Not Everything Is Your Hormones, But They Aren’t Innocent Either
There comes a time in many women’s lives when the list begins.
“I’m gaining weight. I don’t sleep like I used to. My joints hurt. My hair is thinning. I’m tired. I can’t remember anybody’s name. And my sex drive has apparently left town without forwarding its address.”
Inevitably comes the question, “Is this menopause?”
Sometimes, absolutely. And sometimes, it’s midlife. Usually, it’s some combination of the two.
But after taking care of women for decades, I think we’ve occasionally swung too far in the other direction. In our effort not to blame everything on hormones, we underestimate just how profound the menopausal hormonal transition actually is.
I see women every day who are doing the right things. They exercise. They lift weights. They eat well. They don’t smoke. They aren’t living on doughnuts and Chardonnay. Yet somewhere around menopause their bodies begin behaving differently.
They accumulate abdominal fat. Sleep deteriorates. Muscle becomes harder to maintain. Joints begin aching. Sexual interest changes. Bone density falls despite an excellent lifestyle.
That’s not a failure of discipline. Their physiology really did change. And it isn’t just estrogen.
The Ovaries Were Doing More Than Making Estrogen
We tend to talk about menopause as though somebody simply turned off an estrogen faucet. The biology is considerably more interesting.
During the menopausal transition, ovarian production and cyclic patterns of estradiol, progesterone and androgens change. Progesterone commonly becomes erratic earlier as ovulation becomes less reliable. Estrogen fluctuates substantially during perimenopause before eventually settling at much lower levels. And androgen physiology changes across midlife as well.
These hormones aren’t confined to reproduction.
Estrogen receptors exist throughout the brain, bone, blood vessels, skin, connective tissue, adipose tissue and genitourinary tract.
Progesterone and its neuroactive metabolites interact with the central nervous system, including pathways involved in sleep and mood.
Testosterone and other androgens contribute to sexual function and are relevant to muscle, bone and overall physiology.
So menopause isn’t simply the end of menstruation. It’s a major endocrine transition affecting tissues throughout the body.
Progesterone is The Hormone That Often Leaves the Party First
Progesterone deserves more attention than it usually receives.
During reproductive years, ovulation produces the corpus luteum, which produces substantial progesterone. As women enter perimenopause and ovulation becomes inconsistent, progesterone levels often drop well before estrogen permanently declines.
That helps explain one of the paradoxes of perimenopause – a woman may be having symptoms related to changing ovarian function while her estradiol is perfectly normal. This may also leave women in the very unpleasant state of estrogen dominance.
Progesterone is particularly interesting because metabolites such as allopregnanolone interact with GABA-A receptors in the brain. That provides a biological connection between changing progesterone physiology and insomnia, anxiety and suddenly being surrounded by people who seem inexplicably more annoying than they were five years ago..
Clinically, most women report substantial improvement in sleep, anxiety and irritability with progesterone replacement. That doesn’t mean every sleepless 48-year-old needs progesterone. Sleep apnea, restless legs, alcohol, depression, thyroid disease, medications and plain old stress still exist.
But progesterone shouldn’t be treated merely as the thing we add to estrogen to protect the uterus. It has physiology of its own.
Then There Is Testosterone
Testosterone is frequently forgotten in conversations about women’s hormones, as though it somehow belongs exclusively to men. It doesn’t.
Women produce androgens from both the ovaries and adrenal glands. Testosterone is present throughout a woman’s adult life and participates in sexual physiology as well as having effects on multiple other tissues.
The clearest evidence for testosterone therapy in postmenopausal women is for low libido. That’s where the randomized clinical-trial evidence and international consensus are strongest.
Beyond sexual function, testosterone supports muscle, bone, energy and well-being, and these are areas of considerable clinical importance.
When testosterone is prescribed to women, the goal should generally be physiologic female levels, not turning a woman’s laboratory report into that of a 22-year-old linebacker. Supraphysiologic dosing, particularly with preparations that can’t easily be adjusted, creates an entirely different risk-benefit discussion.
The Expanding Waistline
One of the most common things I hear is, “I’m doing exactly what I was doing before, but now I’m gaining weight around my middle.”
Usually she’s right. Menopause doesn’t violate the laws of thermodynamics, but hormones influence the machinery operating underneath them.
Estrogen influences adipose distribution, insulin sensitivity and energy metabolism. Progesterone competes with cortisol, and cortisol tends to put weight around the middle. With menopause, fat distribution tends to shift away from the predominantly subcutaneous hip-and-thigh pattern of younger women toward greater abdominal and visceral adiposity.
At the same time, maintaining lean mass becomes increasingly important. And without testosterone it’s hard to maintain muscle mass. And, one area insulin works best in lean muscle.
Aging contributes. So do sleep, activity, diet and genetics. But I have cared for far too many fit, metabolically conscientious women to tell every 52-year-old with a changing waistline that she simply needs to eat less and exercise more. The playing field changed.
Hormone therapy isn’t a weight-loss medication. But that’s quite different from saying hormones have nothing to do with body composition.
The best approach is usually not hormones versus lifestyle. It’s hormones when appropriate plus lifestyle, especially resistance training, adequate protein, good sleep and metabolic health.
Bones Make the Case Particularly Well
If you want evidence that menopause isn’t simply ordinary aging, look at bone. A woman can do everything right and still lose bone.
She can lift weights. She can walk. She can eat adequate protein. Her vitamin D can be beautiful. Her calcium intake can be appropriate. Those interventions help enormously, but they don’t necessarily reproduce the skeletal effect of ovarian hormones.
Ovarian hormones “turn on the bone factory”. Bone loss accelerates around menopause because estrogen normally restrains bone resorption. When estrogen disappears, bone turnover increases. Estrogen slows bone loss, while progesterone and testosterone actually increase bone gain.
Systemic menopausal hormone therapy prevents bone loss and reduces fracture risk while it is being used. For an appropriate woman near menopause, particularly one who is symptomatic or already demonstrating accelerated bone loss, that is not a trivial secondary benefit.
It’s part of the reason to have the hormone conversation in the first place. The objective isn’t simply to produce a respectable bone density scan at 52. It’s to have enough skeleton remaining at 82 to stay out of the nursing home.
So, Should I Take Hormones?
This is where I think medicine has needed a course correction.
After the initial Women’s Health Initiative reports more than two decades ago, an entire generation of women, and physicians, became frightened of hormone therapy. We now understand that the story was considerably more nuanced than “hormones are dangerous.”
Age matters. Timing matters. Synthetic “look-a-likes” versus natural bioidentical hormones matters. Dose matters. Route matters. Whether a woman has a uterus matters. Her cardiovascular, thrombotic and breast-cancer risk matter.
For an appropriately selected healthy woman who begins treatment when younger than 60 or within roughly 10 years of menopause, menopausal hormone therapy generally has a favorable benefit-risk profile for treatment of bothersome menopausal symptoms and long term disease prevention.
Hormones Aren’t a Substitute for Good Medicine
Being enthusiastic about hormone therapy doesn’t excuse becoming careless about it. “Hormone Wellness” clinics are popping up everywhere. I urge women to seek out experienced practitioners who understand the “symphony” of hormones, including thyroid, cortisol and insulin. There is more to prescribing hormone therapy than meets the eye. And there is more to good medicine that simply adding hormones.
Fatigue can still be iron deficiency. Brain fog can still be sleep apnea. Weight gain can still reflect insulin resistance. Hair loss can still be thyroid disease. Low libido can still be an SSRI, depression, relationship problems or chronic sleep deprivation.
Hormones deserve consideration, but they don’t deserve diplomatic immunity from differential diagnosis.
We should investigate symptoms intelligently rather than dropping everything that happens between 45 and 60 into either the “menopause” bucket or the “you’re getting older” bucket.
Menopause or Midlife?
Usually, the answer is yes. Midlife is happening. Aging is happening. Decades of lifestyle choices are beginning to matter more.
But at exactly the same time, a woman’s hormonal physiology is undergoing one of the largest transitions of her adult life. That isn’t incidental.
And telling a woman who already exercises five days a week, eats beautifully and gets eight hours of sleep that she simply needs to “work on her lifestyle” while she’s having night sweats, losing bone, accumulating visceral fat and wondering what happened to her sex drive isn’t particularly helpful.
Keep doing the fundamentals. Lift weights. Eat enough protein. Keep moving. Protect your sleep. Maintain healthy body composition. Know your glucose, blood pressure and lipids. Don’t smoke. Keep alcohol modest. Protect your bones.
But don’t be afraid to treat menopause. For the right woman, at the right time, with an individualized approach, replacing hormones isn’t an admission that lifestyle failed. It’s simply replacing something biology stopped making.
Menopause is unavoidable. Suffering unnecessarily through it isn’t.
Author
Scott Rollins, MD, is Board Certified with the American Board of Family Practice and the American Board of Anti-Aging and Regenerative Medicine. He specializes in bioidentical hormone replacement for men and women, thyroid and adrenal disorders, fibromyalgia and other complex medical conditions. He is founder and medical director of the Integrative Medicine Center of Western Colorado (www.imcwc.com) and Bellezza Laser Aesthetics (www.bellezzalaser.com). Call (970) 245-6911 for an appointment or more information.
