Menopause Matters Forum
Menopause Discussion => Postmenopause => Topic started by: Mary G on November 05, 2021, 08:00:59 PM
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I had a consultation with a German doctor in Spain last week who specialises in gastroenterology, hormones and migraines. Although his speciality is gastroenterology, he has a special interest in this subject because has wife is menopausal.
Fortunately my silent migraines have reduced to virtually zero since I started using compounded progesterone three years ago but I still have the odd migraine type gastric issues (loose bowels) from time to time so I thought it was worth running this past a specialist.
It was a very interesting consultation. He said that I am probably taking too high a dose of oestrogen for someone who is very post menopause and that it is going straight to the oestrogen receptors in the gut hence the occasional loose bowels. Apparently this is not at all uncommon and he has had other women coming to him with similar problems. I did a FIT test (which was negative thankfully) and he suggested I reduce both the oestrogen and the progesterone dose slightly and see what happens.
Just over a week later, my digestive system is completely back to normal and I'm feeling very good indeed so this suggests he was right.
During the consultation, we talked about how I needed a very high dose of oestrogen to feel good ten years ago and to keep the migraines away and he explained that in the background and over time, my body has changed and I obviously no longer need such a high dose of oestrogen. I was literally dumping the oestrogen my body doesn't need.
So the menopause is an evolving situation and you need to be prepared to make changes to your HRT regime when necessary. I have been on a lowish maintenance dose for some time now but I now realise I need to go slightly lower.
This will only interest a small minority of women on here but I thought it was worth posting my experience.
One further point... I mentioned how so many women have bowel issues with HRT on here (which did not surprise him at all) and he recommended annual FIT tests which he says are very reliable. Migraines at menopause are also very common.
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Lovely to hear from you : :thankyou:
It doesn't surprise me re bowel issues. You have probably read that I was often 'constipated' in the week leading up to a period, followed by the need to rush. I would get the urge 10 mins. B4 a bleed began, even if a period wasn't due. So travelling 'at that time of the month' had to be carefully considered. I had to be near a loo, there was no other option. I can't remember how long this went on for nor how it resolved.
Those who don't require HRT to control symptoms will probably have a 'natural' drop in hormones without realising?
How's the weather in Spain?
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Hello Maryg - that’s really interesting info from your consultant as it’s exactly what I’ve discovered on my meno ‘journey’. God knows I loved my oestrogen, but I got to the point where it just made me feel unwell and reducing made me feel better. I still don’t understand exactly why this happened and suspect there’s some sort of adrenal/thyroid dysfunction at play, but whether that was caused by hrt or not I imagine I’ll never know. I’m currently seeing a private endo and together we’re trying to unpick it all as I’m not averse to continuing a small maintenance dose for all the benefits it brings to overall health. Interestingly I now do well on dhea and progesterone, at low topical doses.
I do wonder if in post meno the hypo-pituitary system just decides no more of this, we need that, in terms of hormone supplements and if general down regulation of receptors is, well, normal. I’m now 59, 10 years of hrt, but the body is having none of it in terms of oestrogen, and no symptoms eg sweats since I stopped oestrogen entirely. Bizarre.
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MaryG, now 9 years postmenopause & as a fellow migraineur & life-long IBS-C sufferer I'm also very interested in the role sex hormones play in functional gut disorders & migraine. I find the opposite effects from higher doses of oestrogen to those you've experienced, i.e. increasing my oestradiol dose slows gut transit, thereby worsening my pre-existing IBS-C. Those of us with migraine tendencies do seem to also be more prone to digestive dysfunction & as both conditions can be profoundly affected by HRT, I think our need for replacement can be especially difficult to manage.
I posted a link to a study some time ago in the long-running "Poo" thread, that found that oestrogen (as well as has been long known - progesterone) delays rather than increasing rate of gastric emptying. I'm not citing this to contradict your experience, rather to agree that in my experience sex hormones can have profound effects on the GI tract & I can absolutely believe your gut is also highly sensitive to the effects of HRT. I won't post the link here as it's not relevant to your main point that we should be open to the possibility our postmenopausal HRT needs may change with advancing age. That point I think is also well made. I'm struggling to get my HRT right approaching 60 & though I feel better in most ways on 37.5mcg - 50mcg oestradiol, the one problem that may prove the deal-breaker for me is that no amount of dietary care, exercise, fluid etc, together with other life-long coping strategies for managing the IBS-C, compensate for the paralysing opioid-type effect oestrogen seems to have on my digestive tract. On 25mcg oestradiol I don't feel the systemic benefits I get on higher doses & really need, but my slow gut transit is more manageable.
The smooth muscle relaxant effect of progesterone further exacerbates the IBS-C for me, but that's another chapter & not for this thread!
For anyone who's interested & in support of our gut-related experiences I'm posting the following link & extracts.
I'm pleased to know reducing your HRT slightly seems to have had a fairly immediate beneficial effect & I hope you continue to feel well on the lower dose as you go further into postmenopause.
https://abdominalkey.com/female-predominance-in-gastroparesis/
"It is well established that female sex hormones (i.e. estrogen, progesterone) play a critical role in reproductive health. Nevertheless, emerging evidence demonstrates that sex hormones can also influence GI motility, with estrogen and progesterone receptors found throughout the GI tract."
"Nonpregnant women who received exogenous estradiol and/or progesterone to levels equivalent in the first trimester of pregnancy also experienced nausea with similar dysrhythmias evoked on electrogastrography. This suggests that elevated levels of progesterone and estrogen can mimic GI symptoms experienced during pregnancy and may concomitantly cause gastric dysrhythmias."
"Estrogen, in particular, interacts with serotonin and augments the serotonergic postsynaptic responsiveness in the brain . Serotonin can therefore mediate the effects of estrogen which further influences depression, pain transmission, nausea, headaches and dizziness in the CNS . Hence, sex hormones modulate different levels of the brain-gut axis in IBS and contribute to alterations in motility"
Wx
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Interesting thread and you make a valid point MaryG about maybe not needing such high doses of hormones as we get older. I have found as I journey into post meno my body doesn’t like high doses of oestrogen and whenever I have tried to up my dose I’ve had awful side effects and had to drop back to 50 (which is an average dose) which my body seems happiest on. Just because oestrogen is the feel good hormone it doesn’t necessarily equate that higher levels will make you feel better, I’ve seen it time and again on this forum when ladies go down this route and end up feeling worse.
Also I have noticed that as I get older (57 now) I do feel better when I’m on the progesterone phase, it’s as if my body needs the balance. Although unfortunately for me I still cannot tolerate any longer than 7 days of utrogestan without it becoming too much and overwhelming me. I feel that is because current options for prog (both synthetic and utrogestan) are just too strong, especially for those with sensitivity. That said the 7 days I’m on utrogestan are now probably the best I have, and that’s very different from 10 years ago when I started hrt.
I cannot comment on the link with gut issues as although I suffer from migraines I seem to have escaped this symptom, but it’s all very much food for thought.
Btw MaryG how are you getting on with the progesterone drops? x
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I can't comment on the gut stuff - mine does what it does (!) - but in terms of high oestrogen - there has been much talk over the years (on this forum) about oestrogen doses (and therefore levels in the body often needing to be much higher than they are) and people saying that (usually private specialists) they have been prescribed higher and higher doses and eg docs suggesting that levels of 800 pmol/l are desirable etc.
However, notwithstanding that individual women are different in their responses and needs, and also the very special case of reproductive depression researched by Prof Studd in which very high oestrogen levels were needed to alleviate the depression, I did read some while ago that on balance HRT doses ideally should reflect the average estradiol levels a woman experiences during her menstrual cycle. This being apparently I read, 300-400 pmol/l, and NOT the ovulatory peak or which can be 1700 pmol/l .
Women do not experience very high levels of oestrogen all the time even in their reproductive years, apart from when we are pregnant - which is a special case - so it is not surprising that these cannot be sustained throughout post-menopausal years. In fact I have mentioned this intermittently on this forum - that we are not designed to need very high levels of oestrogen for 30 or 40 years post-menopause and all that goes with it ( high progesterrone doses needed etc). So - often women are way more than replacing what has been lost.
When women are pre-menopausal also, the situation myabe be different temporarily but this period of time is very short by comparison with post-menopause and I think it is important to bear in mind when women do start to tker HRT pre-menopause.
Many women have no idea what their levels are and we (and NHS doctors) are asked to go by symptoms - but we are hormonally complex - not just sex hormones - so the mantra to keep on increasing oestrogen if you are not feeling quite right on our HRT - may sometimes be misplaced, because there are other factors at work eg testosterone, and thyroid function amongst two notable ones.
So having said that - my experience:
I started HRT when I was very late peri-menopause, when my periods were sporadic, and I had endured hopt flushes (which came and went along with my periods) for mayb 18 months? I started on 50 mcg patches and have barely changed my dose since then. The only time symptoms returned was when I stopped HRT, or when I reduced it (even to 37.5 mcg). A few years ago I settled on a cut down 75 mcg patch so about 62.5 mcg and remain happily stable. My only issue is having to take progesterone to protect my lining and because I am on a long cycle (hate the prog) this necessitates a bleed - very undesirable in my late 60's though there are other women, like me who have to do this to keep well. I have never felt the need to increase oestrogen though I did introduce testosterone 6 years ago which made a huge difference. Maybe I have other endocrine factors which need attention - I am by no means I was 10 years ago - but not enough to feel the need to do anything about it.
I get migraines too but not noticed anything to do with gut. Eeveryone should do their NHS poo test every couple of years when it comes round ( over 60) - gets sent automatically, and report any blood in stools or persistent changes in bowel habit to their doc at whatever age.
Hurdity x
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I agree re hormonal complexity Hurdity & like you I've found testosterone has improved symptoms, but then I have no ovaries, so perhaps more need of it than some women. Also agree re thyroid - in my experience being on thyroid replacement certainly complicates the picture.
Whenever tested, my oestrogen levels postmenopause have always been below 300pmol/L (the last very recently) so it's not excessively high levels worsening IBS for me, though as I said, doses above 25mcg have proved problematic in that respect.
I second the advice re reporting any persistent changes in bowel habit. My slower transit on higher dose oestradiol has proved to be reversible on lowering the dose, so I know that's the cause.
It's been a nagging background worry for me that ability to tolerate exogenous sex hormones may decline with age & this was part of the reason I started a thread a few months back asking whether anyone else felt there might be a window of opportunity for starting it - not in terms of risks outweighing benefits as is sometimes suggested if we start for example after age 60, but rather whether our bodies are, if you like, less agile in their ability to process or be receptive to HRT with increasing age, especially if we come late to it in the first place or start, stop, then have a long gap before resuming. In short do we lose the ability to utilise/tolerate HRT if we go too long without replacement. A different topic to the subject of this thread, but related, in my mind at least.
Wx
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Interesting points Wrensong and although I don't know the answers, in terms of the uterus then I do know that after a certain age the endometrium atrophies apparently - because it is no longer stimulated by oestrogen. I can't remember what I read about this (sorry!) but I do recall the endometrial oestrogen receptors being mentioned although even if HRT is commenced post 60 the atrophy must be reversed otherwise we would be in the wonderful position of not having to take progesterone (those that hate it - at least at the dose needed to protect the womb - I think the majority). So just wondering what happens to oestrogen receptors in other tissues as we age and how responsive they are or how they change?
I am sure that is one reason why docs (and BMS) recommend starting at a low dose patch (eg 25 mcg) in women who commence HRT over 60 as this may well do the trick (in terms of symptoms). The window of opportunity often cited is in connection with cardiovascular disease but of course there could well be other windows as you say not re safety but receptors etc....
Perhaps you could link to your thread as I might have missed it as I've been sporadic on here over the past few months (hopefully I didn't post on it and have forgotten....?)
Hurdity x
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I think these are very important explorations on the forum at the moment to do with postmenopausal challenges, fears and approaches for a stage full of many different questions.
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Hurdity
I do know that after a certain age the endometrium atrophies apparently - because it is no longer stimulated by oestrogen
- yes - I came late to HRT compared with some, not starting until 3 year postmenopause & had hysteroscopy aged about 55 due to postmopausal bleeding on Evorel Conti which bloods showed I absorbed poorly & the report detailed an atrophied endometrium.
So just wondering what happens to oestrogen receptors in other tissues as we age and how responsive they are or how they change?
Yes, exactly!
This is the thread I mentioned:-
https://www.menopausematters.co.uk/forum/index.php/topic,59058.msg831212.html#msg831212
Wx
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Some interesting comments on here and pollywollydoodle, we sound very similar.
I forgot to mention a couple of things in my original post. I wanted to talk to the specialist about Gilbert's syndrome which I inherited from my father. I was wondering if it had any bearing on HRT etc but he told me not to worry about it but to be aware that in times of stress or illness, it can flare up and cause symptoms.
I said it was my understanding that transdermal oestrogen had a very limited effect on the digestive system but he said that in his experience, this is not the case because it still goes into the blood stream and finds its way to the oestrogen receptors in the gut. That said, oral HRT usually causes more digestive side effects so transdermal is the better option.
I admired his honesty when he said that doctors don't have all the answers to the complex female hormone system and as we all know on here, it is impossible to replicate the pre menopause cycle.
Perinowpost, the progesterone drops are working very well and just as good as the lozenges but more user friendly. Will report on my other thread.
CLKD, weather in Spain not good for the past few days but much better today ie not windy with plenty of sun so managed to get through a lot of outdoor work!
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What's a fit test?
I had a consultation with a German doctor in Spain last week who specialises in gastroenterology, hormones and migraines. Although his speciality is gastroenterology, he has a special interest in this subject because has wife is menopausal.
Fortunately my silent migraines have reduced to virtually zero since I started using compounded progesterone three years ago but I still have the odd migraine type gastric issues (loose bowels) from time to time so I thought it was worth running this past a specialist.
It was a very interesting consultation. He said that I am probably taking too high a dose of oestrogen for someone who is very post menopause and that it is going straight to the oestrogen receptors in the gut hence the occasional loose bowels. Apparently this is not at all uncommon and he has had other women coming to him with similar problems. I did a FIT test (which was negative thankfully) and he suggested I reduce both the oestrogen and the progesterone dose slightly and see what happens.
Just over a week later, my digestive system is completely back to normal and I'm feeling very good indeed so this suggests he was right.
During the consultation, we talked about how I needed a very high dose of oestrogen to feel good ten years ago and to keep the migraines away and he explained that in the background and over time, my body has changed and I obviously no longer need such a high dose of oestrogen. I was literally dumping the oestrogen my body doesn't need.
So the menopause is an evolving situation and you need to be prepared to make changes to your HRT regime when necessary. I have been on a lowish maintenance dose for some time now but I now realise I need to go slightly lower.
This will only interest a small minority of women on here but I thought it was worth posting my experience.
One further point... I mentioned how so many women have bowel issues with HRT on here (which did not surprise him at all) and he recommended annual FIT tests which he says are very reliable. Migraines at menopause are also very common.
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Denise didi - FIT test is the standard poo test people over 60 are sent through NHS. They come in the post every two years. Test for blood in stools. I don't know who has them done otherwise. The risk is very low of bowel cancer but increase post 60 but hence my saying to be vigilant re other symptoms ie changes in bowel habit and blood in stools. I wouldn't suggest anyone rushes out to have these done privately!
Wrensong - endometrial atrophy can also occur as a result of too much progesterone as part of hRT so in your case it could have been due to the balance between oestrogen and progestogen tipping in favour of progestogen? If it atrophies too much then the lining can get too thin which can cause ulceration and random spotting/bleeding. It is usually remedied by reducing progestogen or increasing oestrogen. This type of endometrial atrophy is abnormal ie induced by the HRT regime, whereas what I was referring to (as I understand it) the normal state of an endometrium years post-menopause - if you see what I mean?
Thans for the link and will have a look later :)
Hurdity x
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Wrensong - that's really interesting as I've suffered from IBSc since my periods started and during hrt use. Now that I'm pretty much off oestrogen (other than the odd ultra low experiment) my bowels are much more regular. I know that prog gets the blame for this (IBSc) and that definitely impacted me on high standard hrt prog, but not with low (10-20mg) cream doses. And I know from using just oestrogen in cycles that it caused IBSc, I always suspected it was hormone related but it's difficult to come to a conclusion until the hormones are stopped or drastically lowered as in post meno. Interesting.
Maryg - I think you've hit on a really interesting topic for post meno women, and of course, it's only at this stage in our lives that we can do any real comparisons as we're working with naturally low or hrt induced relatively low levels. It's been an eye opener for me and I'm hoping that there may now start to be that elusive 'calm' and 'freedom' from the horrors of hormonal swings as reported by so many post meno women. I can't envisage not using some therapeutic doses of prog and possibly oestrogen (ie. something similar to menostar patch), but the roller-coaster rides seems to be slowing down!
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Hurdity, thank you - I understand the distinction you're making re causes of atrophy. I'd imagined mine was because as confirmed by bloods & persistence of meno symptoms, I wasn't absorbing the oestradiol from Evorel Conti very well & as that was my first HRT (started 3 years postmenopause), either the endometrium had not changed (much) from its natural postmenopause state in response to that minimal exogenous oestrogen and/or the balanced dose of Norethisterone in the combi product had been efficient at doing its job. As an aside, I don't know whether if we absorb one hormone poorly from a combi patch it means we are likely getting a proportionally minimal dose of the other too. Any idea? And yes you're right, the clinic's suggestion was that the bleeding was due to the atrophic state of the lining.
Pollywollydoodle, my IBS-C improved during the 3 years postmenopause before I started HRT & like you I was aware of the progesterone link but I later had cause to read up in relation to oestrogen's effects & found fairly new research suggesting that oestrogen too can cause/worsen slow transit issues. The link I posted at the time is on the long thread juju started entitled "poo". Won't post it here as not that relevant, but if you're interested maybe send me a PM & I'll try to find it for you. I can't recall whether there's more info in it than the one I posted here yesterday but I think it was more focused specifically on oestradiol's effects on constipation rather than sex hormones' influence on gut function as a group.
Wx
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Denise Didi, a FIT test is a faecal immunochemical test which has (mostly) replaced the older type faecal occult blood test because it is more accurate for detecting polyps in the intestine. The FOBt used to pick up a lot of false positives.
The specialist I saw has spent most of his career in Germany where everyone is offered a colonoscopy aged 50. It costs their public health system a lot of money but apparently it has paid off because they have very low rates of bowel cancer. He thinks bowel screening should start aged 50 and I think the NHS are going to start sending out FIT test earlier now in some regions.
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Wrensong and polywollydoodle, I read somewhere (sorry, I can't remember where but I will try to find it) that IBS is more prevalent in postmenopausal women using HRT. This would probably include both IBS-C and D.
The Menostar is a US product but apparently women who use this patch only have to take progesterone every six months. They do have the support of a gynaecologist. It's an interesting idea though and it does seem to prevent osteoporosis. The dose is very low, about 14mcg I think, but it's not available in Europe. I suppose it's possible to either cut a 25mcg patch or use half a pump of Oestogel/Lenzetto spray.
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Many thanks Wrensong, I'll have a look for that thread, but tbh, since I stopped/drastically lowered oestrogen I've not had any problems, although I'm also self-treating what I think is a thyroid problem so that may also have had an impact. But my IBS was hellish on high dose oestrogen so that would make some sense.
MaryG - yes, I'd read about the menostar on various US blogs, and some women seem to do really well on it, however, over the last couple of days, I've had an 'experiment' with a 1/4 oestrogen patch so around the same level as menostar, and even at that very low dose I get hypothyroid symptoms, so it's a no-no right now until I get this sorted. It's filed for future use though!
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Just wanted to add , very interesting thread with lots of very good points.
Yes -We do need to think about the other things that can play in the mix that can effect us too. Thyroid etc
and that higher estrogen is not always the answer - some Docs do seem to push this more now.
PMXX
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I thought that they pushed for more for those women who are poor absorbers of oestrogen to get their readings up to par, rather than wanting high oestrogen per se.
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Yes, but how is poor absorption determined? 🤔
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I imagine through blood tests. Once post Meno these are probably more useful as less likely to be subject to peaks and troughs.
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I think the very high oestrogen doses are mostly aimed at younger women with reproductive depression, very severe menopause symptoms and in my case, migraines.
The thinking behind my high oestrogen dose was to lessen the effects of hormonal instability which was causing my migraines. I also had very severe sweating which needed to be treated with a high dose of oestrogen. The idea was to keep the levels artificially high all the time and I found it worked very well for a number of years but this type of regime has a shelf life because, as discussed above, the body changes over time.
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Just to add to the discussion and the point about low oestrogen doses and osteoporosis
The Menostar is a US product but apparently women who use this patch only have to take progesterone every six months. It's an interesting idea though and it does seem to prevent osteoporosis. The dose is very low, about 14mcg I think,
The extent to which osteoporosis is prevented by oestrogen is dependent on the dose of oestrogen. so a low dose will reduce bone loss but not as much as medium does which in turn not as much as highr doses - though I don't have a study reference for that. There has been work done though.
If you look at this website you will see that the minimum doses licensed to prevent osteoporosis are mostly the medium and higher doses (those marked with an asterisk). https://www.menopausematters.co.uk/treatafter.php
Hurdity x
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Unfortunately, for reasons I still don't fully understand, I'm no longer able to supplement oestradiol, even in ultra low doses. I was concerned re. the implications for osteoporosis and spoke to my endo about this. She explained that there are encouraging studies using DHEA and progesterone, progesterone in particular is thought to have an osteoporosis reversal mechanism, which is great news for those women who can't/don't wish to supplement oestrogen, but have an open mind and may be interested in using either/both of these hormones. The addition of oestrogen in small doses apparently further enhances the action of DHEA and progesterone in bone protection and this may be where this type of patch is valuable.
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Can this thread be moved to the post menopause section please?
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MaryG...Good plan! Just request it of Emma via a PM. 👍
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It’s so much more complex than just taking estrogen and progesterone isn’t it.
I’ve spent the last 2-3 years chasing estrogen to recently realise that I don’t need as much as I thought I did.
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Important thread that illustrates the complexity of HRT. I'm currently at a stage where I've just discovered to my horror that I have the opposite problem, ie. I barely absorb estrogen despite daily estrogel.
As mentioned in this thread, it's not just the amount of the hormone in your body, it's how much is being absorbed and my understanding is that one of the markers that indicates this bioavailability is the Sex Hormone Binding Globulin (SHBG).
My estrogen is very low for someone on HRT while my SHGB is very high, meaning poor absoprtion of what hormones are in my body.
I'm currently trying to get to the bottom of this, with zero support from GP or Chelsea meno clinic but my sense is that very little is still known about the complex network of hormone receptors and their interaction with other systems, eg digestion as discussed here.
And as many of you say, a regime that might work for some time might eventually stop working or need significant modification.
The unfortunate reality is that treatments are far too standardised
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MaryG...Good plan! Just request it of Emma via a PM. 👍
Done!
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Jaylow and laszla, that's why it's good that we have this new, dedicated section of the forum because the menopause is an evolving situation and women need to be aware that things change once again in the post menopause phase - thank you Postmeno3.
Years ago when I was happily slapping on copious amounts of Oestrogel, I unaware that my body was changing in the background and that my HRT needs would change over time. By sharing our experiences on here, at least younger women will be able to recognise those changes (and sometimes quite scary changes) and adjust their HRT regimes accordingly.
If it's any consolation, I think the post menopause phase is easier to manage because you no longer have to counter those dreadful hormone fluctuations with high doses of oestrogen. I'm now 60 and liking the low dose, continuous combined, maintenance regime. It's good to feel the same all the time and I hope I don't have to go to an even lower dose but I will if I need to. I think we must always be prepared to make adjustments to the dose and open to the idea of trying new products when they become available.
I'm so pleased I had that consultation but surprised that a gastroenterologist was so helpful on the subject of hormones!
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Hello ladies.
I find this a very interesting topic because I have received conflicting advice from health professionals.
I am experiencing mood swings with frequent episodes of low mood and anxiety and my meno doctor
wants me to increase my Oestrogen. However I was told by an NHS Consultant that for many women less is more and he advised me to slowly reduce the amount of gel I use. He mentioned that some of his patients use a low dose on alternate days and are doing well.
Obviously this is very confusing, do I need more or less Oestrogen?
I am currently following the advice of the meno clinic but I often wonder if I am doing the right thing.
Wishing you all well ladies.
K.
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Kathleen, what type/dose HRT are you on now? Have you had any hormone blood tests recently? If I remember rightly, you stopped HRT altogether at one point?
Did the NHS consultant tell you what they meant by a low dose every other day? The success of a low dose regime would depend on how old you are, how many years post menopause and whether or not you are drowning out the oestrogen benefits with too much progesterone.
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Kathleen, I would get a blood test asap to see your level of estradiol as well as the SHBG I mention in my previous post (which gives an idea of how well you absorb the hormone rather than measuring the hormone itself). Also measure your testosterone.
I only wish I'd had these tests years sooner - I've been on HRT for three years and only just learnt via said blood test that I have the estradiol level of someone who's never been within 50 feet of an estrogen supplement.
It will give you a more tangible starting point which you can use alongside your symptoms.
All the best