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Dr. Jerilynn C. Prior, Scientific Director, Centre for Menstrual Cycle and Ovulation Research

Ask Jerilynn |

Baseline Testing and Monitoring Changes

Q: 

I’m 52 years old and skipping periods. I went to my doctor because I can’t sleep, I’m awake sweating and worrying half the night. Plus I feel tired and irritable all day. He says I need hormone replacement.

Now I don’t know what to do. I don’t want to take hormone therapy but I’m desperate to sleep through even one night.

Instead of filling the prescription I’ve been on the Internet, read some recent popular books, and had an appointment with a naturopath. All of these sources of information suggest that I need to have my hormone levels checked before I start any hormones.

When I mentioned saliva tests (that will cost over $90.00 for a set) to my doctor he said I was throwing away my money! And then the expectation is that I’ll get another set done when I’m on hormone therapy and feeling better.

But I still want to know where I’m at before I start altering things. Will saliva tests tell me what I need to know about what’s going on for me?

A: 

Thanks for your question. It’s a good one. And I get asked it a lot by women of all ages—young women, women in perimenopause and women who are menopausal.

I agree with your wish to understand where you're at now so that you can measure your progress. Unfortunately, testing hormones is not going to help you. That is true whether you are testing hormones in blood (ordered by your doctor), in saliva (through an alternate care practitioner) or urine (often as part of a research study).

Hormonal testing is not a good way to learn what you want to know. Why? Blood/saliva/urine tests for estrogen and progesterone not very helpful for at least four reasons:

  1. Estrogen levels, and in fact the levels of most hormones, are pulsatile. That means that they have times when they are higher and times when they are lower. (This is because the stimulus for their production originates in the brain that sends messages as bursts of nerve activity—this translates into pulses of hormones). Almost all hormones change from hour to hour and can more than double over that short time.
  2. Normal hormone levels for perimenopausal women are not well defined so the lab won’t be able to tell you whether or not your levels are normal. For menopausal women, estrogen and progesterone levels are normally very low—in fact standard laboratory tests can’t reliably even measure estrogen.
  3. Some common estrogen and progestin hormonal therapies (like conjugated equine estrogen, or Premarin, and like medroxyprogesterone or Provera) are not measured by standard blood tests (or urine or saliva). That’s because they are horse estrogens or are synthesized and not the same as your own hormones.
  4. Even if you use bio-identical estradiol or combined estradiol/estrone/estriol (TriEst) or oral micronized progesterone (compounded in olive oil or as Prometrium) therapy, doctors and laboratories have no clear understanding of what levels are normal for women in different life stages, much less knowledge of what levels will cause improvements in how you feel.

All of that sounds rather discouraging. However, I love to keep track of things myself. And I really want you to monitor and learn about yourself. At the very least it is important to track things because each of us is different and may respond differently to the same therapies.

So I have a more reliable way for you to monitor—and it doesn’t cost anything!

Phases of PerimenopauseFirst, I know from what you’ve told me, that you are in perimenopause, probably Phase D. That means that you may still have very high levels of estrogen but they are also low-normal or even low for some of the time now. By keeping the Daily Perimenopause Diary you can know when your estrogen levels are dropping (from high to normal or normal to low) because you will be getting night sweats. When the night sweats are better and you start to notice stretchy vaginal mucus or breast tenderness, you will know that your estrogen levels are rising to normal or high. Front of the breast soreness is a better indicator of high estrogen levels than a whole bunch of blood tests!

It is quite easy to keep the Daily Perimenopause Diary. Although the Diary implies a cycle and normally starts at the first day of flow (day 1), given that you’ve skipped a period, use the “Cycle Day” to mean the day of the month. At night before you go to bed, just take a couple of moments to score everything you experienced during the past night and the current day.

For example, if you start monitoring on the 17th of April, you’d fill it in like this:

Example of how to start filling in your Daily Perimenopause Diary

If you kept monitoring you’d likely know when you were going to get your next period because you’d notice changes like this:

Perimenopause diary showing increased breast tenderness and mucus secretions

I suggest that you ask your doctor for a prescription for oral micronized progesterone (either as progesterone compounded in olive oil or Prometrium in a dose of 300 mg at bedtime). Then if you started taking oral micronized progesterone, which is what I would recommend for you, you could monitor changes that would likely be like this:

Perimenopause Diary showing decreasing hot flushes with oral micronized progesterone therapy

Notice that I wrote down minutes of exercise (could be walking the dog, yoga, weights at the gym or whatever you prefer). That is helpful for keeping you on track—and the exercise is helpful for night sweats, will cause you to sleep better and to feel less irritable.

The other thing good about using the Diary for monitoring is that you can keep your records and review them one day. This allows you to see progress. Even very subtle improvements you might not perceive.

Because progesterone taken by mouth significantly improves deep sleep, you’ll also immediately start noticing improvements in your sleep. Most women experience this kind of amazing “side effect” of oral micronized progesterone. Even if you still wake, you’ll find it easier to fall asleep again. Unfortunately, although progesterone compounded as cream (20 mg twice a day) significantly improves hot flushes in menopausal women, we don’t have any studies showing it is good treatment for perimenopausal hot flushes. And it doesn’t help sleep.

Perimenopause diary showing decreased sleep problems

When you’ve been one year without a period (or two years if you decide to take 300 mg of progesterone every day), you will graduate to the Daily Menopause Diary!

One day, when you’ve been without day or nighttime hot flushes for at least six months, try stopping the progesterone to see whether the night sweats have gone away. If they start again, then just go back on the progesterone for another year before trying to stop again.

I guess you get the picture—laboratory hormone levels are not helpful. But you can monitor yourself using the Daily Perimenopause Diary and learn far more about what is going on for you.

Hope this is helpful.

All the best,

Jerilynn C Prior MD FRCPC

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