Ask Barbie! Barbara Taylor MD's Q&A addressing your burning questions about Menopause

Ask Barbie: Why Can’t I Use Sex Hormone Labs to Get my HRT Dosage Right?

The Question

Welcome to ask Barbie, where I answer all your burning questions about menopause. Today’s question is a very common one:

“Why can’t I use sex hormone labs to get my HRT dosage right?”

So let’s answer this question in a very systematic manner that will ensure your full understanding of why you can’t use sex hormone labs to get your HRT dosage right.

Sex Hormone Levels

The only logical place to start is at the beginning. And the beginning for your sex hormones was puberty.

At the time of puberty, all your sex hormones started flooding into your body. They included:

Estradiol
Progesterone
Testosterone

These three sex hormones flooded into your body for one reason and one reason only: To make it possible for you to reproduce.

And the two hormones that are the most important for you, as a female, are estradiol and progesterone. Testosterone is much less important.

Estradiol is the hormone that enables you to mature and release an egg for fertilization.
Progesterone is the hormone that protects the baby in utero once you get pregnant.
Testosterone is the hormone that merely gives you an interest in sex at the time of ovulation.

But these sex hormones did not flood in your body in a linear, predictable, or gradual way. Instead, the entire process was completely chaotic.

If you had checked your estradiol and progesterone every day during the three to five years of puberty, the pattern would have looked like this:

Menstrual Cycle Sex Hormones

After puberty, you began having regular menstrual cycles on a monthly basis.

The only purpose of menstrual cycles was to enable you to get pregnant, and to accomplish that goal, the levels of estradiol and progesterone during your menstrual cycles were very high.

Menstrual cycles were somewhat chaotic, too. But, instead of complete chaos, your monthly menstrual cycles consisted of a predictable roller-coaster pattern.

If you had looked at the pattern of your sex hormones during any menstrual cycle, they would have looked like this:

Estradiol Levels During Menstrual Cycles

The big sex hormone difference between puberty and regular menstrual cycles was all about the pattern.

Your sex hormones did not follow a pattern during puberty, but they did follow a pattern during menstrual cycles.

The pattern of your menstrual cycle sex hormones was a repetitive sequence of estradiol and progesterone going up and down, up and down, in a timely and predictable manner.

Did you go through your menstrual cycle reproductive life checking your estradiol and progesterone levels?

If you knew what they were then, would that knowledge help you now?

Of course not.

When you were having your menstrual cycles, the whole purpose of your sex hormones was to enable you to get pregnant. That’s not what you need any more.

So even if you did know what your sex hormone levels were back when you were pre-menopausal, that knowledge wouldn’t help you now in terms of getting your HRT dosage right.

Peri-Menopausal Sex Hormone Levels

At some point, you reach peri-menopause. Peri-menopause is nothing but puberty in reverse.

Puberty is when all these sex hormones enter your body.
Peri-menopause is when all these sex hormones exit your body.

And guess what?
The chaotic pattern is the same. The only difference is this:

At the time of puberty, those sex hormones are chaotically getting higher, and higher, and higher.
At the time of peri-menopause, those sex hormones are chaotically getting lower, and lower, and lower.

If you checked your estradiol and progesterone levels on a daily basis over the two to ten years of peri-menopause, the pattern would look like this:

Menopause_Taylor_Estradiol_Progesteroner_During_Menopause

The only reason you experience peri-menopause is to make it impossible for you to reproduce any more.

So if you were to check your sex hormone labs at any point during peri-menopause, they would mean absolutely nothing. And the reason they would mean absolutely nothing is for the same reason they meant absolutely nothing during puberty.

You already know what’s happening. Your sex hormones are chaotically disappearing from your body. Unfortunately, it takes two to ten years for the process to complete itself.

But here’s the most important thing of all: The goals of hormone replacement at the time of peri-menopause are unlike any goals you’ve ever had before.

Before peri-menopause, your sex hormones serve the purpose of reproduction. At the time of peri-menopause, your sex hormone replacement serves the purpose of:

Alleviating your symptoms of estradiol deficiency.
Preventing the beginning of the diseases of estradiol deficiency, which include:
- Build-up of cholesterol in your arteries, leading to heart attack.
- Loss of bone quantity, leading to osteoporosis and fractures.
- Shrinkage of your brain, leading to Alzheimer’s Disease.

So hormone replacement at the time of peri-menopause serves a completely different purpose. And there is no way for any lab to tell you what hormone level will accomplish your goals. Therefore, it makes no sense whatsoever to try to use the lab to tell you something that the lab can’t tell you.

No sex hormone lab value can tell you whether or not it is adequate for:

Alleviating your symptoms of estradiol deficiency.
Preventing the beginning of the diseases of estradiol deficiency, which include:
- - Build-up of cholesterol in your arteries, leading to heart attack.
  - Loss of bone quantity, leading to osteoporosis and fractures.
  - Shrinkage of your brain, leading to Alzheimer’s Disease.

Post-Menopausal Sex Hormone Levels

Well, what about post-menopause? Post-menopause is when both your estradiol and progesterone are gone.

If you were to check your estradiol and progesterone hormone levels toward the end of peri-menopause and into post-menopause, the pattern would look like this:

Estrogen Levels from Peri- to Post-Menopause

So, how can you do a lab test on something that is absent?

Once again, post-menopause is when your goals entail:

Alleviating your symptoms of estradiol deficiency.
- - Build-up of cholesterol in your arteries, leading to heart attack.
  - Loss of bone quantity, leading to osteoporosis and fractures.
  - Shrinkage of your brain, leading to Alzheimer’s Disease.Preventing the beginning of the diseases of estradiol deficiency, which include:

The overriding goal of hormone replacement therapy for menopause is to ensure that you get a high enough dosage of estradiol to:

Alleviate your symptoms of estradiol deficiency.
Prevent the diseases of estradiol deficiency.

So, as you can see by following the trajectory of your hormones over the course of your lifetime, there is just no way you can use sex hormone lab values to help you get your estradiol replacement dosage right at the time of menopause.

Goals of Hormone Replacement at Menopause

Here’s a scale depicting the dosage ranges of estradiol your ovaries produce over your various sex hormone phases:

During…

puberty, your ovaries produce between 0 and 300 pg/mL of estradiol
your menstrual cycles, your ovaries produce between 100 and 300 pg/mL of estradiol.
pregnancy, your ovaries produce 4000 to 6000 pg/mL of estradiol.
peri-menopause, your ovaries produce between 0 and 300 pg/mL of estradiol.
post-menopause, your ovaries produce 0 pg/mL of estradiol.

The big question about estradiol replacement is: How much estradiol does your body need in order to:

Alleviate your symptoms of estradiol deficiency?
Prevent the diseases of estradiol deficiency?

No lab knows. And no human knows. Only your own body knows.

So why not let your own body tell you?

All Sex Hormones are not Created Equal

Now, even though you have three sex hormones, they are not equally important.

As a female, your primary sex hormone is estradiol, by far. Your entire world revolves around estradiol.

This means that hormone replacement at the time of menopause centers around one hormone and one hormone only: Estradiol.

You make all your decisions around achieving your goals for estradiol replacement, which are:

Alleviating your symptoms of estradiol deficiency.
Preventing the beginning of the diseases of estradiol deficiency, which include:
- - Build-up of cholesterol in your arteries, leading to heart attack.
  - Loss of bone quantity, leading to osteoporosis and fractures.
  - Shrinkage of your brain, leading to Alzheimer’s Disease.

Progesterone is merely for the purpose of preventing uterine cancer. And your progesterone dosage has to accommodate your estradiol dosage.

So, think of progesterone as a piggy-back. It has to just go along with whatever your body needs in terms of estradiol.

How to Determine the Right Estradiol Dosage for YOU

If you can’t use sex hormone labs to get your HRT dosage right, what do you use?

Well, that’s easy. You just stay focused on your goals. You use the very things that accomplish your goals of hormone replacement therapy! Your body talks to you. And it never lies. In contrast, labs lie all the time. So all you have to do is listen to your body. You assess YOUR BODY’S perfect estradiol dosage by listening to your body in three ways:

Symptoms of estradiol deficiency: If your body has enough estradiol, you should have zero symptoms of estradiol deficiency.
Cardiac lipids: If your body has enough estradiol, your cardiac lipids (Cholesterol, LDL, Triglycerides, HDL) should be stable.
Bone loss: If your body has enough estradiol, you should have no bone loss.

You can assess your symptoms every day.
You can assess your cardiac lipids every quarter.
You can assess you bone density every year.

You must achieve ALL THREE criteria to have enough estradiol.

Unfortunately, we do not have a screening test for Alzheimer’s Disease. If we did, we’d use that, too.

Never try to use estradiol levels to determine if your estradiol dosage is right for you. No lab hormone level can tell you.

And not only that! The precise dosage of estradiol that your body needs will vary as you progress throughout your menopause journey. You are not a robot. You will have to assess your body’s estradiol replacement needs over and over again.

That’s easy to do if you rely on:

Symptoms of estradiol deficiency,
Cardiac lipids,
Bone loss.

It’s impossible to do if you rely on sex hormone labs.

Sex Hormone Lab Scams

Unfortunately, because sex hormone labs are expensive … and can make lots of money for the lab tester and the lab requester, there are sex hormone lab scams everywhere.

You can find people pushing sex hormone labs in every way, shape, and form:

Sex hormone labs for:

your estradiol,
your progesterone,
your testosterone or DHEA.

Blood testing,
Saliva testing,
Urine testing.

Testing…

before starting HRT,
after starting HRT,
after stopping HRT.

Remember, there is no such thing as a “normal” result for any of these sex hormones. They’re all gone!
And that’s precisely why so many doctors use them. They can make up their own definition of “normal.” Most will say, “I’d like to see your estradiol levels between X and Y.”

Imagine two scenarios:

Scenario 1:

You tell your doctor you are still having symptoms of estradiol deficiency on your current dosage of estradiol. You still have hot flashes, insomnia, and brain fog. Your husband claims that you’re also quite irritable. In addition to your symptoms, your cholesterol values are creeping up, even though you haven’t changed your diet or exercise. And your first bone density scan reveals bone loss. Your doctor listens to you, and says, “Well, those are all indications of estradiol deficiency. That means you don’t have enough estradiol. Let’s increase your estradiol dosage.”

Scenario 2:

You tell your doctor you are still having symptoms of estradiol deficiency on your current dosage of estradiol. You still have hot flashes, insomnia, and brain fog. Your husband claims that you’re also quite irritable. In addition to your symptoms, your cholesterol values are creeping up, even though you haven’t changed your diet or exercise. And your first bone density scan reveals bone loss. Your doctor has drawn sex hormone labs. So she looks down at your labs, which represent a single snapshot in time, and says, “But your labs are normal. Your estradiol level is just where I want it to be.”

Which scenario do you prefer?

All sex hormone labs are all equally meaningless. Don’t fall for these scams.

No sex hormone lab knows what your body needs to meet your menopause management goals. Only your body knows.

It doesn’t matter whether the test is on your blood, your saliva, or your urine. They all mean nothing.

But they all cost a lot, and you can lose a whole lot of money checking a whole lot of labs that mean absolutely nothing.

So, Here’s Why You Can’t Use Sex Hormone Labs to Get Your HRT Dosage Right!

So, this explains why trying to use sex hormone labs to get your hormone replacement right is a huge mistake. There is no lab that can tell you anything meaningful about your sex hormone levels.

And sadly, if you go to a doctor who uses sex hormone labs to assess anything about your menopause, you will fall prey to a situation in which the doctor listens to the labs but does not listen to you.

And that is a disaster.

Your job is to listen to your body based on your:

Symptoms.
Cholesterol.
Bone density.

The Answer

Your doctor’s job is to listen to you. And if you do sex hormone labs of any kind, at any time … your doctor will not listen to you. So run from any doctor who tries to use sex hormone labs of any kind at any time during your menopausal journey.

It doesn’t matter whether you’re testing any particular sex hormone at any particular time. It doesn’t matter whether you’re testing:

blood
saliva
urine

None of these things has any meaning at all. So, save your time, blood, saliva, urine, and money by skipping all sex hormone labs.

That’s why you can’t use sex hormone labs to get your HRT dosage right.

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