Case 5: Premenopausal Symptoms


Labrix/Doctor Data Inc specializes in hormone and neurotransmitter balance for males and females. This laboratory uses saliva and urine samples you collect at specific times throughout the day to obtain a full spectrum of hormone/neurotransmitters over the entire 24-hour collection period.  This process offers a more comprehensive evaluation than a single blood sample drawn in a lab.  You collect the samples at home using the kit provided and return them to the laboratory in the enclosed FedEx prepaid mailer.

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A 44-year old perimenopausal real estate agent with complaints of loss of energy, insomnia, irritability, anxiety, stress, thinning skin, mood swings, food cravings, dry hair, brittle nails, and difficulty focusing.  Her other established medical issues include hypertension, obesity, and Type 2 Diabetes.  She does not have any hot flashes or night sweats.

Her 24-hour cortisol  response curve shows a “pancake sign” which is diagnostic of the degree of overall stress. The Cortisol Awakening Response (CAR) test is the only physiological parameter that has been clinically useful to document stress: the emotional response the body has when it encounters any stimulus (physical or mental) that it is not prepared to handle.  Cortisol is the “fight or flight” hormone which prepares the body for stress by increasing energy levels (raises glucose and insulin levels, releases adrenaline, and generates greater central vision acuity).  Under normal circumstances, cortisol is decreased at night and increases rapidly after the optic nerve detects daylight at sunrise. Normally cortisol levels increase >50 from baseline in the first 40 minutes after awakening.  Failure to achieve this level or rise is the indicator we used to measure the perceived level of stress as you face the new day. This patient has a flat (“pancake”) response throughout the 24 hour period, which corresponds to her loss of energy and fatigue. 

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The 2nd page shows her estrogen profile.  Estradiol (E2) is the main form of estrogen in the female and while her E2 is within the reference interval (WRI), it is in the lower part of the reference range (2nd quintile) which is characteristic of women who are approaching menopause.  Her progesterone (dominant hormone of pregnancy which is responsible for calming and differentiation of normal fetal development) opposes the stimulatory effects of estrogen.  A normal P/E2 ratio protects a woman from the stimulatory effects of unopposed estrogen, decreases her risk for female cancers, and dramatically improves the quality of her sleep.

DHEA is the most plentiful hormone (by weight) in the body and is a precursor for other hormones, particularly male and female hormones.  DHEA also helps with aging, depression, osteoporosis, and vaginal atrophy (dryness which can contribute to discomfort with intercourse).  One of its effects is to increase hydration in the skin, and this is helpful in women with this problem.  Women are particularly sensitive to small amounts DHEA and should really take this only under a doctor’s supervision.

At this point in her life, stress reduction and appropriate diet and exercise need to be regularly incorporated into her hectic lifestyle.  Her test shows a relative insufficiency of Progesterone to her E2 level and this is called “Estrogen Dominance,” which really reflects Progesterone insufficiency.  This is because progesterone begins to decline in females at about age 35 and falls to approximately 10% of its normal peak level by age 50.  Estradiol begins to decline at about age 45 and by age 51 it is reduced to 60% of its usual peak values. Unopposed Estrogen can increase the risk for blood clots and certain female cancers.


This situation can be corrected with bio-identical sustained release, micronized Progesterone and a “whiff” of DHEA. As she progresses to full menopausal status, she will require bio-identical Estradiol supplementation in addition to progesterone.  Other considerations such as osteoporosis and decreased libido will respond to minute amounts of Testosterone.  Hormone balancing will also help decrease her risk for atherosclerotic heart disease, cerebrovascular disease, dementia, and urinary incontinence.  Having a prior hysterectomy is not a sufficient reason to forego BHRT (Bioidentical Hormone Replacement Therapy), since the main concentration of these hormone receptor sites ( outside of the genitals) is in the brain, heart, and thyroid; all of which are vital organs to preserve our health and sense of well-being.

Please note: this case summary is just an abbreviated discussion of the intricacies of hormone balance.  Most women today will live well past their 80th birthday and they will want to preserve their unique feminine nature.  This is a discussion you should really have with an experienced physician who can guide you through the process, monitor your response, and treat you as an individual case.  BHRT is not the “be all and end all” of graceful aging and serenity; there is a complex relationship between the gut biome, the endocrine system, and conditioned stress response. Environmental toxic exposure, trace minerals, and essential fatty acids need to be simultaneously addressed.

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