It’s My Hormones……Isn’t It?

Yesterday a 60 year old patient came into my office carrying a large notebook, and a folder full of papers. This is usually a red flag — meaning that she is either a patient with a long medical history, and is bringing me records from all of the many medical treatments she has already had, or — more likely, she has had lots and lots of testing done (warranted or not), in a quest to find answers about her unique medical condition and multiple symptoms. That folder is also usually filled with “internet research”, documenting all the articles she has found that seem to prove that the answers she is seeking are “out there”, and she just needs someone to help her implement them.

In this case, as in so many others I have seen, this obviously menopausal woman, who had had no periods for at least 3 years (definition of menopause=12 consecutive months without a period) had just been to some type of a health care practitioner who told her it was necessary to “check her hormone levels”. Why would someone tell this patient, who was not taking any hormones, and who had had no ovarian function for several years, (another definition of menopause=the time at which the ovaries cease to function) that there was a need to “check” her hormone levels? I can tell you what her Estrogen level was, without even doing a test. If there had been no periods for several years, AND the woman was describing even mild symptoms of hot flashes, insomnia, irritability, and/or vaginal dryness, her Estrogen level would be zero — or close to it. And her Progesterone level (Progesterone is made from ovulatory ovaries, and a 60 year old woman has not been ovulating for years) would also be zero, or close to it. Looking further at this “data sheet” that my patient brought with her, there were many other unneeded and unnecessary tests that were done — — Why does someone need to know her Pregnenolone level? or her DHEA level? What would they do with those results? Unless there was some major endocrinological problem in this woman’s history, where her pituitary or her adrenal glands were known to be non-functional these are not tests that would need to be run to properly evaluate and treat a woman in menopause who is looking for relief of her symptoms. Not surprisingly, the practitioner who ran all of these tests (and more) charged her a large fee, and then convinced her that she would have to buy numerous supplements and vitamins from him in order to correct all the “imbalances” that he found.

A good rule of thumb for seeing a health care practitioner is: If someone wants you to pay a large sum of money to diagnose a condition, and then another large (and on-going) sum of money to treat the condition that they found, then it’s appropriate to be skeptical about what they are really offering you. I plan my diagnostics and treatments based on medical EVIDENCE. Unfortunately learning to critically evaluate scientific research is not something taught everywhere so most people are not aware of the process by which we should be making our decisions about diagnosing and treating our patients.

Asking a treating provider where they got the research from to support the testing and treatment protocol they are recommending to you and why they expect it to have a particular outcome is not inappropriate. They should be able to offer you evidence-based studies to back up their claims. They should be able to explain to you their reasoning for the treatment they have chosen, and what health benefits you can expect.

Evidence comes from medical research. The gold standard of medical research is when conclusions are reached by doing randomized, controlled double-blinded studies. What exactly does this mean? Randomized= study patients are randomly placed into various groups that are going to be compared. The study will place subjects in the groups to be studied, making sure that they don’t put all subjects with certain characteristics in one group, and all subjects with a different characteristic in another group, because then they would not know if that one characteristic would influence the outcome of the study. Double-blinded means that if we are comparing the effect of a certain medication on a population of people, then some will be given the medication, and some will NOT be given the medication — and neither the study subjects nor the researchers could know which subjects got the medicine and which did not. In order for that to take place then half of the study subjects would be given something that looks identical to the study medication but which does not actually have the medication in it — -also called a PLACEBO. Then, since a placebo is equal to essentially no treatment, if subjects improved with the treatment, the conclusion would be that taking the medication is better than doing nothing. Although medical research is not really that simple, when we design protocols, or order tests, or prescribe medications, we at least have to have some evidence that our intervention is better than doing nothing!

This week, a young patient came to see me on the recommendation of her chiropractor. He told her that she should come to me and have her “hormones tested”. In listening to her history, this patient described the last 6 months of heavy and irregular periods ever since she stopped nursing her baby. She (and, apparently her chiropractor) were positive that there was some kind of “imbalance” in her hormones that was causing these irregular periods. On further questioning, it was revealed that for the past few months this patient was also on a birth control pill. Assessing someones “hormone levels” is pretty impossible when they are actually taking hormones that are designed to suppress normal ovarian function and stop the production of the very hormones that I was being asked to measure. Rule of thumb about taking birth control and having bleeding irregularities: the abnormal bleeding pattern is likely being caused in some way by the birth control. Taking birth control is an effort to substitute for one’s own ovarian function and replace it with a stabilizing, steady stream of enough Estrogen and Progesterone to suppress ovulation. Only by going off of the birth control and seeing what the naturally occurring menstrual cycle is like, can it be decided whether any kind of “checking” would be necessary — — and usually the answer is NO. Most young women can be managed based on what their end goal is: If they are seeking fertility we have tests we can do to assess fertility. If they are seeking contraception, there are many choices to offer for pregnancy prevention and for cycle control at the same time — -no hormonal testing needed.

There are a few situations where it would be advised or necessary to check someone’s hormone levels.

1- When there is a long interval between periods (months or years), and pregnancy is desired

2- When there is a worry that there is a pituitary abnormality or other endocrine disorder and there are signs or symptoms of decreased hormone production

3- When a woman is unsure whether she is in menopause (last period within the last 12 months) and would like to go on hormone replacement, it may be warranted to check hormone levels to see if any further bleeding would be anticipated

4- When someone is on Testosterone, the free Testosterone level in the blood should be checked to be sure the dose is not too high, as high Testosterone levels can be associated with liver abnormalities and other detrimental side effects

There may be some other occasions where checking hormone levels may be warranted, but if someone suggests that you should have your hormone levels checked, I suggest you ask the reason that they would need to be measured. Randomly checking hormone levels (or doing any other tests) that are not likely to help in formulating a treatment plan is never a good idea. Following the evidence — and the scientific studies — is what’s most likely to lead to the path with the right answers when it comes to “managing” what may (or may not be) a hormonal problem.

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