How do I know if I have a hormone imbalance?

As a women’s health nurse practitioner, I've often heard women say, “I think my hormones are just off," wondering if they're experiencing the symptoms of hormonal imbalance. Hormone levels, such as those pertaining to your thyroid, as well as estrogen, and testosterone (to name a few), are not regularly checked by providers. We typically assume things are working as they should, hormones included. If you are experiencing a problem that may indicate otherwise (irregular menstrual bleeding, nipple discharge, and infertility), pay a visit to your doctor, and provide them with a detailed history of your symptoms (don't forget to let them know if you're on hormonal birth control) and concerns. What hormones do we consider checking when it seems like something might be up? Read on to find out.

The thyroid hormones: thyroid stimulating hormone (aka TSH) and free T4 (fT4)

The thyroid is a small gland in your neck that emits hormones, called TSH (this stimulates the thyroid, and is produced by the pituitary gland) and free T4, that help to regulate your metabolism, amongst other things. An imbalance in the thyroid can also directly impact the production of other hormones, like luteinizing hormone and prolactin (see below), which can cause some irregularities in people with a uterus. So, what symptoms might you experience if your thyroid hormones are a little sluggish? Common symptoms of an underactive thyroid (also called hypothyroidism) are fatigue, feeling cold, weight gain, constipation, dry skin, and irregular periods. What about if you’ve got a thyroid that’s working overtime? Patients with hyperthyroidism often report anxiety, tremors, heart palpitations, feeling hot, sweating, and weight loss, sometimes despite an increased appetite. While I draw thyroid labs fairly often, I don’t regularly see them come back as abnormal. So why check? It’s an easy lab to take and test (just a blood sample) and, if abnormal, a relatively easy issue to treat — sometimes a medication, such as the synthetic hormone levothyroxine, is all you need to get your thyroid hormones back in balance.

Prolactin: a hormone produced in the pituitary gland, responsible for breast milk production

As you may guess, prolactin hormone is elevated in pregnancy (the word "lactate" comes from "lactin" — hello breast milk!), and can be increased with certain medications. Excess prolactin hormone (also called hyperprolactinemia) can present with nipple discharge and changes in periods. Prolactinomas are benign tumors that grow in the pituitary and cause an overproduction of prolactin. They can be removed with surgery or dissolved with medication. If you are experiencing nipple discharge and you’re not currently pregnant or breastfeeding, you should pay your provider a visit for further evaluation.

Androgens: hormones that exist in people with penises, as well as people with vaginas (like testosterone)

Having elevated levels of androgens is referred to as hyperandrogenism, and can present with a few, pretty noticeable, symptoms. Facial hair growth, acne, and menstrual irregularities, as well as insulin resistance, are common. These are symptoms that can often be seen in PCOS (polycystic ovary syndrome), as PCOS does involve above-average androgen production. And what about if your testosterone levels are low? While androgens naturally decline over time in women, an actual disease of low androgens, or androgen deficiency, is very rare.

LH and FSH (luteinizing hormone and follicle stimulating hormone)- hormones produced in the pituitary gland

These two hormones are important players in the regulation of all things gyn-related. Proper LH and FSH levels stimulate the secretion of the hormones progesterone and estrogen. FSH, or follicle stimulating hormone, is responsible for the stimulation of ovarian follicles. Luteinizing hormone, on the other hand, helps to stimulate ovulation. The actual level of these hormones will fluctuate daily, but depending on your age, they should fall within a certain range. If your periods are regular, these hormones are very likely normal. It's good to check in with your doctor, especially if you struggle with irregular periods, or infertility. Elevated FSH levels are commonly seen in menopause and in patients with primary ovarian insufficiency; LH can occasionally be elevated, and FSH low (or on the lower end of normal) in patients with PCOS.

Estradiol - a form of estrogen

Estrogen is typically the hormone that comes to mind when we think “female hormones.” Estrogen is produced in the ovaries, and production of estrogen by the ovaries stops after menopause (or if you have your ovaries removed, or experience primary ovarian insufficiency). And it is, as you may expect, pretty important. That being said, estrogen levels fluctuate throughout the menstrual cycle. Depending on the day, and even the time of day, your “level” will vary. Because of that, random estrogen blood draws are often not performed by providers. This may come as a shock to some people, since estrogen is such a widely-known hormone; but sporadic estrogen draws really don’t give us much information. So where is estrogen testing implemented? Estradiol (a form of estrogen) testing can be done in combination with FSH testing on cycle day 3. Why day 3? This goes back to hormones fluctuating naturally throughout the month. On day 3 of your period, estrogen (specifically estradiol) should be fairly low. This combo of day 3 estradiol and FSH can evaluate for ovarian reserve, or a headcount of the remaining eggs in your ovaries. That being said, aside from fertility concerns, estrogen is often not checked, but if you're concerned about your menstrual cycle (outside of trying to get pregnant), or other health issues, bring it up with your provider. If you’re experiencing abnormal bleeding, vaginal dryness, thinning hair, or hot flashes, you might have low estrogen, which is most often the result of aging. Estrogen dominance, on the other hand, is when you have high levels of estrogen and not enough progesterone, which regulates the menstrual cycle, and maintains pregnancy in its early stages. Decreased sex drive, increased PMS symptoms, irregular periods, and memory loss and are some indicatiosn that you might have estrogen dominance, which can occur naturally, but also can show up if you're on estrogen replacement therapy. Depending on the reason for your estrogen dominance, it can be treated with medication, surgery, or adjustments to your diet.

It’s normal to have fluctuating hormones throughout your menstrual cycle; these natural fluctuations allow for the body to reproduce (or bring you aunt flow!). But the fluctuations can also make checking hormones hard, as levels will often differ depending on the day. If you’re experiencing any new problems, it’s always a good idea to bring them up to your provider. Depending on what you’re experiencing, it may (or may not) warrant some lab work. And if you’re curious about what your hormones can tell you about fertility? Modern Fertility offers testing for these hormones at-home, without a visit to your doctor’s office

Kara Earthman

Kara Earthman is a Women's Health Nurse Practitioner (WHNP) and writer living and working in Nashville, TN. You can find more of Kara's work on her blog EarthWoman.

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