Hormone Therapy: Continuous Progesterone Safer

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

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

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

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

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

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

Iodine Deficiency

by Michael B. Zimmermann


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

PMS: Natural Approaches

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

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

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


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


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

Minerals / Vitamins

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

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

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

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

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

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

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

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

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

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

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

Supportive Treatment: Analgesics, NSAIDs, Diuretics


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

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

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

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


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

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

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

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

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

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

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

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

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

Hormonal Agents


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

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

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

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

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

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

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

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

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

The Bottom Line


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

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

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

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

References
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919 FDA Talk Paper. Impurities confirmed in dietary supplement 5-hydroxy-L-tryptophan. August 31, 1998. Available at: http://vm.cfsan.fda.gov/~lrd/tp5htp.html

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6034 Hardy ML. Herbs of special interest to women. J Am Pharm Assoc 200;40:234-42.

6036 Belch J, Hill A. Evening primrose oil and borage oil in rheumatologic conditions. Am J Clin Nutr 2000;71:352S-6S.

6229 Tamborini A, Taurelle R. [Value of standardized Ginkgo biloba extract (EGb 761) in the management of congestive symptoms of premenstrual syndrome]. [Article in French]. Rev Fr Gynecol Obstet 1993;88:447-57.

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6429 Stevinson C, Ernst E. A pilot study of Hypericum perforatum for the treatment of premenstrual syndrome. BJOG 2000;107:870-6.

6847 Bendich A. The potential for dietary supplements to reduce premenstrual syndrome (PMS) symptoms. J Am Coll Nutrition 2000;19:3-12.

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7055 Schellenberg R. Treatment for the premenstrual syndrome with agnus castus fruit extract: prospective, randomized, placebo-controlled study. Br Med J 2001;322:134-7.

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7078 Berger D. Schaffner W, Schrader E, et al. Efficacy of Vitex agnus castus L. extract Ze 440 in patients with premenstrual syndrome (PMS). Arch Gynecol Obstet 2000;264:150-3.

7079 Loch EG, Selle H, Boblitz N. Treatment of premenstrual syndrome with a phytopharmaceutical formulation containing Vitex agnus castus. J Womens Health Gend Based Med 2000;9:315-20.

7135 Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academy Press, 2002. Available at: www.nap.edu/books/0309072794/html/.

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Local Hero Michael Pollan's Top 10 Food Tips

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

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

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

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

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

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

6. No second helpings, no matter how scrumptious.

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

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

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

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

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

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

13. Make and take your own lunch to work.

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

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

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

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

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

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

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

To D Or Not to D

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

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

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

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

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

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

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

Injured? Stressed Out? Try Yin Yoga

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

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

Practice Yin Yoga. Check it out.

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

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

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

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

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

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

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

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

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

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

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

Yoga: Proven Benefits for Anxiety, Depression & Adrenal Dysregulation

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

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

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

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

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

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