What do we actually mean by a hormonal imbalance?
The term is thrown around pretty wildly, what does it actually mean? It's used to describe an array of hormonal related symptoms such as period pain, heavy bleeding, spotting, irregular cycles, missing cycles, hormonal acne, mood changes, weight gain, hot sweats and premenstrual symptoms. These symptoms can be frustrating because aside from the oral contraceptive pill (OCP) or intrauterine device (IUD), women are not typically offered any support. My intention for this post is to dive into what hormones actually cause these imbalances and why they may be out of balance in the first place, giving you the tools to understand your body and make the best decision regarding appropriate treatment!
Where do we start?
Sex hormones like oestrogen and progesterone rise and fall through different life stages including puberty, pregnancy, perimenopause and menopause. They also fluctuate greatly through the month in those with a menstrual cycle. And that's only the sex hormones. Hormones like cortisol and melatonin fluctuate through the day and night with our natural body clock, the circadian rhythm.
One of the reasons I think it’s important we familiarise ourselves with this is because only knowing that you have a hormone imbalance affecting your skin, cycle and mood without understanding which hormone is out of balance and why, limits your treatment options. We are fortunate to have the option of OCPs and IUDs, but I don’t see them as a cure all for hormonal issues because they only works for as long as you’re taking them and come with their own long list of side effects.
Coming off the OCP can commonly cause an exacerbation of prior symptoms because the OCP shuts off ovulation and natural sex hormone production. Whilst this does often suppress symptoms, it doesn't actually bring your hormones back into 'balance'. If you do choose to take the pill please remember there is nothing wrong with that; I'd just rather you made an informed decision by understanding how it works and the side effects associated with it.
So what hormones are we looking at?
Typically I send patients for a check up with their general practitioner and if they're experiencing hormonal symptoms they may look at the following hormones through a blood test. As a naturopath we can also order these tests privately. For the sake of keeping this post a reasonable length, I'm just focusing on the main female steroid (sex) hormones including oestrogen, progesterone and testosterone. However, you can also test for luteinising hormone and follicle stimulating hormone (pituitary hormones), DHEAs (adrenal androgen), SHBG (binds to various hormones reducing their activity), cortisol (stress hormone), TSH (thyroid stimulating hormone), T4 & T3 (thyroid hormones) and insulin (pancreatic hormone involved in blood sugar regulation). By looking at a range of different hormones we can get a full picture of the areas that may need a little extra love and support.
There are different oestrogen but oestradiol is typically the one we measure on a blood test. Oestrogen is the dominant hormone in the first half of the cycle (the follicular phase - days 1-14). High levels of oestrogen thickens the lining of the uterus and triggers the release of hormones in the brain which stimulate ovulation (the release of the egg). We also know oestrogen also supports the production of cervical mucous and plays a positive role in maintaining healthy bones, heart health, skin and mood.
Typically we test oestrogen on day 2 or 3 of the menstrual cycle, but we can also test approximately 7 days after ovulation if we're also testing progesterone to check for ovulation.
There are two things we're looking at when testing oestradiol. Firstly, we want to see it within an optimal range for that time of your cycle. Secondly, we want to ensure that oestrogen is in a healthy range in comparison to progesterone. If we see oestrogen at the higher end of the range and progesterone at a lower end of the range 7 days post ovulation, we consider this a state of 'oestrogen dominance'. Because oestrogen and progesterone balance each other out, oestrogen dominance can cause symptoms of heavy periods, painful periods, PMS, swollen and painful breasts and fluid retention. High oestrogen not balanced out with healthy levels of progesterone is also associated with conditions such as fibroids, endometriosis and adenomyosis. Low oestrogen can also cause some issues, including irregular, missing or light periods and vaginal dryness. Low oestrogen is what we see during and following menopause.
A simplistic way to differentiate between oestrogen and progesterone is to consider that oestrogen stimulates tissue growth, contributing to heavier menstruation when out of balance. Progesterone in comparison works to lighten the uterine lining prior to menstruation resulting in lighter, easier periods. We want to aim for balance between the two hormones.
Progesterone is a hormone released by the ovaries following ovulation in the second half of the cycle (the luteal phase). If ovulation doesn’t occur, then we don’t release adequate amounts of progesterone. We want healthy amounts of progesterone for regular, easy periods, fertility, to calm the nervous system and support the cardiovascular system.
Because progesterone counteracts the more proliferative effects of oestrogen, low progesterone levels can contribute to heavy and painful menstrual bleeds. Because we release progesterone following ovulation, we may also see irregular or absent periods when progesterone is low and this greatly impacts fertility. Progesterone supports the integrity of the uterine lining, so low levels can also result in spotting before your period.
Low progesterone is also associated with PMS, because like oestrogen, levels drop right before menstruation, effecting various neurotransmitters in the brain like serotonin. Progesterone typically has an antianxiety effect on the brain as it acts on specific calming receptors in the brain. However, women with PMDD may be highly sensitive to the effects of progesterone. Progesterone is converted to a specific compound, called allopregnanolone, which may contribute to PMDD due to an increased sensitivity of receptors in the brain.
We typically want to test progesterone about 7 days after ovulation. In a 28 day cycle this would be day 28, or in a 32 day cycle we would test around day 25. This way we can tell if healthy ovulation has occurred.
Testosterone is sometimes referred to as a 'male hormone' but we know in females we also want healthy amounts for cognition, energy, sex drive, tissue repair and musculoskeletal health. Unfortunately too much testosterone however can have negative effects on the skin (hello hormonal acne), hair loss, hirsutism (excess hair growth on the face & chest in females) and fertility issues. We commonly see these symptoms in women with polycystic ovarian syndrome (PCOS). Too little testosterone in women can result in reduced muscle mass, fatigue, low motivation and a low sex drive.
Typically we would want to test both free testosterone an total testosterone. Total testosterone includes both free testosterone and also the testosterone bound to protein making it less active within the body. We can test testosterone levels at the same time as the other hormones on either on day 2-3 or about 7 days post ovulation. If testosterone is high, I'd also recommend further investigations for PCOS through your GP.
A note on testing:
Sometimes your GP won't tell you what time during your cycle to test specific hormones. Specifically with oestrogen and progesterone this can make it really tricky to tell whether hormones are in a healthy amount or not. If you have an irregular cycle or you can only manage to have the blood tests on random day, please ensure you make note of what day of your cycle you're on. I also generally recommend testing fasting early in the morning to keep the test results consistent and reliable.
It's also worth noting that hormone ranges can be quite broad, so even if you’re 'within range' but sitting at the higher or lower end of the range, this may be enough to cause symptoms. It’s always important to consider symptoms in this case and not just isolated test results.
So, once we understand which hormones are out of balance, we can look at your symptom picture and health history and consider why they might be out of balance. We know that each hormone can be thrown out of balance by different factors, including nutrient deficiencies, poor diet, weight (low body fat or high body fat), stress levels, blood glucose imbalances, gut health and liver function to name a few.
Once we understand your specific triggers, we can work on providing you targeted treatment options that work to address your specific imbalance. Treatment may include looking at nutrition, lifestyle modification, nutritional supplementation and herbal medicine. As a naturopath, I find the right herbal medicine can make such a profound change in patient's with hormonal issues.
If all this seems a little confusing, that's okay! Booking an appointment with a practitioner confident in analysing hormonal test results could save you a lot of time and worry later down the track. Please don't hesitate to get in contact with me if you have any questions or would like to know how I can help!