A Female OBGYN’s Perspective

At least once a day (and it’s usually several times) I hear the same concern from women in my office…

“My hormones are out of balance.”

When I question why they think this may be, it is always the same host of answers: mood swings, low libido, weight gain, fatigue, apathy. And 99% of the time, it’s at the behest of their significant other that they are inquiring about these “hormonal” concerns.

These women are usually the “ticker keepers” of their family – the “cruise directors” if you will. They know, juggle, and arrange the schedules and tasks of the family; and often of their coworkers. They are in the very active phase of parenting, or potentially facing transitions to an empty nest, all with jobs and spouses and parents and siblings and life all around them that puts a significant demand on their time and energy.

And it blows me away EVERY TIME that someone, that anyone, has the audacity to blame their hormones for their exhaustion, their low libido, their moodiness when we live life at a pace such as this. Women are pulled in a million different directions, and the pandemic has done nothing but magnify the intensity of these pulls.

So, when a woman comes in concerned her hormones are “out of whack” of course, as a physician, I do my due diligence to make sure that there is not in fact some endocrinological abnormality. Now before I go step on my soapbox (and jump to the end if you’re just here for a rant), let’s review the “hormonal” things we can fix.

Thyroid

Hypo- and hyperthyroidism are common endocrine problems. Up to 15% of women will have an abnormality in their thyroid function. Our thyroid helps to regulate our body’s metabolism. When it’s not functioning properly, things can feel pretty bad. Common symptoms can include weight changes, skin and hair changes, constipation, diarrhea, and menstrual abnormalities. Thyroid-stimulating hormones (TSH) and thyroid hormones (T3/T4) are tests we draw often, and honestly, it’s usually normal. However, this is always important to rule in or out.

PMS/PMDD

As we move through our 40’s we experience more significant amplitude changes in levels of estrogen and progesterone throughout our cycles. This can mean increased moodiness or sadness in the days between ovulation and your period. And if PMS and PMDD are significant contributors to your mood, then we can fix that!

Hot flushes and night sweats

Yes, these can appear YEARS before menopause. And yes, they are horrible. But yes, they are fixable! But you know what I don’t need to fix them? Bazillions of your hard-earned dollars in meaningless lab work. An astute gynecologist does not need to get bloodwork to verify a woman is in peri-menopause or menopause. In fact, that lab work (often an FSH level) is generally useless and not reliable. I have seen women with “menopausal levels” of FSH continue to ovulate (and yes in one case get pregnant). So P.S. DO NOT take this one to the bank for contraception needs.

Vaginal dryness

This is the sneaky symptom of menopause that no one talks about, but everyone has. There is an effective and safe fix for most every woman. If your libido is tanked because sex is painful due to lack of lubrication – you are my favorite patient, because this is “fish in a barrel” easy.

But sister, let me tell you…

…if your periods are still clockwork your hormones are FINE. FINE, I TELL YOU. Your thyroid is likely functioning normally, and your estrogen and progesterone are fluctuating just as nature intended them. I always remind women who come in having had “hormone testing” done somewhere else that spot-checked levels of estrogen, progesterone, testosterone are irrelevant without the context of the menstrual cycle timing. It is normal, for example, to have a low progesterone before ovulation. That is not “estrogen dominance,” it’s just the normal follicular phase.

There is a whole industry out there trying to demonize normal hormonal fluctuations, and many practitioners who peddle and profit from these hormonal treatments have little knowledge about said hormonal patterns. The “hormone industry” of cash-only, non-FDA-approved treatments requiring costly and frequent lab draws to “adjust” your hormones to some irrelevant specified levels are preying on women who are worn out, and tired, and stressed, and looking for a break.

Now to be clear I am NOT opposed to hormone replacement therapy (or “HRT”). I will do it myself if I have symptoms that will control it. But hormones are not magic. They’re not a fountain of youth. But studied hormones that are FDA approved have great benefits as well as real risks that we know and have been proven over and over again in the literature.

The bigger problem?

My opposition is to the industry. I feel like this is just another way to gaslight women in general. WE are the crazy ones. The ones who need “adjusting.” When, in reality, it is society’s expectations of us that need the adjustment. At 42, I should not be expected to feel and act like I’m 22. I sleep a lot less, work a lot harder, and have a lot more responsibility than I did 20 years ago.

Jacking my testosterone levels to that of a teenage boy might make me feel damn fine, a little randy, and super productive for a bit. But is that what we need? Are anabolic steroids seriously the solution? Do we need to have the energy of a teenager, or do we need to adjust our expectations of what women “should” be doing in our middle ages?

Now don’t get me wrong, I’m not saying that in our 40’s we are old and shriveled and useless. I frankly am healthier and honestly more active (although undoubtedly achier) at 40 than I was at 20, and I know many of my patients, friends, and partners are in the same boat.

Maturity and experience have taught most of us to fuel our bodies with better foods, drink more water, and exercise more consistently than we did 20 years ago. So I think the goal should be to feel the best that we can feel with reasonable expectations of where we are and how we take care of ourselves.

But there’s the crux of the issue, right? Are you taking care of yourself? Or are you spending every waking moment doing for others? For our society, our families, or coworkers to expect us to give nonstop in service of others and not expect us to be moody and exhausted, THAT is what is out of balance.

It’s not you, sis. It’s them.