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Achieving Hormone Balance

Many women come to us with problems that are related to hormone imbalance. In most cases they have entered either perimenopause or menopause. However, many younger women suffer with premenstrual syndrome, heavy periods, uterine fibroids and/or fibrocystic breast disease. Those symptoms also indicate hormone imbalance. The cause is most often the inability to effectively eliminate excess estrogen. So it’s important to understand a little more about hormone metabolism.

How Hormones are Metabolized by the Body

Estrogen is the hormone that stimulates growth, and progesterone is the hormone that slows growth.

Any hormone we make must be used and then eliminated. The body has at least three pathways (see diagram) that can be used to eliminate estrogen. They’re called the E2 pathway, the E4 pathway, and the E16 pathway. Women use all of these pathways at some time or another, but the healthiest one to use is the E2 pathway.



If a woman’s body is predominantly using the E2 pathway, she usually doesn’t have issues with uncomfortable periods, painful breasts, and uterine fibroids. Also, these women will usually go through menopause more easily. Conversely, women using the E4 and E16 pathways predominantly may experience hormone imbalance issues.


Our goal in treating the premenopausal woman who has hormone imbalance is to encourage her to use healthier estrogen detoxification pathways. This is usually accomplished by a diet that is rich in isoflavones and flax, and high in fiber.

For women who had these issues when they were menstruating and are now entering menopause, it’s important that we are very cautious in replacing estrogen and that we encourage the healthy metabolism of estrogen replacement products.

I refer to these women as poor estrogen metabolizers. The worst situation for them is to be placed on estrogen such as Premarin because it is not identical to human estrogen and is more difficult to eliminate. An estrogen such as this cannot use the E2 pathway to be eliminated. Thus it is important that when women replace estrogen, they use bio-identical estrogens which can be eliminated through the E2 pathway.


We can learn a great deal by listening to a patient’s history and not doing any testing at all. For example, if a woman comes in with heavy irregular periods, uterine fibroids, premenstrual breast tenderness and/or unexplained weight gain, it will be obvious that she is estrogen dominant and progesterone deficient. We wouldn’t need to test for the level of progesterone to feel comfortable in replacing it.

When it comes to replacing testosterone and estrogen, it is important to have a way to assess the patient’s level of deficiency or sufficiency. The same is true for adrenal status, where ideally we would test levels of cortisol and DHEA.

Testing can be done with three different methods: serum (a blood draw), saliva, or urine. Each method has its advantages and disadvantages.

The advantage of serum is that most insurance providers recognize this method and reimburse the cost of the test. The disadvantage is that what’s in the serum may not reflect what is in the tissue. Conceptually speaking, the serum represents the highway and the tissue represents the destination. It is thought by many that saliva and urine tests reveal the tissue levels. In our practice, we have tested both serum and saliva. Most of the time we will use serum to give us an idea of hormone balance or imbalance.

When it comes to adrenal testing, there is no doubt that saliva cortisol levels done several times per day is our most accurate way of assessing adrenal sufficiency. A serum morning cortisol along with DHEA level gives us a peek at a person’s adrenal reserves and can be used to initiate a program for adrenal support.

Patricia Deckert, D.O.

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