The Missing Piece in Hormone Balancing

Most of us were taught that hormone balancing in women is just about estrogen and progesterone.  (note the singular “estrogen”).  Actually, it involves all the estrogens, progesterone, and androgens.  Recent research is showing that androgen levels actually fluctuate more than estrogen levels around the final menses; the level of estradiol actually remains fairly constant during the year or so on either side of the final period.  However, androstenediol, 5-diol and dhea go through large swings.  So maybe we’ve been focusing on the wrong thing all along?[1]

I remember being told in medical school that hot flashes and night sweats were from “dropping estrogen levels”.  Then I had patients who were having perfectly predictable periods but also night sweats the week prior to menses.  If they have enough estrogen to have a period, how could they also be having night sweats?  Made no sense to me in light of what I was taught. Looking beyond the ovaries to the adrenals makes more sense.

Then there’s the woman many years past her final menses, who has abdominal obesity and metabolic syndrome, who still gets night sweats and hot flashes.  Should we simply put her on hormone replacement?  That would ignore the connection that her body is making to her insulin and her cortisol; the rise in insulin after meals triggers a hot flash.  Fix the insulin issue, fix the hot flash.

The menopausal transition is so much more than what I first learned in school.  Yes, estrogen and progesterone balance is important.  However, the balance is coming from more than just what is going on in the ovaries.  Is the woman heavy, so she is converting other hormones into estradiol and estrone in adipose tissue?  Is she so stressed out that her adrenals are “swiping” her progesterone and turning it into cortisol, so the result is an estrogen/progesterone mismatch?  Does she have metabolic syndrome, so we need to look at how her insulin is impacting the hormone balance?

It’s not enough to simply put all women with hot flashes onto hormone replacement therapy, even if it is bioidentical and well thought out.  We need to look at the details of each individual; are they missing nutrients in the pathway to form hormones and just need diet changes?  Do they have liver issues so they aren’t breaking down their hormones correctly?  Is their chronic constipation causing a hormone imbalance due to reuptake of estrogen metabolites?  Are they handling the stress in their lives so poorly that they can’t keep their cortisol stable?  There are potentially many answers to one simple question.  Therefore, we need to remember to think of many different possible solutions to the same presenting situation.  And it’s not all about estrogen and progesterone!

[1] Obstet Gynecol Clin North Am 2011 Sept; 38(3): 467-475


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