Did you think taking hormone replacements is just for women over 50? Did you think it was all about the Estrogen? Something you don’t have to think about until you “hit menopause”?
Well, actually, nope. We spoke to Dr. Sarah Yousuff, MD at EVOLVE MEDICAL ASSOCIATES for a more in-depth learning about who should consider Hormone Replacement Therapy (HRT) and why.
For one thing, men seek out HRT for declining testosterone. About 12% of Dr. Yousuff’s clients are men looking to improve and maintain their testosterone levels. And this is just not the randy old guys in those annoying ED commercials. After about age 30, most men begin to experience a gradual decline in testosterone. Sometimes this causes a decrease in sex drive, but it can also result hair loss, fatigue, low energy, loss of muscle and bone mass, fuzzy thinking, increased body fat.
While we could write a post on men & low T, and maybe we will, this post is for us girls. We too can experience significant but addressable symptoms when our testosterone levels begin to decline in our 40s. Your ovaries produce both estrogen and testosterone, and both begin to decline as you age.
Low testosterone can cause one or more of the following symptoms in women:
- sluggishness and fatigue
- muscle weakness
- fuzzy thinking
- sleep disturbances
- reduced sex drive
- decreased sexual satisfaction
If you’re still having a period, but are experiencing some of the symptoms you associate with “menopause” like hot flashes and insomnia or disturbed sleep, night sweats, and mood swings, Dr. Yousuff is going to want to check your testosterone and your progesterone levels, along with your estrogen.
Per Dr. Yousuff, an exact number for optimal levels for any of these hormones are hard to specify because every lab’s measurement metrics are different. Although there are some exceptions, generally her goals for optimal levels will be in the top 20% of the reference range.
Dr, Yousuff explains, “It’s hard to give you a “range” of #’s that is good / normal / bad, since different labs have different standards of measure. The rule of thumb is that free testosterone levels of 1.5 pg/mL or less represent a deficiency. With one lab the ideal range for women to feel at their best between 2-3, with another it is between 3 and 4. Women over age 50 are considered to have a deficiency at a lower level — 1.0 pg/mL or less, and the goal range would be the same as pre-menopausal women.”
Unlike your estrogen (estradiol to be more precise) which fluctuates up and down during peri-menopause, sometimes significantly, your progesterone starts a steady decline about age 45 and drops to its low at menopause in your early 50s. Because of this steady behavior, Dr. Yousuff can monitor your progesterone levels every 4-6 months and adjust your dosage as needed to balance out the decline in your naturally produced progesterone. So, your level can stay somewhat the same, through HRT, despite the age-related decline. Why do you want to do this? Read on 🙂
It’s a lot of science to cover in this blog, but there’s a great video explanation of how this works HERE on a site Dr. Yousuff shared with us called SimpleHormones.com/evolve. One thing we learned, that the estrogen dominance can cause anxiety, depression, mood swings, etc. This occurs as your estradiol levels spike up and your progesterone levels stay on their low steady decline. It’s also what caused those awful PMS symptoms during your cycle when you were younger.
To put it in perspective, pre-menopausal women will have progesterone levels anywhere from 7 to 38 ng/ml during their luteal phase (after ovulation when your body secretes projesterone for potential embryo implantation). Dr. Yousuff explains that menopausal women without HRT will have basically undetectable progesterone levels. Getting your levels up to greater than 2.0 for most women in peri-menopause and menopause seems best to alleviate symptoms.
As long as you are not in menopause, Dr. Yousuff will work with your progesterone and testosterone levels to address and assuage your peri-menopausal symptoms. You can be in peri-menopause for years and should not just live with the symptoms.
The initial estrogen check you’ll get at Evolve is basically to see where you are on the long journey to menopause, which doctors track by your FSH, follicle stimulating hormone level. Once your FSH hits 25, you won’t be getting pregnant. Once you are at this point AND you no longer have a period for a full year, you’re “in menopause”. Menopause onset ranges from age 48 to 52 on average but in your own circle you will know women who are all over that range on either side. The best thing is just to have the blood test to see where you fall, and to keep having it tested every 6-12 months. The crazy symptoms are NOT all in your head; they are specifically being driven by explainable, accountable, often treatable fluctuations in your hormone levels.
Dr. Yousuff prefers to wait to add in estrogen replacement until you are nearing the end of your peri-menopause, and your symptoms are no longer being alleviated by progesterone and/or testosterone. Your estrogen levels rise and fall all the time, during individual days and weeks, and adding to that more estrogen, replacement estrogen, is hard to effectively manage when your levels are naturally rising and falling on their own.
Having a period is not an indication that your estrogen levels are just fine. Basically with estradiol levels lower than 50 picograms per milliliter, many women still have a period but experience symptoms of low estrogen — hot flashes, vaginal dryness, and sleep difficulties.
Menopausal women who aren’t on HRT often have estradiol levels below 25. Generally, it is recommended that you raise estradiol levels to a minimum of 40 to 50 pg/mL to prevent bone loss, with 60 pg/mL or higher as optimal for other organ benefits. Many specialists like Dr. Yousuff advocate levels of 70 – 100 pg/mL
How Are These Levels Optimized?
Most women will take a pill nightly before bed (it helps with sleep) starting at the lowest optimal dose and increasing that if levels do not rise. Dr. Yousuff will have your blood labs done 6 weeks after HRT start or change to check your levels.
Per Dr. Yousuff, determining which testosterone delivery mode (topical cream, pellets (inserted sub-cutaneously), injection, troches (lozenge)) is highly dependent on your lifestyle/habits, budget, levels, etc. She explains “I have quite a few patients in their 30’s and 40’s using pellets. Overall, I usually recommend starting with the cream as it is the most cost effective. I steer away from injections (I don’t have any female patients doing injections) as the injections are painful and there are more side effects associated with this method of testosterone. The troches are a compromise between the cream and the pellets; however, it’s hardest to get dependable blood levels with this method.“
In perimenopause when estrogen levels fluctuate so frequently day-to day, Dr. Yousuff likes to use a spray like Evamist – 1 to 3 sprays on the forearm daily, so there is flexibility in dosing. “When things progress to needing 2-3 sprays daily, then it’s time to switch to an alternative such as patches, pills, topical cream or pellets. If I have a patient in full menopause who has never had hormone therapy in the past, the preferred starting estrogen is a patch for the first year. After this she can move to alternatives (pills, pellets) if desired.”
What About the Risks?
You can and should discuss at length the risks of taking any hormones with several trusted doctors…your ob/gyn, your primary care, your endocrinologist, Dr. Yousuff, etc. Get as many medical opinions and second opinions as you can. Maybe not your dentist, unless she’s a woman who’s gone through the “change” herself 🙂
There’s still some disagreement on the topic of HRT safety, and it tends to be old school & conservative vs. new school & progressive. It’s just that. You’ll need to decide what view and assessment you are most comfortable with, and try not to judge what others decide is best for them.
If you have a known history of cancer or hereditary cancer, blood clots and certain other diseases, most doctors will counsel you to be on the safe side and not take HRT, despite the advances in safety of today’s bioidentical hormones. Most of the doctors I’ve interviewed on the subject for my own personal consideration have said that estrogen replacement with today’s bioidentical hormones likely does not CAUSE cancer, but it could cause an existing cancer to develop more aggressively. For some, that’s just not a risk they’re willing to take. In that case, talk to Dr. Yousuff or your physician about your options.
Interested in learning more? First thing you can do is watch the many informative and short videos on the SimpleHormones site. You can bring this up with your gyno or primary care. And you can schedule a comprehensive consultation with Dr. Yousuff at Evolve, details below.
Your Consult and Evaluation with Dr. Youssuf
Before your first visit, you will need to fill out a detailed questionnaire and send it in. When go for your consultation, the nurse will first check your vital signs before you meet with the doctor. Dr. Youssuf will discuss your symptoms in detail, answer any questions you may have and perform a physical examination. Based on your history and physical exam, the doctor will order the appropriate lab tests. Lab tests can be drawn in their office.
You’ll then return in 1 to 2 weeks to review your test results with Dr. Youssuf. If a hormone imbalance is identified, she will suggest a hormone replacement program that is customized for you.
Approximately 4 to 6 weeks after starting your hormone replacement therapy, you will return again for a follow-up visit & blood labs in order to monitor the effectiveness of the therapy and make adjustments as necessary.
- $295 for the initial comprehensive consultation (includes the return visit in 7-14 days to review your lab results)
- $95 for follow-up visits
- The fee for lab tests is not included, but their rates are well negotiated and much lower than what I’ve seen on regular Drs. bills.
- While they do not accept insurance, the practice will provide the appropriate ICD-9 codes if you plan to file for insurance reimbursement. You cannot file for reimbursement with Medicare or Medicaid.
- Some things not covered by insurance are still covered by FSA and HSA.