EP.289/ High and low oestrogen levels and how to test correctly
So, this week we’re staying on our theme of hormone testing and we’re looking at oestrogen.
There are a number of signs to look out for with oestrogen dominance or excess, and they pretty much all fall under the PMS umbrella, but here are a few tale-tell signs that I often see with clients:
Clotty periods
As we explored last week in our progesterone episode, oestrogen has proliferation properties. In short, this means it helps cells to multiply and increase in number, and this is why oestrogen plays such a key role in puberty and the development of breasts, pubic hair, etc.
These proliferation properties also extend to the endometrial tissue of the uterine lining, essentially, the tissue that makes up that spongey layer in your uterus. As your oestrogen levels rise in your follicular phase and into ovulation, your uterine lining thickens.
If you have elevated oestrogen levels, as in literally, you have too much, this could cause excessive thickening of the uterine lining.
If you have normal levels of oestrogen, but your progesterone levels are too low once you’re in your luteal phase, this means oestrogen will be able to happily continue to fluff up and increase the uterine lining without progesterone coming along to counteract it. This again means you may end up with a thicker uterine lining.
Of course, this lining is what sheds during menstruation, so if you have oestrogen dominance or excess, you may find that you have bigger clots because of this. FYI – little bits of tissue in your period blood is normal, but anything bigger than 2.5 cm would be considered a large clot.
Long periods
A period longer than 8 days is a possible sign of oestrogen dominance, especially if it’s coupled with heavy periods or clotty periods. As we have covered, the proliferative properties of oestrogen could create excessive thickening of the uterine lining, resulting in more tissue to shed and potentially, a longer period.
However, it’s important to note that other problems may cause a longer period, like hypothyroidism, which is common with endometriosis and low iron levels. I’ll link to my episode on low iron levels and some resources on hypothyroidism in the show notes.
Heavy periods
Similarly, just like the thickening of the uterine lining can cause clotty and prolonged periods, it can also cause heavy periods. But what would be classed as a heavy period?
As a rule of thumb, using more than six to ten regular tampons or pads would be considered heavy, however, the caveat is that this is based on fully soaking these pads and tampons, and so if you’re changing before they’re at that point, you’re probably using a few more than that so just take that into consideration.
The NHS also have some helpful guidance. A medically diagnosed heavy period would be classified as needing to change your period pad or tampon every hour or every two hours, emptying your menstrual cup more than is suggested or requiring two period products like a pad and period knickers.
If you are using a menstrual cup, you could in theory measure how much blood you lose. Losing more than 60ml per period would be indicative of heavy menstrual bleeding, especially when coupled with longer periods, clots or it’s much higher than 60ml. To get more specific, 60-100 ml would be considered moderately heavy and above 100ml would be considered excessive.
Again, just as with long periods, heavy periods could also indicate problems like iron deficiency or bleeding disorders, so don’t just blame oestrogen!
Sore and tender breasts (and even breast cysts)
As we explored last week, as oestrogen is our proliferative hormone, it helps breast tissue to grow and multiply. Additionally, it can influence water retention and cause fluid to be held in our breast tissue and the rest of our body (so yes, another sign of oestrogen dominance would be swelling, puffiness, bloating, etc).
When oestrogen levels are too high or they are not counteracted by progesterone because progesterone is too low in the second half of our cycle, our breasts can become sore and tender due to the increased volume.
Fibroids, endometriosis, adenomyosis and polyps
A sign that you may have oestrogen problems is having one or more of these oestrogen related conditions, this could be especially telling if you had a few, like endo and fibroids.
All of these conditions may be worsened by excessive oestrogen levels. For example, let’s look at polyps. Endometrial polyps are growths that protrude out of the uterine lining, so you can already see why over stimulation of the uterine lining could contribute to their growth. In fact, excessive oestrogen is a risk factor for developing polyps, with oestrogen treatments such as HRT increasing the likeliness of developing them.
Similarly, prolonged exposure to oestrogen can also increase someone’s risk of developing fibroids, and they often shrink when oestrogen levels are low for a duration of time, like after menopause or when on hormonal medications that suppress oestrogen.
As many of you well know, whilst endo and adenomyosis aren’t caused by oestrogen alone, it plays a key role in the pathogenesis (meaning development) of the diseases and can aggravate them when it rises during the cycle.
Does this mean oestrogen is the enemy? Absolutely not. Oestrogen is a really important hormone and as you’re about to learn, too low levels can cause some real problems, but if you want to dive a bit deeper into the benefits of oestrogen, I’ve linked to another episode in the show notes.
Okay, so that wraps up my section on oestrogen dominance signs and symptoms. Let’s look at low levels.
Signs of low oestrogen
Again, there are a number of low oestrogen signs and I’ll link to some great resources in the show notes for you to read more about them, but here are some common ones I see with clients.
Pink and watery periods
As you now know, if you have too much oestrogen, you can have a uterine lining that is too thick, so too can you have a lining that is too thin, in the case of low oestrogen. This can result in period blood that is thin and watery, and pale and light.
If you’re wondering what it should look like usually, we want a thick, syrupy texture that flows easily and is a strong, red colour.
Short periods
Following on from that, if you have low oestrogen levels, you may also have a short period due to the thin uterine lining. Medically, a two-day period is considered normal, but in my training, we tend to prefer to see three days. The first two days are typically the heaviest, and so if it tapers out on the third, that’s okay.
If you have a two-day period and struggle with any of these symptoms, it’s definitely worth getting your oestrogen levels checked. If you’ve always had a two-day period and you have no signs of hormonal imbalances, you’re probably good, but I would check your levels, just in case!
Night sweats
When I was under eating many years ago, night sweats were a frequent problem. I’d wake up dripping with sweat. If this is happening, especially in your follicular phase, it’s a major clue that your oestrogen is low. You might think of night sweats as a perimenopausal symptom and you’d be right, but the reason why it’s a symptom is because it’s caused by low oestrogen and oestrogen drops as we head into menopause.
Whilst the exact mechanism is not fully established, one of the ways low oestrogen can trigger night sweats is because it plays a role in temperature regulation in the body.
In case you’re wondering why my undereating was causing low – if you’re under eating, this stresses the body and the body sees it as an unsafe time to conceive, and so it supresses the reproductive system. Additionally, a huge number of nutrients are required to make hormones and for an efficient menstrual cycle, and so when we’re undereating, we’re normally taking in too little nutrients.
Painful sex
I’m listing this one because I think it’s important to raise that your painful sex may not just be down to endo. Oestrogen is responsible for the healthy thickness of your labia, vagina, etc., as well as the production of cervical fluid. When oestrogen levels are low, it can result in thinning of this tissue as well as vaginal dryness. This can result in the area being more sensitive and more easily damaged and can result in painful sex.
I’ve seen this with a number of clients who have been exposed to long-term oestrogen suppression, such as when on Lupron. With these clients, of course, we have to work on re-establishing healthy hormone levels after Lupron, but often topical oestrogen creams are required to repair the tissue and rebuild the tissue to healthy thickness.
Okay, so as I said, there are a number of other signs of low oestrogen, but today is really about spotting some key signs and learning how to test, so we’re not going to deep dive into every symptom today. As I mentioned earlier, I’ve linked to some further reading in the show notes on these topics.
Testing
Right, now onto testing.
Like we discussed last week, the easiest to access oestrogen test is a blood test from your doctor or a finger prick test you can order directly online. They are both the same test, but the test by your doctor will require a blood draw whereas the ones you can order online allow you to prick your finger and perform the test at home.
If you want to order one directly from a company online, I’ve linked to two I use with clients in the show notes. Remember, these are not affiliate links, I don’t get any commission for recommending them, but I trust their testing and accuracy.
Now, unlike progesterone, we are not testing on Days 19-21, we are ideally testing on Day 3, which is when oestrogen starts to rise.
Sometimes doctors will test near your ovulatory window, which is when oestrogen peaks, but standardly, it’s done on Day 3.
If you’re tested on Day 3, the functional medicine optimal range you’re looking for is 25-75 pg/ml (picograms per millilitre), but less than 80 pg/ml. If your levels are above or below that, it could of course indicate oestrogen excess or low levels.
If you’re testing during ovulation, we’re looking for 150-350 pg/ml.
Now just a reminder, these are optimal levels. In functional medicine, we use ranges based on averages from people with healthy hormone levels, whereas conventional ranges are often based upon population averages that include people with lower or higher levels. So, your doctor may tell you your levels are normal despite having a host of symptoms.
If you need to convert these numbers, I’ve linked to a great site that helps you to convert your oestrogen units because they often vary from country to country.
Now, the problem with this test is, it doesn’t tell you the full picture. Oestrogen can be normal in terms of how much you have, but the problem behind your symptoms may be down to how it’s being broken down by the liver.
When the liver breaks down used up oestrogen, oestrogen can be converted into three different metabolites, which are basically the end product of used up oestrogen. These three metabolites are:
2-Hydroxyestrone (2-OH): This metabolite is the healthier metabolite, based on DUTCH test ratios, we want 60-80% of our oestrogen to end up as this.
4-Hydroxyestrone (4-OH): 4-OH has more oestrogenic properties so can cause more of those oestrogen dominance symptoms I listed earlier. It has been linked to an increased risk of breast cancer and DNA damage. We want no more than 11% of our oestrogen to be converted into 4-Hydroxyestrone.
16α-Hydroxyestrone (16α-OH): This metabolite is proliferative and has been linked to hormonal problems like many of the oestrogen excess issues I shared earlier, as well as breast cancer. We want some of this metabolite as it is protective for bones, but not more than 30%.
You might hear of these metabolites as pathways. So, you may hear me say that we want oestrogen to go down the healthier pathway when it’s metabolised. This means, we want the majority of our oestrogen to be metabolised into 2-OH.
So, how do we test for these metabolites?
Urine testing is the best option. Not only can urine testing tell you what your oestrogen is doing on Day 3 or around ovulation, depending on the type of test you choose, it can tell you what your oestrogen is doing all month long. Last week I told you about the DUTCH test and their Cycle Mapping test, this one would give you a detailed insight into your hormones all month long.
So, first up, you could see what oestrogen is up to in more detail, but you can also see how it’s being broken down by the liver.
It will show you your exact ratios of 2-Hydroxyestrone, 4-Hydroxyestrone and 16α-Hydroxyestrone and will give you what they should be ideally.
But this isn’t the only part of oestrogen metabolism we want to check.
The breakdown of oestrogen into those three metabolites occurs in phase 1 of liver detoxication. The next step is phase 2 and this is when these metabolites are methylated by the COMT enzyme. Now, the process behind this and all of the different things that can go wrong is a bit of a complicated topic and a tangent, so let’s save that for another episode and just say that these metabolites are converted into yet another form which allows them to be removed from the body in bowel movements. However, if this methylation process isn’t working well, these metabolites can get stuck as they are and won’t be removed in bowel movements, so can be reabsorbed and create those signs of hormonal imbalances.
So, the DUTCH test and other urine tests will show you whether that methylation process is happening properly. If it’s not, it could be to do with low B12, folate or a genetic mutation. I recommend listening to my episodes on low folate and B12 to get started on understanding this, and I discuss methylation more there too.
But, there’s one more way oestrogen could end up causing us oestrogen dominance symptoms.
Once oestrogen has gone through phase 1 and 2 of liver metabolism, it heads down to the intestines, where it is removed in daily bowel movements. The problem is, there is an enzyme in our microbiome called beta-glucuronidase. In normal levels, it plays a role in keeping our hormones stable, but if it’s too high, it can actually reactive those ready-to-leave oestrogen metabolites and make them shiny and new again, and recirculate them into the blood stream, creating higher levels of oestrogen. It is common for people with endo to have higher levels of beta-glucuronidase and in fact, it’s been implicated in the development of endo.
So, you can get your beta-glucuronidase levels checked. It won’t tell you exactly what your hormones are doing, but if it’s high, you do want to work with someone to get those levels down. You can supplement with calcium-d-glucarate to lower levels, but the reason why levels got high in the first place is due to a microbiome imbalance in the gut, so you need to work on gut health to keep beta-glucuronidase levels down in the long-term. Additionally, you don’t want to supplement without testing, as you could send your levels too low and actually cause an oestrogen deficiency, because as I said, it helps to keep our hormones balanced.
Finally, last week, for progesterone, we also talked about saliva testing. For oestrogen, I’m afraid I wouldn’t recommend it, if possible, as it may be the least accurate out of all three types of testing for oestrogen, and research suggests the results come out as being lower than they actually are. If you’re mainly interest in progesterone though, it’s a good shout.
In terms of your test results for urine testing, the DUTCH and any other provider or urine testing will provide you with a guide to help understand your results, however, with the DUTCH, it is complicated, so I strongly recommend you have your results reviewed by a practitioner.
Okay, that’s it for this week! If you’ve noticed symptoms of hormonal imbalances but you’d like some help working it out all out, I wanted to let you know I have two one on one coaching spaces becoming available in the next several weeks. I work with endo clients one on one for at least six months to address root causes and reduce pain, gut health problems, chronic fatigue and hormonal imbalances to name a few. If you’re interested in learning more, there’s a link to my coaching page and application for in the show notes.
And remember, if you’re not ready for personalised help or you don’t have the budget for it, I’m still running my Endo Awareness Month Flare Up Prevention Mini Email Course. The link to sign up is in the show notes.
Okay, see you next week!
Show Notes
Oestrogen dominance or excess
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6501471/
https://www.nhs.uk/conditions/fibroids/
https://drbrighten.com/what-causes-heavy-periods-how-to-treat-them-naturally
https://www.theendobellycoach.com/podcast/endometriosis-oestrogen-oestrogen?rq=oestrogen
Low iron/B12/folate
https://www.theendobellycoach.com/podcast/low-folate-endo
https://www.theendobellycoach.com/podcast/low-b12-and-endo
https://www.theendobellycoach.com/podcast/endo-vitamin-d
https://www.theendobellycoach.com/podcast/endo-iron-deficiency
Hypothyroidism
https://www.nhs.uk/conditions/underactive-thyroid-hypothyroidism/symptoms/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10234359/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6601386/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6601386/
Low oestrogenn symptoms
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4890704/
https://drbrighten.com/low-estrogen-signs-and-symptoms/
https://www.health.harvard.edu/womens-health/managing-postmenopausal-vaginal-atrophy
Oestrogen metabolism
https://pubmed.ncbi.nlm.nih.gov/23734165/
https://pubmed.ncbi.nlm.nih.gov/11055622/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4505810/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6731443/
https://www.nhs.uk/conditions/fibroids/
https://www.researchgate.net/publication/274076625_Oestrogen_modulation_in_the_management_of_uterine_fibroids_A_potential_role_for_herbal_medicine
Heavy menstrual bleeding
https://www.nhs.uk/conditions/heavy-periods/
https://pubmed.ncbi.nlm.nih.gov/11704173/
https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-018-0627-8
Blood serum test
https://unitslab.com
DUTCH
https://dutchtest.com
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