What can be done to achieve and maintain hormone balance?

Hormone Balance: Evidence-Based Approach

What "Hormone Balance" Actually Means

The concept of "hormone balance" as promoted in popular literature lacks scientific validity and represents an unachievable biological state that reflects commercial rather than medical objectives. 1 The term has semantic flexibility that can signify the opposite of harmony and moderation, making it a problematic framework for clinical decision-making. 1

Legitimate Hormone Replacement Scenarios

For Specific Endocrine Deficiencies

Hormone replacement is medically indicated only for documented deficiencies in specific clinical contexts:

Primary Adrenal Insufficiency

• Hydrocortisone 15-20 mg daily in divided doses (typically 10 mg upon awakening, 5 mg at lunch) is the preferred glucocorticoid replacement. 2
• Fludrocortisone 0.05-0.1 mg daily taken upon awakening for mineralocorticoid replacement 2
• DHEA 10-50 mg daily (typically 25 mg) may be considered for women with persistent low libido/energy despite optimized glucocorticoid and mineralocorticoid replacement, though evidence of benefit is limited 2

Hypothyroidism

• Levothyroxine dosing should normalize TSH levels, with monitoring at 6-8 weeks after dosage changes 3
• In adults with primary hypothyroidism, evaluate clinical and biochemical response every 6-12 months once stable 3

Testosterone Deficiency in Men

• Testosterone therapy should target total testosterone levels in the middle tertile of normal range (450-600 ng/dL) using minimal necessary dosing. 2
• All men should receive counseling on lifestyle modifications (weight loss, increased physical activity) as primary treatment strategy 2
• Testosterone therapy should not be commenced for 3-6 months following cardiovascular events 2
• Never prescribe to men actively trying to conceive, as it interrupts spermatogenesis 2

Premature Ovarian Insufficiency

• 17β-estradiol administered transdermally (patches releasing 50-100 μg daily) is first-line treatment for post-pubertal adolescents/young adults with chemotherapy or radiation-induced POI. 2
• Add progestin (micronized progesterone 200 mg or medroxyprogesterone 10 mg) for 12-14 days every 28 days for endometrial protection 2
• Continue until average age of natural menopause (45-55 years) 2

Menopause Symptoms

• Menopausal hormone therapy is the most effective treatment for vasomotor symptoms in women under age 60 or within 10 years of menopause onset. 4
• Benefits may exceed risks for the majority of symptomatic postmenopausal women in this timeframe 4
• Screen for cardiovascular and breast cancer risk before initiating therapy 4

What NOT to Do

Avoid Hormone Replacement for Prevention

• Current evidence does not justify MHT to prevent coronary heart disease, breast cancer, or dementia 4
• Hormone replacement therapy for age-related hormonal decline often results in adverse events that outweigh potential health benefits 5
• Except in specific individual cases with documented deficiencies, hormone replacement is not recommended for aging 5

Critical Pitfalls

• Never use testosterone therapy in men with recent cardiovascular events (within 3-6 months) 2
• Avoid prescribing testosterone to men attempting conception 2
• Do not stop mineralocorticoid replacement to treat essential hypertension in patients with adrenal insufficiency (add vasodilator instead, though dose reduction should be considered) 2
• Never focus solely on weight loss without addressing psychological aspects in conditions like PCOS 6

Evidence-Based Lifestyle Interventions

For Polycystic Ovary Syndrome

Lifestyle interventions should be first-line treatment for all adolescents with PCOS, with multicomponent approaches including diet, exercise, and behavioral strategies. 6

• Aim for 150 minutes/week of moderate intensity physical activity or 75 minutes/week of vigorous intensity activity 6
• Include muscle-strengthening activities on 2 non-consecutive days/week 6
• For weight loss, target energy deficit of 500-750 kcal/day (1,200-1,500 kcal/day total) 6
• Set achievable weight loss goals of 5-10% in those with excess weight 6
• Implement SMART goal setting and self-monitoring 6
• Metformin plus lifestyle modification improves menstrual cyclicity and hyperandrogenism in girls with PCOS and type 2 diabetes 2, 6

For Age-Related Hormonal Changes

Regular aerobic and resistance exercise programs combined with healthy calorically restricted diet favorably affect endocrine and metabolic functions and act as countermeasures to age-related diseases. 5

• These lifestyle modifications are superior to hormone replacement therapy for most aging individuals 5
• Positive lifestyle changes can reverse age-related biochemical and body composition changes that reduce hormone bioavailability 5

When to Refer to Endocrinology

• All patients with documented adrenal insufficiency require early endocrinology consultation for education on stress dosing, emergency injectables, and medical alert identification 2
• Precocious puberty (Tanner 2 breast development before age 8) after measuring LH, FSH, and estradiol levels 2
• Multiple endocrine abnormalities or new hormonal deficiencies 2
• Persistent symptoms despite apparent adequate hormone replacement 3