Perimenopause: Master the signature of your hormones and titrate your HRT According to your symptoms

purity carr
Jun 1, 2024
2 min read

Updated: Dec 3, 2025

Case Study: 42-Year-Old Perimenopausal Woman on Estrogen Therapy

OverviewAge: 42 yearsStage: Perimenopause (transition into menopause)Treatment: Estrogen gel for hormonal support and symptom control

The appropriate dose of estrogen depends on both age and hormone sensitivity.

Over 45 years: most women do best on 2 pumps daily.
Under 45 years: usually less than 2 pumps is sufficient, which may be a full pump, half pump, or one and a half pumps depending on symptoms.
Dosing should always be individualised and titrated according to symptom response.

The goal is to use the lowest effective dose that provides symptom relief without overstimulation.

Expected Progress Timeline

If the dose is appropriate and basic bloods (especially thyroid) are normal:

At 2 weeks: Hot flushes and night sweats are usually gone or greatly improved.
At 6 weeks: Symptom scores (for example, AMS) should be about half of the original score.
At 3 months: Scores are usually close to zero, and most women feel stable and well.

If symptoms have not improved as expected, something else may be contributing.

Common mimickers include:

MCAS (Mast Cell Activation Syndrome), which can cause flushes, fatigue, and aches.
ADHD or neurochemical imbalance, which can cause anxiety, poor focus, or restlessness despite hormone balance.

Dosing and Cycle Adjustments

Menstrual Phase	Cycle Days	Hormonal Context	Estrogen Gel Guidance
Week A – Ovulation Week	Days 7–14	Natural estrogen peaks	This is the week you should feel your best. If you do not feel fantastic or feel agitated, anxious, or overstimulated, drop your estrogen dose, for example, use half or skip a day.
Week B – Post-Ovulation	Days 15–21	Estrogen dips slightly	If symptoms return after ovulation, you may use 1 to 1.5 pumps for balance.
Week C – Premenstrual (Luteal)	Days 22–28	Estrogen and progesterone decline	You may increase to 1 to 1.5 pumps to stabilise mood, energy, and sleep.
Week D – Menstrual Phase	Days 1–7	Hormones are lowest	Continue your usual dose. Adjust slightly based on symptoms.

Symptoms of Too Much Estrogen

If you notice any of the following, reduce the dose:

Feeling wired or overstimulated
Anxiety, agitation, or poor sleep
Breast tenderness or bloating

Lower by half a pump or skip a day, then reassess after several days.

Summary

Over 45 years: usually 2 pumps daily.
Under 45 years: often less than 2 pumps, using half, full, or 1.5 pumps depending on symptoms.
Titrate dose according to how you feel, especially during Week A (Days 7 to 14); you should feel your best that week.
- If you do not feel fantastic or feel overstimulated, reduce the dose.
By 2 weeks, flushes should be gone.
By 6 weeks, symptoms should be halved.
By 3 months, symptoms should be minimal or resolved.
If symptoms persist despite normal thyroid and hormone levels, consider MCAS or ADHD-type factors as possible contributors.

This flexible, symptom-guided approach matches estrogen therapy to your natural hormonal rhythm and helps support balance and well-being throughout the perimenopausal transition.