Managing hormonal imbalance in women's health

Hormone imbalances are a common presentation in general practice among women of all ages and life stages. The spectrum is broad, encompassing menstrual disorders, thyroid disease, perimenopausal changes, premature ovarian insufficiency (POI), and metabolic dysfunction.

Hormone imbalance

Hormone imbalance usually refers to excess or deficiency in one or more hormones, disrupting normal physiology and function. In women, the most frequent presentations include reproductive, thyroid and metabolic hormone imbalance.

Causes

Common causes include polycystic ovary syndrome (PCOS), perimenopause and menopause, thyroid dysfunction (hypothyroidism and hyperthyroidism), and premature ovarian insufficiency (POI).

Presentation

Women may present with symptoms directly attributable to hormonal disturbance or may present with a perceived hormone imbalance. It is therefore important to clarify specific symptomatology and underlying concerns.

Symptoms can be varied and non-specific, including menstrual changes, fatigue, weight change, mood disturbance, acne and hirsutism. A focused history should include menstrual pattern, medication use (including contraception), fertility desires and psychosocial factors. Red flag symptoms, which may prompt urgent investigation, such as galactorrhoea, rapid virilisation or symptoms of thyroid storm or adrenal insufficiency, should also be specifically screened for.

Investigations

Investigations should be guided by the clinical picture. For menstrual irregularity or fertility concerns, first-line tests include a pregnancy test, serum follicle-stimulating hormone (FSH), luteinising hormone (LH), prolactin and thyroid-stimulating hormone (TSH). For suspected PCOS, total and free testosterone, sex hormone binding globulin (SHBG), and metabolic screening (e.g. fasting glucose, HbA1c and lipid profile) are recommended. In perimenopausal women over 40, fluctuating FSH and oestradiol can make hormone tests unreliable, and clinical history and symptomatology remain the most valuable diagnostic tools in women over 40. Persistently elevated FSH and low oestradiol in a woman under 40 may indicate POI. Thyroid function tests should be performed in women presenting with fatigue, weight change or menstrual disturbance.

In some cases, imaging may be appropriate – such as pelvic ultrasound for suspected PCOS or ovarian pathology, or a pituitary MRI for suspected hyperprolactinaemia.

Management

Management depends on the underlying diagnosis, symptom severity, reproductive goals and patient preference. Lifestyle interventions underpin the management of many hormonal imbalances. Regular exercise, balanced nutrition, adequate sleep and weight optimisation all promote hormonal health and metabolic health.

Pharmacological management is guided by the cause. For women with PCOS, combined hormonal contraception, metformin or anti-androgens (e.g. spironolactone) may be appropriate. For menopause, perimenopause and POI, hormone replacement therapy (HRT) remains first-line therapy for eligible women with vasomotor and/or urogenital symptoms. Where HRT is contraindicated, alternative therapies include selective serotonin reuptake inhibitors or other non-hormonal agents. In POI, HRT is recommended to support bone and cardiovascular health. Hypothyroidism is treated with levothyroxine, while hyperthyroidism management depends on the underlying aetiology.

Referral

For some women with hormone imbalance, referral to endocrinology or gynaecology should be considered, particularly where there is diagnostic uncertainty, treatment-resistant symptoms, suspected pituitary or adrenal pathology or complex fertility concerns.

Effective management of hormonal imbalance in women relies on a nuanced history, appropriate investigations, and a personalised, evidence-based management plan delivered within a holistic framework of primary care.

- Dr Samantha Miller, MBChB

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References

1. National Institute for Clinical Excellence (NICE)(2023). Thyroid disease: assessment and management. https://www.nice.org.uk/guidance/ng145
2. BMJ Best Practice (2024). Hypothyroidism and hyperthyroidism. https://bestpractice.bmj.com
3. The Royal Australian College of General Practitioners (2021). Thyroid disease: Using diagnostic tools effectively. https://www1.racgp.org.au/ajgp/2021/january-february/thyroid-disease-using-diagnostic-tools-effectively
4. Australian Family Physician (2017). Premature ovarian insufficiency in general practice: Meeting the needs of women. https://www.racgp.org.au/afp/2017/june/premature-ovarian-insufficiency-in-general-practic
5. Department of Health, State Government of Victoria, Australia. Better Health Channel: Polycystic Ovarian Syndrome. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/polycystic-ovarian-syndrome-pcos
6. BMJ Best Practice (2020). Polycystic Ovary Syndrome. https://bestpractice.bmj.com/topics/en-gb/141
7. BMJ Best Practice (2020). Abnormal Uterine Bleeding. https://bestpractice.bmj.com/topics/en-gb/658
8. Monash University (2018). International evidence-based guideline for the assessment and management of polycystic ovary syndrome. https://www.monash.edu/__data/assets/pdf_file/0004/1412644/PCOS_Evidence-Based-Guidelines_20181009.pdf
9. Department of Health, State Government of Victoria, Australia. Better Health Channel: Menopause. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/menopause
10. National Institute for Health and Care Excellence (2015). Menopause: diagnosis and management. https://www.nice.org.uk/guidance/ng23/resources/menopause-diagnosis-and-management-pdf-1837330217413