Why Do Women Need Estrogen?

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Estradiol prevents vascular disease, heart disease, stroke, and arrhythmias.

Today, women are very legitimately concerned about the risk of breast cancer. They regularly ask Drs. Maupin and Sullivan to just give them replacement testosterone and not give them estrogen because of this fear. What these women do not realize is that Estradiol does not cause breast cancer, and that Estradiol provides many benefits that lower their risk of other more common and dangerous diseases. Women should receive both estradiol and testosterone after menopause to receive the healthy benefits of both hormones as long as they live. The fear of breast cancer comes from outdated, faulty studies has been unfounded and has caused many women to miss out on the healthy benefits they could receive from replacing their Estradiol. Medicine has finally accepted that taking estrogen is safe for women, yet many doctors have not updated their recommendations since medical school.  There is no need to be in fear of taking estradiol, and it is important to understand why women need Estradiol replaced after menopause.


  1. Estradiol prevents vascular disease: heart disease, stroke and arrhythmias.

An article in Menopause 2017 reviews the importance of estrogen in preventing heart disease. Estradiol is the hormone that keeps the lining of our arteries free of plaque and keeps our arteries supple. Estradiol also stimulates the production of Nitric Oxide (NO) which allows our blood vessels to dilate when we need them to like when our bodies are preparing for sex, or when we exercise. These three actions of estradiol keep our cardiovascular systems healthy and prevent the diseases of aging, stroke, heart disease and heart arrhythmias. Estradiol is one advantage we have over men in regard to lowering our risk of cardio-vascular disease. Women have a lower risk of heart disease than men when we are pre-menopausal, but the risk soars when we become menopausal and do not replace estradiol!

This particular study correlated hot flashes with loss of estrogen. They found that women with the worst hot flashes (and the lowest estradiol levels in menopause), had the highest risk of heart disease after menopause. The underlying science behind this truth is as follows: when a woman loses the ability to make estradiol, her pituitary gland reacts by sending out higher and higher concentrations of FSH (Follicle Stimulating Hormone) which sends the message to the ovary to make more estradiol. After menopause the ovary cannot respond with more estradiol production so the FSH level continues to increase above 23MIU, then the pituitary gland responds to these surges of FSH with an earthquake-like-reaction that surges neurotransmitters through the brain, causing the heat and anxiety centers of the brain to surge with. The lower the estradiol, the higher the FSH level, and the more severely the brain reacts to the FSH surge with heat, sweating and anxiety, and sometimes with a sympathetic surge in heart rate and even arrhythmias.

In short, the more you need estradiol, the more severely you will feel the effects of FSH surges. Hot flashes, anxiety, sweating, sweating, arrhythmias and insomnia. These signs are not to be ignored. They will eventually result in disease and damage to the female body. Should you get these surges and symptoms, recognize that your body is crying for help, and get estradiol replacements appropriately.

Now we know that lack of estrogen causes damage to our bodies beyond just the symptoms from high FSH surges called hot flashes, we also know that it can cause heart disease hardening of arteries and hypertension.

Estradiol depletion also causes pre-diabetes and insulin resistance, atrophy of the vagina and the vulva, make having sex impossible, the drying up of sweat glands in the groin and vagina drying up lubrication, drying and wrinkling of the skin, frontal hair loss, sagging skin, and increases the risk of brain shrinkage causing Alzheimer’s disease and other dementias.

If estradiol is replaced in a high enough dose these outcomes will be averted. The study done on women taking bio-identical estradiol non-orally prolonged the time before women got Dementia by ten years. If you think about it, if your lifestyle and genetics put you at risk for dementia, adding estradiol will give you 10 more years of productive life. For example, if you were designed to have dementia at 80 then the use of estradiol after menopause would defer the onset of dementia until 90. As an aside, the use of T pellets adds another 10 years to the onset of dementia, so you would not get dementia until you were 100.

What is the goal dose and blood level with estradiol after menopause?

Many women come to Dr. Maupin already on oral estrogen, or nothing at all, because their doctors do not “believe in hormone replacement”.  Hormone replacement is not something to believe in, it is a fact that before menopause women have estradiol and testosterone circulating in their bodies, and after menopause they have nothing. Replacing estradiol is just giving women back what they once had and what they desperately need all their lives.

The safety of estradiol depends on WHAT KIND of estrogen you take, HOW you take it (oral, patch, vaginal, or pellet) and the metabolism of the woman who takes it.  Let’s look at the problems with oral preparations of estrogen. These oral preparations are made from pregnant horse urine (Premarin®) or made in the lab from chemicals. The horse urine estrogen is composed of 17   kinds of estrogen that are specific for horses and are not the same as human estradiol, and they are taken orally so they are converted in the liver into estrone (old lady estrogen) which stimulates the breasts and increases fat and belly fat. Premarin is definitely not bio-identical to human estradiol, so women don’t feel the same as they did when they were young. The conversion of oral estrogens in to estrone leaves less pure E2 to do the work of protecting a woman’s heart, blood vessels, vagina and bladder. The oral preparations also put women at risk for blood clots by stimulating the production of clotting factors from the liver as the estrogens have the first pass effect through the liver.

Non-oral preparations like patches are a better delivery system because they do not cause blood clots, however, the blood level never gets high enough to shut down FSH and LH surges that cause hot flashes. Patches have the additional problem of coming off in the shower or bath or in the pool and it is hard to get replacement patches when that happens and insurance won’t give you more, so women may have to do without, or pay a fortune to get an extra patch.  These are just some of the reasons Dr. Maupin stopped prescribing oral Premarin®, Estrace® pills and estrogen patches, and only prescribes chooses bio-identical estradiol pellets to replace the estrogen in her female patients.

When prescribing bio-identical estradiol pellets every 4 months for her patients, her goal for estradiol blood levels is the same range as a woman produces during her fertile years and is individualized to each patient. She adjusts the dose to stop all hot flashes, stop painful intercourse and a dry vagina and create an environment that makes women feel like they did when they were young.   Everyone is different so she tries to find the perfect dose for the individual. She looks not just at the numbers but adjust the dose to resolve all symptoms of low estradiol (menopause):

Hot flashes, dry skin, dry vagina, painful intercourse, dry mouth and other mucous membranes, anxiety and poor memory are what she is looking to resolve. She finds the blood level that is associated with the disappearance of all of these symptoms, and the level that corresponds with physiologic blood levels of E2 for the individual and adjusts the dose accordingly.  If all of the symptoms and blood levels are normal, the last thing she looks at is if the dose of estradiol is enough to normalize the FSH and LH to <23 and <10 respectively. When all of these goals are met, the maintenance dose of Estradiol that a woman will get every 4 months in her pellets is secured!

Are there women who cannot take Estrogen?

Yes, it is true. Some women who have had blood clots, who have estrogen positive breast cancer and those who have a genetic mutation called COMT2 shouldn’t take certain types of estrogen or any estrogen at all.  For those women we often give women testosterone without estrogen, but it is not a frequent occurrence.  We prefer to give both hormones in most women because the two hormones combined make women feel “normal” again.  We don’t give oral estradiol if a woman has a genetic risk for blood clots that is made worse with estradiol even though this delivery system of estrogen doesn’t increase the risk of having another blood clot. Women who have had E2 receptor positive breast cancer who have had cancer spread outside the breast and have not had a mastectomy are not candidates for estradiol replacement, but we can give testosterone pellets which makes life more livable for those breast cancer patients.  Some women don’t have the ability to remove estrogen from their body because of a genetic mutation called COMT2.  If these women take any estrogen, they recycle it over and over but can’t remove it.  For these women, we only give them testosterone and the small amount of E2 and E1 that is made from their testosterone is enough to prevent the symptoms of menopause.

Are there symptoms of Estrogen depletion that are not typical of Menopause, or any other low estrogen state, but that get better with estrogen replacement?

There are other symptoms of E2 depletion that are rarely recognized and should be discussed with your physician:

  1. Vulvodynia
  2. Bladder incontinence
  3. Chronic bladder infections
  4. Painful intercourse
  5. Chronic vaginal infections.
  6. Very thin vulvar skin the cracks and tears with intercourse
  7. Shrinking of the vaginal opening

These symptoms can also be found in young women who are on low dose birth control pills. Simply increasing the dose of estrogen in the pill or menopausal estrogen in pellets, pills or patches should cure these problems.  These symptoms can also be treated with a combination estradiol and testosterone cream that can be directly to the vulvar area if they cannot take any other form of estradiol (like breast cancer patients).

If your doctor doesn’t fix these problems with hormones, then find someone who is expert in estradiol and testosterone replacement to help you.  This is not rocket-science, but many doctors don’t understand that these symptoms/conditions can be simply treated with these two essential female hormones.


This Health cast was written and presented by Dr. Kathy Maupin, M.D., Bio-identical Hormone Replacement Expert and Author, with Brett Newcomb, MA., LPC., Family Counselor, Presenter and Author. www.BioBalanceHealth.com

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