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Endometriosis and estrogen

We often hear that endometriosis is an “estrogen-dependent disease” but this is a bit misleading.

Estrogen-dependent makes it sound like endometriosis depends solely on estrogen and therefore, if we lower estrogen in the body, the endometriosis will just disappear. But this isn’t the case, and people in a low estrogen state (be it natural menopause, medical menopause via GNRH drugs, or surgical menopause) can still have disease progression and pain, and the lesions don’t just disappear. Additionally, endometriosis can make its own local estrogen, even while the body is in menopause. While estrogen is important to endometriosis, it’s not the only hormone that endometriosis is affected by. The interplay of hormones with endometriosis is complex, and progesterone, prostaglandins, and the aromatase enzyme are important too.

Estrogen dominance

Many websites say that estrogen dominance causes endometriosis or that people with endometriosis are estrogen dominant, but neither is true. While estrogen may increase a person’s endometriosis symptoms (and this highly depends on the individual), high estrogen doesn’t cause endometriosis. Additionally, people with endometriosis can have a range of estrogen from low to high – having endometriosis doesn’t mean that you have excess/high estrogen or estrogen dominance.

Hormones

For some of us, our hormones may not be at optimal levels. For example, we may have too little progesterone or too much estrogen. We may have gone through surgical menopause (removal of the ovaries) and now are thinking about hormone replacement therapy. Our hormones are involved in body-wide processes, so if we have too much or too little of a hormone, or our body is having trouble with hormone detoxification, then it can cause us miserable hormonal symptoms.

After losing my ovary, I’m now in perimenopause and was suffering a lot from hormonal anxiety, hot flashes, forgetfulness, and mood changes until I began taking oral progesterone and working with a naturopath* to take specific supplements to support my specific hormone health. Through this experience, I learned that there may be herbs, supplements, and diet/lifestyle habits that can help us with hormone health and relieve symptoms like PMS, insomnia, aches and pains, fatigue, and hormonal migraines. However, it’s individual to our specific situation and what we need, and this isn’t to say that any supplements or habits can take the place of hormone replacement therapy.

*I had a positive outcome with a naturopath. However, my own personal experience doesn’t negate the fact that overall there’s a lack of evidenced based practices within these fields. See my write up here on this.

Hormone replacement therapy

Birth control isn’t HRT

If we are considering HRT, it’s important that the doctor we work with is knowledgeable on hormones. Some doctors think that taking birth control “balances hormones”, but birth controls do not do this. The pills in birth control are synthetic and they usually maintain the hormones at a steady hormone level. If you have ever looked at a chart of your hormones online, you will see that actual natural hormones in a cycling person have a rhythm. For example, in a person with a 28 day cycle, estrogen rises around day 7 until ovulation. After ovulation, progesterone rises, and estrogen starts rising again around day 17. Both peak around day 21 and then fall to a low level when menstruation starts.

With birth control, these peaks don’t happen. Birth control is really helpful for so many of us in this community, be it in preventing pregnancy or managing symptoms of painful periods, heavy periods, endometriosis, adenomyosis, fibroids, and other problems related to periods and cycles. But birth control isn’t hormone replacement therapy, so if you are looking for HRT, and the doctor you are with suggests you take birth control for HRT, this is often an indication that they aren’t well versed in hormones and don’t know how to help. So it’s important to have background knowledge to be able to have healthy skepticism at times of the treatment the doctor is prescribing, to ask questions, and know when to get a second opinion.

Your doctor should have knowledge and experience in hormones and HRT

The North American Menopause Society (NAMS) has a “find a provider” section. You can search by zip code, and it lists doctors who have passed a competency examination developed by NAMS and have been awarded the credential of Certified Menopause Practitioner. It lists gynecologists, endocrinologists, physician assistants, naturopaths, and other types of healthcare professionals. Of course, that doesn’t mean every doctor in their database can all treat you for your specific case, so you still need to look into them as you would for any doctor but it can be a good starting place. If a doctor doesn’t have the NAMS certification, it also doesn’t mean they aren’t qualified to help you. You may also want to be careful with private hormone clinics because some use unregulated hormones.

Ask your doctor questions to see their expertise and treatment approach. Some examples might be:

• Should I take HRT?
• What are the risks vs the benefits?
• How long will I be on it?
• Do you use bioidentical or synthetic hormones?
• How do you test my hormones?
• How do you prescribe them? Will it be oral, a patch, a cream, etc?

Types of HRT

There are many ways a person can take HRT, such as oral, transdermal (patch), percutaneous (cream, gel), intramuscular, sublingual, vaginal (gels, cream, tablet, ring, and pessary), nasal, pellets, etc. The absorption and bioavailability of the hormone can change depending on the delivery route. With each type of hormone delivery, there are pros and cons that you should discuss with your qualified medical professional.

There are many different hormone creams and other versions available that you can buy at the drug store or online. These are considered “nutraceuticals” and my understanding is that they are not controlled or regulated by the FDA. In fact, I was unknowingly taking one when I first started progesterone because it was made by my functional medicine doctor and sold in his online store. This was a huge red flag about him, which luckily I figured out after a few months and got my primary care physician prescribe me (regulated, FDA approved) oral progesterone, which was covered by my insurance, for a fraction of the price.

There are concerns among some about custom-compounding hormones, as well as hormonal pellets. However, I know people who swear by their hormonal pellets, and they work with providers who know how to properly monitor their hormones while on them, so it’s not to say that all pellets are bad. Rather, it’s to say that like with anything medical, we should do research about the hormones we are looking to take and discuss the safety and efficacy with a doctor who is experienced in HRT.

Hormone Testing

There are different types of hormone testing. The most common and reliable are blood tests, which are often covered by insurance.

The DUTCH test has gained popularity among naturopaths and functional medicine doctors. Not only is it not covered by most insurance and can cost $400 or more depending on the practitioner, but the criticisms on the DUTCH test are that it’s unnecessary and even that the info is clinically meaningless for guiding HRT. Most of the same info can be gathered from blood tests with an endocrinologist or gynecologist for a fraction of the price. If you’re working with a doctor who wants you to get the DUTCH test, definitely read unbiased reviews on it before dropping a ton of money on the test and don’t be afraid to ask your doctor to explore using the blood testing options with you. If they won’t or can’t, this could be an indication that they are not fit to treat your hormones or that you may need to work with a different doctor for your HRT.

Here’s a helpful, independent review of the DUTCH test from Abby Langer, RD.

Estrogen plays a protective role in many aspects of our health.

There’s evidence to suggest that if you go into menopause before 45 (and especially before 40), and you don’t use estrogen therapy, it’s associated with a higher risk of osteoporosis, heart disease, dementia, and premature death. This is scary to think about, especially because some of us have had our ovaries removed at a young age. Since estrogen does have a protective effect on many aspects of our health, losing years or even decades of estrogen may have a long term negative effect on our health.

Not to mention, that sudden plunge into medical menopause – or even the transition into natural menopause – can make us suffer with a lot of miserable symptoms from being in a low estrogen state.

There is often a demonizing of estrogen within our community or a fear of it, and so some people may have concerns about taking estrogen as part of HRT because they are worried that estrogen might cause them to have recurrence or symptoms associated with endometriosis. The 2022 European Endometriosis Guidelines do have a short section on hormone replacement therapy, which says clinicians should be aware that people with endometriosis who have undergone an early bilateral salpingo-oophorectomy have an increased risk of diminished bone density, dementia, and cardiovascular disease. It then recommends as a Good Practice Point that clinicians continue to treat people with a history of endometriosis after surgical menopause with combined estrogen-progestogen at least up to the age of natural menopause. You can read more detailed information in the guidelines under the section Endometriosis and Menopause.

Speak with your doctor to see if HRT is right for your individual case or not. Different factors come into play when making these decisions such as:

• your age
• medical history
• your goals
• symptoms of endometriosis vs symptoms of low estrogen