Meet Your Hormones

Today Imma be yackin' online about hormones and how they shift when cleansing, and why.  Was thinking I need a li'l reference guide to each hormone: who they be and what they do.

So...I'm a scholar, seeker, yoga teacher and a doctor. It's serious, sacred stuff.

But.

Imma be honest. I frequently quote The Blackeyed Peas. 

Want me to Quote Top 40 lyrics to you? (Or, if you’d prefer, we can talk very professionally about your hormones, nutrition, thyroid, libido, and lovely lady lumps. Oops, I did it again. Those pesky pop stars.)

Meanwhile, back on the hormone ranch....

Estrogen is the hottie of the group. Keeps you juicy, joyous and jonesin' for sex. Estrogen has over 400 jobs in the female body, and what you feel when there's too much or too little varies from creaky joints to brain fog to depression. As with most hormones, don't want too much or too little. Find your sweet spot with estrogen (estradiol to be precise), and she'll repay you in droves.

Progesterone. Every kite needs wind. Estrogen needs to be sufficiently balanced by progesterone. Progesterone is the soothing compliment to the upper, all-business estrogen. Irregular cycles or you're on the rag more frequently than 5-10 years ago? Probably your ovaries making less of the stuff. Keeps you sleeping all night too.
 

Cortisol. Powers through a car wreck ("fight") and gets you to run fast after your kids ("flight") and makes you fall in bed exhausted at the end o' the day ("collapse"). When your cortisol is too high, welcome the muffin top. When it's too low: depletion. Tank empty. Finito. Done.

Testosterone. Hormone of vitality. Gets you either hungry for sex or receptive. Big difference, and difficult for women to attune to the latter. Key player along with estrogen in governing the perimenopausal and menopausal mood. When cycling regularly, peaks on day 9.

Pregnenolone. Mother hormone of the whole fam, the matriarch, the precursor to absolutely every sex hormone. Involved in your memory, particularly word finding. Involved in keeping your vision in technicolor. Never heard of it? I know, me neither, until I did an advanced course with a very handsome fourth generation endocrinologist from Belgium, and let me tell ya, most European women have heard of it. Disappears when you are stressed.  

Thyroid. Masta of metabolism. Keeps you energized, at a manageable weight (sans extreme measures that many of us in premenopause become reluctantly familiar with), and your locks glossy. Keeps your cholesterol reasonable. Keeps joints working well and pain-free. Keeps those finger and toenails from chippin'. Keeps mood and libido hummin' where it should.

Oxytocin. Hormone of love and bonding. Men need to be hugged three times longer than women to get the same release of oxytocin. Babies produce this in us, which is why most of us women still want to have another baby even when it makes absolutely no rational sense.

I loved the "Cast of Neuro-Hormone Characters" from Louann Brizendine's book, The Female Brain. I credit Louann for inspiring the idea for this post. xoxo

On Cleansing, D#0

A Hindu Scholar named Swami Adiswarananda once said that we must renounce what we've been doing for something that feels better. None of us renounces what feels good for something that feels worse.

His words frame my entry into the official start of our Gottfried Cleanse tomorrow, which is designed to balance your hormones and reduce your toxic load. You can join us via webinar at any time up to March 30. 2011 by clicking right here. I am going to post daily, Monday-Friday, on what is happening while I cleanse for the next 21 days: what comes up, what I'm working with, what about my relationship to food (and self-realization) is shifting, what I'm learning as I transcend the desire for food that makes me ill.

Today I asked our cleansers to start with an inventory of their relationship to food. Here are some questions to consider (please let us know your responses in our comments section!):

• POWER What makes you feel most powerful when reviewing how you eat and your relationship to food? When do you shine with food; what best serves you?
• HARM What is chronic, charged, repetitively not serving you in how you feed yourself?
• STOP What would you like to stop eating or doing with food? Examples: eating standing up, eating in the car while speeding to school to get your kids there on time, drinking 2 glasses of wine when 1 would have been fine.
• FEEL How do you want to feel with food?

Meanwhile, we talked about many fun and practical things that I wanted to share, for instance:

• For getting off caffeine over the next 7 days, meet or re-introduce yourself to the many detoxifying benefits of skin brushing. One cleanser from Oregon tells me there's no Whole Foods Market near her, so could I help a girlfriend out and give a link to where to obtain one. Here you go. Today on our webinar, I demonstrated how to dry skin brush, but my tiny little video didn't quite do it justice - so here's another video on it.
• Eat lotsa greens! Here's a favorite recipe from an old post on massaged greens. Share other fave recipes in our comments section!
• Breakfast ideas. When I'm cleansing, I eat 1 oz dry of quinoa flakes or gluten-free oats (when "wet" they usually weigh 5-6 oz) with 6oz of berries, 10 almonds and 2-3T of flax seeds. I add 2 poached eggs.
• There are significant risks from eating off food cooked on teflon-coated pans. Much better alternative: Scan Pan. Here's a link to scan pans at Sur La Table.

Some come back and join the dialogue as we transform your relationship to food, which I believe is foundational to both hormone organization and self-realization!

Feelin' Testy (Testimonials, That Is)

Thought I'd post a few testimonials, since we women are famous for not seeing the bigger story to our story. Indulge me with a little shameless promotion since I'm short on time today. Even though I'm short on time, I'm not short on gratitude: huge thanks to the lovely women who said such nice things below (plus some less nice things - keeps me humble). xoxox

Dr. Gottfried has been seeing me since 2005 when I first came to her with terrible menstrual cycle issues.  I would often find myself on the floor of the bathroom in a cold sweat purging everything in the first few days of my period.  Most Western doctors over the years tried to alleviate the problem by putting me on the pill...not only am I opposed to taking drugs just to mask a symptom, but the pill wreaked havoc on me emotionally.  Dr. Sara was at Kaiser at the time, and she spent so much time listening and discussing various options with me that I left feeling like I'd been to a spa rather than the circus of Kaiser.  The answer wasn't in a prescription at all, and for the first time I was given a clear and basic understanding of what was happening to me.  I continue to see her now we've got the menstrual cramping under control.  As I age and my body changes, it's so wonderful to have a doctor that I can trust to give me the whole scope of healing possibilities - not just a prescription for pain killer.  I know that I'm in good hands.  I know that she stays up to date on all research, supplements, diets, etc. so I trust that as I'm changing, she's constantly updating her skill set.  I still see my Kaiser physician for the routine exam, but whenever I encounter something that doesn't feel right Dr. Sara is my first call. -- Michelle C of Emeryvile, CA

I went to Dr. Gottfried almost two years ago because I felt completely depleted and did not feel like myself much of the time. Though I thought I was having perimenopausal symptoms (sleeplessness, night sweats), I hadn't sought help. She spent a lot of time talking to me about my whole life picture to determine what the best plan of action was for me. After taking that into consideration and some testing, she prescribed low doses of bioidentical hormones as well as some  other supplements to get my hormones and energy back on track.  Within a few weeks at the most, I felt so much better! I'm forever grateful for her expertise and attention to me as an individual. A lot of traditional western medicine treats patients as if we're all the same.......but all cases are different and our own bodies are constantly changing. During perimenoupause, It's a process of tinkering and refining, and she's great at guiding one through this process. -- Madeleine T of Oakland, CA


I cannot say enough good things about Dr. Sara!  She is not only a very caring and warm human being, but also she's an extraordinarily compassionate doctor.  It's no small matter that she has the most amazing education and credentials (Harvard trained), and is an experienced yoga teacher.  She truly combines the best of Eastern and Western medicine approaches, and she stays abreast of the latest research on nutrition, diet, supplements and clinical tests, thus offering her patients the very best care available today.
Sara will work tirelessly to help figure out the health challenges that most doctors would have no answers for.  She has really helped me get to the bottom of a variety of troubling symptoms related to my stage in life--insomnia, anxiety, fatigue, stress.  Her recommendations have helped me become more balanced and focused, sleep better at night, and feel more serenity in my life.  In every session, she is always ultra-prepared and spends lots of quality time addressing your needs, desires, concerns, etc.  She has a truly holistic view that takes into account each patients individuality.  Especially if you've had any health concerns that your regular doctor has not been able to adequately address, I encourage you to see Sara!  She's the best. -- Sarah H of Richmond, CA


I am overwhelmed with my experience with Dr Gottfried.  My intuitive senses sent me there, but not knowing what to expect.  I was attracted to the word "integrative" in searching for a doctor.  The technological advances in modern medicine are life saving and amazing.  I am dependent on modern medicine and grateful.  This being said, I sensed a lack on being treated as a whole.   I had one doctor for OBGYN issues, one doctor for thyroid disease and a pulmonary doctor.  Having a different doctor for each different body part and disease really started to bother me.  We are not just the sum of our parts.  Dr. Gottfried strives to find the complicated balance for us.  This is alot of work and not just as easy as taking a prescription.  I had always taken good care of my self, but still felt terrible.  I went to Dr Gottfried thinking that I felt terrible because of menopause and that I needed bioidentical hormones instead of the typical prempro prescription I had been given for years.  After listening to my history and complaints, Dr Gottfried recommended lots of testing.  I really did not know where this was going.  Well, here is what happened.  I found that my thyroid was not being treated properly.  I found that my adrenals were shot.  I found that the hormone thing was just the tip of the iceberg.  Again, lots of work, but I decided to follow through with Dr Gottfried.  My first reward was sleep!  I had not slept in years.  I actually hit that deep sleep that my body had lost touch with.  I realize that the repairs and chemical balance that our bodies achieve in sleep is critical.  As an added plus, I see the true definition of 'beauty rest'.  I found out that I did not have to walk around with that feeling of anxiety in my chest.  I am still working on all my adrenal, hormonal and thyroid problems.  Dr Gottfried's approach of treating all these as a system and recognizing the need for balancing everything together is what is working.  Don't think this is easy.  We don't all react the same and Dr Gottfried is constantly throwing new information out there.  I am just beginning, but have confidence that someone is listening.  Hugs to Dr Gottfried -- Patricia P of Castro Valley

Let's post some of the less favorable too. When you're difficult to get into to see, maybe it's time to go more virtual. That's my line of thinking....

She is extremely knowledgeable in hormone balance and very helpful with lifestyle suggestions and referals.  Very difficult to get in which can be frustrating, but worth the wait. - Michele S of Oakland, CA

What I Do: Organic Gynecology & Bioidentical Hormones

Often I get asked what I actually do with clients and in workshops and coming next month in WEBINARS! Here it is, inspired by Danielle Laporte's Burning Questions, and squeezed between seeing patients today and picking up the kids from school. Enjoy! Join the Love Train!

Blood Clot Risk & Route of Hormone Therapy

Is Risk for Venous Thromboembolism Affected by Route and Type of Menopausal Hormone Therapy?

Results of a large observational study suggest that transdermal (in contrast with oral) estrogens do not raise risk.

Although hormone therapy (HT) now is recommended only for short-term relief of menopausal symptoms, risk for idiopathic venous thromboembolism (VTE) is greatest during the first year of treatment. To determine if route of administration or type of concomitant progestogen affects risk for VTE, investigators analyzed data from a prospective cohort study of more than 80,000 French women (mean age at entry, 54) who completed biennial questionnaires for a mean of 10 years. The study was partially funded by a manufacturer of transdermal delivery systems.

During follow-up, 549 first idiopathic VTEs (134 pulmonary emboli and 415 deep venous thromboses) occurred. Past users (i.e., those with no use within 3 months before questionnaire completion) and never users of HT had similar VTE risk. Analysis adjusted for potential confounders showed that users of oral, but not transdermal (patch or gel), estrogen had substantially higher risk for VTE than did never users (hazard ratio, 1.7). No significant associations were found between VTE and concomitant micronized progesterone (Prometrium), pregnane derivatives including medroxyprogesterone acetate (Provera), or nortestosterone derivatives (including norethindrone acetate). However, the norpregnane derivatives nomegestrol acetate and promegestone (not marketed in the U.S.) were associated with significantly higher VTE risk (HR, 1.8).

Comment: This observational study cannot provide irrefutable evidence that transdermal estrogens do not raise VTE risk, but it is the largest study to date that suggests the possibility; moreover, the findings mirror those of earlier studies (JW Womens Health Apr 5 2007). Given that oral, but not transdermal, estrogens can raise levels of factors that lead to clotting, these findings are biologically plausible. The data also provide reassurance that progestogens marketed in this country (when prescribed with transdermal estrogen) do not raise VTE risk.
— Robert W. Rebar, MD

Published in Journal Watch Women's Health April 8, 2010

Citation(s):
Canonico M et al. Postmenopausal hormone therapy and risk of idiopathic venous thromboembolism: Results from the E3N cohort study. Arterioscler Thromb Vasc Biol 2010 Feb; 30:340.

Hormone Therapy Lowers Colon Cancer 25-36%

Here's another post from North American Menopause Society. Seems cyclic progesterone was associated with the greatest risk reduction of colon cancer. Check it out.

Does hormone therapy decrease colorectal cancer risk?

Johnson JR, Lacey JV Jr, Lazovich D, et al. Menopausal
hormone therapy and risk of colorectal cancer. Cancer
Epidemiol Biomarkers Prev 2009;18:196-203.

We evaluated colorectal cancer risk associated
with the duration and recency of specific
menopausal hormone therapy formulations (ie,
unopposed estrogen versus estrogen plus
progestin) and regimens (ie, sequential versus
continuous estrogen plus progestin use) among
56,733 postmenopausal women participating in
the Breast Cancer Detection Demonstration
Project follow-up study. Hormone therapy use
and other risk factors were ascertained through
telephone interviews and mailed questionnaires
from 1979 to 1998. The final cancer group
included 960 women who were identified from
self-report, medical records, state registry data,
and the National Death Index. Poisson regression
was used to generate multivariable rate ratios
(RR) and 95% confidence intervals (95% CI).
We observed a decreased risk of colorectal
cancer among ever users of unopposed estrogen
therapy (RR, 0.83; 95% CI, 0.70-0.99). Among
estrogen users, the largest reduced risk was
observed for current users (RR, 0.75; 95% CI,
0.54-1.05) and users of ≥ten years duration
(RR, 0.74; 95% CI, 0.56-0.96). We found a
reduced risk among users of estrogen plus
progestin therapy (RR, 0.78; 95% CI, 0.60-
1.02), with sequential regimen users (progestin
<15 days per cycle) having the largest risk
reduction (RR, 0.64; 95% CI, 0.43-0.95). Past
users of ≥5 years ago (RR, 0.55; 95% CI, 0.32-
0.98) had the largest risk reduction. In this
study, estrogen plus progestin use, especially
sequential regimen use, was associated with the
largest overall reduction of colorectal cancer
risk.

Comment. This is a retrospective study, the
stated purpose of which was to identify
separate risk estimates for colon cancer
according to menopausal hormone form-
ulations. A paper published 9 years earlier1
from the same database found a suggested
inverse relationship between the use of HT and
colon cancer. The current paper analyzed
postmenopausal women divided into groups of
never users, those who had ever used estrogen,
and those who had ever used estrogen plus
progestogen (EPT), and then further divided
them by sequential hormone use and length of
time exposed to HT. What the current authors
found was that those who had ever used
unopposed estrogen had a decreased risk of
colon cancer. Those who had used sequential
EPT had the largest risk reduction. What does
this information add to our knowledge of this
topic?

Estrogen receptors have been detected on colonic
cells, with estrogen-receptor β being over-
expressed in healthy colon cells and reduced in
colon cancer cells. This overexpression, coupled
with negligible expression of estrogen-receptor α,
is thought to provide protection by HT against
colon cancer. What is also known is that
prescribing patterns for HT vary among race,
with African-American, Asian, and Latina
women receiving less treatment than Caucasian
women. An evaluation of how many women
were represented in each group rather than a
designation of “nonwhite” and a designation of
“person-years” only would have been
informative. It would also have been beneficial if
the groups had been matched by age, ethnicity,
and HT use (perhaps this is a paper that will be
published later).

African-American women have the highest risk
for colon cancer, higher even than white males;
and colon cancer in these women is often
detected at a more advanced stage. If HT really
does reduce the risk of colon cancer, all women
should have a discussion with their healthcare
provider about the potential benefits of HT for
them. A prospective study of matched groups of
women would be very informative regarding risk
reduction across ethnic groups in which there is a
dearth of comparative information available.
Women who use HT are more likely to have
mammograms, as well as Pap smears and
colonoscopies. Colonoscopy, however, is still at
the bottom of the list even for women who
regularly undergo other types of health screening.
It would be helpful if healthcare providers
encouraged women to have a colonoscopy. It has
been shown that if a healthcare provider strongly
recommends a test, a patient will often agree.

As March is National Colon Cancer Awareness
Month, this might be a good time to consider a
large-scale prospective randomized trial of HT
use with timed colon cancer screening across
ethnic groups by those in this field.
Michelle Inkster, MD, PhD
Department of Gastroenterology and Hepatology
Cleveland Clinic
Cleveland, OH

Reference:
1. Troisi R, Schairer C, Chow WH, et al. A prospective
study of menopausal hormones and risk of colorectal
cancer (United States). Cancer Causes Control 1997;

Osteoporosis: Beyond Boniva to Integration

What is bone? It’s a living, active tissue composed of vitamins, minerals and other substances, from calcium, magnesium, boron, strontium, to a protein matrix that attracts calcium and other minerals. We build bone density (or amount of mineral) until age 35 and then it gradually decreases with age with some acceleration in women at the time of menopause due to decreased hormones.

The purpose of this blog entry is to review an integrative approach to the health of your bones, drawing upon nutritional healing and the benefits of movement, the role of pollutants and xenohormones, as well as new information, made available just in the past couple of years, about the benefits of minerals such as strontium and “quarter-dose” natural estrogen in improving bone density and reducing fracture.

Osteoporosis, or porous bone, is a disease of low bone density and structural deterioration of bone tissue, leading to bone fragility and an increased risk of fractures, particularly of the hip, spine and wrist. In most cases, calcium and other minerals leeches out of our system, leading to bones getting thinner and more porous, like Swiss cheese. Women are more affected than men by a 6:1 ratio. Half of Americans over 50 have osteoporosis, which became an epidemic in 1950. Yet since 1950, the rate of fracture has doubled in the U.S. and now millions of fractures occur annually. Why? Some postulate that something has happened in our environment, and the leading suspect is the depleted soil used for most farming. As we’ve used less composting and manure in soil, there is less trace minerals available in our food supply such as zinc, copper, strontium, manganese and silicon. Reinvigorate your commitment to composting, and use it in your garden, as a way of improving your bones!
What are some of the modifiable and non-modifiable risk factors? The main risk factors are Caucasian race, female gender, menopause (especially early), weight less than 127 (fat makes hormones, and thinner women have less); smoking, family history and personal history of fracture. Most of these risk factors you cannot change. Others you can, including low bone density and sedentary lifestyle. Caffeine drinkers and high-glycemic carbohydrate addicts also have an increased risk, and after 2 cups of coffee or sugar, increased calcium is lost through the urine for several hours.

One other risk factor that is not well-known is endogenous estradiol level, or the level of estrogen made naturally by your body. We know in post-menopausal women from a study at UCSF that if you are in the lowest quartile, you have the highest risk of osteoporosis. This makes intuitive sense. On the flip side, women with the highest quartile of endogenous estradiol have the highest risk of breast cancer. This is in women not on hormone therapy, synthetic nor bioidenticals. It seems as usual that the middle road might be best in terms of reducing risk of either osteoporosis or breast cancer, which is where the new quarter-dose estrogen comes in. 

We know from the Women’s Health Initiative that you can reduce your risk of hip and vertebral fracture by taking hormone therapy for 5 years. Yet many women do not want to accept the small risk of other problems such as breast cancer in 1.9% (versus 1.5% in women on placebo pills), stroke in 1.5% (versus 1.1%) and heart attack in 1.9% (versus 1.5%).
Since WHI, millions of women have stopped hormone therapy since the synthetic hormones do more harm than good. Many women found they could not tolerate the poor quality of life associated with the increased hot flashes, night sweats, joint aches and poor mood, and restarted at half-doses. 

The half dose has fewer risks and is almost as effective at reducing symptoms. How low can we go? There is a new natural estrogen patch being tested now that is a quarter of the standard dose, and it has been shown in the best quality study design (randomized controlled trials) to improve the hip bone density by 1% and the spine bone density by 2-3% in just 2 years, with very few risks. We should be hearing more about this in the future, but it may be a great option for thinner women with low endogenous estradiol levels. Other women find that the quarter dose isn’t enough when they’re suffering from hot flashes, poor sleep and mood, and choose a more physiological dose of bioidentical hormones, which are hormones identical to what your body made in your 20s and 30s.

I was trained in OB/GYN residency to hand out Fosamax like Halloween candy to my postmenopausal women with low bone density. Now we have Sally Field telling us to take Boniva instead, since it’s just once/month. Unfortunately bis-phosphonates, like Boniva, Actinel and Fosamax, are toxic and have serious risks from hurting your gastrointestinal system to the more serious osteonecrosis of the jaw. Wouldn’t it be better to approach osteoporosis more from a nutritional perspective, with the idea of using therapies that occur naturally in the body such as mineral therapy?

There are several nutritional deficiencies that increase your risk of osteoporosis. We all know that calcium deficiency is one risk. Yet many women do not realize that their gluten sensitivity, or other cause of bowel inflammation such as food allergies, is interfering with their ability to absorb calcium from their diet.

Women with Celiac disease have an increased risk of osteoporosis and need special care to get sufficient calcium. Vitamin D deficiency is another common cause, especially with our more religious use of sunblock. Magnesium deficiency is also very common and can be associated with fatigue, anxiety, insomnia, migraines, muscle aches as well as osteoporosis. In one study, 84% of women with osteoporosis had magnesium deficiency and most of us don’t get enough from our diet. We have seen in some research studies increased bone density of up to 8% in women supplemented with magnesium. Manganese deficiency is another risk factor and affected famed NBA player Bill Walton until a holistic physician figured out it was the cause of his repetitive fractures that threatened his career. You can get your levels checked for all of these minerals. Another important issue is something Dr. Alan Gaby calls the “homocysteine connection,” which is the increased homocysteine levels we see if some people who have excessive animal protein consumption. Homocysteine levels can also be correlated with heart disease and it is important to know your level.

Heavy metals can also be associated with osteoporosis, including the ubiquitous toxin aluminum. Aluminum is added to some municipal water supplies as a way of reducing particulate matter. Aluminum cans containing beer have three times the amount of aluminum as glass bottles, and for cola, it’s six times! Other risky heavy metals are lead and tin, especially from water pipes and tin cans containing food. Consider getting your levels checked also for heavy metal toxicity if you find yourself with low bone mass.

One promising new approach is to supplement with strontium, which is a natural therapy. Strontium is licensed in Europe but has not yet been approved in the U. S. by the FDA. There are several studies showing that it increases bone density and reduces fracture in women, even in older women over aged 74. One study in particular, published in the New England Journal of Medicine in 2004 showed that in 1649 women aged 50+ who had at least one vertebral fracture, strontium ranelate led to fewer vertebral fractures and increased bone density. Women in the placebo group lost bone density. The dose used in Europe is 2 grams taken at bedtime more than 2 hours after eating or drinking anything other than water. Stontium ranelate is not yet approved for use in the U.S. as it is still under investigation.
Exercise is another important strategy. All exercise is good,e.g. swimming is better than no exercise in terms of your bones and muscles, but some forms are better than other. Most research shows that a combination of impact aerobic exercise such as walking or running, along with resistance training and/or yoga can increase bone density up to 1% per year. 

We all know by now that we should take care to get a total of 1200 mg of calcium from our diet and/or supplements combined with 600-800 IU Vitamin D. Many people reach for their Tums, but take care to get a calcium supplement without aluminum in it. In summary, there are nutritional and lifestyle interventions that can help you prevent and reverse osteoporosis.
If you have osteoporosis, I recommend that you get your Vitamin D, homocysteine, magnesium and manganese levels checked. Supplement if you are low. Optimize your exercise regimen and take care not to ingest heavy metals such as aluminum, lead and tin. Consider bioidentical hormone therapy if appropriate and in consultation with a trusted physician. Consider quarter dose estrogen if your endogenous estrogen is low. Keep an eye out for emerging data on strontium.

Bioidentical Homornes: Are They for You?

by Guest Editor 

Dr. Marsha Nunley, MD

Are you confused about bioidentical hormones and just hormones in general? Well, that is because it is a somewhat confusing story and there are many players in the game who stand to make or lose a lot of money. This, of course, always muddies the water and we have no long term randomized controlled trials (which is the gold standard in the medical literature but very difficult to do with natural substances and hormones) on bioidentical hormones. To further complicate matters, hormones such as estradiol and progesterone are natural substances and cannot be patented and sold as a drug unless they are altered in some way. Synthetic estrogens such as Premarin and progestins such as Provera are made by pharmaceutical companies. Vivelle and other patches are “natural and bioidentical” estradiol but can be sold as a drug because they are in a “special form” ie the patch delivery system. Prometrium is natural progesterone in “micronized form” that is sold as a drug. The drug companies have made billions of dollars and are still making billions of dollars from synthetic hormones and have a great stake in stopping the trend toward compounding “natural bioidentical hormones.” In fact, the Women’s Health Initiative, though flawed in many respects, clearly showed unacceptable risks with oral synthetic hormone therapy. However, the final conclusion was to continue to give synthetic hormones…just not for too long. If you search Pub Med you will find hundreds if not thousands of articles on hormonal therapy, all with their own biases and conclusions and if you search carefully you will frequently find a financial tie that helps explain the conclusions. Compounding pharmacies are not blameless and have rushed to cash in on the bonanza in bioidentical hormone treatment. There is very little regulation of compounded products (though one could argue that the FDA is more interested in protecting Wyeth than women).

A recent review published in Postgraduate Medicine, volume, 121, Issue 1, January 2009, p.73-85 by Dr. Kent Holtorf, MD from Torrance, CA is a meta analysis and literature review of 163 articles. He looked at all types of hormone therapy including synthetic therapies (i.e., The Women’s Health Initiative and Premarin and Prempro) as well as everything he could find on bioidentical hormones including in vitro studies.

Looking at the combined results of these studies, he concluded that “bioidentical hormones (meaning estradiol and progesterone) are associated with lower risks, including the risk of breast cancer and cardiovascular disease, and are more efficacious than their synthetic and animal derived counterparts…and of course that we need randomized controlled trials to delineate these differences.”

Bottom line:
1. If you think you may be a candidate for hormonal therapies, choose bioidentical and choose a physician that is knowledgeable in all fields of hormonal therapies including adrenal, thyroid, and insulin issues. The hormones of your body function in a complex network affecting each other and almost every bodily process. This requires a physician who is knowledgeable and experienced in utilizing bioidentical hormones. With the recent feature of hormonal therapy on Oprah, the interest has exploded and the search engines are hot. This is an area in which physicians are self taught. It is not a standard part of physician training, and I suggest you look for physicians that have received additional training in hormonal therapy such as that received through the Antiaging and Functional Medicine Fellowship offered through the A4M or talk to your friends. They may be your best resource in finding a physician
2. There is no conclusive data that bioidentical hormones are safe. Each woman should discuss her personal risks and symptoms with a knowledgeable physician and decide if it is the right decision for her. There is data that suggests that bioidentical hormone therapy may carry a somewhat less risk and does have a positive impact on quality of life.
3. The only FDA approved treatment for menopause is Premarin and Provera. Don’t rely on the government to protect you. Educate yourself, find a doctor that you trust and make informed choices.
4. Medical research is currently funded primarily by pharmaceutical companies. Many prominent physicians and researchers rely on them for the money to do their research and are on their payroll as speakers. It was recently disclosed that a prominent physician who was paid thousands of dollars by a drug company was instrumental in recommending and greatly expanding the role of using powerful antipsychotic medications in the treatment of psychiatric illness and the use of these drugs in children had interpreted his data in favor of the drugs when in fact, the benefit was minimal at best and dangerous at worst. The research is only as good as the researchers. Money corrupts the process.

Low Libido? Natural Solutions

“I’d rather read a book than have sex with my husband,” Daphne sheepishly admitted during her last pap smear. She checked for my reaction. Would I brush off her complaint? Would I empathize? Better yet, could I offer any solutions?

Daphne is a 44-year old healthy woman and her symptoms, low sex drive and a growing aversion to having sex with her partner, is very common among women in long-term relationships. In fact, 40 to 50% of women her age complain of low libido. You may have noticed that Viagra and its newer cousins haven’t solved the sex problem for women. While most cases of low desire are multi-faceted, there are many proven treatments available. What follows is an integrative, evidence-based path for revitalizing libido to a more evolved place and how to live abundantly and restore balance when your libido feels low.

Daphne got married at 32, had her first baby at 33 and another at 35. Since the birth of her second baby, she has quietly avoided sex with her husband. Now they have sex about once per month and it feels like a chore to her, another pull on her overly busy juggle of work and family. The timing Daphne describes, of a dip in sexual interest after four years of partnership, and especially after a birth, is very common among couples. Daphne is distressed about her waning desire and it is negatively impacting her marriage, which is why she sought help. There are physical and psychological reasons for low libido, but usually the cause is a combination of the two. Primary physical causes of low desire include hormone changes, adrenal burn-out and other medical conditions.

Low estrogen during the post-partum period, premenopause (the time from age 35-50+ when you still have periods and/or cyclic ovarian function) and menopause can dramatically affect your mood and sexual interest as well as cause thinning and decreased sensation to your vulva, clitoris and vagina. Blunted sensation is due to regression of the nerve and blood supply to the genitals as a result of lower estrogen levels. Daphne felt like her clitoris “went numb” after having her last child and stimulation that usually brought her to climax no longer worked. Fortunately, there are simple and often effective remedies for this such as application of bioidentical estrogen cream.

Generally, between the age of 35 and 50, progesterone declines. Estrogen, although it can fluctuate wildly, overall maintains a near-normal level. This imbalance often leads to estrogen dominance, heralded by bloating, mood swings, insomnia, painful breasts, unexplained weight gain, headaches, anxiety, infertility, foggy thinking and weepiness. Often low libido is a byproduct of the lack of restorative sleep and general feelings of being unwell triggered by hormone imbalance. Both low estrogen and testosterone can diminish drive and responsiveness. These are most common in women at menopause or later, or postpartum which is a pseudo-menopausal state in a breastfeeding mom. We are still learning what levels of estrogen and testosterone correlate with a healthy libido for women. Most thought leaders in Sexual Medicine agree that replacement with levels to the upper half of the normal range is the goal. However, synthetic versions of estrogen and testosterone carry significant risks including the recently reported doubling of breast cancer chances in the Nurses Health Study. It is very important to be thoroughly educated regarding these risks, be monitored for them, and to be prescribed the safest and smallest amounts, tailored for you by an experienced medical physician. For instance, all women on testosterone should get liver function tests and a lipid panel every 3 to 6 months to monitor for harm to the liver and heart, which is why I prefer to prescribe bio-identical hormones when possible as they are often more effective and may have less negative side effects.

Another major component of healthy libido is stress management. Who wants sex when it feels like you’re constantly under assault by a crazed schedule, 2 kids and the mortgage crisis? Stress causes cortisol levels to rise above normal, and cortisol then can occupy the progesterone receptor, the lock in a cell into which progesterone fits, and block the action of this important hormone. Many women then experience an imbalance between their estrogen and progesterone. Subtle changes in progesterone action can cause low libido. Often a small amount of progesterone can improve desire along with working to minimize the impact of stress. In addition to progesterone receptor effects, stress causes disharmony between the sympathetic and parasympathetic nervous systems. The sympathetic nervous system triggers our “fight or flight” response, which increases heart rate, blood pressure and breath.

The parasympathetic system controls two crucial functions: digestion and sexual function. Most people who are chronically stressed have an imbalance of the sympathetic and parasympathetic systems, meaning that they are chronically stressed by deadlines, demands, children, work, and poor support systems, and find that their digestion is sluggish and they have no energy for sex. Women also report feeling debilitating fatigue, depleted life force, unstable blood sugar including hypoglycemia, intolerance to exercise, low blood pressure, dry skin, hair loss and sometimes brown spots on their face. This is also known as adrenal fatigue or burned-out adrenals, a popular diagnosis in the alternative medicine community but not recognized by conventional medicine. There are simple tests to assess for whether you have adrenal fatigue, and many supplements available.

Please take care to be diagnosed and treated accurately. I recommend an evidence-based approach to adrenal dysregulation with vitamins, minerals, healthy nutrition with adequate protein and whole grains, rest and stress reduction, and, when needed, supplementation with pharmaceutical-grade cortisol at low doses. Other important physical causes include side effects from medications such as anti-depressants and blood pressure lowering pills. At Gottfried Center for Integrative Medicine, we offer proven protocols for improving low libido while on these agents as well as “Integrative Medicine” approaches to tapering off of antidepressants successfully.

Besides physical causes, there are various psychological and social contributions to low desire. Primary psychological issues include relationship stress, untreated or partially-treated anxiety, depression, chronic stress and a history of abuse. While some of these can be managed by a primary care physician or integrative medicine physician, sometimes psychotherapy and/or sex therapy is advised. Body image, your partner’s age, health and self-care, and your emotional intimacy with your partner all impact your sexual feelings. Most women also don’t realize that male sexual feelings start with drive, then move to arousal, and from arousal and sexual connection, they feel intimacy. Women must feel a sense of intimacy first, then arousal, and then desire. This is subtle gender difference yet fully understanding how this difference plays out in your partnership can be profound.

Practical sex coach tips. While I do not want to discount the importance of treating the previously mentioned multi-factorial causes of low libido, sometimes we also need to bring levity to the bedroom. These are some tried-and-true tips I’ve gathered from seasoned sex therapists combined with my 20 years in practice, counseling women about their libidos.

1. Try something new every third time you have sex. We are living longer in monogamy than ever before, and if we expect our sexual connection to remain vibrant, inject creativity and thoughtfulness. Check out S Factor or OneTaste for ideas!

2. Get the TV out of your bedroom! Consider your bedroom sacred space and for enhancing your parasympathetic nervous system. Bedrooms are for sleep and love making only.

3. Have sex weekly. Studies have shown that you must have sex at least 3 times per month to notice a benefit. It also prevents the need for couple’s therapy in my experience!

Daphne had low progesterone and estrogen dominance. With use of bioidentical hormones, she got her levels back into balance. She attended my class, Sex 101, and learned about emotional intimacy and its role in her receptivity to making love. Additionally, she found ways to manage her volume of stress and her reaction to it. Daphne happily reports that her energy and sex drive have returned, not to pre-children levels but to a mutually satisfying place for her and her husband. She now reports that her marriage feels strong and passionate again. If you felt a strong sexual connection with your partner in your early days of romantic sex, you can reclaim that connection again. Sexual love is mysterious and not easily controlled, yet if suppressed or ignored, it can drain your life force. Often sexual disharmony is an indicator of deeper imbalances. These imbalances once understood and addressed can lead to the restoration of optimal health, energy and libido.

Testosterone: Satisfying Sex Once More per Month

Here's a summary of another study on testosterone in women, this time in women not on estrogen or estrogen plus progesterone. Duration longer than in previous studies: 52 weeks. On average, women on testosterone reported satisfying sex once more per month. Main question is: Is the unknown long-term risk of testosterone worth the benefit to your sex life? Many of my patients would say that contented sex, even if it only happens once more per month above baseline, is worth it. --SG

Testosterone Improves Sexual Function in Women Not Taking Estrogen
Posted 01/16/2009

Robert A. Wild, MD, PhD, MPH
Author Information

Summary

Davis SR, Moreau M, Kroll R, et al, for the APHRODITE Study Team. Testosterone for low libido in postmenopausal women not taking estrogen. N Engl J Med 2008;359:2005-2017.

Therapy with a testosterone patch placed on the abdomen and delivering 300 µg daily provides some benefit to postmenopausal women with hypoactive sexual desire disorder (HSDD) who are not using estrogen therapy (ET) or estrogen plus progestin therapy (EPT), according to this randomized, double-blind, placebo-controlled study. The Phase III Research Study of Female Sexual Dysfunction of Women on Testosterone without Estrogen was initiated to determine the efficacy and safety of the testosterone patch in postmenopausal women not receiving estrogen who are suffering from HSDD and included women from 65 centers in the United States, Canada, Australia, the United Kingdom, and Sweden. The trial was conducted for 52 weeks and included 814 healthy postmenopausal women (aged 20-70 y) who were randomly assigned to receive a patch delivering either 150 µg or 300 µg testosterone per day or placebo. Participants were seen at baseline and at weeks 6, 12, 24, 36, and 52.

Efficacy was measured through women's responses on a weekly sexual activity log for 24 weeks and their scores on a Profile of Female Sexual Function and a Personal Distress Scale that were completed at baseline and at weeks 12 and 24. Adverse events were assessed at each visit through week 52. Some women continued treatment for a second year to provide additional safety data. The primary endpoint was a change through week 24 in frequency of satisfying sexual episodes over 4 weeks.

Baseline scores for frequency of satisfying sexual events, sexual desire, and distress were similar among groups. By week 24, the increase in 4-week frequency of satisfying events was significantly greater in the group with the 300 µg/day patch, with an increase of 2.1 episodes versus 0.7 episodes for placebo; P < 0.001. There was an increase in satisfying episodes of 1.2 in 4 weeks for the group receiving 150 µg testosterone. Both groups receiving testosterone had significantly increased scores for sexual desire and decreased scores for distress by week 24. The overall incidence of adverse events among groups was similar, with incidence of androgenic events highest in the 300-µg group, mainly increased hair growth. Breast cancer occurred in three women in the testosterone groups by week 52 and in an additional woman receiving hormone in the extension phase.

Commentary by Robert A. Wild, Md, Phd, Mph

Prior clinical trials (typically lasting 3-6 mo) with exogenous testosterone have been well conducted. The majority of trials show modest overall improvement in desire, sexual responsiveness, and frequency of orgasm as well as the number of satisfying sexual episodes (an endpoint required by the Food and Drug Administration [FDA] as evidence of efficacy). The short duration of these trials has worried those concerned about potential for serious adverse effects. Studies have been restricted to postmenopausal women taking ET or EPT.

Here, Davis et al assess testosterone therapy in postmenopausal women presumably estrogen deficient for up to 2 years. Efficacy was shown in women who had natural menopause but not in those with surgically induced menopause (probably because of a lack of statistical power). It is reasonable to ask whether the absolute increase of satisfying sexual episodes of 2.1 per month (1.4 more events per month than in the placebo group) was of value. The article does not indicate whether the women were asked if this was meaningful for them. Baseline data suggest it probably was. The mean number of such episodes almost doubled for the high-dose group (84% vs. 28% for placebo).

All groups had reaction at the application site (49.5%-52.8%, which is high) and various androgenic events (acne, alopecia, and voice deepening in less than 8% of each group). A little more than half in each group completed 52 weeks. Reasons for dropping out are well illustrated. Increased unwanted hair growth was significantly more common with 300 µg of testosterone per day (19.9% vs. 10.5% in the placebo group). Of greater concern are the four cases of breast cancer in the groups receiving testosterone, including one case detected 3 months after the extension period ended, versus zero in the placebo group. This could simply be due to chance, yet it is potentially worrisome and cannot be ignored. Findings suggest the need for caution until we understand more about testosterone's possible link with breast cancer and until we are better able to predict which patients are more likely to have negative effects.

Transdermal testosterone is available in Europe for use in surgically postmenopausal women who have persistent symptoms of HSDD despite adequate nonconjugated ET. However, the FDA in the United States is concerned about potential adverse effects over the long term. Breast cancer risk and potential detrimental lipoprotein physiology with unknown cardiovascular disease risk, as well as androgenic side effects (well documented here), have been the major challenges. The reported lipid profiling in this study is reassuring yet not definitive. Small, dense lipoprotein particle concentrations are a better predictor of events but were not measured. The pharmaceutical industry sponsored and analyzed this multisite study.

Because of a lack of FDA-approved testosterone patches in the United States for women, compounding pharmacy preparations for transdermal testosterone are often prescribed. If this route is chosen, full disclosure of off-label use and documentation of the known and unknown risks is strongly recommended. With the breast cancer concern and the need for studies with large numbers of women enrolled to answer this concern, it is likely that the FDA will continue to be very conservative regarding this issue.

From the NAMS First to Know e-newsletter released December 23, 2008

For more, please visit http://www.menopause.org/news.aspx

Libido: Bay Area Boosts

Libido is one of my favorite topics both as an area of physical, mental and spiritual inquiry and as a scholarly pursuit. Plus it's just fun to rev it up as much as possible especially when in a long-term monogamous relationship.

Now, as an aside, let me reassure my friends who are depleted and gave up caring about libido months or years ago: you can get your game back. My heart and pharmacoepia especially goes out to fellow depleted moms. That reminds me - I need to do a blog post on Depleted Mom Syndrome.

We are blessed in the Bay Area (and in New York and Los Angeles, and tell me if there are more libidinously enriching parts of our fine country) to have many places that offer succor to the libidinally-challenged.

My personal fave haunt is S Factor in San Fran, but also available in other cities. What is "S?" It's a hybrid form of movement that weaves yoga, pilates and connecting to your erotic creature. It's completely hot and a lot of fun. Take an intro class or sign up for a private with my dear friend, Michelle Cordero. Since I have a tendency to overachieve, I have attended 3 intros, devoured Sheila Kelly's book on "S" and practiced every DVD she's put out. My husband and I haven't figured out a way for me to attend a session in San Francisco - at two hours plus the commute time - it just doesn't fit into my schedule. But maybe your schedule? Get the intro schedule right here.

Here is Sheila teaching Oprah how to move.

Did you see the cover of last Sunday's NYT's Style Section with the orgasmic woman on the front page? So great. The article was about the Bay Area's OneTaste Urban Retreat Center, a co-ed gathering space with a focus on pleasing women. Where do I sign up? The founder, Nicole Daedone, is the creatrix of the joint, and at 41, she is tapping into a hugely unmet need among women -- the idea that we access freedom, full embodiment, and full-throttle living through our sexualty. A core of 38 men and women live in the SOMA location, but OneTaste offers workshops, a thriving online community (read: free), and a residential program. Check 'em out right here.

My brain tends to cluster around groupings of three, so here is another favorite resource: famous Bay Area sex coaches Celeste and Danielle. I met these women three years ago over lunch at Cafe Gratitude in Berkeley. They offer sex therapy, workshops and hands-on-in-the-bedroom, down and dirty sex couching (they wear gloves!). I have one patient with low libido who had picture-perfect hormones, and we discussed Celeste and Danielle's workshops. She asked her husband to go to their workshop, "Become an Extraordinary Lover," and that was the only intervention she needed to reconnect deeply and wildly with her man.

Wish it were always so easy....

For the rest of us, libido is a complex and very interdependent mix of the right hormonal balance (the players are estrogen, progesterone, testosterone, DHEA, cortisol among others) plus emotional connectivity, healthy body image, time and commitment. More on that later, in the meantime, enjoy your local resources and share via the comments section other discoveries for raising your libido.

Male Menopause or "Irritable Male Syndrome"

If you read the article in last Monday’s San Francisco Chronicle about male menopause and “Irritable Male Syndrome,” you might have recognized your mate. Few men like to acknowledge that they, too, suffer from loss of hormones as they age.

What are the symptoms? Men become angrier and grumpy; they feel less like themselves.
Depression, weight gain and loss of muscle despite a good workout program, feelings of restlessness, difficulty sleeping, a decline in libido, even erectile dysfunction are signs of lower levels of testosterone. Untreated hormonal decline in men may lead heart disease, diabetes, or other age-related diseases.

The Good News?

Male menopause, more commonly called andropause, can easily be corrected. The key is balancing hormones to restore quality of life, vitality, and energy.

Dr. Derek Abbassi, an expert in bioidentical hormone replacement and optimal aging, is our new specialist at Gottfried Center. His focus is the prevention of age-related decline.

“There are diseases related to aging, and there is healthy aging,” Derek says. “Aging doesn’t mean a man has to expect physical, sexual, and mental decline or a life of taking numerous drugs. An integrative medical approach makes it possible for a man to regain vibrant personal and sexual health.

“Bioidentical hormone replacement therapy (BHRT) is core to aiding men as well as women with optimal aging. The natural balance of all the body’s major hormones— the adrenal, thyroid and pancreatic as well as the sex hormones—is critical to maintaining health. A prescription is based on an individualized study of each person’s unique biochemistry as well as their lifestyle and medical history. The results are dramatic and satisfying.”

Dr. Derek Abbassi attended medical school at school at The Ohio State University College of Medicine and completed his residency in OBGYN at the University of Southern California. He has received additional training in Age Management and Anti-Aging Medicine through the Cenegenics Institute and the American Academy of Anti-Aging Medicine. For more information, go to the Gottfried Center online to read about Dr. Derek and the other doctors, including Drs. Marsha Nunley, MD, Sara Gottfried, MD and Charlotte Massey, ND, all of whom are specialists in bioidentical hormone therapy. Both Drs. Nunley and Abbassi specialize in male menopause or andropause.

We welcome your call to Gottfried Center for Integrative Medicine at 510.893.3907. Let Dr.Derek become your age management health practitioner and create a partnership that lasts for your long and healthy lifetime.

Stress, Neurotransmitters, Hormones & YOU!

Are you less stress resilient than you used to be? More overwhelmed by your demands? Irritable and burned out?

The four of us, Drs. Abbassi, Nunley, Massey and me, have been discussing this a lot as we have seen many patients recently who have been under chronic stress for a long, long time. They have sleep problems, brain fog, and do not wake up restored in the morning.

We have many patients who recall life in their 20s: able to focus, concentrate, stay on task, cope with the exigencies of daily life. They rested and relaxed when they could, and enjoyed their time off. Now the weekend is not enough: relationships are more conflictual, home life is not the respite it used to be, achievement doesn't come as easily, which only adds to the stress.

Here are some of the results of chronic stress:

• Insomnia
• Autism
• Poor mood, mood swings
• Anxiousness, irritability, agitation, tension, panic attacks
• Difficulty concentrating, focusing or remembering
• Headaches
• Fatigue, lack of energy
• Weight issues, especially food cravings

Often these symptoms are a result of the body's difficulty responding to chronic stress. The adrenals and brain just can't keep up with the demand. The supply of feel-good neurotransmitters and hormones are limited by diet, genetics and often exposure to toxins.

One helpful approach we've found is to take the following approach:
1. Replace the hormones that are depleted or out of balance, all with bioidentical hormones, all tailored to you and your particular physiology and integrated with your risk factors and genetic disposition. This includes estrogen, progesterone, DHEA, testosterone, cortisol, and thyroid. We often use supplements and nutrition to optimize results.
2. Measure neurotransmitters and develop a customized amino acid protocol based on your results.
3. Make lifestyle and nutritional adjustments, along with refinement of bioidentical hormones and amino acids as needed in the long-term.

We've found this is the best approach for reversing the impact of chronic stress. The result? Vitality. Joy. Love. Less conflict. Connectedness to True Self. Satisfaction. Contentment.

Maca Improves Anxiety, Depression & Lagging Libido

A new study just published in Menopause showed that in a small group of post-menopausal women, a botanical named Maca, also known as Peruvian Ginseng, improved many of the issues our patients at the Gottfried Center complain of, namely anxiety, depression and low libido. Maca was also shown not to affect estrogen or androgen levels. The study was a randomized, controlled clinical trial, the "gold standard" in terms of high quality evidence.

Maca is thought to influence monoamine oxidase levels, one of the targets of prescription anti-depressants. However, as we all know, prescription antidepressants lower libido, whereas maca seems to improve it.

The improvement in libido I think may also be related to effects on the adrenals. This study confirms a previous study showing improved libido in both men and rodents with maca.

We treat both men and women now with symptoms of andropause and menopause, often with bioidentical hormones. In some, it may be more prudent to try proven botanicals first, such as maca.

Dr. Derek Abbassi, MD, Joins Gottfried Center

We are delighted to announce that Dr. Derek Abbassi, an expert in Bioidentical Hormones and Optimal Aging for both men and women, joined us last December. Dr. Abbassi blends 12+ years as a medical doctor with advanced training in both Anti-Aging Medicine, which we call Age Management Medicine, as well as board certification in Women's Health. 

Dr. Abbassi graduated from UCLA and the Ohio State University College of Medicine. He completed OB/GYN residency at USC. He earned many additional certifications from the American College of Sports Medicine, Harvard Medical School's Henry-Benson Institute of Mind-Body Medicine, the American Academy of Anti-Aging Medicine, and the Cenegenics Institute for Age Management Medicine.

Please join us in welcoming Dr. Derek to our practice.

Hormone Imbalance: Symptoms

After many requests, I am re-posting this from my other blog as it is consistently the most popular and my patients seem  to love it. It does not include enough questions related to leptin- and insulin-resistance... more on this in future blogs.

-- SG

How do you know if your hormones are out of balance? I combine a careful history of what my patients are experiencing, their nutritional status, level of activity/lifestyle and sleep along with symptom questionnaires and testing. If any part is left out, we may miss the root cause of the hormone imbalance.  Dr. John Lee's books are helpful with understanding symptoms, and I will provide those below with some modifications I've made.  If you are taking the questionnaire, check off any symptoms that you experience from each symptom group, then we'll integrate at the end.

Symptom Group 1: 

PMS?

Anxiety?

Cyclical headaches (menstrual or hormonal migraine)?

Insomnia?

Early miscarriage?

Lumpy or painful breasts?

Infertility?

Symptom Group 2:

Vaginal dryness or irritation?

Painful sex?

Bladder infections?

Night sweats

Hot flashes

Poor memory?

Depression, especially with lethargy?

Low libido?

Symptom Group 3:

Bloating and/or puffiness?

Abnormal paps?

Rapid weight gain?

Breast tenderness?

Mood swings?

Heavy bleeding?

Depression with anxiety?

Migraines?

Insomnia?

Brain fog?

Red flush on face?

Gallbladder problems?

Weepiness?

Symptom Group 4:

Number of checked symptoms for Group 1 & 3 combined

Symptom Group 5:

Acne?

Polycystic Ovary Syndrome?

Excess hair on face/chest/or arms?

Hyper- or hypo-glycemia and/or unstable blood sugar?

Thinning head hair?

Infertility?

Ovarian cysts?

Midcycle pain?

Symptom Group 6:

Low libido?

Debilitating fatigue?

Unstable blood sugar?

Brain fog?

Low blood pressure?

Thin or dry skin?

Intolerance to exercise?

Brown spots on skin?

For assessment, tally the total number of symptoms in each category.  If you have 2 or more symptoms from a grouping - you may have the following diagnosis. I recommend you sort this out with an integrative physician.

Group 1:  Progesterone deficiency.  This is the most common hormone imbalance of all ages.  Best approaches are to optimize diet, reduce synthetic hormones if you are taking any (including birth control pills) and add bioidentical progesterone if appropriate.

Group 2:  Estrogen deficiency.  This is most common in menopausal women, especially skinny minnies.  Dietary changes and herbal therapies are often helpful as a first approach.

Group 3:  Excess estrogen. We see excess estrogen when women are taking synthetic estrogen, too much bioidentical estrogen (estradiol, estriol, tri-est), or are exposed to environmental xenoestrogens.  Xenoestrogens refer to the 700+ chemicals in the environment that act like endrocrine disruptors in the body, usually by binding the estradiol receptor.  Xenoestrogens have estrogen-like effects such as fertilizers, pesticides and lauryl sulfates.

Group 4:  Estrogen dominance.  Usually caused by not having sufficient progesterone to balance estrogen.  Causes vary from not enough progesterone to too much estrogen, or as is common in premenopause (age 35-50):  low estrogen but superlow progesterone.

Group 5: Excess androgens or male hormones.  Often this is caused by insulin and/or leptin resistance, and we can reverse this with dietary changes and supplements, but other approaches are effective as well.

Group 6:  Cortisol excess or deficiency.  Most people need a laboratory test to differentiate.  This is caused by adrenal fatigue which results from chronic stress.

I find very few women survive work and kids without some degree of adrenal fatigue.

There also is interdependence among these different hormonal systems with each other as well as with neurotransmitters.  For instance, estrogen acts like a selective serotonin reuptake inhibitor and helps mood in many women.  Also, if adrenal hormones are off, this can interfere with conversion of T4 (inactive thyroid hormone) to T3 (active form of thyroid hormone).

For all of these conditions or for further information, I recommend consulting an integrative physician in your area such as those in this database.

Treatment for Vaginal Dryness

We know that one quarter of women at or past menopause note vaginal thinning, irritation, decreased sexual response or dryness, and seek medical attention for it. I find the numbers are actually much higher if you ask women routinely. I'm a big fan of natural lubricants first, and if that doesn't work, try a tiny dose of natural estriol vaginal cream. I like estriol because you usually need less of it than the other forms of estradiol. It is by prescription, and needs to be formulated by a reliable compounding pharmacy. The good news is that it takes about 2 weeks to re-estrogenize the tissues, and it also prevents bladder infections. Remember that pre-menopausal women can have thiss too -- especially thin women who don't have much estrogen on board. Below are some guidelines, published by the North American Menopause Society.
SG

New Guidelines Issued for Treatment of Vaginal Atrophy
News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD

May 15, 2007 — The North American Menopause Society (NAMS) has issued a 2007 position statement about the treatment of vaginal atrophy with local vaginal estrogen. The guidelines, which are published in the May-June issue of Menopause, state that therapy should be guided by clinician and patient preference.

Using the general principles established for evidence-based guidelines, NAMS convened a panel of clinicians and researchers with expertise in genitourinary disease to review, synthesize, and interpret the current evidence on vaginal estrogen therapy for vaginal atrophy, develop conclusions, and make recommendations. The advice of this expert panel was used to assist the NAMS Board of Trustees in publishing this position statement.

"Although hot flashes typically accompany the loss of ovarian estrogen production at menopause, they usually abate over time regardless of whether estrogen therapy is used," Editorial Board Chair Gloria A. Bachmann, MD, said in a news release. "In contrast, vaginal symptoms (eg, vaginal dryness, vulvovaginal irritation and itching, and painful intercourse) are usually progressive and unlikely to resolve spontaneously. Left untreated, vaginal atrophy can result in years of discomfort, with a significant impact on quality of life."

About 10% to 40% of postmenopausal women have symptoms related to vaginal atrophy, most of whom require treatment. However, only about 25% of symptomatic women seek medical attention.

The therapeutic standard for moderate to severe vaginal atrophy is estrogen therapy, administered either vaginally at a low dose or systemically. There has been a relative lack of randomized controlled trials performed to date, but they have shown that low-dose, local vaginal estrogen delivery is effective and well tolerated for treating vaginal atrophy.

In North America, US Food and Drug Administration–approved treatments of vaginal atrophy symptoms that offer localized vaginal delivery of estrogen include cream, tablet, and ring formulations. These products are associated with fewer adverse effects than systemic estrogen. At the doses recommended in labeling, all of the low-dose vaginal estrogen products approved in the United States for treatment of vaginal atrophy are equally effective. The choice of treatment should therefore be individualized based on clinical experience and patient preference.

In general, creams may be associated with more adverse effects than ring or tablet formulations, perhaps because there is more potential for women to apply higher-than-recommended dosing with cream. However, a Cochrane review reported no significant differences among the delivery methods in terms of hyperplasia, endometrial thickness, or the proportion of women with adverse events. The most commonly reported adverse effects associated with vaginal estrogen therapy are vaginal bleeding and breast pain, with nausea and perineal pain reported less frequently.

When low-dose estrogen is administered locally for vaginal atrophy, progestogen is generally not indicated. Data are insufficient to recommend annual endometrial surveillance in asymptomatic women using vaginal estrogen therapy.

Vaginal estrogen therapy should be continued as long as women continue to have distressing symptoms. Management of vaginal atrophy is similar for the group of women without a cancer history and for women treated for non–hormone-dependent cancer. However, for women with a history of hormone-dependent cancer, management recommendations are individualized and vary based on each woman's preference in consultation with her oncologist.

Specific recommendations are as follows:

The primary goals of vaginal atrophy management are symptom relief and reversal of atrophic anatomic changes.

For women with vaginal atrophy, first-line treatments include nonhormonal vaginal lubricants and moisturizers.

Symptomatic vaginal atrophy that does not respond to nonhormonal vaginal lubricants and moisturizers may require prescription therapy.

Randomized controlled trials in postmenopausal women are limited. However, they have demonstrated that low-dose, local, prescription vaginal estrogen delivery is effective and well tolerated for treating vaginal atrophy while limiting systemic absorption.

Low-dose vaginal estrogen products approved in the United States for treating vaginal atrophy include estradiol vaginal cream, conjugated estrogens vaginal cream, the estradiol vaginal ring, and the estradiol hemihydrate vaginal tablet. These are equally effective at the doses recommended in labeling, so specific choice depends on clinical experience and patient preference.

When low-dose estrogen is administered locally for vaginal atrophy, progestogen is generally not indicated.

Closer surveillance may be required for women at high risk for endometrial cancer, those using a higher dose of vaginal estrogen therapy, or those with symptoms such as spotting or breakthrough bleeding. Evidence is insufficient to recommend annual endometrial surveillance in asymptomatic women using vaginal estrogen therapy.

Vaginal estrogen therapy should be continued for as long as women have distressing symptoms.

For women treated for non–hormone-dependent cancer, management of vaginal atrophy is similar to that for women without a cancer history, but for those with a history of hormone-dependent cancer, management recommendations should be based on each woman's preference and the advice of her oncologist.
"Overall, subjective improvement occurs in 80% to 90% of women treated with local vaginal estrogen," the authors conclude. "Vaginal atrophy unresponsive to estrogen may be due to undiagnosed dermatitis/dermatosis or vulvodynia, so treatment failure warrants future evaluation and careful examination."

Novo Nordisk supported the development of this position statement through an unrestricted educational grant. Members of the Editorial Board have disclosed various financial relationships with Berlex, Duramed, Johnson & Johnson, Pfizer, Roche, Wyeth, Paladin Labs Canada, Wyeth Canada, Procter & Gamble, and/or Merck.

Menopause. 2007;14:357-369.

Hear Better with Hormones

Here are some recent articles showing that women on hormone therapy have better hearing than women who do not take hormones. What?! This is part of my crusade to make sure women are careful to get a nuanced view of whether they would benefit from hormones, rather than the over-simplified view that all hormones are bad. Hormones, taken at the lowest doses and preferably bioidentical, can be safe and life-altering. They've been proven to help mood, libido, vasomotor symptoms, and now HEARING!
SG

Acta Otolaryngol. 2007 Feb;127(2):149-55. Hearing in women at menopause. Prevalence of hearing loss, audiometric configuration and relation to hormone replacement therapy. Hederstierna C, Hultcrantz M, Collins A.

Department of Audiology, Karolinska University Hospital, Stockholm, Sweden. christina.hederstierna@karolinska.se

CONCLUSION. Hormone replacement therapy (HRT) may have a protective effect on hearing impairment in postmenopausal women. New guidelines for classification of audiometric configuration in age-related hearing loss are suggested. OBJECTIVES. To describe prevalence of hearing loss and audiometric configuration in a group of middle-aged women with respect to menopausal stage and HRT. SUBJECTS AND METHODS. A total of 143 women around menopause were sampled through the Swedish population register. The mean hearing threshold levels were compared according to menopausal status. The audiograms in the 57 women with hearing loss were classified according to audiometric configuration. RESULTS. In all, 57 women (40%) had any kind of hearing loss; 42 had very minute hearing loss; 15 had a 4FA (average of thresholds at 0.5, 1, 2, and 4 kHz) of at least 20-39 dB HL in at least one ear. Two of these had a 4FA of 40-69 dB HL in at least one ear. The most common configurations were: gently sloping (47%), steeply sloping (14%), and high-frequency U-shaped (14%). The postmenopausal women who were not on HRT had poorer hearing mainly at 2 and 3 kHz, compared with pre- and perimenopausal women, and postmenopausal women on HRT.

Acta Otolaryngol. 2006 Jan;126(1):10-4. Estrogen and hearing: a summary of recent investigations.
Hultcrantz M, Simonoska R, Stenberg AE.

Department of Otorhinolaryngology, Karolinska University Hospital, Stockholm, Sweden. malou.hultcrantz@karolinska.se

Is the female sex steroid estrogen the key to preserved hearing in the aging human? This question remains unanswered, but hearing loss is more profound in elderly males than females. There are also well-known sex differences in the auditory brainstem response (ABR), i.e. women have shorter latencies than men. Moreover, menopausal women who are administered hormone replacement therapy have slightly better hearing than those who are not, and women with Turner's syndrome (45,X), who are biologically estrogen-deficient, show longer ABR latencies and early presbyacusis. These findings are also supported by animal experiments. When boosted with estrogen or testosterone the non-reproductive female midshipman fish alters its inner ear auditory mechanism so that it can hear the male's hum-like call. If estrogen receptor beta is knocked out in mice, severe progressive hearing loss occurs, leading to early deafness. In apparent contradiction to these findings, there have been case reports suggesting that hormone replacement therapy and oral contraceptive use can lead to hearing loss, but of another type, namely acute sudden deafness. Such contradictory aspects of the action of estrogen are commonly found and may spring from the fact that there are two estrogen receptors, alpha and beta, both of which are present in the inner ear of mice, rats and humans. Knowing how sex steroids can alter hearing ability may give important clues as to how estrogen can preserve hearing in humans. In this review we present a summary of current knowledge about hearing and estrogen.