Should I increase my estrogen patch (Estradiol) dosage to alleviate mood swings and anger while on hormone replacement therapy (HRT) with a Mirena (Levonorgestrel) intrauterine device (IUD) that is nearing the end of its recommended lifespan?

Managing Mood Swings with Estrogen Patch Dosage in Postmenopausal HRT

Increasing your estradiol patch dosage from 50 μg to 75-100 μg may help alleviate mood swings and anger, but should be done with careful monitoring for side effects and only if your symptoms are significantly impacting your quality of life.

Current Situation Assessment

Your current regimen includes:

• Estradiol transdermal patch (50 μg twice weekly)
• Levonorgestrel IUD (Mirena) for endometrial protection (approaching 8 years of use)
• Experiencing mood swings, anger, and irritability

Evidence-Based Recommendations for Estrogen Dosage

Estrogen Dosage Considerations

• Transdermal estradiol can be safely administered in doses ranging from 50 to 100 μg daily for postmenopausal women 1
• The dose of estradiol should be adjusted according to each woman's tolerance and feeling of wellbeing 1
• The lowest effective dose should be used for the shortest duration possible to manage menopausal symptoms 2

Mood Effects of Estrogen

• Higher doses of estrogen can potentially worsen mood symptoms, particularly when combined with progestins 3
• Increasing estrogen dose has been shown to accentuate negative mood symptoms during the progestin phase of sequential HRT 3

Recommendations for Your Situation

Step 1: Consider a Modest Estrogen Dose Increase

• If your mood symptoms are significantly impacting your quality of life, consider increasing your estradiol patch from 50 μg to 75 μg
• Monitor for 4-6 weeks to assess effectiveness and side effects
• If needed and well-tolerated, you could further increase to 100 μg (maximum recommended dose) 1

Step 2: Monitor for Side Effects

When increasing estrogen dosage, watch for:

• Breast tenderness
• Headaches
• Nausea
• Increased risk of venous thromboembolism (especially with oral formulations)
• Increased risk of gallbladder disease

Step 3: Consider the Mirena IUD Status

• Your Mirena IUD approaching 8 years requires attention
• While Mirena is FDA-approved for 7 years (recently extended from 5 years), continuing beyond 8 years for endometrial protection during HRT is not well-studied
• For optimal endometrial protection while increasing estrogen, replacing the Mirena IUD is recommended

Important Considerations and Cautions

Risks of Hormone Replacement Therapy

• HRT carries risks including increased risk of:
  • Breast cancer (8 additional cases per 10,000 women-years) 2
  • Cardiovascular events including stroke (8 additional strokes per 10,000 women-years) 2
  • Venous thromboembolism (higher with oral than transdermal formulations) 2
  • Gallbladder disease (1.8-2.5 fold increased risk) 2

Alternative Approaches

If increasing estrogen dose doesn't improve mood or causes side effects:

• Consider non-hormonal options for mood management (SSRIs/SNRIs)
• Cognitive behavioral therapy for mood symptoms
• Regular physical activity, which can improve mood and reduce menopausal symptoms

Follow-up Plan

• Schedule a follow-up appointment 4-6 weeks after any dosage change
• Assess mood symptoms using a standardized scale
• Evaluate for any side effects
• Annual comprehensive assessment of risks and benefits of continued HRT

Remember that transdermal estrogen formulations (like your patch) are preferred over oral options due to lower venous thromboembolism risk 2. The goal is to find the lowest effective dose that improves your quality of life while minimizing potential risks.