When you started hormone replacement therapy (HRT), you hoped it would finally kick your perimenopause symptoms to the curb. But a few months in, you’re still dealing with hot flashes and wondering—could you need a higher dose?
Men’s hormones are like an amusement park carousel: they’re steady. Doctors can easily measure them with blood work to spot issues like low testosterone. Women’s hormones are more like a roller coaster: Estrogen and progesterone fluctuate dramatically during perimenopause (1). Blood tests can only capture a snapshot of your hormone levels at a given moment, so they’re not useful for diagnosing perimenopause (despite what you may have heard). That’s why HRT is prescribed based on symptoms—hot flashes, itchy skin, unexplained bloating; you know the drill—not hormone levels.
Finding the correct dose can be a bit of trial and error. “I tend to start women at a lower dose of their preferred method of HRT, and then we keep going up until they don’t have symptoms,” menopause specialist Natasha Spencer, M.D. says.
Many doctors take this cautious approach, especially since a flawed 2002 study linked hormone therapy to cardiovascular disease and cancer. Two decades later, some physicians still hesitate to prescribe higher doses (2). But Spencer says recent research shows promise. The latest Menopause Society guidelines encourage doctors to make sure women are on the right dose—and for as long as they need.
About the Experts
Natasha Spencer, M.D., is a board-certified OB-GYN and menopause specialist at Orlando Health.
Greg Brannon, M.D., FACOG, is a board-certified OB-GYN and anti-aging medicine physician at Optimal Bio, a Bioidentical Hormone Replacement Therapy (BHRT) practice based in North Carolina. He specializes in menopause care.
How Do I Know If I Need a Higher Dose of HRT?
Anytime you start a new drug, it takes time to see results. Spencer says menopause hormone therapy can take anywhere from a few weeks to a few months to kick in. It just depends on the person. But, if you’re still experiencing some symptoms after three months, that’s a sign your doctor might need to up your dose.
If you’re only noticing partial symptom relief, talk to your doctor about increasing the dose, suggests menopause specialist Greg Brannon, M.D. But what does partial relief look like?
Maybe your hot flashes have mostly disappeared, but they continue to make rogue appearances at the most inconvenient times. Or, perhaps you’ve closed the gap on your insomnia-induced witching hour but still struggle to wind down before bed. And while those frequent UTIs have hit the road, your vaginal dryness is still sabotaging your sex life.
While any improvement in perimenopause symptoms is cause for celebration, Spencer emphasizes that the goal is to find a dose that eliminates them entirely.
“I’ve had patients who experience anywhere from 15 to 20 hot flashes a day, which is a LOT to experience. I don’t know how they get through the day,” she adds. “If your hot flashes only get cut in half, that’s not where we want to be.”
What does being on the Goldilocks “just right” dose of HRT feel like?
Your symptoms are gone
No jokes here, just facts. “If your symptoms have completely resolved, that’s the best sign your dose is correct,” Brannon says. Women on their perfect dosage aren’t bothered with hot flashes, have a balanced mood, and regain their sex life.
So, how will you know when you’ve hit the sweet spot? Every time your dose changes, it takes your body a little time to adjust. “I tell women to wait two to four weeks after we increase the dose,” Spencer says. “If they feel like they’re not where they want to be, we’ll go to the next dose up and check in again.”
The good news? You’re likely not far away from your dream dose.
You’re side effect-free
For most women, increasing their dose of HRT is safe. But it may increase the likelihood of side effects (3). The most common side effects of menopause hormone therapy include (4):
Nausea
Headache
Irregular bowel movements
Vaginal bleeding or spotting
Rash, acne, or skin changes
Mood changes, depression, and/or anxiety
These side effects usually disappear as your body adjusts to the new dose (4). If they continue, your doctor may change the type of menopause hormone therapy you’re taking. For example, some women find estrogen patches or creams have fewer side effects than tablets (5).
Spencer notes that in some cases, your doctor might lower your dose until you achieve the perfect balance of symptom relief and minimal side effects.
Keep Your Doctor in the Loop
Landing on the right dose of HRT is a collaboration between you and your doctor, so expect some back-and-forth. Spencer recommends check-ins every three months to discuss symptoms and whether you’re satisfied with the dose and delivery method. Your doctor might also add testosterone to your HRT cocktail if you’re struggling with libido, mood, energy, or concentration (6, 7).
The Bottom Line
Not every woman experiences complete relief from perimenopause symptoms on the same dose of HRT. You’ll know you’ve hit the perfect dose for you when your hot flashes, bloating, anxiety, and any other symptoms are minimal or have virtually disappeared. If you only get partial relief, talk to your doctor to see if you need a higher dose or a change in treatment (for example, adding testosterone).
Rebekah Harding is a Health Writer at The Edge. She is an experienced health and lifestyle writer with both digital and print bylines in Men’s Health, Cosmopolitan, Yoga Journal, Giddy, and more.
