When a woman walks into my practice describing months or years of fatigue, brain fog, and mood swings, I’m looking for what other practitioners missed.
Not because they’re incompetent. Because they’re trained to look at absolute values instead of relationships.
They see estrogen at 150 pg/mL and progesterone at 2 ng/mL and declare both “within normal range.” They miss that the progesterone to estradiol ratio is completely off, creating an imbalance that drives every symptom she’s experiencing.
This is the gap between “normal” and “optimal” that leaves women suffering unnecessarily.
The Ratio Problem Nobody’s Checking
Estrogen dominance sounds like you have too much estrogen. That’s not quite right.
It means estrogen levels are high relative to progesterone, not that estrogen itself is elevated outside typical ranges. This imbalance exists even when absolute estrogen levels are normal or low, because the protective and balancing effect of progesterone is insufficient.
I see this pattern constantly in lab work. Estrogen levels sitting comfortably in the normal range while progesterone has dropped, especially in the luteal phase. The ratio is what matters.
Women with this imbalance experience breast tenderness, mood swings, weight gain, heavy periods, and brain fog. Their doctors tell them everything looks fine. The labs say otherwise if you know what to look for.
The optimal progesterone to estradiol ratio falls between 100-500 pg/mL. When both hormones are individually “normal” but the ratio is off, symptoms persist. This is why detailed hormone panels matter more than basic screening.
I also look at metabolite patterns. Increased levels of proliferative estrogen metabolites like 16-hydroxyestrone versus protective metabolites like 2-hydroxyestrone signal impaired estrogen metabolism. This tells me how her body is processing hormones, not just producing them.
Why Women with “Too Much” Estrogen Still Need Hormone Therapy
Here’s the counterintuitive part that confuses people.
A woman can have estrogen dominance and still benefit from hormone therapy. The treatment goal is balance, not suppression.
Progesterone balances estrogen’s proliferative effects on tissues. When progesterone falls, estrogen’s effects become unopposed and problematic. Supplementing bioidentical progesterone restores the healthy ratio and receptor balance.
This is fundamentally different from the one-size-fits-all approach that either adds estrogen indiscriminately or avoids hormones entirely out of fear.
Functional approaches also focus on improving estrogen clearance through nutrition, lifestyle, and targeted supplements. Supporting how the body metabolizes and eliminates estrogen matters as much as what you’re replacing.
Delivery Methods That Match Your Life
Once we understand the imbalance, the question becomes how to deliver the therapy.
I prefer topical hormone delivery in my practice. Creams and gels allow precise, incremental dose adjustments based on symptom response and lab monitoring. This flexibility is invaluable early in therapy or with sensitive patients who need slow hormone introduction.
Topicals give patients control over timing and application sites. They can adjust as needed, which fosters engagement and autonomy.
But I recognize topicals aren’t ideal for everyone.
Jane came to me after discontinuing oral hormone pills due to side effects. She presented with debilitating brain fog, mood swings, insomnia, and erratic cycles. Previous practitioners had offered standard solutions that made her feel worse.
Her labs showed estrogen dominance with low progesterone and fluctuating estradiol. Because she was highly sensitive to oral dosing and struggled with daily adherence due to her work schedule, I referred her for pellet therapy.
Pellets provide slow, steady hormone release over 3-6 months, mimicking natural secretion and minimizing fluctuations. They bypass first-pass liver metabolism and avoid GI side effects.
Within four weeks, Jane reported clearer thinking, stable mood, improved sleep, and regular but lighter cycles. Over six months, her energy and wellbeing markedly improved, transforming her work-life balance and relationships.
The pellet delivery matched her lifestyle and biochemistry. Had she continued with daily hormones, she likely would have struggled with inconsistent absorption and delayed relief.
The choice between delivery methods balances pharmacologic stability, patient lifestyle, symptom profile, and metabolic factors. Personalized assessment ensures the chosen route optimizes efficacy and adherence.
The Gut-Liver-Hormone Triangle
Most people think hormone therapy is just replacing what’s missing. That’s incomplete.
Hormones don’t act in isolation. The gut, liver, and nutritional status form a critical support network for hormone health.
The gut microbiome produces enzymes like beta-glucuronidase that influence estrogen metabolism through what’s called the “estrobolome.” Imbalances or dysbiosis lead to increased reabsorption of estrogen, contributing to dominance and disrupting balance.
Overgrowth of certain gut bacteria increases beta-glucuronidase levels, preventing estrogen excretion and allowing reabsorption. This is why addressing intestinal health is critical when treating estrogen dominance.
Poor gut health also impairs nutrient absorption, leading to deficiencies in B vitamins and magnesium that are essential for hormone synthesis and regulation.
The liver metabolizes hormones for excretion. When liver function is overwhelmed by toxins, alcohol, medications, or poor diet, hormone clearance slows. This leads to buildup of active hormone forms or harmful metabolites, exacerbating symptoms.
Nutrition provides the building blocks. Healthy fats, protein, vitamins A, D, and B-complex, plus minerals are essential substrates for hormone production and signaling. Poor diet impairs signaling pathways, worsens insulin and cortisol dynamics, and blunts hormonal feedback loops.
Chronic stress elevates cortisol, which is made from precursors that include progesterone. With increasing cortisol demand, progesterone levels may decrease, disrupting the estrogen-progesterone balance. This creates a vicious cycle.
I’ve seen many patients receive BHRT but continue struggling because gut dysbiosis, nutrient gaps, or liver sluggishness impair hormone metabolism and function.
Supporting these systems with targeted nutrition counseling, gut restoration protocols, liver detox support like cruciferous vegetables and milk thistle, plus stress management markedly improves outcomes. Patients feel symptom relief faster with more stable hormone levels.
Prioritizing Foundations Without Delaying Relief
The question becomes: do you start with hormones or fix the foundation first?
My approach depends on clinical urgency and patient readiness, but generally I stabilize foundational systems when possible.
Establishing baseline gut health improves nutrient absorption and reduces systemic inflammation. Supporting liver detox pathways optimizes hormone metabolism and clearance. Introducing targeted nutritional supplementation corrects deficiencies critical for hormone synthesis.
Why first? Because impaired foundation slows hormone metabolism and can contribute to hormone resistance. Hormone therapy alone may be less effective or provoke side effects.
If a patient has significant debilitating symptoms or marked hormone deficits, I may initiate low-dose BHRT early alongside gentle gut and liver support. Dosing is conservative and closely monitored, allowing titration as foundational health improves.
Then I layer integrative care over time. Modifying nutrition, stress reduction, sleep, and detox protocols as hormone therapy progresses and labs shift. Maintaining contact and adapting plans with patient feedback and retesting.
Urgency and symptom burden drive personalized sequencing. The goal is balancing immediate hormone support with gradual foundational restoration.
The Paradigm Shift Happening Now
By 2025, more than one billion women globally will be perimenopausal or postmenopausal, with many spending 50% of their lives in a postmenopausal state.
This demographic reality is driving demand for better solutions. Women are refusing to accept that debilitating symptoms are just “normal aging.”
They’re seeking practitioners who understand that normal lab values don’t equal optimal function. Who recognize that hormone ratios matter more than absolute numbers. Who address root causes instead of prescribing antidepressants for what’s actually a progesterone deficiency.
The shift toward personalized, evidence-based hormone therapy represents a fundamental change in how we approach women’s health beyond reproductive years.
Quality of life matters. Mental clarity matters. Energy and wellbeing matter.
When we optimize the estrogen-progesterone-testosterone trinity while supporting gut health, liver function, and nutrition, we’re not just managing symptoms. We’re restoring vitality.
This is what functional hormone optimization looks like. It’s what women deserve, and increasingly, what they’re demanding from their healthcare providers.
The conventional approach that dismisses symptoms as inevitable aging is becoming obsolete. Women are driving this change by seeking practitioners who will dig deeper, test comprehensively, and treat the whole system.
That’s the future of women’s healthcare. And it’s already here for those who know where to look.
Dr. Belinda Ferguson
Dr. Ferguson is a Doctorally prepared, Board-Certified Family Nurse Practitioner, Holistic Wellness Provider, Certified Professional Coach, Leadership Development, Burnout Strategist Expert, and Speaker with over 23 years of healthcare expertise.
She is committed to helping individuals transform their mindset, performance and wellness, empowering those ready for change—without letting excuses or life circumstances hold them back. Dr. Ferguson specializes in stress management and burnout prevention with a focus on wellness, weight loss, hormonal balance, and chronic disease prevention and management, using a holistic, functional, and integrative team approach to optimize well-being. Recognizing the unique challenges of high-achieving individuals balancing personal and professional performance admist busy lives, she provides a personalized approach to achieving sustainable wellness, resilience, and success. Dr. Ferguson is not your run-of-the-mill coach using an ineffective one-size-fits-all model. Through her researched and evidence-based methods, she uses a one-of-a-kind approach that helps patients and clients uncover root causes in the present moment, break through barriers, and reclaim their energy, focus, and confidence. Dr. Ferguson resides in North Carolina with her family.
Qualifications
– Doctorate of Family Nurse Practitioner degree from the University of Gardner-Webb University
– Doctorate (DNP) project publication titled ‘Women Experiencing Unexpected Pregnancy.’
– Institute… Read more
