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Female Hormones for Athletes

Female Hormones for Athletes

The purpose of this article is to review the impact of the female hormones on the athletic performance of women. Particular emphasis will be placed on the changes associated with perimenopause, the ten-year period leading up to menopause. I will briefly review the most recent scientific research on estrogen and describe the physiological effects of estrogen and progesterone as they relate to female athletes. The role of the stress hormones will be considered along with the safe and effective natural solutions available, including the newest diagnostic lab tests.

In July 2002 the scientific research community was rocked by the news of the latest long-term study on hormone replacement therapy. A ten-year clinical trial conducted by the National Institutes of Health, studying over 16,000 women, was abruptly halted by a safety monitoring board because the rate of several life threatening diseases among the subjects rose above the agreed upon safety levels. Pulmonary embolism risk (blood clots in the lungs) among these thousands of women had gone up 114%, heart attacks and cardiac death increased 29%, breast cancer rates experienced a 26% rise, and there was a 41% increase in risk of stroke. There were reductions in colon cancer risk and hip fractures that were not significant enough to outweigh the dangers. In an article published in the Journal of the American Medical Association this summer, the researchers concluded: "The risk-benefit profile in this trial is not consistent with the requirements for a viable intervention for primary prevention of chronic diseases."

One might assume the drug being tested, prempro, was new or unfamiliar, but in fact, it is currently used by six million women in the USA, and premarin, the estrogen contained in prempro, has been prescribed widely since the early 1960's. Forty years after its introduction to the USA, premarin, the most widely used form of estrogen, has been determined to be no longer safe. This latest study confirms research conducted over the last thirty years on the benefits and risks of estrogen therapy. Estrogen has now been proven to increase the risk of heart attacks and strokes and does not help to improve
the health of the cardiovascular system as previously thought. Of course, any drug that interferes with the health of the heart and leads to increased clots that block blood
vessels is going to also adversely affect running capability as well.

Yet estrogen itself is neither good nor bad. It is a vital hormone that, when maintained in a natural balance, contributes greatly to women's health and athletic ability. However, research has convincingly shown that there are obvious risks involved with estrogen when taken in high doses for long periods.

Estrogen, quite simply, causes things to grow. Estrogen is responsible for female sexual development at puberty, including development of the reproductive organs and growth of the bones. It plays a role in the development of the female body contours by promoting the laying down of fat in the hips and thighs and the enlargement of the breasts. As part of its role in fertility it has a powerful effect on storage of body fat. In its fertility function estrogen causes the uterine lining to grow and thicken in preparation for a fertilized egg. At the end of the cycle the built up lining is shed as estrogen and progesterone levels drop and bleeding occurs.

The myth promoted by drug company advertising over the last forty years is that estrogen deficiency is the major problem creating female hormone symptoms at menopause. However, in natural medicine we view menopausal symptoms as a sign of overall hormone imbalance in both the ovarian hormones and the hormones that generate stress response produced by the adrenal glands.

Dr. Peter Ellison of Harvard University has pioneered the use of salivary hormone testing. He has found that in industrialized countries women have estrogen levels that are at the high extreme of the world wide levels measured and should be considered abnormal. Dr. Ellison believes these abnormally high levels of estrogen may relate to our current high levels of breast and uterine cancer. In his studies conducted on people from all over the world, he demonstrates a relationship between hormone levels, diet and exercise. An inactive woman who consumes more calories than she uses will have elevated estrogen levels. Dr. Ellison has shown how the tendency of Americans to overeat and under-exercise, reflected in the 61% of the population that is overweight or obese, explains the tendency toward higher estrogen levels.

Moreover, with these initially inflated estrogen levels, as women hit menopause and estrogen production drops, the estrogen levels have farther to fall, and it is the drops in estrogen that trigger symptoms such as hot flashes, night sweats and mood changes. This unexpectedly large fall in estrogen may create the more dramatic symptoms reported by women in advanced western countries compared with their counterparts in less developed countries.

It stands to reason that female runners in the USA have higher physical activity levels and far less obesity than their inactive counterparts. I believe this reflects the underlying physiological reasons why running provides so many psychological benefits to women as they enter menopause. In 1998 the Melpomene Institute conducted a study that observed 625 women runners. The women reported being able to reduce the discomforts of menopause with an increase in physical activity and the more active runners were able to maintain an appropriate weight for their height and age. There are several possible reasons for these findings, including the connection of estrogen with body fat and physical activity, elucidated by Dr. Ellison. Oddly enough, an overweight post-menopausal woman can produce more estrogen from her body fat than a slim pre-menopausal female. At least this one common reason for estrogen dominance, excess body fat, can be easily addressed through running.

Excessive estrogen levels are further promoted by exposure to xenoestrogens, which are chemical compounds found widely in our environment, mostly as byproducts of the petrochemical industry. These toxic compounds in the air and water and exert a powerful estrogen-like effect when they enter the female body. One commonly unrecognized source of xenoestrogens derives from heating plastic food containers or Styrofoam cups in microwaves, which releases xenoestrogens from the plastic into the food or liquid that is consumed. Using glass containers prevents this problem.

There has been much written about xenoestrogens in the area of wildlife biology describing how the reproductive health of many species is being compromised by this type of toxic environmental exposure. We also consume the hormones added to our food supply, further raising estrogen levels. Dr. John R. Lee has provided us with an excellent summary of this problem in his books and has coined the term 'estrogen dominance' to describe this dynamic.


Excessive estrogen has a negative impact on a woman's cardiovascular system. Estrogen promotes blood clots in the lungs, increases the risk of heart attack, contributes to spasms of the blood vessels, increases blood pressure and diminishes the oxygen carrying capacity of the blood. These changes account for part of the increased risk of cardiovascular disease found with estrogen replacement therapy and they create more stress on the heart and blood vessels, impairing athletic ability.

Adequate estrogen is required for healthy functioning, but in excess it creates many problems for runners. Estrogen triggers water and sodium (salt) to enter into your cells, leading to water retention that women experience as bloating and weight gain. As salt filters into cells, excess estrogen promotes the loss of potassium and magnesium, two minerals essential for optimum muscle contraction. Low levels of potassium or magnesium lead to poor muscle function and greater likelihood of cramping during longer runs.

Estrogen use is associated with increased gall bladder problems. Estrogen thickens bile, the substance stored in the gall bladder, resulting in lower absorption of fat-soluble nutrients critical for running because they are involved in energy production and fat- burning metabolism. Estrogen excess also causes loss of zinc from cells and retention of copper. Zinc plays a key role in the repair of soft tissue damaged in training through its role in converting beta-carotene to vitamin A within cells, a step in building the collagen matrix of cartilage and bone.

The imbalance between estrogen and progesterone is further exacerbated by the fact that many women experience lower than optimum progesterone levels. This in combination with estrogen excess leads to a variety of problems. It is the balanced ratio of these two hormones that maintains healthy body functioning; an excess of either can create problems.

Progesterone is the pro-gestational hormone. Its role in fertility is to keep the uterine lining intact when a woman becomes pregnant. Whereas estrogen promotes movement of salt and minerals into cells, progesterone protects the integrity and function of cell membranes, the outside lining of cells. As part of its antagonistic role to estrogen, progesterone is a diuretic. Progesterone increases fat-burning metabolism and has an anti-inflammatory role. It maintains proper cell oxygen levels and importantly protects against the negative effects of estrogen. It is often difficult for women to determine if they are low in progesterone because this can occur even in the course of a monthly period.

Dr. Jerilyn Prior, professor of endocrinology at the University of British Columbia, found that it was common for women athletes to have anovulatory periods (a full menstrual cycle with bleeding, but without ovulation). She also discovered that many women who trained very hard found that their periods stopped. However, when Dr. Prior went to find a control group for her research she discovered that anovulatory cycles in women from there mid thirties to forties were common. This lack of ovulation means a tremendous decline in progesterone will occur, but there is still a menstrual period. Without ovulation there is insufficient progesterone output since progesterone is produced in response to the release of a healthy egg.

Stress also reduces progesterone production by chaining the levels of two other hormones, cortisol and DHEA. When the ratio of cortisol to DHEA shifts due to chronic stress, a phenomenon known as pregnenolone steal occurs wherein progesterone is shunted into the stress hormone pathways, making less progesterone available for its important role in many body functions. The vast majority of women athletes I have worked with find relief from their female hormone symptoms as they correct their cortisol and DHEA ratio.

Progesterone levels are also declining as we eat fewer and fewer of the 5,000 known plants that have progestogenic effects. Our increasing reliance upon grains and decreased consumption of fruits and vegetables contributes to this trend.


Janet Alexander, Dip. P.E., Dip. Tchg, C.H.E.K IV of the Chek Institute in Encinitas, California specializes in developing rehabilitation exercise programs for female athletes. She states, "overtraining, blood sugar control and women's problems with food are the major causes for female hormone imbalances in athletes of all levels." She goes on to say that these three issues all contribute to changes in cortisol and eventually lead to adrenal hormone exhaustion or adrenal burnout. Many women find that their entire female hormone imbalance is corrected with an adrenal hormone program. Some women also require the additional support of natural progesterone. Ms. Alexander goes on to report that many women runners believe being smaller will allow them to run faster, and so they lose excessive amounts of body fat. Estrogen levels can then drop too low and create another host of problems. Again, it is the balanced ratio of the hormones that leads to optimum health and optimum athletic performance.

Over the last twenty years the alternative medicine community has been conducting month long salivary hormone tests and much has been learned from these thousands of cases that is not reported in the more traditional scientific literature.

The most significant observation clinicians have made is that women with adrenal exhaustion due to overtraining, emotional stress or diet problems, will tend to develop deficiencies of progesterone in the second half of the cycle that lead to symptoms of decreased performance. These women with cortisol and DHEA imbalances are prone to develop problems at menopause as the ovarian output of hormones decreases and greater reliance is placed on the sex hormone output of the adrenal glands. When a woman is under chronic stress, cortisol and DHEA production demand rises and there is a subsequent drop in progesterone output as it is used for adrenal hormone production. This leads to hot flashes, night sweats, mood swings, low sex drive and many other symptoms of hormone imbalances..

The key to achieving optimum physical functioning for female athletes and to safely relieve the symptom,s of menopause is to balance the adrenal hormones while establishing an appropriate diet, to eliminate overtraining and to balance progesterone and estrogen levels. Either an excess or deficiency of any of these hormones will create an imbalance. In most cases a woman runner's progesterone/estrogen ratio is altered in such a way that progesterone therapy alone is sufficient to correct the imbalance.

After working with hundreds of women in interpreting these lab tests I have learned to trust a woman's perceptions of her own hormonal cycle and have seen over and over again how accurately a woman can intuit what we see on the monthly lab tests. Estrogen excess is consistently perceived accurately by women as is progesterone deficiency. Many women become frustrated with the standard lab tests for menopause because they do not offer any information other than whether or not menopause has begun yet. There are also few choices in terms of medical treatment outside of estrogen therapy. The month long test panels used by the alternative medical community include a minimum of eleven saliva samples over the course of a month which maps the entire cycle and gives information specific to each woman for the proper natural therapy. For women who have not had their period for several years, single day saliva tests are available to ascertain the levels of estrogen, progesterone, testosterone, cortisol and DHEA.

Once a determination has been made as to the appropriate therapeutic option, there are many delivery systems available for progesterone. Progesterone creams are a popular option now and offer a rapid delivery since the progesterone in the cream is taken up directly by the bloodstream. Still, there are two disadvantages to the creams; one is the difficulty of getting exact dosages each day; the second is that some women build up high progesterone levels with extended use of the creams or with improper dosing. Although this is relatively rare, it can create a variety of hormone levels to rise, including estrogen, which creates estrogen excess, the very problem the woman is trying to avoid.

In my practice I have found progesterone in a tablet taken under the tongue or in liquid form to be the best option for most women. It is the easiest way to get precise doses each day and the progesterone is absorbed directly into the bloodstream. It shares the advantages of the creams with direct delivery into the blood stream, but does not require as much follow-up testing after the initial baseline levels of progesterone are established. This method bypasses the digestive tract and liver and so allows dosages to be far lower than with an oral form, thus preventing unnecessary work for the liver that occurs with oral, higher dose forms of progesterone.

CASE STUDY #1: Helen K.

Helen is a 58 year-old athlete with a long history of hormonal problems that culminated in an hysterectomy after which she was placed on estrogen. She came to my clinic with the following complaints: inability to lose weight despite a restricted diet and heavy training schedule (she had what she called a "tire around the tummy"), back pain and lower extremity joint pain after running and a noticeable decline in running times. During her consultation she reluctantly revealed she was experiencing extreme moodiness and depression after starting estrogen and that the problems were getting progressively worse (she frequently felt like putting an ax in her husband's head!). While it is easy for most of us to reveal our physical complaints to health care practitioners, we often feel less inclined to reveal the psychological disturbances that may be equally significant sources of our stress.

Salivary lab tests revealed her estrogen levels while using hormone replacement therapy were 600% over the acceptable range, and she was not taking any progesterone, so her ratio of progesterone to estrogen disturbed. She needed to lower her estrogen dosage or eliminate it entirely and increase her progesterone levels. It was no wonder she was feeling off balance. Fortunately, after just a few weeks of treatment with natural progesterone and a gradual reduction of estrogen intake, she eliminated the mood swings and reduced the depression dramatically, to the point where she was beginning to feel like herself again. Happily, her husband survived this ordeal became an object of her affection once again, never realizing the danger he was in! Helen also had stage two adrenal exhaustion the correction of which provided the underpinning for maintaining the improvement in her female hormone balance and completely eliminated the depression.

Without the excess water weight and body fat promoted by the estrogen, she returned to her normal weight. The progesterone also provided an anti-inflammatory effect and helped her resolve her musculoskeletal complaints along with a rehabilitation exercise program that was prescribed. Once the adrenal exhaustion was corrected after about six months into the treatment program, her run times were back on track.

CASE STUDY #2: Emily S.

Emily is a 52 year-old runner whose major complaint was a 10-15% reduction in her marathon times in the last year alone. She also suffered from anxiety, inability to sleep, low sex drive, low energy, excess neck and shoulder tension, decreased stamina and the beginnings of osteoporosis. Her run times had begun to decrease in the several years before menopause and the steady decline was troubling her. She was also beginning to experience the onset of fatigue after her longer training runs, rather than the usual pick up in energy she had been accustomed to with exercise. Fatigue after training in a person used to the boost exericise can provide is a key indicator of stress hormone problems. She was evaluated by testing the following hormone levels: progesterone, estrogen, testosterone, cortisol, DHEA and melatonin; all lab assays were taken from saliva samples. A mother of two, she stated that the best she ever felt in her life was when she was pregnant, a comment women frequently make when they are chronically low in progesterone. It was determined that her estrogen levels were normal, but because her progesterone levels were so low, she was experiencing estrogen dominance, as the ratio of the two hormones was abnormal. She also had low cortisol and DHEA levels and low melatonin. In Emily's case we had nowhere to go but up! She was advised to take a specific dose of progesterone to bring her into the right balance between progesterone and estrogen and to undertake a complete nutritional and dietary program to correct her cortisol and DHEA imbalances. She also used melatonin for one month in the evenings, in conjunction with progesterone, to restore her sleep cycle.

Within three nights her sleep and anxiety had improved. Within the first month of the program Emily reported that her sex drive and energy had returned and her neck and shoulder tension had disappeared. In many cases such dramatic improvements have a downside. Her symptoms began to return in the second and third months of her program even though she increased her progesterone dosages. After a follow-up consultation, Emily revealed that due to the immediate changes she had experienced when beginning the program, she let the lifestyle and diet changes lapse. After reiteration of the purpose and importance of the lifestyle component of the program, she got back to the right food regimen, started going to sleep at ten in the evening rather than midnight and by the end of month three was back on track and symptom free. Now one year into her program, she is on a low maintenance dose of progesterone and remains symptom free as long as she carefully controls her blood sugar and avoids extended periods of over-exercise.

Dr. Kalish works with people nationwide through phone consultations. He has designed lab-based nutritional programs to help a wide variety of athletes overcome health problems and achieve optimum performance. Dr. Kalish teaches seminars for health professionals and the public on stress, healthy weight loss and natural female hormone balancing