How do I know when I should increase my HRT (estrogen) or if I have enough? I have an estrogen patch now, but wondering if more is better.
—Peri-gal@MallofAmerica
In my first two years of medical school, one of the required courses was called The Art and Science of Medicine. The goal of the course was to teach medical interviewing and physical exam skills, but the overarching theme of it is one that is relevant to this question: there are many areas of medicine that are evidence-based, but there are some that are still very much art learned through practice and experience.
In many ways, prescribing hormone replacement therapy falls squarely into the art side of medicine. Sure, there is data that shows that estrogen is the most effective treatment for symptoms like hot flushes, night sweats, and sleep disruption.
The dosing recommendations that came from the fallout of the Women’s Health Initiative call for the smallest dose that effectively manages a woman’s symptoms. Even if we all agree that that is the right amount of estrogen, it will be different from one woman to the next. There is no evidence to support checking estrogen levels and titrating the dose of estrogen based on those levels. There is also no evidence to suggest that more estrogen is better.
My typical approach is to begin with an estrogen patch or gel in a midrange dose. I ask the patient to follow up in three months and we discuss if her symptoms are improved and what, if any, side effects she is experiencing. If she is feeling good, we are both happy and we leave the dose alone. If her symptoms could be better, we will adjust the dose or maybe change to a different formulation of estrogen, like a ring or pill.
The upshot: Dosing estrogen is more art than science. The right dose is the one that best manages your symptoms with a minimum of side effects.
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