Menopause Myth #9: More HRT Isn’t Always Better: Understanding Optimal Dosing

“Can’t you just increase my dose?”

I hear this regularly from women on HRT who are still experiencing symptoms. The logic seems straightforward: if a standard dose isn’t fully controlling symptoms, a higher dose should work better. More medicine = more relief, right?

A 51-year-old woman sits in front of me. She’s been on transdermal oestrogen (100 mcg patch) for six months. Her hot flushes have improved significantly — from 20-25 per day to about 5-6. Her sleep is better. Her mood is more stable.

But she’s still having those 5-6 hot flushes daily, and they’re bothering her. She’s read online that some women use higher doses. She’s convinced that if she just increases to 150 mcg, all her symptoms will disappear.

“Can we just try a higher dose and see if that gets rid of the rest?” she asks.

This is where I need to have a careful conversation about HRT dosing — because it’s not that simple.

The Myth: Higher Dose = Better Control

The pervasive belief: The higher the oestrogen dose in HRT, the better your symptom control will be. If standard doses aren’t working perfectly, the solution is to increase the dose.

The reality: More is NOT always better. Beyond a certain point, increasing oestrogen doesn’t provide additional symptom relief — it just increases side effects and risks without benefit.

The goal of HRT isn’t “as much oestrogen as possible.” The goal is finding your optimal dose — the lowest effective dose that:

  • Controls your symptoms adequately
  • Protects your long-term health (bone, cardiovascular)
  • Minimizes side effects
  • Keeps risks as low as possible while maintaining benefits

What Happens When HRT Doses Are Too High

Beyond your optimal dose, more oestrogen doesn’t improve symptoms — it creates new problems.

Side Effects of Excessive Oestrogen:

Breast tenderness and swelling:

  • One of the most common signs of too much oestrogen
  • Breasts feel heavy, tender, painful
  • Can be severe enough to interfere with sleep or physical activity
  • Bras become uncomfortable

Bloating and fluid retention:

  • Feeling puffy, swollen
  • Abdominal bloating
  • Rings tight on fingers
  • Weight fluctuations from water retention
  • Uncomfortable and distressing

Headaches or migraines:

  • In susceptible women, too much oestrogen can trigger or worsen headaches
  • Particularly problematic for women with history of migraines

Nausea:

  • Feeling queasy, especially in the morning
  • Can interfere with appetite and eating

Mood swings and irritability:

  • Surprisingly, TOO MUCH oestrogen can cause mood symptoms
  • “Oestrogen dominance” creates irritability, emotional lability
  • Different from low oestrogen symptoms but equally unpleasant

Heavy or irregular bleeding:

  • If you still have a uterus and are on cyclical HRT, excessive oestrogen can cause very heavy withdrawal bleeds
  • If you’re on continuous combined HRT, can cause breakthrough bleeding

Increased risks:

  • Breast cancer risk is dose-dependent (higher doses = higher risk)
  • While HRT at appropriate doses has an acceptable risk-benefit profile, unnecessarily high doses increase risks without providing additional benefits

Why “More Is Better” Doesn’t Apply to HRT

Several factors explain why increasing oestrogen beyond your optimal dose doesn’t improve symptoms:

1. Receptor Saturation

Oestrogen works by binding to oestrogen receptors throughout the body — in the brain, bones, cardiovascular system, reproductive tissues, etc.

But there are a limited number of receptors.

Once all available receptors are occupied (saturated), additional oestrogen doesn’t do anything — it’s just circulating in your bloodstream with nowhere to bind and no effect to exert.

Think of it like parking spaces: If there are 100 parking spaces and 100 cars, all spaces are full. Adding another 50 cars doesn’t create more parking — those cars just circle around with nowhere to go.

Beyond receptor saturation, more oestrogen provides no additional benefit.

2. Individual Variability in Receptor Sensitivity

Women vary in how sensitive their oestrogen receptors are.

Some women have very sensitive receptors — they respond well to low doses of oestrogen. Other women have less sensitive receptors and may need higher doses to achieve the same effect.

This is why the “right” dose is individual.

It’s not about what dose your friend takes or what’s “standard” — it’s about what YOUR body needs based on YOUR receptor sensitivity, YOUR symptoms, and YOUR response.

3. Non-Linear Dose-Response Relationship

The relationship between oestrogen dose and symptom control is not linear.

It’s not: “50 mcg controls 50% of symptoms, so 100 mcg will control 100% of symptoms.”

Instead, the dose-response curve often looks more like this:

  • Low doses: Minimal effect
  • Moderate doses: Significant improvement in symptoms
  • Higher moderate doses: Continued improvement up to a point
  • High doses: Plateau (no additional improvement) and increased side effects

There’s a “sweet spot” where you get maximum benefit with minimum risk. Going beyond that doesn’t help and may harm.

Finding Your Optimal Dose

So if “more” isn’t automatically better, how do you find the dose that’s right for you?

The Goldilocks Principle

Think of HRT dosing like Goldilocks and the three bears: Not too little, not too much, but just right.

Too little: Symptoms persist, you’re still suffering, long-term health not optimally protected

Too much: Side effects develop (breast tenderness, bloating, headaches, mood swings), risks increase

Just right: Symptoms adequately controlled (may not be 100% perfect, but significantly improved and manageable), side effects minimal or absent, long-term health protected, risks minimized

Start Low, Go Slow

The standard approach to HRT dosing:

1. Start with a standard moderate dose:

For transdermal oestrogen:

  • Patches: 50 mcg typically starting dose
  • Gel: 1-2 pumps/sachets daily (depending on product)

2. Give it time to work:

HRT doesn’t work immediately. Full effect can take 3-6 months.

Common timeline:

  • Weeks 1-2: May notice some improvement in hot flushes
  • Weeks 4-6: Sleep often improves
  • Weeks 8-12: Mood, energy, other symptoms begin improving
  • 3-6 months: Full benefit reached

Many women make the mistake of increasing dose too early because they expect immediate results and don’t give the initial dose enough time to reach full effect.

3. Assess response after adequate trial period (minimum 3 months):

After 3 months, evaluate:

  • Which symptoms have improved?
  • To what degree?
  • Are there any side effects?
  • Is the improvement sufficient, or are you still significantly symptomatic?

4. Adjust if needed:

If symptoms are inadequately controlled after 3 months AND no side effects:

  • Consider increasing dose (e.g., from 50 mcg to 75 mcg or 100 mcg patch)
  • Give new dose another 2-3 months to reach full effect
  • Reassess

If symptoms are well-controlled:

  • Continue current dose
  • Regular review (every 6-12 months)

If side effects develop:

  • Consider reducing dose, or
  • Changing formulation (e.g., from patch to gel, or vice versa), or
  • Adjusting progesterone type/dose (if side effects related to progesterone)

The Role of Blood Tests in Dosing

Routine blood tests of hormone levels are NOT recommended for monitoring HRT.

Why?

  • Hormone levels fluctuate throughout the day and month (especially during perimenopause)
  • There’s no “target” level that correlates with symptom control
  • Women respond to the same blood level very differently based on receptor sensitivity
  • NICE Guidelines explicitly state blood tests are not useful for monitoring HRT

The exception: If you’re on testosterone (for women who’ve had ovaries removed or have severe symptoms), blood testosterone levels should be monitored to ensure levels are in appropriate range and not too high.

HRT dosing should be guided by:

  • Symptom control (primary factor)
  • Side effects (absence or presence)
  • Individual circumstances (age, time since menopause, risk factors)
  • Regular clinical review

When Higher Doses Might Be Appropriate

While the general principle is “use the lowest effective dose,” some women do need higher doses to achieve adequate symptom control.

Higher doses might be appropriate if:

Persistent symptoms despite adequate trial:

  • You’ve been on standard dose for 6+ months
  • Symptoms remain significantly troublesome
  • No side effects from current dose
  • Other causes of persistent symptoms have been ruled out (thyroid, B12, sleep disorders, stress, etc.)

Premature or early menopause:

  • Women who experience menopause before age 40 (premature) or before 45 (early) often need higher doses
  • Younger women’s bodies expect higher oestrogen levels
  • Higher doses may be needed to achieve adequate symptom control and health protection
  • Can continue higher doses until around age 51 (average natural menopause age), then reassess

Surgical menopause:

  • Women who’ve had ovaries removed (especially if young) often need higher doses initially
  • Sudden, complete loss of endogenous oestrogen may require more replacement

Individual variation:

  • Some women simply need higher doses due to less sensitive receptors or faster metabolism of hormones
  • This is individual variation and perfectly fine if symptoms are controlled without side effects

The key is: Higher doses should be used when clinically indicated (persistent symptoms despite lower dose), NOT automatically or because “more must be better.”

Why Your Symptoms Might Persist (It’s Often Not the Dose)

If you’re on HRT and still experiencing symptoms, the issue might not be that your dose is too low. Several other factors could explain persistent symptoms:

1. Type or Formulation of HRT

Different women respond differently to different formulations.

Oestrogen type:

  • Patches vs. gel: Some women find gel more effective; others prefer patches
  • Brand differences: Different brands of patches or gel may be absorbed differently

Progesterone type:

  • If you have a uterus, you need progesterone alongside oestrogen
  • Different types of progesterone have different effects and side effects
  • Synthetic progestogens (like medroxyprogesterone or norethisterone) cause more side effects than body-identical micronized progesterone
  • Switching progesterone type can dramatically improve symptoms and reduce side effects

Delivery schedule:

  • Cyclical vs. continuous combined HRT
  • Some women in perimenopause do better with cyclical; others prefer continuous

If standard dose isn’t working, before increasing dose, consider: Trying a different formulation, changing progesterone type, switching from patch to gel or vice versa.

2. Testosterone Deficiency

This is the most commonly missed piece.

If you’ve had your ovaries removed (bilateral oophorectomy), you’ve lost approximately 50% of your testosterone production immediately.

Even if you’re on adequate oestrogen HRT, if testosterone is deficient, you’ll experience:

  • Profound fatigue (despite adequate sleep)
  • Complete loss of libido
  • Difficulty building or maintaining muscle
  • Low motivation, lack of drive
  • Flat affect (feeling emotionally numb)
  • Brain fog and difficulty concentrating

Standard HRT provides oestrogen (and progesterone if needed). It does NOT provide testosterone.

If you’re on HRT but still experiencing the above symptoms, ask about testosterone replacement. Many women need BOTH oestrogen AND testosterone to feel well.

3. Timing (Not Enough Time on Current Dose)

HRT takes 3-6 months to reach full effect.

If you’ve only been on your current dose for 4-6 weeks and are still symptomatic, you likely just need more time, not a higher dose.

Be patient. Give it at least 3 months before deciding the dose is insufficient.

4. Lifestyle Factors

HRT addresses the hormonal piece. But if lifestyle factors are significantly contributing to symptoms, HRT alone may not fully resolve them.

Sleep deprivation:

  • Even on HRT, if sleep is poor, you’ll experience fatigue, mood issues, brain fog, increased hot flushes
  • Optimize sleep: consistent schedule, cool room, no screens before bed, limit caffeine/alcohol
  • If night sweats are still disrupting sleep despite HRT, discuss increasing dose or adding additional interventions

Chronic stress:

  • High cortisol (stress hormone) worsens every menopause symptom
  • Stress management is non-negotiable: daily breathwork, boundaries, saying no to non-essential commitments, therapy if needed

Poor nutrition:

  • Blood sugar instability worsens hot flushes, mood, energy
  • Adequate protein crucial for muscle maintenance, satiety, neurotransmitter production
  • Anti-inflammatory eating pattern

Sedentary lifestyle:

  • Lack of movement worsens fatigue (paradoxically), mood, cognitive function, bone health, metabolic health
  • Strength training 2-3x/week non-negotiable for menopause

Alcohol:

  • Even moderate alcohol consumption significantly worsens hot flushes, sleep, mood, weight
  • Many women find that reducing alcohol to 1-2 drinks per week (or eliminating) dramatically improves symptoms

If lifestyle factors are not optimized, increasing HRT dose won’t fully resolve symptoms. Address both medical and lifestyle factors for best outcomes.

5. Other Health Issues

Persistent symptoms might not be menopause at all — or not only menopause.

Thyroid dysfunction:

  • Hypothyroidism causes fatigue, weight gain, hair loss, mood changes, brain fog — identical to menopause symptoms
  • Up to 20% of perimenopausal women have thyroid issues
  • Check TSH, free T4, free T3, thyroid antibodies if symptoms persist

Vitamin deficiencies:

  • B12 deficiency: Causes profound fatigue, brain fog, mood changes, neurological symptoms
  • Vitamin D deficiency: Contributes to fatigue, mood, bone health issues
  • Iron deficiency: Causes severe fatigue, hair loss (especially if periods are heavy)

Sleep disorders:

  • Sleep apnea increasingly common post-menopause (weight distribution changes, loss of oestrogen’s protective effect)
  • Causes severe fatigue, brain fog, mood issues despite “sleeping” 8 hours
  • If loud snoring, gasping in sleep, extreme daytime fatigue, consider sleep study

Medications:

  • Statins: Cause fatigue, muscle pain, brain fog in some people
  • Beta-blockers: Cause profound fatigue, low mood
  • Antidepressants: Can cause weight gain, sexual dysfunction, emotional blunting

If persistent symptoms despite HRT, investigate other potential causes before assuming dose is too low.

The Risks of Excessive Doses

Using higher doses than necessary increases risks without providing additional benefit.

Breast Cancer Risk

Breast cancer risk with HRT is:

  • Dose-dependent: Higher doses = higher risk
  • Duration-dependent: Longer use = higher risk
  • Type-dependent: Oestrogen-only HRT (for women without uterus) has lower risk than combined HRT (oestrogen + progesterone)

Absolute risk remains low for most women (especially if using body-identical micronized progesterone rather than synthetic progestogens). But using higher doses than necessary increases this risk without providing additional benefit.

The principle: Use the lowest effective dose for the shortest necessary duration to achieve your goals (noting that “shortest necessary duration” might be many years or indefinitely if benefits continue to outweigh risks).

Cardiovascular Considerations

For women starting HRT within 10 years of menopause or before age 60, HRT has neutral or possibly beneficial effects on cardiovascular health.

But higher doses may have different risk profile. While transdermal oestrogen doesn’t increase VTE (blood clot) risk at standard doses, very high doses might have different effects.

Using appropriate doses optimizes the risk-benefit balance.

Side Effects Impact Quality of Life

Even if high doses don’t increase serious health risks significantly, side effects impact quality of life:

  • Breast tenderness can be severe and distressing
  • Bloating and fluid retention feel awful
  • Headaches interfere with daily functioning
  • Mood swings affect relationships and wellbeing

Why tolerate side effects from excessive doses when a lower dose would control symptoms without side effects?

What You Should Do

If You’re Considering Starting HRT:

Work with a healthcare provider who understands individualized dosing:

  • Start with standard moderate dose
  • Give it adequate time (minimum 3 months, ideally 6 months for full effect)
  • Track symptoms systematically
  • Adjust only if needed based on response and side effects

Be patient. HRT is not a quick fix. It takes time to work.

If You’re Already on HRT But Still Symptomatic:

Before assuming you need a higher dose, consider:

1. Have I given current dose enough time?

  • If <3 months, give it more time

2. Are lifestyle factors optimized?

  • Sleep: 7-9 hours, good sleep hygiene
  • Stress: Daily management practices
  • Exercise: Strength training 2-3x/week, daily movement
  • Nutrition: Blood sugar stability, adequate protein, anti-inflammatory eating
  • Alcohol: Limited to 1-2 drinks/week or eliminated

3. Could the TYPE of HRT be the issue rather than dose?

  • Try different formulation (patch vs. gel)
  • Switch progesterone type (to body-identical micronized progesterone if not already using it)

4. Could I need testosterone?

  • Especially if ovaries removed
  • If experiencing profound fatigue, no libido, low motivation despite adequate oestrogen

5. Could something else be causing persistent symptoms?

  • Check thyroid function
  • Check B12, vitamin D, iron
  • Review medications for side effects
  • Consider sleep study if severe fatigue with snoring

Only after addressing all of these should dose increase be considered.

If You’re Experiencing Side Effects:

Side effects suggest dose might be too high (or formulation not optimal).

Breast tenderness, bloating, headaches, mood swings, nausea:

  • Discuss reducing dose with your prescriber
  • Or changing formulation
  • Or adjusting progesterone (many side effects are from progesterone rather than oestrogen)

Don’t tolerate significant side effects. HRT should improve your quality of life, not create new problems.

Regular Review

HRT isn’t “set it and forget it.”

You need regular review (every 6-12 months) with your prescriber to assess:

  • Symptom control: Are symptoms adequately managed?
  • Side effects: Any new issues?
  • Changes in health: New conditions, new medications, changed risk factors?
  • Continued appropriateness: Do benefits still outweigh risks?

Doses may need adjusting over time:

  • As you transition from perimenopause to post-menopause, needs may change
  • As you age, needs may change
  • As symptoms evolve, dosing may need tweaking

Individualized, ongoing care is essential.

The Bottom Line

More HRT is NOT automatically better.

Beyond your optimal dose, additional oestrogen doesn’t improve symptoms — it just increases side effects and risks.

The goal is finding YOUR optimal dose — the lowest effective dose that:

  • Adequately controls your symptoms (recognizing “adequate” might not mean 100% perfect, but significantly improved and manageable)
  • Protects your long-term health
  • Minimizes side effects
  • Keeps risks as low as possible

If you’re on HRT but still symptomatic, the answer might not be “more oestrogen.” It might be:

  • Changing the TYPE or formulation of HRT
  • Adding testosterone (if deficient)
  • Addressing lifestyle factors (sleep, stress, exercise, nutrition, alcohol)
  • Investigating other causes of persistent symptoms (thyroid, deficiencies, sleep disorders, medications)

HRT dosing is an art as much as a science. It requires individualized assessment, adequate time to reach full effect, systematic symptom tracking, and partnership between you and your healthcare provider.

Don’t expect or demand “more” without considering whether that’s actually what your body needs. Sometimes less is more. Sometimes the same dose with different formulation is the answer. Sometimes lifestyle factors need addressing alongside medical treatment.

Comprehensive, individualized care beats automatic dose escalation every time.

Need Support?

If you’re struggling to optimize your HRT regimen and wondering whether dose, type, or other factors need adjusting, I can help.

As a registered nurse and prescriber specializing in menopause care, I provide thorough assessment and individualized HRT management.

Book a consultation to review your current regimen and create an optimization plan.

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