Estrogens and Menopause

by Donald Michael, MD

A 37-year-old patient has tested for estrogen levels less than 32 pg/mL.  She has all symptoms of menopause and post-menopause in spite of continuing monthly periods.  How can this happen?

I've long said that judging the adequacy of a woman's hormonal status by the presence or absence of periods is like judging the adequacy of a man's hormonal status by the presence or absence of a five o'clock shadow.

Actually, women are more complicated than that. While a man's five o'clock shadow fluctuates fairly well with his relative testosterone level, a woman's periods reflect the estrogen levels for the entire time since her last period.

Following the last menses, the body starts to increase estradiol levels causing the new lining of the uterus (endometrium) to proliferate (grow thicker). If mid-cycle ovulation occurs, the body begins making progesterone shortly after that. Progesterone stops the proliferation of the endometrium, and helps it mature into one suitable for implantation of a fertilized ovum.

Then, if there is no pregnancy, the progesterone levels will drop 12-14 days following ovulation. It is this drop in progesterone that begins the next period, when everything is working right.

The level of estradiol needed to make the endometrium grow is often much lower than the body and brain needs for optimal function. Additionally, a blood test is a snapshot of a dynamic process that varies from day to day, and even hour to hour.

Most importantly, those "normal" ranges that doctors use to check estradiol levels are not necessarily "healthy". They simply reflect what is average for specific age groups in the women (usually those that we suspect are too low on estradiol) we send to the Laboratory.

At our lab, "normal" estradiol levels are:

Obviously these "normal" ranges are too broad to accurately reflect how a woman is really doing. Imagine, if those numbers were to represent how much air to put in your tires. You then begin to see how terribly useless it is to predict how well a woman will  do in these “Normal Ranges.”

A lack of natural estrogens (those estrogens that are naturally found in people) can cause a wide variety of symptoms; and, much of the time, the synthetic estrogens (chemicals not found in people) do not have the same beneficial effect on the brain.

If you and your physician decide upon hormone supplementation to normalize symptoms it is important to know the difference between “bioidentical” and “synthetic” hormone replacement.

"Bioidentical" simply means hormones with the same molecular structure as those found naturally in the body, as opposed to those extracted from pregnant mare urine (Premarin and others), or those made in a laboratory and patented so higher prices can be charged for them.  Medically, natural hormone replacement (lab-created hormones molecularly identical to those naturally made in the body; often referred to as "bioidentical" hormones), mostly acts to postpone the degenerative changes that occur with menopause. The side effects tend to be much less, and the benefits tend to be much better, than with synthetic hormones.

Synthetic hormones simply means those that are “put together in a laboratory.”  They may or may not be molecularly identical to those found in the human body. 

One of the more commonly used  estrogens is extracted from the urine of horses. Premarin, (PREgnant MARe urINe) can cause elevation in blood pressure, joint pains, and trigger autoimmune responses in some people.  A very common situation is that the foreign estrogens (those not naturally found in the human body) may work well for some of the things that estrogen does, for example, get rid of hot flushes or bring about a period, but they may not help the brain with mood or memory in the same manner as bioidentical estrogens.

On the other hand, carefully used natural or bioidentical hormone supplements can actually improve mood, memory, energy, and sleep.  At the very least, natural progesterone can save women from bone loss and prevent billions of dollars in health care costs for osteoporotic-related fractures and the long term pain and disability.

In "Screaming to be Heard: Hormonal Connections Women Suspect...And Doctors Ignore," Dr. Elizabeth Vliet gives an excellent explanation of these phenomena.

I have observed in my profession that many doctors like to feel that they know what is "right" for the patient, and are not particularly interested in discussion. Other physicians like to provide information about options so informed consent can be provided for any treatment received.  I strongly suggest finding a physician in the latter group.  It is quite possible that addition health issues such as thyroid problems, adrenal deficiencies, and vitamin deficiencies (especially B-12 and D) may show up.  It is extremely common for women with thyroid problems to have a hysterectomy for painful, heavy clotting periods.  Most docs have forgotten that the problems that hypothyroid women most frequently have include "periods from hell," infertility, miscarriages, and depression.

In addition to considering hormone replacement with bioidentical hormones if a low estrogen status is found, it would be a good idea to have a DEXA bone density test to determine the state of bone health and steps can be taken to prevent bone loss.  I would encourage you to read our segment on osteoporosis http://www.project-aware.org/Health/Osteo/osteo-what.shtml for more information, particularly the section on "therapies" (choose from the right-hand column).

D. Michael, MD, PC

July 18, 2008