Low Estrogen Symptoms in Women: Signs, Causes, Testing and Treatment

What are the symptoms of low estrogen in women?

Estrogen acts on far more than the reproductive system. It has receptors in the brain, skin, bones, blood vessels, bladder and vagina. So when estrogen falls, most often in perimenopause and after menopause, the symptoms can show up almost anywhere. Low estrogen symptoms in women tend to cluster in a few body systems.

Not everyone gets all of these, and many have other possible causes, from thyroid problems to depression to sleep apnea. The pattern matters more than any single symptom.

Hot flashes and night sweats

Hot flashes and night sweats (vasomotor symptoms) are the best-known signs of low estrogen. They often last longer than people expect: in the SWAN study, women with frequent symptoms had them for a median of 7.4 years, and longer when they started early in perimenopause (Avis 2015). Night sweats are a common reason for poor sleep, which in turn feeds fatigue, irritability and brain fog. See our guide to hot flashes for more.

Vaginal, urinary and sexual symptoms

Tissues of the vulva, vagina, urethra and bladder depend on estrogen to stay thick, moist and elastic. When estrogen stays low, many women develop genitourinary syndrome of menopause (GSM): dryness, burning and irritation; less lubrication, discomfort or pain with sex; and urinary urgency, pain with urination or repeat urinary infections (Portman 2014). Unlike hot flashes, these symptoms usually don't fade with time and may slowly worsen. Our guide to genitourinary syndrome of menopause covers it in depth.

Bone health

Estrogen helps protect bone. Bone loss from low estrogen causes no symptoms until a fracture happens, which is why it matters even if you feel fine. Hormone therapy prevents bone loss and fractures after menopause (Menopause Society 2022), and bone loss is also a recognized complication of low estrogen in younger women whose periods stop (Gordon 2017).

What causes low estrogen?

Perimenopause and menopause

This is by far the most common cause in women over 40. Estrogen doesn't fall in a straight line. In perimenopause, the ovaries respond less predictably and estrogen swings up and down from cycle to cycle. In SWAN, average estradiol levels didn't start falling until about 2 years before the final period, then dropped fastest around the final period and leveled off about 2 years later (Randolph 2011). That is why symptoms can come and go for years before periods stop. For the timeline, see perimenopause symptoms.

By the numbers

How estradiol falls around the final period

~2 yrsbefore the final period, average estradiol starts to fallSource: Randolph 2011

~2 yrsafter the final period, estradiol levels offSource: Randolph 2011

Surgery and cancer treatment

Removing both ovaries causes an immediate drop in estrogen, often with sudden and strong symptoms. A hysterectomy that leaves the ovaries in place doesn't stop estrogen production right away, though periods end; see estrogen after hysterectomy. Chemotherapy and pelvic radiation can damage the ovaries, and some breast cancer treatments deliberately lower estrogen.

Other causes, especially before 40

• Primary ovarian insufficiency (POI). The ovaries stop working normally before 40. It affects about 1 in 100 women by age 40, and many, though not all, develop low-estrogen symptoms such as hot flashes, sleep disruption and vaginal dryness (Nelson 2009).
• Functional hypothalamic amenorrhea. Stress, weight loss, intense exercise or a combination can pause the brain signals that drive ovulation, lowering estrogen. Bone loss and infertility are among its complications (Gordon 2017).
• Other medical conditions, such as pituitary disorders, can also lower estrogen and need a medical workup.

Should you get your estrogen levels tested?

For most women over 45 with typical symptoms and changing periods, a blood test adds little. During perimenopause, estradiol and follicle-stimulating hormone (FSH) fluctuate widely, so a single result can look normal one week and menopausal the next. A review of hormone changes across the transition concluded that there are no validated hormone cutoffs to pinpoint where you are, and that diagnosis should rest on clinical signs and symptoms (Su and Freeman 2009). A normal result doesn't mean your symptoms aren't real.

Testing is more useful when:

• Your periods stop or become irregular before 40. POI is diagnosed with repeated FSH tests at least a month apart, along with an estradiol level (Nelson 2009).
• Another cause needs ruling out, such as pregnancy, thyroid disease, high prolactin or anemia.
• You've had a hysterectomy and can't use your cycle as a guide, and symptoms are unclear.

How are low estrogen symptoms treated?

Hormone therapy

Replacing estrogen is the most effective treatment for hot flashes and night sweats and for genitourinary symptoms, and it prevents bone loss. For women under 60 or within 10 years of menopause who have no contraindications, The Menopause Society considers the benefit-risk balance favorable (Menopause Society 2022). The Endocrine Society's guideline reaches a similar conclusion and advises screening for cardiovascular and breast cancer risk before starting (Stuenkel 2015).

• Systemic estrogen (patch, gel, spray, pill or cream) treats whole-body symptoms. If you have a uterus, you also need progesterone or another progestogen to protect the uterine lining.
• Low-dose vaginal estrogen treats dryness, pain with sex and some urinary symptoms with very little absorption into the bloodstream.
• Younger women with POI are in a different situation from women after natural menopause. Experts generally agree that replacing estrogen and progestogen at physiologic levels is reasonable for them, and that risk data from older women in the Women's Health Initiative don't apply directly (Nelson 2009).

Amie offers Amie HRT+, a compounded cream combining estradiol and progesterone, with the strength chosen by a licensed clinician after an online review of your symptoms and health history. It is not FDA-approved. The clinician decides whether it is appropriate for you, and FDA-approved estradiol and progesterone products are widely available as alternatives.

Nonhormonal options

If you can't or prefer not to take estrogen, The Menopause Society recommends cognitive behavioral therapy, clinical hypnosis, certain SSRI or SNRI antidepressants, gabapentin, fezolinetant and oxybutynin for hot flashes. It does not recommend most supplements, herbal remedies or soy products (Menopause Society 2023). For vaginal dryness, vaginal moisturizers and lubricants are a good first step. If you're curious about plant-based options, our guide to natural estrogen replacement explains what the evidence shows.

When should you see a clinician?

• Your periods stop or become very irregular before 40, or before 45 with symptoms.
• You have any bleeding after 12 months without a period.
• Symptoms are disrupting your sleep, work, mood or relationships.
• You have pain with sex, repeat urinary infections or urinary urgency.
• You have risk factors for osteoporosis or have had a fracture from a minor fall.

The bottom line