Thank you always for the evidence based information. I signed up for the Wisdom Study because I feel it is my duty to help with more research on women’s health. An unrelated question, is there much research on MHT for peripheral neuropathy symptoms (symptoms that have no other obvious medical cause - labs already done etc.).
A fantastic master class. Thank you. I'm a registered dietitian that specializes in sport nutrition and eating disorders. In younger women, our treatment teams often see pretty low estradiol levels with chronic energy restriction/eating disorders that is much improved/even normalized with nutritional rehabilitation. Peri-menopause and menopause are high-risk times for sustaining and/or developing of disordered eating, as well - especially in a culture that sadly believes smaller is healthier. I'm curious if you see restrictive eating play a significant role in those that seem like poor responders/absorbers?
One of the reasons that women come to me is that they do not want the birth control pill for various reasons (during perimenopause). It is much more difficult to control symptoms with menopausal hormone therapy (which I tell them) but they are still very adamant that this is what they want to try. I have a feeling that rather than cost or appearance of getting something for their money - it is patient preference and selection bias. I would love to be able to use OCP in the right patient - though I also want to take into consideration their choice.
Thank you, as always, for your incredible work. I hope someone somewhere will very carefully track the health of the women who were prescribed excessively high doses, as there seems to be a complete absence of empathy for them on social media.
Thank you for this article. As always amazing to hear an evidence based response to menopause care.
I have a question regarding Progesterone only therapy in the late reproductive and early perimenopause period. It seems a lot of Women are being prescribed Progesterone only (100mg of Micronized Progesterone nightly) either daily or cyclical for mood and sleep symptoms. In theory this regime makes sense given progesterone states declining first. But I have yet to find this practice supported in any of the guidelines, other than 300mg of micronized progesterone nightly for VMS symptoms when pt. Is unable to take estrogen.
Any thoughts on the practice of 100mg micronized progesterone nightly for mood and sleep in the later reproductive and early perimenopause period?
It isn't supported by any practice, and in actual studies, it doesn't perform very well for sleep. It's likely benign, but of course, we don't know for sure.
I am so grateful for your information - I’m a therapist doing training in meno-informed CBT. But I’m also in the throes of peri and most recently, the mood shifts are becoming very difficult to manage (extreme lows) - along with all the other peri symptoms. My period is every 21-23 days for a week.
I am so confused no matter how much I read - I hear so many women who are still having regular periods and start on HRT to regulate mood changes and other symptoms. My dr says not until menopause.
If anyone can help me understand which is correct- I will consider any treatment advice but can’t take the birth control pill unfortunately.
Very helpful detailed article. I also feel so much not known for our POI and early BSO patients. So many don’t feel well on 0.1 patch or 2mg PO estradiol and so hard to know what do we do next? Check level? Switch preparation? Seems many people feel it’s ok to add more than one patch for these patients or increase to 3-4mg. CHC an option but so many patients don’t like it.
This is my problem, my subjective feeling as a patient with early surgical meno is that peroral estradiol works better for some tissues (vagina dryness and control of hot flushes), but transdermal estradiol makes me better level of estradiol in the bloodstream and it works better for osteopenia treatment (my score is getting better on oestrogel, on peroral 2mg estradiol valerate it decreased), transdermal is more natural way to get hormones in comparison with peroral. But could it work together if peroral E2 is increasing SHBG level, so after adding the transdermal, will there be enough free E2 for tissues, not binding on SHBG? I am doctor as well, but I cant help me as a patient, I dont know what is right option for me.
All I can tell you is that it is bad advice to use hormone levels for the medical management of menopause. We don't aim for specific estradiol levels. Transdermal is overall the safest due to the lower risk of clots, but oral is fine too.
I think there is very important the ratio SHBG/E2 for optimal meno treatment, and maybe that is why some women like me have the symptoms despite optimal estradiol level in bloodstream. I made a attempt on myself. First: peroral 2mg estradiolvalerate (good control of symptoms but poor bone protection, the ratio SHBG to E2 was good but free E2 on just 2mg were too little for bone tissue). My second attempt was transition to transdermal estradiol: I aimed optimal values of estradiol in my bloodstream, and after 10-12hours after doses on 9.day of treatment my E2 level was 533pmol/l, but I have had vaginal dryness and brain fog and terrible hot flushes and shrinked breasts. In this time my SHBG level was just 77nmol/l. So good E2 level but the ratio SHBG/E2 was not “optimal”. I can see in healthy premenopausal women SHBG around 140-150nmol/l in early follicular phase and E2 around 200pmol/l. My third attempt was using peroral estradiol with transdermal, my SHBG increased from 77 to 149nmol/l (thankx to peroral estradiol) and my E2 level in bloodstream was 530pmol/l (thanx to transdermal estradiol). In this combination I have not hot flushes, no vaginal dryness, no brain fog and my breasts werent shrinked (on just transdermal estradiol I have shrinked breasts despite E2 level 600!). All I can say that it is “feeling medicine” for me, and I am always looking for the balance, to not be too much exposed to supraphysiological doses of hormones and at the same time to protect my endometrium enough. It is a struggle for someone with “POI”. This doses I didnt find in guidelines of Meno Society. So, you re right, increasing of the doses of transdermal estradiol is not always the answer on symptoms.
Thanks for this class and spelling out what we know and don’t know at this time. As someone with a genetic connective tissue disorder, which was only diagnosed in mid-perimenopause after years of symptoms, I’ve grown very accustomed to the phrase “we don’t know.” There will be no “true” evidence based medicine for me in menopause. I will always be the citizen scientist and need health care providers who can collaborate with humility.
I will add that for me, I need the higher Estrdiol dosing (.1 patch X 2 a week) benefit from a small amount of testosterone and struggle mightily with progesterone.
Dear Dr Jen, thank you so much for this article. I am very missing the answer on special situation. What do with premature menopause - surgical menopause. Young, intelligent and active woman, 10years on estradiol valerate 2mg, good control of symptoms - no hot flushes, no brain fog, no vagina dryness, but poor sleeping and poor bone protection (on DEXA scan osteopenia, almost osteoporosis, despite healthy lifestyle, normal weight and protein intake). For this low bone protection transition to transdermal estradiol - lenzetto 6 sprays a day but no control symptoms like hot flushes, so she is trying oestrogel 4 pumps, E2 level are good 640pmol/l after 11hours after doses. This maybe protects the bone, but she have still hot flushes, brain fog, vagina dryness. So the question. What is the better for this woman- good level E2 with transdermal estradiol but with terrible symptoms (hot flushes = increased CVD risk), she has utrogestan 14days 300mg, or good control hot flushes but low dose peroral estradiol 2mg without bone protection. Is there any guideline for combination peroral estradiol and transdermal? Thank you much if you find the time to respond.
Thank you always for the evidence based information. I signed up for the Wisdom Study because I feel it is my duty to help with more research on women’s health. An unrelated question, is there much research on MHT for peripheral neuropathy symptoms (symptoms that have no other obvious medical cause - labs already done etc.).
A fantastic master class. Thank you. I'm a registered dietitian that specializes in sport nutrition and eating disorders. In younger women, our treatment teams often see pretty low estradiol levels with chronic energy restriction/eating disorders that is much improved/even normalized with nutritional rehabilitation. Peri-menopause and menopause are high-risk times for sustaining and/or developing of disordered eating, as well - especially in a culture that sadly believes smaller is healthier. I'm curious if you see restrictive eating play a significant role in those that seem like poor responders/absorbers?
One of the reasons that women come to me is that they do not want the birth control pill for various reasons (during perimenopause). It is much more difficult to control symptoms with menopausal hormone therapy (which I tell them) but they are still very adamant that this is what they want to try. I have a feeling that rather than cost or appearance of getting something for their money - it is patient preference and selection bias. I would love to be able to use OCP in the right patient - though I also want to take into consideration their choice.
Thank you, as always, for your incredible work. I hope someone somewhere will very carefully track the health of the women who were prescribed excessively high doses, as there seems to be a complete absence of empathy for them on social media.
This is very informative especially the comparison to the birth control pill.
Thoughts about using Prometrium vaginally to minimize side effects?
Thanks for another great article.
I recently came across (an ad for) a book by Dr. Mary Claire Haver. Is she legit., or one of the 'imposter' NAMS cert'd practitioners?
Thank you for this article. As always amazing to hear an evidence based response to menopause care.
I have a question regarding Progesterone only therapy in the late reproductive and early perimenopause period. It seems a lot of Women are being prescribed Progesterone only (100mg of Micronized Progesterone nightly) either daily or cyclical for mood and sleep symptoms. In theory this regime makes sense given progesterone states declining first. But I have yet to find this practice supported in any of the guidelines, other than 300mg of micronized progesterone nightly for VMS symptoms when pt. Is unable to take estrogen.
Any thoughts on the practice of 100mg micronized progesterone nightly for mood and sleep in the later reproductive and early perimenopause period?
It isn't supported by any practice, and in actual studies, it doesn't perform very well for sleep. It's likely benign, but of course, we don't know for sure.
I am so grateful for your information - I’m a therapist doing training in meno-informed CBT. But I’m also in the throes of peri and most recently, the mood shifts are becoming very difficult to manage (extreme lows) - along with all the other peri symptoms. My period is every 21-23 days for a week.
I am so confused no matter how much I read - I hear so many women who are still having regular periods and start on HRT to regulate mood changes and other symptoms. My dr says not until menopause.
If anyone can help me understand which is correct- I will consider any treatment advice but can’t take the birth control pill unfortunately.
Very helpful detailed article. I also feel so much not known for our POI and early BSO patients. So many don’t feel well on 0.1 patch or 2mg PO estradiol and so hard to know what do we do next? Check level? Switch preparation? Seems many people feel it’s ok to add more than one patch for these patients or increase to 3-4mg. CHC an option but so many patients don’t like it.
This is my problem, my subjective feeling as a patient with early surgical meno is that peroral estradiol works better for some tissues (vagina dryness and control of hot flushes), but transdermal estradiol makes me better level of estradiol in the bloodstream and it works better for osteopenia treatment (my score is getting better on oestrogel, on peroral 2mg estradiol valerate it decreased), transdermal is more natural way to get hormones in comparison with peroral. But could it work together if peroral E2 is increasing SHBG level, so after adding the transdermal, will there be enough free E2 for tissues, not binding on SHBG? I am doctor as well, but I cant help me as a patient, I dont know what is right option for me.
All I can tell you is that it is bad advice to use hormone levels for the medical management of menopause. We don't aim for specific estradiol levels. Transdermal is overall the safest due to the lower risk of clots, but oral is fine too.
I think there is very important the ratio SHBG/E2 for optimal meno treatment, and maybe that is why some women like me have the symptoms despite optimal estradiol level in bloodstream. I made a attempt on myself. First: peroral 2mg estradiolvalerate (good control of symptoms but poor bone protection, the ratio SHBG to E2 was good but free E2 on just 2mg were too little for bone tissue). My second attempt was transition to transdermal estradiol: I aimed optimal values of estradiol in my bloodstream, and after 10-12hours after doses on 9.day of treatment my E2 level was 533pmol/l, but I have had vaginal dryness and brain fog and terrible hot flushes and shrinked breasts. In this time my SHBG level was just 77nmol/l. So good E2 level but the ratio SHBG/E2 was not “optimal”. I can see in healthy premenopausal women SHBG around 140-150nmol/l in early follicular phase and E2 around 200pmol/l. My third attempt was using peroral estradiol with transdermal, my SHBG increased from 77 to 149nmol/l (thankx to peroral estradiol) and my E2 level in bloodstream was 530pmol/l (thanx to transdermal estradiol). In this combination I have not hot flushes, no vaginal dryness, no brain fog and my breasts werent shrinked (on just transdermal estradiol I have shrinked breasts despite E2 level 600!). All I can say that it is “feeling medicine” for me, and I am always looking for the balance, to not be too much exposed to supraphysiological doses of hormones and at the same time to protect my endometrium enough. It is a struggle for someone with “POI”. This doses I didnt find in guidelines of Meno Society. So, you re right, increasing of the doses of transdermal estradiol is not always the answer on symptoms.
Thanks for this class and spelling out what we know and don’t know at this time. As someone with a genetic connective tissue disorder, which was only diagnosed in mid-perimenopause after years of symptoms, I’ve grown very accustomed to the phrase “we don’t know.” There will be no “true” evidence based medicine for me in menopause. I will always be the citizen scientist and need health care providers who can collaborate with humility.
I will add that for me, I need the higher Estrdiol dosing (.1 patch X 2 a week) benefit from a small amount of testosterone and struggle mightily with progesterone.
Thank you for this information. You mentioned thyroid, diabetes and low iron levels which I think most women do not consider.
Can’t thank you enough!
Very helpful, and informative as always. What about using FSH levels > estradiol serum levels to assess the bodies reception of estradiol therapy?
Dear Dr Jen, thank you so much for this article. I am very missing the answer on special situation. What do with premature menopause - surgical menopause. Young, intelligent and active woman, 10years on estradiol valerate 2mg, good control of symptoms - no hot flushes, no brain fog, no vagina dryness, but poor sleeping and poor bone protection (on DEXA scan osteopenia, almost osteoporosis, despite healthy lifestyle, normal weight and protein intake). For this low bone protection transition to transdermal estradiol - lenzetto 6 sprays a day but no control symptoms like hot flushes, so she is trying oestrogel 4 pumps, E2 level are good 640pmol/l after 11hours after doses. This maybe protects the bone, but she have still hot flushes, brain fog, vagina dryness. So the question. What is the better for this woman- good level E2 with transdermal estradiol but with terrible symptoms (hot flushes = increased CVD risk), she has utrogestan 14days 300mg, or good control hot flushes but low dose peroral estradiol 2mg without bone protection. Is there any guideline for combination peroral estradiol and transdermal? Thank you much if you find the time to respond.