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[Shannonplussed]

I've seen smatterings of this over many posts, but here in one spot, can you share how you know you've got to the right dosage for you? This is tricky business, since excess and deficiency symptoms are often the same, and we are dealing with both estrogen and progesterone (sometimes testosterone, too!

Absence of hot flashes is an obvious one, but that's not a symptom I've personally struggled with. One person noted that when her estrogen needed to be raised, she felt tired. My foot pain seems to be the last thing to have resolved. Anxiety often is mentioned in the forum. So who found their sweet spot and left it, and who (like me!) continues to chase a (possibly unattainable) improvement? Tinkering isn't great, is it, since one adjustment affects the other/ratio, and effects can take time to manifest 

[jennyr265]

Great post! I'm still trying to get to my sweet spot I'm afraid.
I used gel and Utro for 7 months last year and had no improvement in symptoms and 2 blood tests showed oestradiol levels to be less than 100pmol. So i was put on Elleste solo 1mg which i took for 3 months, still no improvement in symptoms but levels went up to about 231. So now on 2mg tablets and 1 month in and still feel horrible!
Hot flushes and night sweats have never been a symptom for me even in peri. My main issues are low energy levels, joint and body pain, acid reflux and digestive problems,  dehydration in spite of drinking loads of water and dry eyes, lips etc.
I'm 54 and 5 years post menopausal.
The progesterone doesn't seem to affect me. I use it for 3 weeks out of 4. Take it orally. Have never had a bleed.
If the tablets don't work i will probably give up. I'm totally fed up with it all!!

[Sgtvhilts]

HI,
Yep , i am probably one of the worst 'tinkerers'. 
Truth be told, i don;t think anyone knows what dose is the 'right' dose until you find nirvana by tinkering.
I guess i was in the 'what am i prepared to tolerate' zone.  Still am i guess. Although i am now in a good place, i still have some symptoms, but the worst have gone.  It was only when i upped the dose that things improved.
Why did i do what i did?- I felt awful and just wanted it all to go away, so i suppose i got to the point where i thought 'that's it, what have i got to lose'.
I am glad i have done what it have done.  I think i have found the right dose for me, but it was me that drove the agenda.  Meno clinic were appaling- just reading off the NICE.  My GP was much better and really listened to my ideas and what was working for me.
I didn't read any research or articles or certainly 'experts' i just followed my nose.

[Ladybt28]

jennyr265 - sounds to me like you need to increase your oestrogen for sure. (Birdy's right). Some consultants go by tests but by and large most go by "controlling symptoms". However, your tests support the fact your oestrogen is low. All you describe are symptoms of low oestrogen and it sounds like you are not absorbing it properly.  Unfortunately, the bad news is that for some of us it takes 4/5/6 go's at finding the right hrt that works for our bodies.
Docs say that "all oestrogen is the same"...well in theory yes but it depends on the dose and the delivery method as to whether it works for the individual.  How many pumps of gel were you on?  The normal prescribing dose is 2 but it took 4 (which is just the higher end of the range) to control my symptoms and they took 5 months to start to come under control and a total of 7 months to go completely. xx  Transdermal seems to have a better reputation for some ladies than tablets which have to go through the liver and the stomach and kind of get diluted by the stomach acid.

There are plenty of things you can try, I had to have 6 types before I got the right thing. xx

[jennyr265]

Thanks Birdy and Ladybt28 for your advice.
I was on 2 pumps for about 4 months and then 3 pumps for another 6 weeks but my levels fell when I increased the pumps so my consultant put me on tablets.
I do feel that they aren't working either although my levels have increased marginally as i just feel exactly the same as before. But the consultant felt that I wasn't absorbing the gel so patches wouldn't work either. So I'm stuck on the tablets until the 3 months is up at beginning of March so 6 months in total. Not sure what else i can do!
My younger self was hyperandrogenic, not that it was called that back in the 80s but i had dreadful acne, very greasy skin, excess hair in all the wrong places and probably had 3 periods a year. So not a standard mix of hormones but that is the problem for us all isn't it? We don't know the original base line!

[Shannonplussed]

"what I am prepared to tolerate zone" is right! I do feel fine, certainly better than the sleepy slug I was last winter, but I can't say I feel great. It's true, wouldn't it be great to know what our baseline was at the time everything was running tickety-boo?

[Ladybt28]

but shannonplussed that's far too sensible and organised and would be far too helpful!

[GypsyRoseLee]

I have mentioned this many times on here before, but when ladies report a failure to absorb transdermally I always wonder if they're using a moisturising shower gel and/or body lotion on their skin before applying the gel/patch?

It's very important to never use a moisturising shower gel/soap and/or body lotion/fake tan on the area of skin where you apply gel or patches. This is because they leave a residue on your skin that creates a barrier, stopping absorption.

I had this confirmed by Besins.

[Hurdity]

Shannonplussed - I think I must be one of the lucky ones! I got to the right dose immediately. I started HRT in very late peri - just the occasional period, and doc started me on the standard post-menopausal medium dose patch - 50 mcg - which worked within days and I have stayed on or around this dose ever since (currently approx 62.5 because I take testosterone too). Flushes only returned when I stopped or decreased the dose (or once when I changed to gel) otherwise I have been completely flush and sweat free - and that has been my yardstick. I have only occasionally had my estradiol levels measured - once when I was late peri when they were very low, once when the doc thought I was having too much oestrogen (because I was using estriol cream as well as a patch - little did she know  ) - which I wasn't, and once recently as part of general levels being measured as I am on testosterone. I think it's easier starting HRT when late peri or post-menopause because your own cycle is pretty much non-existent rather than the wild fluctuations of peri-menopause.

If you don't get flushes then I don't know how on earth you would know as that is the baseline minimum to achieve I would say - and then if you don't feel brilliant when they have gone then try to increase a bit? The other factors/hormones also come into play - anyone taking a progestogen continuously may well have ongoing side effects because of this.

jennyr265 - I agree with Birdy re SHBG and tesosterone. If you are taking oral oestrogen, SHBG can be increased which binds free tesosterone so you could have symptoms of low T on account of this. I am surprised by your consultant thinking that you would absorb patches as well ( or badly) as you would absorb gel? Notwithstanding GypsyRoseLee's important point about what you put on your skin, there is huge variation on how each woman absorbs oestrogen from the different methods, and long experience on here also shows that some women do better on patches than gel or vice-versa. Utrogestan taken orally may well be adding to your reflux and acid problems, and may also affect energy levels since it is a sedative.

Hurdity x

[Foxylady]

I'm also still searching for the 'sweet spot' too! Currently on oestrogel started just over a wk ago as no longer able to source Everol 75mcg. I did read up re products not to use & surprise I can no longer shower with Dermol 500 although so far no skin rashes just a bit dry elbows etc. I'm peri & biggest issues still for me is sleep. Will give gel some more time & then review ?increase by half pump initially. x

[jennyr265]

GypsyRoseLee i was always very careful to apply to clean skin with no cream/shower gel etc applied beforehand. I also always let it dry naturally once i had rubbed it in.
In September my SHBG was 64nmol ( range 32.4 - 128),
Testosterone was 1.77 (range 0.101- 1.42]
Free androgen index - 2.77 ( range 0.2- 7.1)
Prolactin - 86 (range -102-496)
I was told that none of these are abnormal. This was before I started on the tablets.
Hurdity yes i would have liked to try the patches and if I don't feel any better by March then i will ask to try them.

[Sammiejane]

sharonplussed

do u take progesterone at all ?

which estrogen patch and testosterone are you on ?

did you start testosterone later on then estrogen ?

[Shannonplussed]

For progesterone, I take Prometrium (which is identical to Utro), 100mg continuous. I tried 200mg cyclical and prefer continuous. I also did 400mg for 10 (I think) days after my scan showed possible endometrial hyperplasia (I'm STILL waiting to see an OBGYN about that). I don't get a period but still occasional bleeds/spotting while things settle (and my tinkering, of course). I use estrogel, currently 2 pumps a day but have tried 3 pumps recently when my foot pain returned and I was needing evening naps. In the summer when I tried 3 pumps, I found I was getting frustrated and tearful at work which I attributed it to the extra estrogen. No testosterone, since my GP doesn't agree with it, but I'm waiting to ask the OBGYN for it because my libido needs help.

@Hurdity As for "if you don't get flushes then I don't know how on earth you would know"--I had loads of other symptoms to judge by, that slowly went away. One day, I realized my coccyx didn't hurt when I got up from a chair in the break room. Vaginal dryness was slower to resolve, but did. Energy and stamina improved (very noticeably, but it took 4-6 weeks). My foot pain was the last to go, and has been the first to come back, maybe a dip. I had acne on my chest that took months to go away, but finally did. I do feel good, but someone mentioned a buzzy feeling with the right estrogen level, and being interested in sex again. Good is good, but that sounds GREAT.

[Sooze]

Shannonplussed,
I can only explain by putting it like this, I know the dosage is right for me because I feel most like my younger self. 

I made a spreadsheet of my undesirable meno symptoms before I went on HRT for the second time, and rated them on a scale of 1-10 how much they bothered me every couple of months, which were as follows:
Low libido, lack of sexual response, vaginal comfort, general energy, evening energy, sleep, mental stability, joint comfort, general flexibility, stamina for exercise and flushes. The lower the score the worse the symptoms, so in Aug 2016, before starting HRT I was rating 0 on the sexual ones and under 4 for everything except sleep.  Updating the spreadsheet as my treatment has changed since then has been helpful in focusing on what has improved in comparison to previous treatment, so that I know if the change has been for the better.  At the moment I would rate myself between 8-10 for all categories, and this has been the case for around 10 months.

I also used the spreadsheet to take to my gynaecologist and GP to help me in explaining how over time what symptoms were originally improved, but were then not improved as much.  This helped with getting treatment changed, rather than plodding on with something that wasn't working for me.  With changes I gave myself 6m of settling and checked my symptoms monthly.  If I'd had really undesirable side effects or worsening of symptoms I would have gone back to my GP.

I would say that if you're peri it's more difficult to get the balance right, due to the influence of your own hormones, and what might work in peri may need changing when you're post.  I'm a bit like Hurdity, I started my first HRT late peri and when I stopped it around 18m later due to undesirable side effects I never had another period.  I then suffered badly for a couple of years because I thought all HRT would give me the same side effects as the first I'd tried, before seeing my GP with my catalogue of symptoms and in a very desperate state.  Referral to a very good gynaecologist and things have improved massively in the past 4yrs.
HTH,
S

[Shannonplussed]

That spreadsheet is an excellent idea! Very comprehensive.