Higher than licensed dose of oestrogen- GP suddenly refusing to prescribe

[Mrsbunnychops]

I’ve been on HRT for a few years and had a terrible time with awful symptoms for years before with an early menopause, my GP started HRT but due to lockdown and the fact that even on the maximum dose I still felt dreadful, I turned to Newson Health.

I had many tweaks over the years, tried different types and doses and for the last few years and seem to have finally got to a sweet spot, feeling bit better overall, Newson health sent letters to my GP etc and was getting my bloods done there 1-2 x year and at least an annual review then BOOM - today the GP asked me in for a review and without even asking how I was etc she told me she wasn’t prepared to take the risk anymore as higher than licensed dose 😩!! She wasn’t interested at all on anything I had to say and she just told me to pay for it all via Newson Health.
I have been feeling the most ‘well’ I ever have and my BP etc are the best they’ve been for a long while… I am so upset 😭

Just to add, the GP surgery had been prescribing it for 5 years

What are you using op, what is the dose?

Sadly there have been a number of cases recently of extreme high dose off license oestrogen with poor outcomes.

your gp is entirely within their remit to review and stop.

harsh though it is for you if you want to continue at this dose it won’t be through your gp.

you may also find that when it comes to having to take the risk of signing the prescription, your private provider also declines. (Most people are unaware the legal responsibility lies with the person signing it - not the consultant suggesting it)

The panorama program was a bit scare mongery if you are referring to that?

I am on 2 X 100 patches - but this has been reviewed and monitored over a number of years and blood tests demonstrating poor absorption. Worse when on Lenzetto and Also poor on Oestrogel - patches seem to work best but my levels stay at around 600

So happy and feel more stable with reduced symptoms but it’s taken ages

I don't absorb transdermal HRT. I got up to 150 estradot patches and my levels were around 100.

My consultant suggested oral HRT and though I was reluctant, its worked better then transdermal HRT.

I understand your perspective but, I also get where your GP is coming from

What was her suggestion moving forward?

Measuring oestrogen levels is not a good indicator of your circulating oestrogen.

I’m not surprised a gp wants/ needs to stick to the licensed dose. The implications for them if you become unwell on it would be catastrophic.

I’m also on the same dose as you and it has taken years to get an effective level that treats my mental health and physical symptoms. I am also a Newson Health patient but last review they wanted to increase to 250mg and I was not comfortable with that after the panorama programme came out and actually I feel stable enough at the dose I’m on now. I spoke to me GP around the time the programme came out about how to reduce it to 100mg and she was keen that I did but didn’t insist on timescales or threaten to withdraw the off licence dose. I did gradually get down over months to 100mg and felt awful mentally and so tired and demotivated to exercise or do anything. Will your GP continue to prescribe the maximum licensed dose and then you might be able to get a top up privately from NH? Would another GP be willing to prescribe it?

I had the same happen to me earlier this year, and on asking about it here I was treated to a chorus of tutting and pursed lips from posters quick to point out GPs are forbidden from prescribing off licence doses (they are not) and what was I thinking messing around with ridiculously high doses. I take 125mcg. The maximum licensed dosage is 100mcg. Over the last 3 years I have had numerous blood tests which all show I am a poor absorber of oestrogen and probably fall into the up to 20% of women for whom the highest licensed dosage still dose not pull their blood oestrogen levels up to a therapeutic level. Doctors are routinely told though that the blood oestrogen levels are not the primary way of deciding if a dose of HRT is effective, the primary method to evaluate efficacy should be control of symptoms. Well, let me tell you on a lower dose I have a temper that makes me unsuitable to go out in public, and a memory which renders me incompetent. Both of which are unsuitable symptoms for my job (they could result in me losing my medical if they become too prevalent.) A carefully considered and monitored approach to HRT prescribing has all my symptoms under control, although my blood oestrogen is still below therapeutic levels both the specialist I saw and I are happy that the amount I am taking is a good balance between efficacy and a sensible dosing strategy. So imagine how pissed off I was when my GP, without even seeing me and without having the grace to discuss it face to face (she sent a clueless locum in to speak to me when I made an appointment to see her about it,) arbitrarily reduced my dose to 100mcg without giving me any sort of back up plan or advice as to how to manage my symptoms. I tried 100mcg for a week to see if I was being silly, and reverted to not being able to remember what I was talking about. So I went back to the private clinic and paid for my regular prescription there. I find it so demoralising that GPs have taken this approach when it is not necessary if they were to educate themselves more on HRT. Most GPs have only a basic knowledge, and rely on one specialist in a practice to see most of the women who want HRT. You are then at the mercy of that one doctor, usually with no alternative except to go private.

For anyone who wants to go into poor absorbers in more detail, there is a very good research paper here about it.
https://pmc.ncbi.nlm.nih.gov/articles/PMC12147738/

My GP had no suggestions apart from getting Newson clinic (who I see anyway)
to prescribe it which is fair enough as it is their specialist who sees me and suggests.

I do get it, but at the same time, she has a patient in front of her who’s health has improved significantly over the last few years and I now have to pay for the prescriptions too. I struggle enough to pay for the annual Newson clinic reviews!

Thank you for sharing and the info , my goodness, it’s 💩 isn’t it?!! I’m genuinely dismayed and fed up - it’s like she just didn’t care about any other factor, no individualised or patient centered care going on - I’m pretty sure if my thyroid became symptomatic after years they would tweak without argument! 😢

I'm sorry you're having this issue but the GP is working professionally.

If your GP will not prescribe off-licence that is reasonable.
They have to protect themselves in case of an outcome where a patient becomes unwell and could take legal action. Whoever prescribes a drug takes legal responsibility for it, if it's off-licence.

The issue with the insistence on taking blood is that it is not accurate for estrogen levels. My consultant (highly qualified and very experienced ) will not do blood tests for estrogen - they are not accurate. To get an accurate reading they have to take blood over 24 hours- not practical.

The link by the previous poster is not totally valid as it's done by the Newson clinic and it was a small number of women using the clinic.

There are other research papers out there that show the opposite.

Have you read the BMS guidance on this?
Their report says that there is no evidence that extremely high doses make any difference . In addition if you double the maximum estrogen dose you also have to double the progesterone. The 100mcg daily progesterone dose is for women on up to 75mcg patch / 3 pumps of gel but some need 200mgs daily on that estrogen.

If you go to 100ms x 2 = 200mgs, that could increase to 400mcgs a day to protect your womb lining.

It looks as if you want to carry on with that dose you have to stay with the private clinic.

I cannot think of any other condition where a GP would say ‘you can’t have the dose that works, and we don’t have another plan to help you. Bye.’ It effectively dismisses up to 20% of women who are just expected by their GPs to crack on and put up with symptoms - which let’s remember are not unmanageable.

It's a legal issue. It's not unique to HRT but applies to any drug. A GP (not a private consultant) is not legally obliged to provide a drug or dose prescribed elsewhere. It's to do with their professional protection and ethics, not personal about the patient.

This is the info from the BMS on dosage.

There may be some points here that help you have a chat with your GP so it's worth reading.

thebms.org.uk/wp-content/uploads/2025/07/24-NEW-BMS-ToolsforClinicians-Measurement-of-serum-estradiol-JULY2025-B.pdf

Thanks, that’s useful, I’m aware of the BMS guidelines but they seem to say individualised treatment too? My symptoms are controlled on my dose and to be honest, increasing my progesterone would be fine as it doesn’t make me feel unwell, quite the opposite- my issue is that if we go by symptoms as the most accurate assessment and it takes a higher dose to improve those but then there is a ceiling of 100 micrograms? It all seems quite vague.
I understand in primary care they don’t have time / expertise to tweak and review in depth so maybe that’s why they use this approach but if a Menopause specialist which I’ve been seeing for 5 years and having longer, thorough consultations with suggests a higher amount of- why would a GP feel they know best?

but if a Menopause specialist which I’ve been seeing for 5 years and having longer, thorough consultations with suggests a higher amount of- why would a GP feel they know best?

It's not about who is right or wrong. It's about legal responsibility for your treatment.

A private consultant takes personal legal responsibility for prescribing. An NHS GP is not a private consultant.

GPs work within the licenced doses of the drug.
They do not want to be sued by a patient who develops an illness as a result of an unlicensed dose. This is not about HRT- it applies to any drug.

You can't usually mix privately off-licensed doses with a GP agreeing to risk their job.

But the gp,isn’t saying you can’t have it, they are saying you need to go private as they are not able to prescribe over the permitted dose.

I guess a similar thing would be weight loss injections, albeit due to cost. Gp’s just won’t prescribe, the nhs guidelines are much stricter than the mhra prescribing guidelines. So no matter how much you need it or feel great on it. Your gp is going to say no.

It doesn’t leave the majority of patients in a great place though! I’m a healthcare professional myself btw and request prescriptions from GP’s all the time - prescribing and aware of the legalities etc oestrogen just feels like it’s become like an
nhs football at times! Ultimately, I’m
able to just about afford to get it privately although I’ll need to go without - it feels unfair that some women won’t have the financial means to get the care they should

@JinglingSpringbells I’ve sat the ABPI exams (ironically with Female Reproductive Health as one of my special subjects, although back then HRT was still a Very Rare Thing) and passed with distinction, so am comfortable with legislation and ethics surrounding prescribing off license. This is one of the topics I would often end up discussing with doctors as my specialist area of knowledge (pain control) would often require creative solutions and a willingness of a doctor to step outside of the normal bounds of drug licensing.

Since you are convinced on this thread, and on the thread I started some months back, that GPs simply cannot prescribe outside the licensed usage and dosage of a drug, how do you explain my GP’s comfort level with prescribing testosterone off license? One of my children is also on a drug which this same GP prescribes off license. Of course GPs can prescribe off license, just as any doctor can, but what normally limits this is that the breadth of knowledge they are required to maintain at superficial level in order to serve a broad spectrum of patients means they are rarely a specialist in one area. Consultants, otoh, as well as private specialists, have a much narrower scope of practice, so are much more knowledgeable and confident in their field.

It’s entirely within the power of a GP to prescribe a drug off license, both at a higher or lower than recommended dose and for purposes for which the drug has not been formally tested. As an example, my DC has taken nifedipine in the past for severe Raynauds Phenomenon. Nifedipine is an old fashioned calcium channel blocker licensed for high blood pressure. It is often used for various other reasons though, despite not being licensed for them. My GP happily prescribed it off license to a child below the minimum age on the drug license, even though the side effects include potential heart failure.

I think that the poster using the example of weight loss drugs is getting confused about the reasons a GP cannot or will not prescribe a drug. Do you know about practice and/or local authority formularies? A formulary is the list of pharmaceuticals that a doctor can choose to prescribe from, as set out by either their practice or their local authority depending on how the local health service operates. With weight loss drugs, the costs mean that prescribing criteria are restricted to only certain groups of patients, even though many more fall within the allowable range of symptoms for the drugs. So a patient could be suitable for a weight loss drug (or a cancer treatment) under the licensing for that drug, but the local formulary prohibits the prescription of it. Where we are at with HRT is that GP practices are still keeping these drugs in their formulary, but refusing to prescribe outside of the maximum licensed dosing.

Wrt the comparison between weight loss drugs and HRT, it could be argued (although many users of WLI will disagree here) that you can lose weight without drugs if you try. I have not yet come across anyone who has managed to reduce the clinical symptoms of the change in hormone composition brought about by their menopause by ‘trying harder.’

There is definitely scope for further research on the safety and efficacy of higher doses of HRT.

Have you read the BMS guidance on this?
Their report says that there is no evidence that extremely high doses make any difference .

Just want to add that "no evidence that [high doses] make any difference" doesn't mean the same thing as "there is evidence that there is no difference". Sometimes "no evidence" means that not enough high quality studies have been done to give a conclusion one way or another

Makes no difference to what? You mean no increase in risk to the endometrium?

The BMS actually says that there is a condition where too much estrogen actually exacerbates symptoms.

They issued a very strongly worded statement after the Panorama programme and said no women should be on huge doses.

If someone is having a dose that is twice the maximum, there should be safeguards in place to check that hyperplasia is not developing. That should mean OP is using more progesterone or having regular scans.

Honestly, don’t get me started on that Panorama programme! 🤬