For countless women, the word “menopause” is associated with the phrase “low estrogen.” This is the narrative many have been told, the explanation offered when hot flashes strike, sleep becomes elusive or moods swing unpredictably. Conventional medicine largely operates on this premise, with hormone replacement therapy (HRT) frequently prescribed to replenish what is believed to be lost — estrogen.
But what if this long-accepted understanding of menopause isn’t the complete picture? Research is increasingly questioning the singular focus on estrogen deficiency, suggesting instead a more nuanced reality. Studies indicate that estrogen levels in menopausal women aren’t plummeting across the board. In fact, levels are often surprisingly high in certain tissues, even as circulating blood levels suggest otherwise.
This challenges the assumption that simply replacing “lost” estrogen through HRT is an appropriate solution. Indeed, boosting estrogen further, when it’s already abundant in tissues, creates imbalances. It’s important to understand what’s really happening with hormones during menopause, and why a more informed perspective could change how you approach your own health journey.
HRT Use Leads to Significant Estrogen Increase in Fat Tissue
A 2024 study published in The Journal of Clinical Endocrinology & Metabolism sought to understand how HRT affects sex hormones in postmenopausal women.1 Researchers were particularly interested in examining hormone concentrations not just in the bloodstream but also directly within adipose tissue, commonly known as body fat.
• The study involved postmenopausal women with and without HRT — This research involved 63 postmenopausal women, some using oral HRT and others not.
Scientists measured concentrations of key sex hormones like estrone, estradiol, progesterone and testosterone, in both their subcutaneous fat (fat just under the skin) and visceral fat (deeper abdominal fat), as well as in their blood serum. The findings indicated that HRT dramatically elevates estrogen levels specifically within fat tissues while also altering androgen concentrations.
• HRT users showed dramatic increases in estrogen within fat — Women using HRT experienced a fourfold to sevenfold increase in the concentrations of two major estrogens, estrone and estradiol, within both subcutaneous and visceral fat, compared to women not on HRT.
While estrogen soared in fat, testosterone, an androgen hormone, decreased in visceral fat by about 30% in the HRT group compared to the non-HRT group. Although total testosterone levels in the blood remained similar between both groups, the amount of freely circulating testosterone in the blood was lower in the HRT users.
• Estrogen-to-androgen ratios surged in fat tissues with HRT — Further, the researchers calculated the ratios of estrogens to androgens within fat tissue, and the results were striking. In women using HRT, these estrogen-to-androgen ratios were between nine and 12 times higher in subcutaneous fat and four to six times higher in visceral fat when compared to women not using HRT.
• HRT shifted hormone balance to favor estrogen locally in fat — This shift toward estrogen dominance within fat tissue suggests that HRT creates a hormonal environment in fat that’s heavily skewed toward estrogen relative to androgens. Even more granularly, the study noted that in women using HRT, visceral fat had lower concentrations of testosterone compared to women not on HRT.
These findings point toward a significant influence of HRT on what’s called intracrine sex steroid metabolism within adipose tissue. Intracrine metabolism refers to hormone production and action within the cells and tissues themselves, rather than solely relying on hormones circulating in the bloodstream.
The study’s results, particularly the consistently high ratio of estrogen in fat tissue compared to serum even in HRT users, suggest that HRT fundamentally alters how fat tissue processes and metabolizes sex hormones locally.
Menopause Often Involves Estrogen Dominance, Not Deficiency
Georgi Dinkov, a respected expert in metabolic health, provided commentary on The Journal of Clinical Endocrinology & Metabolism study, shifting the focus from estrogen deficiency to estrogen dominance in menopause.2 Dinkov’s analysis emphasizes that looking at hormone ratios, rather than just absolute levels, paints a very different picture of the hormonal landscape during and after menopause.
• Dinkov detailed the hormone levels in women not using HRT (the control group) — Contrary to the common belief that menopausal women are estrogen-deficient, Dinkov points out that the absolute levels of key estrogens — estrone, estradiol and estrone sulfate — measured in these women were not actually low. In fact, their estrogen levels were well within the normal laboratory reference ranges.
• Menopause should not be seen as an estrogen-deficient state — This observation challenges the foundational idea that menopause is fundamentally a condition of estrogen scarcity. Further, hormonal balance isn’t just about the quantity of individual hormones, but about their ratios to one another. In the case of female hormones, the progesterone-to-estrogen ratio is a key indicator of endocrine health.
• For optimal health, this ratio should ideally be quite high, in the range of 200 to 500 — A ratio below 100 is typically considered indicative of estrogen dominance, a state associated with various health problems, including increased risk of hormone-sensitive cancers.3
Upon calculating the progesterone-to-estrogen ratio from the data of the non-HRT group in the study, Dinkov revealed these “healthy” menopausal women already exhibited significant estrogen dominance. In blood serum, the progesterone-to-estrogen ratio was a mere 16. In subcutaneous fat, it was around 20, and in visceral fat, approximately 38.
• Such low ratios would be concerning in premenopausal women — All of these ratios fall well below the optimal range and squarely within the zone of estrogen dominance. Dinkov argues that if these women were premenopausal and presented with such low progesterone-to-estrogen ratios, it would trigger alarm bells, likely leading to a diagnosis of endocrine imbalance and interventions to raise progesterone levels.
Dinkov concludes that the widespread use of estrogenic HRT needs serious reconsideration in light of these findings. If menopausal women already tend toward estrogen dominance — even without HRT—then further increasing estrogen levels with HRT could exacerbate this imbalance, worsening health rather than improving it.
Estrogen’s Double-Edged Sword — Essential Yet Problematic
A comprehensive review published in Biomedicine & Pharmacotherapy highlights the complex role of estrogen in human health.4 Estrogen has a dual nature that’s both necessary for numerous bodily functions and, paradoxically, a driver of disease when its levels are out of balance. In fact, estrogen is far more than just a sex hormone; it’s a key player in overall health and well-being, with effects that span far beyond reproduction.
• Estrogen supports critical body systems but is also disease-linked — Estrogen is involved in maintaining glucose and lipid balance, supporting a robust immune system, ensuring bone strength, promoting cardiovascular health and facilitating healthy brain function. However, the very same estrogen is also implicated in numerous diseases, ranging from infections and autoimmune disorders to metabolic disturbances and degenerative conditions.
• It increases intracellular calcium levels and decreases mitochondrial function — This contradictory nature of estrogen — both life-supporting and harmful — is what the paper calls its “necessary evil” aspect. The point is that both too little and too much estrogen leads to chronic and acute health problems.
• Environmental chemicals increase estrogen dominance — The paper points out that increased exposure to inflammatory agents and endocrine-disrupting chemicals (EDCs) in your daily environment actually increase estrogen levels, or mimic estrogen’s effects, leading to estrogen dominance.
This surge in estrogen, or estrogen-like activity, then overstimulates estrogen receptors throughout your body, causing harm to tissues, increasing the risk of autoimmune diseases and even fueling the development of cancers.
• Rising rates of hormone-related diseases point to imbalance — The authors suggest that the rising rates of conditions like polycystic ovarian syndrome (PCOS), infertility, breast cancer, ovarian cancer and gynecomastia (breast tissue in males) is an indication that estrogen levels are becoming increasingly imbalanced in the population.
Further, because estrogen interacts intricately with many other hormones, enzymes and metabolic pathways, simply manipulating estrogen levels directly — for example, through HRT— often has unintended and complex consequences. The researchers recommend wise dietary choices and consciously minimizing exposure to harmful chemicals in order to naturally restore and maintain estrogen balance.
Taking Control of Your Estrogen Balance
Managing menopause is less about a simple estrogen “top-up” and more about achieving a balanced hormonal environment in your body. Given the understanding that estrogen dominance, not deficiency, is a key issue for many, a strategic approach is essential.
You have significant power to influence your hormone balance through everyday choices, bypassing the need for conventional hormone therapies altogether. Here are several concrete steps you can take right now to naturally support healthy estrogen levels and counter estrogen dominance.
1. Know your prolactin level — Many people believe they’re low in estrogen due to bloodwork, when they actually have high levels in their organs. This is because serum estrogen levels are not representative of estrogen that’s stored in tissues. Estrogen is often low in plasma but high in tissues. Prolactin levels serve as a reliable indicator of estrogen activity, as estrogen directly stimulates your pituitary gland to produce prolactin.
When prolactin levels are elevated, it signals increased estrogen receptor activation, whether from your body’s own estrogen production or environmental exposures to EDCs in microplastics and other pollutants. This relationship is particularly significant when combined with low thyroid function, making prolactin an important marker for identifying hormonal imbalance.
2. Eliminate seed oils in your diet — Processed foods commonly contain seed oils, rich in polyunsaturated fatty acids (PUFAs) like linoleic acid, which mimic estrogen, contributing to estrogen dominance. As a result, PUFAs disrupt hormonal balance and mitochondrial function. Keep your LA intake below 5 grams daily, ideally aiming for less than 2 grams. Use an online nutrition tracker to monitor your intake.
3. Become a conscious consumer of everyday products — Nearly 1,000 everyday items are laced with estrogen-mimicking compounds, including xenoestrogens. These sneaky EDCs are common in microplastics, personal care products and household cleaners.
To minimize your exposure, choose natural and organic personal care products, scrutinizing labels for parabens and phthalates. Swap out conventional cleaners for natural, nontoxic options — vinegar, baking soda and essential oils are safe, simple alternatives.
Importantly, reduce your plastic use, particularly for food and drinks. Favor glass and stainless steel, and don’t heat food in plastic, as heat accelerates the leaching of these estrogenic chemicals into your food. Filter your tap water to remove microplastics and if you buy bottled water, choose glass. If you have hard tap water, boiling it for five minutes before use drastically reduces microplastic content.5
4. Reconsider estrogen-based therapies and contraceptives — Carefully evaluate your use of estrogens in HRT and birth control pills, as they contribute to estrogen dominance. Explore therapies and contraceptive methods that prioritize your body’s natural hormonal equilibrium. Remember, bioidentical estrogen, while often marketed as natural, is still an external estrogen source that contributes to your estrogen load.
5. Consider natural progesterone to counter estrogen — For those reaching perimenopause and menopause, natural progesterone is a particularly helpful consideration. Progesterone acts as a natural antagonist to estrogen, helping to balance its effects. Given the tendency toward estrogen dominance, incorporating natural progesterone helps restore a more balanced hormonal ratio.
Frequently Asked Questions About Estrogen Balance in Menopause
Q: Is menopause really just about low estrogen?
A: While conventional wisdom says menopause is due to estrogen deficiency, recent research indicates that estrogen levels aren’t always low and that many menopausal women actually experience estrogen dominance,6 meaning they have too much estrogen relative to progesterone. This shifts the focus from simply replacing estrogen to achieving overall hormonal balance.
Q: If estrogen isn’t always low, why is HRT so often prescribed?
A: Many people believe they’re low in estrogen due to bloodwork, when they actually have high levels in their organs. This is because estrogen is often low in plasma but high in tissues. Conventional HRT is often prescribed based on this mistaken idea of estrogen deficiency. However, studies show HRT dramatically increases estrogen levels, especially in fat tissue,7 exacerbating estrogen dominance in women who already have it.
Q: What does “estrogen dominance” mean for menopausal women?
A: Estrogen dominance refers to an excess of estrogen. A surge in estrogen, or estrogen-like activity, overstimulates estrogen receptors throughout your body, causing harm to tissues, increasing your risk of autoimmune diseases and even fueling the development of cancers. Excess estrogen also increases intracellular calcium levels and decreases mitochondrial function.
Q: What can I do to avoid estrogen dominance?
A: Lifestyle and dietary changes are powerful tools. Avoid processed foods, as they commonly contain seed oils rich in polyunsaturated fatty acids (PUFAs) like linoleic acid, which mimic estrogen. Also reduce your exposure to synthetic estrogens like oral contraceptives and estrogen-mimicking chemicals in everyday products, including plastics.
Q: Are there any natural options to help balance my hormones during menopause?
A: Yes, there are. Beyond lifestyle and diet, consider discussing natural progesterone with a health care provider knowledgeable in hormone balance. Natural progesterone acts as an estrogen antagonist, helping to restore a healthier progesterone-to-estrogen ratio during perimenopause and menopause.
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