Think You're Goin' Crazy During Perimenopause?

You are. We lose our minds, can't remember sh%@,  & don't sleep restoratively. --SG


Role of psychiatric comorbidity on cognitive function during and after the menopausal transition
Jeanne Leventhal Alexander†, Barbara R Sommer, Lorraine Dennerstein, Miglena Grigorova, Thomas Neylan, Krista Kotz, Gregg Richardson and Robert Rosenbaum

While cognitive complaints are common during the menopausal transition, measurable cognitive decline occurs infrequently, often due to underlying psychiatric or neurological disease. To clarify the nature, etiology and evidence for cognitive and memory complaints during midlife, at the time of the menopausal transition, we have critically reviewed the evidence for impairments in memory and cognition associated with common comorbid psychiatric conditions, focusing on mood and anxiety disorders, attention-deficit disorder, prolonged stress and decreased quantity or quality of sleep. Both the evidence for a primary effect of menopause on cognitive function and contrarily the effect of cognition on the menopausal transition are examined. Impairment in specific aspects of executive function is explored. Evaluation and treatment strategies for the symptomatic menopausal woman distressed by changes in her day-to-day cognitive function with or without psychiatric comorbidity are presented.

Expert Rev. Neurotherapeutics 7(11), S155–S178 (2007)

Hormone Therapy Helps Brain Fog

Here's a study showing that hormone therapy helps women in perimenopause, which can last 10 years, with brain fog, memory trouble, word finding & other cognitive problems. However, you get better if you start hormones before your final menstrual period (this is a recurring theme in the hormone literature). If you start hormones after your final menstrual period, you get worse. That sucks. More good news: postmenopause, your cognition rebounds back to premenopausal levels. -- SG

Effects of the menopause transition and hormone use on cognitive performance in midlife women.
Greendale GA, Huang MH, Wight RG, Seeman T, Luetters C, Avis NE, Johnston J, Karlamangla AS.

Division of Geriatrics, David Geffen School of Medicine at UCLA, 10945 Le Conte Avenue, Suite 2339, Los Angeles, CA 90095-1687, USA. ggreenda@mednet.ucla.edu
BACKGROUND: There is almost no longitudinal information about measured cognitive performance during the menopause transition (MT). METHODS: We studied 2,362 participants from the Study of Women's Health Across the Nation for 4 years. Major exposures were time spent in MT stages, hormone use prior to the final menstrual period, and postmenopausal current hormone use. Outcomes were longitudinal performance in three domains: processing speed (Symbol Digit Modalities Test [SDMT]), verbal memory (East Boston Memory Test [EBMT]), and working memory (Digit Span Backward). RESULTS: Premenopausal, early perimenopausal, and postmenopausal women scored higher with repeated SDMT administration (p < or = 0.0008), but scores of late perimenopausal women did not improve over time (p = 0.2). EBMT delayed recall scores climbed during premenopause and postmenopause (p < or = 0.01), but did not increase during early or late perimenopause (p > or = 0.14). Initial SDMT, EBMT-immediate, and EBMT-delayed tests were 4%-6% higher among prior hormone users (p < or = 0.001). On the SDMT and EBMT, compared to the premenopausal referent, postmenopausal current hormone users demonstrated poorer cognitive performance (p < or = 0.05) but performance of postmenopausal nonhormone users was indistinguishable from that of premenopausal women. CONCLUSIONS: Consistent with transitioning women's perceived memory difficulties, perimenopause was associated with a decrement in cognitive performance, characterized by women not being able to learn as well as they had during premenopause. Improvement rebounded to premenopausal levels in postmenopause, suggesting that menopause transition-related cognitive difficulties may be time-limited. Hormone initiation prior to the final menstrual period had a beneficial effect whereas initiation after the final menstrual period had a detrimental effect on cognitive performance.

Neurology. 2009 May 26;72(21):1850-7

Hormone Therapy: Continuous Progesterone Safer

Which is better: to take progesterone continuously or sequentially (e.g., day 12-26 each month)? There are arguments on both sides, but this latest study shows that continuous progesterone has a 76% lower risk of endometrial cancer after 3-5 years. That is why I recommend regular uterine monitoring every 6+ months in women on sequential progesterone. -- SG

The long-term safety of different hormone therapy regimens has not been adequately studied in the context of endometrial cancer risk. In a national cohort study, investigators followed 224,000 Finnish women (age, >50) who used oral or transdermal estrogen-progestin (E+P) HT from 1994 to 2006. HT regimens were considered to be sequential if daily estradiol was accompanied by 10 to 14 days of progestin monthly or, in long-cycle regimens, during each 3-month interval. In continuous regimens, both estradiol and progestin were used nonstop. Incidence of endometrial cancer in E+P users was compared with that in all Finnish women.

A total of 1402 cases of incident endometrial cancer were identified. Compared with the general population, E+P users overall had 54% and 23% higher relative risk for type I and type II endometrial tumors, respectively. Monthly sequential E+P HT was associated with 69% (5 years' use) and 156% (10 years' use) higher risk for type I tumors. At 5 and 10 years of use, long-cycle sequential HT was associated with substantially higher risk for type I tumors than was monthly sequential HT. The endometrial safety of transdermal and oral sequential HT was similar; sequential HT with medroxyprogesterone acetate and norethindrone acetate also exhibited similar endometrial safety. Use of continuous E+P HT was associated with lower risk for type I tumors than in the overall population (76% risk reduction after 3–5 years' use).

Comment: Unopposed estrogen therapy or E+P hormone therapy with inadequate progestin raises risk for low-grade endometrial adenocarcinoma (i.e., type I) in menopausal women. Risks for high-grade serous papillary carcinoma and clear-cell adenocarcinoma (i.e., type II) are less clearly associated with HT use. These results are important in clarifying that, although long-term continuous E+P HT is protective, sequential therapy substantially raises risk for endometrial adenocarcinoma. The authors estimate that among 1000 women who use E+P HT for 10 years, eight additional cancer cases will be diagnosed if HT is sequential and monthly, whereas three to four fewer cases will be diagnosed if HT is continuous. For women who use sequential E+P HT long term, endometrial monitoring is appropriate.
— Andrew M. Kaunitz, MD

Published in Journal Watch Women's Health December 17, 2009

Citation(s):
Jaakkola S et al. Endometrial cancer in postmenopausal women using estradiol–progestin therapy. Obstet Gynecol 2009 Dec; 114:1197.

Iodine Deficiency

by Michael B. Zimmermann


Institution Human Nutrition Laboratory, Swiss Federal Institute of Technology Zurich, CH-8092 Zurich, Switzerland; and Division of Human Nutrition, Wageningen University, 6708 Wageningen, The Netherlands
Title Iodine Deficiency.[Review]
Source Endocrine Reviews. 30(4):376-408, June 2009.
Abstract Iodine deficiency has multiple adverse effects in humans, termed iodine deficiency disorders, due to inadequate thyroid hormone production. Globally, it is estimated that 2 billion individuals have an insufficient iodine intake, and South Asia and sub-Saharan Africa are particularly affected. However, about 50% of Europe remains mildly iodine deficient, and iodine intakes in other industrialized countries, including the United States and Australia, have fallen in recent years. Iodine deficiency during pregnancy and infancy may impair growth and neurodevelopment of the offspring and increase infant mortality. Deficiency during childhood reduces somatic growth and cognitive and motor function. Assessment methods include urinary iodine concentration, goiter, newborn TSH, and blood thyroglobulin. But assessment of iodine status in pregnancy is difficult, and it remains unclear whether iodine intakes are sufficient in this group, leading to calls for iodine supplementation during pregnancy in several industrialized countries. In most countries, the best strategy to control iodine deficiency in populations is carefully monitored universal salt iodization, one of the most cost-effective ways to contribute to economic and social development. Achieving optimal iodine intakes from iodized salt (in the range of 150-250 [mu]g/d for adults) may minimize the amount of thyroid dysfunction in populations. Ensuring adequate iodine status during parenteral nutrition has become important, particularly in preterm infants, as the use of povidone-iodine disinfectants has declined. Introduction of iodized salt to regions of chronic iodine deficiency may transiently increase the incidence of thyroid disorders, but overall, the relatively small risks of iodine excess are far outweighed by the substantial risks of iodine deficiency.

PMS: Natural Approaches

PMS always worsens this time of year - so I thought I'd post the latest data from a favorite database: Natural Medicines Comprehensive Database. Short version of what is proven to be helpful:

• calcium 1200 mg/day
• Chasteberry
• Ginkgo
• Magnesium
• Pyridoxine
• Vitamin E

While I agree with what they say about the glories of calcium, magnesium and chastetree, I disagree with their comments on natural progesterone. Here's what they say....


The cluster of symptoms called "premenstrual syndrome" got its official name in 1931, but it has been recognized since antiquity. Up to 85% of women are affected by PMS to varying degrees. It often starts with development of menstruation in young women and tends to follow a consistent pattern until menopause.


Over 150 symptoms associated with PMS have been catalogued. The most common are irritability, agitation, headache, depression, breast tenderness, fluid retention, and weight gain. These symptoms typically show up in the second half of the menstrual cycle, about 7-10 days before the start of the next period.

Minerals / Vitamins

ACOG guidelines suggest that several nutrition supplements are worth trying as a first step in treating PMS.

Calcium is one of the more interesting minerals used for PMS. Researchers began to suspect a calcium-PMS connection when they noticed that calcium deficiency and PMS share similar symptoms. In addition, women who have PMS tend to have abnormally low levels of calcium at the time of ovulation, compared to women without PMS.13776 Low calcium levels stimulate overproduction of parathyroid hormone. Too much parathyroid hormone can affect mood, possibly by interacting with serotonin.13777,13778

Some evidence suggests that women who consume an average of 1283 mg/day of calcium from the diet have about a 30% lower risk of developing PMS, compared to women who consume 529 mg/day.13094

What really makes the case for calcium is that clinical trials show giving 1000-1200 mg of elemental calcium daily for a few months to women with PMS significantly improves mood and decreases bloating, food cravings, and pain.1822,1823,1824

Calcium makes sense for most women with PMS...especially if they don't already get enough calcium in their diet.

Magnesium deficiency might be another factor that contributes to symptoms of PMS. Women with PMS tend to have lower magnesium levels than other women.6847 Women with PMS who take 360 mg/day of magnesium supplements seem to have improved mood and less fluid retention.1187,1188,6847 Taking magnesium might also reduce premenstrual migraine.1186,6847

Magnesium might be beneficial because it is involved in the activity of serotonin and other neurotransmitters. Magnesium also has a role in vascular contraction and cell membrane stability.

There is less evidence for magnesium than calcium. It's too soon to recommend magnesium for most women, but it might be worth considering for women with premenstrual migraine, fluid retention, and poor mood, despite other treatments.
Vitamin E is sometimes suggested for PMS. There is some evidence that women with PMS who take vitamin E 400 IU/day for three cycles have improved mood, reduced PMS-related anxiety and food cravings.4719,4720 Women with PMS do NOT seem to have reduced vitamin E levels. It is not known how vitamin E might work to improve symptoms of PMS. The evidence isn't strong enough to recommend vitamin E for most patients just yet.

Practice Pearl - Advise women with diabetes or heart disease NOT to use vitamin E supplements in doses of 400 IU/day or more. There is some concern that these doses of vitamin E could increase the risk of heart failure in patients with diabetes or heart disease. More evidence is needed to verify this potential risk. In the meantime, explain to these patients that the potential benefit of using vitamin E doesn't outweigh the potential risks.
Vitamin D is now being studied for prevention of PMS. There is some evidence that increasing total or dietary intake of vitamin D is associated with a decreased risk of developing PMS. Women with an average vitamin D intake of 706 mg/day seem to have about a 40% lower risk of developing PMS compared to women with an average vitamin D intake of 112 mg/day;13094 however, taking vitamin D supplements does not appear to reduce the risk of developing PMS. And there is no evidence that vitamin D can decrease symptoms in women with existing PMS. Advise patients to make sure they get adequate amounts of vitamin D in their diet.

Pyridoxine (vitamin B6) is another vitamin that is recommended for PMS. One theory is that PMS might be related to low dopamine levels. Pyridoxine is a co-factor needed for dopamine production. Another theory is that pyridoxine and other B vitamins might prevent fat accumulation in the liver. This could improve estrogen metabolism and potentially affect PMS symptoms.
There is not much scientific support for these theories. But there is some evidence from clinical studies that pyridoxine might help. Taking 100 mg/day of pyridoxine supplements seems to decrease overall symptoms of PMS as well as depression.3093

Practice Pearl: Advise patients to be careful with pyridoxine. High doses can cause peripheral neuropathy. Recommend not using doses over 100 mg/day. This is generally safe...plus there's no evidence that doses over 100 mg/day are any more effective.
Manganese is a lesser known mineral. It's in most multivitamins, but in very small amounts. Low intake of dietary manganese has been linked with increased symptoms of PMS.7135 There is some evidence that taking manganese in combination with calcium might improve symptoms of PMS...irritability, depression, anxiety, tension, restlessness, etc.2004 But its not known if this benefit is due to the calcium or the manganese. For now, don't recommend manganese for PMS. Instead, let patients know that if they take a multivitamin, they're probably getting enough manganese.

Supportive Treatment: Analgesics, NSAIDs, Diuretics


Supportive treatment is also recommended as a first step in treating PMS. These treatments generally target specific symptoms.

For relief of headache, backache, or cramping, acetaminophen (Tylenol) or NSAIDs (ibuprofen, naproxen, etc) are typically used. For bloating and fluid retention, spironolactone (Aldactone) is often used. It works as a diuretic to decrease fluid retention, and it has the added benefit of having an antiandrogen effect. This might further contribute to symptom relief in women with PMS.

Women with PMS also often turn to natural products for supportive treatment.
Ginkgo (Ginkgo biloba) is sometimes tried. We don't usually think of it as a traditional "woman's herb," but there is some evidence ginkgo leaf extract can relieve PMS fluid retention and its consequences...breast swelling and tenderness, pelvic pain and swelling, and swollen hands and feet.6229 Investigators started looking into ginkgo because women who were taking it for memory reported relief from fluid retention associated with PMS. No one is quite sure why ginkgo seems to work for this indication, but one theory is that it INHIBITS platelet activating factor (PAF).5719,9760 PAF normally triggers inflammation, leading to vascular congestion, edema, and breast swelling. Therefore, it is thought that ginkgo might have an anti-inflammatory effect.
Evening primrose oil (Oenothera biennis) is often recommended for PMS. Evening primrose oil contains the omega-6 fatty acid, gamma-linolenic acid (GLA). It is thought that some women with PMS are deficient in gamma-linolenic acid, possibly due to a defect in their ability to convert linoleic acid to gamma-linolenic acid.6034 This could be important because GLA and its metabolites are precursors to the anti-inflammatory prostaglandin E1.6036,12470

In theory, by taking evening primrose oil, women could boost GLA levels, decrease inflammation, and possibly relieve some symptoms of PMS. But the clinical evidence says otherwise. Several small-scale studies suggest that evening primrose does NOT relieve symptoms of PMS.1105,1106,6847,8219 Don't recommend it.
Antidepressants


Selective serotonin reuptake inhibitors (SSRIs) are now being used more for PMS. In fact, fluoxetine, under a different brand name Sarafem (to distinguish it from Prozac), and sertraline (Zoloft) are approved for the more severe symptoms of premenstrual dysphoric disorder (PMDD). Fluoxetine and sertraline primarily help severe mood changes, including depression and anxiety, but can also improve breast tenderness, bloating, irritability, and headache.12337,13779,13780

The ACOG guidelines suggest considering antidepressants in Step 2, for women who don't respond to supportive treatment and lifestyle changes. Fluoxetine or sertraline are considered the first line antidepressants for PMS or PMDD.12337,12349

Some women are reluctant to use conventional antidepressants. Many turn to "natural" alternatives.

St. John's wort (Hypericum perforatum) is the most popular herbal antidepressant...and the best studied. Numerous studies show that it can be beneficial for mild to moderate depression. But there is only very preliminary evidence that it can help for PMS symptoms.6429
Before patients try St. John's wort, remind them of its downside...St. John's wort causes LOTS of drug interactions. It is a potent INDUCER of cytochrome P450 3A4. It can decrease levels and the effectiveness of lots of drugs. Some of these include the HIV protease inhibitors, non-nucleoside reverse transcriptase inhibitors, oral contraceptives, cyclosporin, some statins, and many others.

Practice Pearl - Tell women who take St. John's wort that if they use oral contraceptives for birth control they should use a back up method of contraception. St. John's wort can decrease the effectiveness of oral contraceptives, which could result in unexpected pregnancy.11886,11887

SAMe (S-adenosyl-L-methionine) is another well-known natural antidepressant. SAMe works by donating methyl groups to various physiological processes, including synthesis of neurotransmitters. SAMe increases levels of serotonin, norepinephrine, and dopamine.5196,5231,5232,9110 It does seem to help for depression and seems to be safe. But there is no reliable evidence that it works for symptoms of PMS. Don't recommend it.

Advise patients to avoid supplements containing L-tryptophan or 5-HTP. These products are precursors to serotonin. They are often marketed for depression, anxiety, and sometimes for PMS. There's actually some evidence that L-tryptophan might improve some symptoms of PMS.6246 But there are lots of questions about the safety of these products. Years ago these products were linked to several cases of eosinophilia myalgia syndrome (EMS).902,919,7067,8053,10084,10085,11474,11478 Until more is known about the safety of 5-HTP and L-tryptophan, tell patients not to use them.

Practice Pearl - Tell women who take St. John's wort that if they use oral contraceptives for birth control they should use a back up method of contraception. St. John's wort can decrease the effectiveness of oral contraceptives, which could result in unexpected pregnancy.11886,11887
SAMe (S-adenosyl-L-methionine) is another well-known natural antidepressant. SAMe works by donating methyl groups to various physiological processes, including synthesis of neurotransmitters. SAMe increases levels of serotonin, norepinephrine, and dopamine.5196,5231,5232,9110 It does seem to help for depression and seems to be safe. But there is no reliable evidence that it works for symptoms of PMS. Don't recommend it.

Advise patients to avoid supplements containing L-tryptophan or 5-HTP. These products are precursors to serotonin. They are often marketed for depression, anxiety, and sometimes for PMS. There's actually some evidence that L-tryptophan might improve some symptoms of PMS.6246 But there are lots of questions about the safety of these products. Years ago these products were linked to several cases of eosinophilia myalgia syndrome (EMS).902,919,7067,8053,10084,10085,11474,11478 Until more is known about the safety of 5-HTP and L-tryptophan, tell patients not to use them.

Hormonal Agents


Lots of theories about PMS are based on hormone imbalances. Some investigators attribute PMS anxiety and depression to high estrogen and low progesterone. They think food cravings, headache, fatigue, and palpitations might be related to increased insulin resistance, low anti-inflammatory prostaglandin E1, and high levels of pro-inflammatory prostaglandin 2. And they attribute PMS fluid retention to high aldosterone levels.
Some clinicians try to adjust a woman's hormonal balance in an effort to address this potential underlying cause. Hormone therapy is usually directed toward suppressing ovulation. Oral contraceptives or gonadotropin-releasing hormones (leuprolide, goserelin) are tried. Oral contraceptives are most popular and make sense if the symptoms are mainly physical...breast tenderness, headache, etc. But when they are initiated, they can sometimes make these symptoms worse. And they're usually not helpful for mood changes. Many clinicians are reluctant to use gonadotropin-releasing hormone because they produce a "chemical menopause" that can lead to bone loss.

ACOG guidelines consider these hormonal options as the third step in treating PMS symptoms.

Lots of natural products are promoted for their hormone-like effects. Many women turn to these products with the hope of symptom relief, without the downside of conventional drugs.

Chasteberry (Vitex agnus-castus) is a very popular "woman's herb" evaluated in several studies for PMS. Chasteberry seems to be best for physical symptoms such as breast tenderness, edema, and constipation. It also seems to improve irritability, mood, anger, and headache.7055,7076,7078,7079 In some women, chasteberry improves symptoms by as much as 50%.7055 But chasteberry does not appear to be very helpful for symptoms of bloating.7055

There is also some evidence that chasteberry might help for the more severe symptoms of PMDD. One study found chasteberry to be comparable to fluoxetine 20-40 mg/day; however, chasteberry tended to be more effective for physical symptoms, while fluoxetine was more effective for psychological symptoms.12207

Exactly how chasteberry works for PMS is not known. But chasteberry has a variety of pharmacological effects that might be beneficial. Chasteberry might affect dopamine, acetylcholine and opioid receptors.7014,7015,10122 Chasteberry might also have estrogen and progestin activity.10979,11456

Chasteberry is very promising based on the evidence so far. But the evidence is somewhat limited due small sample sizes or inadequate study designs. Due to these limitations, chasteberry shouldn't be recommended just yet to most patients.

Natural progesterone is another product that is promoted for PMS...often over the Internet. But it doesn't work any better than placebo.1220,10332 Urge your patients to save their money and steer clear.

Black cohosh (Actaea racemosa), red clover (Trifolium pratense), and soy (Glycine max) are widely known as "women's herbs." They may be helpful for menopausal symptoms, but there isn't much evidence they work for PMS symptoms. Don't recommend them.
Also, steer patients away from dong quai (Angelica sinensis) for PMS. There is no reliable evidence that it is effective...and not enough is known about its safety.

The Bottom Line


If your patient wants to take a natural approach to relieving PMS symptoms, suggest 1200 mg of calcium daily. Be sure she understands that benefits would not appear for at least a few months. Even if she doesn't see an improvement in PMS symptoms, she will at least be getting some protection against osteoporosis.
Other minerals and vitamins might be helpful...magnesium, vitamin E, and pyridoxine. But there is not as much evidence for these as there is for calcium. If patients want to try pyridoxine, remind them not to exceed 100 mg/day due to risk of neuropathy.

Chasteberry is the herb with the most evidence in support of efficacy for PMS. But it is still not enough to recommend to most women.

A few other natural products have some preliminary evidence, but more research is needed before these can be recommended...ginkgo, St. John's wort, and manganese.

Tell women that using evening primrose oil, progesterone, black cohosh, red clover, soy, or dong quai is unlikely to improve PMS symptoms.

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11886 Pfrunder A, Schiesser M, Gerber S, et al. Interaction of St John's wort with low-dose oral contraceptive therapy: a randomized controlled trial. Br J Clin Pharmacol 2003;56:683-90.

11887 Hall SD, Wang Z, Huang SM, et al. The interaction between St John's wort and an oral contraceptive. Clin Pharmacol Ther 2003;74:525-35.

12207 Atmaca M, Kumru S, Tezcan E. Fluoxetine versus Vitex agnus castus extract in the treatment of premenstrual dysphoric disorder. Hum Psychopharmacol Clin Exp 2003;18:191–195.

12337 PMS Guidelines. Pharmacist's Letter/Prescriber's Letter 2000;16(8):160803.

12349 The American College of Obstetricians and Gynecologists. Clinical management guidelines for premenstrual syndrome. ACOG Practice Bulletin. No. 15. April 2000.

12350 Patel S, Popovich NG. Premenstrual dysphoric disorder. US Pharmacist CE. September 2004.

12470 Furse RK, Rossetti RG, Seiler CM, Zurier RB. Oral administration of gammalinolenic acid, an unsaturated fatty acid with anti-inflammatory properties, modulates interleukin-1beta production by human monocytes. J Clin Immunol 2002;22:83-91.

13094 Bertone-Johnson ER, Hankinson SE, Bendich A, et al. Calcium and vitamin D intake and risk of incident premenstrual syndrome. Arch Intern Med 2005;165:1246-52.

13776 Thys-Jacobs S, Alvir MJ. Calcium regulating hormones across the menstrual cycle-evidence of secondary hyperparathyroidism with PMS. J Clin Endocrinol Metab 1995;80:2227-32.

13777 Borer MS, Bhanot VK. Hyperparathyropidism: Neuropsychiatric manifestations. Psychosomatics 1985;26:597-601.

13778 Rojansky N, Halbreich U, Zander K, et al. Imipramine receptor binding and serotonin uptake in platelets of women with premenstrual changes. Gynecol Obstet Invest 1991;31:146-52.

13779 Steiner M, Steinberg S, Stewart D, et al. Fluoxetine in the treatment of premenstrual dysphoria. N Engl J Med 1995;332:1529-34.

13780 Yonkers KA. Antidepressants in the treatment of premenstrual dysphoric disorder. J Clin Psychiatry 1997;58:4-14.

Local Hero Michael Pollan's Top 10 Food Tips

These are Michael's favorite food rules from his readers, reported last month in the New York Times.

1. Don’t eat egg salad from a vending machine.

2. Don’t eat anything that took more energy to ship than to grow.

3. If you are not hungry enough to eat an apple, then you’re not hungry.

4. Eat foods in inverse proportion to how much its lobby spends to push it.

5. Avoid snack foods with the “oh” sound in their names: Doritos, Cheetos, Tostitos, Ho Hos, etc.

6. No second helpings, no matter how scrumptious.

7. It’s better to pay the grocer than the doctor.

8. You may not leave the table until you finish your fruit.

9. You don’t get fat on food you pray over. (Meals prepared at home, served at the table and given thanks for are more appreciated and more healthful than food eaten on the run.)

10. Breakfast you should eat alone. Lunch you should share with a friend. Dinner, give to your enemy.

11. Never eat something that is pretending to be something else (artificial sweeteners, margarine, etc.)

12. Don’t yuck someone’s yum. There is someone out there who likes deep-fried sheep eyeballs and, well, more power to them.

13. Make and take your own lunch to work.

14. Eat until you are seven-tenths full and save the other three-tenths for hunger.

15. I am living in Japan and following these simple rules in preparing each meal: GO HO – incorporate five different cooking methods, GO SHIKI – incorporate five colors, GO MI – incorporate five flavors.

16. One of my top rules for eating comes from economics. The law of diminishing marginal utility reminds me that each additional bite is generally less satisfying than the previous bite. This helps me slow down, savor the first bites, stop eating sooner.

17. Don’t eat anything you aren’t willing to kill yourself.

18. When drinking tea, just drink tea. I find this Zen teaching useful, given my inclination toward information absorption in the morning, when I’m also trying to eat breakfast, get the dog out, start the fire and organize my day.

19. When you’re eating, don’t talk about other past meals, whether better or worse. Focus on what’s in front of you.

20. After spending some time working with people with eating disorders, I came up with this rule: Don’t create arbitrary rules for eating if their only purpose is to help you feel in control.

To D Or Not to D

Our press is rife with the preventive power of Vitamin D against the flu, breast cancer, osteoporosis, multiple sclerosis, depression & arthritis. Yet there is controversy still about how much is enough. My response? Show me the data. 

What's Your Level? When we are figuring out if you have enough, we measure in your blood 25-hydroxyvitamin D [25(OH)D]. I happen to agree with the National Osteoporosis Foundation (NOF) and believe you should have a level of:

• 75 nmol/L or higher
• 30 ng/mL or higher 

How much should I take? Our government set the RDA goal at 400 IU/day, which is ridiculous in my opinion. NOF has a higher goal: 400-800 IU/day for those < 50, and 800-1000 IU/day in those > 50. 10-20 min of sunshine per day gets you 10,000-20,000 IU. From nutritional sources such as mild, egg yolks, and oily fish (salmon, tuna - you know, the ones that contain mercury), you get about 100 IU per serving or less. I generally recommend 1000-2000 IU/day. Ergo, you need a supplement. 

How much is too much? From my review of the data, I believe you can safely take up to 10,000 IU/day especially in the Bay Area of California where we have dense cloud cover much of the year. Toxic symptoms are kidney stones and kidney problems, both thought to be related to high blood calcium levels. NOF suggests that you can only become toxic if you are using a prescription form of Vitamin D, and supplements are relatively safe. 

Which supplement? There are two types: D2 (ergocalciferol) and D3 (cholecalciferol). Old data suggested D3 was superior but recent research suggests they are equally good. 

What about my pumpkins? We have no consensus on the best level in kids, despite recent studies in this week's Pediatrics urging higher levels. Last year, the American Academy of Pediatrics recommended 400 IU/day in all kids beginning within the first few days of life and including breastfed infants. Funny, my pediatrician didn't mention that in our 10-minute appointment each year.

Injured? Stressed Out? Try Yin Yoga

While planting my organic dye garden today, I banged my little toe. Ouch. Probably not broken, but my first thought was, “What about my rockin’ yoga habit?”

What to do when injured? From healing injured shoulders to little toes, yin is the answer.

Practice Yin Yoga. Check it out.

Yin yoga developed in the Taoist lineage in Ancient China. It’s based on passively-held yoga asanas, usually seated, that work the trunk, hips and legs. You hold these poses for 5-10 minutes. And you will be amazed at how these asanas unblock your chi flow through the meridians of your body, which happen to run through the connective tissue of your body. Connective tissue is where the action is -- it's what is worked, nourished and hydrated by Yin Yoga, and it's where injuries are healed by the action of fibroblasts and your immune system.

Local Abundance: Sarah Powers. We’re blessed in the Bay Area with Sarah Powers, a leading yoga teacher who lives in Marin. She teaches a combination of yin and yang practices and finds that yin prepares the body optimally for more invigorating yang practices. Check here for an interview with Sarah on Yin Yoga, and here to see her schedule. Sarah is a busy mama yogini, and teaches all over the world. Go work with her at Esalen or Jakarta, or go local at her newly opened Insight Yoga Institute in Marin - click here for more info on the local offerings.

At Gottfried Center for Integrative Medicine, we offer Sarah's DVDs and audio CDs for sale as well as workshops on Yin Yoga for healing particular conditions and aging optimally. The CDs, DVDs and workshops will help you establish a home practice of Yin Yoga.

But I have no time! Sarah recently taught at her series in Deer Run that if you are short on time, sit in baddha konasana (see my photo by Angela Lang, above) with the bottom of the feet together, and bend forward over your feet. You should rest your forehead on a block (unlike the photo), a pillow, or make fists, stack your hands and lean your head on your fist tower. This works most of the meridians and helps your flow of chi.

Further north, in Ashland, Oregon lives another great contributor to the field, Paul Grilley. Here are his thoughts on Yin or Taoist Yoga:

Yin Yoga is not “yet another” brand name of Yoga postures, it is part of a larger conception of Yoga that can be called Taoist Yoga. The fundamental tenet of Taoism is that all things can be described by their mutually complementary Yin and Yang aspects. Yin and Yang can be used to describe all things we are capable of experiencing whether they are clouds, stars, forests, our thoughts or our bodies.

And here's a little more. Basic examples of Taoist analysis would be: There is always a front and a back to a coffee cup but we can never experience both at the same time. The exposed part of the cup is Yang, the concealed part is Yin but both are necessary to form the cup. Or consider the fact that inhaling and exhaling are opposite movements. Inhaling is Yang, exhaling is Yin but together they are the “Tao of Breathing.”

A Taoist analysis of Yoga practice emphasizes the critical difference between Yin and Yang tissues of the body. Muscles and blood are Yang, connective tissues and joints are Yin. Yin and Yang tissues do not respond to training in the same way and a student’s practice becomes more effective when the difference is understood.

Go on... Most forms of Yoga practiced today are Yang, they emphasize muscular movement and contraction. By contrast Yin Yoga targets the connective tissue of the hips, pelvis and lower spine. Yin postures are held three to five to ten minutes at a time. This type of practice complements the more muscular styles of Yoga and is a great aid for learning to sit in meditation.

Paul has several helpful DVDs, which are available on his website as well as sold at The Gottfried Center.

Try Yin, especially when injured. I especially recommend Yin for adrenal dysregulation. Your bones, joints, tendons, ligaments, fascia, and other "yin" elements of your body with thank you with abundant healing.

Yoga: Proven Benefits for Anxiety, Depression & Adrenal Dysregulation

If you practiced yoga daily, you wouldn’t need us doctors at the Gottfried Center to help you feel optimized. Yoga will change your life, for the good, but only if you commit deeply. You cannot proceed casually and expect transformation. Part of my job is to provide evidence to you – evidence that, in this case, yoga heals and transforms. What follows is the science supporting yoga for anxiety, depression and adrenal dysregulation, conditions that affect 100% of you. Please also keep in mind the wise words of BKS Iyengar:

“Words fail to convey the total value of yoga. It has to be experienced.”

Anxiety. There is 100% incidence of anxiety in our culture. There is a broad spectrum here from a little worry to the more debilitating problems such as obsessive thinking, insomnia, migraines, panic attacks, shortness of breath and palpitations. Excessive worry blocks healing. Simple tools such as deeper, belly breathing can help. Specifically, deep, slow breathing activates the Parasympathetic nervous system and releases the body’s own valium – GABA. Generally, we know that yoga increases our GABA levels. Other scientific evidence? Two studies show that yoga is as or more effective than tranquilizers such as Xanax or Ativan. In Germany, a group of 24 women with anxiety were randomized to two 90-minute yoga classes per week for 3 months or a waitlist. Significant reductions in both anxiety symptoms and salivary cortisol levels were found in the yoga group. Also interesting was that the women who reported headaches or back pain noted marked relief from pain.

Depression. Don’t co-opt the message from your conventional doctor that the answer to your sluggish mood and lack of joy can be found in a pill. Here’s the science: (1) A randomized trial from UCLA of 28 women with mild depression were treated with yoga twice/week compared to a control group placed on a waitlist. The yoga group had significant improvements in mood and anxiety, after only 2.5 weeks in class. (2) Another study of 80 people found that yoga for 3 to 6 months was as effective as a older treatment for depression – a tricyclic antidepressant (TCA), imiprimaine. Both yoga and the TCA raised serotonin and resolved symptoms, and while yoga took a little longer to have a significant effect, the effect lasted longer when patients stopped the therapies. Another randomized trial of Mindfulness-Based Stress Reduction showed it cut the recurrence rate for depression in half.

Adrenal dysregulation. If you have high cortisol levels, yoga has been shown to lower cortisol. High cortisol can cause depression, bone loss, poor memory and thick waistlines. Yoga activates the parasympathetic nervous system, which balances our chronically-activated sympathetic nervous system, or “fight or flight.”

Many of us look for a quick fix for depression, anxiety, fear, insecurity, stress, relationship problems, feeling numb, and emotional immaturity. Go with the long view: figure out what's not working for you and slowly manifest what would suit you better. Yoga helps you cultivate joy, peace, radical self-acceptance and vibrant health. It's proven.

Clearing Negative Beliefs

Just reading Shakti Gawain’s Reflections in the Light, and found this “Clearing” exercise to be very helpful for myriad issues: establishing a home yoga ractice, reigniting your spiritual path, cutting out sugar, getting a new job that aligns better with your values, etc.

This is quoted directly from Shakti’s book.

Here is a basic clearing process that you can use to clear out negative beliefs in order to attain a goal. First, state your goal in the form of an affirmation. Second, write “The reasons I can’t have what I want are:” and then start listing every thought that comes into your head. Third, decide which of the negative statements have the most power over you, and make a mark by those. Write an affirmation to counteract each one. Meditate on these affirmations every day along with your original goal.

I am now clearing my negative beliefs.

Click here for more info on Shakti’s inspirational and original work. We’re working on incorporating some of her processes into our next round of yoga and integrative medicine workshops. Sign up here for our newsletter for more info.

A+ Vacation: How to Recharge the Batteries

My husband and I just returned from Vancouver where we had four blessed days, sans kids. David was there to give his “New World of Green” speech – and if you don’t know the man, here’s his claim to fame: he’s done more than any individual to reverse climate change over the past 15 years through his visionary leadership and founding the world’s fastest-growing nonprofit, the USGBC, and the World GBC.

Here’s what we found in Vancouver: the best battery recharge ever. We arrived Friday to extraordinary weather, and a gorgeous hotel room overlooking the water and Stanley Park.

We dined Friday at Radha and ate scrumptious, lovingly prepared raw and cooked vegan food. Radha is a revolutionary spot that has manifested my long-held vision of combining yoga with extraordinary food and community. Add some integrative physicians and you have my vision.

I’ve noticed recently that vegan and raw food both deepen my meditation experience profoundly – I don’t fidget, I don’t get distracted, I stay on task.

Saturday, after researching every yoga teacher within a 10-mile radius, I settled on Christine Price Clark at YYoga in Yaletown. She is an Anusara teacher, and the class was for intermediate-advanced folk.

I walked into a densely filled, sweaty room tense with the anticipation of students devoted to their teacher. In walks guru Christine, singing “Business Time” by Flight of the Conchords. When I did my teacher training in 2002, we were taught to set carefully a healing container at the beginning of class, a vessel to hold the energy and emotion of our students during class. Christine claimed her container as loving, playful, irreverent and totally original.

Class was intense. She set an intention of us all getting connected to our Grand Vision. She told a story of her family member’s lukewarm enthusiasm for her own Grand Vision to step away from an unsatisfying job and into the flow of yoga teaching.

Class was outstanding. Intense, meaningful, the right mix of artful language and creative sequencing. I walked home to the hotel, inspired and connected to my Grand Vision – you know, the one about being a High Priestess of Energy and Libido, helping women connect to their inner priestess and deep well of vibrant energy and vitality. I found David finishing up the refinements to his speech, and we walked together in the sunshine to the Vancouver Art Gallery to learn about Emily Carr and be transported by her vivid charcoals of the British Columbia forests.

I won't give you all the details, but suffice it to say I went to every class Christine taught, bought some gold lame hot pants, and we arrived home yesterday flush with energy, love and vitality. The formula for this vacation worked.

Are Those Pearls on your Ovary?

Polycystic Ovarian Syndrome (PCOS) is a problem of hormonal imbalance that creates sputtering ovulation and hyperandrogenism (too much male hormones, which causes increased male-pattern hair growth and acne). Most important in the diagnosis is exclusion of other causes, as no single lab result leads to the diagnosis. Over 6-10% of women have PCOS.

Other findings include multiple cysts on the ovary (called the “string of pearls” sign on ultrasound - see image below), overweight or obesity, high blood pressure, and acanthosis nigrans – a weird skin finding of darker, velvety skin on the back of the neck.



While the cause is unknown, we mostly consider PCOS to be a metabolic problem. About half of women with PCOS have high insulin levels (or hyperinsulinemia). Lowering insulin levels with exercise, eating low-glycemic foods, and other measures can correct erratic ovulation. Some of the natural therapies that have been shown to be helpful in PCOS include bioidentical progesterone use and cinnamon. Tieraona Low Dog, MD, showed in a small study published in Fertility and Sterility in July 2007 that cinnamon (0.5 teaspoon per day) lowers insulin resistance in PCOS.

I want to emphasize the role of exercise – it’s essential in PCOS, no exceptions! I recommend 30 minutes per day, 4 to 5 days per week, of cardio exercise at a minimum as the primary treatment.

One of the findings of PCOS is estrogen dominance – too much estrogen versus progesterone. Reducing estrogen levels can be very effective and I suggest the following measures:

• Meat/Dairy: avoid conventionally raised meat and dairy products, which contain growth promoters that act as xenoestrogens - these stimulate estrogen receptors in the body and disrupt normal hormonal signaling. Omnivores should choose organic products.

• Cruciferous Veggies: increasing consumption of cruciferous vegetables, such as broccoli and brussel sprouts, which increase metabolism of estrogens.

• Gluten-free: reducing gluten lowers your estradiol levels by 30% or more.

Finally, natural progesterone, prescribed and monitored by a knowledgeable provider, can also help balance estrogen dominance.

Women with PCOS are at greater risk of type 2 diabetes and metabolic syndrome, and should be additionally screened with glucose testing and a full fasting lipid profile.

Adrenals Burned Out?

Adrenal fatigue or dyregulation is the change in the ability of the adrenal glands to carry out their normal job. The main symptoms is fatigue, or in the case of hyperadrenalism, feeling tired but wired.

In response to chronic stress, many folks suffer from adrenal dysregulation, which can be either low production of adrenal hormones (hypoadrenalism) or high production, or a combo of the two. Many of my patients wake up in the morning with low cortisol, drink a cup of coffee to wake up, and then have high cortisol (coffee raises cortisol) and feel wired. Then they’re exhausted when the caffeine wears off by 2-4pm.

What causes adrenal fatigue? At Gottfried Center for Integrative Medicine, every case is individualized, but there are four common causes as identified by Dr. James Wilson:

• Disease that overwhelm the body such as auto-immune conditions or cancer;
• Physical stress such as poor nutrition, addiction (especially to sugar and/or flour), injury, exhaustion;
• Environmental stress, e.g., toxic chemicals in air, water, clothing or food;
• Emotional stress – usually arising from relationship, work or psychological sources.
  

Overlap with other hormone systems
Over 80% of people with adrenal dysregulation suffer from some type of decreased thyroid function. We often find that people who have both adrenal dysregulation and hypothyroidism do not get relief from thyroid replacement alone, and need adrenal support to get better. Dr. Marsha Nunley, MD, and Dr. Charlotte Massey, ND, L.Ac., are especially good at addressing both simultaneously. Dr. Nunley is available to coach patients who live outside of California, but you must visit her in Oakland to receive prescriptions.

Testing
We recommend saliva or blood testing to check your adrenal function. For your adrenal home test, order a diurnal cortisol test. Alternatively, ask your doctor to order a morning cortisol level in your blood. For your thyroid, we recommend TSH, free T3 and free T4 tests.

Weight Gain in PeriMenopause & PostMenopause

Good post on how estrogens, when they are reduced by perimenopause and menopause, lower your metabolic rate. Unfortunately, this can start at early as age 35-40. Welcome to Perimenopause, My Friends! But there are things we can do about it. Read on....

Question: Does exercise attenuate or prevent the weight gain that occurs during peri- and post-menopause?

Commentary from:
Wendy M. Kohrt, PhD
Professor of Medicine
University of Colorado, Denver
in Menopause E-consult by the North American Menopause Society

The short answer is, yes, exercise can attenuate
or prevent weight gain during peri- and
postmenopause. The prevention of weight gain
at any age requires only that energy intake not
exceed energy expenditure. Thus, it is possible
to maintain body weight by modifying exercise
and/or eating habits. However, although simple
in theory, there are physiologic changes that
make it particularly challenging for middle-aged
women to maintain energy balance (ie, intake =
expenditure). Because the menopause transition
occurs over a number of years, it is difficult to
determine whether the increased propensity for
weight gain at midlife is primarily a
consequence of the menopause transition or of
advancing age. Both involve factors that make
weight maintenance a challenge.

Menopause-related factors that promote weight
gain. Studies of laboratory animals provide
compelling evidence that estrogen plays an
important role in the regulation of body weight.
Oophorectomy has consistently been found to
cause excess weight gain, and this is prevented
by estrogen replacement.1 There appear to be
multiple mechanisms by which estrogen
deficiency leads to weight gain in animals,
including increased food intake, decreased
spontaneous physical activity, and a suppression
of metabolic rate. If such effects of estrogen
deficiency also occur in humans, this would
suggest that there is a “biological drive” around
the time of menopause toward weight gain.

In fact, there is evidence that estrogen regulates
body weight in women. A number of large,
randomized, placebo-controlled, and open-label
trials of estrogen-based hormone therapy (HT)
have provided strong evidence that weight gain
and, more specifically, fat gain, is attenuated in
women on HT when compared to women on
placebo or no HT.2 Suppressing sex hormone
levels in premenopausal women with
gonadotropin-releasing hormone (GnRH)
agonist therapy also causes fat gain. For
example, women treated for 16 weeks with a
GnRH agonist gained 1.0 kg of fat, which
equates to an energy excess of about 80 kcal per
day.3 Because it is difficult to accurately
measure changes in energy intake and
expenditure of this magnitude in humans, it is
not clear whether the suppression of sex 2
hormones influences eating and/or exercise
habits. However, short-term hormone
suppression has been found to cause a decrease
in resting metabolic rate of 40 to 70 kcal per
day.4 This reduction in metabolic rate would be
expected to cause weight gain if not
accompanied by a compensatory decrease in
energy intake or increase in physical activity.

Aging-related factors that promote weight gain.
Even if the menopause transition does not alter
bioenergetics in a way that promotes weight
gain, there are unavoidable factors related to
aging that do so. Two important factors are the
loss of muscle mass and the decline in maximal
aerobic power. Lean body mass is an important
determinant of resting metabolic rate. As lean
mass declines with aging, there is a decrease in
metabolic rate and, therefore, daily energy
expenditure. The decline in metabolic rate will
result in weight gain unless appropriate
behavioral changes are adopted (ie, decrease in
energy intake or increase in physical activity).

Maximal aerobic power, also referred to as
aerobic capacity or VO2 max, is a direct index of
the rate at which an individual can expend
energy during exercise. For example, a healthy
young woman with an average VO2 max for her
age can easily increase her energy expenditure
by 8 to 10 kcal per minute during exercise.
However, there is a decline in VO2 max with
aging that cannot be avoided, due in part to the
inevitable decrease in maximal heart rate (ie,
maximal heart rate = 220 minus age).
Accordingly, with advancing age there is a
decline in the rate at which energy can be
expended during exercise, even in people who
maintain a vigorous level of physical activity.5
Rather than being able to increase energy
expenditure by 8 to 10 kcal per minute during
exercise, middle-aged women may be able to
burn only 6 to 8 kcal per minute. This has an
important impact on how women can use
exercise to maintain body weight as they age.
Because the rate at which energy can be
expended decreases gradually with aging,
maintaining the same level of total exercise
energy expenditure may require an increase in
the amount of exercise time.
Do physically active women gain less weight
than sedentary women during peri- and
postmenopause? Exercise can prevent weight
gain in peri- and postmenopausal women, but
factors related to menopause and aging make
weight maintenance a challenge. Even though
regular exercise does not come with a guarantee
against weight gain, prospective studies of
perimenopausal women indicate that the most
active women gain the least weight.6,7 Most
important, women should not abandon their
exercise habits if they become discouraged by
what they perceive as a lack of effectiveness of
exercise to prevent weight gain. Exercise has
numerous health benefits that are independent of
its effects on body weight regulation.8

Disclosure: Dr. Kohrt reports: Research support—
National Institutes of Health.

References:
1. Shi H, Clegg DJ. Sex differences in the regulation of
body weight. Physiol Behav 2009 Feb 27. [Epub ahead of
print]
2. Lobo RA. Metabolic syndrome after menopause and
the role of hormones. Maturitas 2008;60:10-18.
3. Yamasaki H, Douchi T, Yamamoto S, Oki T,
Kuwahata R, Nagata Y. Body fat distribution and body
composition during GnRH agonist therapy. Obstet
Gynecol 2001;97:338-342.
4. Day DS, Gozansky WS, Van Pelt RE, Schwartz RS,
Kohrt WM. Sex hormone suppression reduces resting
energy expenditure and beta-adrenergic support of resting
energy expenditure. J Clin Endocrinol Metab 2005;90:
3312-3317.
5. Hawkins SA, Marcell TJ, Victoria JS, Wiswell RA.
A longitudinal assessment of change in VO2 max and
maximal heart rate in master athletes. Med Sci Sports
Exerc 2001;33:1744-1750.
6. Sternfeld B, Wang H, Quesenberry CP Jr, et al.
Physical activity and changes in weight and waist
circumference in midlife women: findings from the Study
of Women’s Health Across the Nation. Am J Epidemiol
2004;160:912-922.
7. Macdonald HM, New SA, Campbell MK, Reid DM.
Longitudinal changes in weight in perimenopausal and
early postmenopausal women: effects of dietary energy
intake, energy expenditure, dietary calcium intake and
hormone replacement therapy. Int J Obes Relat Metab
Disord 2003;27:669-676.
8. Haskell WL, Lee IM, Pate RR, et al. Physical activity
and public health: updated recommendation for adults
from the American College of Sports Medicine and the
American Heart Association. Circulation 2007;116:1081-
1093.

Vulvodynia: Natural Approaches

This is a great intro to vulvodynia, which is a common syndrome affecting up to 15% of women and causing pain, burning or irritation of the vulva. Tori Hudson did a fine job in this essay, and rather than re-invent the wheel, I thought I'd post her work. -- SG

Vulvodynia: Diagnosis and Treatment

by Tori Hudson, ND

Vulvodynia or vulvar pain syndrome is a multifactoral clinical syndrome of vulvar pain, sexual dysfunction, and psychological distress. Recognizing the four specific subtypes of vulvodynia is important in the management approach. The most common four subtypes are vulvar vestibulitis syndrome, cyclic vulvovaginitis, dysesthetic vulvodynia, and vulvar dermatoses. Simple clinical guidelines can be developed to improve the evaluation and treatment of these often long-suffering patients.

Vulvodynia is different from itching or vulvar pruritus. Vulvodynia actually precludes itching because the burning and pain cause an intolerance to scratching. Over the years, the terminology used to describe vulvodynia has varied. The term vulvodynia has now been recommended by the International Society for the Study of Vulvar Disease (ISSVD) to describe any vulvar pain, regardless of etiology.

Vulvar pain usually has an acute onset. The onset can be associated with vaginitis (yeast, bacterial), changes in sexual activity (new sexual partner), or medical procedures on the vulva (cryotherapy, laser). In most cases, the vulvar pain then becomes a chronic problem varying in length from months to years. The intensity of the pain can vary from mild to disabling. It can be burning, stinging, irritating or raw. Most women with vulvodynia have been to many physicians either with inaccurate diagnoses or unsatisfactory treatment. Many women have been left feeling especially frustrated and at times mistreated because they have been told that their problem is purely psychological and there is nothing physically wrong with them. Because of the dramatic impact on their lives these women continue to seek help, and can become increasingly fearful and anxious about cancer or sexually transmitted diseases.

The incidence of vulvodynia is not known but it is clearly more common than is generally thought. In a general gynecological practice the prevalence can be as high as 15% when actively looked for.1 Characteristics of the patients with vulvodynia are nonspecific. The age distribution ranges from mid-20s to late 60s. Their Ob/Gyn history is unremarkable. They generally do not have other chronic health problems, and rarely have a history of sexually transmitted diseases. Sexual promiscuity is generally not a factor in these cases. Often, women with vulvodynia do report depression, but it is just as easily a result of the condition as it is a cause.

The pain reported can be in the general vulvar area, but is typically located in the vulvar vestibulum. The vestibule comprises the area between the labia minora and the hymenal ring, anteriorly from the frenulum of the clitoris, and posteriorly from the fourchette to the vaginal introitus. The urethra, Skenes glands, Bartholins glands and the minor vestibular glands are all located in the vulvar vestibule.

Only minimal findings are detected on the physical examination and most of the time there are not physical findings at all. The cotton tip applicator is used to determine the location of the pain. Touching the vestibulum lightly with a moist cotton-tipped swab reveals a sharp pain most often in the posterior vestibule, anterior vestibule or both. Occasionally red spots of inflammation can be detected at 5 oclock and 7 oclock or in a U-shaped area at the posterior fourchette.

Classification of Vulvodynia
Vulvar Dermatoses
Vulvar dermatoses can often cause both itching or pain and can be acute or chronic. Dermatoses are also dissimilar to other causes of vulvodynia because there can be physical signs of erythema, erosion or blisters. A partial list of vulvar dermatoses includes psoriasis, seborrheic dermatitis, tinea cruris, contact dermatitis, lichen simplex chronicus, lichen planus, lichen sclerosus, pemphigus, and erythema multiforme. Many dermatoses can be difficult to diagnose and may require a biopsy for a definitive diagnosis.

Cyclic Vulvovaginitis

Cyclic vulvovaginitis (CVV) is probably the most common cause of vulvodynia. The pain is typically cyclic and specifically worse during the luteal phase of the cycle. Symptoms are characteristically aggravated by vaginal sexual activity with the pain being usually worse the next day.2,3 CVV is thought to be caused by a hypersensitivity reaction to Candida antigen. If Candida cannot be detected during the symptomatic phase by culture, due to the bodys immune response, then culture specimens during an asymptomatic phase.

Conventional treatments include antimycotics for temporary relief, but symptoms recur soon after the treatment. Boric acid suppositories twice daily for 4 weeks and then once per day for 5 days during the menses only, for 4 more months is generally more successful for chronic yeast vaginitis than conventional antifungal agents. Boric acid suppositories were effective in curing 98% of the patients who had previously failed to respond to the most commonly used antifungal agents.4 However, many women do not tolerate the boric acid that leaks out of the vagina and further irritates the tissue. Lanolin or vitamin E oil or petroleum jelly or some other ointment (calendula) can be used to coat the vulvar tissue at the posterior fourchette where the irritation would be greatest. Other alternative treatments include local treatments such as lactobacillus suppositories, tea tree suppositories, garlic suppositories, herbal combination suppositories or douches (berberis hydrastis, usnea); systemic immune support (A, C, E, Zn, Glycyrrhiza glabra, Allium sativum, Hydrastis canadensis). Swabbing the vagina with genitian violet has been a longstanding specific treatment for candida, as has iodine douching (one part iodine in 100 parts water, twice daily for 14 days). Reinoculation from the anus requires attention to hygiene and possibly an approach that also addresses the gastrointestinal tract. Dietary considerations include a diet low in simple carbohydrates and refined foods, low in alcohol, and low in fats.

Vulvar Vestibulitis Syndrome
Vulvar vestibulitis syndrome (VVS) is characterized by dyspareunia, severe point tenderness on touch (positive cotton swab test), and erythema. The etiology of VVS is unknown. Some cases are aggravated by yeast vaginitis. Other suspected causes include chemical sensitivities, other irritants, a history of laser or cryotherapy, and allergic drug reactions. Some studies have suggested that VVS may be associated with human papillomavirus (HPV).5,6

Treatment of VVS is difficult and can require great patience and persistence on the part of both patient and practitioner. Conventional treatment is often fraught with overtreatment using antimicrobials and destructive or ablative therapies for suspected HPV. Conventional treatment can escalate to include interferon injections and vestibulectomy for severe incapacitating cases. The most promising alternative treatment that I have experienced in my practice is the use of calcium citrate. In patients whose urine shows evidence of excess oxalate, epithelial reactions similar to those found in vulvodynia are observed. Women have periodic hyperoxaluria and pH elevations related to the symptoms of vulvar pain. 1000mg of calcium citrate daily, in divided doses, is given to modify the oxalate crystalluria. A low oxalate diet is an additional cornerstone to managing these cases.7

In addition, I can cite cases in my private practice where an eclectic treatment plan of a topical ointment (vitamin A, tincture of thuja and lomatium isolate), oral beta carotene (75,000IU to 150,000/day), eliminating food intolerances, and a constitutional homeopathic remedy, have yielded anywhere from 50% improvement to 100% improvement. Unfortunately, I can also cite cases where there was only minimal improvement. I have heard anecdotal reports using elaborate chemical desensitizing methods and dramatic improvements, but I have not personally investigated these cases. Psychological intervention must always be considered for assistance in dealing with the illness, and perhaps therapeutic intervention can then allow the immune system to adequately address the chronic syndrome.

Dysesthetic Vulvodynia
This subtype of vulvodynia is more common among older women who are either perimenopausal or postmenopausal. Patients have constant noncyclic vulvar or perineal discomfort. These women have less dyspareunia and less point tenderness than the women with VVS. No significant changes are observed on the physical examination except diffuse hyperaesthesia which occurs on a wider area compared to VVS. Sharp pain can also be elicited with light touch. The hyperaesthesia is thought to be a result of an altered sense of cutaneous perception. A neurological basis is probably the explanation for the nonspecific burning. The sensation mimics the neuralgia associated with herpes. Urethral or rectal discomfort is often associated with their vulvar pain.

Conventional medicine often prescribes tricyclic antidepressants8 for dysesthetic vulvodynia. Side effects are a common problem with tricyclics, and occur in up to half of the patients. Theoretical nutritional and botanical alternatives for dysesthetic vulvodynia include Folic acid, B12, Piper methysticum (kava-kava), Ginkgo biloba, Hypericum perforatum (St. Johns Wort).

Physical Therapy for Vulvar Pain
The use of physical therapy to relieve vulvar pain should not be overlooked. Spasm of the inner thigh muscles or hip muscles can be a result of guarding against the pain of weight resting directly on vulvar skin while sitting. There are specific devices for removing pressure from the vulvar area when sitting. Manual therapy techniques can also be used to relieve pain by releasing severe muscle spasms. Trigger points in the pelvic floor muscles from fibromyalgia can refer pain to the vulvar skin and the vagina. Trigger point therapy and pelvic floor muscle strengthening and relaxation can also relieve pelvic floor muscle spasms.

Vulvar pain syndromes provoke psychological as well as physical distress. Sexual relationships become seriously strained in women with vulvodynia. Women tend to feel defective, less womanly, less sexually attractive ashamed and embarrassed. Dealing with spouses and partners who are having difficulty coping is an additional stress. Anxiety and depression set in with unsatisfactory visits to their health care practitioners and unsatisfactory results. Hopelessness can become the greater illness but practitioners should be cautioned against being overly optimistic in encouraging them to try another promising treatment. If it fails, it further escalates the hopelessness.

Knowledge of the specific subsets of vulvodynia is extremely important in improving the diagnosis and treatment of this complex multifactoral syndrome. Simple guidelines and recommendations augment the evaluation and management.9

Rule out underlying problems
Biopsy suspicious lesions
Do not overlook cervix
Use a multidisciplinary approach
Differential diagnosis of vulvar dermatoses
Differential diagnosis of vulvar erosions
Provide empathy and support
Educate the patient in their understanding of the problem
Help the patient to cope with the problem
Inform them that symptoms fluctuate
Best questions to be asked
Are there any days without burning?
Is the pain related to menses?
How is the pain associated with vaginal penetration?
Set simple goals
Less bad days, more good days
Getting better takes some time
Coach them to stick with the treatment

References

1. Goetsch MF. Vulvar vestibulitis: Prevalence and historic features in a general gynecologic practice population. Am J Obstet Gynecol 1991; 164:1609-16.

2. McKay M. Vulvodynia: a multifactorial clinical problem. Arch Dermatol 1989; 125.

3. McKay M. Subsets of vulvodynia. J Reprod Med 1988; 33:695-8.

4. Jovanovic R, Congema E, Nguyen H. Antifungal Agents vs. Boric Acid for Treating Chronic Mycotic Vulvovaginitis J Reprod Med 199;36:593-597.

5. Turner MLC, Marinoff SC. Association of human papillomavirus with vulvodynia and the vulvar vestibulitis syndrome. J Reprod Med 1988; 33:533-7.

6. Umpierre SA, Kaufman RH, Adam E, Woods KV, Adler-Storz K. Human papillomavirus DNA in tissue biopsy specimens of vulvar vestibulitis patients treated with interferon. Obstet Gynecol 1991; 78:693-5.

7. Sollomons C, Melmed M, Heitler S. Calcium Citrate for Vulvar Vestibulitis. J Reprod Med 1991; 36:879-882.

8. McKay M. Dysesthetic (essential) vulvodynia. Treatment with amitriptyline. J Reprod Med 1993; 38:9-13.

9. Paavonen J. Diagnosis and Treatment of Vulvodynia. Ann Med 27:175-181, 1995. Resources The Vulvar Pain Foundation, P.O. Drawer 177, Graham, North Carolina 27253; 910-226-0704.

Adrenal Dysregulation Syndrome

This is a fantastic review of Adrenal Dysregulation (aka "Adrenal Burn Out" or "Adrenal Fatigue" in other circles) by our Portland neighbor and wise doc, Tori Hudson, ND. Stop that coffee, People! Drink yerba mate or green or white tea!

ADRENAL DYSREGULATION SYNDROME and ELEVATED SALIVARY CORTISOL LEVELS

Tori Hudson, N.D.

First things first: A bit about the naming of adrenal fatigue and adrenal failure. Most practitioners of alternative medicine often use the term adrenal fatigue or adrenal failure to name the complex array of symptoms their patient is having, presumably related to dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. I would assert that the term adrenal failure should be reserved for Addison's disease. What we are looking to name, is not adrenal failure, or even adrenal fatigue necessarily, but a syndrome with several phases and many different manifestations, caused by dysregulation/dysfunction of the HPA axis. As such, I would propose we avoid the terms adrenal failure or adrenal fatigue, and rather use the term adrenal dysregulation syndrome.

Adrenal functions and stress adaptation mechanisms are among the most far reaching network of endocrine, nervous and immune system interactions regulating our life. The HPA glands and their interactions are responsible for the secretion of critical hormones vital to the control of carefully orchestrated production, synthesis and communication of these hormones. In response to stress, the hypothalamus secretes corticotropin-releasing hormone (CRH) that then stimulates the anterior lobe of the pituitary gland to secrete adrenocorticotropic hormone (ACTH). ACTH then reaches the adrenal cortex and cortisol is synthesized and secreted into the bloodstream. This hormone, cortisol, is the major glucocorticoid that acts as both mediator and inhibitor of the stress response. Cortisol is an insulin antagonist and maintains blood glucose levels by inhibiting glucose uptake and oxidation.[i] Its enhancement of catecholamine release leads to improved cardiac function and blood flow. Cortisol also suppresses collagen synthesis, osteoblast activity, hematopoiesis, protein synthesis, immune responses and kidney function.

Under usual circumstances, our stress response, and the acute/alarm phase is temporary. The HPA axis is under negative feedback control from cortisol. Cortisol then is the primary regulator of the HPA axis with negative feedback on ACTH and CRH, exerting its control of both the hypothalamus and the pituitary gland. Under prolonged stress or increasing intensity of the stress, the HPA axis no longer responds to this negative feedback. This prolonged stress response can then cause continuous cortisol synthesis and chronically elevated cortisol levels. In this state of prolonged stress, increased cortisol levels are linked to metabolic syndrome, overweight and obesity, chronic fatigue syndrome, chronic inflammatory states, coronary artery disease, anxiety, insomnia, depression, and more. This is referred to as the resistance phase of the stress adaptation syndrome. If allowed to persist, there is a significant increase in risk of these diseases. This can also lead to the final stage of the stress adaptation syndrome, i.e. exhaustion. This exhaustion phase may manifest as more acute and serious collapse of vital organ systems and functions.

A comprehensive medical and social history will be the primary tool that will help to identify our patients' phase of stress. Physical exams and select laboratory testing will help to determine not only underlying causes of stress, but also help to diagnose current diseases and to evaluate for risk factors for other significant concerns. This in turn will help with prioritizing treatments and strategizing risk reduction with the goal of restoring hypothalamic-pituitary-adrenal balance.

Many, if not most of the manifestations of chronically elevated cortisol, are more common in women. For example, chronic fatigue syndrome (CFS) occurs more frequently in women than in men. Most commonly, the onset is between 20 and 40 years of age. The majority of patients are middle class and in the helping professions such as nurses, doctors and teachers. Overweight, obesity, insomnia, depression, anxiety and metabolic syndrome, all associated with chronically elevated cortisol levels, are also among the health disorders more common in women. In addition, the hormonal influences of premenstrual syndrome, postpartum, perimenopause and menopause add another layer of complexity and interaction unique to women and adrenal regulation.

It is this chronically elevated cortisol state, most easily identified with salivary cortisol testing, that I wish to address in the rest of this article.

The most effective way to manage chronically elevated cortisol levels is to ensure that the adrenal glands are supported with the proper nutrients. Vitamin B6, pantothenic acid, and vitamin C, often become depleted when the demands on adrenal gland cortisol production are continuous. An abnormal adrenal response, whether it is deficient or excessive hormone release, can be in large part addressed with these key nutrients. These nutrients play a critical role in the optimal function of the adrenal gland and in the optimal manufacture of adrenal hormones. Levels of these nutrients can be diminished during times of stress. Urinary excretion of vitamin C is increased during stress. A deficiency of pantothenic acid results in fatigue, headaches, insomnia and more. L-tyrosine and L-theanine support the adrenal glands by combating fatigue and anxiety related to stress. In addition, the cortisol feedback control mechanism is dependent on adequate amounts of calcium, magnesium, potassium, manganese and zinc.

Ashwaganda (Withania somnifera), also known as Indian ginseng, has been in historical use in the Ayurvedic medical system for over 3,000 years. Ashwagandha has been shown to reduce corticosterone, a glucocorticoid hormone structurally similar to cortisol., An array of clinical trials and laboratory research also support the use of ashwaganda in enhancing mood, reducing anxiety and increasing energy. , , 10 ,

Magnolia (Magnolia officinalis), also known as Holly Bay and White Laurel, has been historically used for weight loss, obesity, anxiety, stress, depression and inflammation. A randomized, parallel, placebo controlled study in overweight premenopausal women resulted in a decrease in transitory anxiety, although salivary cortisol levels were not significantly reduced. Through some of its reported antidepressant and anxiolytic effects, magnolia can improve mood, increase relaxation, induce a restful sleep and enhance stress reduction.

A proprietary blend of two plant extracts, one from Magnolia officinalis and the other from Phellodendron amurense has shown promise in lowering cortisol. In initial evaluations, by the research and development company behind this proprietary product, they found that eight out of 10 stressed individuals felt more relaxed, seven out of 10 enjoyed more restful sleep, and nine out of 10 said it was gentle on the stomach.

In a study conducted at the Living Longer clinic, in Cincinnati, Ohio by Dr. LaValle, (unpublished), the same proprietary blend was shown clinically to normalize the hormone levels associated with stress-induced obesity. It was demonstrated that this combination lowered cortisol levels by 37 per cent and increased DHEA by 227 per cent.

Phosphatidylserine (PS), also known as lecithin phosphatidylserine, is a fat-soluble phospholipid that is the most abundant phospholipids in the human brain. PS is a component of the mitochondrial membrane where it serves as a reservoir for other phospholipids. It is vital in neuronal membrane functions, signal transduction, cell-to-cell communication, cell growth regulation and secretory vesicle release. We obtain most of our PS from dietary sources, although we do synthesize PS as well. PS is known to blunt the rise in cortisol and ACTH following strenuous training, and significantly reduce both ACTH and cortisol levels after exposure to physical stress. Phosphatidylserine also has been shown to improve mood.

Combinations of the above mentioned ingredients can be used together and in multiple ingredient formulations as part of a whole system approach to correcting adrenal dysregulation with elevated cortisol levels. In a recent unpublished study of another proprietary formula, study subjects took a product containing ashwagandha, phosphatidylserine, magnolia and L-theanine. The nutritional/botanical supplement consistently decreased salivary cortisol levels in relation to baseline levels. In addition, participants reported increased relaxation, improved sleep, deeper sleep, and reduced stress levels.

Numerous other adaptogens may be considered in cases of adrenal dysregulation. Traditional herbal definitions of an adaptogen states that an adaptogen is an agent that produces a nonspecific response to counter physical, chemical or biological stressors, thus allowing the body to "adapt" to the stressful circumstance. This normalizing influence on physiology is irrespective of hyperfunction or hypofunction of an organ or organ system. Western botanical researchers look at the effect of adaptogens on regulating the hypothalamic-pituitary-adrenal axis and use them to regulate the neuroendocrine and immune systems. Adaptogenic herbs support the entire neuroendocrine system, in particular the adrenal function and the stress response, which results in a modulating and regulating effect on the use of cortisol. Adaptogens known for their anti-stress qualities and stabilizing effect on the HPA axis include American ginseng, ashwagandha, Asian ginseng, astragalus, cordyceps, reishi, eleutherococcus, holy basil, rhodiola, schisandra, and licorice. Again, combination/multi-ingredient formulations are common in a whole system approach to restoring adrenal regulation.

Reducing cortisol levels and restoring adrenal regulation can be a very effective management approach to addressing stress management, chronic fatigue, sleep disturbances and anxiety, while also reducing the long term risks associated with elevated cortisol levels.
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