“You don’t need progesterone because you don’t have a uterus anymore.” I cannot tell you how many of my female patients have told me this is the statement they hear from their healthcare providers while they are being prescribed estradiol and/or testosterone and complain of not feeling balanced.
I truly cannot understand this logic. Why would a woman need estradiol and not progesterone? What does a uterus have to do with anything at this point? If a functioning uterus is somehow a determining factor in hormone balancing, why is estrogen important and not progesterone when they both work on the uterus?
How Estrogen and Progesterone Work Together
Estrogen’s job is twofold when it comes to managing the female menstrual cycle. Estradiol promotes cell proliferation and cell growth. First, estradiol grows the egg in the ovary. Second, estradiol develops the lining of the uterus to allow for implantation.
Once ovulation occurs and the egg leaves the ovary, the empty follicle gets a new name. Now it is the corpus luteum. The job of the corpus luteum is to send out high levels of progesterone. If implantation occurs, then progesterone levels remain high and the pregnancy is maintained. If implantation does not occur, then progesterone levels drop, the lining of the uterus is shed, and things start all over again the next month.
Since both estradiol and progesterone manage the uterus during the menstrual cycle, why would a healthcare provider suggest that a woman needs one and not the other? I simply do not follow this logic.
The Rise in Estradiol Prescriptions
With the removal of black box warnings on the use of estradiol, we now see a surge in prescriptions from conventional medical providers for estradiol. My concern is that women are being prescribed estradiol without appropriate testing, monitoring or balancing of all their hormones. This kind of mismanagement increases the risk of cancer, mood and emotional disturbance, weight gain and decreased quality of life.
The potential safety of estradiol is no longer being brought under such scrutiny, so what are the benefits of estradiol and why do so many women want it?
Benefits of Estradiol
Estradiol has been associated with:
- Decreased hot flashes
- A reduction in fatal cardiovascular events
- Improved bone density
- Decreased risk of developing Alzheimer’s disease
- Improved vaginal dryness
- Decreased risk of cognitive decline
Benefits of Progesterone Beyond the Uterus
If estradiol has all of these systemic benefits, it only makes sense that progesterone would also act outside the uterus. Progesterone is the natural balancing act to estradiol. Studies demonstrate that women on combination estradiol and micronized progesterone had lower breast cancer compared to women taking combination synthetic progestins and estradiol.
Progesterone is a known neurosteroid. Its other benefits include:
- Decreasing anxiety and depression
- Improving sleep quality and quantity
- Acting to protect the uterine lining by inhibiting the growth of cancer
- Improving fat burning
- Helping balance insulin sensitivity
- Improving elasticity of the skin
- Supporting serotonin activity in the brain
- Improving premenstrual syndrome
- Assisting with alcohol withdrawal
- Improving epilepsy
- Improving learning and memory
Why Personalization Is Essential
Knowing the benefits of estradiol and progesterone, can we infer that all women need to be medicated and given standardized doses? Absolutely not. This is where personalization is KEY to balancing hormones and improving quality of life while mitigating any potential health risks or adverse reactions.
The Sex Hormone Cascade
It is important to understand that estradiol is an end product in the sex hormone cascade. Estradiol does not just appear out of nowhere. It comes directly from testosterone, which comes from DHEA, which comes from pregnenolone which is synthesized from cholesterol and vitamin D. When helping women (and men too) balance hormones, we must understand all the sex hormones in their body.
Additionally, hormones require cofactors to be both synthesized and safely broken down and eliminated. It is not always the absolute levels of hormones in a body that impact symptoms, but how those hormones are broken down that is actually the problem. Understanding the body in which hormones are acting as messengers is just as important as looking at hormone levels.
Testing and Monitoring Hormones
Testing is essential at baseline and to monitor response to treatment. A full hormone panel must be done to examine the entire sex hormone pathway. These tests include:
- DHEAs
- Testosterone (free and total)
- Estradiol
- Estrone
- Progesterone
- Lipid panel
- Vitamin D
- Vitamin B12, folate and homocysteine
- Complete blood count
- Comprehensive metabolic panel
- Sex hormone binding globulin
- TSH, FT4, FT3 and RT3 (thyroid panel)
Blood Work vs Saliva Testing
In menopausal women I always check blood work and a saliva test when I am first collecting information. Blood work tells us how much total hormones are in a system, and this includes both bound and unbound hormone levels.
The unbound hormone is the only hormone available to move through the tissues and bind to hormone receptors to actually do the work. This is where saliva testing helps us understand the complete picture. Saliva levels only look at unbound levels of hormones. Comparing the two tests gives us a really good idea of what can be contributing to symptoms and also how to personalize a hormone replacement treatment plan.
Symptoms Matter During Treatment
When evaluating how a woman is responding to treatment, symptoms matter. Symptoms matter a LOT. Once on a personalized hormone therapy treatment plan, symptoms should be improving. If symptoms are not improving, then the plan needs to be revised or something else is going on. Follow ups and working with a healthcare provider who takes the time to sit and listen is essential for a successful treatment.
Balancing Hormones as Part of Whole Health
I always tell women that balancing hormones is like the icing on a cake. The hormone signaling system is influenced by a number of factors including stress, diet, sleep, movement, genetics and environmental exposures.
Sometimes, even when a woman is feeling very hormonally imbalanced, we have to start with other lifestyle changes before we address hormone levels directly. Often, getting back to balance requires a step by step approach.
References
Tomi S. Mikkola, Pauliina Tuomikoski, Heli Lyytinen, Pasi Korhonen, Fabian Hoti, Pia Vattulainen, Mika Gissler, Olavi Ylikorkala, Vaginal estradiol use and the risk for cardiovascular mortality, Human Reproduction, Volume 31, Issue 4, April 2016, Pages 804–809, https://doi.org/10.1093/humrep/dew014