How do you treat hormone imbalances?

Treatment of Hormone Imbalances

The treatment of hormone imbalances depends entirely on which specific hormone system is affected—there is no universal "hormone treatment" protocol. Each endocrine disorder requires targeted replacement or suppression therapy based on laboratory confirmation and clinical presentation.

Primary Adrenal Insufficiency

For primary adrenal insufficiency (PAI), glucocorticoid replacement with hydrocortisone is essential, combined with mineralocorticoid replacement using fludrocortisone. 1

Glucocorticoid Replacement

• Hydrocortisone is the preferred glucocorticoid, typically dosed at 15-25 mg daily in divided doses 1
• Administer in a pattern mimicking physiological cortisol secretion: larger morning dose upon awakening, with smaller doses in early afternoon 1
• Avoid evening doses to prevent sleep disturbances 1

Mineralocorticoid Replacement

• Fludrocortisone 50-200 mcg daily (up to 500 mcg in children, young adults, or third trimester pregnancy) is vital for maintaining blood pressure and electrolyte homeostasis 1
• Take as single morning dose upon awakening 1
• Monitor clinically by assessing salt cravings, orthostatic blood pressure, and peripheral edema 1
• Avoid concurrent use of diuretics, acetazolamide, NSAIDs, liquorice, and grapefruit juice—these interact dangerously with fludrocortisone 1
• Under-replacement is common and may predispose to adrenal crises 1

Adrenal Androgen Replacement in Women

• For women with PAI experiencing persistent low libido or low energy despite optimized glucocorticoid/mineralocorticoid replacement, offer a 6-month trial of DHEA 25 mg daily 1
• Guide dosing by morning serum DHEAS, androstenedione, and testosterone levels (maintain in normal range) 1
• Continue only if clinically effective after 6 months 1
• Use with caution given unknown long-term effects 1

Special Situations in PAI

• During pregnancy, increase hydrocortisone by 2.5-10 mg daily in third trimester; fludrocortisone often requires increase due to progesterone's anti-mineralocorticoid effects 1
• During delivery, give 100 mg hydrocortisone IV bolus, repeat every 6 hours as needed 1
• Double oral dose for 24-48 hours postpartum 1

Hypothyroidism

For hypothyroidism, levothyroxine sodium is the principal treatment, with dosing guided by TSH monitoring. 1, 2

Adult Dosing

• Starting dose typically 1.6 mcg/kg/day for new-onset overt hypothyroidism 2
• Monitor TSH 6-8 weeks after any dosage change 2
• Once stable, evaluate clinical and biochemical response every 6-12 months 2
• Maintain TSH in normal range for primary hypothyroidism 2
• For secondary/tertiary hypothyroidism, monitor free-T4 and maintain in upper half of normal range 2

Pregnancy Considerations

• Measure TSH and free-T4 immediately upon pregnancy confirmation and each trimester 2
• For pre-existing hypothyroidism, increase levothyroxine by 12.5-25 mcg/day to maintain TSH in trimester-specific range 2
• Monitor TSH every 4 weeks until stable 2
• Reduce to pre-pregnancy dose immediately after delivery; monitor TSH 4-8 weeks postpartum 2

Critical Drug Interactions

• Administer levothyroxine at least 4 hours apart from calcium carbonate, iron supplements, bile acid sequestrants, and ion exchange resins 2
• Proton pump inhibitors, antacids, and sucralfate reduce absorption by decreasing gastric acidity 2
• Phenobarbital and rifampin increase hepatic metabolism, requiring higher doses 2

Monitoring Pitfalls

• Persistent hypothyroidism despite adequate dosing suggests poor absorption, non-compliance, or drug interactions 2
• Levothyroxine has a narrow therapeutic index—both over- and under-treatment cause significant morbidity 2

Iatrogenic Premature Ovarian Insufficiency (Post-Chemotherapy/Radiation)

For post-pubertal adolescents and young women with treatment-induced POI, transdermal 17β-estradiol is the first-line approach when contraception is not required. 1

When Contraception NOT Required

• First choice: Transdermal 17β-estradiol patches releasing 50-100 mcg daily 1
• This approach avoids first-pass hepatic metabolism, reducing cardiovascular risk in cancer survivors who already face elevated cardiovascular risk 1
• Better bone mass accrual profile compared to oral estrogens 1
• Reduces risk of focal nodular hyperplasia (FNH) in liver 1

If Withdrawal Bleeding Accepted

• Second choice: Sequential combined patches—17β-estradiol alone for 2 weeks, then combined 17β-estradiol + progestin for 2 weeks (e.g., 50 mcg estradiol + 10 mcg levonorgestrel) 1
• Alternative: Continuous transdermal 17β-estradiol with oral/vaginal progestin 12-14 days every 28 days (e.g., micronized progesterone 200 mg or medroxyprogesterone 10 mg) 1

If Avoiding Withdrawal Bleeding

• First choice: Combined patches with 17β-estradiol + progestin continuously (e.g., 50 mcg estradiol + 7 mcg levonorgestrel daily) 1
• Second choice: Combined tablets with 17β-estradiol + progestin continuously (e.g., 1-2 mg estradiol + 5 mg dydrogesterone or 2 mg dienogest) 1

When Contraception IS Required

• First choice: 17β-estradiol-based combined oral contraceptives (17β-estradiol + nomegestrol acetate OR 17β-estradiol + dienogest) 1
• Second choice: Ethinylestradiol-based combined oral contraceptives 1

Hyperthyroidism

Treat hyperthyroidism with antithyroid medications (methimazole) or definitive thyroid ablation (radioactive iodine or surgery). 1

• Treatment generally recommended for TSH <0.1 mIU/L or undetectable, particularly with overt Graves disease or nodular thyroid disease 1
• Treatment typically not recommended for TSH 0.1-0.45 mIU/L or when thyroiditis is the cause 1

Elevated DHEA Levels

For confirmed adrenal neoplasms causing elevated DHEA, surgical intervention is first-line treatment. 3

• Laparoscopic adrenalectomy for benign tumors when feasible 3
• Open adrenalectomy for suspected malignancy (size >4-5 cm, irregular margins, heterogeneous appearance) 3
• Medical management with ketoconazole 400-1200 mg/day can inhibit adrenal steroidogenesis for functional DHEA excess 3
• Monitor liver function tests with ketoconazole use 3
• Watch for adrenal insufficiency with high-dose steroid suppression 3

Key Principles Across All Hormone Replacement

• Never initiate hormone therapy without laboratory confirmation of deficiency and identification of the specific hormone system affected 1, 2
• Hormone replacement requires ongoing monitoring with both clinical assessment and laboratory testing 1, 2
• Drug interactions are common and clinically significant—always review medication lists before initiating hormone therapy 1, 2
• Dosing requirements change with physiological stress (surgery, illness, pregnancy) 1, 2
• Contraindications must be ruled out before starting therapy—for example, levothyroxine is contraindicated with uncorrected adrenal insufficiency 2