October 2009

An Updated Solution to an Age-Old Problem

Author: Kristi Blessitt, M.D., F.A.C.O.G.

Women have been looking for a tonic to ease the symptoms of menopause since Lydia E. Pinkham began brewing up her famous elixir on her kitchen stove in 1875. Her remedy, which was composed primarily of black cohash and 18 percent alcohol, eventually became one of the best known patent medicines of the 19th century, and versions of this product are still available today. This is not the remedy that most modern women would choose today, but it is incredibly disheartening that almost 135 years later, despite the advances in modern medicine, it is reported that 80 percent of women are still experiencing symptoms of hormone imbalance.

Menopause is a natural part of a woman’s life. It is technically when the menses stops. The average age is 52, but it can occur at any point between 30 and 60. It has been referred to as “adolescence in reverse”—a rocky time of fluctuating hormones and emotions. The symptoms are caused by hormonal imbalances and changes, not necessarily just a lack of estrogen. The symptoms that are common complaints in menopausal women may be caused by diminished or elevated levels of sex hormones including estrogen, progesterone and testosterone. These same symptoms can also be the result of high or low cortisol levels from chronic stress response, thyroid disease, micronutrient deficiencies, or even some other less common chronic disease states.

Testing hormone levels is of upmost importance. The reason for this is that the picture can get very confusing with the overlap in symptoms. Many different fluctuations in hormones can occur at this time. To demonstrate my point, I will take some of the common complaints of menopausal women and give some of the possible etiologies:

WEIGHT GAIN: high estrogen, low progesterone, low cortisol, low thyroid

MOOD SWINGS: high estrogen, low progesterone, high testosterone, low or high cortisol

DECREASED LIBIDO: low estrogen, low progesterone, low testosterone, high cortisol, low thyroid

INSOMNIA: low progesterone, high testosterone, high cortisol

And so it goes for the myriad of unpleasant symptoms women may experience from their specific hormone imbalance. The cause can be any one or a combination of hormonal variations. This can be different in each individual according to their weight, activity level, diet, life stressors and genetic predisposition. Also playing a role can be medications a person takes or chronic illness. By not measuring the hormones before and after treatment, the hormone picture is, at best, an educated guess. Hormone levels vary from woman to woman by 200-1500 percent. Some women may need only one type of hormone replaced to restore their balance and some may require three or four different kinds to get back into balance.

Testing allows a physician to achieve appropriate and compatible physiologic levels of hormones while optimizing the levels for minimum dose to relieve the symptoms and avoiding overdosing. The FDA has released a statement that it does not consider hormone therapy to be a therapy that necessitates customized dosing (i.e., compounded). While it is true not all women need customized therapy, there are women who have refractory symptoms, and tailored therapy is a legitimate option. This affords them relief and returns them to the quality of life that they deserve. I like to use the analogy of an ill-fitting suit that makes a woman uncomfortable and miserable until a tailor alters the suit to custom fit that particular woman and she is then comfortable, confident and feels beautiful again. The persistent symptoms are like the malfitting suit and the tailored therapy is like the customized fit.

Estradiol, testosterone and progesterone have been FDA approved and in wide use for over 25 years. They are recognized as useful for symptom relief and have been studied and proven safe for human use. Hormone level testing has been somewhat controversial in the past, and some of that thinking still persists. Providers who do the testing usually do it through serum (blood testing via venipuncture at a lab) or salivary kits. A recent article in a local magazine made the statement that the American College of Obstetrics and Gynecology considers salivary testing “useless.” This excerpt was based on an ACOG Committee Opinion from 2005 with empirical data dating from the 1980s and 1990s.

The saliva hormone tests now use technology that was developed less than five years ago where the hormone being tested is extracted from the sample and amplified individually. This technology allows for very low concentrations to be evaluated and measured accurately. In fact, salivary testing is used by NASA and the U.S. military to test cortisol levels in astronauts and fighter pilots who will be entering war zones. The kits are easy to use and convenient, allow for collection of multiple samples, the cost is considerably less than venipuncture, and the testing is covered by most insurance companies.

As with any medical therapy, there are risks and benefits associated with initiating a new treatment. This is why it is of upmost importance for the patient to find a physician who is open to and understanding of the patient’s needs and goals as well as one who is knowledgeable and up to date about all of the treatment modalities available. In that scenario, the patient and physician can work together to formulate the safest, most beneficial and satisfactory treatment for that individual.

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