The balancing process

Although there are the ever-present individual differences that make one woman's experience different from another's, there are also a lot of things we all go through in common. Broadly speaking, the process of balancing hormones begins with the operating room and never ends.

Never!? No, because our bodies continue to use hormones for internal communication, whether or not we keep the supplies at the right level. Even in surgical menopause, that underlying need will never go away and we may never be entirely able to "get by" on what we alone make as well as if we fulfilled our needs fully. That doesn't mean that hormone requirements don't change: they do. They change as we age, they change as our overall health and fitness and lifestyle change, and thus the issue of balance never entirely disappears.

In the OR, then, you and your ovaries part company and your hormone production plummets. Whether your surgeon begins your HRT immediately or some months later, we have already discussed the fact that the (roughly) first three post-op months are a time of transition and fluctuation in which long-running balance is not likely to be achieved. This doesn't mean that you need to be in misery, but that you need to be a little tolerant of failure to achieve total balance.

Most typically, we are given estrogen alone when we do start our HRT. This is appropriate, for the majority of women in surgical menopause are able to meet all of their post-fertile hormone needs by supplementing this hormone alone and allowing their bodies to shuffle around the needed reactions to make the rest.  Estrogen balancing is a process of determining where you fall on the continuum between too much and not enough and trying to get to the most satisfying "sweet spot" in the middle. Some women get there, are happy, and that ends, for now, their adventures in hormone balancing. Others spend considerably more time trying out various routes and doses to find the best fit.

At some point in that process, though, some women find that they cannot address all the symptoms of one extreme without pushing themselves too far in the opposite direction. At this point, where we have adjusted our estrogen for the best possible balance, we are ready to open the question of whether or not we would benefit from the supplementation of other hormones in addition to estrogen.

Why not earlier? Why not help out a bad estrogen balance by adding some other hormones? The thing is, we can't tell what we do or don't need while estrogen needs remain unmet. They skew the whole picture because estrogen is such a priority that we'll pillage other systems to support our estrogen needs first of all. So until that estrogen pillaging is relieved, we don't have a firm place to begin from or even to tell what else we might need. This isn't just us talking; this is the fundamental premise of hormone supplementation as voiced by the specialists in the field, the American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Menopause (free signup required to read). What that means is that when estrogen is imbalanced, we're propping up that imbalance by using other hormones that have an even worse risk profile. And that's a picture that lacks charm, isn't it?

So, we've tuned and tweaked our estrogen, auditioned different routes and types if needed, and are confident that we're getting absolutely the best estrogen coverage we can from our estrogen hrt. At that point, if we have specific goals that remain unmet and we're aware of the risk profiles of progesterone or testosterone, we're ready to consider supplementation of the hormone that specifically addresses those other unmet needs.

And, before we launch into specifics, let's consider one more important thing. It's always good to keep in mind that interactions with other body systems may impact the balancing of ovarian hormones.
The thyroid is an obvious one, since estrogen is something of an antagonist to thyroid hormone and progesterone helps keep minerals and electrolytes in cells that are necessary for the cell to convert thyroid hormone to its active form. Many, many of the symptoms of ovarian hormone imbalance are similar to or intertwined with those of thyroid imbalance and neither system can be balanced wholly in isolation from the other.

Because of this, if you are having marked difficulties achieving HRT balance, you may want to consider include thyroid hormone testing in your evaluation. Further, this testing should not be limited to the typical measure, TSH level determination, but rather should include measuring of free T3 and T4. More about this is in our thyroid and hrt article.

One other system worth considering if HRT balance remains elusive is the adrenal. While the "diagnosis" of adrenal insufficiency or adrenal fatigue is genuine, it is also heavily abused by less scrupulous practitioners whose primary motive is sales of tests or supplements.

It makes sense that while the ongoing drain on our adrenals to cope with the loss of the ovaries would be genuine, unless there is a demonstrable deficit of some particular adrenal factor, it seems more straightforward to remove the stressor by correcting the estrogen deficit than by providing the raw materials (such as DHEA) for the adrenals to go on being overstressed. Whichever way you choose to go, should adrenal support be something under consideration, we would strongly urge you to demonstrate specific deficiencies by testing before taking adrenal supplements, and to neither start nor stop them suddenly and without direct supervision by a qualified health care professional. Our adrenal glands are way too important to the functioning of our entire body to mess with them at all casually.


Yeah, it is confusing. There is no easy instruction manual for this stuff. There aren't even any "right" answers. So here's a recap in short form:
  1. Learn: what hormones do, what route considerations bring into the picture, what your family and personal history suggest in terms of present concerns and future risks
  2. Set goals for menopausal health: which specific hormone actions are important to you and are the ones you will measure success by? what particular monitoring will you need to keep checking on your specific risks?
  3. Develop preferences: which methods and/or HRTs appeal to you as a starting point?
  4. Plan: with your health care provider for how you will begin and how you will move on through the balancing process
  5. Observe: journal it all as you go
  6. Revise: this is where the go slow and making one change at a time comes in, plus keeping in mind that we are forever a work in progress
A lot slower and more involved than you had in mind? Sorry to be the bearers of unwelcome news. Many women are shocked to get into surgical menopause to find that medicine, which seems to have always promised quantified testing and accurate remedies, has suddenly turned them loose and said: "Here! Try stuff! You are now a chemistry experiment! Let us know if any of it works! Good luck!" But in the end, that's what goal-driven treatment comes down to. And remember, if you reach a point where you would find it helpful to bounce things off of someone else, we're always there in the forums