Insomnia, incontinence, and vaginal dryness and itching can often be relieved with bioidentical hormone replacement therapy (BHRT) in post-menopausal or even perimenopausal women. There are a number of different thoughts and protocols on how to best implement this from different doctors, books, websites, etc., so all I can do is tell you what I chose, and why.
Oral, sublingual, or transdermal delivery was the first decision I had to make, and I chose transdermal, because it doesn’t make a first pass through the liver. Oral estrogen raises thyroid binding globulin (TBG), which binds and reduces Free T4, so is not the best choice for someone like me who is also taking thyroid hormone.  With oral estrogen, a certain amount is also lost when it passes through the liver, but how much? It’s much easier to adjust the dosage if it’s transdermal.
Estrogen is available by prescription as estradiol (E2), bi-est (E2+E3), or tri-est (E1+E2+E3) . I chose tri-est, because it seemed more complete and more closely replicates a female body’s natural output, in the same way that desiccated thyroid replicates normal thyroid function by containing all the hormones and not just T4. I take about .8 mg of topical estrogen on days 1-25 and follow a formula by Dr. Jonathan Wright called Esnatri that I have compounded. This formula is 90% estriol (E3), 7% estradiol (E2), and 3% estrone (E1).
Dr. John Lee’s books on transdermal progesterone made a lot of sense to me, and following his guidelines, I now take about 12 mg of topical progesterone for two weeks out of the month.
Testosterone at only .1 mg gave me acne, but I found pregnenolone in pill form to be a good substitute for raising both testosterone and DHEA-S. I used to take 2.5 mg twice a week, or 5 mg/week, until I decided it was giving me too much testosterone.
Estrogen should be balanced with progesterone, especially if one still has a uterus. Without the monthly drop in progesterone, the uterine lining could continue to grow, which is not desirable. The actual proportion of estrogen to progesterone that a woman needs is very individual and is often found through trial and error. Some studies report that progesterone offers some protection against breast cancer.  Newer studies are saying progesterone may be a risk factor for breast cancer.  It may be that progesterone is just one of several factors that are involved in breast cancer.
The Women’s Health Initiative study (which was halted before completion in 2002 because of some dangerous results) showed that progestin, or synthetic progesterone, had negative side effects on the heart.  This is not the same bioidentical progesterone one gets from compounding pharmacies. Also, while Premarin would not be my first choice for estrogen, some find it very effective. It is made from horse urine, so does not contain the human estrogens. It can raise SHBG, lower free testosterone, lower Free T4, and raise free cortisol levels. 
Breast cancer probably has several causes, and it is probably the interplay of multiple hormones with a genetic susceptibility combined with environmental toxins that provides the perfect setup. When thyroid levels are low, all processes, including detoxification, will be sluggish. This means toxins could stay in the body far longer than they should. If thyroid is not optimized, it might be wise to delay adding any estrogen or progesterone until that is corrected. Breast tenderness during the second half of the cycle suggests that thyroid, estrogen, and/or progesterone levels need adjusting; one or more of these hormones are either too high or too low. It should be noted that some women on the T3-only protocol have reported painful breasts, and high T3 levels are positively associated with breast cancer, but not other cancers. 
Saliva labs are said to be better than serum for monitoring sex hormones, yet others say just the opposite, that serum is better. Out of curiosity, I did saliva and serum labs one day apart to see if the labs would show a great disparity, and the surprise was that for estrogen and progesterone, they didn’t. Both were roughly in the same part of the range for their respective labs. I was absolutely meticulous about not applying the hormones to my face/neck area, and not getting the topical hormones on my fingertips for a few days prior to the saliva testing so that I wouldn’t contaminate or skew the saliva results. The other result that surprised me was the DHEA-S, which came out almost at the top-of-range in serum, but rock bottom in saliva. One study explained that the DHEA-S molecule is too big to pass thru saliva, so that may explain the discrepancy. 
Should estradiol be high or low or in the middle of the range? That depends on what your natural levels were before menopause. High estrogen women are very busty and curvaceous; they have naturally high levels. Low estrogen women are tall, lean, and fairly flat-chested, with boyish figures. If you look at families, most of the women in a family will have a similar build. This is normal and healthy for them, because they were obviously able to reproduce. A naturally low estrogen woman would only need a small dose of hormone to restore estrogen levels to what is normal for her. The sex hormones are better dosed by symptoms rather than lab results, though lab results can be used as rough guidelines for when one is too high or too low.
Thanks to BHRT, I fall asleep easier and my sleep is deeper (no more insomnia!), I look younger because of the tri-est, the vaginal dryness and itching is gone, the incontinence from laughing or sneezing is gone, and I have great muscle tone for someone my age. You will note that I am taking extremely low doses next to what others are prescribed. More is not always better!
- Norman A. Mazer. Interaction of Estrogen Therapy and Thyroid Hormone Replacement in Postmenopausal Women. Thyroid. April 2004, 14(supplement 1): 27-34. http://www.liebertonline.com/doi/abs/10.1089/105072504323024561
- Tracy Marsden . Bioidentical Hormone Replacement: Guiding Principles for Practice. Natural Medicine Journal 2(3), March 2010. http://naturalmedicinejournal.net/pdf/NMJ_MAR10_LR.pdf
- JoAnn E. Manson, Judith Hsia, Karen C. Johnson, Jacques E. Rossouw, Annlouise R. Assaf, Norman L. Lasser, Maurizio Trevisan, Henry R. Black, Susan R. Heckbert, Robert Detrano, Ora L. Strickland, Nathan D. Wong, John R. Crouse, Evan Stein, and Mary Cushman. Estrogen plus Progestin and the Risk of Coronary Heart Disease. N Engl J Med 2003; 349:523-534. http://www.nejm.org/doi/full/10.1056/NEJMoa030808
- Shifren, Jan L., Desindes, Sophie, McIlwain, Marilyn, Doros, Gheorghe, Mazer, Norman A. A randomized, open-label, crossover study comparing the effects of oral versus transdermal estrogen therapy on serum androgens, thyroid hormones, and adrenal hormones in naturally menopausal women. Menopause: November/December 2007 – Volume 14 – Issue 6 – pp 985-994. http://tinyurl.com/4b9rsct
- DHEA and DHEAS: An Introduction to Their Function and Measurement. Saliva 501 – The Fundamentals of Saliva. 9/2/10. http://www.salimetrics.com/documents/Saliva_501_-_DHEA_and_DHEAS.pdf
- Brisken, Cathrin. Progesterone signalling in breast cancer: a neglected hormone coming into the limelight. Nature Reviews Cancer 13.6 (2013): 385-396. http://infoscience.epfl.ch/record/186735/files/Progesterone signalling in breast.pdf
- Tosovic, Ada, et al. Triiodothyronine levels in relation to mortality from breast cancer and all causes: a population-based prospective cohort study. European Journal of Endocrinology 168.4 (2013): 483-490. http://www.eje-online.org/content/168/4/483.abstract