Hypoestrogenism, or estrogen deficiency, refers to a lower than normal level of estrogen, the primary sex hormone in women. Estrogen levels vary with woman’s age (Pic. 1). The average value is about 150 pg/mL. In case of 10-20 pg/ml we speak about low levels of estrogen. In general, lower levels of estrogen may cause differences in the breasts, genitals, urinary tract, and skin.

Lower levels of estrogen are typical and physiological in postmenopausal women. In young women hypoestrogenism is related to pathological background. Hypoestrogenic women may have premature ovarian failure (POF), or are suffering from amenorrhea (an absence of a menstrual period); however, it is also associated with hyperprolactinemia (high prolactin level) and the use of gonadotropin-releasing hormone (GnRH) analogues in treatment of endometriosis (an abnormal growth of endometrial cells outside the uterus). It has also been linked to scoliosis and young women with type 1 diabetes mellitus.

Diagnosis of hypoestrogenism is simple. The only thing which is necessary is blood from which the serum is separated. The level of estrogen is than examinated from the serum in special laboratories.

Hormone replacement therapy (HRT) with estrogen can be used to treat hypoestrogenism in both premenopausal and postmenopausal women.

Symptoms

  • hot flashes
  • headaches
  • lowered libido
  • breast atrophy
  • urogenital atrophy (vaginal dryness, vaginal irritation and itching)

Associated diseases

  • Kallmann syndrome (a failure to start or a failure to complete puberty)
  • hyperprolactinemia
  • hypogonadism (a diminished activity of the gonads, i.e. tester or ovaries)
  • uterine fibroids (noncancerous growths of the uterus)
  • premature ovarian failure (POF)
  • obesity
  • osteoporosis
  • polycystic ovary syndrome (PCOS)
  • anorexia nervosa
  • endometriosis
  • type 1 diabetes

Complications

Vaginal complications

Effects of prolonged hypoestrogenism are observed on physical examination of the vulva and vagina and clinical findings include loss of vaginal rugae (wrinkles), reduced elasticity, sparse vaginal content and thinning of the vaginal mucosa. All these aspects influence the daily lives of patients on account of clinical manifestations, such as symptoms of vaginal dryness, pain or discomfort during intercourse (dyspareunia), and urinary symptoms such as dysuria (painful urination) and urgency. It is accompanied with an increased vaginal pH that possibly renders the vagina more susceptible to infections, such as urinary tract infections.

Genitourinary dysfunction

Genitourinary dysfunction, i.e. affecting urinary organs as well as genital organs, in turn, characterized by sagging, dystopia (organ displacement) and incontinence, may be made worse with the decrease in collagen secondary to hypoestrogenism affecting the support mechanisms, fasciae, and ligaments of the pelvic floor.

Osteoporosis

In fact, estrogen deficiency accelerates the effects of aging on bone by decreasing defense against oxidative stress (an imbalance between the production of free radicals and antioxidant defenses). Estrogen protects the adult skeleton against bone loss by slowing the rate of bone remodeling and by maintaining a focal balance between bone formation and resorption. The acute loss of sex steroids shows an increase in the rate of bone remodeling, resulting from an increase in osteoporosis.

Risk factors

  • depot medroxyprogesterone acetate (DMPA) for contraception
  • premature menopause
  • exercise training
  • stress

Prevention

Hypoestrogenism can be prevented by hormonal replacement therapy (HRT), but prescription and dosage has to be determined by the doctors. 

However, certain herbs have also been found to be effective in alleviating the symptoms of an estrogen deficiency, such as alfalfa, black cohosh, dong quai, dill, ginkgo biloba and thyme.

In women, hypoestrogenism causes an anovulatory infertility and a decrease in menstruation. When anovulation takes place, most women will appear to menstruate as normal, but ovulation will not occur and no egg is released and cannot be fertilized. In some women, menstruation may disappear altogether (secondary amenorrhea). In others, menstruation may become irregular or menstrual flow may change.

In these cases, there is still possibility to conceive a child, but it depends on frequency of spontaneous ovulation. In severe cases, an estrogen deficiency may also contribute to infertility. 

A woman's ability to support a pregnancy is certainly dependent on the secretion of estrogen as well as progesterone (a sex hormone produced in the ovaries). Since estrogen is a primary female sex hormone that is essential for reproductive processes, an estrogen deficiency must be treated at the earliest. Because estrogen levels could fall due to a wide range of reasons, diagnostic tests must be conducted in order to ascertain the underlying cause.

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