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 here. 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!
Rachel Gelman, DPT