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You've been on hormone replacement therapy for months, maybe even years. Your doctor said you're on a "standard dose" and told you to monitor how you feel. But here's the problem - you still wake up at 3 AM, struggle with brain fog, feel irritable with your family, and that stubborn weight around your middle won't budge.

Sound familiar? You're not alone, and more importantly, you're not stuck.

This article breaks down insights from Dr. Jila Senemar, a board-certified OB-GYN with over 20 years of experience who specializes in menopause optimization. Her approach goes far beyond the outdated "lowest dose for the shortest time" mentality that leaves so many women undertreated.

This guide is for women who know they deserve better than barely surviving menopause. Whether you're just starting hormone therapy or you've been on it for years without getting the results you want, you'll learn what truly optimized hormone therapy looks like and how to advocate for the care you deserve.

The information shared here is for educational and informational purposes only and is not intended as medical advice. Always consult your healthcare provider before making any decisions about your health or treatment. The views expressed by guests are their own and do not necessarily reflect the views of the host or Pleasure in the Pause.

Prerequisites

Are you ready for this approach?

This optimization approach makes sense if you're experiencing persistent symptoms despite being on hormone therapy, or if you want to move beyond just managing symptoms to actually feeling amazing. You should be ready to take an active role in your healthcare and advocate for comprehensive testing and monitoring.

What you'll need:

• A healthcare provider willing to check hormone levels

• Access to comprehensive hormone testing (estradiol, progesterone, testosterone, FSH)

• Time for proper follow-up appointments (30+ minutes, not 5-minute visits)

• Openness to adjusting doses, delivery methods, or adding components to your regimen

• Commitment to lifestyle factors that support hormone optimization

• Patience for the process (hormone optimization takes 2-3 months to see full effects)

Step-by-Step Guide to Hormone Therapy Optimization

Step 1: Understand Why Your Current HRT Might Not Be Working

Most women start hormone therapy with hope, only to find themselves months later still struggling with the same symptoms that brought them to the doctor in the first place. The problem isn't that hormone therapy doesn't work - it's that many women are being undertreated with outdated protocols. The old approach of "lowest dose for the shortest time" often leaves women with hormone levels too low to provide real symptom relief or long-term health protection. Many doctors still operate from fear-based medicine rooted in misinterpreted studies from decades ago, rather than current research showing the benefits of optimized hormone levels. The result is women on doses like the 0.025 estradiol patch that barely register therapeutic levels in their bloodstream, leaving them feeling like hormone therapy "just doesn't work for them."

Key takeaway: Your symptoms aren't in your head, and you're not asking for too much.

• "Standard doses" often aren't therapeutic for individual women

• Your doctor should be checking your hormone levels, not just asking how you feel

• Absorption varies greatly between women - what works for others might not work for you

• You deserve symptom relief AND long-term health protection

• Current research supports higher, optimized hormone levels for better outcomes

Step 2: Know Your Target Numbers for Optimal Hormone Levels

Here’s something most women never hear from their doctors: there are actual target ranges for optimal hormone levels - levels where many women start to feel significantly better. According to Dr. Jila, optimal estradiol levels typically fall between 65–100 picograms per milliliter. This range isn’t about replicating your reproductive years; it’s about finding the therapeutic zone that supports symptom relief and long-term health benefits for your bones, brain, and heart. Yet many women walk around with estradiol levels in the 30s or 40s, wondering why they still feel terrible despite being “on hormones.” Without knowing your numbers, you're flying blind, and your doctor can't make informed decisions about your care. Regular monitoring every 3–6 months, especially early on, helps ensure you're not just taking hormones, but actually absorbing them at levels that make a difference.

Key takeaway: Optimal hormone levels have specific ranges backed by research.

• Target estradiol levels: 65-150 picograms per milliliter

• Levels below 60 may not provide adequate symptom relief or health protection

• Regular testing every 3-6 months is essential for optimization

• Symptoms alone aren't enough - you need the data to make informed adjustments

• Your levels should guide dosing decisions, not just how you feel

Step 3: Master the Four Pillars of Complete Hormone Optimization

Most women think hormone therapy means estrogen and maybe progesterone, but complete optimization involves four key components working together like a symphony. Estradiol (bioidentical estrogen) forms the foundation, addressing hot flashes, sleep, mood, and providing long-term protection for your bones and heart. Progesterone acts as your "chill pill," calming your brain, helping you sleep, and protecting your uterine lining. Testosterone boosts energy, libido, muscle mass, and mental clarity - yes, women need testosterone too. Finally, vaginal estrogen works locally to prevent atrophy and maintain intimate health, and it's safe to use alongside systemic hormones. Each pillar addresses different aspects of your wellbeing, and when one is missing or inadequate, you'll feel it. The goal isn't just to stop hot flashes; it's to optimize every system in your body that hormones support.

Key takeaway: Complete hormone optimization requires all four pillars working together.

• Estradiol: Foundation hormone for symptoms and long-term health protection

• Progesterone: Calms anxiety, improves sleep, protects uterine lining

• Testosterone: Boosts energy, libido, muscle mass, and mental clarity

• Vaginal estrogen: Prevents atrophy and maintains intimate health safely

• Each hormone addresses different symptoms and body systems

• Missing pillars leave gaps in your optimization and symptom relief

• All four can be used together safely when properly monitored

Step 4: Troubleshoot When Your HRT Isn't Delivering Results

When your hormone therapy isn't working, don't assume you're a "non-responder" - become a detective. The first step is ensuring you're using your hormones correctly, because even with written instructions, mistakes happen. Are you changing your patch every three to four days, not once a week? Are you taking your progesterone consistently, not skipping doses during travel or busy periods? Next, investigate absorption issues by checking your blood levels - you might be on a higher-dose patch but only absorbing minimal amounts, leaving you undertreated despite thinking you're on adequate therapy. Consider whether your delivery method suits your lifestyle and body - some women absorb gels better than patches, or vice versa. Finally, examine timing and dosing adjustments, because the difference between taking progesterone at 8 PM versus 10 PM can mean the difference between feeling rested or having a hangover effect the next day.

Key takeaway: When HRT isn't working, systematic troubleshooting reveals the solution.

• Verify you're using hormones correctly with proper timing and frequency

• Check blood levels to confirm adequate absorption, not just assume it's working

• Consider switching delivery methods if absorption seems poor

• Adjust timing of doses to minimize side effects and maximize benefits

• Don't suffer for months - address issues within 6-8 weeks

• Most "non-responders" actually need dosing or method adjustments, not discontinuation

Step 5: Solve Progesterone Problems Before They Derail Your Progress

Progesterone sensitivity can make or break your hormone therapy experience, yet many women suffer in silence rather than work with their doctor to find solutions. If progesterone makes you feel groggy, depressed, or hungover the next day, you have options beyond just "toughing it out." Start by adjusting timing - taking it earlier in the evening can prevent morning grogginess. Try different forms like vaginal progesterone, which often causes fewer systemic side effects while still protecting your uterine lining. Consider a progesterone-containing IUD, which provides continuous protection without daily pills that affect your mood. Some women benefit from lower, compounded doses, though these aren't FDA-regulated and may vary in potency. The key is recognizing that progesterone problems are solvable, not something you must endure. Your doctor should be willing to try different approaches rather than letting you become non-compliant and risk endometrial hyperplasia from unopposed estrogen.

Key takeaway: Progesterone sensitivity has multiple solutions - don't give up on hormone therapy.

• Adjust timing to take progesterone earlier if you experience morning grogginess

• Try vaginal progesterone for local protection with fewer systemic side effects

• Consider a progesterone IUD for continuous protection without daily mood effects

• Explore lower doses through compounding pharmacies if standard doses are too strong

• Don't become non-compliant - work with your doctor to find solutions

• Every other night dosing can help some women build tolerance gradually

Step 6: Address the Metabolic Component for Complete Success

Hormone therapy alone won't make you lose weight, but it can reset your system so that healthy lifestyle changes actually work again. During perimenopause and menopause, hormonal shifts create inflammation that can lead to insulin resistance and that stubborn visceral fat around your middle. This isn't the same as subcutaneous fat you might have carried in your twenties - it's metabolically active fat that's wrapped around your organs and much harder to lose. Optimized hormones reduce this inflammation and can improve insulin sensitivity, but you still need to address the metabolic component through nutrition and movement. Focus on whole foods, adequate protein at every meal, and regular movement that includes both cardio and strength training. For some women with significant insulin resistance, medications like GLP-1 agonists may have a place in treatment, but only under proper medical supervision as part of a comprehensive approach, not as a quick fix or replacement for lifestyle changes.

Key takeaway: Hormone optimization and metabolic health work together for lasting results.

• Hormones reduce inflammation and can improve insulin sensitivity

• Weight loss requires addressing both hormonal and metabolic factors

• Focus on whole foods and adequate protein rather than restrictive dieting

• Include both cardio and strength training in your movement routine

• GLP-1 medications may help some women but require medical supervision

• Lifestyle changes become more effective once hormones are optimized

Step 7: Support Your Mental and Emotional Health Throughout the Process

Hormone therapy can take the edge off mood swings and anxiety, but it doesn't erase years of putting yourself last or bypass the need for emotional healing. Many women in midlife are dealing with accumulated stress from decades of caregiving, career building, and life challenges while their hormonal support system was declining. The irritability, anxiety, and mood changes of menopause often amplify existing patterns or unresolved issues. This is particularly true for women with histories of postpartum depression, PMDD, ADHD, or trauma. While optimized hormones provide a stable foundation for better mental health, you may still need additional support through therapy, stress management techniques, or even anti-anxiety medications. The goal isn't to return to who you were before menopause, but to become the best version of yourself with the wisdom and experience you've gained. This often means learning to set boundaries, saying no more often, and actually prioritizing your own wellbeing.

Key takeaway: Complete optimization includes mental and emotional health alongside hormones.

• Hormone therapy provides stability but doesn't erase life stress or trauma

• Women with histories of mood disorders may need additional support

• Therapy and stress management complement hormone optimization

• Learning to prioritize yourself is part of the midlife transition

• Setting boundaries and saying no becomes essential for wellbeing

• The goal is becoming your best self, not returning to your younger self

Conclusion

The big idea here is simple but revolutionary: you don't have to settle for barely surviving menopause. Truly optimized hormone therapy can help you feel like yourself again - maybe even better than you felt in your thirties.

Most women are walking around undertreated, accepting symptoms as "normal aging" when they could be feeling energetic, sleeping well, and maintaining their health for decades to come. The difference between basic hormone replacement and optimization is like the difference between a black-and-white TV and 4K resolution - technically both show pictures, but the experience is completely different.

Your action steps to implement these insights:

1. Track your symptoms in detail before your next appointment

2. Find a provider who specializes in hormone optimization, not just basic replacement

3. Request comprehensive hormone testing including estradiol, progesterone, testosterone, and FSH

4. Ask for your actual numbers and whether they fall in the optimal ranges (estradiol 65-150 pg/ml)

5. Schedule regular follow-ups every 6-8 weeks initially for proper monitoring and adjustments

6. Address all four pillars - don't accept partial treatment when complete optimization is available

7. Support your hormones with proper nutrition, regular movement, and stress management

8. Seek additional support for mental and emotional health as needed

Remember, you are the CEO of your body. You deserve care based on current research, not outdated fears from decades-old studies. You have the right to understand your hormone levels, to feel your best, and to age with vitality and strength. The tools and knowledge exist - now it's time to demand the care you deserve.

ABOUT DR. JILA:

Dr. Jila Senemar, M.D., FACOG is a board-certified obstetrician and gynecologist with over 20 years of experience who has become one of the leading voices in menopause optimization. She's the founder of JilaMD, a concierge practice in Miami specializing in personalized hormone therapy, metabolic optimization, and longevity science. Dr. Jila is also the founder of the Miami Menopause Collective, where she collaborates with women to create truly individualized treatment plans. What sets Dr. Jila apart is her commitment to helping women thrive—not just manage symptoms—in their second half of life through evidence-based, personalized care.

CONNECT WITH DR. JILA:

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LINKS MENTIONED:

The Menopause Society

Dr. Mary Claire Haver