karenmartel

It’s time to shift our approach.

The Problem with Outdated Thinking  

Medicine is an evolving science. What we knew about hormones 30 years ago is vastly different from what we understand today. Yet, many doctors continue to prescribe hormones using the "lowest dose possible to eliminate symptoms and no more" approach. Some even recommend waiting until a woman’s estrogen levels are critically low—often less than five picograms per milliliter—before starting replacement therapy.

This approach is flawed for several reasons:  

• It ignores the global impact of hormones beyond just symptom relief.  
• It dismisses the idea that early intervention can prevent long-term health decline.  
• It fails to recognize that hormones function as a system, not isolated components.  

Instead of micromanaging individual hormones, we should be supporting the body’s natural rhythms—giving it the basic hormonal foundation it needs to function optimally.

The Shift Toward Physiologic Restoration  

A growing wave of experts is advocating for physiologic restoration of hormones, a method that mimics the natural hormonal patterns seen in a woman’s most vibrant, fertile years—her late teens and 20s. These years represent a time of peak health, and fertility itself is a vital sign of female well-being.

Dr. Gersh, a leading expert in women’s health, emphasizes that maintaining hormonal balance similar to this optimal phase of life can have profound benefits on aging, metabolism, and overall vitality.

Power of Hormonal Rhythms: Why 'Low and Slow' Isn’t the Answer  

One of the biggest misconceptions about hormone replacement therapy is the idea that women should receive the lowest possible dose just to eliminate symptoms. But when we look at how hormones naturally function in a healthy, youthful woman, we see a completely different picture—one of rhythm, fluctuation, and dynamic interaction.

Women in their 20s don’t have static, minimal hormone levels. They have fluctuating estrogen, progesterone, and testosterone that rise and fall in a carefully orchestrated dance. This ebb and flow is not random—it plays a crucial role in immune regulation, metabolism, brain health, and even cancer prevention.

Why the Menstrual Cycle Matters for Overall Health  

The menstrual cycle is far more than just a reproductive function—it’s a vital sign of a woman’s overall health. Each phase of the cycle serves a biological purpose, regulating inflammation, immune response, and even cellular repair.

• Low Estrogen = Inflammation  

During menstruation, estrogen (specifically estradiol) is at its lowest. This is actually a pro-inflammatory state, designed to help the body shed the uterine lining and trigger immune cells to clean up old tissue.  

• Estrogen Surge = Anti-Inflammatory  

As estrogen rises in the first half of the cycle, it reduces inflammation—a critical shift that helps support ovulation, immune balance, and even sperm survival. When estrogen peaks before ovulation, it enhances progesterone receptor sensitivity, setting the stage for the second half of the cycle.

• Hormones and Cancer Protection  

The natural ups and downs of estrogen and progesterone regulate tumor suppressor genes like P53, helping the body clear out damaged cells before they turn cancerous. Studies have even shown that women on hormone replacement therapy experience a 30% reduction in multiple types of cancers—a fact that completely contradicts the old fear-based messaging around HRT and breast cancer.

How This Relates to Bioidentical Hormone Therapy  

Physiologic hormone restoration aims to replicate this natural rhythm, rather than just delivering a tiny, static dose of hormones to blunt symptoms. By mimicking the hormonal patterns of youth, we can:  

• Support immune function and reduce chronic inflammation  
• Enhance brain health, sleep, and mood  
• Improve metabolic function and weight regulation  
• Maintain youthful skin, hair, and energy levels  
• Reduce the risk of hormone-related cancers  

This is the opposite of the outdated “low and slow” hormone replacement model. Instead of waiting for a woman to become completely depleted, this approach supports her body in a way that aligns with how hormones are meant to function.

The Need for a Paradigm Shift in Hormone Replacement Therapy  

As we've learned, hormones are more than just messengers. They’re central to the optimal functioning of multiple systems in the body, from immune regulation to metabolic health. The idea of using lowest-dose, one-size-fits-all protocols for hormone replacement misses the mark entirely. The truth is, hormones are not static; they fluctuate in complex rhythms, much like our circadian rhythm or the lunar cycle. These rhythms are essential not only for reproduction but also for optimizing health across all stages of a woman’s life, from menstruation to menopause and beyond.

In order to truly optimize women’s health, we need to shift away from the outdated protocols that reduce hormonal intervention to simply "symptom elimination." Instead, we need to embrace a more holistic, rhythm-based approach that acknowledges the role of hormones in supporting the immune system, metabolism, brain health, and more.

The Role of Estrogen and Other Hormones in Immune and Metabolic Health  

Hormones are intricately involved in upregulating and downregulating other hormones and signaling molecules in the body. For example, estrogen has a profound effect on AMP kinase, a signaling molecule in cells that plays a role in energy production and fat metabolism. This means that estrogen doesn’t just influence reproductive health; it helps your body burn fat, regulate blood sugar, and ensure healthy fat tissue, like adipocytes and their hormones (leptin, adiponectin).

Estrogen’s influence extends into the immune system too, acting as an immunomodulator. It helps turn inflammation on or off depending on the body’s needs. The "lowest dose possible" approach to hormone replacement often ignores this crucial dose-response relationship. Too little estrogen means we miss out on its role in inflammation control, which can have a cascading negative effect on overall health, including increased risk of chronic diseases.

Why We Should Move Beyond the "Lowest Dose" Approach  

At the heart of this outdated protocol is the idea that a low, static dose of hormones will suffice. However, this fails to account for the complexity of hormonal interactions. For example, estradiol, the most bioidentical form of estrogen, plays a vital role in immune function, inflammation resolution, and overall metabolic health. It helps regulate aromatase, an enzyme that converts androgens like testosterone into estradiol in peripheral tissues. This conversion is vital, especially as estradiol works to both ignite and turn off inflammation, promoting tissue repair, immune response, and overall homeostasis.

When women are prescribed only estriol (the weakest form of estrogen), they are often given a fraction of the estradiol they need. Many traditional protocols use estriol in disproportionate amounts, leading to an imbalanced estrogen profile that doesn’t support the body’s need for estradiol. The issue with using predominantly estriol (especially when combined with other estrogens) is that it doesn’t have the same balanced impact on the full spectrum of estrogen receptors, particularly those that modulate immune response and inflammation.

The Consequences of Using Outdated Estrogen Protocols  

Unfortunately, many women on hormone replacement therapy today are given biased protocols (a higher dose of estriol and a lower dose of estradiol), which can contribute to imbalanced estrogen receptor activity. This approach, based on old data from the 1980s, doesn’t take into account the nuanced, interconnected role of hormones in metabolic health, immune function, and cellular repair.

The "low-dose" paradigm has also been connected to a reduced ability to manage inflammation and might even increase chronic disease risk. Additionally, estriol doesn’t provide the same protective benefits against autoimmune conditions, cellular repair, and cancer prevention that estradiol does.

A balanced approach using estradiol helps ensure that hormonal systems work in harmony, supporting optimal metabolism, immune function, and healthful aging.

A New Approach: Comprehensive Hormonal Restoration  

Instead of prescribing minimal doses or mismatched estrogen ratios, we need to focus on restoring hormonal balance that mimics the body’s natural rhythms—one that supports health at every life stage. From perimenopause to postmenopause, our goal should be to maintain healthy estrogen levels that help balance inflammation, metabolism, and immune function. These protocols should be individualized, ensuring that women receive the right types and amounts of hormones that align with their body’s specific needs.

The future of hormone replacement therapy lies in physiologic restoration, which replicates the natural hormonal rhythm that occurs during our most vibrant years. This means giving women the hormonal foundation needed to thrive, without unnecessarily low doses or inappropriate estrogen combinations. By embracing this more nuanced understanding, we can revolutionize HRT and improve women’s health outcomes across the lifespan.