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

Case Study: 42-Year-Old Woman in Perimenopause Using Oestrogen Gel

Perimenopause is a time of fluctuating ovarian hormones, not simply low oestrogen. Younger women may still produce substantial amounts of their own oestrogen, particularly around ovulation, so they often need less additional oestrogen than women later in the menopause transition.

How Much Oestrogen?

In my clinical experience:

• Over approximately 45 years: around 50 micrograms transdermal oestradiol, approximately the medium-dose range or around 2 pumps of Estrogel, is often effective.

• Under approximately 45 years with preserved ovarian function: around 25 micrograms, approximately the low-dose range or around 1 pump of Estrogel, is often sufficient.

• Some younger women need less or no additional oestrogen around ovulation, when their own oestrogen is naturally high, and may need a small amount again during the luteal phase as oestrogen falls.

• Always use the lowest effective dose and adjust according to symptoms within the treatment plan agreed with your clinician.

What Improvement Should You Expect?

If the dose is right and other contributors, particularly thyroid dysfunction, have been excluded:

• 2 weeks: hot flushes and night sweats should be greatly improved.

• 6 weeks: your menopause symptom score should be approximately halved or clearly improving.

• 3 months: symptoms should be minimal or significantly improved.

If this is not happening, do not automatically keep increasing oestrogen. Consider other causes, including MCAS, ADHD or neurodivergence, thyroid disease, sleep problems and other medical conditions.

Learn Your Hormonal Signature

In younger women who are still ovulating, I find it useful to start by looking at Days 7–14, when natural oestrogen is rising.

Phase	Cycle Days	What Is Happening	Oestrogen Guidance
Week 1: Approaching Ovulation	Days 7–14	Your own oestrogen rises and peaks around ovulation.	You should usually feel your best here. Younger women may need less or sometimes no additional oestrogen if they feel well. If you feel wired, anxious or overstimulated, the dose may be too high.
Week 2: Menstrual / Early Follicular	Days 1–7	Oestrogen and progesterone are initially low, then oestrogen starts rising.	Use your usual low dose or less according to your established symptom pattern.
Week 3: Post-Ovulation / Early Luteal	Days 15–21	Oestrogen falls after ovulation while progesterone rises.	If symptoms return, some younger women may need approximately ½ to 1 pump within their prescribed range.
Week 4: Premenstrual / Late Luteal	Days 22–28	Oestrogen and progesterone fall before the period.	Symptoms may increase. Some women need the upper end of their individually prescribed range during this phase.

These days are a guide. Perimenopausal cycles vary, and ovulation does not always occur on Day 14.

Signs You May Have Too Much Oestrogen

Consider reducing the dose within your agreed treatment range if you consistently develop:

• Feeling wired or overstimulated

• Anxiety or agitation

• Poor sleep

• Breast tenderness

• Bloating

• Headaches or migraine

The timing matters. If these symptoms appear during Days 7–14, when your own oestrogen is already rising, more oestrogen may not be the answer.

What If You Are Still Not Doing Well?

If hot flushes and night sweats have improved but you still have significant symptoms, do not assume that you simply need more HRT.

There may be another pathway contributing.

I use a pathway approach because not every symptom in midlife is caused by hormones alone. Some women have a mainly hormonal pathway, others have a stronger histamine/MCAS pathway or metabolic pathway, and many have a mixed pathway where several are contributing at the same time.

The purpose is to identify the main driver of symptoms so treatment is directed at the whole picture: rather than simply increasing HRT when something else may also need attention.

Pathway	What It Means	Typical Clues
Hormonal Pathway	Symptoms are mainly being driven by fluctuating or falling oestrogen and progesterone during perimenopause or menopause.	Hot flushes, night sweats, sleep disturbance, vaginal dryness, mood change, brain fog, headaches, reduced libido and symptoms that follow a clear menstrual-cycle pattern. Symptoms usually improve significantly with appropriately titrated HRT.
Histamine / MCAS Pathway	Mast cells are more easily activated and release histamine and other inflammatory mediators. Hormonal fluctuations, especially oestrogen changes, can aggravate this pathway.	Flushing, itching, hives, headaches, migraine, palpitations, dizziness, nasal symptoms, reflux, bloating, diarrhoea, food reactions, fatigue, body aches, bladder symptoms and brain fog. Symptoms may be triggered by foods, alcohol, heat, stress, infection or hormonal changes.
Metabolic Pathway	Symptoms are being influenced by insulin resistance, altered glucose regulation, visceral fat, inflammation, poor muscle mass or other metabolic changes that often become more apparent around midlife.	Weight gain around the abdomen, increased hunger or cravings, difficulty losing weight, fatigue after meals, poor energy, raised triglycerides or glucose, fatty liver, sleep apnoea, hypertension and worsening cardiovascular risk.
Mixed Pathway	More than one pathway is contributing at the same time. This is very common. Hormonal changes may be present alongside histamine, metabolic, neurodivergent or other drivers.	HRT improves some symptoms but significant problems remain. For example, flushes improve but gut symptoms, headaches and palpitations continue, or sleep improves but fatigue, weight gain and metabolic symptoms remain. Treatment needs to address each contributing pathway rather than continually increasing HRT.

In simple terms: Hormonal Pathway = hormones are the main driver. Histamine Pathway= mast cells are contributing. Metabolic Pathway = insulin, weight and metabolic health are contributing. Mixed Pathway= more than one pathway is active at the same time.

Possible Contributor	Typical Clues	What to Look For
MCAS / Histamine Pathway	Flushing, headaches, migraine, palpitations, itching, nasal symptoms, reflux, bloating, diarrhoea, fatigue, body aches, brain fog and reactions to foods, alcohol, heat or medications.	Symptoms may fluctuate with hormones because oestrogen can influence mast-cell activity. If classic menopause symptoms improve on HRT but multiple allergy, gut, skin or histamine-type symptoms remain, consider an MCAS or histamine pathway.
ADHD / Neurodivergence	Poor concentration, executive dysfunction, procrastination, overwhelm, restlessness, emotional dysregulation, poor sleep and difficulty coping with demands that were previously manageable.	Hormonal fluctuations can worsen previously compensated ADHD symptoms. HRT may help the hormonal component, but increasing oestrogen will not necessarily treat the underlying ADHD.
PMDD	Severe mood symptoms that appear mainly in the luteal phase, usually in the week or two before the period, and improve markedly shortly after menstruation starts. Symptoms may include severe irritability, anxiety, depression, emotional sensitivity and feeling unable to cope.	The key feature is a clear symptom-free or much-better interval during the follicular phase. Prospective daily symptom tracking over at least two cycles is useful.
PME: Premenstrual Exacerbation	A condition such as anxiety, depression, ADHD, migraine or another chronic problem is present throughout the month but becomes significantly worse premenstrually.	Unlike PMDD, symptoms do not disappear during the rest of the cycle. There is a baseline problem with a clear premenstrual worsening.

PMDD and PME Are Not the Same

This distinction is important.

With PMDD, the woman is generally much better during the follicular phase and then develops severe cyclical symptoms during the luteal phase.

With PME, there is already an underlying condition throughout the month, but hormonal changes before the period make it significantly worse.

For example:

ADHD all month + marked deterioration before the period = possible PME of ADHD.

Little or no mood disorder for much of the month + severe predictable premenstrual mood symptoms = consider PMDD.

This is why tracking symptoms against the menstrual cycle can be so useful.

The Key Message

Under 45 and still ovulating: I often find women need around 25 micrograms or approximately 1 pump, sometimes less around ovulation, with small increases during the luteal phase if symptoms return.

Over 45: I often find around 50 micrograms or approximately 2 pumps is an effective working dose, although every woman is different.

Do not chase every bad day with more oestrogen.

Look for the repeating pattern across the cycle.

And if the hormonal symptoms have improved but you are still not well, think beyond oestrogen:

MCAS. ADHD. PMDD. PME. Thyroid. Sleep. Metabolic health.

Treat the whole person.

Learn the signature of your hormones and use the lowest amount of additional oestrogen that keeps you well.

If you have a uterus, appropriate progesterone or progestogen protection is still required.

Under 45 and still ovulating: I often find women need around 25 micrograms or approximately 1 pump, sometimes less around ovulation, with small increases during the luteal phase if symptoms return.

References

1. Australasian Menopause Society. AMS Guide to MHT/HRT Doses, Australia. Low-dose therapy includes Estrogel 1 pump daily and 25–37.5 microgram oestradiol patches; medium-dose therapy includes Estrogel 2 pumps daily and 50 microgram oestradiol patches.

   
   

By Dr Purity Carr

GP and Menopause Doctor

Daily Instagram live at 7am at #drpuritycarr

Harvey, WA

6220