Is There Such Thing as Too Much Estrogen? An Expert Weighs In (2024)

Almost all menopausal symptoms can be traced to one culprit: the dramatic drop in estrogen levels that happens when your ovaries head into retirement. Because you have estrogen receptors throughout your body, this sudden hormonal shift sets off a cascade of crazy-making symptoms, from hot flashes and broken sleep to memory and mood issues to joint pain and vaginal dryness. (For more on the transition, see our primer.)

Boosting your estrogen levels via hormone replacement therapy (HRT) can greatly reduce or even alleviate these symptoms. But there are significant long-term benefits, too. The wonder hormone can help reduce inflammation, lower the risk of coronary heart disease, maintain metabolic health, and improve the way neurotransmitters such as serotonin function in your brain.

All of which leads to the question: If estrogen is so critical to squashing menopause symptoms and safeguarding your bones, heart, and brain, wouldn’t you want to take as much of it as possible? More estrogen, more benefits? Not so, says Sharon Malone, MD, an ob-gyn, certified menopause practitioner, and chief medical advisor at the menopause telehealth platform Alloy. Here, she explains the nuances of estrogen dosing and how to get the optimal amount for you.

Is there such a thing as too much?

Yes, you can have too much estrogen. “The number of postmenopausal women who go beyond two milligrams of estrogen is exceedingly low,” says Malone. “I have never given anyone three milligrams.” The largest premade dose of estrogen is two milligrams (larger doses could be compounded at a specialist pharmacy, but Malone says it would be “exceedingly rare” to prescribe more than two milligrams). The issue, she explains, is that the risk of certain symptoms increases with higher doses: “Women who are more sensitive to estrogen might have more nausea or breast tenderness.”

The risk of developing a blood clot also goes up as the dose increases, but only if you take oral estrogen (i.e., a pill.) The risk doubles with this mode of delivery because it has to pass through your liver for activation—that’s how it’s metabolized—and passing through the liver increases the blood-clotting factors. Malone is quick to point out that “even though the risk doubles with oral HRT, the baseline level is very low.” (We’re talking about an increased risk factor from a baseline of 6 in 10,000 to 12 in 10,000.) For most people, she notes, this shouldn’t be a concern.

Transdermal estrogen (in the form of a patch, cream, gel, or spray) doesn’t come with the same risks because it bypasses the liver. However, some women may not absorb estrogen as well with this method (more on this below) and may do better with tablets. Others prefer tablets because they are often half the price of patches—or becausethey dislike the sticky residue that patches can leave behind.

To put things into perspective, levels of estrogen from HRT are much lower than those found in the contraceptive pill. “The amount that you take in menopausal hormone therapy is anywhere from a half to a third of what the dose is in birth control pills,” says Malone. “Even in perimenopause, the dose is equivalent to low-dose birth control pills.” Because of the higher doses of estrogen, the contraceptive pill comes with different contraindications: a slightly increased risk of cardiovascular issues, and a blood clot risk of 1 in 3,000 (much higher than that associated with taking oral HRT).

Is there a perfect dose?

This is totally subjective. Malone says she always starts her patients on a low dose—orally, this is 0.5 milligrams, while the lowest-dose transdermal patch is 0.025 milligrams (although she most often skips this dose in favor of the next one up—0.375 milligrams, which is more effective for most women). If a patient still has symptoms a week later, she’ll gradually increase it. “We used to give the advice that you should be on the lowest possible dose for the smallest amount of time,” she explains. That is no longer the case. These days, the recommendation is that you should be on the dose that takes care of the symptoms for as long as you want (providing you don’t develop one of the contraindications to using HRT, such as breast cancer. Note: For women without a history of breast cancer, there is no significant increased risk from taking body-identical HRT for the first five years—and after that, the risk is lower than that associated with drinking two glasses of wine a night, not exercising, or being overweight). “There’s no value in saying, ‘Well, I feel kind of okay.’ You should feel good,” she says. “It’s not about cutting your hot flashes from ten to five; they should go from ten to zero.” In other words: Pay close attention to how you feel (take notes if it’s helpful), don’t accept partial relief, and speak up.

What else impacts the dose you need?

How much estrogen you need will depend on everything from your own physiology to the way your body absorbs estrogen. “We don’t know why some women absorb estrogen better than others—just as we don’t know why others are more sensitive​​ to it,” notes Malone. It’s hard to predict just how your body will react to HRT—making it even more important to advocate for yourself.

Another factor in dosing is how long it has been since you reached menopause (this milestone happens one year from the date your last period started). “Younger women who are newly menopausal may need a higher dose—one milligram instead of 0.5 milligrams, for example,” explains Malone. “The age of the person matters, as does the recentness of their last period.” Most of the time, women will stay on the dose that works for them—usually, there’s no need to taper down with age. “I’ve been on the same dose for 15 years,” she says.

Can I mix local and systemic estrogen?

If you’re on oral or transdermal HRT, you may worry that using a local estrogen—such as an estriol face cream or some kind of vaginal topical—will mean hormonal overload. Don’t worry, says Malone. “The amount in a standard topical vaginal estrogen—be it a cream, a ring, a tablet—is usually a very low dose, and it tends to stay where you put it. Studies show that with both the face cream and vaginal estrogen, the dose isn’t enough to be picked up systemically.”

What if my dose stops working?

Once you and your doctor have found the appropriate dose to keep symptoms at bay, you’ll most likely be able to stick with it. Per Malone: “Very rarely do we have to adjust the dose once someone is settled on it.” If a patient experiences a reemergence of symptoms, though, Malone considers whether there might be issues with absorption—for example, a patient might be taking a new medication that causes an interaction that impacts the body’s ability to utilize estrogen. If she suspects there’s an issue with the body’s uptake of HRT, she’ll order blood work to check how well the body is absorbing the estrogen. She’ll also double-check that the patient isn’t taking a compounded version of hormone—something she doesn’t recommend, because “you don’t have a guarantee that they are manufactured to a standard. Is it consistent? Is it the same dose? Just because it says it on the bottle doesn’t mean it’s the same thing.”