I receive a fair number of emails asking me to post about hormone replacement therapy (HRT) for women. Frankly, I’ve been avoiding it, for two reasons. First, I don’t see many patients for this issue. While some Endocrinologists do, I find that most peri- or postmenopausal women in my region discuss HRT with their Gynecologist, primary care provider, or naturopath. While I do follow the medical literature regarding HRT, opportunities for me to prescribe it come few and far between.
Second, I tend to write about things that have not been beat to death elsewhere on the internet – at least not beat in exactly the same way that I would cover it. There is already plenty of excellent debunkery to counteract the quackery about HRT.
So why am I writing about HRT now, and – more importantly – why should you give credence to anything I say, given my lack of clinical experience in this arena? I decided to write this post because, despite all the good information out there, you either: aren’t finding it, aren’t sure whom to believe, or you simply want my opinion because I’m the “most trusted endocrinologic source on the internetTM.”*
I also figure that, if Alternative Medicine can publish the copious nonsense that ruins the signal-to-noise ratio on the internet, then it’s probably okay for me to point out fallacies and offer better advice when I think I have it. But, because I value the trust you have placed in me, I did go one step further. I discussed every aspect of this post with one of my closest friends, who is a well-respected Obstetrician/Gynecologist of nearly 20 years. As good as I may be at dissecting medical literature, that should be used as an adjunct to clinical experience – not a substitute.
In the interest of full disclosure, which I know you don’t get at most Alt Med sites, you should take this post with a grain of salt. This post is based on my interpretation of the medical literature and my relationship with one OB/GYN specialist. I am using this trusted friend as a proxy for how most mainstream Gynecologists practice. She has won just about every type of award out there over the years – best teacher at a medical school, top doctor among her peers, top doctor among patients, etc. So I think she knows what she’s talking about, but that’s an assumption.
In order to keep this focused and manageable, the scope of this post will be fairly narrow. I will explore what Estrogen Dominance means, why peri- and postmenopausal women should not spin their wheels trying to test for it, and a sensible philosophy for treating symptomatic women at this stage of life. The following topics will be outside the scope of this post, but may be covered in future posts: the risks of and indications for HRT, testing for and use of bio-identical HRT, PCOS (polycystic ovarian syndrome), and other “reproductive stage of life” hormone issues. Nonetheless, some of the content in this post will be applicable to the issues I’m not covering today.
What is Estrogen Dominance and Why Should You (not) Care About it?
The main problem with the theory of Estrogen Dominance is that, depending on who you ask, it means different things to different people. Most medical doctors don’t use the term but might think it refers to a reproductive-age woman with anovulatory cycles (no egg is released during the menstrual cycle). Alternative Medicine might use it to refer to any premenopausal woman with a constellation of nonspecific symptoms (fatigue, bloating, mood changes, poor sleep, etc) that are often what we call “symptoms of a busy life.” Extreme Alties use it to refer to people who have been “poisoned” by endocrine disrupting chemicals with estrogenic effects, from their food supply or plastics they use. Or, Estrogen Dominance could refer to a perimenopausal woman with hot flashes and other menopausal symptoms.
When evaluating any medical theory you encounter on the internet, you should ask yourself two questions: is it coherent, and does it generate meaningful search results on PubMed?
Estrogen Dominance certainly fails the coherence test. If one tries to boil the theory down to something sensible, the best one can do is say that ED (Estrogen Dominance, not Erectile Dysfunction!) describes a state in which there is more estrogen than progesterone. This, of course, describes normal ovarian physiology for most of a woman’s reproductive life:
Attribution: Chris 73 / Wikimedia Commons [GFDL 1.3 (www.gnu.org/licenses/fdl-1.3.html) or CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]
As you can see, estradiol starts rising significantly in the late follicular phase, with progesterone levels still fairly flat until they finally start rising during the luteal phase. Advocates of finding pathology in this normal process seem to believe that, when estradiol is high and progesterone is low, hysteria ensues and hormones need balancing – whatever that means. Another way of looking at this is – please scroll back up to the diagram for a second – if Estrogen Dominance is bad, then the menstrual cycle should have evolved to simply be one long luteal phase, with no follicular phase. That would ensure a proper “natural balance” of estrogen and progesterone, right? There’s only one problem: every female on the planet would have only one egg that could be fertilized over the course of her life, leading to a contraction of the world population and eventual extinction of humans. That is not happening.
The ED theory seems to abound in the treatment of symptomatic peri- and postmenopausal women, so that’s where I’d like to focus.
Claim: Classic medical teaching says that estrogen levels fall as a woman enters menopause, until the ovary loses the ability to make much at all. Mainstream medicine attributes hot flashes to these low estrogen levels. But, there is evidence that estrogen levels are high, not low, in perimenopause. This proves that high estrogen levels, in combination with low progesterone levels (Estrogen Dominance), are responsible for a woman’s symptoms. Obviously, the correct treatment is to give progesterone to help antagonize the excessive estrogen levels, alleviating symptoms.
HD: Partly True. Surprised? Expecting “Mostly False?” It is true that we used to think estrogen levels fell from the onset of menopause through the transition until the ovary was barely capable of making any. One of the most elegant studies demonstrating that estrogen levels are actually high in perimenopause was published in JCEM by Santoro et al in 1996. While the authors found that estrogen was high and progesterone low in the study population, they could only postulate that dysfunctional uterine bleeding and other gynecologic symptoms might be related to this hormonal milieu.
In fact, nobody has been able to figure out the precise pathophysiology for many menopausal symptoms, particularly hot flushes. Nonetheless, the claim that mainstream medicine believes that hot flushes are due to low estrogen levels is false. If we believed that, then all women between their 50s through death should be walking around in a constant state of flushing. They aren’t. We don’t. We believe that hot flushes are due, at least in part, to the rollercoastering estrogen levels seen during the menopausal transition. This theory that wild swings of estrogen in perimenopause cause symptoms is consistent with the data presented by Dr. Santoro and her colleagues.
Claim: It is inappropriate to give estrogen + progesterone (E+P), the mainstream standard of care, because estrogen levels are already high.
HD: False. As stated earlier, we believe that menopausal symptoms are due to wide swings in estrogen levels. Giving estrogen alone or E+P will provide a steady state level of estrogen, reducing the wide swings. Proponents of the ED theory claim that supplemental estrogen or E+P will not suppress the body’s own production of estradiol, because the hypothalamus/pituitary are too “dysregulated” at this time of life. Basically, they’re saying that the pituitary gland’s stimulation of the ovary to make estradiol will not respond to the negative feedback of E or E+P medication. To the best of my knowledge, there is no data to support this assertion. When we give steady doses of these hormones, that should result in suppression of pituitary gonadotropins (the hormones that stimulate the ovaries).
Claim: Progesterone-only medication is the most appropriate treatment for perimenopausal symptoms.
HD: Mostly False. There is no medical evidence to support this claim. However, if standard E or E+P therapy doesn’t work as desired, or if the woman prefers P alone, that’s fine. There’s nothing wrong with trying oral, natural micronized progesterone, which can be given cyclically in a higher dose or continuously in a lower dose.
Claim: You should test your estradiol and progesterone levels, to see if you suffer from Estrogen Dominance.
HD: False. You’ve seen the graphic above. If you are cycling regularly, you know that your hormone levels will depend entirely on when within the cycle they are drawn. The only thing those numbers can tell you is that you are cycling (not talking about fertility/ovulation issues today), which you kind of already knew! If you are perimenopausal and starting to have some irregular cycles plus other symptoms, you know there’s a good chance that your estradiol levels will be swinging widely, which should not affect your choice of treatment. If you are postmenopausal, then it’s ludicrous to test anything, because estrogen and progesterone levels will be low, by definition.
Remember when I recommended asking yourself two questions when evaluating a medical theory you find on the internet? I’ve already addressed ED’s lack of coherence. The second question is, what do you find when you plug the search term into PubMed? In the case of Estrogen Dominance, you find nothing of value, which should be a giant red flag. Do yourself a favor: forget about the theory, certainly don’t try to test for it, and work with your doctor to find a hormonal regimen that adequately addresses your menopausal symptoms.
Come back soon for my next post, Are Bioidentical Hormones Safe?
*Lest I cause the U.S. Patent and Trademark Office’s knickers to become twisted, I should make it clear that I have not trademarked this ridiculous phrase.
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