Four Common Types of Hormonal Imbalance – Perimenopause/PMS

by | Oct 18, 2019


There are four common categories of patients that new BHRT providers can expect to see repeatedly in their practices. This 4-part series will cover these along with the causes, typical lab findings, and treatment suggestions. These include: 

  • Perimenopausal / PMS – these patients are typically progesterone deficient
  • Menopause – patients with estrogen changes along with progesterone deficiency
  • Androgen Excess – associated with elevated testosterone and may include hormone imbalances 
  • Androgen Deficient – associated with low testosterone and / or DHEA and may include hormone imbalances 

To start off the series, it seems logical to cover the very common hormone issue, progesterone deficiency, since progesterone is typically the first hormone to decline often affecting patients in their mid-thirties and forties. Progesterone is primarily made in appreciable amounts when women ovulate, approximately 20-25 milligrams daily. (Smaller amounts are also made by the adrenals and CNS.)  Therefore, once ovulation begins to sputter in the mid-thirties is when many patients notice significant cycle related symptoms. 



With receptor sites in every cell of the body, progesterone affects virtually all of them. Progesterone performs over 300 functions in the body, not limited to just reproductive functions.  These include functions in the central nervous system to regulate cognition, mood, inflammation, mitochondrial function, the formation and development of nerve cells, myelination, precursor to estrogen, androgens and adrenal hormones and even helps recovery from brain injury. With so many responsibilities, a deficiency of progesterone can trigger symptoms and put women at risk for certain conditions. Symptoms affect women on a physical, gynecological and emotional level. 




Physical symptoms or related conditions:

Gynecological symptoms or related conditions:

Emotional symptoms or related conditions:

  • Weight gain
  • Low body temp
  • Headaches
  • Poor thyroid function
  • Hair loss
  • Fluid retention
  • Allergies/sinusitis
  • Bone loss
  • Increased risk CAD
  • Acne
  • Facial hair
  • Foggy thinking
  • Heart palpitations
  • Night sweats
  • Sleep disturbances
  • Breast pain/cysts
  • Increased risk of breast cancer        
  • PMS
  • Fibroids
  • Heavy cycles
  • Irregular cycles
  • Cycles too frequent
  • Endometriosis
  • Cramps
  • Anxiety
  • Depression
  • Irritability
  • Tendency to be stressed   easily
  • Mood swings


The incidence of progesterone deficiency is far reaching. Some experts believe that half of all women are progesterone deficient by age 35. Moreover, progesterone declines as much as 80% between the ages of 30 to 50.  However, the age-related change in progesterone production is not the only factor that triggers progesterone deficiency.



  • Lack of ovulation (due to age-related changes or oophorectomy) 
  • Blocked ovulation (from synthetic hormones)
  • Poor diet
  • Lack of vitamin A, B, C, Zinc, and Magnesium
  • Low thyroid function
  • Stress (can deplete progesterone in order to offset elevated cortisol or act as substrate for cortisol if it is low)



Let’s take a look at the major roles progesterone plays by category to get a better understanding of its importance.

  • Gestation – enables egg implantation, protects against miscarriage, supports fertility and fetal brain development.  
  • Estrogen balance and metabolism – permits action of estradiol by increasing sensitivity of estrogen receptors, helps keep estrogen and its effects in balance by positively influencing estrogen metabolism and promoting cellular differentiation; thus possibly inhibiting growth of fibroids and breast cysts, decreasing menstrual bleeding and normalizing endometrial shedding.
  • Cardiovascular protection: increases HDL, reduces triglycerides, and protects against atherosclerosis.
  • Central Nervous System – protects the brain and improves brain structure, function, and memory, modulates GABA receptor function reducing irritability and anxiety, promotes normal sleep patterns and lowers nighttime cortisol level, and promotes myelin repair.
  • Skin – prevents collagen breakdown by stimulating collagen synthesis and promoting the normal actions of collagen and elastin.
  • Skeletal system – builds bone by stimulating osteoblast production.
  • Breast health – stops breast cell proliferation and reduces estradiol induced breast cell proliferation.
  • Miscellaneous – prevents and reduces PMS, enables growth, development and tissue repair, has anti-inflammatory properties, decreases hot flashes, may increase libido, helps facilitates thyroid hormone utilization and opposes the stress hormone cortisol.



Comprehensive lab testing that distinguishes between hormones bound to carrier proteins and unbound “free” or “available” hormone levels should be ordered. This is important because these types of tests correlate with tissue levels of hormones. This includes capillary blood spot, saliva or dried urine test.   Progesterone deficiency as identified by symptoms and lab results can often be simply alleviated by replacing progesterone with bioidentical progesterone cream or capsules by prescription to a compounding pharmacy. Physiological dosing yields the best results. For perimenopausal women, common starting doses utilized by BHRT providers is 20mg for topical cream and 200mg sustained release capsules used days 5-26 (or 7-28) of the cycle. For younger patients some providers prefer to add progesterone days 12-26 (or 14 -28).   


On a personal note, I have been on progesterone cream for 27 years to help manage symptoms of PMS, perimenopause and now menopause. This includes usage  3 of my 4 pregnancies. I notice the benefits countless other women experience clinically such as improved sleep, mood, improved estrogen balance, relief from night sweats and relief knowing progesterone is breast protective.  Progesterone can make a life changing difference for patients dealing with PMS related mood issues and sleep disturbances as well as other cycle related problems such as heavy periods or periods that come too close together.  Women also report less cycle related breast pain, cravings, water retention and headaches. 

To get a handy tool to assess hormone imbalance for your patients download my Signs and Symptoms of Hormone Imbalance Checklist. It’s an excerpt from the training manual of the BHRT Providers Program online training program. I think you will find it helpful. 


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