The role of bioidentical hormone replacement in postpartum recovery

Author, Dr Fiona MacRae, a specialist in integrative women’s health and bioidentical hormone balancing for the Marion Gluck Clinic, discusses the role of bioidentical hormone replacement in postpartum recovery

The postpartum period, often referred to as the “fourth trimester”, marks a time of profound biological, psychological, and emotional transition for women. While medical attention during this stage frequently centres on obstetric complications, breastfeeding support, and neonatal care, the mother’s endocrine recovery is often overlooked. Yet, for many women, the dramatic withdrawal of reproductive hormones following placental expulsion precipitates a range of debilitating symptoms, including mood instability, fatigue, cognitive dysfunction, and urogenital complaints.

For a select group of postpartum women, particularly those experiencing moderate to severe hormonal withdrawal symptoms, bioidentical hormone replacement therapy (BHRT) may offer a physiologically congruent and clinically meaningful intervention. While not part of standard postnatal care guidelines, growing clinical interest and early research suggest BHRT could serve as a valuable adjunct in managing postpartum neuroendocrine imbalance.

Hormonal shifts after delivery

During pregnancy, the placenta acts as a powerful endocrine organ, producing vast quantities of estradiol, progesterone, and human chorionic gonadotropin (hCG), among others. Estradiol levels rise more than 100-fold above non-pregnant levels, and progesterone surges to maintain uterine quiescence, immune tolerance, and neurosteroid balance. Testosterone, while modestly elevated during pregnancy, tends to drop postpartum, often below baseline.

Following placental expulsion, estrogen and progesterone levels fall precipitously within hours—a hormonal crash unparalleled in its speed and magnitude in any other physiological state. DHEA and testosterone levels may remain suppressed for weeks to months, particularly in breastfeeding women, whose hypothalamic-pituitary-ovarian (HPO) axis is further inhibited by prolactin and oxytocin signalling.

These abrupt hormonal shifts are not merely biochemical phenomena,they have significant clinical implications:

• Estrogen withdrawal is linked with vasomotor symptoms (e.g. night sweats, hot flushes), vaginal dryness, dysphoria, and a reduction in serotonergic tone.
• Progesterone withdrawal contributes to sleep disturbances, irritability, and anxiety through its role in GABA-A receptor modulation.
• Androgen decline, especially DHEA and testosterone, may underlie postpartum fatigue, loss of libido, muscle catabolism, and reduced cognitive drive.

Clinically, this endocrine profile mimics perimenopause or surgical menopause, albeit in an acutely condensed timeframe. The degree of symptomatic burden varies widely, and some women may remain asymptomatic, while others experience debilitating symptoms that impact maternal-infant bonding, emotional wellbeing, and overall recovery.

What is BHRT?

Bioidentical hormone replacement therapy involves the use of hormones that are structurally identical to those produced endogenously by the human body. This typically includes:

• 17β-estradiol (transdermal or sublingual formulations)
• Micronized progesterone (oral or transdermal)
• DHEA or testosterone (transdermal -Testosterone, oral – DHEA, or sublingual – both, when indicated)

Unlike synthetic hormone analogues, such as ethinylestradiol or medroxyprogesterone, bioidentical hormones interact with receptors in a physiologically precise manner, potentially offering improved tolerability and reduced metabolic risk.

Indications for BHRT in postpartum women

While not routinely prescribed in conventional postpartum care, BHRT may be considered in women with:

• Severe postpartum mood disorders (PPMD, PMDD, PPD)
• Vasomotor symptoms such as hot flushes and night sweats
• Genitourinary syndrome of lactation: vaginal dryness, dyspareunia, and atrophy
• Profound fatigue and low libido
• Postnatal depression unresponsive to SSRIs

Mood disorders

There is a growing body of evidence suggesting a link between estrogen withdrawal and postpartum depression (PPD). A small RCT by Gregoire et al. (1996) demonstrated that transdermal estradiol (200 µg/day) significantly outperformed placebo in alleviating PPD symptoms. Similarly, Ahokas et al. (2001) reported rapid symptom remission using sublingual estradiol in women with severe PPD.

Importantly, transdermal or sublingual estradiol is preferred over oral routes in the postpartum context due to the elevated risk of venous thromboembolism during this time. These routes bypass hepatic first-pass metabolism and minimise impact on clotting factors.

Neuroactive steroids and anxiety

The postpartum drop in allopregnanolone, a GABA-A modulating neurosteroid derived from progesterone, has also been implicated in postpartum anxiety and insomnia. Brexanolone, a synthetic allopregnanolone analogue, has been licensed for severe PPD, but micronized oral progesterone taken at night may offer a gentler, naturalistic alternative in milder presentations.

Urogenital symptoms

Lactational amenorrhea and hypoestrogenism often cause vaginal atrophy, irritation, and dyspareunia—collectively termed the genitourinary syndrome of lactation (GUSL). In these cases, topical estriol or low-dose vaginal estradiol is both effective and generally considered safe in breastfeeding women, with negligible systemic absorption and minimal impact on milk production or infant development.

Libido and fatigue

Low testosterone and DHEA-S are well-documented contributors to reduced sexual desire and vitality. If levels are found to be low in symptomatic women, cautious replacement with physiological doses of DHEA or testosterone may be considered, though this remains off-label in many countries.

Clinical considerations and safety

• Breastfeeding: Systemic BHRT should be avoided or used with caution. Local estrogen therapy is preferred.
• Monitoring: BHRT requires careful symptom tracking, informed consent, and monitoring of hormonal levels and side effects.
• Contraindications: Active liver disease, hormone-sensitive malignancy, and thromboembolic history must be ruled out.
• Formulations: Transdermal estradiol and oral micronized progesterone have the most favourable safety profile.

Functional and integrative perspectives

From a functional medicine standpoint, BHRT may be complemented with:

• Nutritional support: Omega-3 fatty acids, magnesium, B-complex vitamins
• Adaptogens and cortisol modulation: To support adrenal recovery
• Thyroid screening: Particularly in women with fatigue, anxiety, or a history of autoimmune disease, as postpartum thyroiditis is relatively common.

Conclusion

While not yet part of mainstream postpartum protocols, bioidentical hormone replacement therapy offers a promising, physiology-based approach to managing the hormonal aftermath of childbirth. For women suffering from severe mood changes, vasomotor symptoms, genitourinary complaints, or persistent fatigue, BHRT, when appropriately indicated and closely monitored, can significantly enhance quality of life and functional recovery. Further large-scale research is needed, but in the meantime, this therapeutic strategy warrants thoughtful inclusion in personalised postpartum care.

About The Marion Gluck Clinic

The Marion Gluck Clinic is the UK’s leading medical clinic that pioneered the use of bioidentical hormones to treat menopause, perimenopause and other hormone related issues. Founded by Dr. Marion Gluck herself, the clinic uses her method of bioidentical hormonal treatment to rebalance hormones to improve wellbeing, quality of life and to slow down ageing.

Image: Canva

Staff Writer