What you should know about estrogen dosing in HRT

Recently here in the UK a BBC documentary raised concerns that the prominent menopause specialist Dr Louise Newson had been prescribing excessively high doses of hormone replacement therapy treatments at her clinics. 

More than a dozen patients of Newson Health told the BBC they had experienced complications including for some a thickening of their womb lining. 

Newson Health denies any wrongdoing but the documentary sparked a debate in this country with some menopause campaigners saying the documentary was a setback that could deter women from seeking HRT.  

Others, including Dr Philippa Kaye who has written a book called The Science of Menopause, said it is time to call out ‘the over-medicalization of the menopause’. 

Clearly this is a hot topic around the world right now and there are strong feelings on either side so to give us a balanced and informed view, I turned to the respected, British Menopause Society accredited specialist, Dr Naomi Potter who herself has a considerable following on social media, and who is the founder and director of the Menopause Care clinic.  

Dr Naomi co-authored the best-selling book Menopausing with the television presenter Davina McCall as a guide for women to help them make informed decisions about how they navigate the menopause. 

Here she explains why some women are prescribed high doses of estrogen and the kind of conversations doctors should be having with us to help us make those decisions. 

Should blood tests always be used to confirm whether HRT might be an appropriate course of action?

Dr Naomi says:

The very short answer to that is no, you don’t need to. And the test results can be misleading and falsely reassuring. Or the opposite. They can be useful in excluding other conditions. So if you have younger women particularly or older women, but where you’re a little bit unsure if something else could be going on then you would look for lots of other underlying causes.  

So you look at things like full blood count, thyroid function, vitamin D, B12, folate, liver function tests, kidney function, and then depending on what you find, you could look further so you can exclude other conditions in younger women. It’s also nice to have a diagnosis. Particularly under the age of 40, you want to know if you possibly can, if they are menopausal. And then there are hormone tests that you can do, but if you get a normal result to those hormone tests, it doesn’t necessarily mean that you are not perimenopausal.  

So that’s the danger of doing those tests. You don’t want the false reassurance when those results can can be normal but using hormone replacement could make a difference. You can’t really start HRT too young because you’re not going to do any harm, apart from maybe a bit of disruption of a normal menstrual cycle.

So if you had somebody where you were suspicious it was an early menopause, the blood results were all normal, you have a trial of HRT. If somebody gets better, then the chances are you’ve cracked it. You’ve found your diagnosis. If it doesn’t make the slightest bit of difference, it’s probably not if you’ve really explored all the available HRT options.  

Do you think that all women could benefit from HRT at some point?  

Dr Naomi says:

It’s a really tricky one. I think there is a potential for benefit from HRT, but using HRT is such an individualized decision. It’s not without hassle. There are side effects. There’s bleeding, you can have breast tenderness, you can have nausea. It needs frequent monitoring. You have to go to see your doctor. You have to obtain prescriptions.  

So I don’t think it’s a, ‘yes very woman should be on HRT’. I think every woman should be given the opportunity to discuss it for them. And if they want to try it and they are aware of the benefits and the risks, then they should be allowed to. So I don’t think it should ever be withheld. But I do think it can be very nuanced and it’s very individualized.

Some women won’t take a paracetamol for a headache because they don’t want to do anything that is any sort of intervention, in which case those are often the women that just don’t want to take HRT and that is absolutely fine.

Equally, if you’ve got a woman that wants HRT, then they should be offered it after a discussion about the benefits that would be available to them.  

Can we take HRT for the rest of our lives?

Dr Naomi says:

I definitely feel women have a right to autonomy over their own body, and I don’t feel like any professional should withhold something that a woman wants if she’s understood the implications from taking it. So I don’t believe that any woman should have their HRT stopped after 55 or 60, or because they’ve had HRT for five years, or any other reason.

I believe women are very clever. They understand and if they want to remain on HRT, then I think they should be allowed to make that decision for themselves.  

Does it give them a health advantage? Do we know that yet?  

Dr Naomi says:

We don’t know that yet, because we don’t have that data. What we do know is that it certainly helps protect bones from osteoporosis or the thinning of bones. And that’s very important. If you have a fracture of your hip in later years then you have a 30% chance of dying from that within a year. So that is a significant risk.

So we want to make sure that women don’t have osteoporosis.

It’s also cardioprotective. So we know that it protects the blood vessels of the heart and the circulatory system, and that the leading cause of death for women is heart disease. So we know that there are potentially lots of advantages, but we don’t have data to say that if you are on HRT for the rest of your life you are more likely to live a long, healthy life than for those women that don’t.  

I suspect that in our lifetime we will have much more information on that going forwards.  

What was your reaction to the suggestion from the BBC documentary that estrogen is being prescribed in too high doses?

I’m a believer that if there is a question regarding clinical care then the appropriate channels should be followed or pursued in order to identify whether there is inappropriate prescribing happening.

I can tell you what we do in our clinic. We prescribe according to guidelines and according to our levels of expertise and on occasion, there might well be an indication to prescribe off license or off label where you might prescribe higher than necessary doses of estrogen.

Sometimes you need to do that in order to help the patient experience symptom free living. So I think that’s the important message. There are sometimes situations whereby it is necessary as specialists and you just need to make sure that you counsel patients, you tell them about the risks and the benefits and what we know and what we don’t know.  

Then patients can make that decision themselves.

Why might some women need higher doses than others?  

It’s like any medication. So some people respond very quickly to lower doses and some need higher doses. But as well as the symptom relief from specific doses, when we talk about estrogen replacement, we’re often referring to transdermal so estrogen through the skin.

Women seem to absorb estrogen through the skin very differently. So you might have two women who look very similar. They might be the same height, the same weight, the same skin type and you can still see really significant differences in how much they seem to absorb for symptom relief.

If you’ve got somebody who, despite using the the maximum licensed dose, is still completely symptomatic, you would question what are they absorbing? And then you would look at their bloods to see whether their estrogen levels were non-existent. So we don’t really understand why some women just don’t seem to absorb as well as others. But that does seem to be a phenomenon.  

What should you be told before taking high doses of estrogen?

Dr Naomi says:

Some women who are desperate to take control of their symptoms sometimes self prescribe. They take the advice of their friends or the advice of the internet, and they will increase and increase their dosage without really understanding the ramifications.

There’s a lot of word that you can take as much estrogen as you need, which is not strictly true.  

So that’s when it can be potentially very harmful, especially because the higher the dose of estrogen, the more progesterone we should be taking in order to protect your endometrium. And that’s the other conversation that you have with patients if they’re on the higher doses.