Menopause has gotten a bad rap. Women in their 40s and 50s who have any symptoms – from moodiness to insomnia and headaches – may believe that it’s a normal part of aging and there’s not much they can do about it.
Fluctuating hormones caused by the normal decline of ovarian function can trigger the typical symptoms associated with menopause. One approach is to give the body a drug that mimics ovarian function, such as estrogen or hormone replacement therapy. This was a common treatment, until multiple studies showed increased risk of urinary incontinence, stroke, dementia and breast cancer from using menopausal hormone therapy.
Fortunately, there is another approach to improving the body’s ability to adjust to hormone fluctuations that doesn’t increase the risk of breast cancer and dementia. This approach looks at the other organ systems that are involved in addition to the ovaries. For instance, hot flashes will be greatly exaggerated in a woman who has blood-sugar problems – even if those don’t show up on a standard blood test.
Some women use bioidentical hormones instead. While they appear to have fewer immediate side effects, there is no evidence that they have fewer long-term risks.
At a recent functional medicine conference I attended, there were several discussions on how to address hormone “saturation” – the experience many women have after being on bioidentical hormones for several years and then having a return of their previous symptoms. We’re learning that underlying imbalances in gut function, adrenal hormones and blood sugar can have a major effect on a woman’s experience of her perimenopausal years.
IT’S NOT JUST THE OVARIES
Technically, menopause occurs when a woman hasn’t had a period for 12 consecutive months. The symptoms that can occur for years before that are due to the ovaries becoming less predictable in their hormone production. This means that estrogen levels can spike and fall like a roller coaster.
Unfortunately, once a woman knows that her hormones are fluctuating, she is likely to explain away all her symptoms as perimenopausal. But ovaries are not the only glands affected by hormone changes. The pancreas, thyroid and adrenal glands play key roles in determining how easy or difficult the perimenopausal years will be.
The most common, end-stage effect of pancreas dysfunction is diabetes. But long before the body reaches a disease state, there are more subtle effects. For instance, a woman with low blood sugar or insulin resistance will experience more severe hot flashes than a woman with normal blood-sugar regulation.
Following are common symptoms associated with perimenopause and factors that can determine the severity of those symptoms.
• Heavy or frequent periods. These can be worsened by blood-sugar and thyroid imbalances that don’t show up on routine blood work. Checking free and total levels of T3 and T4 as well as thyroid antibodies can be helpful.
• Hot flashes or low libido. Underlying adrenal stress can result in cortisol levels that are too high or too low, or reduced DHEA (precursor to several hormones). Cortisol levels are best tested with multiple saliva samples over a 24-hour period.
• Insomnia. With or without hot flashes, insomnia is often due to chronic stress, which causes the adrenals to produce excess cortisol.
• Mood changes and brain fog. Moods can be affected by the stress hormone cortisol as well as imbalanced neurotransmitters. Neurotransmitters such as serotonin are made primarily in the gut and can be evaluated with a urine test. Low levels of serotonin can also increase overall pain levels.
• Hair loss and weight gain. There may be underlying thyroid stress that doesn’t show up on routine blood work but requires a more detailed look at free and total levels of T3 and T4 and thyroid antibodies.
Once these underlying issues are identified, they can be addressed through food choices, lifestyle factors and specific supplements.
Marina Rose, D.C., is a functional medicine practitioner, certified clinical nutritionist and chiropractor with an office at 4546 El Camino Real in Los Altos. For more information, visit DrMarinaRose.com.
Have you recently experienced a major stress in your life, be it illness, job, death, children, etc? After this stress, have you felt as though you just cannot seem to get yourself together, or at least back to where you used to be? Are you usually tired when you wake up, but still “too wired” to fall asleep at night? Is it hard for you to relax or to get exercise? Do you find that you get sick more often and take a long time to get well? If so, then you, like many other Americans may be experiencing symptoms of Adrenal Fatigue.
Adrenal fatigue is not a new condition. People have been experiencing this condition for years. Although there is increasing physician awareness, many are not familiar with adrenal fatigue as a distinct syndrome. Because of this lack of knowledge, patients suffer because they are not properly diagnosed or treated.
Adrenal fatigue is a condition in which the adrenal glands function at a sub-optimal level when patients are at rest, under stress, or in response to consistent, intermittent, or sporadic demands. The adrenal glands are two small glands that sit over the kidneys and are responsible for secreting over 50 different hormones—including epinephrine, cortisol, progesterone, DHEA, estrogen, and testosterone. Over the past century, adrenal fatigue has been recognized as Non-Addison’s hypoadrenia, subclinical hypoadrenia, neurasthenia, adrenal neurasthenia, and adrenal apathy.
Generally patients who present with adrenal fatigue can often be heard saying, “After______, I was never the same.” The onset of adrenal fatigue often occurs because of financial pressures, infections, emotional stress, smoking, drugs, poor eating habits, sugar and white flour products, unemployment and several other stressors. After experiencing many of these events over a long period of time, the adrenal glands tend to produce less cortisol, the body’s master stress hormone. Cortisol’s main role in the body is to enable us to handle stress and maintain our immune systems. The adrenal gland’s struggle to meet the high demands of cortisol production eventually leads to adrenal fatigue.
Patients with adrenal fatigue have a distinct energy pattern. They are usually very fatigued in the morning, not really waking up until 10 AM, and will not usually feel fully awake until after a noon meal. They experience a diurnal lull in their cortisol (the stress hormone produced by the adrenal gland) and as a result, they feel low during the afternoon, generally around 2-4 PM. Patients generally begin to feel better after 6 PM; however, they are usually tired after 9 and in bed by 11 PM These patients find that they work best late at night or early in the morning.
Some key signs and symptoms of adrenal fatigue include salt cravings, increased blood sugar under stress, increased PMS, perimenopausal, or menopausal symptoms under stress, mild depression, lack of energy, decreased ability to handle stress, muscle weakness, absent mindedness, decreased sex drive, mild constipation alternating with diarrhea, as well as many others.
Although there no specific tests that will provide a true diagnosis of adrenal fatigue there are tests that may contribute to an assessment, such as a postural hypotension test, an AM cortisol test, or an ACTH stimulation test. It is customary for a physician to assess the adrenals together with thyroid tests to rule out insufficiency, which sometimes occurs in long-standing hypothyroidism.
A single determination of plasma cortisol or 24-hour urinary free cortisol excretion is not useful and may be misleading in diagnosing adrenal insufficiency. However, if the patient is severely stressed or in shock, a single depressed plasma cortisol determination is highly suggestive. An elevated plasma ACTH level in association with a low plasma cortisol level is diagnostic.
Treatment for adrenal fatigue is relatively simple. Lifestyle modifications can be initiated to treat this condition. Simple changes such as more laughter (increases the parasympathetic supply to the adrenals), small breaks to lie down, increased relaxation, regular meals, exercise (avoiding any highly competitive events), early bedtimes and sleeping until at least 9 AM whenever possible can all benefit those experiencing adrenal fatigue.
A diet that would be conducive to treating adrenal fatigue includes one that combines unrefined carbohydrates (whole grains) with protein and oils (nuts and seeds) at most meals—olive, walnut, fiber, flax and high-quality fish oil. It is also important for patients to eat regular meals, chew food well, and eat by 10 AM and again for lunch. Patients should look to avoid any hydrogenated fats, caffeine, chocolate, white carbohydrates, and junk foods. Diets should have a heavy emphasis on vegetables. It may be of additional benefit that patients add salt to their diet, especially upon rising and at least a half-hour before their lowest energy point of the day. (Preferably, 1/8 to 1/2 teaspoonful of sea salt, Celtic salt, or sea salt w/kelp powder added to an 8 oz glass of water). In adrenal fatigue, one should not follow the USDA’s Food Guide Pyramid, as these patients tolerate fewer carbohydrates and need more protein.
The addition of nutritional supplements may also offer additional benefits to patients experiencing adrenal fatigue. They should consider the addition of:
- Vitamin C 2,000-4,000 mg/day Sustained Release
- Vitamin E w/mixed tocopherols 800 IU/day
- Vitamin B complex
- Niacin (125-150 mg/day) – as inositol hexaniacinate
- B-6 (150 mg/day)
- Pantothenic acid (1200-1500 mg/day)
- Magnesium citrate (400-1200 mg)
- Liquid trace minerals (zinc, manganese, selenium, chromium, molybdenum, copper, iodine)– calming effect
- If depression is present – Add SAM.e 200 mg bid; DL-Phenylalanine (DLPA) 500 mg bid
Some herbal remedies that have been noted as possible therapies include Licorice, Ashwagandha, Maca, Siberian Ginseng, Korean Ginseng. Note: Licorice can and, if taken over time, does have a propensity to elevate blood pressure. It should not be used in persons with a history of hypertension, renal failure, or who currently use digitalis preparations such as digoxin.
Under the supervision of a physician hormone supplementation with DHEA, Pregnenolone, and Progesterone may also offer some benefits. There are several glandular extracts on the market that contain adrenal, hypothalamus, pituitary, thyroid, and gonadal that are also often recommended.
Sometimes the initiation of hydrocortisone (Cortef®) may be necessary as a replacement hormone when cortisol is not being produced by the adrenals. While the initiation of corticosteroids, such as hydrocortisone may have quick and dramatic results, they can sometimes make the adrenals weaker rather than stronger. As a result, the initiation of hydrocortisone is usually a last resort. It is important to note that patients may have to undergo treatment for 6 months to 2 years.
While a cortisol measurement may be helpful to confirm any thoughts or ideas that a patient may have decreased adrenal function, typically blood cortisol levels would be tested along with blood levels of potassium, and sodium. If the pituitary gland is the cause of adrenal failure electrolyte levels are usually normal. Practitioners usually pay attention to extremely low cortisol levels, which generally diagnoses Addison’s disease—a condition in which the adrenal glands are completely depleted, also considered a medical emergency.
THE MANY MYTHS OF hypothyroidism
By Kenneth Blanchard, M.D.
Read the transcript of Dr. Kenneth Blanchard (coming soon!)
Thyroid disorders are extremely common and, in my opinion, are often undiagnosed or poorly treated due to a total reliance on laboratory testing and some-long standing but fundamentally flawed principles of treatment. Of the many standard teachings in this area, I believe the most common mistake physicians make in every day practice is to “rule out” hypothyroidism on the basis of laboratory tests .alone, especially use of the TSH (thyroid-stimulating hormone) test. There are few teachings in medicine more sacrosanct than an elevated TSH test as the “gold standard” for a diagnosis of hypothyroidism. I believe that there are millions of patients (mostly women) who would benefit from thyroid hormone but who are not treated because of results from this test.
A common story in popular magazines is “The Diagnosis your Doctor Will Probably Miss”. The story is that many individuals (mostly women) with symptoms like fatigue, depression, muscle aching, constipation, etc., see a physician who orders a T4 test and, on the basis of this, are told that hypothyroidism has been “ruled out”. The “smarter physician” also orders a TSH test because this is more sensitive and often reveals an abnormality even when T4 results are normal. While this scenario can happen, I believe it is far more common to find both T4 and TSH tests registering normal in the face of significant clinical hypothyroidism. In my practice, if the medical history and physical findings are highly suggestive of hypothyroidism, patients are treated with a therapeutic trial of the hormone and the results are overwhelmingly positive. As of early 2001, opinion in this field is still that the TSH test is absolute, although the upper limit of normal has been questioned, which is starting to include more individuals in this diagnosis.
Another common teaching that I believe to be fundamentally wrong is that all treatment should be done with 1OO% T4 hormone L-thyroxine (Synthroid, Levoxyl, etc.). The normal secretion of the thyroid gland contains small amounts of the T3 hormone (triiodothyronine) and I believe that giving some T3 is an important part of effective treatment for most individuals. The standard medical view is the T3 is unnecessary because T4 is converted to T3 in the body. But many patients taking the standard 100% T4 hormone report chronic fatigue, depression, menstrual abnormalities, fibromyalgia, irritable bowel syndrome (IBS), restless legs and other complaints, and these complaints are almost always better when some T3 is added. This particular teaching in medicine has been breached by a paper appearing in the New England Journal of Medicine in 1999 in which patients on standard 100% T4 were given some T3 and all patients felt better mentally and physically. The use of T3 has been standard in my practice since 1990 and I am quite sure it will be routine in the near future, although many physicians at this point still do not use T3 in addition to T4.
Thyroid hormone activity has a variety of complicated interactions with other hormones. For instance, I believe that thyroid hormone treatment is effective in PMS (premenstrual syndrome) despite the fact .that there are major studies in the literature which say this is not true. It is most likely that PMS fundamentally represents a deficiency of progesterone production prior to menstrual flow, but I believe that normalization of thyroid deficiency enables the woman to make more progesterone, thus relieving the symptoms. The woman in her mid-forties who is just starting to have irregular periods and notices some hot flashes, sweats and sleep disturbance at night can often be treated simply by optimal thyroid replacement, specifically including some T3. While such symptoms are commonly regarded as estrogen deficiency and will respond to the use of estrogen, I find that many such women have normalization of symptoms on proper thyroid therapy alone. The fundamental reason for this may well be that normalization of thyroid function enhances estrogen production by the ovaries themselves and by, the increased production of estrogen in fat tissue from adrenal hormone precursors.
If a woman at this age has frequent migraine headaches that are clearly related to the menstrual cycle (essentially premenstrual), these will often respond to balanced T4- T3 treatment, again possibly because of raising and/or stabilizing levels of estradiol. While clinical depression is not an integral part of menopause, there are many issues at this time of life that can cause emotional upset or depressed feelings. Again, use the T3 hormone in a physiologic way can be very helpful. Indeed, much of the current use ofT3 is in the hands of psychiatrists, who. use it as an adjunctive treatment for depression that is not responding well to standard antidepressants. Although this can be extremely effective, psychiatrists tend to use pharmacologic doses rather then physiologic doses. In other words, they exceed the amount needed to reproduce normal hormone balance. For virtually every purpose, a physiologic dose is desirable since excessive doses yield no additional benefits. I also disagree with the use of Armour thyroid by itself for the same reason, that it does not contain a physiologic balance of T4 to T3. The human thyroid produces roughly 95% T4 and 5% T3. Armour thyroid is an animal thyroid that contains 80% T4/20% T3. People who take Armour thyroid usually feel better for a short period of time because they were deficient in T3 but, after a period of time, the Armour thyroid will cause a T4-T3 imbalance at tissue level and a variety of undesired symptoms can then develop over time. One can get a better balance by giving some T4 with the Armour.
Some doctors are reluctant to prescribe (and some women reluctant to take) thyroid hormones in the belief that this will somehow increase the risk of osteoporosis. . I personally do not believe that there is good evidence for this, although my guess would be that excessive thyroid hormone does contribute to bone loss. Since there is no benefit in going above the normal physiologic levels of thyroid hormone, following the TSH result and clinically monitoring the patient will prevent overdose and resultant adverse effects.
Every organ system in the body is affected to some degree by treatment with thyroid hormone. I believe that the proper treatment of hypothyroidism with physiologic amount ofT4 and TI is critical in managing many complex medical problems at mid-life. If treatment is carefully monitored, there are no adverse effects. Management of hypothyroidism with T4 and TI is significantly more complicated than the standard 100% T4 therapy that has been used for the past 30 years or so. TI dosage must be monitored and altered precisely for optimum effect and this must be done by the use of compounded T3 time-release capsules. These are almost always made in units of 1OO capsules for practical reasons. Patients are initially seen every three months in order to adjust the dosage for the next prescription of T3. Another practice that will eventually become standard in this field is the adjustment of thyroid dosage for seasonal change, i.e., higher dosage in the colder weather and reduced dosage in the warmer weather.
Once dosage has been adjusted over 3 to 5 3-month visits and everything appears stable, visits are done at 6-7 month intervals. Patients must be ready to keep their appointments and take the medication exactly as directed. At the present time, there are many patients on a waiting list so that patients who drop out of the treatment plan fall back to the end of the list. Patients who have difficulty with the practices outlined above should stay with their current therapy.
By Power-Surge guest:
Kenneth Blanchard, M.D
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