Normal vs Optimal Hormone Levels - When HRT doesn't Provide The Results You Hoped For....

Recently, I worked with two women in their 50s who had something interesting in common: both had already gone through menopause, both had started hormone replacement therapy (HRT), but both were not seeing much improvement.

They hadn't experienced any particular side effects, but they hadn't noticed much improvement either.

Their energy levels were still low, they were struggling with weight gain, and they certainly weren't experiencing the benefits they had hoped for when they started treatment.

Interestingly, both women had already spoken to me about hormone therapy before becoming clients. They had subsequently approached their doctors, received prescriptions, and started treatment.

So when we met again, I was curious to understand why neither of them was feeling much better.

What Their Blood Tests Revealed

As part of our review, we looked at their blood work, including their hormone levels. And that's where things got interesting.

One woman had been taking a combined pill of estradiol & progesterone (synthetic). You can see her result below - especially her estradiol was extremely low at only 9 pg/ml.

The other client was taking estradiol gel and progesterone pill - bioidentical hormones. Her result was already a bit better: she had 31pg/ml of estradiol.

But neither was feeling much better. They weren't experiencing any particular side effects, but their energy was still low, and both were struggling with weight gain.

The laboratory considered both results perfectly normal for a postmenopausal woman.

But here's the question: Does a normal lab range mean optimal?

Now, here's something important to understand about laboratory reference ranges. The first is that each lab (even within the same country) sets their own reference ranges (you can see both of my examples show different ranges that they consider normal and even though the results of estradiol and progesterone are particularly low even according to the lab, they have not been flagged as such.)

When a woman is categorized as postmenopausal, the laboratory automatically compares her hormone levels against the reference range for postmenopausal women.

For perspective, estradiol levels in naturally cycling women fluctuate considerably throughout the month. During the days leading up to ovulation, they can reach 200–300 pg/mL or even higher.

After menopause, levels typically fall dramatically, often below 30 pg/mL.

Of course, the goal of HRT isn't to recreate the hormonal fluctuations of a menstrual cycle. And there isn't one magic estradiol number that guarantees better energy, mood, metabolism, or long-term health.

What we are seeing in practice is that most women feel best around 90 pg/mL or above, depending on the individual and the treatment approach.

What matters is the bigger picture: the type and dose of hormones being used, how they are absorbed, the symptoms we're trying to address, and how the woman is actually responding.

Normal and Optimal Are Not Necessarily the Same Thing

I don't believe this is necessarily a question of doctors being incompetent. I think it's also a reflection of how our healthcare system works.

Doctors are often under enormous time pressure. Blood results arrive with reference ranges and convenient little flags highlighting anything that falls outside them. When nothing is flagged, it's easy to conclude that everything looks fine.

But laboratory reference ranges are not necessarily treatment targets.

And when a woman is still exhausted, struggling with her weight, or simply not feeling like herself, there's a tendency to look for other explanations.

She's over 50. She has a demanding job, a family, and a busy life. She's probably stressed. Maybe she needs to eat less, exercise more, or simply accept that she's getting older.

Sound familiar?

I hear versions of this from women in my practice all the time. I also see countless conversations in women's health groups where someone explains that she's had all her blood tests done, her doctor says everything is normal, and yet she still feels terrible.

Now, stress, nutrition, sleep, and lifestyle absolutely matter. In fact, they're a big part of the work I do with my clients. But that doesn't mean we should automatically attribute every unresolved symptom to stress or aging without looking at the bigger picture.

This is something I talk about frequently in my practice.

A laboratory reference range generally describes values observed in a particular population or establishes a threshold used for clinical interpretation. It doesn't necessarily tell us what is ideal for every individual, in every situation.

And this distinction becomes particularly relevant when we're looking at hormone therapy.

It's also important to recognize that not every symptom is caused by low estrogen. Fatigue, weight gain, brain fog, and poor sleep can have many contributing factors, from thyroid function and insulin resistance to nutrient deficiencies, inflammation, and chronic stress.

And this is precisely why I believe we need to look beyond individual numbers.

What About the Benefits We Can't Feel?

There's another important aspect of hormone therapy that I think deserves more attention. And that's what our hormones do behind the scenes.

We tend to judge the success of HRT by how we feel. Are the hot flashes gone? Are we sleeping better? Has our energy returned?

But estrogen does much more than help manage menopausal symptoms. It also plays an important role in maintaining our bone density, cardiovascular function, and brain health.

Take our bones, for example. Bone loss doesn't necessarily come with obvious symptoms. You don't wake up one morning feeling that your bone density has dropped. Yet declining estrogen levels after menopause can accelerate bone loss, increasing the risk of osteoporosis and fractures. One of the well-established benefits of systemic estrogen therapy is its ability to help prevent that bone loss.

And then there's progesterone. For women who still have a uterus, taking systemic estrogen without adequate progesterone or another appropriate progestogen can stimulate excessive growth of the uterine lining, increasing the risk of endometrial cancer. Ensuring sufficient endometrial protection is therefore an essential part of a safe HRT regimen, even when a woman feels perfectly fine.

And let's not forget testosterone, which is often overlooked when we talk about women's hormones. Although we produce much less testosterone than men, it still plays an important role in our physiology, including sexual function, muscle and bone metabolism.

The relationship between estrogen, heart health, and brain health is more complex. Estrogen influences both systems, and the timing and type of hormone therapy may affect its benefits and risks. However, we don't yet have evidence that achieving a particular estradiol level will prevent cardiovascular disease or dementia.

So while symptom relief is important, it's not the only consideration when evaluating hormone therapy.

We also need to think about longer-term health, appropriate dosing, and whether the treatment is providing the benefits we're looking for without introducing unnecessary risks.

And that's another reason why I believe hormone therapy deserves a more individualized approach rather than relying on laboratory reference ranges alone.

Does This Mean You Need More Estrogen?

Not necessarily.

I certainly wouldn't suggest that every woman with an estradiol level of 30 pg/mL needs to increase her dose.

Estradiol blood levels can vary depending on the type of hormone therapy, when the medication was applied or taken, and when the blood sample was collected. With transdermal preparations, absorption can also differ considerably between women.

Routine estradiol testing isn't always necessary for HRT management, but in certain situations, particularly when symptoms persist despite treatment, it can provide useful additional information.

The point is not to chase a particular number. It's to understand whether the treatment is doing what it's supposed to do.

If you've started HRT and don't feel any better, that deserves a proper conversation with your prescribing doctor. It may be worth reviewing the dose, formulation, absorption, duration of treatment, and whether other factors could be contributing to your symptoms.

Simply being told that your hormone levels are normal for a postmenopausal woman doesn't necessarily answer those questions.

Your Symptoms Are Part of the Picture - But There's More to It!

Hormone therapy can make a meaningful difference to a woman's quality of life, particularly when she's struggling with menopausal symptoms. But it's not a magic solution for every problem that appears after 50, and it isn't always a matter of simply increasing the dose.

Sometimes we need to review the treatment. Sometimes we need to look elsewhere. And often, we need to consider several factors together.

We also need to remember that some of the benefits of hormone therapy aren't necessarily things we can feel. Protecting bone health and ensuring that the uterine lining is adequately protected are just as important as addressing the symptoms that brought us to treatment in the first place.

Because the purpose of hormone therapy isn't simply to produce a blood test that looks acceptable. It's to help improve our quality of life while supporting our longer-term health.

And if you're not experiencing the benefits you expected, I think it's perfectly reasonable to keep asking questions.