Perfect Balance
By Robert Greene, MD, and Leah Feldon

The following exerpt is from Perfect Balance: Dr. Robert Greene's Breakthrough Program for Finding the Hormonal Health You Deserve, published in 2005 by Clarkson Potter/Random House.


Hormones are an extremely confusing issue today for any woman who is considering taking a hormone supplement or replacement, whether for menopause, disease prevention, symptom management, contraception, or simply to feel better. I've had patients come to me in tears because they felt positively horrible after they stopped their hormone replacement therapy but were afraid to resume their treatment because of alleged health consequences.

There's no doubt that much of their fear and confusion was (and still is) fueled by the media. The media thrives on sensational headlines and rarely delves very deeply-especially when reporting on complicated medical issues. The termination of the first arm of the Women's Health Initiative (WHI) study in 2002 is a perfect case in point. The study's focus was the potential correlation between hormone therapy and risk of breast cancer and other health problems like heart disease. When they prematurely closed the study (ostensibly because of health risks to the participants), the WHI reported that women taking Prempro (a combination estrogen/progestin therapy) faced a 26% increased risk of developing breast cancer. These were scary, but misleading, figures. As it turns out, the 26% increase has almost no meaning in the real world since it doesn't factor in the average, or baseline, risk. The baseline risk for developing cancer around the time of menopause is 2%. A 26% increase of a 2% risk means that your risk 
of developing breast cancer around menopause is only 2.5%. (Actual math: 26% of 2%.) That's a very minimal increase in real-life terms-and that's the way the story should have been reported. 

The heart disease aspect of this arm of the WHI study was misleading for a different reason. The study (whose participants were mostly Caucasian women who started on hormones at the average age of sixty-five) concluded that if you start combination hormone therapy at 65 years old-which is many years after most women's bodies stop producing hormones-you'll have a slight increase in your risk of heart disease. But what caused the slight increase-being estrogen deficient for more than fifteen years, or taking the combination hormone replacement for 5.2 years? The kicker is that two months after the study conclusions were published, we found out that 30% of the women in the study were obese and about 25% were tobacco users. Were these the women who had an increase in heart disease? And how do those statistics apply to you? If you're a slim, fifty-year-old black or Asian woman who doesn't smoke, probably not much. Finally, when the WHI closed down the arm of the study looking at menopausal women taking estrogen o
nly (as opposed to the estrogen-progestin combo) they found that women had about a 25% lower risk of developing breast cancer. And they didn't find any increased risk of heart disease. These updated results were also published-albeit with considerably less fanfare. But by then most women were so scared they didn't want to consider hormone therapy anyway. 

Perhaps the most distressing thing to me about the WHI study (as well many other major studies) is that they don't consider how you feel. They only focus on disease prevention or treatment. The WHI study participants were symptom-free-that is, they didn't feel any of the symptoms of hormonal imbalance. (That, in fact, was a requirement for women enrolling in the study.) So there was no way to determine if hormone therapy improved or worsened their symptoms-they didn't have any. How they felt was simply not a factor. But certainly quality of life is a huge issue. It is for my patients, and I'm sure it is for you, too. 

Am I advocating hormone therapy? No … and yes. I'm advocating symptom-free hormonal balance-perfect balance, and if it takes prescription hormone therapy to achieve that, I believe it should definitely be considered-and we'll be discussing the best, safest, and most appropriate therapies for your specific symptoms in the second half of the book. But very often you can improve or alleviate common symptoms of hormonal imbalance-the mood swings, bloating, hot flashes, sleep disorders, low libido, memory problems, migraines, and other disturbances so many of you experience-through changes in your diet, exercise and lifestyle habits, or alternative approaches such as mind-centering techniques, vitamins, or herbs. That should always be the first line of defense. My feeling is if you can solve your problem naturally, there's no reason to go the HT route. 

If there's one thing I've learned from all my research and clinical experience, it's that hormones are not a one-size-fits-all issue. Every woman's hormonal balance, imbalances, and symptoms are different. That's why no conscientious healthcare provider or study should ever suggest that all women should be on HT or all women shouldn't, or that the same HT will work for every woman. What works for your neighbor or sister won't necessarily work for you. 

My philosophy is simple-listen to your body. We now know that hormonally induced symptoms are not just annoyances, but rather warning signs, red flags sent up by your brain to get your attention-to alert you of hormonal imbalance. Very frequently the severity of your symptoms-be they depression, anxiety, hot flashes and night sweats, insomnia, agitations, fatigue or aches, or even the worsening of "normal" pains-correlates with the severity and importance of the hormonal imbalance. If the imbalance is minor, your symptoms are usually subtle-sort of like a whisper from your brain. If the imbalance is more severe, your symptoms become more intense-more a roar than a whisper. 

Your decisions regarding hormone treatment should be based on your individual symptoms, your "hormonal whispers." They're the best determination of hormonal imbalance-more accurate than blood tests or study reports. If you have symptoms, they are happening for a reason and shouldn't be ignored. My goal here is help you learn how to interpret those signals from your brain, get to their root core, and correct the imbalance. While the discomforts of hormone imbalance may not indicate a serious disease, they can have a huge impact on how you feel day to day, and correcting them now could prevent serious trouble ahead. 

The Last Reproductive Years: Late 30's to Early 50's

The transition from the reproductive to post-reproductive years starts in about your mid-thirties. This is when your fertility rate begins to decline and your hormonal patterns get increasingly chaotic and unpredictable-and for some women it can be a pretty bumpy ride. One month your body may produce too much estrogen (a result of higher signals of FSH from the brain); another month you might not produce progesterone at all because you don't ovulate. As a result, symptoms can vary wildly: from bloating, breast tenderness, and heavy bleeding one month, to hot flashes and crying spells the next. Feelings and issues seeming unrelated to hormones, like mood instability, unprovoked anger, unexplained weight gain, miscommunication with peers and mates may seem to spring up from nowhere. It can be a real challenge. 

With a few exceptions, this "mid-life" hormonal chaos, that's often referred to as perimenopause (literally "around menopause"), is remarkably similar to what you went through during puberty. Unfortunately, the "exceptions" tend to exacerbate the challenge rather than lessen it. During these years, unlike in puberty, testosterone levels get progressively lower, adding to feelings of vulnerability, fatigue, and diminished self-confidence. You've also got symptoms of estrogen withdrawal to deal with, and your stress hormones are most likely elevated too thanks to the pressures of everyday adult responsibilities. On the positive side, as an adult you have a fully formed frontal lobe in your brain, so at least impulse control should be much less problematic this time around. Still, the disruption of your quality of life from sex hormone imbalances can be devastating. Studies have shown that 50-85% of perimenopausal women experience symptoms like hot flashes, night sweats, mood swings, forgetfulness, fatigue and s
leep disturbances. Luckily, as you'll see in the later chapters, there are viable solutions to all these problems.

During this transition, the time between periods (menses) typically becomes shorter at first, and then shifts toward progressively longer and longer time spans between periods. And there may be several months interspersed when you return to normal cycling. Like all things hormonal, there's a wide degree of variability involved when it comes to timing-some women may experience these inconsistent cycles much earlier or later than others. Ultimately, though, upon entering menopause, every woman's menstrual cycle stops all together. Not surprisingly, all this unpredictability is a big part of the frustration felt by so many women during this time.

The bottom line is that your hormonal balance is more easily disrupted during these years than it was before. Anything, like tobacco use, poor nutritional habits, or severe stress that may have caused a minor hormone imbalance earlier in your journey is now amplified. Smoking, for instance, accelerates ovarian aging by converting estrogens to mild anti-estrogens (called catecholestrogens) that diminish the number and quality of fertile eggs. Even without these kind of harmful disruptions, your risk of conceiving (without contraception) between the ages of forty and forty-four is about ten percent a year. That rate drops two to three percent per year for the years between the ages of forty-five and forty-nine. This isn't to say you can't get pregnant. You still ovulate during these transitional years, just less consistently than during your peak fertility years, so there's still potential for pregnancy, and you still need to use contraception if you're not looking to conceive.

As we briefly discussed, your testosterone production slowly and steadily declines, not just during these late reproductive years, but all through your childbearing years as well. Although there are exceptions, usually by the time you're forty years old, your testosterone level is only about half of what it was when it peaked in your twenties. And by the time your reach fifty, it's halved again, leaving you with only 25% of the testosterone you had in your reproductive prime. Not surprisingly, the substantial drop in testosterone can have a heavy impact on your quality of life. Not only does it tend to diminish your libido, but it also contributes to a loss of muscle mass. For most women the rate of muscle loss averages about a half pound per year. This silent loss of muscle is one of the leading causes of age-related weight gain. Muscles use calories, and when there's no muscle to burn the calories, the calories are stored as fat.

As testosterone levels fall, it also takes more effort to maintain your fitness level. As your muscles lose their fullness, they also lose the protein that gives you strength, and the glycogen they store as their fuel supply. So, as testosterone levels fall you have to work harder to stay fit. If you don't, you'll notice a greater sense of fatigue, less strength, and more muscle aches when you do exert yourself. In essence, the surging hormones that let you get away with a lot of bad habits in your teens, twenties, and early thirties, tend to catch up with you as you approach forty.

As your free testosterone level continues to fluctuate along with your estrogen level, your degree of alertness may also be reduced. Aside from fatigue, that's one of the most common complaints women have during these chaotic transitional years. And then there's the mood fluctuation. Testosterone and estrogen together tend to create the ultimate feel-good cocktail for women. Since you're used to enjoying that cocktail, you tend to notice when it's not being served up. Testosterone has also been linked to a strong sense of self-confidence; when levels are lower you feel less confident and more anxious. There's no doubt in my mind that the combination of low testosterone and fluctuating estrogen levels is a big contributor to the anxiety so many women feel during this time period. 

This hormonal wallop is in fact the same mixture that generally follows the delivery of a child, and there too it frequently results in profound anxiety, often combined with depression. Postpartum anxiety, though, at least served a useful adaptive purpose-behavioral psychologists believe the anxiety made a new mother a more vigilant protector of her highly vulnerable little infant. But the same feeling during these late reproductive years, even if it is a vestige of the adaptive response, serves no real purpose at all. 

Aside from libido, there are a number of ways that hormonal changes during transitional years affect your sexuality. As estrogen and testosterone levels fall, the tissue that lines the vagina becomes thinner, drier and more easily irritated, so that even with the best lubricant, intercourse can become uncomfortable or even painful. Lower estrogen levels also make you more sensitive to pain sensations and reduce vaginal blood flow, which diminishes sexual arousal and lessens orgasmic response. And the lower testosterone levels reduce the sensitivity of the clitoral area as well. So by the time you reach your late forties, your hormonal balance has shifted in ways that not only reduce libido, but decrease the likelihood that sex will be as enjoyable as it once was.