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Remember, this is educational information only and not medical advice (and I am not a doctor nor an expert on endo). Always check with your qualified medical professional before making any changes to your treatment plan.
Hormones and hormone replacement therapy
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.
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.
For some of us, our hormones may not be at optimal levels. For example, we may have too little progesterone or testosterone. 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 micronized progesterone and testosterone gel. I get these prescriptions through a NAMS-certified gynecologist, and for the first year I did work with a naturopath* to take a few specific supplements to support my specific hormone health. Through this experience, I learned that there may be herbs, supplements, and/or diet/lifestyle habits that can help us 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 (HRT)
“Hormone therapy remains the most effective treatment for vasomotor symptoms (VMS) and the genitourinary syndrome of menopause and has been shown to prevent bone loss and fracture. The risks of hormone therapy differ depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. Treatment should be individualized using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of the benefits and risks of continuing therapy.” (Source: NAMS position statement)
HRT can take 8-12 weeks to start having an impact on your symptoms.
If we get both our ovaries removed, one ovary removed, or even a hysterectomy in which we keep our ovaries, we may have changes to our hormones. This is especially likely if we have both ovaries removed and are plunged into surgical menopause. But it’s also important to know that some people go into menopause earlier after having a hysterectomy (hysterectomy without ovary removal). In addition, the NHS also states that after a hysterectomy, your ovaries could fail within 5 years of having your uterus removed, because the ovaries receive some of their blood supply through the uterus.
I had one ovary removed during my surgery, and I was told that because I was 34 and had the other ovary, I would be just fine. Yet about 6 months post-surgery, I began having all kinds of symptoms that I didn’t pinpoint as low hormone output (and me needing HRT) for another year after that, because my symptoms didn’t seem indicative of hormones problems and the surgeon had told me my hormones would be fine. This led to unnecessary suffering, and I was emotionally unprepared for what I went through and how hard it would be to get accurate info on HRT. If you’re having both ovaries removed, you may want to begin researching HRT and speaking with (if possible) a NAMS-certified menopause specialist so that you are prepared if bothersome menopause symptoms begin.
Systemic estrogen can be taken oral vs transdermal (like a patch, cream, or gel). Speak to your doctor about the pros and cons of each delivery method and any contraindications because of your personal health. Estrogen is often given transdermal because it appears to have lower risks than oral.
Local estrogen can be used vaginally, as a cream, suppository, etc. This can help urinary-genital symptoms in that area (such as vaginal dryness, overactive bladder, UTI symptoms, etc) and doesn’t appear to have the same risks as systemic estrogen. It can be started at any age and continued for life. Unfortunately though, vaginal estrogen has a black box warning on it because the FDA requires this on all estrogen products. This scares people away from using vaginal estrogen, even though vaginal estrogen has not been shown to have the same risks as systemic estrogen. Some menopause experts have come together to petition the FDA to remove the black box warning from vaginal estrogen. A fabulous resource on vaginal estrogen is Kelly Casperson.
You can take vaginal estrogen in addition to systemic estrogen.
“The menopause-related indication for progestogen use is to prevent endometrial overgrowth and the increased risk of endometrial cancer during estrogen therapy (ET) use.” (Source: NAMS position statement)
However, oral micronized progesterone may be helpful to people without a uterus, or people not taking estrogen therapy. Progesterone may help lighten heavy periods, lengthen menstrual cycles, or improve histamine intolerance symptoms, sleep, anxiety, or even hot flashes in those in perimenopause. Like all HRT, it’s individual to each person.
Progesterone is not the same as progestins. Some people may do terribly on progestin-only birth controls and have a lot of mood-related or PMS symptoms, but are fine taking progesterone. This was actually the case for me. However, some people find progesterone worsens or causes PMS or PMDD symptoms.
Testosterone – the forgotten hormone
Unfortunately, the current North American Menopause Society (NAMS) Guidelines only recommend testosterone for low libido. Because of this, many providers, even NAMS-certified providers, often ignore the important role testosterone plays in people assigned female at birth or even demonize it, telling stories of a patient’s negative experience on it. (Note: often times these negative experiences are when patients are on the pellet with a practitioner that doesn’t know how to correctly adjust the dose, and therefore the patient is getting unnecessarily large doses of testosterone). These types of stories add to people’s misconceptions of testosterone, which is often talked about as a “male” hormone, when in reality people of all sexes have testosterone, as it plays an important role in our bodies! Taking testosterone within the normal female range is not going to cause a person to grow a beard or transition – the HRT doses are to replace what you’ve lost and stay within the female range of testosterone.
This lack of understanding about the role testosterone plays in people born with ovaries is a massive disservice to us. Did you know that our ovaries produce 3 times more testosterone than estrogen prior to menopause? For many people who have low levels of testosterone and start taking it, it can be a lifesaver and can make them feel like themselves again! The ovaries are a main producer of testosterone, so if a person has an oophorectomy at a young age, they may find taking it to be really beneficial. Some people prefer to go on estrogen HRT first for their symptoms, and if they persist, look into testosterone replacement. In my own case, my estrogen levels are fine, but my testosterone is extremely low. I’m having a lot of anxiety/sleep related symptoms, so I began testosterone gel.
“And in our clinic experience here at Newson Health, patients tell us that in addition to improved libido, testosterone can help improve other menopause-related symptoms such as anxiety, brain fog, and fatigue as well as improving exercise intolerance. Many menopause specialists, and increasingly general practitioners, are realizing the widespread benefits of testosterone replacement for most women. Benefits of testosterone can include improved muscle mass and strength, enhanced concentration and memory, and better sleep.” [Source: Newson Health – Menopause and Wellbeing Center].
But isn’t HRT dangerous?!
This idea came about from the Women’s Health Initiative (WHI) results, published in 2002, which seemingly showed that HRT had more risks than benefits (with increased risk of breast cancer, heart disease, stroke, and dementia). Rightfully so, many people stopped using HRT and became afraid of it. Nowadays though, the stance of many doctors, researchers, and menopause societies has changed. New studies have been done on the safety and effectiveness of different HRT formulations, regimens, and delivery methods, and new analyses were reached.
The results of the WHI study can’t be extrapolated to all hormones formulations nor for all people – these were specific outcomes for certain hormones for certain people: The average age of the women in the WHI was 63, so that is 12 years past the average age of people (51) when they go into menopause! These study participants were also asymptomatic and didn’t have menopause symptoms. 16,608 healthy postmenopausal women with a uterus, ages 50-79, were randomized to either test or placebo group, and given conjugated equine estrogen alone or in combination with a single progestin, medroxyprogesterone acetate.
The current stance of the North American Menopause Society (NAMS):
“The 2022 recommendations reiterate the importance of shared decision-making and patient education when addressing treatment options, stating that—for most healthy, symptomatic women under the age of 60 who are within 10 years of menopause onset—the benefits of hormone therapy outweigh the risks.” [Source: Contemporary OB/GYN].
“The risks of hormone therapy differ depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. Treatment should be individualized using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of the benefits and risks of continuing therapy.”
“It can be considered for continuation beyond age 65—after appropriate evaluation and benefits-risks counseling—for persistent VMS [vasomotor symptoms], quality-of-life issues, or osteoporosis prevention.” [Source: Contemporary OB/GYN].
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 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:
- Does HRT generally help with symptoms like mine?
- What are the risks vs the benefits?
- How long will I be on it?
- Do you use bioidentical or synthetic hormones?
- Will you test my hormones? If yes, how will you test them?
- 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 bio availability 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.
Most of the menopause specialists I follow say to use FDA approved products because they are regulated, and to avoid custom-compounded hormones or pellets if FDA approved options are available. An example of when a custom-compounded hormone is helpful is when a person has an allergy to an ingredient in an FDA approved product. Another example is for testosterone: unfortunately, there are no FDA approved testosterone products for females. Some providers will prescribe the male FDA approved product and tell the patient to use a smaller dose. Others will prescribe custom-compounded testosterone instead.
In terms of pellets: I know people who swear by their hormonal pellets, and they work with providers who know how to properly monitor their testosterone levels while on them. It’s not to say that all pellets are bad, but rather there are many providers out there who don’t know how to properly dose pellets, leading to their patients having extremely high testosterone levels and therefore a lot of side effects! 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.
Unfortunately, when I first started taking progesterone, it was a product made by a functional medicine doctor and sold in his online store. This was a huge red flag about him which I wasn’t aware of at the time. Eventually, I learned that better options were available, and got my primary care physician to prescribe me regulated, FDA approved oral micronized progesterone, which was covered by my insurance, for a fraction of the price.
The term bioidentical has been used in different ways. When people say bioidentical, they are typically referring to hormones that are as close to what ovaries make as possible, such as oral micronized progesterone. This is different from the non-bioidentical progestins in birth control, which have names like levonorgestrel or drospirenone.
However, bioidentical hormones is actually a term invented by marketers, and has no scientific meaning, so some people exploit the term bioidentical to use for marketing their custom hormones, like the functional medicine doctor I saw did – when in reality, there were much better, FDA approved, regulated hormone options available to me.
You can find a list of FDA-approved hormone products here: NAMs menonote on bioidentical hormone 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 hormonal birth control “balances hormones”, but birth controls do not do this. The hormones in birth control are synthetic, and they usually maintain 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 immediately suggests you take birth control for HRT (without any discussion about estrogen therapy), this is often an indication that they aren’t well versed in hormones.
Having said this, that isn’t to say that hormonal birth control isn’t right for you in your individual situation – this depends on your symptoms, your treatment goals, your side effects, and other factors. You can discuss the pros and cons of different options with your doctor. At the same time, remember that many gynecologists are not well versed in HRT, so it’s important for you to go in with background knowledge too so you can know when to get a second opinion if needed.
There are different types of hormone testing. The most common and reliable are blood tests, which are often covered by insurance. “Salivary and urine hormone testing to determine dosing are unreliable and not recommended.”(Source: NAMS position statement)
“It is not necessary to check blood, urine, or saliva hormone levels to find the right [HRT] dose. During reproductive life, estrogen levels vary throughout the menstrual cycle and during each day, so there is no perfect hormone level for any [person].” (Source: NAMs menonote on bioidentical hormone therapy.)
Usually HRT treatments are based on your symptoms, because treatment is prescribed to improve perimenopause or menopause symptoms, and not to aim for a certain level on blood tests. However, some doctors may do an initial blood test to see your levels. If after a few months on HRT it doesn’t seem like you are responding to it, they may check your levels again to gauge if you are absorbing the hormones you are taking and if you need to change the dose or delivery method. However, many doctors treat solely on symptoms and do not do any blood tests.
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, and as mentioned above, most HRT treatments are based on your symptoms, not on your hormone levels. 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.
Is there a test for perimenopause?
There is no lab test that can tell you, but depending on your age and symptoms, you can likely distinguish if you are in perimenopause.
Here’s a list of common perimenopause symptoms (in no particular order):
- irregular periods
- hot flashes
- sleep problems like insomnia, waking during the night
- mood changes, low mood, depression
- decreased libido
- dry eyes
- migraine headaches
- aches and pains, increased fibromyalgia-like pains
- vaginal dryness
- increased urinary problems, UTI-like symptoms
- burning mouth
- gum problems
- changing cholesterol levels
- onset of histamine intolerance or increased allergies
- racing heart
- and so much more
I feel like the perimenopause and menopause symptoms we hear most about are hot flashes and mood changes, but there are so many more ways that we can be affected. Some people don’t have any hot flashes but have a bunch of other seemingly random symptoms like racing heart, burning mouth and dizziness. This is why it’s important to familiarize ourselves with perimenopause and menopause symptoms because we can go on a wild goose chase trying to figure out what is going on with our downturn in health. This happened to me unfortunately, I was sent to allergists, dermatologists, cardiologists and other doctors, and no one figured out that I was in perimenopause. Unfortunately, we haven’t been taught body literacy around menopause and neither have most doctors.
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
For more info
- North American Menopause Society (NAMS). They have position statements on hormonal and nonhormonal therapy, “menonotes” or short info sheets on important topics, and 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.
- Newson Health – Louise Newson, MD, is a GP and Menopause Specialist and holds an Advanced Menopause Specialist certificate with Faculty of Sexual and Reproductive Healthcare. There is loads of educational material on her website and podcast. I especially appreciate that she has information on testosterone as most menopause specialists don’t understand the importance of it in people assigned female at birth. Some of my favorite episodes on testosterone on her podcast were 116, 118, and 119.
- You Are Not Broken – Kelly Casperson, MD is a NAMS-certified urologist who has an amazing podcast on hormones, sex, and other topics. Browse her podcast! Some of my favorite episodes were on vaginal estrogen, an overview of HRT (episode 225 and 205), and testosterone.
- Millenium Wellness Center – helpful info on hormones, especially on pellets. Pellets have a bad reputation and many clinics that insert pellets don’t monitor well the testosterone levels resulting in extremely high levels for some people. If you are thinking about using pellets, it’s important to work with a provider who is willing to work with you to get your levels right.
- Hot and Bothered: What No One Tells You About Menopause and How to Feel Like Yourself Again – book by Jancee Dunn. I’ve read several books on menopause but none of them made the cut to this list. However I enjoyed this humorous and informative book on menopause. She shares personal experiences in a lighthearted way, while weaving in info from her interviews with menopause experts. One part I didn’t like was that the only mention of testosterone HRT painted it negatively, even though it’s an important hormone for people assigned female at birth as well.
- Lara Briden – The Period Revolutionary – I wasn’t sure if I should link Lara Briden on her because I find some of her info problematic, so I’ve linked her last because I did find her general information helpful to understand the menstrual cycle, perimenopause, and menopause, and how to support our bodies during this time. However, as for her information on endometriosis, I have seen misinformation there, so take any of that info with a grain of salt. Having said that though, some of her recommendations may be helpful for some people to manage endometriosis symptoms, but not to suppress the disease, shrink, or remove it. While she links to some studies on how X supplement etc can “reduce lesions” and other claims, these studies have design flaws. Remember – no matter the diet, lifestyle, herbs, supplements, etc, endometriosis still remains and can even progress leading to fused organs, bowel blockages, silent kidney death, etc, even if a person becomes asymptomatic.
Related Podcast Episodes
- Ep 55- Endometriosis and Estrogen
- Ep 62 – Estrogen Metabolism
- Ep 69 – Hormones 101. Part 1 – The Hormone Jungle
- Ep 70 – Hormones 101. Part 2 – Stress and Hormones
- Ep 71 – Hormones 101. Part 3 – Miscellaneous
- Ep 75 – Perimenopause, Menopause, and Progesterone
- Ep 76 – HRT – Hormone Replacement Therapy
- Ep 113 – Endometriosis and Hormone Receptors with Dr. Dulemba