Integrating Bio-Identical Hormones and Herbal Protocols: Naturopathic Clinical Pearls – Jannine Krause, ND

Integrating BioIdentical Hormones and Herbal Protocols: Naturopathic Clinical Pearls

Dr. Jannine Krause

Explore a naturopathic method that combines bio-identical hormones and herbal remedies to help women navigate hormonal changes during peri-menopause and menopause.

Understanding Hormone Therapy Options

Hormone Replacement Therapy (HRT) and Bio-Identical HRT (Bio-HRT) are often debated in the medical community, leaving many women confused about their options. This article explores a naturopathic approach that combines bio-identical hormones with herbal options to support women through hormonal changes, especially during peri-menopause and menopause. The approach considers individual needs, emphasizing that effective hormone therapy is not a one-size-fits-all solution.

The Women’s Health Initiative and Its Impact

Over the last few decades, the Women’s Health Initiative studies have significantly shaped conventional and naturopathic medicine’s stance on HRT. Now, as those studies have been challenged, medical practitioners are aligning themselves with either hormone-based or herbal protocols.1 This leaves women feeling like they must choose between the two, unaware of hybrid approaches. 

A Personalized, Flexible Strategy for Hormone Therapy

With over 17 years of practice, I’ve found methods to integrate bio-identical hormones with herbal treatments, offering a custom approach to hormone balance and opening up options for women who are sensitive to interventions or those who have not tolerated specific protocols in the past. While social media and mainstream medicine often portray hormone therapy as a one-size-fits-all approach, my view is that it’s an individual approach yielding the best results. 

Hormone Needs During Peri-Menopause

Hormone needs vary throughout the month, particularly during the erratic hormone phase of perimenopause. I might prescribe estradiol patches post-ovulation combined with black cohosh, sage, and Schisandra berry during other phases. This allows for symptom relief while considering the body’s natural fluctuations in estrogens at this time.

Micronized progesterone is often micro-dosed orally at 10-25 mg2 and used post-ovulation or the last week of the luteal phase combined with evening primrose oil3 throughout the entire luteal phase to support fatty acid production. 

Addressing Libido, Fatigue, and Vaginal Dryness

For low libido and fatigue, I may add DHEA and/or testosterone in cream form,4, depending on the patient’s free testosterone and fatigue levels. For some women, oral DHEA supplementation5 may work better than in a vaginal cream. Daily topical-based testosterone supplementation is my go-to; however, I do have some clients who use injectable forms weekly. It’s not uncommon for me to use DHEA the entire month orally and add vaginal testosterone cream starting after the period ends in peri-menopausal women. 

Compounded estriol cream is my go-to for treating vaginal dryness and signs of aging skin. Estriol’s versatility and decreased impact on blood estrogen levels6 allow it to be used on various skin areas, offering aesthetic and functional benefits7.  When used vaginally, after an initial loading dose nightly for 2 weeks, I often recommend a maintenance regimen, applying estriol vaginally 1-2 nights a week and to the face the rest of the week. Estriol has even been used in breast cancer patients to counter vaginal atrophy.8

For many women experiencing a decrease in sexual interest due to dryness and reduced libido in peri-menopause, DHEA and testosterone can be combined with estriol cream for vaginal use.  Clients who desire an anti-aging, non-toxic approach to skin care can combine estriol with Vitamin C powder, hyaluronic acid, and Vitamin E, formulated by compounding pharmacies to support skin health while addressing deeper hormonal needs.

Hormonal Adjustments During Menopause and Beyond

As women transition into menopause, their hormone needs shift. Treatment may include continuous estradiol patches or bi-est cream formulations (a blend of estriol and estradiol) with varying ratios. Depending on symptom severity, I recommend periodic breaks from hormone use to allow the body to reset. This is particularly relevant for women who have been using hormones for over a year and have stable levels. This break can support detoxification and prevent hormonal dependency.

In my practice, I’ve found that women 10 years past menopause often require lower hormone doses than those newly transitioning. Adjusting hormone levels through tapering and micro-dosing can maintain a balance that supports the body’s changing needs while minimizing symptoms. However, it is important to recognize that some women continue to experience symptoms and may require sustained hormone support for longer. 

This is why I’m a huge fan of testing and not guessing, as well as taking a break from hormones for a week or so to see how you feel. 

Importance of Hormone Testing and Detoxification

Monitoring DHEA-sulfate levels and understanding symptoms are key to determining whether a patient will benefit more from bioidentical hormones or herbal support. The transition of hormone production from the ovaries to the adrenal glands involves assessing adrenal and nervous system health. This process helps determine the best combination of herbs and hormones for each client. Liver function, gut health, and methylation capabilities must also be assessed before introducing hormone support.

A comprehensive understanding of a client’s ability to detox hormones through liver function, the gut microbiome, and cellular methylation is crucial. Identifying detoxification bottlenecks can prevent side effects and enhance treatment outcomes. Additionally, evaluating nervous system health is vital. 

Integrating Nervous System and Hormonal Health

Hormonal changes can be more challenging for those whose nervous systems are in a chronic state of fight, flight, or freeze. A protocol addressing hormonal and nervous system balance—including adaptogens, breathwork, and lifestyle modifications—can improve overall results.

A whole-body approach to hormone balancing is necessary, and many naturopathic and functional medicine practitioners have realized this and have completed programs to address all aspects of hormone health. It is concerning how some mainstream sources portray hormones as universally “safe” despite the potential risks from pharmaceutical formulations containing parabens and phthalates—chemicals known to disrupt hormones. This becomes especially problematic when combined with daily habits that may impair detoxification, like alcohol consumption.

Understanding a client’s exposure to toxins, lifestyle, and family history, especially concerning cancers such as breast, uterine, or ovarian cancer, is imperative. While cancer history was once seen as a contraindication for hormone use, new insights into delivery methods and absorption rates of hormones suggest that personalized hormone support is possible even in such cases.9  Research has shown that breast cancer survivors have been able to use testosterone cream successfully, and many are using estriol for vaginal atrophy.9 I’m currently seeing a 47-year-old female who was diagnosed with breast cancer at 40 and has been using 0.3% estriol cream vaginally as well as on her face for the last 5 years without any complications or excessive rises in her estriol or estradiol levels in her blood or urine on testing. 

A core aspect of my practice is educating clients about their hormonal cycles, the influence of lunar phases, and the benefits of herbal and hormonal interventions. Encouraging clients to track their cycles—even after menstruation has ceased—provides valuable insights into their needs and helps fine-tune protocols. Journaling enables clients to understand physical and emotional fluctuations and better informs them when testing should occur.

Urine hormone metabolism tests, now accessible for home use, offer a practical way to monitor hormone levels throughout the month. Knowing when to use blood versus saliva tests also helps refine treatment. For clients struggling with hormone metabolism, combining herbs with hormone therapies can reduce side effects like acne, puffiness, and lethargy. Customizing progesterone dosage, sometimes as low as 10 mg, can be effective for sensitive clients.

When hormone detoxification is challenging, dietary and herbal supports can be effective. Supplements like DIM (di-indole methane), sulforaphane, and cruciferous vegetables10 are beneficial for estrogen detoxification. Herbal options like sage, red clover, and black cohosh can complement hormonal therapies.11 For testosterone detox, I use saw palmetto, inositol, and licorice.12, 13

Balancing the gut microbiome to reduce beta-glucuronidase levels also plays a critical role in hormonal health. Probiotics, Calcium-D-glucate (CDG), and gut-lining support can assist in this area. A deeper microbiome analysis can guide treatment adjustments if testing indicates gut imbalances.

Hormone protocols must evolve as clients age. In their 30s, women’s protocols focus on supporting ovarian function, while later strategies shift to emphasize adrenal health. Personalized adaptogenic herbs are often essential during this transition, and I’ve found in my practice that ashwagandha and Schisandra berries benefit younger women. At the same time, Siberian ginseng, Rehmannia root, and Rhodiola are better suited for older clients.14

Understanding a client’s emotional landscape, stressors, and past trauma is critical in creating effective hormone support. Adaptogens, alongside education about lifestyle factors like the moon cycle and personal rhythms, empower clients to participate actively in their healing process.

A Whole-Body Approach to Hormonal Balance

Combining bio-identical hormones with herbal treatments offers a flexible and practical approach to supporting women through hormonal transitions. A personalized method, grounded in naturopathic principles, considers each woman’s unique needs and evolving biology. By educating and involving clients in their healthcare, practitioners can guide them through the complexities of hormone balancing, ensuring they feel supported and empowered throughout their journey.

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