What do you do if you have an incorrect dose of estrogen? Make it right! Yeah, we know—easier said than done. There are several variables that come into the picture that may help you sort that part out.
Keep in mind, too, that all of this is a little artificial, since we're really discussing estrogen in a vacuum. As soon as we add other hormones to the picture, it gets somewhat more complex. But for now, let's look at the pure estrogen symptoms and how we might get there.
Low estrogen
A low level may be caused—simplest case—by a low dose. In that case, increasing the dose may be all that is required. It could be, however, that the route by which you are taking it is an ineffective one in your case. If you raise the dose and don't feel you are then moving towards improvement (bearing in mind that hot flashes are a sign of fluctuation, not a direction indicator), it would be worthwhile to consider that a change in delivery route might help. If your dose sometimes seems enough but you have uneven results, your coverage seem to fluctuate and sometimes isn't enough, then either your route is intermittently failing to deliver or the time/dose relationship is a problem. You may then need to either change the times you are taking your dose or chose a delivery method that provides a more reliable dose delivery curve.
High estrogen
If, on the other hand, you are thinking you have an excess of estrogen, then clearly lowering your dose is what you want to think about. Cutting your dose back in amount or frequency (so you lower the overall intake/day) should be effective, although it make take some time to tune things just right if you make frequency changes.
One frequency change that has not been notably successful for most women, however, is taking estrogen some days but not others. Your body doesn't seem to carry enough (of a daily-dosed hrt; this does not include patch changes or injections, which are considered steady-state dosing) over from one day to the next to make it through without extreme fluctuations. Dose intervals longer than about 24 hours, then, are not likely to provide the steady level you need in surgical menopause. Women with lower body fat tend to have a shorter tolerable dosing interval than women with more body fat, thanks to the storing/metering effect of that fat reservoir, but in any case, women in surgical meno are generally not successful at prolonging dosing beyond that 24-hour span.
If your estrogen is grossly in excess, you may not want to stay in excess for the amount of time it takes for you to eliminate the excess while still taking a new, revised maintenance dose. Instead, it may be preferable to stop estrogen altogether for a short time until it drops back to normal levels. Some doctors will give you a timeline for this—stop estrogen for X days and then start your new dose. This schedule may or may not suit your own body's rate of elimination, however, so don't hesitate to call if you start feeling like you're coming up short and the allotted period isn't over yet.
If you're doing this on your own, this is where the "listen to your body" comes in. You want to watch for the excess to diminish but catch yourself before you crash on into empty. You'll see resolution of the swelling or reduction of the headaches—that should be fairly clear. But running into the low range (remember: hot flashes aren't an accurate judge) is trickier to call. For those of us here who've tried the crash dump, our first clue that we'd crossed the ideal and were headed downhill was a sort of uneasiness, an unsteadiness of mood, a tremulous sort of sadness looming just over the horizon. When we felt like saying "enough," we listened to ourselves, and said "enough."