By Dr. Shawna Darou, ND
The majority of my practice focuses on hormonal health – ranging from issues at puberty, with fertility, thyroid disorders, PCOS, endometriosis, irregular periods, perimenopause and menopause. I wanted to explain some of the common pitfalls in treating hormonal issues which can save a lot of time in assessment and treatment.
(1) Testing hormones at a random cycle day
It’s not uncommon for women to bring in hormone testing, but they were not instructed to do testing on a certain cycle day. Random levels are rarely useful. If you are menstruating, your hormones fluctuate significantly through the month, so it is important to do testing at the right point in your cycle to make the readings relevant.
Typically for a woman who is still cycling, hormones are tested on day 2 or 3 to check for fertility, perimenopause, menopause, PCOS, or premature ovarian insufficiency. Tests that are typically done at this time include FSH, LH, estradiol especially.
The second date for testing is mid-luteal phase, which is day 21 if you have a 28 day cycle, or earlier / later if you have a shorter or longer cycle. Testing at this point in the cycle would include progesterone and estradiol. This will catch the peak progesterone level, and relatively how much estrogen is produced at this time.
Also, the reference ranges for hormones are extremely large, and it is actually rare for a level to be out of range. I base my assessment on optimal ranges for fertility at each cycle time, or a change over time for your own levels.
Bottom line: if you have had hormone testing done at a random cycle day, and were told that your levels were normal, this was not an accurate assessment.
(2) Assessing thyroid function with only a TSH value
Yes, the TSH is valuable in assessing thyroid health, and can indicate the presence of hypo- or hyper-thyroidism, but this is not the only lab result to look at for a thorough assessment.
A full thyroid panel includes TSH, free T4, free T3, Thyroperoxidase antibodes and Thyroglobulin antibodies, and sometimes reverse T3 as well. When all values are looked at, you can learn how well the thyroid is working, how the body is converting T4 to T3, and whether there is an autoimmune condition present. Usually the additional assessment is necessary to optimally treat any type of thyroid dysfunction. (If you are on thyroid medication, but still have thyroid symptoms, read more here).
Bottom line: if you have symptoms of hypo- or hyper-thyroidism, a full thyroid panel is recommended.
(3) Not checking for metabolic stress in the hormone assessment
Metabolic stress is caused by either under-eating calories, restricting carbohydrates or fats, extended fasting, or over-exercising – all of which are extremely common with practices of intermittent fasting, keto diets, or lots of intense workouts. Metabolic stress causes significant hormone imbalance, ranging from missed or irregular periods, infertility, or hair loss, fatigue and weight fluctuations. A key marker that suggests metabolic stress is a low free T3 level in the bloodwork, with normal TSH and T4. The body is literally trying to slow down your metabolism in response to restriction. As trendy as low-carb, ketogenic diets and intermittent fasting are right now, for many women they can create hormone imbalance. (Learn more about intermittent fasting and hormones here; and overtraining syndrome here).
Bottom line: if you are experiencing a change in hormones that may be related to a change in your diet or exercise habits, testing for metabolic stress is recommended.
(4) Relying only on fasting glucose and HbA1C to assess blood sugar regulation
Yes both fasting glucose and HbA1C are the most accurate tests to diagnose diabetes, but there are additional important tests that can show issues with blood sugar balance and and regulation before diabetes develops.
A simple test for fating insulin can often indicate insulin resistance, or the gold standard test of an insulin-glucose challenge. Other markers that indicate issues with blood sugar imbalance include a low level of sex-hormone binding globulin, and high triglycerides. (Read more about insulin resistance here).
Bottom line: fasting insulin levels in addition to fasting glucose and HbA1C is recommended to thoroughly test for blood sugar regulation issues, especially to be proactive in preventing future diabetes.
(5) Looking only at hormone production and hormones levels, and forgetting the gut for estrogen dominance, PMS, painful periods and endometriosis
One surprising fact that you may not know is that your hormones and your menstrual cycle are influenced by your gut, specifically the balance of bacteria called the microbiome. When the gut microbiome is out of balance, certain bacteria which are now termed the “estrobolome” produce an enzyme called beta-glucuronidase that reactivates estrogen so that it goes back into circulation. Similarly, if you are chronically constipated estrogen is not being eliminated very effectively and is also being reabsorbed. Both of these situations create an excessive load of estrogen. One thing that I learned years ago, is that the quickest way to get relief from annoying PMS symptoms such as bloating, irritability, acne, mood swings, food cravings and more, is to go straight to the gut flora first. When the microbiome is out of balance, it contributes to estrogen dominance which can exasperate PMS, painful periods, heavy menstrual flow and endometriosis. (Read more about the gut and estrogen dominance here).
Bottom line: if you are experiencing hormonal symptoms, addressing the gut microbiome and digestive function may also be important.
(6) Not asking about alcohol intake
High alcohol intake (more than 4 drinks per week) can affect hormone balance, and aggravate PMS, perimenopause mood issues, menopausal hot flashes, and especially sleep quality. Remember that your hormones are first processed and detoxified through the liver, and when the liver is stressed there will be more hormonal symptoms. Women in their perimenopause and menopause years tend to be most sensitive to alcohol, meaning their hormonal symptoms are amplified in response to moderate or heavy alcohol intake.
Bottom line: looking at alcohol intake may be necessary to address hormonal symptoms, especially during perimenopause and menopause.
(7) Prescribing hormone replacement therapy without looking at personal genetics
The first criteria in checking for safety with hormone replacement (including bioidentical hormones) it to check or a personal or family history of breast cancer or other hormonal cancers. After this however, there are certainly more safety checks. We can look at the liver detox pathways that will metabolize hormones to see if there are any issues with clearance. Slow detox pathways can potentiate the effect of the hormones and increase risk of hormone-sensitive cancers as well as other side effects, regardless of family history.
To simplify, looking at each of these pathways gives an idea of whether a woman will be able to detoxify extra hormones well, or whether the hormones may be creating additional risk based on slow pathways. (Learn more about using personal genetics for your health and hormones here).
Bottom line: we can more safely prescribe hormone replacement therapy by looking at personal genetics.
(8) Not talking about stress with any type of hormone issue
I always consider stress as the amplifier – wherever there is an imbalance in hormones, persistent high stress will make it worse. It can affect fertility, perimenopause, endometriosis, PCOS, menopause, irregular periods, luteal phase issues, thyroid disorders, and more. Stress levels can be assessed by testing hormones – blood levels of cortisol and DHEA, or detailed saliva or urine panels to measure the cortisol rhythm. (Read more about how living in stress-hormone overload impacts your health and hormones here).
Bottom line: chronic high stress, or acute high stress can impact almost all hormonal issues and amplify symptoms or hormone imbalance.
(9) Not recommending hormone replacement for women entering early menopause
There are many good reasons to strongly recommend hormone replacement therapy for women who have started menopause early – before the age of 45 especially. Hormone replacement can reduce the risk of cardiovascular disease (1), reduce the osteoporosis (2), support brain health & cognition (3), and reduce the aging affects of low estrogen. Before beginning hormones, it is important to screen for risk factors for breast cancer or other hormonal cancers, as well as blood clotting disorders or migraine with aura. Many women who have experienced menopause in their late 30’s or early 40’s are not started on hormone replacement, and this can create more long-term health issues.
Bottom line: if you have gone into menopause before the age of 45, after careful risk assessment, hormone replacement therapy is strongly recommended until you reach the age of typical menopause (50-52).
(10) Forgetting that all systems in the body communicate
From a naturopathic and functional medicine perspective, all systems in the body interact and communicate. One of the biggest mistakes people make in treating hormonal issues is to start with the hormones. You will get longer-lasting, and permanent changes if you begin with overall health: – nutrition, sleep, exercise, stress, liver detox pathways, gut function, emotions, and correct imbalances here first. This follows the principles of treating the underlying cause of first. The underlying cause of a hormone imbalance is typically not a lack of hormones or over-production. It is more likely caused by issues with detoxification, gut health, blood sugar imbalance, poor nutrition, or too much stress.
Bottom line: remember that when addressing anything hormonal, it is important to look at the whole body in order to get to the root cause of hormone imbalance or hormone symptoms.
I hope this short article has shown you some of the ways you can better understand your hormones, and get straight to optimal treatment of hormonal issues. If you would like to learn more about your individual case, you can book in for an appointment anytime.
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