Bioidentical Hormone Replacement Therapy

Do women really need that much estrogen?

Historically, it has most often been assumed that when a woman enters perimenopause and begins to experience symptoms which include hot flashes, it means she needs estrogen. However, a woman’s estrogen levels do not decline until the last 6 to 12 months of perimenopause. When she first enters perimenopause, estradiol levels usually rise slightly. The hot flashes that she experiences at this stage of life are not caused by a lack of estrogen.

Many health practitioners were taught to measure FSH levels to confirm that estrogen levels were low. However, estrogen has been shown not to be the major controller of FSH. FSH is controlled primarily by inhibin, a hormone produced in the corpus luteum. When a woman does not ovulate, she does not produce a corpus luteum or inhibin, and the FSH rises due to a lack of inhibin, not a lack of estrogen. Progesterone is also produced by the corpus luteum, so elevated FSH is reflective of a decrease production of progesterone. A physiologic amount of progesterone is required to make estrogen work correctly. In early peri-menopause, a woman’s hot flashes are most often caused by a lack of progesterone, not a lack of estrogen.

Although progesterone is a key in obtaining optimal effects of estrogen, other hormones may cause or influence the symptoms we often perceive as a lack of estrogen. High cortisol levels can also cause weight gain, irritability, irregular cycles, and hot flashes even in the present of normal estrogen levels. Consistent low cortisol can also cause or aggravate hot flashes. Low thyroid function can cause similar symptoms that appear as estrogen deficiency; insulin resistance can do the same. Over the recent years, one of the largest changes in the approach to obtaining physiologic hormone balance in women is the way estrogen replacement is approached. Since so many other hormone levels affect estrogen and estrogen receptors, correcting other hormone issues have led to further and drastic reduction in the amount of estrogen commonly administered. In other words, if the other hormone or endocrine issues are addressed first, then the amount of estrogen required to treat the assumed “estrogen deficiency” symptoms becomes smaller.

No symptom or set of symptoms guarantees a woman needs estrogen, as some symptoms can be explained by another possible hormone deficiency. Vaginal dryness or atrophy, which almost always indicates a lack of estrogen, can exist when estrogen levels are normal. Vaginal tissues are also supported by testosterone and thyroid, and a significant deficiency in one or both of these hormones can be the source of the problem. Lack of progesterone could result in the estrogen not being effective. Properly assessing estrogen need and assessing response to estrogen therapy requires balancing the other endocrine hormones simultaneously or prior to estrogen administration.

Although most of the time, measurement of estrogen levels via saliva testing is very accurate, there is a small window of time in woman’s life when it may not reliably indicate estrogen need. Estradiol levels begin to fluctuate during peri-menopause, with much wider vacillations towards the end of perimenopause. During this period, proper measurement of hormone levelsalong with symptom assessment should be reviewed. The best approach would be to correct deficiencies or issues with progesterone, cortisol, thyroid, insulin resistance, and nutrition or lifestyle, then correlate remaining symptoms with levels, and address estrogen therapy as required.

About the Author

Jim Paoletti, RPh, FAARFM is Director of Provider Education for ZRT Laboratory, Beaverton, Oregon. Jim has over 25 years experience with bio-identical hormone therapies in clinical practice in retail pharmacy, as a pharmacy consultant, educator, and educational program developer.  Jim was instrumental in developing a compounding laboratory at the Medicine Shoppe, Beavercreek, Ohio. As the Vice President/Director of Continuing Education for Professional Compounding Centers of America, Inc. (PCCA), Jim developed and implemented Continuing Education programs for doctors, nurses, and pharmacists. He also consulted with compounding pharmacists located throughout the United States, in Canada, Australia, and New Zealand, helping them to solve patients’ unique medication problems.

Jim has lectured extensively and internationally on all aspects of BHRT, including dosage forms and guidelines, testing and monitoring effectiveness, lifestyle and nutritional influences on BHRT outcomes, adrenal and thyroid hormones, and patient consultation. Jim has published numerous articles on different aspects of BHRT in International Journal of Pharmaceutical Compounding and in American Druggist, and served as review editor for the International Academy of Compounding Pharmacists’ publication, Contemporary Compounder.

Jim obtained his Bachelor’s of Science degree in pharmacy from Ohio State University in 1976.  He is a graduate and faculty of the Fellowship of Anti-aging and Functional Medicine.

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This entry was posted on Saturday, March 29th, 2008 at 4:16 am and is filed under Uncategorized. You can follow any responses to this entry through the RSS 2.0 feed. Responses are currently closed, but you can trackback from your own site.