Individualisation of hormone replacement therapy
every woman is different
How much estrogens?
Normal concentrations range from 150 to 400 pgr/ml. The Bioavailability after intake of a pill varies at least 4 times. Therefore the right dose in individual women varies more than 4 times, with 0.5 mg being enough in some, and 2 mg being insufficient in other women.
Unfortunately, the decision is clinical, with trial and error since blood exams to determine the ideal dose in the individual woman do not exist.
Therefore hormone replacement, is started with a ‘standard’ dose, knowing that this will be too low for most, but avoiding an overdose in some.
The adjustment of dosis is clinical and experience based. This is difficult with commercially available products: half a dose could be given, but consider giving 3/4 or 5/4.
Individualise administration
Except for contra-indications, it is a choice of the woman to use oral, transdermal or vaginal administration or implants.
Which Hormones ?
The are >4 oestrogens (e.g. estradiol, estrone, ethinyl-oestradiol), >10 progestagens and several androgens. These products vary in solubility, metabolism, effect on microbiota with a slightly different effects on the end-organs. The relative efficacy on several end organs, such as the breast, vagina and uterus, is relatively well known, but brain effects, either directly or secondary to bowel microbiota, are poorly understood. Since research from trials address the ‘average effect in the average woman‘, individualisation of the right combination results from clinical experience.
Most women are not happy with a standard dose. Not every pill is ok for every woman but there is a perfect pill for every woman 
Which regime of administration
- sequential with menstruation. This mimics the menstrual cycle, but the amount of blood loss can be adapted.
- estrogen only e.g. in women without a uterus
- continuous-combined with amenorrhoea in most women, but 30% will have spotting, which can generally be solved by changing products
Conclusion: individualisation is necessary
- Commercially available products are ok for the average woman
- Individualisation requires experience and knowledge such as simple rules of >10 days of progestagen intake
- For every woman, an optimal (combination) therapy can be found.
Decision tree
I do not have complaints, and I do not like hormones: only symptoms are treated.
or
I understand the advantages of HRT
- to feel better
- with many advantages.
- and less colon cancer and cardiovascular diseases as a bonus
- Breast cancer; not more cancers but increased growth and early diagnosis of a less invasive cancer
Ageing versus HRT
HRT is not a prevention of ageing.
The mechanisms of ageing and the place of melatonin, growth hormone, food intake and microbiota are not clear yet.
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