Why are my periods so bad when my oestrogen is normal?

This post goes with episode 5 of The Naturalist Podcast, "Normal oestrogen, awful periods. Why?" Listen here

A normal oestrogen result tells you how much oestrogen is circulating in your blood on the day it was taken. It does not tell you how your body breaks that oestrogen down and clears it, and that is often where heavy, painful periods and premenstrual symptoms come from.

Two women can have almost exactly the same oestrogen result and live completely different months. One has periods that are a little uncomfortable. The other has tender breasts for a week beforehand, feels bloated and flat, and bleeds so heavily she plans her day around being near a bathroom. They have the same number and a very different picture.

Is oestrogen the problem?

Oestrogen has been treated as the villain in women's health for a long time. It isn't. It's one of the most important hormones you have. It builds the lining of your uterus each month and supports your bones, skin, brain and mood.

Oestrogen is a stimulating hormone. Its job is to grow and activate things. That is wonderful in the right amount and the right place. It is also why your body needs a reliable way to switch oestrogen off and move it out once it has done its job. When that clearing process struggles, you can feel very oestrogenic even when your oestrogen level looks normal.

How does your body clear oestrogen?

Clearing oestrogen happens in three stages. I think of it as a journey with three stops.

The first stop is your liver. Here, a family of enzymes called the CYP enzymes attaches a small chemical tag, called a hydroxyl group, to one point on the oestrogen molecule. This step is called hydroxylation. Where the tag lands decides how that oestrogen behaves from then on, and it gives the three routes their names.

• 2-hydroxy: the gentle, protective route. It is much less stimulating on your tissues, and it is the one we want most of your oestrogen to take.

• 4-hydroxy: driven mostly by inflammation. It is more reactive and needs to be neutralised properly, so we want it kept small and well managed.

• 16-hydroxy: very stimulating. It holds onto oestrogen receptors and keeps the signal switched on for longer, so we want it kept in balance.

The second stop is neutralising and packaging. The main step here is methylation, done by an enzyme called COMT. Methylation makes the more reactive 4-hydroxy oestrogen safe and finishes the protective work of the 2-hydroxy route. COMT relies on nutrients such as magnesium, B12 and folate, and stress uses up those same resources.

The third stop is your gut. Packaged oestrogen leaves through your bile and into your bowel. A community of gut bacteria called the estrobolome helps metabolise and clear it. When that community is out of balance, some bacteria make an enzyme called beta-glucuronidase, which unpacks the oestrogen and lets it be absorbed back into your bloodstream. If you are constipated, oestrogen sits in the bowel for longer, which gives that recycling more time to happen.

When all three stops work well, oestrogen comes in, does its job and leaves quietly. When one of them struggles, oestrogen takes a more stimulating route, stays active for longer, or keeps coming back around.

What does poor oestrogen clearance feel like?

• Heavy periods, sometimes with clots

• Painful periods

• Breast tenderness before your period

• Bloating

• Low mood or mood swings before you bleed

• Headaches or migraines around your cycle

• Feeling puffy, heavy and irritable for part of the month

These symptoms are so common that they often get put down to just having bad periods. They are worth understanding rather than putting up with.

A composite from clinic

Let's call her Ella. She is in her early thirties, with heavy bleeding, tender breasts and a low mood before her period. Her blood oestrogen came back in the middle of the range. Her dried urine test told a different story. Most of her oestrogen was going down the stimulating 16-hydroxy route, very little was taking the protective route, and her methylation step wasn't fully neutralising the 4-hydroxy oestrogen. She also only opened her bowels every second or third day. Ella wasn't making too much oestrogen. Her problem was what happened to it afterwards.

Ella is a composite, a pattern I see often rather than one client.

Why doesn't a blood test show this?

A blood test measures hormones while they are in transit. That includes oestrogen that is bound to its carrier protein as well as oestrogen that is free. So even a perfectly timed blood test only shows how much oestrogen is circulating, not where it is going.

There are four reasons this gets missed.

1. It isn't ordered. Oestrogen metabolites aren't part of a standard hormone workup in New Zealand, and a standard blood test can't measure them.

2. The range is wide. Oestradiol rises and falls so much across a cycle that the lab range has to cover every phase. A result that is out of proportion for you can still sit comfortably inside it.

3. Timing. Bloods are often taken on a random day or early in the cycle, when hormones are naturally low. The result can be accurate for that day and still miss the second half of your cycle, where symptoms are often worst.

4. Blood can't measure the journey. The route, the neutralising step and the gut recycling are a different question, and they need a different kind of test.

What is dried urine testing?

When your body breaks oestrogen down, the pieces it makes along the way, called metabolites, leave your body in your urine. A dried urine test measures those metabolites. Instead of measuring the hormone on its way in, it shows what your body has actually done with it.

• A blood test measures hormones circulating at one moment. It doesn't show the three routes, methylation or cortisol across a day.

• A dried urine test (EndoMAP) measures hormones and the metabolites your body makes as it breaks them down. It shows the three routes, methylation, and your cortisol across a day from four samples, and it is collected at home.

The EndoMAP is collected at home on one day. You collect four small urine samples: on waking, two hours later, in the late afternoon and before bed. Each one goes onto a filter-paper strip that dries completely before you post the strips to the lab. For most cycling women it is collected five to seven days after ovulation, confirmed with LH strips or temperature tracking. You don't need to stop hormonal contraception or HRT. The collection is timed around your dose, and that is factored into how the results are read.

Blood and urine testing answer different questions. Blood shows what is travelling around your body. Dried urine testing shows what your body is doing with it. Reading the two together gives the full picture.

Why oestrogen clearance matters for endometriosis, fibroids and adenomyosis

Endometriosis, fibroids and adenomyosis all involve tissue that responds to oestrogen. If more oestrogen takes the stimulating 16-hydroxy route, that signal stays switched on for longer. If the 4-hydroxy route is busy and methylation can't keep up, that adds to inflammation and oxidative stress, which sit at the centre of endometriosis in particular. If your gut is recycling oestrogen, your body deals with the same oestrogen more than once. None of this shows up as a high oestrogen number.

If your periods are heavy, it is also worth knowing that heavy bleeding draws down your iron stores every month. You can read more about that in my post on what a good ferritin level is for women.

What to do with this

1. Find out what was run. Was it a single oestradiol result, and do you know what day of your cycle the blood was taken?

2. Notice your own pattern. Track when your symptoms show up in your cycle, and notice how regularly you open your bowels.

3. Understand why before you take anything. A busy 16-hydroxy route, an overloaded methylation step and a gut that is recycling oestrogen are three different problems. Some supplements sold for "oestrogen detox" lower your overall oestrogen as well as shifting the route. That can help one woman and make things worse for another. Without knowing which route your oestrogen is taking, you are guessing.

Frequently asked questions

Can my oestrogen be normal and still be causing my symptoms?

Yes. A blood test shows how much oestrogen is circulating. It doesn't show how your body breaks oestrogen down or how well it is cleared, and that is often what drives heavy, painful periods and premenstrual symptoms.

Is a dried urine test better than a blood test?

They answer different questions. Blood shows what is circulating at one moment. Dried urine testing shows the metabolites your body makes as it processes hormones. Reading them together gives the clearest picture.

Can I do a dried urine hormone test on the pill?

Yes. You don't need to stop hormonal contraception or HRT. The collection is timed around your dose, and that is taken into account when the results are read.

What should I take to clear excess oestrogen?

That depends on which part of the clearance process is struggling, and it is something to work through with a practitioner who knows your history. Some popular supplements lower overall oestrogen levels, which can make symptoms worse if your levels are already normal or low.

Find out where your oestrogen is going

My Hormone Reset includes the EndoMAP, a full interpretation and a strategy session where we build your plan from your results. Read about the Hormone Rehttps://www.naturalist.co.nz/hormone-resetset here.

Not sure it's the right fit? Every path starts with a free fifteen-minute Discovery Call. Book your Discovery Call here.

This post is general education. It does not diagnose, and it does not replace medical care.