Memo to Your Thyroid: Role of Adrenals & Estrogen/Progesterone, etc

Somehow I made it through med school, residency and years of medical practice before I figured out a key epiphany: interdependence of the glandular systems of thyroid, adrenals and sex hormones (estrogen, progesterone, testosterone). Turns out I needed to teach it to myself - it's not in the medical textbooks or even conventional medical discourse. Once I got "it," meaning how all these crazy thryoid, adrenal and sex hormones fit together, much of my thryoid chaos fell away, for myself and more importantly, for my patients.

Here's the memo I never got.

1.   Got estrogen? Got too much estrogen? Estrogen dominance is common with hypothyroidism. Symptoms are: moodiness, cysts (ovarian, breast), weight gain, night sweats/hot flashes, irregular cycles. Too much estrogen raises thyroid-binding globulin, and this in turn can bind your free thyroid hormones, even if they are present in the right amounts. Think see-saw: if estrogen is high, free thyroid hormone is low. And vice-versa.

2.   Conversely, hypothyroidism causes sex-hormone binding globulin (SHBG) to decrease – this raises both free testosterone and estrogen. Note the significant overlap between estrogen dominance and hypothyroid symptoms – there is both redundancy in this system and crossover. Best fix: balance both systems simulataneously or sequentially. Most conventional docs will look at you like you’re nuts if you mention estrogen dominance – find an integrative doc here or test yourself.

3.   Adrenals operating properly? Adrenal function and thyroid function have a relationship also like a see-saw: when one is up, the other is down. Get both systems balanced so the see-saw is even.

4.   More on cortisol: correct amount of cortisol (not too much, not too little) helps the conversion from T4 (inactive thyroid hormone with 4 iodine atoms) to T3 (active form – 3-4 times more potent than T4, 3 iodines). You can check a questionnaire to assess for this, or even better, get it tested right here. Another benefit of balanced adrenal hormones is less thyroid inflammation.

5.   Polycystic ovaries? Another key aspect of interdependence is the dance between PCOS, your adrenals and your thyroid.  While the cause isn’t well-delineated, I believe most of PCOS begins with the stress cascade of overtaxed adrenals and too much cortisol in the fight-flight-collapse response, and leading to insulin resistance (typically defined as fasting insulin > 7), which is toxic to the ovary and makes progesterone levels drop. This leads to irregular cycles and imbalanced hormones (high androgens, high estrogens). One treatment is more progesterone, preferably the natural flavor as Chastetree Vitex, progesterone cream or prometrium. But that’s another blogpost for another day. Key point is that high cortisol when stressed can block your progesterone receptors, keeping the progesterone you make from doing its job. Another cause of high cortisol? HYPOTHYROIDISM! Oy, interdependence is a vicious cycle until you understand it. But know this: women with PCOS are four times more likely to have hypothyroidism due to autoimmune thyroiditis

6.   Speaking of inflamed thyroids, have you been tested for thyroid antibodies? Know your titers? Crucial, my friend. More often than not, your under-active or over-active thyroid is a result of autoimmune thyroiditis. What makes autoimmune thyroiditis worse? You guessed it, adrenal dysregulation and estrogen dominance. Oh, and digestive inflammation.

7.     Iodine, as the differentiator between thyroid hormones, is essential to the right balance of thyroid. I find most of my patients are deficient in the Bay Area of California, but too much can cause problems too. Best plan of action is to perform a iodine challenge test, available through Meridian Valley Labs in Washington among other places.

8.     Nutrition – what does that have to do with hormones? A ton. Just going gluten-free reduces estradiol (the key estrogen of our reproductive years and bioidentical hormone therapy in women 40+) by 30-40%. Big help if you’re estrogen-dominance.

9.     Got goitrogens? I’ve never heard a conventional doc talk to patients about foods (called goitrogens) that lower your thyroid function. Tell me your stories of docs who are sharing this info! Yet, as with most things, the info is easy to find online. Raw foods are lightly goitrogenic (cooking inactivates the goitrogenic compounds). Short version: strawberries, pears, peanuts, pine nuts, cassava (yucca), Brassica veggies such as broccoli, bok choy and brussel sprouts. I know, I know – they help your estrogen metabolism but recall the see-saw analogy.

10.  Polyendocrinopathy? Long word, key concept – refers to more than one endocrine gland malfunctioning at a time. Sometimes the thyroid is the first to manifest (or perhaps more commonly, the only one to be tested and/or recognized by your doc), yet one or more endocrine glands is on the wane. This can cause a more complex array of symptoms that are harder to treat. This is where a root cause analysis and step-wise or multi-system hormone treatments can be helpful.

You maybe wondering with all this complexity and interdependence, which is the chicken and which is the egg? Often we don’t know. That’s where balancing all three systems either simultaneously makes the most sense.

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Originally posted on the fantastic site for thyroidistas, Dear Thyroid.

Resolving Differences in Libido

Yesterday, I taught "Yoga for Restoring Energy & Libido" at Yoga Kula in Berkeley, and realized afterward that we didn't spend the 10-15 min I had prepared on how to resolve differences in desire, and sometimes, when needed, to compensate for both high and low libido when your libido is discordant than your partner's. Most partners have discordant libido, and how your find the middle path together is an essential part of a deepening, mature, mutually toe-curling sexual connection.

I mean "compensation" in the most loving, inclusive way -- such as how a kinesthetic learner would compensate for a class that requires visual learning, such as in Art History. I mean it with no judgment and no shame associated with it.

If you have low libido, I recommend a comprehensive medical exam, ideally with someone who is well-versed in hormones and their role in energy and libido. While causes for low libido such as adrenal dysregulation, fatigue, low testosterone, estrogen dominance, and underactive thyroid are described in previous blogs, as well as their natural solutions, I will focus here on the ways that have been shown to help bridge the divide if you have a partner with a higher or lower desire than yours, at least stronger than yours, and perhaps it's motivating you to do something about it.

For those with low libido:

1. Lean into your strength - Identify and fortify your sexual strengths. Even when desire is relatively low, often other aspects of your sexuality such as technique, variety, talking about sex, sensuality, romance, verbal intimacy or body image are areas where you are interested in putting more energy. For more info on this, and to perform a helpful survey to identify your sexual strengths and your partner's, read Pat Love's book, Hot Monogamy, esp pages 18-39, Mapping Your Sexual Relationship. 
2. Realize the power of receptivity. Recent thought leaders such as Rosemary Basson have recognized that spontaneous drive is common for men, and relatively uncommon for women. In fact, our most recent conceptual model shows that women do not need to have sexual desire or drive to have a satisfying sexual connection with their partner. Further, many women have difficulty distinguishing desire from arousal. Sometimes just a small opening in our receptivity to our partner's bid for sex can mean the difference between a mutually satisfying sexual connection and a connection that causes distress. 
3. Fan the fire when it strikes. Sometimes we have a small glimmer of interest in sex or sensuality, and the more we act on it, fan it, encourage it, the better. A crucial task here is to identify patterns in your life that are associated with greater libido: perhaps Friday or Saturday is a better day for you than during the week, maybe it's after your husband watched the kids while you went to a yoga or meditation workshop. Maybe it's day 9-14 of your menstrual cycle, when testosterone peaks.
   

For those with high libido:

1. Initiate sex out of love and desire, not habit. We often get locked into how sex needs to be, and breaking out of this habit will create more life and vitality in your connection. 
2. Improve technique. New expertise in love-making can go a long way in getting your less libidinous partner interested and receptive to your bid. We can always learn more and try new things. If you live in the Bay Area, attend a workshop at Good Vibes in Berkeley, or Celeste and Danielle's Become An Extraordinary Lover.  
3. Be respectful of your partner's parameters on sex. This requires verbal fluency in talking about sex, and how to optimize your partner's interest and openness to your bid. Ask your partner what some of their preconditions for sex are (kids are in bed and asleep, dishes are done, prefers sex in the mid-day), and do your best to satisfy them. 
4. Don't take your partner's lower libido personally. Many of us are just born with lower libidos - it's a bell-shaped curve. Find the way to negotiate a mutually satisfying plan for sex that honors your needs as well as those of your partners. Your partner's low libido is your issue as a couple - do not make your partner feel inadequate or that there is something wrong. 
5. Broaden your definition of sex. One brilliant sex therapist I love, Ruth Cohn, defines sex as "any erotic activity that is pleasurable, connecting, makes me feel good about me, good about you (my partner) and good about us." You can create your own list of what would now be defined as sexual activity, and it may include watching a romantic movie together while you hold hands and laugh together, or giving each other a massage and delighting in the pleasure of touch without it becoming sexual.

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.