What are the symptoms of low estrogen?

The buzz around hormones — testing them, balancing them, tracking them — has become louder than ever. That, combined with what feels like a renewed focus on menopause, has put low estrogen in the spotlight. Most commonly linked to the menopause transition, low estrogen could be brought on by other causes as well and can have some pretty unpleasant side effects. Here are the top symptoms of low estrogen, why it happens, and what you can do about it.

What is estrogen?

While estrogen is often referred to as a single hormone, it’s actually a group of hormones that play a huge role in women’s sexual and reproductive function, as well as metabolism and overall health in general. They include estradiol — which is the most potent and prevalent and is produced by the ovaries — and estrone, which is a weaker, less prevalent estrogen produced by your ovaries and via the conversion of other hormones produced mainly in fat tissue. Another type is estriol, which is made during pregnancy by the placenta.

While estrogen is crucial for keeping the female reproductive system functioning smoothly for much of your life — it regulates your menstrual cycle, for instance — it also helps maintain bone health, increases good cholesterol, regulates urinary function, and influences mood, among many other roles. These functions are mostly carried out by estradiol during your reproductive years. But once you go through menopause, estradiol drops significantly — this would be “low estrogen” — and estrone, the weaker estrogen, replaces it as the primary form of estrogen in the body.

Signs and symptoms of low estrogen

First, know that “low estrogen” is very normal. “Women go through low estrogen cycles throughout their life, not just menopause,” says Dr. Sally MacPhedran, M.D., the director of the Midlife Women's Center at University Hospitals Cleveland Medical Center and a professor of reproductive biology at Case Western Reserve University School of Medicine. For example, estrogen is extremely low when you’re postpartum, and breastfeeding can further suppress it.

But during these times, most women don’t experience any symptoms besides perhaps a delay in getting their period post-baby. When your low estrogen results from menopause or a health condition, however, you’re much more likely to notice signs.

On that same note, low estrogen menopause symptoms don’t impact everyone the same way. “I've had some women who present just with joint pain,” MacPhedran says. “And I've had some who present just with hot flashes and some that just are worried about their memory. So every person is different in terms of what impacts them the most.” That said, here are some things to look out for.

Physical symptoms of low estrogen

Because estrogen plays a role in regulating your periods, one of the main signs of low estrogen is a change in your menstrual cycle. This is usually the first thing people notice as they near perimenopause, which is the time frame leading up to menopause marked by dropping estrogen levels. “They can have bleeding that's very close together, or the period can be really long,” says Dr. Lauren Roth, M.D., a double board-certified OB/GYN and reproductive endocrinologist at Shady Grove Fertility in Rockville, Maryland.

Besides that, the most common physical sign of low estrogen is hot flashes. “This could feel like a sense of being warm, or it could feel like heat coming out of your head, your hands, or your feet,” says MacPhedran. “It could also look like you're completely drenched with sweat.” Other common physical symptoms include joint pain, skin changes like dryness and wrinkles, and hair thinning, according to MacPhedran. This is because estrogen supports key functions in all of these areas of the body.

Lastly, low estrogen can also lead to weight gain. Estradiol helps regulate appetite and increase satiety, so when levels go down, you may feel hungrier and not as full.

Cognitive and emotional symptoms of low estrogen

Both menopause brain fog — which often manifests as difficulty recalling certain words — and mood swings are common symptoms of low estrogen, according to MacPhedran. Estrogen influences activity in the brain during cognitive tasks, so a drop in levels may impact your cognitive health. On top of that, other physical symptoms of low estrogen, like night sweats, can impact your sleep — and in turn do a number on how sharp you feel in the morning.

Estrogen can also impact your mood. The thinking is that estrogen helps carry out various functions in certain regions of the brain involved in regulating your mood. So as estrogen levels drop, those areas become dysregulated, which can contribute to the higher rates of depression and anxiety that are present in menopausal women.

Sexual symptoms of low estrogen

Estrogen also plays a lot of roles below the belt, which is why sexual and general urinary symptoms can pop up when levels of the hormone drop too low. For instance, estrogen maintains vaginal moisture and health in women by stimulating the growth of the vaginal cell lining, increasing glycogen content, and promoting a healthy vaginal microbiome. This helps defend it against infections and maintains bladder function. With low estrogen, you might notice symptoms like decreased sexual desire, vaginal dryness/irritation, and leaking urine, says MacPhedran.

What causes low estrogen?

While estrogen fluctuates naturally with every menstrual cycle, the ups and downs get even more dramatic as you near menopause — and overall levels get lower and lower. Here’s more on what happens during the menopause transition, as well as other reasons you may have low estrogen.

Natural causes

As something all women experience, menopause is the most common cause of low estrogen. It all starts during perimenopause, which is the time leading up to menopause marked by fluctuating hormone levels. “The drops can be so abrupt, which is what causes the symptoms,” says MacPhedran.

Then, once you experience menopause, which is the moment you’ve gone 12 months without a period, your estrogen bottoms out at a very low level. While your ovaries stop making estradiol, your fat cells do continue to churn out estrone, but it’s a much weaker estrogen so it doesn’t make up the difference.

Menopause isn’t the only reason you might have low estrogen. Here are some other natural causes:

• Functional hypothalamic amenorrhea (FHA): This is when you don’t get your period due to extreme weight loss or extended intense exercise (think professional ultramarathoners). Up to a third of people who haven’t gotten their period for three months or longer and aren’t in perimenopause have FHA, according to one study. “These are all an energy imbalance,” says Roth. During this time, your body simply doesn’t have enough energy to send signals from the brain to the ovaries for them to produce estrogen. “Once we see restoration of energy balance and weight, for most people, their periods will come back,” Roth says. And their symptoms will similarly resolve themselves.
  
  
• Postpartum period: Estrogen production drops during this time in order to encourage milk production and delay ovulation. Besides a delayed period, breastfeeding has also been linked to some other low-estrogen symptoms, such as vaginal dryness and discomfort, Roth says.

Medical causes

There are some genetic conditions, like premature ovarian failure, that can cause low estrogen, but the medical causes for low estrogen are primarily cancer treatment — namely, “either chemotherapy or radiation to the ovaries,” says MacPhedran. These treatments can inadvertently damage healthy, estrogen-producing cells. There are also “breast cancer medications like aromatase inhibitors that block estrogen function,” she says, causing levels to drop.

Health risks of low estrogen

Low estrogen can have a cascading effect on your body, especially on your heart health. This is one reason why reproductive-aged women with normal estrogen levels are at a much lower risk of cardiovascular events, like a heart attack or stroke, than men. But when estrogen levels drop “right around menopause and postmenopause, women then equal the risk of men,” says Roth.

The link between low estrogen and heart health is also true for premenopausal women who have low levels due to other reasons: One recent study found that 69 percent of young women with coronary artery disease have low levels of estrogen — largely due to overexercising, undereating, or some combination of the two.

Osteoporosis is another serious and well-studied risk associated with low estrogen, since estrogen is important for building and maintaining bone density. Without it, the bones can lose density, increasing the risk of breaks and fractures.

On top of that, both cognitive decline and metabolic syndrome (which includes conditions like high blood pressure and high blood sugar) tend to be more common among people in perimenopause or who experienced menopause prematurely, according to Roth. So although the exact link is unclear, this “does seem to be due to the lack of ovarian function,” she says. The link between dementia and estrogen is so profound that supplementing estrogen via hormone therapy can help protect against it, according to one study.

How is low estrogen diagnosed?

Low estrogen isn’t really something that’s tested for, since levels can naturally fluctuate wildly. “You could have a low estrogen in the morning and a high estrogen at lunch,” says MacPhedran. Instead, experts usually rely on a combination of symptoms and your menstrual-cycle history.

Treatment for low estrogen

First, know that hormones are never “balanced,” no matter what social media ads would have you believe. They are meant to go up and down based on what time it is and other factors. “Progesterone, estrogen, testosterone — they fluctuate every day, all day long,” says MacPhedran. “There's no way to have it balanced.”

If your goal is to improve symptoms of low estrogen, lifestyle interventions can be a good first step. For most symptoms, particularly hot flashes, night sweats, mood changes, and trouble sleeping, “maintaining a healthy weight, exercise, yoga, mindfulness, and acupuncture are good options,” says MacPhedran. But if your symptoms are severe, your provider might consider other options, which include hormonal and non-hormonal medications.

Hormone replacement therapy (HRT)

Hormone replacement therapy (HRT), also called menopausal hormone therapy (MHT), supplements estrogen in the body to bring levels back up. It comes via a pill, a patch, or topical formula and can be very effective. “For people who are having low estrogen symptoms — and that's mostly going to be hot flashes, vaginal dryness, and low bone mass — we would recommend hormone therapy,” says Roth.

One meta-analysis of existing research found that HRT significantly improved the quality of life for menopausal women in multiple ways: It helped control hot flashes and night sweats, alleviate vaginal discomfort, improve urinary issues (like incontinence), and increase bone density. It also might be helpful for improving symptoms like mood and joint pain. “Nobody knows, but it does seem to help in some situations,” says MacPhedran.

Non-hormonal treatments

For prescription-level medications to treat symptoms of low estrogen, “it is only for hot-flash management that we have actual clear research and data,” says MacPhedron, pointing to Veozah (fezolinetant) as one option, which is FDA approved for moderate to severe vasomotor symptoms.

For vaginal dryness, Roth’s first recommendation is local treatment with non-hormonal vaginal moisturizers. “Some people get good improvement with that,” she says. Otherwise, your provider will try to treat your specific symptoms. “We might steer towards an antidepressant if mood is the major issue and hot flashes are kind of secondary,” says MacPhedran.