Why more oestrogen isn’t always the answer in perimenopause

Over the past year, I have noticed a pattern emerging in clinic that I feel needs to be talked about more openly.

More and more women are being prescribed increasing doses of oestrogen during perimenopause. Often this is done with good intention, and in many cases it is genuinely helpful. But I am also seeing a growing number of women who are not improving in the way they expected. Some feel better initially, only for symptoms to return. Others find that as the dose increases, new symptoms begin to appear.

This is not a criticism of HRT. Oestrogen can be incredibly supportive and, when used well, can be life-changing. But the idea that more oestrogen is always the answer is, in my view, an oversimplification of something far more complex.

What is actually happening

Perimenopause is often framed as a gradual decline in hormones, particularly oestrogen. In reality, it is far more dynamic than that.

Hormone levels fluctuate. Signalling changes. The nervous system becomes more sensitive. Trauma that has been kept hidden for years comes to the surface. The way the body processes and responds to hormones shifts.

In this context, it can be tempting to interpret symptoms as a straightforward deficiency. If someone is experiencing low mood, poor sleep, anxiety, or hot flushes, it seems logical to increase oestrogen. And sometimes that works.

But not always.

What I am increasingly seeing is women being moved up dose by dose, without stepping back to ask a more important question. Is this actually a deficiency, or is something else driving these symptoms?

When more is not better

There is a group of women who do not feel better as their oestrogen is increased. Instead, they describe feeling more wired, more anxious, more reactive. Bloating worsens. Sleep becomes more unsettled. There can be a sense that the body is no longer responding in a predictable way.

In many of these cases, progesterone is either under-supported or not adjusted in line with oestrogen. In others, the issue is not the hormone level itself, but how the body is handling it.

Oestrogen does not simply act in isolation. It needs to be metabolised, cleared, and balanced within the wider system. If that system is under strain, increasing the dose does not necessarily resolve the issue. In some cases, it can amplify it.

The missing piece: the wider system

This is where a functional medicine lens becomes so important.

Perimenopause is not just about hormone levels. It is about how the body is functioning as a whole. The nervous system plays a significant role. Chronic stress changes how we respond to hormones and how sensitive we are to fluctuations.

The gut is also central. The microbiome influences how oestrogen is processed and recycled, which is something I have explored in more detail in my blog on gut health and oestrogen balance. If clearance is impaired, symptoms can persist regardless of how much is being prescribed.

The liver and detoxification pathways matter too. Oestrogen needs to be broken down and eliminated effectively. If this is not happening efficiently, increasing levels can lead to a feeling of overload rather than relief. DUTCH testing is really helpful here as it allows us to determine your own uniquq detoxification pathways.

There is also the question of receptor sensitivity. Sometimes the issue is not how much hormone is present, but how the body is responding to it.

When these factors are not considered, it becomes very easy to keep adjusting the dose without ever fully resolving the underlying imbalance.

Why this is happening

It is worth saying clearly that this is not about blame. General practitioners are working within time constraints, with limited training in the complexity of hormone physiology and very little capacity to explore the wider picture. Oestrogen is one of the most accessible and well-supported tools available to them, so it makes sense that it is often the first approach. HRT is all the rage and women - quite rightly - want access to it.

Awareness of menopause has increased significantly in recent years, which is a positive shift. More women are being offered support where previously they may not have been. But with that has come a tendency to simplify the narrative. Symptoms are often attributed directly to low oestrogen, and the solution becomes increasing the dose.

For some women, that works well. For others, it does not go far enough.

A more complete way of thinking about perimenopause

If you have read my previous blog on what perimenopause actually is, you will know that I see it as a phase of transition that affects multiple systems in the body.

Hormones are part of the picture, but so are:

• nervous system regulation

• metabolic health

• gut function

• inflammation

• detoxification and elimination

When we take this broader view, it becomes clear why a single lever is not always enough. What women often need is not simply more oestrogen, but better balance and better support for the systems that allow those hormones to work effectively.

What this means for you

If you are using HRT and feeling better, that is important and valid. There is no need to question something that is working well for you. But if you are finding that your symptoms are not improving as expected, or that each adjustment brings only partial or temporary relief, it may be worth stepping back and looking at the bigger picture.

Questions to consider might include:

• Is progesterone being supported appropriately alongside oestrogen?

• How well is your body clearing and metabolising hormones?

• What is the state of your gut health?

• How is your nervous system functioning day to day?

• Are there other stressors or imbalances that need attention?

These are not always addressed in a standard consultation, but they can make a significant difference.

A more balanced approach

Oestrogen is not the problem. It is a valuable and often necessary part of supporting women through perimenopause. The issue arises when it is used in isolation, without considering the wider context in which it operates.

In my work, the aim is not to replace one approach with another, but to bring these pieces together. To use hormones where appropriate, while also supporting the systems that allow the body to respond well to them.

A final thought

If something in your body does not feel settled, even after making adjustments, it is worth listening to that.

Perimenopause is not just something to get through. It is a phase that offers important information about how your body is functioning and what it needs. Sometimes the next step is not increasing the dose, but widening the lens.