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[flaxhigh]

Hi,

Does anyone know what the optimal oestradiol level should be in post-menopause on HRT? Or is it a case of just taking enough to rid oneself of menopause symptoms?

I'm being encouraged to up my dose of evoral 50 patch twice a week to two patches twice a week but every time I increase I get palpitations. I seem to have found the level that helps my hot flushes/mood etc but my level recently checked was only 141. Is that high enough?

I'm mainly taking HRT to counter my osteoporosis so am afraid this isn't high enough. But what to do if I can't increase the patch dose? Can't manage any other type of HRT - I've tried!

Any advice would be greatly appreciated!

[joziel]

If you're taking it for osteoporosis, no that isn't high enough. You really want to get it up to 400pmol-ish at least. For prevention they say over 250pmol but for treatment, higher is better because it is dose dependent (ie your bones will do better if you take a higher dose).

If you are currently on a 50 Evorel and are just doubling that up to 100 right away, no wonder you are getting palpitations and side effects - that's a huge leap, by passing 75mcg.

Have you tried cutting a 50 patch in half and using 1.5 patches to begin with?

[Hurdity]

Hi flaxhigh

Firstly one measurement alone of estradiol is not necessarily accurate enough to say that it is consistently that low. 50 mcg patch is licensed for the prevention of osteoporosis but of course women absorb differently and as joziel says that protection is dose dependent ( on oestrogen).

Serum levels as measured will vary depending on several factors but especially in relation to patch change date. eg mine varied by 100 pmol/l between being taken on the morning I was due to change my patch and  half way through - say day 2 after new patch, (I used to change it every 3.5 days now every 3). My levels were around 90 at the lowest and then just under 200 during the middle of the patch life. Since then I have increased very slightly from 50 mcg to 62,5 mcg. I am 70 and I have not lost any height. Never had BMD measured but not worried. I imagine my levels are somewhere around 200 but maybe a bit more? When younger - possible late 50's or early 60's I remember them being 212 - on 50 mcg patch.

In terms of research and absolute estradiol levels, I have several times unsuccessfully tried to find a study which said that minimum levels should be something like 165 or 185 - but this was quite a few years ago and I can't remember what the study was. Have just looked again and have found these studies:

1     https://pubmed.ncbi.nlm.nih.gov/1458336/

Minimal levels of serum estradiol prevent postmenopausal bone loss

We conclude that in postmenopausal women receiving an estrogen replacement therapy (ERT), a significant reduction of bone resorption is achieved when circulating levels of estradiol reach a value (60 pg/ml) corresponding to the one measured, in eugonadal women, during the last days of the early follicular phase of the menstrual cycle. We suggest that oral or percutaneous ERT should induce a minimal value of 60 pg/ml to prevent postmenopausal bone loss

[60 pg/ml = 220 pmol/l]


2    https://journals.sagepub.com/doi/pdf/10.1258/0004563021902107

Hormone replacement therapy (oestradiol-only preparations):
can the laboratory recommend a concentration of plasma
oestradiol to protect against osteoporosis? (2002)

In the discussion the paper quotes Studd's research but using implants:

"Studd and co-workers44 were the first to look at the
relationship between plasma oestradiol and bone
density in women, using 6-monthly implants of
75mg oestradiol and 0¢1mg testosterone. Bone
density was measured at the lumbar vertebrae and
neck of femur by dual-photon absorptiometry before
therapy and after 1year of subcutaneous therapy. The
method of measurement of oestradiol was not
reported. Of the 23 patients studied, 22 showed an
increase in bone density after 1year of therapy. All
patients had a pre-implantation serum oestradiol
concentration greater than 200 pmol/L at 1year and
a correlation between oestradiol level and bone
accretion was observed. There was no correlation
between plasma testosterone level and the increase in
bone density.
In a later study, by the same group, the oestradiol
levels using three different doses of implant, 25,50 and
75mg, were reported.45 This study also found a
significant relation between plasma oestradiol levels
and increases in bone density at the lumbar spine and
proximal femur. They concluded that none of the
women lost bone density at the clinically important
sites of spine and femoral neck if their oestradiol levels
were above 300 pmol/L."

So it seems they are suggesting a higher level than I recall, but also asd you see below, that more research is needed and they say earlier, with different preparations of oestrogen:


"Conclusion

…., the trend to use HRT
preparations which deliver lower doses of oestradiol
means that the clinical need for establishing a bone
density response is greater than ever. Early measurement
of oestradiol levels within the first few months of
treatment has been proposed to fulfil this need.
However, there is a paucity of evidence to support the
setting of target levels at present. Further studies are
clearly required in this area.”

Looking at this and if your levels are consistently 140 ish then an increase would be advisable. Joziel I would love to see the references for those figures if you have them? ie the 400 pmol/l for treating osteoporosis?

I did read some years ago too that the aim of HRT was to average the level the average woman achieved over the menstrual cycle when fertile - and this was approx 300 pmol/l (from memory) - but that was not for bone density, but general relief from symptoms and well-being and I think for women undergoing the menopausal transition (not sure if that level was based on research either!).

What progestogen are you taking?

I agree with joziel that a gradual increase is advisable. If you are very sensitive to sudden increases, I would start with 75 mcg patch, and cut down to approx 62.5 for a few weeks, and then 75 mcg etc.....if your levels are being measured then ask for a measurement after you are stabilised on 75 mcg and get the measurement taken half-way through the patch change cycle.

Also change your patch every 3 days....

Hope this helps

Hurdity x

[flaxhigh]

Hi there - many thanks for both of your replies Hurdity and Joziel - so appreciated!

I did a general women's health check so it was a one off reading the day before I changed my patch (I change Sunday and Thursday) so that does look as if my levels are too low.

I took about a year to get on to one patch I'm so super-sensitive! I had to build up with bits of patch. Studd put me on oestrogel and even on half the dose I felt I was having a heart attack! Hence building up instead on patches.

I have tried to increase very slowly by adding strips of patch but not successfully. The tiniest strip gives me palpitations. I will try again but not sure I can manage it.

I'm on 100mg utrogestan a night (vaginally as suggested by Studd)

I have bad osteoroporosis (already in my early 40s). Now in my late 50s so I do need to try to increase the patch. I shall try again!

[flaxhigh]

Hurdity- I've just re-read your reply. What do you mean by change your patch every 3 days. I change mine Sunday and Thurs as per instructions. That's therefore every 4 and then 3 days. Are you saying every 3 days so I get a higher dose?

And who advised you to do this?

[flaxhigh]

Sorry - keep finding things to add!

Hurdity - that low measurement was the day before I changed my patch - during the 4 day gap  - So I had the test on Weds and hadn't changed my patch since Sunday - next change was Thursday. So I can assume from what you are saying that the reading must have been at my lower end.

I still need to get on to more oestrogen though - sigh!

[Hurdity]

Hurdity- I've just re-read your reply. What do you mean by change your patch every 3 days. I change mine Sunday and Thurs as per instructions. That's therefore every 4 and then 3 days. Are you saying every 3 days so I get a higher dose?

And who advised you to do this?

No-one! It was just common sense to me based on the fact that my reading was at its lowest on patch change day, and double the amount when I was half-way through the patch change time so my oestrogen was obviously declining at the end of the patch life.

I started as you do - twice a week - in the mornings, and then I changed to 3.5 days to try to make it more even - so one change in the morning and then 3.5 days later the second change would be evening. Then I decided just to go for the 3 days - but I haven't had levels measured since then, which is a few years ago now I think - because there is no need to. It means I get through patches marginally quicker, but I've never had a problem getting them prescribed slightly early.

Hurdity x

[flaxhigh]

Well that certainly makes sense!