If you have severe asthma, you probably rely on inhalers or medicine to open your airways so you can breathe on a fairly regular basis. You’re also no stranger to the doctor’s office or — for severe attacks — the emergency room.
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And if you were assigned female at birth (AFAB), you’re more likely to find yourself in this situation.
“Females are hospitalized for asthma twice as frequently as males, and their mortality is twice as high,” says pulmonologist Neha Solanki, MD.
Could sex hormones, which rise and fall throughout our lives, be the reason?
Research shows that lung function is affected when:
- Estrogen levels are higher, which happens after puberty for females.
- Testosterone levels are lower, which happens before puberty for males.
“The evidence linking the sex hormones to asthma continues to grow,” Dr. Solanki states. She breaks down the research we have to date on this topic — and what it could mean for your treatment options.
Asthma through the years
Asthma is a curious illness. The statistics around prevalence, severity and hospitalizations jump back and forth based on age.
“Up to age 14, males are more likely to need office and ER visits, as well as hospitalization, for asthma,” Dr. Solanki notes. “But asthma prevalence, severity and hospitalizations are greater for older females, especially those 40 to 60 years of age.”
Estrogen levels start falling after menopause. “The research suggests menopause may actually protect against severe asthma,” she adds.
Cue another role reversal. Males tend to bear the brunt of their asthma later in life, probably because their testosterone levels decline with age.
Can hormones affect your breathing?
“The current research strongly suggests that sex hormones affect asthma,” Dr. Solanki reiterates. “But how exactly they affect the lungs is still poorly understood.”
One theory is that sex hormones affect the pace at which hair-like cilia clear mucus out of the airways.
Dr. Solanki underscores that, “Until the exact mechanism is identified, the research suggests that doctors should consider factors that impact the sex hormones — like age and personal medical history — when treating people for asthma.”
The power of sex hormones
Up to this point, we’ve been talking about symptom severity in general terms. But it’s important to realize just how significantly sex hormones may impact people living with severe asthma. So, let’s put a number to it: One-third of females of reproductive age find that their asthma symptoms get worse immediately before getting their period.
One-third is a lot of people, and the result — more visits to the ER — is no small thing. The physical and emotional resources (not to mention the time and money) poured into managing severe asthma can be draining.
And there’s more. Asthma prevalence is also higher in people who get their period early in life, have multiple pregnancies and/or have hormonal conditions like polycystic ovary syndrome.
Asthma and oral contraceptives
If hormone levels can impact your asthma symptoms, you may be wondering: What happens to people who take hormonal birth control?
In a study, researchers found that people who took oral contraceptives had a 14.3% risk of developing asthma in their lifetime. Females who didn’t take birth control had a lifetime risk of 8.8%.
But wait! It gets more complicated.
“We think birth control pills may actually benefit some people who get premenstrual asthma,” Dr. Solanki adds. “If they take it because their period is irregular, it may reduce their hormonal peaks. But studies have been inconclusive, and more research is needed.”
Endometriosis and asthma
“Both asthma and endometriosis are related to an imbalance of the sex hormones — and estrogen, in particular,” Dr. Solanki explains. In fact, there’s growing evidence to suggest that people who are transmasculine (and take testosterone as part of their transition process) experience endometriosis at higher rates than cisgender (people whose gender identity corresponds with what they were assigned at birth) women do.
Research suggests that there’s an association between asthma and endometriosis. While research is ongoing, there’s early evidence to suggest the two conditions may be genetically linked.
Can hormonal imbalances trigger asthma?
You may be noticing a pattern here. The available research tells us that if your body grows and develops in a typical way, changing levels of sex hormones may impact your experience of asthma over the course of your life. And if your hormones are imbalanced — when, for whatever reason, they aren’t behaving as expected for a person your age — you may be even more likely to experience severe asthma symptoms.
If you’re living with severe asthma, that might be a scary thought. So, what can you do about it?
How does this information impact you?
If you were assigned female at birth, you might be wondering: Should I stop taking birth control pills?
“We don’t want patients to just stop taking oral contraceptives,” Dr. Solanki stresses. “They’re effective for preventing pregnancy and managing certain chronic conditions, and most people tolerate them well.”
In fact, oral contraceptives may keep premenstrual asthma symptoms from worsening at the end of your menstrual cycle.
“We’re simply asking patients to be vigilant,” she says. “Tell your doctor if you notice more asthma attacks while on birth control pills. If you feel like your contraception method is having a negative impact on your health, your provider can help you decide what alternative is right for you and your situation.”
After menopause, your asthma will likely improve. But if hot flashes or other symptoms become unbearable during the transition, will it be safe to take hormone replacement therapy (HRT)?
Because HRT contains estrogen, Dr. Solanki notes that it may temporarily worsen your asthma. But don’t take that as a sign that you shouldn’t take a prescribed medication. Instead, watch your symptoms, and alert your provider if you have any concerns.
“Hopefully, randomized, controlled trials will lead to better recommendations soon,” she says.