Hormone profile questionnaire

October 12, 2016

Hormonal Balance Questionnaire

Do you have or have you experienced in the past 6 months?…

PART A

  • A feeling you’re constantly racing from one task to the next?
  • Feeling tired yet wired?
  • A struggle calming down before bedtime or a second wind that keeps you up late?
  • Difficulty falling asleep or disrupted sleep?
  • A feeling of anxiety or nervousness – can’t stop worrying about things beyond your control?
  • A quickness to feel anger or rage – frequent screaming or yelling?
  • Memory lapses or feeling distracted?
  • Sugar cravings (you need a “little something” after each meal, usually of the chocolate variety)?
  • Increased abdominal circumference, greater than 35 inches (the dreaded abdominal fat or “muffin top” – not bloating)?
  • Skin conditions such as eczema or thin skin?
  • Bone loss (osteopenia or osteoporosis)?
  • High blood pressure or rapid heart beat?
  • High blood sugar (prediabetes, diabetes or insulin resistance)? Or shakiness between meals (blood sugar instability)?
  • Indigestion, ulcers or GERD?
  • More difficulty recovering from physical injury than in the past?
  • Unexplained pink to purple stretch marks on your belly or back?
  • Irregular menstrual cycles?
  • Decreased fertility?


PART B

  • Fatigue or burnout (you rely on caffeine to boost your energy or fall asleep while reading or watching a movie)?
  • Loss of stamina, particularly in the afternoon, from 2-5pm?
  • An atypical addiction to a negative point of view?
  • Crying bouts for no reason?
  • Decreased problem-solving ability?
  • Feeling stressed most of the time (everything seems harder than before and you have trouble coping)? Decreased stress tolerance?
  • Insomnia or difficulty staying asleep, especially between one and four in the morning?
  • Low blood pressure?
  • Postural hypotension (you stand up from lying down and feel dizzy)?
  • Difficulty fighting infection (you catch every virus you meet, particulary respiratory)?
  • Difficulty recovering from illness or surgery or healing wounds?
  • Asthma? Bronchitis? Chronic cough? Allergies?
  • Low or unstable blood sugar?
  • Salt cravings?
  • Excess sweating?
  • Nausea, vomiting or diarrhea? Or loose stool alternating with constipation?
  • Muscle weakness, especially around the knee? Muscle or joint pain?
  • Hemorrhoids or varicose veins?
  • Your blood seems to pool easily or your skin bruises easily?
  • A thyroid problem that has been treated, you feel better and suddenly you feel palpitations or have rapid or irregular heartbeats (a sign of low cortisol/low thyroid combo)?


PART C

  • Agitation or PMS?
  • Cyclical headaches (particularly menstrual or hormonal migraines)?
  • Painful and/or swollen breasts?
  • Irregular menstrual cycles or cycles becoming more frequent as you age?
  • Heavy or painful periods (heavy: going through a superpad or tampon every 2 hours or less; painful: you can’t function without ibuprofen)?
  • Bloating, particularly in the ankles and belly and/or fluid retention (in other words, you gain 3-5 lbs before your period)?
  • Ovarian cysts, breast cysts, endometrial cysts (polyps)?
  • Easily disrupted sleep?
  • Itchy or restless legs, especially at night?
  • Increased clumsiness or poor coordination?
  • Infertility or subfertility?
  • Miscarriage in the first trimester?


PART D

  • Bloating, puffiness or water retention?
  • Abnormal Pap smears?
  • Heavy bleeding or postmenopausal bleeding?
  • Rapid weight gain, particularly in the hips and butt?
  • Increased bra-cup size or breast tenderness?
  • Fibroids?
  • Endometriosis or painful periods?
  • Mood swings, PMS, depression or just irritability?
  • Weepiness, sometimes over ridiculous things?
  • Mini breakdowns? Anxiety?
  • Migraines or other headaches?
  • Insomnia?
  • Brain fog?
  • A red flush on your face (or diagnosis of rosacea)?
  • Gallbladder problems (or removal)?

PART E

  • Poor memory (you walk into a room to do something, then wonder what it was or draw a blank midsentence)?
  • Emotional fragility, especially compared to how you felt 10 years ago?
  • Depression, perhaps with anxiety or lethargy (or more commonly, dysthymia: low-grade
    depression that lasts more than 2 weeks)?
  • Wrinkles?
  • Night sweats or hot flashes?
  • Trouble sleeping, waking up in the middle of the night?
  • A leaky or overactive bladder?
  • Bladder infections?
  • Droopy breasts or breasts lessening in volume?
  • Sun damage more obvious on chest, face and shoulders?
  • Achy joints?
  • Recent injuries particularly to wrists, shoulders, lower back or knees?
  • Loss of interest in exercise?
  • Bone loss?
  • Vaginal dryness, irritation or loss of feeling?
  • Dry eyes, skin?
  • Low libido?
  • Painful sex?

PART F

  • Excess hair on your face, chest or arms?
  • Acne?
  • Greasy skin and/or hair?
  • Thinning head hair?
  • Discoloration of your armpits (darker and thicker than your normal skin)?
  • Skin tags, especially on your neck and upper torso?
  • Hyperglycemia or hypoglycemia and/or unstable blood sugar?
  • Reactivity and/or irritability or excessively aggressive or authoritarian episodes?
  • Depression? Anxiety?
  • Menstrual cycles occurring more than every 35 days?
  • Ovarian cysts?
  • Midcycle pain?
  • Infertility or subfertility?
  • Polycystic ovarian syndrome

PART G

  • Hair loss, including of the outer third of your eyebrows and/or eyelashes?
  • Dry skin?
  • Dry, straw-like hair that tangles easily?
  • Thin, brittle fingernails?
  • Fluid retention or swollen ankles?
  • An additional few lbs or 20 that you just can’t lose?
  • High cholesterol?
  • Bowel movements less often than once a day or you feel you don’t completely evacuate?
  • Recurrent headaches?
  • Decreased sweating?
  • Muscle or joint aches or poor muscle tone?
  • Tingling in your hands and feet?
  • Cold hands and feet? Cold intolerance? Heat intolerance?
  • A sensitivity to cold (you shiver more easily than others and are always wearing layers)?
  • Slow speech, perhaps with a hoarse or halting voice?
  • A slow heart rate or bradycardia (fewer than 60 bpm and not because you’re an elite athlete)?  Lethargy?
  • Fatigue, particularly in the morning?
  • Slow brain, slow thoughts? Difficulty concentrating?
  • Sluggish reflexes, diminished reaction time?
  • Low sex drive and you’re not sure why?
  • Depression or moodiness?
  • A prescription for an antidepressant but you’re still not feeling like yourself?
  • Heavy periods or other menstrual problems?
  • Inferilty or miscarriage? Preterm birth?
  • An enlarged thyroid/goiter? Difficulty swallowing? Enlarged tongue?
  • A family history of thyroid problems?

PART A: High Cortisol

This is by far the most common hormone imbalance affecting modern women. 5+ symptoms: Chances are that you are high in cortisol.
3-4: You may need to address this hormone imbalance.
<3 or unsure: Consider testing your cortisol level.

PART B: Low Cortisol

You can have both high and low cortisol—even on the same day, within a twenty-four-hour period. 5+ symptoms: You are likely low in cortisol.
<5: Consider checking your cortisol level.

PART C: Low Progesterone

Low progesterone is the second most common hormone imbalance experienced by women over 35. 5+ symptoms: You are probably low in progesterone.
3-4: You may need to address this hormone imbalance.
<3 or unsure: Consider testing progesterone level on day 21 of your cycle

PART D: Excess Estrogen

Wherever you fall on the spectrum, you should become more aware of your possible exposure to xenoestrogens.

5+ symptoms: Probably high in estrogen. Estrogen dominance affects 80% of women over 35. 3+ symptoms: High estrogen is a significant possibility.

PART E: Low Estrogen

Most women don’t notice a significant drop in estrogen until their forties or even fifties. 5+ symptoms: You are probably low in estrogen.
3+: There’s a good chance you are low in estrogen.

PART F: Excess Androgens

This is the most common hormonal reason for infertility in women.
5+ symptoms: You are very likely high in androgens.
3-4: You might have excess androgens and this hormone imbalance should be addressed. <3 or unsure: Consider testing free testosterone level.

PART G: Low Thyroid

5+ symptoms: You likely have a thyroid problem. Consider testing your thyroid hormones, particularly with the most sensitive tests that measure Thyroid-Stimulating Hormone (TSH), free triiodothyroxine (T3), and reverse T3.

3-5: You might have a thyroid problem.

– Adapted from Dr. Sara Gottfriend, MD

 

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