At any age or stage your hormones can become imbalanced. You may be fed up with stubborn weight gain, mood swings, fatigue, and other symptoms of hormone imbalances even though you are trying to eat healthy and exercise. 

Hormone optimization is not something providers are often taught during conventional, allopathic training and something that is often left out of Western medical treatment.

Treatment with sex hormones in particular is quite controversial for a number of reasons, many of them centered on the results of the large Women's Health Initiative Study (WHI) released in 2002.

The WHI was significant in that it demonstrated more harm than benefit for a very specific population of women taking hormones, resulting in a drastic reduction in hormone therapy for women of all ages.

Though the details surrounding this study, and many other studies designed to explore the benefits and harms of hormone therapy are too detailed to be outlined here, my opinion is that hormone therapy can be very beneficial for women who are experiencing symptoms related to reproductive hormone imbalance, at any stage in their reproductive, and post-menopausal years.

My training and clinical experience in hormone optimization provides women the opportunity to engage in therapy based on a careful assessment and treatment plan.  

My approach to hormone optimization includes the following:

1. Detailed medical and behavioral health history that allows me to elucidate risk factors that may preclude a woman from receiving sex hormone therapy. 
2. Detailed, personalized laboratory evaluation that is tailored to age and symptomatology. I utilize evidence-based serum lab testing only. I use saliva testing ONLY for evaluation of the hypothalamic-pituitary axis (cortisol). 
3. Referral to resources that allow women to fully understand the literature, risks, and benefits of hormone therapy.
4. A detailed discussion of the risks and benefits of hormone therapy for each woman based on their history, symptoms, and reasons for wanting to engage in treatment. 
5. Discussion regarding realistic expectations for symptom improvement using hormones. 
6. Discussion regarding commitment to engaging in lifestyle behavior modification if needed to maximize outcome. 
7. Continuing hormone therapy only if there are measurable benefits, minimal risks, and compliance with follow-up laboratory testing and office visits, and preventative screening according to guidelines. 

This approach, along with ongoing continuing education about the risks and benefits of therapy on my part, allows me to provide treatment to women that improves function and vitality while minimizing risk and continually re-evaluating treatment protocols and outcomes. 

Bio-identical Versus Compounded

Not all bio-identical hormones are compounded. There are pharmaceutical-grade, FDA-approved bio-identical hormones including estradiol, progesterone, and thyroid hormones. Bio-identical, compounded hormone formulations can be used for women who cannot use pharmaceutical-grade hormones or need a personalized dose that is not available. 

Bio-identical

There is considerable misinformation provided to consumers about bioidentical hormone therapy. Bio-identical means that the compound being used is molecularly the SAME as the hormone the woman makes on her own. The primary estrogen made by women is E2 or estradiol.

In my practice, I use only bio-identical estradiol which is available as a pharmaceutical product in oral and patch formulations. An example of a non-bio-identical estrogen formulation is Premarin.

This is a conjugated estrogen product that is made from the urine of mares. I do not use this in my practice as I have been trained to use estradiol and feel more comfortable with the evidence regarding efficacy and safety. Women synthesize progesterone naturally.

I use bio-identical micronized progesterone available as a pharmaceutical oral formulation, for hormone therapy in my practice. Non-bio-identical PROGESTINS are used in oral contraceptive and hormone replacement formulations and are associated with an increased risk for blood clots.

I do not use these formulations for hormone optimization for women. I do use oral contraceptives for women if they are safe to do so as well as progestin intrauterine devices (IUD). There are no bio-identical testosterone formulations for women. 

Compounded 

Bio-identical hormones can be formulated as a compounded product. Compounded means that the product is created by a compounding pharmacy rather than as a pharmaceutical-grade product. These products can be formulated as one of the following:

1. Oral capsule – estradiol and progesterone 
2. Topical cream – estradiol, progesterone, and testosterone creams and gels that can be used on the skin or inserted vaginally
3. Troche-estradiol, progesterone, and testosterone can be inserted vaginally
4. Pellet – estradiol, progesterone, and testosterone are formulated into a small compact pellet which is inserted during an office procedure just under the skin. A capillary bed grows around the small pellet and hormone is directly released into the bloodstream, delivering hormone over the course of 3-4 months

Compounded hormones are not FDA-approved. There can be risks associated with using compounded products including drug quality problems, either too much or too little active ingredients, or contamination. Working with a reputable compounding pharmacy and following laboratory values during treatment is critical to ensuring safe and effective compounded hormone therapy. 

Other than testosterone, as there are no FDA-approved pharmaceutical formulations available for women, I most often use pharmaceutical-grade hormone products. If a woman needs a vaginal preparation of estradiol or progesterone, cannot use a pharmaceutical preparation for a number of different reasons, or needs a specialized dose, I work with reputable pharmacies both in Utah and nationally to provide the safest most effective compounded therapy. 

Reproductive age and menopausal women can experience a wide variety of symptoms that may suggest hormone imbalance.

• Absent or irregular cycles and heavy bleeding
• Acne or hair growth
• Worsening PMS symptoms or new headache
• Weight gain - especially in the midsection
• Hot flashes and night sweats
• Mood swings
• Sleep disturbances
• Fatigue
• Brain fog
• Decreased libido

Perimenopause

Women’s bodies begin to transition from the reproductive years in the 30's and 40's. Fluctuations in estrogen and progesterone may cause irregular cycles, heavy bleeding, sleep disturbance, mood changes, hot flashes, and night sweats. These symptoms may be present for years until a woman reaches menopause. 

Menopause

Women in their late 40s to 50s enter menopause when they no longer have a menstrual period for one year. Women may experience hot flashes and night sweats, heart palpitations, vaginal dryness, frequent vaginal or urinary infections, weight gain, brain fog, sleep disturbances, and mood changes. Once a woman reaches menopause, her symptoms may improve without treatment, but she will always be in menopause. There will no longer be any physiologic production of estrogen or progesterone, and a significant reduction in testosterone production. Loss of estrogen increases a woman's risk of developing osteoporosis, heart disease, and dementia. 

Hysterectomy With Oophorectomy

Women who have genetic or medical conditions that necessitate the removal of the uterus and/or ovaries will immediately lose endogenous production of estradiol and progesterone, as well as the primary source of testosterone. Women who lose their ovaries in the reproductive and peri-menopausal years should be offered hormone replacement to treat symptoms as well as to prevent osteoporosis, heart disease, and dementia. Women with BRCA 1-2 can safely be treated with hormones, including estradiol, as long as they do not have a personal history of breast cancer. 

Low Testosterone

Women may experience symptoms and have low levels of testosterone on lab testing for a variety of reasons. These include hormone changes related to perimenopause and menopause, medications like opioids and oral contraceptives, trauma, anxiety and stress, and substance use. There is little scientific data regarding "normal" levels of testosterone in women, and the benefits and risks of testosterone therapy in women. What we do know is that women who experience symptoms of low testosterone do feel better with increased serum testosterone levels found with testosterone therapy. Symptoms that improve with testosterone therapy include low libido, poor sexual function and painful intercourse, fatigue, reduced exercise tolerance and muscle mass, and mood. 

High Testosterone

Polycystic ovarian syndrome (PCOS) presents differently among reproductive-aged women. Symptoms can include acne, excessive facial or body hair, abnormal or absent menstrual cycles, infertility, and weight gain. Many women with PCOS have imbalances in blood sugar and insulin, thyroid hormones, and hormonal imbalances favoring testosterone. Women may or may not have "high" serum levels of testosterone on testing. The goal of treatment for PCOS is to restore normal menstrual cycles, improve fertility if desired, and treat blood sugar/insulin balance. Women with untreated PCOS may be at increased risk for uterine and breast cancers as well as osteoporosis.

Premenstrual Dysphoric Disorder (PMDD)

PMDD is a severe form of Premenstrual Syndrome. Those who suffer from PMDD may experience physical changes including tiredness, bloating, and breast tenderness, as well as irritability, sadness, and extreme moodiness. These symptoms interfere with normal function. 

Thyroid Hormone Imbalance

Women may experience thyroid dysfunction at any time during their life. Women may have low levels of thyroid hormone secondary to an autoimmune process causing the destruction of the thyroid gland. This is called Hashimoto's Thyroid Disease and is the most common cause of hypothyroidism in our country. Other causes of low thyroid function include medications, surgery, radiation, and in many women, high levels of circulating cortisol secondary to trauma and stress. It is important to work with a provider who understands thyroid hormone production, metabolism, and function in order to receive appropriate laboratory testing and treatment.