Everything you need to know about Hormone Replacement Therapy

By Kim Crawford, M.D. Last updated: September 6, 2018

How to tell if you have a Hormonal Imbalance

A hormonal imbalance is having too much or too little of any of the myriad of hormones I’ll be discussing in this article. Out-of-whack hormone levels can cause just about any symptom imaginable. You can have weight gain or weight loss, hair loss or excess hair growth. You can become lazy or anxious, sleep too much, or have insomnia! It’s no wonder people scratch their heads trying to self-diagnose. When you receive a diagnosis, you often don’t receive a full explanation, right? Bottom line: If you think you need hormone replacement therapy, seek a Physician who specializes in hormone replacement. To begin, let’s define “hormones.”

What are Hormones?

Hormones are the body’s “chemical messengers” which transport information from the brain to the “target glands” and then the target glands secrete their hormones to then affect their target cells.

Next, the cells send their messengers back to the brain to regulate how much message the brain needs to continue or not continue sending. Our bodies contain about 60 trillion cells which must communicate with each other to carry out hormonally based functions. For hormones to be in balance, everything needs to work together; much like a symphony orchestra.

Hormones enter the cells through receptor sites. This can be thought of as akin to a key unlocking a door. Once inside, they flip the switches that control growth, development, and mental and physical functions all throughout life.

As we age, the hormones that work to keep us healthy begin to decline. Hormonal balance is lost, causing unwanted symptoms, disorders and even diseases. In other words, the hormonal symphony plays out of tune and out of cadence.

The A-Z of Where Hormones are Made
  • Adrenals: Produces the hormones that control sex drive and the stress hormone cortisol, as well as the hormone that controls salt and fluid in the body; aldosterone. DHEA is produced here too.
  • Hypothalamus: Responsible for body temperature, hunger, moods and the release of hormones from other glands. Controls thirst, sleep and is the “master supervisor” endocrine gland.
  • Ovaries: Secrete estrogen, testosterone, and progesterone, the female sex hormones.
  • Pituitary: The other “master control gland,” which controls other glands and makes the hormones that trigger growth. This is what happens in the anterior pituitary. The posterior pituitary produces ADH; controlling thirst and urination. It also provides endorphins.
  • Pancreas: Produces the insulin that helps control blood sugar levels. Glucagon is secreted here too.
  • Parathyroid: Controls the amount of calcium in the body.
  • Pineal: Produces derivatives of melatonin, which affects sleep and more.
  • Testes: Produces the male sex hormone, testosterone, and produces sperm; obviously in males.
  • Thyroid: Produces hormones associated with metabolism.
  • Thymus: Plays a role in the function of the immune system and the maturity of the thymus, and is the primary source for immune “fighter” T-cells early in life.

Hormone Replacement Therapy “Done Right”

A little known but important fact about hormone replacement is there are two types of hormones available for hormone replacement therapy: Bioidentical hormones and Synthetic hormones. This is important because of side effects.

Bioidentical hormones are made from natural substances using a compounding process that results in an exact biological replica of the substance produced by our bodies. This is why they do not produce undesirable side effects when administered properly.

In contrast, synthetic hormones are synthesized from a variety of chemicals and, although these molecules resemble those produced by our bodies, they are not biologically identical replicas. As a result, their use can result in severe side effects, as evidenced not only by the warnings on the labels but as shown by research and clinical studies as well.

Furthermore, in addition to avoiding the risk of side effects and thus being safe, bioidenticals have been shown by most clinical studies to be protective when administered properly. Meanwhile, the latest studies are refuting prior claims that synthetic and bioidentical hormones are “the same.”

I did specify “when administered properly” because hormone replacement therapy is a complex and delicate balancing act that needs to be individually tailored to each patient, often requiring a combination of hormones in conjunction with other mitigating “integratives.”

This can only be accomplished by a physician who has specialized in this field. Unfortunately, too many physicians claim to be qualified after attending a few weekend seminars and the use of synthetic hormones is widespread. My advice is to do research and ask the right questions before choosing a genuinely “qualified” hormone replacement therapy physician.

Now, let’s see if you need to have your hormones manipulated.

Do you have Hormone Imbalance Symptoms?

I receive new patient inquiries all of the time via email, with complaints listed such as decreased energy, sleep disruption, and reduced libido. This is usually (at least partially) due to an imbalance (usually too little; not too much) of one or more hormones. However, to determine what the problems are, I have to “think through” every hormone system as well as every organ system—tying everything together as in the symphony metaphor I used above. Rather than explain why you can’t self-diagnose your own hormonal imbalance issue or issues, below you’ll find a synopsis of hormone function. This will prepare you to ask the right questions when you see a specialist.

What the heck is Aldosterone?

Most of you have never heard of this hormone even though it plays an important role in cardiovascular health. The adrenal glands produce aldosterone. Aldosterone affects the body’s ability to regulate blood pressure. It sends the signal to the kidneys to increase or decrease the amount of sodium (salt) the body sends into the bloodstream or the amount of potassium excreted in the urine. Indirectly, aldosterone also helps maintain the blood’s pH and electrolyte levels.

Aldosterone is closely linked to two other hormones: renin and angiotensin—which is basically how your body uses the kidneys to regulate your blood pressure. When these three hormones are “out of whack” your blood pressure can go up.

Anti-Diuretic Hormone (ADH)

This hormone is secreted by the posterior pituitary gland to work in conjunction with the kidneys; regulating what is called the osmolarity of your blood. Osmolarity is basically how much your blood and urine gets concentrated as it passes through the kidneys. People with biotoxin illness (mold and Lyme) often have low ADH issues, as do people with a history of head trauma. The symptoms are excessive thirst and urination—the same symptoms we associate with the onset of diabetes.


Calcitonin is a hormone released by the C-cells in the thyroid gland. It opposes the action of the parathyroid hormone, which you’ll read about further down our list. Both hormones regulate the blood’s calcium and phosphate levels. While it can be used to treat severe osteoporosis, I choose to use the Parathyroid hormone, instead. Calcitonin is also used to treat Paget’s disease of the bone.


You have heard about the fight or flight hormones cortisol and adrenaline, right? Cortisol increases under stress which is a good thing for your body in the short-term. However, long-term high cortisol levels can lead to increased coronary placquing, a depressed immune system with its associated risks for an increased risk of cancer and measurably impaired brain function, just for starters! In the intermediate term, high cortisol levels can zap your energy by interfering with mitochondrial function. It can make you feel fatigued, and it’s not just because high cortisol levels interfere with regular sleep patterns.

Cortisol causes symptoms I’ll call “annoyances” only because that is how individuals tend to treat them. High cortisol can trigger sugar cravings. If you are trying to build muscle it does just the opposite, being what is called “catabolic.” It not only can decrease muscle mass, but it also reduces bone mass and can slow down your metabolic rate too. Lastly and disastrously, it can trigger leaky gut syndrome. This is the only hormone that actually (for the most part) increases as we age.

It is necessary to bring cortisol levels down for people under constant stress and most individuals over 55 years of age and older for all of the reasons mentioned above. I usually do this with a combination of herbal adrenal fatigue supplements as well as an adrenal glandular preparation. This is the one “hormone arena” where people who read about HPA axis dysfunction (popularly termed adrenal fatigue) can generally self-diagnose much of the time. Please note that if you self-diagnose and supplement and do not get better within a couple of months, you need a medical workup.

DHEA (Dehydroepiandrosterone)

I don’t know why this hormone gets a weird “rap”—for instance, it’s linked to anabolic steroids. This wonderful hormone is either not-well-known or is unfairly demonized, in my opinion. DHEA will amp up your immune system a little and help calm inflammation. Studies show seniors with good DHEA levels have less depression than those with low levels. Lastly, it’s super important for bone thickness and prevention of osteoporosis. You wouldn’t detect a DHEA hormone imbalance or deficiency which is why everyone needs key hormones checked as they age. Recent “brain studies” show that DHEA causes brain stem cell stimulation which is another reason I insist all patients have this hormone normalized.

This is another hormone which is safe to take unless you are a male who has had a “male cancer” or a female who has had either a “female cancer” or PCOS. DHEA metabolites might be a problem. But, you can safely take the 7-keto form of DHEA which has the added benefit of being a bit of a metabolic stimulant.

Since when is Vitamin D a hormone?

Vitamin D is a pro-hormone the kidneys produce which helps control blood calcium concentration and immune system function. The amount of Vitamin D made when sunlight hits the skin and then is converted to the active substance called calcitriol by the kidneys is insufficient for the vast majority of people. Recent studies reveal many cancers are linked to low vitamin D levels.

A low vitamin D level is also related to other issues such as heart disease, autoimmune disease, and even depression. This loosely translates into about 5000 IU’s per day of vitamin D which should be consumed with vitamin K for optimal absorption. This is another lab test that should be checked (at least) annually. Recent guidelines recommend levels of 50-75 ng/dl as ideal. If you have an autoimmune disease, the literature is trending to higher vitamin D levels as optimal.


Estrogen is responsible for the development of “female pubertal changes.” I would say the majority of women who contact me for Skype or Phone consults are interested in what to do when they have symptoms of estrogen deficiency due to menopause.

If you have gained the “menopause 25” it is due to an imbalance of several hormones, including a deficiency of estrogen. Losing the menopause weight without bioidentical hormone replacement is hard. Poorly done estrogen replacement (and yes, I have seen this) causes weight gain. Estrogen replacement, along with replacement of other hormones and balancing of cortisol levels makes weight loss quite a bit easier. Estrogen counters most of the signs and symptoms women refer to as the side effects of menopause.

However, that’s not the only reason to replace your missing estrogen. Estrogen helps your heart, bones, skin, and brain. I don’t know why “length of treatment” remains a controversial topic—likely because synthetic hormones which are dangerous, has clouded the collective thinking on bioidenticals.

Note: I won’t discuss PCOS which is a hormonal disorder at the cause of many cases of infertility.


This hormone is secreted by the pancreas and directly impacts the liver to control blood sugar levels. Glucagon prevents blood glucose levels from dropping to dangerously low levels. It does this first by stimulating the conversion of stored glycogen to glucose in the liver. It also keeps the liver from consuming glucose. This allows more glucose to enter the bloodstream when needed. Lastly, glucagon is essential for a process called gluconeogenesis: the production of glucose from amino acids.

HGH (Human Growth Hormone)

This is another hormone which gets “maligned”—likely due to its misuse in professional sports. HGH is necessary for many bodily functions. It helps heal injuries. Remember how quickly a sprained ankle healed when you were younger? That’s due to human growth hormone. A patient of mine, an M.D., had been to several well-known medical “hubs” because he had such fragile skin. He bruised or bled with even a touch from someone else. When he contacted me, he had the lowest HGH markers I have ever seen. Therefore, he had incredibly fragile skin, and that was why he had the problem. Within three months of hormone replacement therapy, his symptoms vanished.

The FDA approves HGH for treating specific problems. The “side effects” are what has made this hormone notorious. It hastens the shedding of body fat and development of lean muscle mass. It increases bone density and improves immune system function, according to most studies. Overall, it gives people a better sense of well-being. In clinical studies, it shows to increase the thickness of the dermis—the layer of skin which contains the building blocks of skin called elastin and collagen. In fact, HGH users report they look younger.

HGH is not to be used in cases of active cancer, as it causes existing tumors to grow. Despite the controversy over whether it does or does not cause cancer, there have been no studies which show that it (de novo) causes cancer. But, I need to emphasize this controlled substance should only be used under FDA guidelines.


The pancreas secretes insulin. Type 1 diabetics have insufficient secretion. It’s an autoimmune disorder, and some cases are reversible. People with Type 2 diabetes have inadequate or unresponsive receptors for glucose uptake. Most individuals with Type 2 diabetes are overweight or obese. The entity most doctors call pre-diabetes is “framed” as having a fasting blood sugar of 99 ng/dL. What is normal blood sugar? Your fasting blood sugar should be 75-85 ng/dL, or you are “glycating.” See the referenced article for details on how to achieve that.

Insulin is responsible for getting blood sugar into all cells. By doing so, it increases muscle mass and fat storage. However, if insulin levels are too high, there is an increased risk of diabetes, heart disease, Alzheimer’s disease and probably cancer. We use insulin as a biomarker for inflammation which is tied to most if not all disease states and aging in general. This is one hormone you want to keep at a nice, low level—around 2-3 uIU/ml. You can get this level down with weight loss, curcumin, omega-3 fatty acids, green tea and toxin removal, if applicable.


Melatonin is one of the most under-rated hormones. Most of us need supplementation by the time we’re 30 to have truly deep, restful and restorative sleep. You can protect your natural melatonin secretion by maintaining a good circadian rhythm which includes blocking blue lighting as the sun sets. There are apps for tablets and phones you can set to dim your screen at sunset, and I suggest that you do so. I recommend slightly higher doses of melatonin than you may be used for patients and family based on research that I find to be exciting. Here is just a sampling of “what else” melatonin can do for your health.

It reduces oxidative stress (free radical damage) thereby decreasing inflammation. Research now shows it also helps block the process which shortens telomeres; meaning it likely effects genetic aging. It further reduces inflammation by reducing pro-inflammatory cytokines.

It augments immune function by increasing CD4 cells and also increases what are known as natural killer cells.

Melatonin helps preserve brain mitochondria, slows age-related cognitive decline, and inhibits beta-amyloid formation in the brain. In addition, an exciting discovery is that we still have stem cells in our brain even as adults. And guess what? Melatonin turns on these stem cells. Due to all of the brain-healthy effects, inexpensive but powerful melatonin makes it to my best brain supplements list.


In women, oxytocin is responsible for signaling contractions of the womb during labor. The hormone stimulates the uterine muscles to contract, so labor begins. Because of this effect, synthetic oxytocin is sometimes used to induce a woman to start labor if she cannot begin naturally. Once the baby is born, oxytocin promotes lactation by moving the milk into the breast. When the baby sucks at the mother’s breast, oxytocin secretion causes the milk to release so the baby can feed.

At the same time, oxytocin releases into the brain to stimulate further oxytocin production. Once the baby stops feeding, the production of the hormone stops until the next feeding. For men, oxytocin function is less important, but it does appear to affect the production of testosterone in the testes.

Recent studies show oxytocin is an important hormone that controls some human behavior and social interaction. Oxytocin triggers the bond between a mother and an infant, and it may also play a role in recognition, sexual arousal, trust and anxiety between partners and friends. It is released when we interact with a loved one, including our dogs; yes, our dogs. A relatively recent study shows you can bond your dog more to you and you to your dog by staring into your dog’s eyes. And there is leftover oxytocin for you to use with your partner, family, and close friends!

Other fascinating research reveals that oxytocin hormone may affect addiction and stress levels. It also helps people overcome sugar habits with varying success. What intrigues me the most is it’s likely mitigating effect on our perception of pain.

Parathyroid Hormone

In the intestines, parathyroid hormone helps with vitamin D metabolism. This allows the body to absorb more of the calcium it digests from food. In the kidneys, the hormone stops the release of calcium through the urine (stones!), while also increasing vitamin D production. This is one of the hormones where excessive amounts are more common than a deficiency when we are younger, but as with every other gland the parathyroid glands can fail as we age.


This is another hormone you might not have heard about but if you’re anxious you’ll certainly want to see if you’re deficient. It helps repair brain and nerve tissue, decreases anxiety, improves sleep quality, improves general well-being and is probably brain-protective too. Self-medication with controlled amounts is generally fine.


Low progesterone complaints are often mistaken for psychological symptoms as all-too-many progesterone-deficient women are handed prescriptions for pharmaceuticals to treat anxiety and depression. Lack of progesterone causes PMDD symptoms, anxiety, irritability, depression and more. Peri-menopausal sleep issues are generally the result of a dip in progesterone—the first female hormone “to go.”

Adding oral progesterone to the nightly regimen helps with sleep initiation and maintenance. I said “oral” because progesterone creams don’t pass the blood-brain barrier. Please check the referenced article for details on low progesterone symptoms and treatment. To point out, pregnenolone can be used as a stop-gap measure in progesterone deficiency because progesterone is a major metabolite of pregnenolone.

Regarding the role of progesterone replacement in menopause, note that the menopausal weight gain referenced in an earlier section is partially due to loss of progesterone.

Lastly, if you are on bioidentical estrogens, you must also be on progesterone; whether or not you have had a hysterectomy. You must protect not just your uterus but also your breasts from “unopposed estrogens.”


Testosterone is the most important of all male hormones. We know what happens in puberty, so we’ll skip that part. In adulthood, testosterone is a major energy hormone for men. It increases bone density and is responsible physically for libido and quite a bit of sexual function. The right amount (not too much) is good for cholesterol levels, and it improves cardiac health.

Bad publicity based on poorly done studies about a year ago has been completely debunked; testosterone doesn’t cause heart disease. If you take it in massive doses, who knows? But that shouldn’t happen. It also prevents prostate enlargement and probably helps prevent prostate cancer. It is neuroprotective and decreases the incidence of Alzheimer’s disease in both men and women. Further, it increases muscle mass and bone density in men and women as well. The testosterone that is available on the black market requires self-diagnosis and a trust that the substances are safe. Please consult a hormone specialist and don’t treat yourself for “low-T.”

Thyroid hormone

The active form of thyroid hormone (T3) is made from the inactive form (T4) which needs an enzyme which requires quite a lot of minerals so make sure you are on a good multi-vitamin-multi-mineral supplement. I often see labwork where the Free T4 is normal, but Free T3 is low; indicating decreased T4 to T3 conversion the majority of the time. Remember, T3 is the active form of thyroid hormone.

T3 increases energy, fat burning and helps control weight. It increases appetite and heart rate. Too little causes chilliness, a loss of the outer 1/3 of eyebrows and a decreased morning basal temperature (below 97.3F). If you are looking to self-diagnose before having lab results, you can measure your morning temperature for a week. If it’s lower than 97.3, chances are you’re hypothyroid—no matter what your lab testing shows. Insist on the proper lab testing. Here’s what to ask for: TSH, FREE T3, FREE T4, reverse T3, TPO antibodies.

Why do Hormones Decline?

Hormonally and physically speaking, your body peaks around the age of 25. We often assume that things like foggy memory, low libido, menopausal weight gain, hair loss, and wrinkles are simply a part of “getting older.” Worst of all, that’s what most doctors think too! But, we can relieve these symptoms with the use of bioidentical hormones.

However, before jumping into hormone replacement therapy, a good workup is necessary to rule out (or diagnose and treat) weight issues, inflammation, tumors, toxins, food allergies, head trauma, leaky gut, silent autoimmune disease, and excessive stress. A great form of natural hormone replacement is to simply repair the underlying cause of the hormonal issue(s). Once these problems are properly addressed, we can assess what truly needs to be replaced. Here are the basics.

In women, the symptoms of hormonal aging often first appear during early menopause (peri-menopause), when estrogen and progesterone levels begin to wane, and then they continue to decline throughout menopause. The hormone imbalance symptoms can begin as early as age 30.

Men usually experience a more gradual loss of hormones; mainly testosterone, and the result is called andropause. Unlike the sudden loss of estrogen that women face during menopause, the gradual loss of testosterone happens over time and is often misdiagnosed or even dismissed as “male mid-life crisis.”

Both men and women usually experience weight gain, loss of energy, sleep disruption and more during this time of life when (understandably!) most divorces occur. To read about the typical progression of hormonal loss by decade, refer to this article for details.


Is Hormone Replacement Therapy Right for You?

In my opinion, most people benefit from vitamin D and melatonin replacement. It’s a good idea to monitor DHEA-S, estrogen, progesterone, thyroid, insulin and testosterone levels once you hit age 30. If you need replacement, I am hoping that by now you’ll “go with” natural hormone replacement and choose bioidenticals. I also hope you will find a specialist who doesn’t replace your primary care doctor but works with him/her. Please save this article to refer to in case you develop symptoms in the future. Check out the “by decade” article in the paragraph above if you’d like more specific information about what happens at your particular age.

Selected References

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