Mid-Life Wisdom

Menopausal issues…while some women sail through this stage with no problems, many suffer multitude of symptoms. Hot flashes and mood swings, depression, vaginal dryness, painful intercourse, dry skin, night sweats, sleeplessness and irritable bladder symptoms, brain fog, memory laps….the list goes on. Here are just a few points to consider when you are thinking about HRT so you can have an informed discussion with your health care provider. 1.Make sure you understand the pros and cons and understand the research papers. Many researches have demonstrated the benefits and risks HRT may cause.[1]  Because hormones are so complex, prescribing for Hormone Replacement Therapy (HRT) requires much thought.  If someone tells you that you should take or not take estrogen after a 5-minute discussion, get a second opinion. Benefits of HRT doesn’t stop at reduced menopausal symptoms.  Other benefits of hormone replacement therapy for post-menopausal women, include:
  • Increased elasticity of the blood vessels, allowing them to dilate (widen) and let the blood flow more freely throughout the body
  • Decreased risk of osteoporosis
  • Decreased incidence of colon cancer
  • Possible decreased incidence of Alzheimer’s disease
  • Possible improvement of glucose levels
  • Possible reduction in risk of cardiovascular disease
Risks of HRT include:
  • For women with an intact uterus, Increased risk of endometrial cancer (But only when estrogen is taken without progestin). For women who have had a hysterectomy (removal of the uterus), this is not a problem.
  • Increased risk of breast cancer with long-term use
  • Increase in inflammatory markers (such as C-reactive protein)
  • Increased risk of blood clots and stroke, especially during the first year of use in susceptible women
  • Increased risk of cardiovascular disease (including heart attack)
So all that came from numerous research data…. but wait! How does estrogen protect the heart, yet at the same time increase the risk of cardiovascular disease at the same time? This is where we need to read research carefully and understand what happened. Most of the studies that demonstrated cardiovascular benefits were conducts as observational studies prior to 2000. Observational studies were viewed as inferior to randomized, controlled trials (RCTs) as earlier observational studies tended to inflate positive treatment effects. However, understanding this flaw, researchers improved on methodology used for this type of studies. Later, it was found that observational studies conducted between 1985 to 1998 were methodologically improved, and the effects of treatment in observational studies vs. RCTs were similar in most areas. (Benson K 2000:342:18)   RCTs also have their own biases, depending on the subjects. The Women’s Health Initiative (WHI), was the first study to come out against past evidence, and stated that women on HRT, not those on estrogen alone, had a slightly increased relative risk of heart events[2]. This only applies to women in the first year of taking HRT. Later, this data was re-analyzed, and reported that the increase in cardiac risk was seen only among women who were 20 or more years beyond menopause at the time they joined the study.[3]  And in 2007, the original author and investigators revised their report. The conclusion now indicates that women who started HRT within 10 years of the onset of menopause had reduced their risk of coronary artery disease, while those who started after that slightly increased their risk.[4] This was confirmed by an observational study, the Nurses’ Health Study.[5]  So what happened to WHI study? Well, the sample subjects were reported as healthy. But looking into the details, the median age of the women was 63. Only 10 percent of the study subjects were between age 50-54, 70% were between ages 60-79. And we know that as we age, women are more susceptible to heart diseases. Further, fully 70 percent of the study participants were seriously overweight, and half were obese. Nearly 50% were smokers or ex-smokers, and 35 percent had been treated for high blood pressure. Hardly a “healthy” population?  Yet, we rushed into making a judgement call against hormone use. Some practitioners can be very biased about HRT one way or another. Speak with someone who is well versed on this topic and able to help you weigh out the pros and cons. 2.  HRT should be a very personalized process. No two women are alike. Before starting HRT, it’s always a good idea to have baseline hormone levels measured. This can be done via serum, saliva, or urine tests. If you are considering transdermal HRT, saliva or urine test may be the best. When I was looking for options in treating my night sweats, I opted for the Complete Female Panel through DUTCH urine test. I chose this method because I was curious about how I metabolize hormones. This would be important information to have if I do decide to use HRT to manage menopause. Why am I concerned about hormone metabolism? Generally, we want estrogens to metabolize through methylation into 2-hydroxy-estrone. This is the “good” metabolite.  Some women may have issues metabolizing estrogen and any estrogen given is metabolized into 4 hydroxy-estrone and 16-hydroxy-estrone, associated with DNA damage and cancer development respectively. So, it is a good idea to confirm if methylation is going to be an issue. Our hormonal symphony is not just about estrogen and progesterone. You will also want to know about other hormones too. One of them is your four-point cortisol relating to your stress levels. Sometimes because of the cortisol demands, we experience what’s known as Cortisol Steal. This is where other hormones are shunted to make more cortisol rather than sex hormones. By testing, my results provided me with all the information I needed to understand what was happening in my body. 3. Understanding the differences between Bio-identical hormones vs. Synthetic hormones.  Both are derived from a laboratory. Bio-Identical means the hormone was made to have the same chemical structure as your natural hormones.  A synthetic hormone is not the same in chemical structure as those produced by your own body; close, but not the same.  Both bio-identical hormones and synthetics are available commercially. However, bio-identicals can also be made at your compounding pharmacy. The benefit of compounded formulation is that you can have the hormones suitable for you at the exact dosing as prescribed. For example, if the physician prescribes a combination of two types of estrogen, Estradiol and Estriol (known as Bi-est) at 50:50 for 2.5mg daily. You will not find this in a commercial formulation, it must be compounded. Note that most of the studies conducted in the past were based on women using synthetic hormones. Namely Premarin for estrogen (Conjugated Estrogen from mare’s urine), and Provera, medroxyprogesterone acetate (MPA), added to estrogen for women with intact uterus. Many are now questioning the wisdom of using synthetic hormones. We don’t really know what direct effects these synthetics have in our bodies. Hormones have specific receptor sites, and for most hormones we have receptor sites throughout our bodies. Synthetic hormones will attach to some receptor sites, but not all (e.g. MPA was designed for endometrium only). This produces incomplete messages to the body, and potential side effects. Compared to bio-identical hormones for which the body fully recognizes the molecule and is able to utilize it, I would probably opt for bio-identicals for now. 4.  Understanding Other Hormones Involved The steroidogenic pathway is fascinating to me. Have a look at the graph! Did you know all our sex hormones originate from cholesterol? Aside from estrogen and progesterone, some people believe taking a hormone from higher up the pathway may be better. For example, pregnenolone or DHEA.  This may seem like a good idea at first because wouldn’t these hormones simply metabolize into the appropriate hormone that your body requires?  Unfortunately, there is no guarantee they will convert into the appropriate hormones as required. First, each enzymatic step must be fully functioning. Second, as in my case, stress causes these hormones to be converted to cortisol. Symptoms of high cortisol are surprisingly like menopause: low energy, night sweats, irritability, and brain fog. Now it’s adding to the very symptoms you are trying to treat! 5. Monitor, Monitor, Monitor So now you are on HRT. Does that mean you just keep on using it and not worry about it, ever?  Like other drugs, you want to pay attention to how you are feeling, and how your body is responding to this new addition. Have your hormone levels checked regularly as our bodies change over time, and biochemistry can change due to external factors. If you are thinking about ways to address menopausal symptoms, make sure you discuss this with your health care professional and have all your questions answered. HRT is a serious health matter, be wise!
[1] Cleveland Clinic Article: Estrogen and Hormones. https://my.clevelandclinic.org/health/articles/16979-estrogen–hormones [2] Roussouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Womenès Health Initiative Randomized Controlled Trial. JAMA. 2002;288:321-33. [3] Speroff L. A clinicianès review of the WHI-related literature. Int J Fertil. 2004; 49:252-67. [4] Rossouw JE, Prentice RI, Manson JE, et al. Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA. 2007; 297:1465-77. [5] Grodstein F, Manson JE, Stampfer MJ. Hormone therapy and coronary heart disease: the role of time since menopause and age at hormone initiation. J Women’s Health. 2006;15:35-44.

Polycystic Ovary Syndrome (PCOS)

Originally Posted 3/1/2018

A client came to me because her birth control pills are not working. Did I just get your attention? Birth control pills (BCPs) are generally used to prevent pregnancy. They are also used for other hormonal conditions. This client was using BCPs for Polycystic Ovary Syndrome (PCOS).

I’ve had a lot of questions on this lately, Please note this is not meant as medical advise. This is for information only. For treatment specific for you, discuss your condition with your physician or qualified health care professional.

PCOS is a common endocrine disorder in women of reproductive age. In the US, PCOS affects nearly 10% of the female pop……………..

PCOS is a common endocrine disorder in women of reproductive age. In the US, PCOS affects nearly 10% of the female population. 85% of the women with androgen excess and hirsutism have PCOS.  For diagnosis, the patient must have 2 of the 3 symptoms below:

  1. Irregular periods – infrequent, irregular, or prolonged menstrual cycles.
  2. Clinical or biochemical signs of excess androgen activity
  3. Polycystic ovaries on ultrasound

Patients with PCOS have different menstrual cycle physiology vs. what is considered normal. For example, there may be increased circulation luteinizing hormone (LH), and decreased follicle stimulating hormone (FSH) leading to excessive production of androstenedione and testosterone (androgens). With low FSH, the follicles grow but do not mature, leading to degeneration of developing follicles. Patients often have low progesterone or even absent, leading to increased secretion of gonadotropin-releasing hormone (GnRH). This further contributes to high LH and low FSH in a vicious cycle.

Many researchers believe that PCOS has a hereditary component. It is suggested that women with PCOS are born with a gene that triggers higher than normal levels of androgen and/or insulin. Genetics aside, other factors may play a role in the development of PCOS include: Excess insulin (increase androgen production by decreasing sex hormone binding globulin (SHBG) levels; low grade inflammation (stimulates polycystic ovaries to produce androgens); Excess Androgen (ovaries produce abnormally high levels of androgen, resulting in hirsutism and acne).

Environmental toxins may potentiate the development of PCOS. Phthalates, Bisphenol-A (BPA), cadmium and mercury toxicities have been shown to be related to PCOS. These toxins alter the hormones to cause anovulation, develop insulin resistance, and increase level of androgens.

Stress may be a contributing factor to PCOS. Many women with PCOS cannot process cortisol effectively, leading to elevated cortisol levels in the body. Further, when women are under stress, prolactin is released. If too much, this may impede the ovaries from producing the right balance of hormones.

Hypothyroidism may also be a cause of PCOS. Studies have found that 27% of women with PCOS had elevated thyroid antibodies. Another study was conducted on teenage girls with PCOS who were treated for hypothyroidism. The study demonstrated that the ovarian cysts resolved once hypothyroidism was reversed. Our body truly is a hormonal symphony!

Some symptoms of PCOS often develop around the time of the first menstrual period during puberty. Signs and symptoms of PCOS vary greatly from patient to patient. Aside from those used for diagnosis, patients may also experience the following:

  • obesity or inability to lose weight with weight gain usually being around the waist as opposed to overall weight gain.
  • infertility/recurrent miscarriage
  • Hirsutism
  • Oily skin/acne
  • Hair loss (male-pattern baldness)
  • Skin tags
  • Depression/irritability/tension
  • Sleep apnea
  • Pelvic pain
  • Elevated insulin level or insulin resistance
  • Decreased SHBG
  • Abnormal lipid profile
  • Hypertension

Back to the BCP client. What are some other options for her?

  1. Fiber-Yes, fiber! Soluble fiber lowers blood sugar, blood pressure and cholesterol.
  2. Low Glycemic Index diet and exercise-study with 18 women with PCOS on a 6 month program showed 11% reduction in central fat, 71% improvement in insulin sensitivity, 33% decrease in fasting insulin level, 39% decrease in LH levels, and 50% of the women started ovulating. There are studies showing that exercise alone improved the condition without other interventions.
  3. Stress reduction – To reduce cortisol level
  4. Essential fatty acids – Decreases inflammation, and slows down the absorption of carbohydrates into the blood.
  5. Nutrient supplementation – Vitamin D deficiency is common in women with PCOS. d-chiro-inositol lowered insulin and testosterone levels in study subjects. N-acetyl-cysteine, when used in conjunction with clomiphene increased ovulation and pregnancy rates vs. clomiphene alone.
  6. Herbal therapies – Use of adaptogens for stress improves stress response. Adaptogens include Ashwagandha, ginseng, Rhodiola, Schizandra. Black cohosh binds to estrogen receptors and lowers LH. Chasteberry reduces prolactin secretion. Saw Palmetto inhibits the conversion of testosterone to DHT and decreased androgen effects. Nettle root binds and increases SHBG, decreasing the amount of free testosterone.  Green Tea increases SHBG, and decreases testosterone. Licorice root can decrease testosterone synthesis, but can also increase blood pressure. Spearmint Tea – lowers testosterone level. White Peony increases progesterone, reduces testosterone, modulates estrogen and prolactin.
  7. Detoxification – Test for toxic metals and detoxify if needed.
  8. Medications
  9. Anti-androgen medications such as spironolactone
  10. Testosterone metabolism blockers (finasteride)
  11. GNRH antagonists (leuprolide)
  12. Insulin Resistance regulator (metformin)
  13. Progesterone
  14. Surgery: Ovarian wedge resection or laparoscopic ovarian drilling.

My client and I had a long, detailed discussion about her history, adn we agreed that diet and exercise modification may be the logical approach as she comes off her BCP.  Interestingly, lifestyle modification was not discussed with her when she was first diagnosed a year ago.  Yet, lifestyle modification is the one thing that you have control over, and could really help you no matter what disease.  As much as you’d like to think so, there is no magic bullet.  Even with prescription medicines, you can have a better outcome if you have a healthy lifestyle. For the best options, speak with a health care professional who can help you to understand your condition and work with you to address them at the root cause.