If you were to ask 10 different doctors about their approach toward hormone replacement therapy, you’d get at least 12 distinct answers.
What type of doctor did you ask? - your general practitioner? - your functional medicine doctor? - your endocrinologist? - your gynecologist? Which hormone(s) are we talking about? - thyroid? - estrogen? - testosterone? - cortisone?
And of course, the complex history of each individual patient also plays a role in the conflicting opinions...
Even after painfully detailed dissections and in-depth dives into the topic of hormone therapy at conferences, it’s still a bit of a murky topic among everyone by the end. I have a theory on why this may generally be, and a crucial part of the theory rests on the endocrine (hormone) system’s unrelenting demand for balance. While in life we just love to label things “good” and “bad” (good fat, bad fat, good carb, bad carb, good politics, bad politics, the right exercise, the wrong exercise) without much in between, that simply doesn’t work with hormones. To be honest, it doesn’t work with most things naturally occurring in the human body, but hormones are the least forgiving.
Healthy hormone levels have a narrow range usually, and the consequences for being outside of those ranges can be severe because these molecules have such broad impacts on all of your body systems. The concept of hormesis is applicable here. Hormesis describes the dose-dependent effect of toxins in the body, but it relates to hormones especially when we talk about exogenous/prescribed hormones. Prescribed hormones are, after all, drugs which your body has to metabolize just like any other toxin it encounters. Too little of a hormone in the organism causes a host of symptoms and downstream effects on multiple body systems. Too much of a hormone in the organism also causes a host of symptoms and downstream effects on multiple body systems. And the real wrench in the equation (especially in the functional medicine equation) is that having too high or too low levels of a hormone relative to another hormone can also create a functional imbalance and subsequent symptoms of concern.
To sum up, we’ve got a bunch of compounds each with a narrow therapeutic window and the tendency to affect many body systems simultaneously. On top of that, hormones also have to be metabolized properly and excreted from the body, an efficiency that is subject to the health of the individual patient’s detoxification processes such as those heavily concentrated within the liver.
Yikes. That’s a lot of variables. Seeing as how it is my job to understand these variables as much as possible and apply that knowledge to each patient as he/she individually presents, it comes as quite a shock to me how often patients are prescribed hormones without initial testing of any kind, and often without any follow-up testing either. I have had female patients come to my office after having taken hormone replacement estrogen/testosterone/progesterone for the previous 10 years and report never having had a test done to evaluate their hormone levels at baseline or at follow-up. I recall one patient in particular who fell into this category when she first came to my office. When we finally did test her hormones, they were off-the-charts high. So high in fact, it knocked the wind out of me. Why?
Remember: hormones have a narrow therapeutic window and are also technically drugs that have to be metabolized and excreted by the body the same way that toxins are processed.
Some of these hormones - estrogen in particular, dramatically increase one’s risk for certain cancers if gone unchecked. And I don’t mean to single women out here; men who take testosterone and are not appropriately tested on an on-going basis face increased disease risks as well.
Flooding my readers with fear and anxiety is not my goal by posting this. Rather, I mean to express the incredible importance of hormone balance within the body and how important it is to affect hormone level changes in a humble and holistic way. By humble I mean - doctors are not God. While we know an incredible amount about the human body and its complex biochemistry, we did not create its complexity and we need to appreciate that what we know is only the tip of the iceberg (and maybe a little bit beneath the surface…). By holistic I mean - understand that hormones do not function independently. They function as networks or “axes”. One hormone triggers another hormone which triggers another three hormones which in turn affect a dozen other body tissues and organ sites.
One of the “mantras” within functional medicine when it comes to affecting the endocrine system is:
“First treat the adrenal glands, then the thyroid, then the sex hormones”.
This mantra comes from understanding that hormones move in a cascade that can be likened to a domino chain. Often, the low testosterone in a middle-aged man or the luteal-phase defect in a 28yo woman is not unilaterally caused by a problem within the testicle or the ovary, but rather a problem that started 10-dominoes-upstream in the HPA axis. If we want to truly fix the problem, we need to look upstream. I spend a lot of my days and research efforts analyzing these domino chains and figuring out where best to intervene.
That doesn’t mean I avoid using hormones. I absolutely use hormone therapy when indicated. Many patients with hypothyroidism (for example) require thyroid hormone replacement, at least for some time, and often indefinitely. Many menopausal women suffer greatly with various symptoms due to a rapid drop in hormone levels that can be abated by temporary use of biodentical hormone treatment. A great many young women rely on oral contraceptive pills to help them plan for when and if they would like to start a family. Hormone therapy is an important clinical tool and treatment method for a host of concerns. But it is indeed a powerful tool that must be understood in the context of the whole human body.
Undoubtedly, I will spend many more blog posts delving into hormone balance. But my point today is simply to reinforce the idea that hormones deserve a level of respect and understanding that exceeds the “black and white” tendencies of the human mind. We need to look at hormones as whole systems. In functional medicine, analyzing hormone systems can be done by focusing on these four steps applied to each individual hormone:
What are the factors that affect each hormone’s production and which of these is present in the individual patient’s case? (-For example, sex hormones require adequate cholesterol levels for production. If a patient’s cholesterol level is too low, this may drive sexual hormone dysfunction.)
What are the factors that affect each hormone’s movements and concentrations through the body? (-For example, a patient’s blood sugar dys-regulation could in turn reduce the concentration of the protein SHBG that binds estrogen, resulting in too much active/unbound estrogen in the body, increasing the risk for estrogen-related disease.)
How do hormones interact with different body tissues and how do these interactions become adulterated? (-For example, a deficiency of Vitamin A will prevent active thyroid hormone from being able to bind to its receptor site, causing symptoms of hypothyroidism despite healthy thyroid hormone levels)
How is each hormone metabolized and excreted from the body, and what impedes it from being done efficiently? (-For example, an increase in the enzyme beta-glucuronidase in the stool indicates that estrogen is likely going to be recirculated from the intestinal tract back into systemic circulation rather than being eliminated, causing increased levels of estrogen metabolites that increase risk for estrogen-dependent disease.)
When we apply these steps, we can ensure that hormones are analyzed and modulated in a safe and gentle way.
And finally, when treating hormone imbalances, always look upstream for the initial domino whenever possible. That initial domino could be a stressful event that preceded the biochemical change, it could be a nutritional insufficiency, sleep deprivation, or possibly a “separate” illness or disease process within the body that is compromising the function of a hormone-producing gland. By picking up the initial dominoes, the goal of reversing a disease process creating lasting health outcomes is possible.
In Health,
Dr. Otto