Troubleshooting Menopausal HRT
1. Recurrent vaginal spotting/bleeding
Inform women who are recently menopausal that the lining of their uterus may be thickened and
bleeding may occur with starting estradiol-progesterone. It initial bleed occurs, stop both hormones
until bleeding has ceased for 24hrs. then restart both the same night at the same doses. If bleeding
recurs later, assess the amount of estrogen effect in the rest of the body, check estradiol level if needed.
If she appears to have sufficient or excessive estrogen effect, then first try lowering estradiol dose. Have
patient stop estradiol and progesterone to allow a complete shedding of the lining, then restart both
hormones together with the lower estradiol dose. If bleeding recurrs, stop both hormones and restart
with lower estradiol dose. If a lower estradiol dose begins to produce estrogen-deficiency symptoms,
then increase the estradiol to a sufficient dose and either increase the progesterone dose, or change the
route to a more effective one—e.g. from transdermal to sublingual, or sublingual to vaginal.
2. Hair Loss
Women lose scalp hair from time-to-time for various reasons, but will want to know if their hormone
regimen is involved. Progesterone is neutral for hair growth. Estradiol is very good for scalp hair growth.
Testosterone and/or DHEA supplementation can promote scalp hair loss in some women—perhaps they
carry the family’s male-baldness gene. Their body is also more androgen sensitive in general after having
very low levels for decades. if a woman complains of scalp hair loss make sure that the estradiol dose is
sufficient, and lower or stop the testosterone dose. If the problems resolves, see if she is willing to
restart testosterone at a lower dose.
3. Persistent breast tenderness
Breast fullness/tenderness suggests a persisting stimulative effect on the glands. First assess estrogen
status and try lowering the estradiol dose. As progesterone counteracts estradiol in the breast tissue, a
higher progesterone dose or more effective delivery route should be tried. Testosterone counteracts
estradiol also and should be added or the dose increased. Another possible cause is iodine deficiency—it
is known to contribute to fibrocystic breast disease. Add Iodoral or i-Throid 12.5mg tablets, 1 po twice
weekly. Once the breast symptoms resolve lower the dose to once weekly indefinitely.
4. Virilization effects with testosterone
Having better testosterone levels is a major benefit of HRT. Remind women that testosterone acts on a
continuum. A woman who has no testosterone will be hairless, sexless and weak. With increasing
testosterone levels she will have more body hair, libido and muscle strength. Testosterone also helps
reduce anxiety and improve cognition. So the best dose is the dose that produces the best compromise
between benefits and unwanted virilization effects. Women vary greatly in their susceptibility to
virilizing effects. The physician simply has to give the woman all the information she needs to make an
informed choice about her testosterone dose. Some women will love the benefits and desire higher
doses. For such women, it is safe to provide testosterone doses that produce levels above the female
ranges at all times. Women who benefit from high levels with few unwanted effects are reassured to
know that their levels are still far below the bottom of the male free-testosterone range.