No, really. It's a myth. Yes, we know the notion that this will solve all of our hormonal ills is a very popular, very prevalent theme in women's hrt discussions online. But it's really neither possible nor necessarily desirable.
Stop sputtering. Yes, we do understand that the ups and downs of the various delivery routes can be problematic, causing all sorts of unpleasant symptoms. But that doesn't mean that the attempt to do away with them by taking ever more frequent tiny doses is going to work. That's right: even if we were to walk around with a constant IV drip of estrogen, we still wouldn't eliminate fluctuation.
That doesn't mean that we can't smooth things out, but it does mean that we need to look into the situation a little more intently to determine what exactly it is that needs to be fixed.
Life isn't a perfectly stable system
To begin with, nothing around us is perfectly stable. Today we are stressed by a deadline at work; tomorrow we will have a cold; the day after that is our birthday and we'll have that surprise party even though you know how we feel about surprises. Everything around us changes and our bodies are built to cope with that. We need that ability to cope, because there will always be something out there, a stressor good or bad, or even the relief of stress.
Our interactions with the world affect our hormone supplies as well as the demands upon them. We eat foods that contain estrogens, either as plant estrogens or as hormones given to commercial meats or as estrogenic pesticides applied to plants and coating them or eaten by the animals we then go on to eat. We drink water supplies into which every day vast quantities of drugs and pesticides are flushed and, because their content is not legislated, we never see test results to show us how very many things are still in our "clean" water. Every molecule of the hormonally-active compounds we consume becomes a part of our hormone reservoir, a reservoir that changes from moment to moment, hour to hour, day to day.
Neither is a woman's body
Our endocrine system (that portion of our physiology to do with hormonal regulation of various functions) is itself not a static system.
First, our bodies need to be able to keep things running in that ever-changing world we live in. We need reserves to allow us to cope, to ramp things up when we're facing stresses and to ramp things down when stress eases off.
And we need to maintain cycles of our own. We're used to the cycles of fertility, but there are many more cycles in our bodies. One of the most important is our daily cycle of sleep and waking, the latter encompassing various stages of alertness and, well, not so much.
Our estrogen is a critical component of our daily cycle. Our levels naturally are highest in the morning, fall gradually during the day and evening, and reach their lowest point around 4 or 5 am. This cycle keys in with with many other hormone cycles, including that of melatonin, another hormone that helps regulate our sleep cycle. It also interacts with thyroid hormone as part of our metabolic regulation. If estrogen levels were completely static, our whole system would come adrift from this important regulatory relationship. And if our hrt were absolutely continuously stable, we'd spend most of our time with either too much or too little to meet our bodies' demands during our daily cycle.
Change, then, is both an inescapable part of both internal and external hormonal regulation and response. But that doesn't mean that it doesn't pose challenges when we do it to ourselves with our hrts.
But the ups and downs are killing me!
The problem is that our body wants to regulate things so we stay on a fairly even keel amidst all of these changes. We work hard, all the time, to do so. When that doesn't happen, of course, the resulting temporary imbalance and the shifts of it coming and going all cause symptoms that can range from annoying to devastating. And it's a feature of our response to change that the greater the fluctuation, the greater the response to it will be.
The most comfortable hrt, then, is going to be one that eases into our bodies with the least disruption, is taken at a dose that lasts long enough that its falling effectiveness meets the rise of the next dose without either great troughs or peaks, and provides a reservoir of hormonal potential to get us through the times of day when we must respond to a need for greater hormonal activity. And as it turns out, none of that actually requires anything like a completely continuous supply.
Minimizing the ups and downs due to uptake
There are two important facets of getting hrts into our bodies. First, they have to physically get into our systems and, second, they need to impact our circulation in a fairly tolerable manner. Both of these factors can present us with problems when hrt characteristics are a mismatch for our personal capabilities.
In dealing with the first problem, we need a delivery method that our bodies can absorb smoothly and reliably. A patch that is stuck now and flapping later isn't going to do that; instead, it will provide us with a roller coaster of ups and downs. Oral deliveries may not work reliably for all women. A gel might be sweat off on the days we go to the gym. All hrt delivery routes have ways they can fail to work smoothly, and so when we're not happy with how a dose is taken up by our bodies, we need to take a close look at just what kinds of interference we might be experiencing at this basic level of delivery.
But it's not enough to get those hormones into our bodies effectively. We also have to weather the rise in circulating hormone levels. Each hrt will create a slightly different uptake curve. A patch will start delivering fairly rapidly, but if the previous patch was exhausted and our hormone support from it had dropped, even the small dose delivered by a patch will be seen as a sharp uptick by our bodies. Some women find that the rapid absorption of a whole day's transbuccal dose doesn't dissipate rapidly enough to prevent being hit by something of a slam.
Each hrt has its own time and type of uptake. When we are troubleshooting these, we can look at alternatives that might perform differently. For example, if a cream transdermal dose seems to provide too abrupt an uptake to be comfortable, perhaps the slower uptake of a gel would be more gentle while still otherwise providing a transdermal profile of effects.
But an often-neglected aspect of uptake has to do not so much with delivery route but what specific hormone we're delivering. When we're taking estradiol, we're using the active form of the hormone. If we dump a day's estradiol into our systems at once, we may have trouble moving quickly enough to convert the portion of it that we don't need to have active at that exact moment into the inactive reserve form, estrone. If this is the case, our dose might give us a fierce headache or palpitations or excessive jumpy nervousness.
For women who experience this problem, it’s possible to get around this effect somewhat by switching to an hrt that contains some or all estrone. That way, the net total hormone support delivered in a dose cycle is still provided, but the initial slam of excessive activity can be dodged. Not all women experience this problem, but for those who do, this can be a highly productive direction to explore. This is especially true for women who suffer from migraines when they take estradiol, perhaps because the two estrogen versions affect somewhat different areas of the brain.
Minimizing the ups and downs due to duration
If the dose of hrt we take doesn't last until the next dose is taken, our hormone support will taper down far enough that both its decline and the rise of the next dose's uptake will cause uncomfortable fluctuations. While women often address this gap by trying to take smaller doses more frequently, that often doesn't provide a fully satisfactory coverage, not to mention becoming increasingly impractical.
A common misunderstanding of the concept of "half life" often drives this attempted solution. Half life in medical terms is simply how long it takes for half of a dose to be metabolized. The fact that a dose is half gone, however, doesn't mean that another full dose is needed; it only means that the body has taken its normal steps to tune our hormone supply to meet our present needs.
If a dose interval is meant to be a full day, then, it's appropriate that the half life be 12 hours. That means we'll have used up most of yesterday's dose by the time we add today's. Yes, that's some up and down, but our bodies can handle a fair amount of variability through their own storage mechanisms if we're not shorting ourselves down too far between doses. The other direction, taking a new dose before we've used up most of the last, only takes us into excess...and excessive risks. In fact, many women tune their dose exactly so that they do feel a bit short in the morning or so that they do have a hot flash or at least warm spell at that 5am low point in their daily hormone cycle, just so that they know they're skimming along the edge of "lowest effective dose."
So in practical terms, if a woman feels as though she's running out far too soon, she might do more good by re-examining her total dose amount and consider whether taking more would make it last longer and round out her dose period. Taking it more frequently only speeds up the cycle of ups and downs and doesn't really improve her coverage.
Minimizing the ups and downs due to reservoir
There's another factor, beyond simply how long the dose lasts, and that is the form in which it lasts.
Yes, the measured amount of our hrt goes up and then down, but focusing on that alone misses the fact that our overall hormone capacity is not represented by just one form. When she is taking estradiol, a woman's body will normally move quickly to convert any excess beyond her momentary need into estrone, which will exercise less activity. In the course of her dose interval, that estrone will gradually be converted back to active estradiol as she needs, throughout this period, to do more estrogen work.
We’re not sure of the physiology behind this, but some women seem more comfortable when they have a considerable reservoir on board. Now, that’s not an excess we’re talking about; we only mean the sort of buffer that a day’s dose provides. Women for whom this is the case often feel edgy and stressed, never quite comfortable in their bodies, on trickle-dosed hrts (patches, pellets), as though something isn’t right even though they may have lab tests that put them in an ostensibly normal hormone level range. Unfortunately, this is often the sort of situation in which women move to trying to manage their hrt levels even more closely—something that is actually moving in the wrong direction. Switching to daily dosing, which allows their bodies to regain and manage a reservoir to meet their fluctuating needs in a more natural process can help alleviate that problem and provide a better fit between hrt and how their body best functions.
This is vague. Also, confusing.
Yes, we know. We’re getting into the more subtle aspects of hrt “fit” here and there are no real rules, no body of research knowledge. By standard medical thinking, all hrts must work exactly alike and if there’s a problem, it’s somehow with the patient.
But in the decade we’ve been watching hrt use and talking with women about what they’ve tried and experienced, these seem to be common trends and the strategies that seem to have good, durable results for dealing with them.
These aren’t recipes, however. We need to think about the ways our current hrt can be ill-suiting us and we need to know enough about hrts to know which ones hold different characteristics. This is way more subtle than the situation where if we try one patch at one dose and aren’t happy, our only option is whatever oral hrt our doctor most often prescribes. Our hrt pages here can help you with some of this (they're arranged by hormone, so check the Table of Contents for links). If nothing else, we hope that this will help keep you from wasting a lot of time and effort adding and subtracting bits of patch every hour during the day (yes, we’ve actually read accounts of women so desperate to get that impossiblly even hormone state that they’ve tried this). And encourage you that there are some fairly subtle things that can be done to manipulate our hrts’ effects to make them fit better.
As ever, we’re more than happy to discuss this in greater detail on our forums. While we can’t provide answers for everyone, we can often ask questions that help them discover their own best answers.