What Happens When Women Age?
Both providers and patients alike are aware that our body changes as we age. Like it or not that’s to be expected. We anticipate that women will go through perimenopause and menopause at some point which of course correlates with changes in steroid hormone levels.
Since the menopausal transition is perfectly normal, why do at least 75% of women struggle with various symptoms such as vasomotor symptoms, mood changes, or sleep issues that challenge their quality of life?
Understanding what is supposed to happen with hormone levels will help us understand how to navigate the changes to reduce symptoms and possibly prevent diseases associated with aging. Perhaps even more importantly, we need to be aware of potential changes in hormone levels that deviate from what’s supposed to occur and how to address those.
The Age-Related Decline of Progesterone
As you can see from the graph, progesterone is normally the first hormone to decline around the age of 35 and drops 75-80% by menopause. Women make the majority of their progesterone from corpus luteum when they ovulate. However, ovulation begins to sputter during this time in a woman’s life resulting in deficiency. Postmenopausally, women may only make less than 1% of what they made in their younger years. This decline is normal and expected.
Perhaps as much as 75% of women experience symptoms of progesterone deficiency such as PMS, heavy periods, breast pain or cysts, night sweats, poor sleep, along with mood related changes like anxiety and irritability. (See previous blog, FOUR COMMON TYPES OF HORMONE IMBALANCE – #1: PERIMENOPAUSE / PMS for more information on progesterone.)
Aside from the expected progesterone decline from skipped or missed ovulation, other factors frequently trigger progesterone deficiency or worsen the effects. These include stress-induced chronically elevated cortisol which in turn depletes progesterone and interferes with estrogen clearance. This scenario can affect the progesterone-to-estrogen ratio causing estrogen dominance. Symptoms resulting from estrogen dominance include breast pain, fluid retention, and heavy menstrual cycles.
In addition to the effects of stress on progesterone levels, lack of key nutrients that support the production, metabolism, utilization and clearance of hormones can affect progesterone levels. Beyond elevated cortisol, thyroid hormone levels and function can negatively affect progesterone levels.
The Age-Related Decline of Estrogen
Estrogen typically declines later than progesterone, often in the late forties or early fifties. Since estrogen stimulates the build up of the endometrial blood lining each month its decline is necessary for cessation of menstruation. As estrogen production changes approaching menopause, it can fluctuate wildly month to month between high levels or very low levels leaving women bouncing between symptoms of excess or deficient estrogen. These fluctuations can trigger irregular and missed cycles and symptoms that alternate from PMS to menopausal symptoms.
Women can be very sensitive to the changes in estrogen and in particular the decline of estrogen. Symptoms include: hot flashes, vaginal dryness, insomnia, depressed mood, weight gain, and foggy thinking. (For a more in depth of the symptoms and effects of deficient estrogen, please see FOUR COMMON TYPES OF HORMONE IMBALANCE – #2: MENOPAUSE)
A number of factors can make the effects of the age-related changes in estrogen worse. For example, progesterone is necessary for estrogen receptor sensitivity. Progesterone is also important to keep the progesterone-to-estrogen ratio in check and for healthy estrogen metabolism. Therefore, the far too common progesterone deficiency in women exacerbates symptoms of both elevated or deficient estrogen as well as healthy detoxification of estrogen.
Once again, stress wreaks havoc on estrogen levels as well as the symptoms of estrogen deficiency. For example, elevated cortisol can block estrogen from its receptors triggering symptoms of low estrogen. If both cortisol and catecholamines (norepinephrine, epinephrine, and dopamine) are elevated from the stress response when estrogen levels are low, this can intensify menopause symptoms, particularly vasomotor symptoms.
As with progesterone, estrogen production, utilization and clearance is also affected by diet, nutrient and microbiome status.
The Age-Related Decline of Testosterone
Typically, testosterone gradually declines so that by age 40 production is about half the amount manufactured during the twenties. However, with an oophorectomy there can be an abrupt decline. If testosterone declines to a deficient level, it leads to symptoms such as low libido or reduced sexual function, mood changes, loss of muscle mass and bone mass. (For more information see blog, FOUR COMMON TYPES OF HORMONE IMBALANCE – #3 LOW ANDROGENS)
Since a significant amount of testosterone production comes from the adrenals, chronic stress affects total testosterone levels. Depression is also known to be a cause of low testosterone.
Addressing Hormone Deficiencies
Despite the fact that hormones are supposed to decline, frequently they drop to below normal for the appropriate menstrual status. To help you serve your patients presenting with hormone related symptoms the initial obvious step is to assess their hormone levels. In this case, the commonly ordered FSH testing will not identify abnormalities in estrogen, progesterone, or testosterone.
Comprehensive lab testing for hormone levels report ranges for premenopause, menopause or post-menopausal levels. Perhaps more importantly laboratories have suggested optimal ranges. The question is do you want your patient to have barely enough hormones to put them in the normal range or do you want them to have an optimal level? They want their symptoms addressed and ideally to help offset the diseases of aging associated with declining hormones such as cognitive decline, heart disease and bone loss. It frequently takes optimum levels to achieve symptom control and possible disease prevention.
Age appropriate hormone levels can be restored with the use of bioidentical hormones as indicated in conjunction with specific protocols that support hormone balance.
Beyond Sex Hormones
As discussed, additional factors can cause or worsen the effects of the age-related decline of hormones. Understanding this, BHRT providers go beyond hormone replacement by assessing adrenal and thyroid hormones. They must address the culprits that initiate a chronic stress response such as inflammation, poor blood sugar management, and lack of sleep. In recent years, experts have now taught us that the health of the microbiome is yet another factor to be considered in hormone balance. Therefore, ideal nutrition, appropriate supplementation, diet and lifestyle modification are critical to hormone balance and optimizing the aging process.
What will you do for your patients as their hormones change with age if they come to you with symptoms?