Thanks, Dr. Jen. Is there a post on questions to ask your doctor? What I mean is that I have clients who are struggling with symptoms related to perimenopause and their doctors just blindly give them anti-depressants and/or mood stabilizers without taking into account the stage of life they are in. Maybe they do need those things but it seems as though women don't even know the questions to ask so they can be in a more educated place when they see their doctor.
Sometimes the answer is estrogen, but sometimes antidepressants are needed. So I always tell people it's important to be open to both. But I will be writing more about the subject and so hopefully that will offer some guidance.
Gyne doc here: a few comments. I think a fourth option for a new start is .1 mg transdermal to get people feeling good FAST then dial it down after two months. I just want patients to sleep again ;)
Can you comment for your readers why you didn't talk about pellets? People pay cash for these and therefore think they are so much better. It drives me crazy.
Also Mirena is good for 8 yrs now.
Thanks for distilling this info for our patients, I send many to your site each week. Your work is important💛
There are many ways to look at it, and I'm sure if you asked 10 GYNs you'd get ten nuances to starting therapy! A 50 mcg patch does perform really well, and some people can have breast tenderness with higher doses. Lots of discussions to have and different options work for different people.
Mirena is good for eight years for contraception, but it has not been studied for eight years for MHT that I can find. It would take shared decision-making to decide to use it for eight years as part of MHT.
And thank you! Just trying to make it easier for everyone, except the grifters. Trying to make it harder for them!
Please do a chart that includes Estrogel and/or Vivigel. I've been trying to figure out how they compare as far as daily dose of estradiol goes, and it's really hard to figure out. The Estrogel package says that it delivers .75mg of estradiol per pump, but that would be 750mcg! That puts it way above any of the other options as far as dose goes. That can't be right. So what's amiss? How do you compare the gels and the patches or tablets or ring as far as dosing goes?
Thank you for being a guiding light and trusted source of information. It's astounding to think I have gone my entire life figuring out everything related to my cycle on my own. From my period, to learning about fertility (the monthly "discharge" was a healthy sign of ovulation?!), to now. During perimenopause, my lovely PCP told me my symptoms were a normal part of aging, and they were, but... He is anti-HRT, and I appreciate he was looking out for my best interests from his perspective, but it's outdated. I took Lexapro for a short time, and it helped until it caused sleep issues. I'm glad I dug deeper. For me being on HRT is the right decision. It took me awhile to arrive at that decision, though, and information you provided hugely helped. I'm in a "health" and "natural" world in LA, and I have friends going to naturopaths, getting pellets, etc. I'm happy to get my pharmaceutical grade patches and progesterone from Walgreen's! (Though I did get my vaginal estrogen compounded. The generic cream caused pain and irritation. Estrace did, too. The compounded cream is soft and not waxy, it absorbs and doesn't end up in the toilet, so I'm grateful for that!) I just moved from 0.025 patch to 0.050,. Maybe that would take care of the vaginal issues, but I had a 6-month misdiagnosed UTI, and I'm going to keep my urogenital area in tip-top shape to the degree I can. You are amazing and this blog is one of the best investments. I serve a population of GenX and GenX-adjacent individuals, and you are a regular referral. I recently was told my grandmother struggled with aging,. She's built like me, and I wonder if she had similar issues with menopause that were untreated... She self-medicated with alcohol... I can't imagine having to continue suffer with some of what I was feeling. Thanks again!
This is helpful, but it would be great to have an international perspective; there seem to be significant differences betweeen US and European practice, although the science really should be the same.
My wife started MHT in the US with oral estrogen and 2 week monthly progesterone within 18 months of her last period and when her symptoms were no longer bearable (hot flushes, dyspareunia, bone loss, depression). MHT was like magic for her and for her QOL. She stated that she would give up her MHT "when they pried it from her cold dead hands."
We moved to Italy (my home country) when she'd been on MHT for 7 years and the Italian OB-GYN switched her to transdermal gel estradiol (claims that evidence suggests much lower risk for strokes) and IUD for the progestin (claims the lower systemic progesterone reduces breast cancer risk, even lower than baseline). She (Italian OB-GYN) claims this is the right change for somebody who wants to stay on MHT "indefinitely". She also claims that in a few years (when IUD is exhausted) my wife should switch to Tibolone (a drug that is not approved in the US) because inserting a new IUD will be very painful for a woman in her 60s and Tibolone provides estrogenic, progestogenic, as well as mild androgenic activity (which is apparently desirable for maintaining libido and QOL and supported by the European menopause society).
This appears so different from the practice of the US OB-GYN that it's at least confusing as to whether it is the right path. Also we wonder about why a drug is approved in Europe (which has pretty strict safety-effectiveness evidentiary requirements) but not in the US and that worries us a little.
The Italian doctor is correct that transdermal is the safest therapy, especially for the long term. No data supports the IUD is a lower risk for breast cancer vs oral progesterone, so if your wife is happy with oral progesterone, I would see no need to switch. There is data linking the IUD with a low risk of breast cancer, just as there is for progesterone.
Tibolone isn't available in the US, so I have no experience with it. It's not a safety thing per se. However, the FDA has different clinical trial requirements, and many companies with existing drugs don't want to do the studies to enter the US market. Personally, I think the FDA is stricter regarding approvals. This is why we have so many fewer IUDs in the US versus other countries; the companies don't want to pay for the studies the FDA will require or bother with the expense of filing. Lots of people have asked about Tibolone, so I will read up and let you know what I find in a post.
Oral progesterone had some negative impacts on her mood, so she much prefers the IUD. In fact, she would probably prefer to stay on the current regimen were she not concerned about pain (insertion was quite painful, enough that she would want to avoid it particularly if it becomes worse with age).
Yes! Half patch has significantly reduced my flashes (I was having about 7 per night and I am down to about 2). And I feel like I can remember things better than before I started estrogen. The whole dose patch + daily progesterone was too much for me as monthly periods returned. To which my GYN even questioned if I was menopausal so she ordered an FSH level that confirmed it. I am sensitive to meds so I don’t need much. I too definitely need further clarification on progesterone “2 times per year”. Not sure what that exactly means?
For people taking Menostar (which is 0.014 mcg patch), two weeks of progesterone twice a. year was considered enough. I will review that data more in the post on managing progesterone intolerance.
Oh this is music to my bloated/constipated midsection! Two weeks of progesterone twice per year?? GAH!! Thank you SO MUCH for your guidance. I look forward to learning more from that post, specifically about the timing of those two weeks/year. Thank you, Dr. Jen!
I am on a 0.025 patch but cutting it down to about 0.018 (just a little over half) because a full dose brings on a monthly cycle. I take oral progesterone every other day or every third day and then have to take miralax weekly to deal with the constipation. I am going to talk to my GYN about switching to a progesterone only IUD vs a systemic oral pill.
Can’t you get away with progesterone twice yearly then? Yes constipation is awful. Does same to me. Magnesium Oxide helps without cramps etc. but it has to be oxide.
Hi Dr Jen - I’m currently taking 2 pumps of estrogel with 100g of progesterone daily.
I don’t see gel on your chart. Would 2 pumps be considered a medium dose? I had recently gone to one pump but it started a period so it was recommended that I take two pumps again.
Progesterone alone isn't really MHT. There is one (maybe two) studies looking at 300 mg a day for hot flashes. But then again, we don't know the long-term safety with that dose. It's not the gold standard for any symptoms.
Prior JC, Cameron A, Fung M, et. al. Oral micronized progesterone for perimenopausal night sweats and hot flushes a Phase III Canada‑wide randomized placebo‑controlled 4-month trial Scientific Reports 2023; 13:9082. https://www.nature.com/articles/s41598-023-35826-w
I addressed the data on progesterone for hot flashes in the previous post. https://vajenda.substack.com/p/progestogens-and-progestins-and-progesterone The gold standard is estrogen. I would never offer it as first-line therapy for hot flashes, and it is not in any guideline as first-line therapy for hat flashes. It would be an option we would consider for someone who just couldn't take estrogen.
This is very thorough and informative. I am one of the "progesterone intolerant" women in your audience and I am anxiously awaiting your "tips and tricks." Help!
Duavee was awful. Apparently sinus congestion is a side effect, which I did not know. I spent almost a month feeling like I had literal cement in my nose. I finally googled and realised it was the Duavee….I stopped and restarted it three times just to be sure. I am using Evamist now. It is pretty low dose but gives you the option to use 1,2,3 sprays. The study they did, the woman only used medroxyprogesterone acetate for 12 days at the end of 3 months, so quarterly progesterone. This is what I am going to do and then just have a uterine ultrasound to make sure that my lining remains unchanged.
I have tried just about everything but divigel and I am done. I was bloated and retained enough water while cycling that I am not about that life in menopause lol. I’m officially over it all. I hope you find some relief.
Family doc here: do you typically prescribe the once weekly or twice weekly estradiol patches? And when you prescribe the "twice weekly" patches what do you actually advise patients in terms of when to change it? Every 3 days? Every 4 days? Something else? 🤔
Hi! Love your site. Sorry if I missed this, but for those of us in perimenopause, nervous about taking hormones and not experiencing major symptoms but hoping for better sleep/mood and protection against dementia , what's the lowest combination that could yield some of these benefits? Thanks!
We don't currently recommend estrogen for the prevention of dementia. If poor sleep is due to hot flashes/night sweats, it is very reasonable to start at a 25 mcg patch dose (or equivalent) with progesterone 100 mg at night or 200 mg 12 days a. month and then see how that helps. Mood is different, and for people struggling with depression, the dose is higher. I will be addressing that in an upcoming post.
Such a helpful and perfectly timed article for me! I’m 47 and had a hysterectomy (kept ovaries) years ago. I’ve been having horrible night sweats and brain fog for some months now. My doctor just started me on .0375 estradiol patch and I’m very hopeful for some positive effects. Thanks for fighting the good fight!
Thank you for sharing your knowledge and guidance, you are such a beacon of light in a confusing time of life. I take MHT for hot flashes/brain fog. My question is…is it okay to take progesterone 100mg every other day (due to side effects, constipation and bloating mostly) while on a very low dose of estradiol? (cutting the 0.025 patch in half). Am I getting enough progesterone to protect my uterus from the estrogen?
Do you find 1/2 of a patch helps for flashes/fog and energy or mood? I’ve thought about trying this myself because I am progesterone intolerant. I thought an article Dr. Jen wrote stated if you took ultra low dose estrogen patch that you only need a progesterone twice a year. But we would def need to confirm.
Incredibly informative. Thank you Dr. Jen! A quick question about sprays. I’m American but live in Mexico where gels and patches are hard to get. So for now I’m on a spray called Lenzetto, which is the same as Evamist I believe. 1 spray is 1.53 mg, and it’s recommended that users don’t go above 3 sprays per day. How does this conversion play out in regards to the dosing of patches and gels, which are much more commonly discussed. Is there an equivalent gel or patch dosage for 1 Lenzetto spray? Thanks so much!
Another informative and much needed post! Thank you Dr. Jen. I so appreciate and value this information!
Thanks, Dr. Jen. Is there a post on questions to ask your doctor? What I mean is that I have clients who are struggling with symptoms related to perimenopause and their doctors just blindly give them anti-depressants and/or mood stabilizers without taking into account the stage of life they are in. Maybe they do need those things but it seems as though women don't even know the questions to ask so they can be in a more educated place when they see their doctor.
Sometimes the answer is estrogen, but sometimes antidepressants are needed. So I always tell people it's important to be open to both. But I will be writing more about the subject and so hopefully that will offer some guidance.
Thanks!
Gyne doc here: a few comments. I think a fourth option for a new start is .1 mg transdermal to get people feeling good FAST then dial it down after two months. I just want patients to sleep again ;)
Can you comment for your readers why you didn't talk about pellets? People pay cash for these and therefore think they are so much better. It drives me crazy.
Also Mirena is good for 8 yrs now.
Thanks for distilling this info for our patients, I send many to your site each week. Your work is important💛
There are many ways to look at it, and I'm sure if you asked 10 GYNs you'd get ten nuances to starting therapy! A 50 mcg patch does perform really well, and some people can have breast tenderness with higher doses. Lots of discussions to have and different options work for different people.
I've written about pellets before. You can find that post here: https://vajenda.substack.com/p/what-you-need-to-know-about-pellet
Mirena is good for eight years for contraception, but it has not been studied for eight years for MHT that I can find. It would take shared decision-making to decide to use it for eight years as part of MHT.
And thank you! Just trying to make it easier for everyone, except the grifters. Trying to make it harder for them!
Please do a chart that includes Estrogel and/or Vivigel. I've been trying to figure out how they compare as far as daily dose of estradiol goes, and it's really hard to figure out. The Estrogel package says that it delivers .75mg of estradiol per pump, but that would be 750mcg! That puts it way above any of the other options as far as dose goes. That can't be right. So what's amiss? How do you compare the gels and the patches or tablets or ring as far as dosing goes?
Thank you for being a guiding light and trusted source of information. It's astounding to think I have gone my entire life figuring out everything related to my cycle on my own. From my period, to learning about fertility (the monthly "discharge" was a healthy sign of ovulation?!), to now. During perimenopause, my lovely PCP told me my symptoms were a normal part of aging, and they were, but... He is anti-HRT, and I appreciate he was looking out for my best interests from his perspective, but it's outdated. I took Lexapro for a short time, and it helped until it caused sleep issues. I'm glad I dug deeper. For me being on HRT is the right decision. It took me awhile to arrive at that decision, though, and information you provided hugely helped. I'm in a "health" and "natural" world in LA, and I have friends going to naturopaths, getting pellets, etc. I'm happy to get my pharmaceutical grade patches and progesterone from Walgreen's! (Though I did get my vaginal estrogen compounded. The generic cream caused pain and irritation. Estrace did, too. The compounded cream is soft and not waxy, it absorbs and doesn't end up in the toilet, so I'm grateful for that!) I just moved from 0.025 patch to 0.050,. Maybe that would take care of the vaginal issues, but I had a 6-month misdiagnosed UTI, and I'm going to keep my urogenital area in tip-top shape to the degree I can. You are amazing and this blog is one of the best investments. I serve a population of GenX and GenX-adjacent individuals, and you are a regular referral. I recently was told my grandmother struggled with aging,. She's built like me, and I wonder if she had similar issues with menopause that were untreated... She self-medicated with alcohol... I can't imagine having to continue suffer with some of what I was feeling. Thanks again!
This is helpful, but it would be great to have an international perspective; there seem to be significant differences betweeen US and European practice, although the science really should be the same.
My wife started MHT in the US with oral estrogen and 2 week monthly progesterone within 18 months of her last period and when her symptoms were no longer bearable (hot flushes, dyspareunia, bone loss, depression). MHT was like magic for her and for her QOL. She stated that she would give up her MHT "when they pried it from her cold dead hands."
We moved to Italy (my home country) when she'd been on MHT for 7 years and the Italian OB-GYN switched her to transdermal gel estradiol (claims that evidence suggests much lower risk for strokes) and IUD for the progestin (claims the lower systemic progesterone reduces breast cancer risk, even lower than baseline). She (Italian OB-GYN) claims this is the right change for somebody who wants to stay on MHT "indefinitely". She also claims that in a few years (when IUD is exhausted) my wife should switch to Tibolone (a drug that is not approved in the US) because inserting a new IUD will be very painful for a woman in her 60s and Tibolone provides estrogenic, progestogenic, as well as mild androgenic activity (which is apparently desirable for maintaining libido and QOL and supported by the European menopause society).
This appears so different from the practice of the US OB-GYN that it's at least confusing as to whether it is the right path. Also we wonder about why a drug is approved in Europe (which has pretty strict safety-effectiveness evidentiary requirements) but not in the US and that worries us a little.
The Italian doctor is correct that transdermal is the safest therapy, especially for the long term. No data supports the IUD is a lower risk for breast cancer vs oral progesterone, so if your wife is happy with oral progesterone, I would see no need to switch. There is data linking the IUD with a low risk of breast cancer, just as there is for progesterone.
Tibolone isn't available in the US, so I have no experience with it. It's not a safety thing per se. However, the FDA has different clinical trial requirements, and many companies with existing drugs don't want to do the studies to enter the US market. Personally, I think the FDA is stricter regarding approvals. This is why we have so many fewer IUDs in the US versus other countries; the companies don't want to pay for the studies the FDA will require or bother with the expense of filing. Lots of people have asked about Tibolone, so I will read up and let you know what I find in a post.
Thank you - that is very helpful.
Oral progesterone had some negative impacts on her mood, so she much prefers the IUD. In fact, she would probably prefer to stay on the current regimen were she not concerned about pain (insertion was quite painful, enough that she would want to avoid it particularly if it becomes worse with age).
Yes! Half patch has significantly reduced my flashes (I was having about 7 per night and I am down to about 2). And I feel like I can remember things better than before I started estrogen. The whole dose patch + daily progesterone was too much for me as monthly periods returned. To which my GYN even questioned if I was menopausal so she ordered an FSH level that confirmed it. I am sensitive to meds so I don’t need much. I too definitely need further clarification on progesterone “2 times per year”. Not sure what that exactly means?
For people taking Menostar (which is 0.014 mcg patch), two weeks of progesterone twice a. year was considered enough. I will review that data more in the post on managing progesterone intolerance.
Oh this is music to my bloated/constipated midsection! Two weeks of progesterone twice per year?? GAH!! Thank you SO MUCH for your guidance. I look forward to learning more from that post, specifically about the timing of those two weeks/year. Thank you, Dr. Jen!
What strength patch are you halving? I’m super sensitive also and Progesterone is awful for me. Even the estradiol is making me retain lots of water.
I am on a 0.025 patch but cutting it down to about 0.018 (just a little over half) because a full dose brings on a monthly cycle. I take oral progesterone every other day or every third day and then have to take miralax weekly to deal with the constipation. I am going to talk to my GYN about switching to a progesterone only IUD vs a systemic oral pill.
Can’t you get away with progesterone twice yearly then? Yes constipation is awful. Does same to me. Magnesium Oxide helps without cramps etc. but it has to be oxide.
Hi Dr Jen - I’m currently taking 2 pumps of estrogel with 100g of progesterone daily.
I don’t see gel on your chart. Would 2 pumps be considered a medium dose? I had recently gone to one pump but it started a period so it was recommended that I take two pumps again.
yes, would love to know gel equivalents!
Great article! Would love to see info on testosterone in future posts :)
Hi,
Obgyn here as well. The Vajenda is SO good I read it religiously.
Some people advocate to start progesterone alone in the perimenopausal phase when women still have regular period and/or heavy flow/breast tenderness
What do you think of that?
Thanks!
Progesterone alone isn't really MHT. There is one (maybe two) studies looking at 300 mg a day for hot flashes. But then again, we don't know the long-term safety with that dose. It's not the gold standard for any symptoms.
study on prometrium for perimenopause
Prior JC, Cameron A, Fung M, et. al. Oral micronized progesterone for perimenopausal night sweats and hot flushes a Phase III Canada‑wide randomized placebo‑controlled 4-month trial Scientific Reports 2023; 13:9082. https://www.nature.com/articles/s41598-023-35826-w
I addressed the data on progesterone for hot flashes in the previous post. https://vajenda.substack.com/p/progestogens-and-progestins-and-progesterone The gold standard is estrogen. I would never offer it as first-line therapy for hot flashes, and it is not in any guideline as first-line therapy for hat flashes. It would be an option we would consider for someone who just couldn't take estrogen.
awesome, thank you i missed this one during a lapse in my subscription!
This is very thorough and informative. I am one of the "progesterone intolerant" women in your audience and I am anxiously awaiting your "tips and tricks." Help!
Same, it is awful for me. I started Duavee but once I see her other article on tips/tricks I may be willing to switch.
How did you feel on the Duavee? I'm 2 years P-Meno and weighing the options.
Duavee was awful. Apparently sinus congestion is a side effect, which I did not know. I spent almost a month feeling like I had literal cement in my nose. I finally googled and realised it was the Duavee….I stopped and restarted it three times just to be sure. I am using Evamist now. It is pretty low dose but gives you the option to use 1,2,3 sprays. The study they did, the woman only used medroxyprogesterone acetate for 12 days at the end of 3 months, so quarterly progesterone. This is what I am going to do and then just have a uterine ultrasound to make sure that my lining remains unchanged.
Thanks for your response. I have decided against it.
I have tried just about everything but divigel and I am done. I was bloated and retained enough water while cycling that I am not about that life in menopause lol. I’m officially over it all. I hope you find some relief.
Family doc here: do you typically prescribe the once weekly or twice weekly estradiol patches? And when you prescribe the "twice weekly" patches what do you actually advise patients in terms of when to change it? Every 3 days? Every 4 days? Something else? 🤔
Hi! Love your site. Sorry if I missed this, but for those of us in perimenopause, nervous about taking hormones and not experiencing major symptoms but hoping for better sleep/mood and protection against dementia , what's the lowest combination that could yield some of these benefits? Thanks!
We don't currently recommend estrogen for the prevention of dementia. If poor sleep is due to hot flashes/night sweats, it is very reasonable to start at a 25 mcg patch dose (or equivalent) with progesterone 100 mg at night or 200 mg 12 days a. month and then see how that helps. Mood is different, and for people struggling with depression, the dose is higher. I will be addressing that in an upcoming post.
Such a helpful and perfectly timed article for me! I’m 47 and had a hysterectomy (kept ovaries) years ago. I’ve been having horrible night sweats and brain fog for some months now. My doctor just started me on .0375 estradiol patch and I’m very hopeful for some positive effects. Thanks for fighting the good fight!
Sounds like you got some quality medical care! Just keep in mind estrogen doesn't really help brain fog, but it's great for night sweats.
Good to know, thanks!
Thank you for sharing your knowledge and guidance, you are such a beacon of light in a confusing time of life. I take MHT for hot flashes/brain fog. My question is…is it okay to take progesterone 100mg every other day (due to side effects, constipation and bloating mostly) while on a very low dose of estradiol? (cutting the 0.025 patch in half). Am I getting enough progesterone to protect my uterus from the estrogen?
Do you find 1/2 of a patch helps for flashes/fog and energy or mood? I’ve thought about trying this myself because I am progesterone intolerant. I thought an article Dr. Jen wrote stated if you took ultra low dose estrogen patch that you only need a progesterone twice a year. But we would def need to confirm.
Incredibly informative. Thank you Dr. Jen! A quick question about sprays. I’m American but live in Mexico where gels and patches are hard to get. So for now I’m on a spray called Lenzetto, which is the same as Evamist I believe. 1 spray is 1.53 mg, and it’s recommended that users don’t go above 3 sprays per day. How does this conversion play out in regards to the dosing of patches and gels, which are much more commonly discussed. Is there an equivalent gel or patch dosage for 1 Lenzetto spray? Thanks so much!
I will be doing a post on that coming up!