Hormones drive me crazy. As a woman, my biological clock seems to be more like an overactive alarm clock lately. For example, on a certain day I may see a baby and feel an intense urge to procreate. It is as if my uterus wants nothing more than for me to have 18 babies right now and then star in my own reality show on TLC. If we fast forward a week, I may see the same baby and be grateful for birth control. Although each month I experience some sort of unending hormonal rollercoaster, my patient’s ride may come with more than just cravings for chocolate and binging on episodes of The Bachelor. In fact, these hormonal fluctuations may greatly contribute to their pain levels and even their ability to function.
In my professional life, I find helping my patients navigate the world of hormones to be frustrating. Why? Because hormone levels are constantly changing: daily, weekly and monthly. So if a patient wants to be tested for a potential hormone dysfunction, it is difficult to ensure that any lab work done will show the full hormonal picture for that particular person. It is not impossible mind you, but still difficult. Also, there isn’t just one hormone for one body part or one hormone that controls one bodily function (It makes sense since there isn’t even one brand of toothpaste nowadays, so why would the human body be any simpler but I digress). With this in mind, it is my goal to uncomplicate the topic of hormones. To make it even easier, (and to keep this post from becoming a dissertation) I will only discuss on the “main” hormones of the female reproductive system. Some of these hormones are also present in men, but again to keep things simple I will only talk about these hormones and how they impact women.
Let’s start with the three that get the most notoriety: Estrogen, Progesterone and Testosterone.
Wait a minute, I thought only men have testosterone!? That is false. The ovaries, along with the adrenal glands, produce a small amount of testosterone. This hormone is involved in bone and muscle mass formation. Testosterone may be linked to a woman’s sex drive, but like with most things libido can be impacted by many other factors, like some Marvin Gaye and pictures of Ryan Reynolds, but that is just a personal preference. Speaking of sex, testosterone helps keep the glands in the vulva functioning like a well oiled-machine. These glands contribute to increased lubrication during sexual arousal, which can make sexual activity more fun. Now during the menstrual cycle, testosterone peaks right around ovulation, which may be the body trying to promote the chance of intercourse and therefore pregnancy. To understand why this would happen, it is important to understand the process the body goes through to prepare for a potential pregnancy, which brings us to our next hormone: estrogen.
There are actually three types of estrogen: Estradiol, Estrone and Estriol. Estradiol is the most common form in nonpregnant women and is produced by the ovaries. Estriol is most abundant in pregnant women as it is produced in large amounts by the placenta, and estrone is produced in lower amounts from the ovaries, liver and fat tissue. Again, to keep things simple for the remainder of this post I will refer to all the forms as estrogen.
Estrogen is the hormone responsible for that fun time known as puberty. It is the sex hormone that causes breast development, hair growth and for menstruation to begin (Woohoo!). During the reproductive years (teens to forties) estrogen levels fluctuate during the month. During menstruation, one’s estrogen levels are pretty low, and your body has some cool Jedi skills that sense this and cause a release of two other key hormones Follicle-Stimulating Hormone (FSH) and Luteinizing Hormone (LH). FSH and LH go tell the ovary that it’s time to get another egg ready to be released. The ovary begins to produce more estrogen, which is telling your uterus to get ready for the upcoming houseguest and helps “ripen” the egg into maturity. A woman’s estrogen levels continue to rise until mid-cycle, which causes a spike in LH which is what tells the egg, in Price is Right style to “Come on down!” Estrogen levels begin to increase again (along with progesterone, which I’ll talk more about later) to help keep the uterus nice and habitable in the event the egg is fertilized. If the egg is not fertilized, then estrogen levels drop and the body sheds the uterine lining and the whole process starts again.
Now what if the egg is fertilized? In pregnant women estrogen levels continue to rise, until the end of the first trimester and then they level out. However, during delivery estrogen levels sky-rocket and then plummet. A woman’s estrogen levels will continue to be low during the postpartum period, especially if a woman is breastfeeding, as the hormone that allows for lactation is antagonistic to estrogen production. This decrease is estrogen may be one of the causes of Postpartum Depression (PPD) as estrogen can impact mood and behavior.
Now as women age, estrogen levels continue to change. Estrogen levels continue to decline which is what results in something called Menopause. Many people associate this with the end of their periods and therefore a cause for celebration, but a decline is estrogen comes with negative side effects.
First, Estrogen is also involved in bone health, which is why osteoporosis is a concern during menopause. Estrogen helps prevent bone resorption, or breakdown, so as your estrogen levels drop, which they do during menopause, your bones are no longer as protected and susceptible to bone loss. Second, the vulva and the vagina are big fans of estrogen, because this hormone keeps the tissue thick, elastic and moist. So less estrogen can mean thinner, drier and impaired vaginal tissue. A decrease in estrogen can cause an increase in the vaginal pH which puts postmenopausal women at an increased risk for UTIs.
Now let’s move on to another important hormone: Progesterone. Progesterone is also produced by the ovaries, as well as the placenta and the adrenal glands. As your estrogen levels decrease mid-cycle, your progesterone levels begin to increase to help prepare the uterine lining in the event pregnancy occurs. Again, if the egg is not fertilized progesterone levels drop and menstruation begins. But during pregnancy, the placenta continues to produce progesterone to maintain the uterine lining. Progesterone, along with estrogen, help maintain pregnancy by preventing ovulation. Similar to estrogen, progesterone levels rise and then plateau. This hormone relaxes smooth muscle in the body, including the uterus, as well as blood vessels in the body. This can lead to low blood pressure or dizziness during pregnancy. It also stimulates milk gland production during pregnancy. During delivery, progesterone levels also increase and then drop dramatically. This drop in progesterone allows for an increase in prolactin which stimulates breast-milk secretion. A decline in progesterone may also play a role in PPD, as progesterone plays an important role in brain health. Similarly, a disruption in progesterone can be the cause of PMS. Since most of these hormones impact one another, any mishap in the many feedback loops can lead to a hormonal imbalance.
But wait, if our bodies are amazing self-regulating machines, how can our hormones get all out of whack?
First, there is our good pal genetics. Some researchers suspect that some individuals carry genes that lead to hormone imbalance which can then cause certain diseases, such as endometriosis and polycystic ovarian disease (PCOS). The jury is still out on that one, but some women may just be wired to over or underproduce certain hormones.
Luckily, there are some more concrete factors that can impact hormone levels. For example, diet can affect your hormone levels, some key dietary culprits that can mess with your hormone levels include: sugar, dairy, meat and soy products. (I will discuss this topic more in a later post, so stay tuned).
Stress is another factor that can bully our poor hormones. To break it down, stress leads to increased production of a stress hormone: cortisol. Cortisol is very helpful when produced in appropriate quantities, but if a person is continually stressed and the body overproduces cortisol it can begin to mess with the balance of other hormones, including the sex hormones discussed above. Making sure you take time to relax during your busy workday is important to allow for hormonal harmony to exist. For those of you hip with the times, there are some great apps these days for mindful meditation such as: Headspace, Insight Timer and Breath. Making sure you get enough sleep is also important in keeping your hormone levels in check.
Finally, there are medications that can impact hormone levels, primarily oral contraceptive pills (OCPs). A few years ago, we discussed the impact of OCPS and vulvodynia.To summarize, OCPs produce a protein that inhibits androgen-hormones ie testosterone. This can lead to problems with lubrication during arousal and sexual activity and therefore lead to pain. OCPs can also mess with your bodies natural hormone production of progesterone and estrogen, which as we know play a role not only in mood and brain health but vaginal and vulvar integrity. A decrease in these sex hormones can lead to the same structural changes as described in postmenopausal women. This is not to say that taking the birth control pill is going to cause you to go into early menopause or develop pain with intercourse, but it is something to consider if you are noticing symptoms and are unsure of the cause.
Now that was a lot of information. Again, I couldn’t cover everything and plan to return with more information regarding hormones and all the fun things they do. But hopefully this cleared a few things up or taught you something new! Or maybe it raised more questions? Please let me know your thoughts!
Regards,
Rachel Gelman, DPT
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
This is such a well done post! Thank you very much.
What a great post! Just one question– you said above in menopause the ph of the vaginal mucosa becomes more basic/increases? Is there a way to balance this naturally that you know of?
Author Rachel Gelman says:
“Hi there!
Thank you and great question. First, I would recommend consulting with a naturopath or integrative medical provider to determine if your pH is imbalanced and if it is due to estrogen deficiency or something else. In general the research suggests that adding probiotics or fermented foods to your diet can be helpful in boosting the natural vaginal bacteria which can improve the vaginal pH. Again, I recommend consulting with a provider as every individual is different and what might work for one person, may not work for the next!”
Any helpful advice for those of us with PCOS? I was put on OCP’s at age 16 to regulate hormones due to PCOS. I remained on them until I was trying to have my children and took myself off them between child # 2 and 3. I am now 37. Have had such a difficult time with my weight. Have been “successful” with Whole 30, however, I cannot be off the Whole 30 now because I am gaining now faster than ever.
Thank you for any help.
Author Rachel Gelman says:
It is hard to answer that question without more information. I would recommend seeking out an integrative medical provider or nutritionist with a background in women’s health to determine what would be the best fit for you. Typically, lab tests need to be performed to determine what nutrients/foods need to be added or taken away.
Fantastic post Rachel! I recently understood the complexity of female hormones, especially how it impacted on my health and wellbeing, and your post makes it so clear to understand just exactly how a woman’s hormones can impact on their health & wellbeing. Thank you for writing.