as it relates to route. This research is not yet heavily publicized even though it's incorporated into the major medical group consensus documents on menopause and hrt, so many physicians remain unaware that these are reasons for women to downrate oral hrts when they are evaluating their options.

Transdermal progestins?

We've been discussing progestins lately, both with those who have endometriosis and want to include the suppressive effects of progestogens (progesterone-acting compounds) in their hrt, and with those who have had their ovaries removed but still have an intact uterus and a need to utilize a progestogen to maintain its health.

There's some evidence that progestogens that deliver into pelvic circulation provide better local coverage with lower systemic impact as compared to other routes of systemic delivery, something very attractive where the alternative has long been simply having to tolerate an unpleasant hormone imbalance for the sake of therapeutic effect.

To date, local progestogen delivery has been possible only via IUDs such as Mirena ( dispensing the progestin levonorgestrel) or other higher-dose progestin-dispensing contraceptive IUDs (like Progestasert), or vaginal forms such as the progesterone gel Prochieve, off-label use of oral Prometrium caps vaginally, or various vaginal-application compounded forms of progesterone. That means that for individuals who want the stability of a progestin, which cannot be converted to other hormones as progesterone itself can be, if they didn't have a uterus they were out of luck for anything other than oral delivery and its associated systemic impact.

But this article supports the premise that progestins are in fact capable of being absorbed through the skin (and, by extension because they have similar properties, vaginal lining). Gestodene is the progestin mentioned as being possibly suitable for this kind of delivery in this article and norelgestromin is the progestin in the currently-available patch, but the article also suggests that "other progestins, including those with poor oral absorption, could be utilized in a transdermal patch."

While that doesn't mean that anyone's going to rush a vaginal or transdermal progestin onto the market, especially one suited for the use of those in surgical menopause (a rather small market), it does open up some other avenues for the adventurous to explore.

How? Vaginal use of a portion of a plain progestin tablet meant for oral use might work (it would obviously make sense to try one of the progestins the article mentions unless one can get solid information from a pharmacist that a different progestin is known to be suitable in terms of through-skin absorption capability). Why only a portion? Remember: oral formulations have a lot of wastage from first pass built into them, while lower losses with transdermal delivery mean we have to start at a lower dose level when converting between the two. Clearly, this is really out-on-the-edge experimentation and definitely something to discuss with one's health professionals, but it does provide the hint of a possibility for those willing to experiment a bit in order to get an hrt form and dose they are more comfortable with.

Another approach, although we're not sure if it's feasible or not, would be to see if a compounding pharmacy could custom formulate a progestin meant for oral use into a vaginal-suitable dose and vehicle. We've hesitated suggesting this in the past because we had no reason to suppose it would be absorbed, but given the encouragement of this article, it sounds much more like something to pursue.

Have you tried this? Thinking about trying it? We'd love to hear from you about your experiences on our discussion forum.

HRT for those with a uterus but no ovaries

Although this site focuses mainly on those who have had both an oophorectomy (ovaries removed) and hysterectomy (uterus removed), some individuals choose to have diseased (or high-disease-risk) ovaries removed and yet retain their (healthy) uterus. Others who might fall into this category are those who have sustained such a severe chemical menopause due to cancer treatments that they are now without functional ovaries although they remain technically intact.

While they will experience the same issues to do with choosing hrt as those in full surgical menopause, the need to keep their uterus healthy must also be taken into account and this will change their ultimate hrt options.

The crux of the issue is that exposing a uterus to estrogen stimulates the growth of the uterine lining or endometrium. In our fertile years, this stimulation is necessary to prepare the uterus to support a fertilized egg. When no pregnancy occurs, our hormone balance naturally cycles to cause our unused uterine lining to be shed in the form of menstrual flow, resulting in a period.

But when we no longer have ovaries to manage this cycling, uterine health becomes an issue. If we fail to shed that lining, it can build and build and over time, this unshed lining may turn to uterine cancer. Yeah, that's bad. It's so bad that it's a fundamental rule of hrt use that anyone with a uterus must include provisions in their hrt to prevent this from happening.

Like what? There are two basic strategies: we can artificially create a hormone cycle with our dosage pattern, thus causing the lining to shed regularly in a period OR we can balance our hormones in such a fashion as to suppress that lining buildup in the first place, eliminating periods. Let's look at both of these a little more closely.

Hormone cycling

This is the classic approach. We take an estrogen hrt for part of the month and add some sort of progestogen (progesterone or a synthetic version that acts like it) for a shorter time, often a week to ten days, to stimulate a period. Many individuals find this sort of cycle reassuring, since it mimics what they experienced in their fertile years. Many doctors prefer it because they feel that their patients do best with what they are accustomed to or that they are less likely to become confused keeping track of their hrt on a short schedule.

This kind of cycling does carry a cost, however. If you suffered through PMS or your monthly cycle of ups and downs with mood swings and bloating, maybe going on doing that doesn't sound all that appealing. Maybe you would be just as happy to make fewer trips down the feminine products aisle at the store and wear more white underwear without fear. Maybe you'd like to balance uterine protection with a little more comfort and freedom from that cycling.

There is nothing magical about monthly cycles once our ovaries aren't controlling things. Research in recent years has found that we really only need to cycle a few times a year to preserve uterine health, either using oral contraceptives (while we are in our fertile years) or hrt (when we are post-fertile for whatever reason). A conservative schedule for this long-period cycling would be quarterly, although some individuals find that they can successfully go even longer without undue risk. So long as they are not having break-through bleeding (which indicates that their lining is building up beyond normal levels), they only take a progestogen every three or four months to produce a period. This requires keeping track of this schedule so we doesn't go too long without completing that cycle and it requires that we use separate estrogen and progestogen hrts—neither of which are necessarily difficult to achieve. There will still be the same ups and downs of cycling and anyone using this approach will still have periods, but they'll happen less often.

Is this strategy appropriate for all of us? Not necessarily. Those of us with endometriosis, for example, may find that this is still too much estrogen stimulation. Those with cancer risks or metabolic disease or risk factors for blood clots may not be best served by this sort of a dosing scheme. Maybe you don't consider having periods or hormonal cycling an important part of your identity at all. This is one situation in which each individual needs to sit down with their doctor and consider carefully all of the factors that are involved in their use of hrt.

Continuous combined HRT

The other approach to uterine protection involves suppressing the growth of that uterine lining by continuously and simultaneously taking both estrogen and a progestogen. The lining never has a chance to grow, so there is no need to have a period to shed it. Hey, that sounds pretty good, doesn't it?

But there's a cost, and that cost might not suit every one of us. In order to accomplish this, we must deliberately induce a hormone imbalance. We have to take more of that progestogen than we really have a need for otherwise to balance our hormones. Or, to put it another way, we need to have a deliberately progesterone-heavy balance.

For some, that's not a problem: they're perfectly comfortable with a standard dose of any of the retail progestogens made for this purpose.

Others, however, find this balance subjects them to an uncomfortable excess of progesterone effects. For them, then, the challenge is minimizing those effects while still providing the protection that their uterus needs.

And, finally, some are increasingly concerned about the risks of progestogen use that have been revealed in the past couple of decades of hormone research.

Luckily, there is more than one way to approach this problem. If we are going to use a progestogen in a continuous, imbalanced manner, it's worth trying different progestogens to see if one is less unpleasant in this regard than another. Amongst the progestins, each one is very different in structure and characteristics, and will act differently in the body. So if this is your choice, it may be worth auditioning a variety of them. Route may also make a difference, so even if your choice is progesterone itself, taking it via a different delivery route may also help you manipulate its effects.

But another way of dealing with this—and especially with the risks—is to maximize the impact of your progestogen on your uterus while minimizing it elsewhere. This is done by using a more local delivery, either via the vagina or the uterus itself. This way, the highest levels are experienced in the pelvic organs, where they're most needed, and less of that dose makes its way to systemic circulation, where it's not needed. In fact, one source suggests that this can represent a pretty significant difference:

Furthermore, vaginal administration of micronized progesterone has been shown to enhance progesterone delivery to the uterus by about 10-fold in comparison to im injection, despite the markedly higher (about 7-fold) circulating drug concentration achieved with im injection.

Further, this technique is specifically cited by the International Menopause Society in their 2011 position statement as having particular merit.

Sound interesting? There are actually several different hrts that provide for local delivery. Prochieve is a progesterone gel specifically designed for vaginal use, but some individuals have reported successfully inserting a Prometrium gelcap vaginally and allowing it to be absorbed that way (typically, overnight). Vaginal suppositories such as Endometrin are also available, as are versions that can be custom-made by compounding pharmacists. And Mirena is a progestin-releasing IUD that works directly in the uterus and so can get by with an especially low level of dosing.

We also have come across some interesting information that indicates that at least some progestins may be capable of transdermal delivery--something we probably could have put together before given that contraceptive and combined-hormone hrt patches aren't exactly new. That raises the question of whether certain of the progestin hrts meant for oral delivery could be used vaginally (at a suitably lower dose). We don't know the answer but it seems to be something that might be worth looking into if using a local progestin by other than IUD would be your preference. More on that in this news discussion.

Will I have to do this the rest of my life?

No. You will, however, need to tailor your hrt for uterine protection so long as you take enough estrogen to stimulate your uterus.

Our hormone needs diminish with age. For that reason, it's a good practice when taking hrt in any form of menopause to challenge ourselves every few years to be sure that we're taking no more than we truly need to achieve the effects that we define as important. By trying out a slightly lower dose every 3-5 years, we can find out if our bodies have been slowly easing down in needs without us noticing.

In theory, we'll all, if we live long enough, reach a point where our hormone needs are low enough that we no longer need to supplement with hrts. What we produce ourselves plus what we take in from foods and environmental contaminants will fully meet our then-current needs. And when that happens, we're probably not stimulating our uterus enough to need to continue to provide progestogen protection for it. That's something to review with one's doctor, of course, but that's the expectation. Until that time, however, so long as we've got a uterus and are supplementing estrogen, we need that progestogen coverage as well.

How will I know I'm taking enough progestogen?

You won't. The general guideline is to look for spotting. This is taken to mean that your lining is growing enough that the progestogen isn't providing adequate suppression, whether you're taking it cyclically or continuously.

If, however, you have a high risk situation where you aren't comfortable waiting for this symptom to tip you off, there's another method for monitoring uterine lining response: ultrasound measurement of the thickness of the uterine wall. This can be ordered by your doctor, is a bit uncomfortable but generally not painful, and if properly coded should be covered by most health insurance.

There is not, regrettably, any magical formula for relative doses, such that if we take this amount of estrogen, we know we'll need that amount of progestogen and then we'll be sure we're safe. Or if we have this measured level of circulating estrogen, we need that level of circulating progesterone to cover it. Hormones don't behave in a simple relationship like that—there are many other factors that can affect our hormone supplies and relationships. We can't force our hormones to go where we want and do our bidding. What we can do is provide the supply and then watch carefully to see what happens. If what happens is no uterine lining shedding, no spotting, then we most likely have the situation covered. And if we don't, then a simple ultrasound will tell us how our uterus is doing and whether we just have a brief unusual situation or whether we need to tweak our doses.

Let's repeat that, because it's pretty important: the test of our hormones is not in what we want them to do, but in what they actually do. Results are the most reliable place to focus our vision.

So that's it?

Yeah, pretty much. Outside of protecting a uterus, our other hrt needs are essentially the same as for those without a uterus: meeting our post-fertile needs as we define them while exposing ourselves to the least amount of risk possible. So the information on hrt-balancing that is covered elsewhere on this site is just as applicable to you as it is to the those in full surgical menopause.

Got questions? Other concerns? Join us at our discussion forums.

Vaginal dryness

Many of us are led to believe that, at menopause, we "just dry up." Our partners may believe this as well. Our doctors certainly do: although the condition that leads to this (we'll talk about that below) is very well known and easily diagnosed, they are apparently so reluctant to do so that incidence has been termed an "epidemic" (free signup required to read link; see also Part 2) by the medical community. With an estimated 50-60% of polled women complaining about this problem, it's not as though we don't have company.

So, what is the problem?

Its proper name is "vaginal atrophy*" or, even more broadly, "urogenital atrophy*" (see bottom of this entry for a new terminology update). Sound scary? Yeah, us too. But what it means is simply deterioration of the tissues of the bladder, vagina, and various supporting structures due to the loss of adequate levels of estrogen in those tissues.

Yes, that area of our bodies is very sensitive to estrogen levels, and after menopause, we simply may not have enough estrogen there to keep those tissues healthy. This happens with natural menopause and it happens with surgical menopause. It even happens when we are taking hrts.

If you did a double-take at that last sentence, you've got lots of company. But in fact current prescribing guidelines for estrogen hrts call for using the lowest dose that meets one's objectives in taking hrt. That's for a good reason: our breast cancer risk seems to correlate fairly well to our lifetime exposure to estrogen, so the least estrogen that works for our needs, the lower our overall risk.

But while that may work out fine for systemic (whole body) needs, it may not cover the very specific needs of these particular tissues. Wouldn't the answer then be to simply take a larger hrt dose so that it would? No, because then that risk goes back up.

Today's typical hrt strategy is to meet our greater vaginal estrogen needs in a different way, one that doesn't do as much to raise overall risks but does serve to keep those critical tissues healthy. That strategy is to use as low a systemic hrt dose as otherwise meets our needs and to supplement that with a second form of estrogen hrt that specifically meets vaginal needs. That means a little more work to manage our hrt and, yes, a little more expense, but the benefit of those costs is meeting all our needs at a lower level of health risk.

Vaginal atrophy: what it does

Let's look a little more closely at what vaginal atrophy really means for us.

Estrogen supports a number of functions in vaginal and urinary tissues. It helps maintain elasticity, moisture, lubrication, immune function, and sensation. Without estrogen, blood vessels shrivel up and become less functional, and our nerves in that area begin to deteriorate. We can't bring blood to initiate the healing processes that protect us from infection. At the same time, these more delicate tissues are even more susceptible to injury or irritation.

That means that without estrogen, vaginal (and to some extent, vulval) tissues become dry all of the time, and hence more irritated by things like soaps or even contact with underwear. It means that we may be more susceptible to infections and it means that we may be more allergic or at least more prone to irritations, rashes, or itching due to contact with products like soaps, fragrances, or laundry products, even ones that we weren't bothered by in the past.

The loss of sensation, caused by the nerves being starved, means that while we may feel irritation just fine, we tend not to feel the pleasurable sensations of arousal or orgasm. "Dead down there" is a common way of expressing this. Because we don't have the capability to respond to arousal with tissue swelling and lubrication, we literally don't feel aroused. And the lack of elasticity and lubrication means that even if we go ahead with penetration, it will be at best uncomfortable and unpleasing, and at worst cause tearing and further irritation. No matter whether or not we provide a systemic "itch" for sexual contact with testosterone, if we can't respond physically because of the effects of low estrogen in these tissues, we will not seek or enjoy sexual relations. We'll talk more about the issue of libido support in another post here, but this is the important relationship: if the equipment isn't working, it doesn't matter how hard you push it. And estrogen is the foundation of "working" here.

So what do we do?

Luckily, treatment of vaginal atrophy is easy, has relatively inexpensive options, and is generally successful within a short time.

HRTs intended specifically to meet vaginal estrogen needs are different from those for systemic needs. It's especially important not to confuse them with products for systemic use that are also delivered through vaginal tissues. Our estrogens HRTs page distinguishes these, so check out your brands there to make sure you've got the correct one for your intentions: even health practitioners have been known to mix this up.

Vaginal estrogen HRTs are all designed to be delivered in vehicles that are non-irritating to atrophied vaginal tissues and well-absorbed by them. Even more importantly, they deliver only a very low dose of estrogen, only enough to meet the local tissue needs. The objective of this is to have all of the dose absorbed and used in those local tissues rather than being passed along to systemic circulation. And that means that adding a vaginal estrogen supplement doesn't mean making an adjustment to our systemic HRT to take that addition into account.

It also means—and this is important—that we can use it intermittently. Our systemic HRT, you'll remember from discussions elsewhere on this site, needs to be kept at a fairly consistent level to avoid causing symptoms from fluctuating hormone levels. But because vaginal HRTs don't affect systemic levels, they can be used only as often as needed to provide the level of maintenance coverage we turn out to need.

Most vaginal HRTs are given at a relatively frequent dose interval, usually daily, for a six- to eight-week period. This provides a steady supply of estrogen to promote recovery of health.
Often, we use a cream for this treatment phase: it spreads out well and provides maximal contact with tissues. Further, these are older products and doctors are more familiar and comfortable with them, hence more likely to prescribe them.

Other options are available, however: typically these are rings and vaginal tablets, either retail prescription or compounded. While they may be less messy than creams, because they are low doses meant for maintenance, this first, treatment phase can take longer with these forms. Whether or not this is a good idea for any particular individual really depends upon just how uncomfortable they are and how rapidly they want to turn things around.

It's perfectly legitimate to use a combined approach: a cream for the treatment phase and then a switch to another form for long term maintenance. Alternatively, one can continue using a cream and simply use a smaller amount of it at a less frequent interval, making it less messy and inconvenient. All of the commercial vaginal estrogen HRTs work, so it's really a matter of preference.

What we can expect from vaginal estrogen supplementation

Beginning vaginal estrogen HRT can sometimes be annoying and uncomfortable. Some individuals have such damaged tissues that even the creams, meant to be non-irritating, are too much to tolerate immediately. If you have a reaction of burning or rash upon beginning any vaginal HRT, by all means call your doctor right away and ask for something else: it's not an effect that will go away quickly and there's no point to suffering. If nothing else, a compounding pharmacy can make you a preparation containing the same amount of estrogen as the retail products, but in a hypoallergenic base. In extreme situations, we may need to use the cream externally only for a period, and then gradually increase penetration to progressively treat vaginal tissues.

It's not at all uncommon to see reports of vaginal infections in the early weeks of treatment. These are due to the impaired immune function recovering at a different pace from other aspects of tissue healing, such that the vagina becomes a fertile place for bacterial growth before we're really able to fight those bacteria off. Additionally, using the cream runs the risk of introducing infections through the applicator and tube if we are not careful with their cleanliness.

Infection is not a contraindication for continued HRT use, however, and infections can (and should) be treated at the same time. It may take more than one round of treatment before health is restored and we require less intervention, so some persistence can be needed to see this process through. What's important to keep in mind, though, is that it's not the new vaginal HRT causing the infections (this is a common misunderstanding), but rather, it's the stage of healing that actually makes us susceptible to the infections.

Now, we've said above that the idea of the low dose level of these products is so that they will be consumed entirely locally, without systemic impact. And that's true. Except, maybe not so much at first. When we first begin treating established vaginal atrophy, those tissues may have lost enough of their circulatory capacity that they can't pick up and distribute all of the estrogen quickly enough and some of it does "leak" into systemic use. We may experience a few hot flashes from the fluctuation in our systemic levels, or see a slight shift in our usual state of balance.

But because even atrophied tissues can benefit from the estrogen they absorb, healing is happening. And as those tissues recover, they'll use more and more of the dose until that state of total local use is achieved. For this reason, it's generally not considered to be a situation in which we should modify our systemic HRT intake. It's temporary and so long as we're not miserably uncomfortable, we don't need to change anything; we can wait it out, knowing it's time-limited and will gradually be resolving.

So we use the HRT daily for those six to eight weeks and find that things are feeling considerably better. Normal lubrication should be restored and sensation should also be more normal, assuming we experienced no actual nerve damage from our surgeries. Now it's time for maintenance mode.

Our doctors will tell us to use our maintenance vaginal HRT on a less frequent schedule and may suggest once or twice a week. But that's only a rough guess, and we each have to consider tuning that to create our own best schedule.

If we're still using cream, we can also work on determining a reduced dose. What we hear most often is something like "a pea-sized dab a couple times a week," which is pretty vague but is an okay general guess to work from.

For those using a ring, of course, the dose is taken care of (although it's important not to neglect change dates).

For tablet users, the frequency is the only factor to be adjusted, but once to twice a week still seems to be where most users start. If symptoms of dryness or other hallmarks of atrophy return, it should be obvious that the dose or frequency or both should be stepped up a bit. If twice a week is seeming good, it might be reasonable to step down a bit to twice every week and a half, just to make sure that we're not using more than we need. In other words: we feel our way along, looking for our personal bottom limit and then aiming just above that.

The fine print

Great, so what are the drawbacks? Yeah, it's never a free lunch with menopause, so you knew there would likely be a catch or two.

In this case, vaginal atrophy treatment has to lead into vaginal health maintenance, which means that we will need it more or less the rest of our lives—or, at least, until our hormone needs drop so low as to no longer require supplementation. Maintenance requires a lower dose, generally accomplished by a longer dose interval and/or a change of product after initial healing takes place. If we stop using our vaginal estrogen supplement, our atrophy will return: this is an ongoing need, not a "disease" that we will "cure" with a one-time treatment. Just as we have to eat every day to keep nourishing our bodies, so we have to keep providing the estrogen needed to nourish vaginal health.

Vaginal estrogen supplementation isn't for everyone. Those of us who have hormone-sensitive risks in the pelvic area, such as endometriosis, are generally discouraged from using vaginal hrts because they concentrate potentially higher levels of hormones in pelvic circulation.

Those at high risk for estrogen-stimulated cancers anywhere in their bodies who are being treated by estrogen exposure restriction, either by withholding estrogen supplementation or by drugs that specifically combat estrogen exposure, used to be routinely advised not to use vaginal estrogens. Although these products nominally are fully consumed by local tissues and don't spill over into systemic circulation and hence risk, enough has been shown to escape to raise the fear that this might be just enough to help a tumor cell survive. In fact, the North American Menopause Society, in their 2017 position statement on hrt (that was cosigned worldwide) said:

Because of the potential risk of small increases in circulating estrogens, the decision to use low-dose vaginal ET [estrogen therapy] in women with breast cancer should be made in conjunction with their oncologists. This is particularly important for women on aromatase inhibitors (AIs) with suppressed plasma levels of estradiol, although no increased risk was seen in an observational trial of survivors of breast cancer on tamoxifen or AI therapy with low-dose vaginal ET during 3.5 years’ mean follow-up.

One other concern we've heard voiced is about transferring hormones to our partners. Yes, this can happen if a cream dose is still present at adequate hormone levels. Timing of use can help manage this. The ring for this use releases such a low level of output that it's certified as safe enough to leave in during intercourse (although you may, of course, remove it if either partner prefers). Otherwise yes, some care is needed but so long as the HRT isn't freshly applied and still present in volume, it's believed that the risk is minimal. For 100% protection, however, a condom can be used as a barrier.

But isn't there some natural solution?

That kind of depends on what you mean by "natural." Since it's loss of our natural estrogen that causes vaginal atrophy, we can't really think of anything more natural than simply replacing that supply.

But perhaps what you mean is you prefer something you can purchase over the counter, something made from a blend of herbs, something that doesn't carry the risk of hormones. In that case, we're sorry to have to tell you that this doesn't exist. There is no substance, whether grown in a plant or refined in a lab that can fulfill vaginal estrogen needs other than real human-type estrogen. Yes, there are many sales websites that will try to tell you differently, but in fact these products do not address the specific need for estrogen and so will not treat vaginal atrophy.

Lubricants or vaginal moisturizers may feel soothing, but will not actually promote healing or improve the other physical damages of vaginal atrophy. Some things of this type that users have found useful include commercial moisturizers, commercial lubricants, vitamin E capsules, or small balls of (chilled to harden) coconut oil. These can be good things to try if your other options are limited or you believe that dryness is the only symptom you're experiencing, but they aren't really treatments for vaginal atrophy.

Douching, especially with perfumed products, is not recommended in vaginal atrophy because douche solutions can actually damage tissues further and increase infection risk. Similarly, while douching with live-culture yogurt or other probiotic agents may help restore a good flora balance after health is restored, they will not alone restore that health and will not do so durably.

Must it be treated? Of course not. It's up to us to choose what we consider important. Some have said they feel the loss of sexual responsiveness grants them a return to a purer, more childlike condition. Others don't find the symptoms troubling or find that simple over the counter lubricants and a switch to unscented washing products are adequate to deal with the degree of atrophy that develops.

Each of us gets to decide these things for themself. What we want you to know, however, is that this is a treatable condition, not a life sentence. Menopause does not mean "dead down there" or intractable pain. If you aren't happy with the state of your vaginal health, it needs to start by speaking up. Yes, we know it's hard if you're not used to discussing this part of your body or your sexual needs. You may be embarrassed, or you may worry that your doctor may make you feel wanton or unclean. But this is perfectly normal physiology and your doctor really should be a mature enough individual to handle such a request politely and smoothly. In fact, shame on them for not asking directly whether you need treatment of this kind in the first place. At some point, though, one or the other of you needs to suck it up and just raise the question, and since you're the one who's hurting, yes, we're looking at you.

Not sure what to say? How about something along the lines of "Doctor, I'm concerned about developing vaginal atrophy. Lately I've been experiencing dryness and loss of sensation, and I'd like to consider using some supplemental vaginal estrogen to help keep things healthy. Would you write me a prescription for this?"

More questions?

We have a number of bookmarked articles on this topic in our general bookmarks account, and you may find it helpful to do more reading on this.

Beyond this, we're always happy to discuss specifics on our forums, so feel free to join us there.

*Update: A new name for this has been proposed for this condition, GSM or "Genitourinary Syndrome of Menopause." This doesn't represent a change in thinking about treatment, but it is hoped that it will make it easier to discuss. You can read more about this proposed change in terminology in a separate entry.