Estradiol Medication (& Hormone) Guide for Menopause & Low Estrogen

Are you suffering from hot flashes, weight gain, depression or other symptoms of low estrogen?

Have you considered using the medication estradiol to help reduce these symptoms?

If so, this is the article for you. 

We are going to discuss the importance of estradiol in the female body, how it interacts with other important sex hormones, the symptoms associated with low estradiol and how to supplement/medicate with this hormone

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What is Estradiol (The Hormone)? 

As a woman, it is very likely that you've heard of the term estrogen before. 

But do you know what the term "estrogen" actually refers to?

Estrogen is really a non-specific term used to describe a class of hormones which all act on the estrogen receptors in your cells which are located throughout your body. 

The most potent, the most powerful, and perhaps the most important estrogen in your body is known as estradiol (1).

Estradiol is the most abundant estrogen in your body and it's considered to be the strongest out of all estrogens. 

Estradiol is the sex hormone in the female body which is responsible for MANY of the changes that we associate with the female body. 

Breast development, the texture and glow of the skin, the placement and development of fat in certain areas of the body (2) (hips/butt/etc.), sex drive/libido (3), mood/temperament (4), body weight, etc.

These very important characteristics, displayed by women, are all felt to be the result of estradiol (and other estrogens) action on your cells

Not only does estrogen play a critical role in the development of your body, but it also plays a very important role in your overall health. 

The decline in estradiol after menopause is felt to be one of the major and driving catalysts of heart disease (5), stroke, and cancer that women experience as they age. 

estradiol action on cardiovascular function in women

This has lead to experimentation with estradiol replacement therapy to try and blunt the negative effects associated with the aging process. 

This article will focus on how and when to use estradiol as a medication, but also how to use it safely. 

There are many other estrogens in your body, including metabolites which are created as your body breaks down estradiol and other estrogens which your body creates intentionally (6), but none are as powerful as estradiol. 

Whenever you hear Doctors or other patients, talk about estrogen you can bet that they are almost always referring to estradiol. 

In fact, most Doctors aren't familiar with or know how to interpret, other estrogens such as estrone and estriol

Because of this, estradiol is almost always the topic of discussion when you heard someone talking about estrogen. 

But estradiol is more than just a hormone, it's also a medication and one that can be used in situations of low estrogen. 

Using Estradiol for Menopause & HRT

Estradiol, as a hormone, is one of the best ways to treat women who are suffering from menopause. 

Menopause is a condition that all women will eventually face as they age. 

When women hit menopause they often suffer from very specific conditions such as hot flashes, depression, weight gain, brain fog and low energy (7).

You probably intuitively realize that these symptoms are the result of hormonal change which occurs in the body, and you would be right to think so. 

What you may not realize is that the MAJORITY of these symptoms result from the dramatic drop in estradiol levels seen in menopausal women

Menopause is the result of ovarian failure (the main place that estradiol is produced) which brings estradiol down from "normal" levels to almost near zero levels. 

This rapid drop, which usually occurs over the course of a few months, is what triggers the intense symptoms of menopause (8).

Imagine spending your entire life as a menstruating woman, with all of your cells recognizing and used to normal estrogen receptor activity, when all of a sudden it basically drops to zero levels. 

You can imagine how your body reacts to such a situation and this is one of the reasons that women have a very tough time the menopause transition!

Because the majority of the symptoms associated with menopause are caused by the rapid drop in estradiol levels, it makes sense that using estradiol as a treatment would help reduce those symptoms. 

And that's exactly what we see happen when menopause women use estradiol. 

Hot flashes fade, women generally stop gaining weight, their mood lifts, they feel more themselves and so on (9).

effectiveness of estradiol at reducing menopausal symptoms in women

While it is true that estradiol therapy is an incredibly effective tool for menopause, it should be noted that it is not without its controversy. 

Some Doctors believe that the use of estradiol may increase the rate of breast cancer and stroke. 

Some studies show this to be the case, but there are ways to not only use estradiol without increasing your risk of these side effects but to also reduce your risk of developing dementia and other medical conditions (10).

The controversy surrounding HRT (hormone replacement therapy) has to do with the exact amount that is used. 

When HRT was a relatively immature field and practice of medicine, Doctors would use very high doses of synthetic and bio-identical hormones simply because they didn't understand how dosing worked in the female body

The negative side effects associated with HRT stem from the over-use of estradiol and the use of synthetic estrogens (11) (not bio-identical estradiol). 

As long as estradiol is used in low doses (only a sufficient amount to reduce your symptoms but without causing symptoms of excess) then the risk of these outcomes is reduced (12).

From a logical standpoint, why would the use of estradiol (in normal levels that your body has been used to for decades) cause breast cancer all of a sudden?

The use of estradiol as a hormone can scare people, but remember that you should only aim to use the exact amount that your body is used to. 

Using this amount should NOT result in negative outcomes. 

Afterall, if your body tolerated it for 40+ years why would it all of a sudden reject the exact same hormone now? 

There are an art and a science to hormone replacement therapy, especially with estradiol, and you should never take estrogens unless you have a known and documented deficiency

Testing for Low Estrogen/Estradiol (Test before you use!)

One of the best and most effective ways to identify low estrogen is to simply use a standard blood test. 

Serum blood testing can be used to isolate and quantify the number of hormones that your body is able to produce. 

Estradiol, along with progesterone, can be tested in your blood and should be tested before you decide to use this powerful hormone. 

These basic hormones can be easily ordered by your physician and are covered by insurance (so it shouldn't cost you any out of pocket money in most cases!). 

Identifying and diagnosing low estradiol is actually much easier than high estrogen

Low estrogen, including estradiol, is seen in loads of women who are post-menopausal. 

Why?

Because the ovaries no longer produce the hormone!

So, classic blood tests in post-menopausal women look like this: 

post menopausal progesterone and estradiol levels

In this example, you can see that the estradiol level is less than 15 pg/mL which is the most sensitive range that this particular lab test can quantify. 

This kind of presentation is classic among post-menopausal women. 

Whenever you decide to test for estradiol, make sure that you also test for progesterone. 

These hormones should not be evaluated in isolation, and instead should always be ordered in pairs. 

Progesterone is the perfect counter-balance to estradiol, so using one without the other may cause imbalances in the body and further symptoms. 

You can read more about progesterone testing in this article

Just like estradiol, progesterone levels tend to be very low in menopausal women

Dosing Estradiol & Other Estrogens

It would be nice if I could give you the exact guide to dosing estradiol but, unfortunately, it's not quite that simple. 

You have to realize that each person is slightly different in terms of what is "normal" for them and how well they will "tolerate" hormone replacement therapy. 

What this means is that each person will probably need their own unique dose of estradiol which will need to be adjusted to over time. 

The best way to get to that point is with frequent blood tests and with frequent symptom evaluation. 

Dosing based off of these two principals will help you achieve the optimal dose without increasing your risk of the negative side effects we discussed previously

You will notice that most standard pharmaceutical estradiol preparations come in standardize doses which are not necessarily easy to titrate or adjust. 

Because of this, it may be necessary to get your estradiol in a compounded cream or gel. 

Compounded estradiol (especially if in the bi-est formulation), at low doses, is easier to titrate when compared to some standardized pharmaceutical formulations

Afterall, it's both safer and easier to increase your dose as opposed to reduce your dose. 

When in doubt make sure to follow the outline below and always start low and go slow! 

Do's and Don'ts of Estradiol use: 

DO'S

  • Take enough to reduce your symptoms (hot flashes, etc.)
  • Use estrogen via the transdermal route
  • Check your serum estrogen and progesterone level frequently
  • Use in conjunction with progesterone
  • Take a "hormone holiday" either weekly or monthly
  • Take only in the setting of documented deficiency of estrogen after evaluating your own personal risks (history of breast cancer, etc.)

DON'TS

  • Don't use enough estradiol to cause breast tenderness or menstrual bleeding
  • Take estradiol orally
  • Take hormones without assessing your serum levels over time
  • Use estradiol by itself or without progesterone
  • Use continuously, without taking hormone holidays or breaks for your body
  • Take because of "suspected" low estrogen without testing your blood first (other imbalances can mimic low estrogen)
  • Take if you are menstruating

It should be noted that HRT, of any kind but especially estradiol, should be done with the guidance and care of a knowledgeable physician. 

There is simply no substitute for this kind of care which will dramatically increase the amount of time it takes for you to adjust your medication and find an optimal level for you. 

Bi-est vs Estradiol vs Progesterone for HRT

As a medication, estradiol can be taken by itself or, more frequently, used in combination therapy with other hormones or even estrogens. 

Among physicians who specialize in hormone replacement therapy, bi-est is rarely given by itself. 

Instead, it is often compounded together with another estrogen known as estriol. 

The combination hormone of estradiol + estriol is known as bi-est and this combination is usually further paired with progesterone. 

The reason that estradiol is paired with estriol is that, by itself, estradiol is a very potent estrogen. 

Remember, one of the main tenets of hormone replacement therapy is to provide only the exact amount of hormone necessary to the body (without providing excess hormone). 

Estriol, a weaker estrogen, is felt to be protective to certain tissues (such as breast tissue) when combined with estradiol. 

In this way, it's possible to take estriol as an estrogen blocker of sorts (even though it is an estrogen itself), to help combat the potency of estradiol. 

Most formulations of bi-est contain around 80% estriol to 20% estradiol, so the dose of estradiol necessary is often much smaller than you realize. 

The ratio and concentration of estrogens in bi-est can be further titrated or adjusted based on the needs of the individual (some women will simply need more estradiol compared to others). 

In addition, bi-est is often paired with progesterone which also has antagonistic effects on the growth potential of estrogen. 

Progesterone, from the perspective of the body, helps to balance estrogen (13).

Under normal physiologic conditions (such as what occurs during the menstrual cycle) your body produces both estrogen and progesterone (14).

When you undergo hormone replacement therapy, you will want to mimic this natural pattern to the best of your ability. 

Doing so will help reduce unwanted and negative side effects. 

Side Effects of Estradiol

Is Estradiol safe to take? Does it have side effects?

The short answer is yes, the long answer is maybe. 

Most of the side effects associated with estradiol stem from either over-use of the hormone (meaning your dose is too high) or the fillers/binders in the gel/cream preparation (meaning an inactive substance inside of the medication). 

It's very unusual for someone to be "allergic" to the active hormone ingredient of estradiol

Your body should be used to this hormone because it has produced it naturally for decades. 

Having said all of this, I've provided a list of some of the symptoms associated with estradiol use reported by women: 

  • Weight gain
  • Bloating
  • Hot flashes
  • Breast tenderness
  • Menstrual bleeding
  • Irritability
  • Mood changes
  • Headaches

Many of these symptoms tend to subside by adjusting your dosing. 

And this is where a knowledgeable physician can help you dramatically. 

When you experience symptoms always do your best to determine if the symptoms you are experiencing are caused by excessive dosing (meaning too much) or by insufficient dosing (meaning too little). 

It's very possible to use estradiol and still exhibit symptoms such as hot flashes, but with a little bit of finer titration, the symptoms will subside. 

Because estradiol is a potent estrogen it is not available over the counter (unlike progesterone which is available OTC). 

This means you will need a prescription from your Doctor to get this hormone. 

Final Thoughts

Estradiol is a powerful and potent hormone which can be used as part of hormone replacement therapy for women who suffer from low estrogen (or the symptoms of low estrogen). 

The most common condition which causes low estrogen is menopause and this is something that ALL women will experience at some point in their life. 

This doesn't mean that all women necessarily have to taken estradiol therapy, but it can, and should, be considered in women who suffer from quality of life symptoms associated with menopause. 

Whenever you consider using estradiol ensure that you are using a small, but sufficient, dose which will take away your symptoms without overmedicating your body. 

This strategy will help you reduce almost all of the negative and unwanted side effects associated with estradiol use. 

For many reasons, it may be better to use the formulation bi-est instead of estradiol therapy

In addition, you should always consider using progesterone along with estradiol to help combat the growth-enhancing effects of estradiol on endometrial and breast tissues

Now I want to hear from you:

Do you have low estradiol levels?

Are you also in menopause?

Have you considered HRT before?

Are you using it now?

Is it working for you?

Leave your comments below! 

References (Click to Expand)

Dr. Westin Childs

Dr. Westin Childs is a Doctor of Osteopathic Medicine. He provides well-researched actionable information about hormone-related disorders and formulates supplements to treat these disorders.He is trained in Internal Medicine, Functional Medicine, and Integrative Medicine. His focus is on managing thyroid disorders, weight loss resistance, and other sex hormone imbalances.You can read more about his own personal journey here.

25 thoughts on “Estradiol Medication (& Hormone) Guide for Menopause & Low Estrogen”

  1. Great article! I wonder though about women like me who take birth control pills and still are low in estrogen. I’m only 27! So not menopause age.

    Reply
    • Hi Julie,

      If you test your estradiol while you are taking birth control then your values will be suppressed due to the synthetic hormones, the only way to determine if you are actually low in estradiol is to go off of the birth control medication and let your body rebound.

      Reply
    • Hi Sandy,

      In the majority of cases, it is safe, but each person should be evaluated on an individual basis. Things like a strong family history of breast cancer might be reasons to avoid HRT.

      Reply
  2. I agree that one should use bio-identical hormones when possible in lowest possible dosing. BUT there are some of us for whom the bio-identical hormones do not work, we cannot absorb through the skin. Have tried every transdermal option, even the Femring, creams, gels, spray, patches, etc.. they have not raised my level one bit. The only option that works for me (surgical menopause) is injecting Depo-estradiol. I will not use Premarin either.

    Did you know that women in natural menopause can still produce up to 40% of their hormones after menopause? Those of us in surgical menopause produce almost nothing especially if adrenal function is compromised. So it’s even more important to replace hormones for those in surgical menopause. Drs make it sound so easy to replace hormones after a hysterectomy/oophorectomy but they are so wrong.

    If you are in surgical menopause and replacing hormones (estrogen, progesterone, testosterone), do you still need to take a hormone holiday? It seems like the fluctuations in levels would be more difficult to deal with than staying on a constant low (necessary) level of hormones.

    Reply
    • Hi Fio,

      If the transdermal route doesn’t work you can try vaginally or peri-anally which is technically mucosa (different from skin) and usually does the trick. It’s difficult to address every situation in a short article, especially something as complicated as this, but in general, I believe that some fluctuation in hormone levels (with hormone holidays) is beneficial to the body and should be attempted.

      Reply
  3. Great article, just when I needed it! I’ve been suffering from horrible hot flashes lately (I don’t think I have slept a whole night since January when my periods just stopped…for good, it would seem). I have also been suffering from mood swings and feeling less energetic than I used to. My family doctor even offered me antidepressants which I declined…I have now found a doctor specializing in hormones and using bio-identical hormones only, and I so look forward to getting the help I desperately need. After all, I’m only 49 and don’t want to live like this for years to come…this article has helped me prepare better for my doctor’s appointment, and now I know which questions to ask.

    In this context, Dr. Childs: do you agree with many articles and books on the subject saying that estradiol is only safe to use for five years (sorry if it’s mentioned in the article and I missed it)?

    Catherine

    Reply
    • Hi Catherine,

      If used correctly, and in low but adequate dosages, it can be used longer than 5 years. In fact, the benefit to memory and cognition (and reduced rate of Alzheimer’s) isn’t realized until 5-10 years of use.

      Reply
  4. I am taking bio-identical hormones for many years and I am 70 years old now. I would love to know which reference range to use if I am taking bio-identical hormones. I don’t think I should use the menopause reference range. but I am not sure which one to look at.

    I have Mercury poisoning and autoimmune Hashimoto’s thyroiditis and my estradiol is very high so I have stopped taking it for a while until I get straightened out.

    Please tell me what is the reference range to look at if I am taking bio-identical hormone cream, and the progesterone cream?

    Reply
    • Hi Dhyanna,

      I tend to avoid looking for estrogen/progesterone to fit a specific “reference range” because it’s difficult to know what is optimal for each individual (it varies from person to person). I tend to try and find the lowest possible dose which is effective clinically.

      Reply
  5. I had a total hysterectomy done @ she 32 (Endometriosis).
    I wore Estrogen HRT patch 0.05, for 24 years.
    My health insurance refused to pay for the Estraderm patch which was working perfectly. They would give me a patch but it was @ their choice of the manufacturers & SIZE. None of them stayed on well or they were so LARGE (size of a dessert plate) & colored to match ‘who knows who’s skin, not mine! I found the new patches annoying & a constant reminder that I had to wear a patch.
    In frustration, I stopped wearing the patch. It’s now been 9 years. My ability to sleep has increased (I now sleep 90 mins per night) I have hot flashes 3-4 per hour all day & night long. I’m depressed, gaining weight, I have no energy & feel like I can’t recall or think straight. (Also, a decrease in my immune ability).
    I have mentioned this to my primary which I have since changed doctors trying to get a new prospective view, with no understanding or luck.
    My question to you is: can I restart an estrogen hormone?
    Thank you for any time you put into this matter.
    Corky

    Reply
    • Hi Corky,

      You may be able to restart estradiol to help with your hot flashes but you will need a knowledgeable physician to prescribe it and dose it for you. Most of the time you’ll have much better luck looking outside of your PCP or endocrinologist as they really don’t specialize in HRT management.

      Reply
  6. I’m struggling find a physician and would like to understand my lab results so I understand when to increase or decrease estradiol and if I have estrogen dominance. Can you please give us a guide to interpreting blood serum levels and the ratios?
    I am 46, had a hysterectomy at 42 with my ovaries left intact. I not ever had an issue with my weight and have been the same weight for the last 12 years. Between July-Sept went from 121 to 126 and Oct to present, 131 lbs.
    In Aug, I suspected that my hormones were off: weight gain, excessively tired, brain fog, anxious, no libido, loss of muscle tone, and a tendency to feel gloom-all not normal for me. I saw an gyn. and blood tests showed that I was post menopausal.
    Serum Test: <3, LH: 40.3, FSH: 97.5, Estradiol: 53.1, Vit D <20 and deficient, Thyroid normal. The Dr. recommended pellet therapy, oral Dim, 10,000 Vit D supplent for 3 mths.
    1 mth after pellets, I was experiencing incredibly oily skin and hair, acne on jawline, neck, chest, back. I ordered my own labs: Estradiol: 75.8 and Testosterone: 388. I scheduled an appt. Dr. said test. was high, she would reduce dose at next insertion, wanted to give me an estrogen boost, and prescribed minocycline for acne. I chose not to continue pellets. 4 mths later, no treatment: Testost: 94, Estradiol: 23.9. She then prescribed .1 transdermal estradiol, 2x week. One month after patches only, acne started to return. So I stoped everything.
    It’s been 2 mths since any treatment, other than taking Vit D, 10,000. Here are my current lab results:
    Testosterone, Serum 45
    Free Testosterone(Direct) 0.6
    DHEA-Sulfate 44.8
    Estradiol 25.7
    Progesterone 0.1
    Estrogens, Total 112
    Estrone, Serum 63

    I’d love to find a physician in San Antonio, but I still need to understand my levels? Too high, too low, estrogen dominant…It’s massively confusing! My priorities right now are: getting the weight off, improving energy, clearing my brain- without getting the acne of a 14 year old boy. I feel fat, funky and greasy and that feeling seems to be the biggest factor in my loss of libido and funk.

    Reply
  7. I had surgical menopause at age 45 some 21 years ago. Started synthetic estrogen with regular doctor then switched to bio-creams of estrogen, progesterone and testosterone at age 55. Did this and felt great until I had to change doctors and had to go back to synthetic estrogen patch. Fast forward now age 66 and have pellets of estriol and testosterone for about 6 months. Testosterone’s 385 and estriol is 90. I like my libido and vaginal health but I’ve gone from 128 to 134 and am gaining about a pound a month. Would adding progesterone help? I also use synthroid and cytomel which shows normal and stable labs.

    Reply
  8. I am currently taking Life-flo BIest (OTC preparation of 80% estriol/20 estradiol)….I am experimenting. My main concerns are sleep, bloating (big belly that I never had before), weight gain although I am also on hydrocortisone for adrenal insufficiency. I have also been in the past on estradiol patch 0.025 which seemed to be right for me because if I did more my boobs were sore. Sleep has not improved with HC or anything. How do I get the sleep I used to have without taking 1/2 unisom each night?

    Reply
  9. I just went to a new doctor last week. She tested my blood and prescribed Estrodial (E2) 1mg in capsule form. I saw that you posted that the hormone should not be taken orally. Why is this? Thank you!

    Reply
    • Hi Beth,

      Because of the first-pass metabolism in the liver by all oral medications. Taking it transdermally bypasses the first pass metabolism and allows saturation of estrogen receptors in the body at lower doses.

      Reply
  10. What type of specialist should I look for to help me menopause symptoms? I am considering taking a hormone therapy as I have horrible brain fog and not able to get a full 8 hours of sleep each night. I want to find someone who will run the proper blood work, etc. Would you be able to recommend anyone in the VA/DC/MD area?

    Reply
  11. Hello!
    Your article was very well-worded and comprehensive. Thank you!

    I am 27, and I just went in to test my hormone levels because I have been experiencing severe hot flashes, mood swings, anxiety, brain fog, fatigue, etc and it usually worsens around my period (which lasts for about 2 days and is very light). My results came back indicating that I have near-zero levels of Estradiol, and my doctor wrote me a referral to a gyno and said I should have a sonogram of the uterus area first and speak to them about further treatment.

    I am currently taking a low-dose birth control (Gestoden .075mg, Ethinylestradiol .02mg) and I saw that you mentioned birth control could skew the test results. Is it worth stopping the birth control and re-taking the test, or is it likely that my levels are still within the very low range?

    Any insight would be so helpful, thank you!!

    Reply
    • Hi Anya,

      All women on birth control will have near-zero estradiol levels because of how birth control pills work. They suppress LH and FSH levels which are what naturally stimulate estrogen and progesterone. The synthetic hormones in your birth control pills are taking over for your natural estrogen and progesterone and this is part of the reason that certain birth control pills increase your risk of breast cancer.

      You can’t accurately test estradiol or progesterone while taking OCP unless you stop them completely and let your HPA axis recover. Most women don’t know this is occurring in their body, which is very unfortunate.

      Reply

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