HRT: Dose

Doses of estrogen

Estrogen should be started with a low dose, since symptoms often respond well to a low dose and there is no need to take more than required. Starting with a higher dose is more likely to cause side effects.

Sequential preparations in tablet form are available in low or medium doses of estrogen with appropriate progestogen. Sequential transdermal HRT is only available in a medium dose of estrogen and appropriate progestogen.

Tablet form continuous combined preparations are available in a range of doses of estrogen; ultra low, low, medium and high, all with appropriate progestogen included.

Continuous combined patches provide a medium dose of estrogen and appropriate progestogen. To provide a low dose of transdermal estrogen as recommended to start with, using a low dose patch gel or spray, a separate progestogen, eg Utrogestan 100mg taken daily at bedtime can be used. For a simpler regimen, half a continuous combined patch can be used. Patches are not licensed to be cut, but we believe that the hormones are evenly distributed across the patch, though we do not know if cutting affects absorption. However, this is a simpler and more convenient option than separating estrogen and progestogen.

Current recommendations advise that the lowest effective dose of estrogen be used, which applies to all therapy areas. For some women, the dose of estrogen may need to be increased to adequately control symptoms, and a gradual increase (no sooner than 3 monthly) is in line with recommendations; the lowest effect dose for one woman will be very different from what is the effective, appropriate dose for another. Any need for a change in dose is assessed by presence or not of menopausal symptoms and side effects. Blood tests to measure hormone levels are rarely needed nor helpful.

While dose adjustment may be needed, it is also important to address any other factors which may be contributing to symptoms such as diet and lifestyle, rather than solely increase the dose of estrogen.

In situations when a higher estrogen dose is needed and progestogen is taken separately, great care must be taken to ensure that the progesterone is adequate for protection of the womb lining. It should be noted that no data is available for the effect on the womb lining of varying doses of transdermal estrogen and Utrogestan.

It should be noted that response to any preparation is unique to each woman, some women responding well to a low dose of one preparation while not responding well to a high dose of another.