I’ve already talked to my doctor extensively, and done a lot of internet research, as well. So this isn’t really a factual/medical question, it’s a values/preferences question.
Basically, the question is: I’m taking estrogen for menopausal symptoms. Should I take enough to feel “good”, or should I take the least dose I can to not feel “bad”? The “not feel bad” dose would be considered a relatively low dose. I’m not certain how much I would have to take to feel good. But probably it would be a moderate dose.
Taking more is probably a little riskier. Honestly, the risks are all small enough that the studies all show different results. But there are always risks to messing with stuff.
If you want background in medical treatment of menopausal symptoms with hormones, here’s an excellent summary of the latest medical thinking, with references:
All the big studies were done when the drug companies hoped they would find that everyone should use the stuff. Instead, the studies were halted as various risks emerged. They were done with doses that would now be considered “moderate”, and they were done with slightly different drugs than what are usually used today. Small studies suggest the modern drugs are probably a little safer. Long-term follow ups of the women in randomized and observational studies generally find either no statistical difference in all-cause mortality, or (observational studies only) a small benefit.
These references are reassuring, for instance:
Here are the details… you probably don’t need to read it to respond, as this is, after all, not really a medical question.
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So, I recently reached menopause. I had perimenopausal symptoms for several years, including hot flashes and some irregularity, but my periods were fairly regular until about a year and a half, maybe 2 years ago. And ended just a year ago.
Two months ago, I got fed up with the persistence of hot flashes and was generally feeling old, and I asked my doctor about trying estrogen. So he put me on oral estradiol (0.5mg) with progesterone.
So I took my first pill, and two hours later I realized that I’d been suffering from PMS (or hormone-related depression, anyway) for the past year. The feeling of being overwhelmed and not being able to cope, and not wanting to start anything lifted, as did a lot of my moodiness and lack of mental resiliency when confronted by disappointment or change.
And that’s when I started researching hormone therapy for menopausal women in earnest. The first thing I noticed was that a lot of the risks are more associated with progesterone than with estrogen, and I was still wearing a progesterone-based IUD (Mirena, which releases levonorgestrel). I asked my doctor if I needed additional systemic progesterone, and after some research, he said I didn’t, and so the next week I shifted from the first set of pills to estradiol tablets.
I noticed all sorts of positive effects from taking estrogen, including that I slept through the night without waking to pee every night for a month – having not done that for the prior two years.
I still had some minor hot flashes, but over the course of the month, my mood declined. I didn’t feel overwhelmed or unresilient, but I started to feel sad. And it got worse and worse. And I was still having hot flashes.
So, both because of the sadness, and also because my research indicated that transdermal estrogen is likely safer than oral estrogen, I asked to try a patch. I got a set of 0.025mg estridiol patches. The key thing to realize in thinking about patch vs. pill is that when you eat estrogen, it passes through the liver before entering the general bloodstream, and most of the estradiol is converted to the much-less-biologically-active estrone. The literature tends to treat all estrogens as interchangeable (except for effectiveness) but I’m pretty sure the high estrone/estradiol ratio was making me feel down. (I guess I have no evidence for that, except timing of my symptoms.)
Now, different women absorb drugs differently through their skin, and different women break down drugs differently in their livers. So while the population stat says that 0.025mg transdermal estridiol = 0.5mg oral estridiol, they can be different for any particular woman. Based on my symptoms, the pill was clearly a higher dose than the patch.
Anyway, I’ve increased my dose to 0.0375mg, and I’ve achieved “not bad”. My energy is okay, my resiliency is normal (not PMS-y), I’m only a little sad, I’m waking up once to pee, around 5am, I’m getting a few hot flashes, but they aren’t awful, oh, and my skin is much better – all sorts of little cuts that had been accumulating have healed. (I have an affectionate cat who is elderly and has some arthritis in her paws. I get a lot of little cuts.)
My guess is that I could get to “good” at 0.05mg (although I haven’t tried it.) I’m a little worried the stuff may be addictive, in that if I decide to reduce the dose I may get withdrawal symptoms.
I am more than likely done with menopause and don’t really need them anymore, but I feel so much better when I’m taking them. I am in a low-risk group so I feel there’s no hurry to quit. I did notice a difference when I went from 1.0 to 0.5 mg. My doc told me that there aren’t really withdrawal symptoms and I could just stop anytime. But I know I’ll feel crummy if I stop taking them.