MenoPassage – a holistic Journey through the menopausal years
In the menopausal years, our hormones vastly diminish, no doubt about it. Whether
to opt for hormone replacement or not is perhaps one of the most hotly debated subjects concerning menopause, it is a multifaceted subject and there are many schools of thought, each supported by volumes of scientific literature and statistics. In the end, a woman must of course chose what feels right for her body, and we encourage her to develop the sensitivity to know what that might be. By being in tune with our body’s needs and tending to its holistic care, we make the choice easier for ourselves and place it in the framework of a larger perspective, that of the MenoPassage Journey, a gateway to new chapter full of creativity and vitality.
The very short answer to the question “Do I NEED estrogen?” is : MAYBE
One principle that has always worked in my practice is: respect the body’s own self regulatory physiology and intelligence. Listen to you your body and its cues and see what is really going on with you… then find a practitioner that is willing to work with support you in the most appropriate manner. The fact is that even if you do supplement with hormones, they will always be “extrinsic”, i.e. applied from the outside and not incorporated into the regulatory loop that has dictated our hormone levels until now. Their levels are now imposed upon the body, it no longer has a say as to what they should be according to its own intelligence. In health, the level of all hormones are regulated by the brain with the aid of feedback loops so that we can make adjustments from day to day, according to need and circumstances. When you ingest or apply a topical hormone, that is outside of the feedback loop.
The following discussion by Jim Paoletti, (BS Pharmacy, FAARFM, FIACP, Clinical Consultant with over 30 years’ experience creating and using bio-identical hormone and faculty member for the Fellowship of Functional Medicine) very much resonates with my own clinical experience. His approach facilitates a healthy and fruitful MenoPassage Journey.
First of all, let us address the need for estrogen in the PERIMENOPASUSAL years, while a woman is still menstruating…
“The truth is: A woman’s estrogen levels do not decline until the last 6 to 12 months of perimenopause. Furthermore, estradiol levels typically rise slightly when a woman first enters perimenopause, so the hot flashes experienced at this stage of life are not actually caused by a lack of estrogen.”
Many health practitioners were taught to measure FSH levels to confirm that estrogen levels were low. However, it has been shown that estrogen is not the major controller of FSH. Instead, FSH is controlled primarily by inhibin, a hormone produced in the corpus luteum i.e.the ovaries.
Once ovulation ceases, the corpus luteum will no longer produce inhibin, so FSH rises due to lack of inhibit and not lack of estrogen. Progesterone is also produced by the corpus luteum, so elevated FSH is reflective of decreased 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 rather than lack of estrogen.
Although progesterone is key for obtaining optimal effects of estrogen, other hormones may cause or influence the symptoms that 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.
In recent years, one of the biggest changes to approaching physiologic hormone balance is the way estrogen need is approached. Because so many other hormone levels affect estrogen and estrogen receptors, correcting other hormone issues have led to further and further 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 her assumed “estrogen deficiency” symptoms becomes much less.
No symptom or set of symptoms guarantees estrogen needs.
Many symptoms can be explained by another possible hormone imbalance. Even 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 can also result in ineffective estrogen. Properly assessing estrogen need and assessing response to estrogen therapy requires balancing the other endocrine hormones simultaneously or prior to estrogen administration.
At certain stages, even precise estrogen level measurement may not reliably indicate need. Estradiol levels begin to fluctuate during peri-menopause, with much wider vacillations towards the end of perimenopause. Therefore, it is wise to not rely on estradiol level measurements during this period. 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.
Does she really need that much estrogen?
Even when women do need estrogen replacement therapy, they are often given too much. Excessive estrogen may help control the hot flashes for a month or two, but eventually the symptoms return.
Too much estrogen causes the same symptoms as too little estrogen, just with a slight time delay before the symptoms return.
At first, excessive estrogen increases the number of estrogen receptors, but after a period of time the body downregulates the number of receptors, so the estrogen cannot work properly regardless of how much is there.
The keys to optimal physiologic estrogen replacement therapy are:
- Make sure she needs estrogen by correlating symptoms with measurement of levels.
- Never assume a woman needs estrogen.
- Always restore progesterone to a physiologic level before assessing how much—if any—estrogen is needed.
- Test cortisol with a 4 x per day saliva test to help determine adrenal influence on “estrogen deficiency” symptoms. Address as necessary.
- If symptoms of hypometabolism (hypothyroid) are present, test the TT4, fT4 direct, fT3 direct, TPO and TSH to properly assess. Address appropriately.
- Check insulin resistance if symptoms indicate and address appropriately
- ALWAYS start very low on estrogen dosing and make changes slowly.
- Take steps to ensure safe estrogen metabolism by optimizing liver conjugation, bowel elimination, methylation and glutathione conjugation and by reducing lipid peroxidase activity.”
*From Jim Paoletti, A Practitioner’s Guide to Physiologic Bioidentical Hormone Balance, 2015.
Thus it is really about addressing the foundation of your health before moving forward to hormone replacement and not just treating the symptoms without understanding the underlying condition.
These endocrine imbalances mentioned above also very much reflect the wisdom of Chinese medicine and their view on the multiple self regulatory systems involved in menopause. Once properly identified, they can all be supported in their own specific manner to support overall wellbeing and a holistic approach to menopause.
Understanding these principles is an essential step in a healthy MenoPassage, a journey that can lead you to the next stage of your life in a balanced and well supported state that opens the doors to new vitality and creativity.
by Angela Ingendaay, MD
