Hormone Replacement Therapy for Women

The Dance of Hormones

Many of our hormones have a daily or circadian rhythm. Melatonin rises as we prepare for sleep. Cortisol and growth hormone prepare us for arousal in the morning. Both men and women share these daily cycles. Women, however, have another whole symphony overlaid on this daily rhythm, the monthly cycle of the reproductive hormones.

The precisely controlled rise and fall of estrogen and progesterone is part of complex feedback system responsible for the preparation of the development of the egg and preparation of the uterus for implantation and pregnancy.

The daily fluctuations overlaid with the monthly cycles make balancing hormones in women all that more important. Conditions of hormone imbalance are much more frequent in women. Some of these imbalances are specific to women (PMS, polycystic ovary disease, fibroids, migraines, etc) and some are shared by both genders but more frequent in women. An experienced thoughtful approach to this re-balancing is essential.

Some of the conditions that are affected by hormone imbalance are listed below.

1. Hypothyroidism

Facts about hypothyroidism:

  • It is the most common hormone deficiency in adult Americans
  • About five percent of adults have some degree of thyroid insufficiency
  • Hypothyroidism remains under-diagnosed and under-treated by mainstream physicians 
  • There are constantly changing guidelines for diagnosis and treatment of low thyroid states
  • Physicians often misinterpret laboratory tests for thyroid disorders ("Your thyroid is normal") 
  • Hypothyroidism is one of the easiest hormone deficiencies to identify and treat

The top ten signs and symptoms of low thyroid are:

  • fatigue
  • cold intolerance
  • weight gain
  • constipation
  • myalgia
  • menstrual irregularities
  • slow movement and slow speech
  • skin changes
  • hair changes and hair loss
  • cognitive impairment

Thyroid insufficiency can span a range from a mild deficiency that is only evident when the body is stressed to a near complete lack of thyroid hormone which results in all of the above (and more). Thyroid hormone is a "major" hormones ("major" meaning necessary for life). The "big three" major hormones, cortisol, thyroid, and insulin, play central roles in the regulation of metabolism and growth. Without them, we cannot survive for long.

Fortunately, we have good simple tests to assess thyroid gland function. Unfortunately, most physicians order only one (TSH) and often under-interpret TSH levels. Using the appropriate tests and assessing symptoms in relation to lab results can help most patients achieve the proper balance of this vitally important hormone.

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2. Low Libido

After food and survival, sex has be third most important human drive. Without sex and its intended (or unintended) consequence of pregnancy, the species cannot survive. Why then is lack of libido (low sex drive, lack of interest in sex) so common?

There are many causes of lack of libido. Some of the more common include:

  • Medications
  • Psychological conditions
  • Hormone imbalances
  • Sedentary lifestyle
  • Concurrent illness
  • Alcohol
  • Recreational drugs
  • Prescription drugs*

*Many prescription drugs can affect libido. The prime offender among these is probably antidepressants of the SSRI class. Even while depression can cause low libido, some of the most effective treatments for depression can, strangely enough, cause it as well. This is a common situation which requires a careful managementto balance effective antidepressant therapy and control of this well-known side affect.

Other common prescription medications that can cause low libido are: beta-blockers, benzodiazepines, narcotic pain medications, statins, blood pressure medications, medications for benign prostatic hypertrophy (BPH), and others.

The list of psychological conditions that result in low libido is lengthy. Special note should made of depression as low libido so commonly associated that it is one of the diagnostic criteria for depression.

Low testosterone and low estrogen in BOTH men and women can cause low libido. A proper balance must be maintained to have a healthy sexual drive. Other hormone imbalances that are associated with are hypothyroidism and adrenal fatigue.

Alcohol and recreational drugs (particularly opiates and marijuana) can depress libido both through their direct effects on the brain and through the indirect effect of depressing testosterone.

Other illnesses can depress libido not only by affecting hormone balances, but also through the release of substances that cause fatigue.

By properly balancing hormones, addressing underlying issues and understanding care low libido can effectively be treated in almost all cases.

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3. Menopause and Perimenopause

Menopause is one of two major hormonal transitions in a woman's life. The onset of menstrual cycling (menarche) is the first and end of menstrual cycling (menopause) is the second. It is important to understand a few terms that are commonly used in any discussion about menopause.

Menopause — Menopause is defined by 12 months of no periods after the final menstrual period. On a physiologic level, the ovary has stopped making eggs, estrogen, and progesterone.

Perimenopause — Perimenopause means "around the menopause," and typically starts with the onset of irregular periods and ends 12 months after the last menstrual period.

Postmenopause — Postmenopause begins after menopause.

Perimenopause is characterized by the all the signs and symptoms associated with "the change". Common perimenopausal signs and symptoms include:

  • Hot flashes
  • Irregular cycles
  • Sleep disturbances
  • Vaginal dryness
  • Lack of libido
  • Urinary incontinences
  • Depression and other mental disturbances
  • Breast tenderness
  • Skin changes
  • Gastrointestinal complaints
  • Joint pain
  • Loss of balance

Many of these symptoms can be attributed to the declining or rapidly-changing levels of estrogen and progesterone that accompany perimenopause.

The average age at which menopause occurs is 52. However, there is wide variation and natural menopause can be diagnosed at any age between 40 and 56. The age of menopause can be influenced by many factors including genes, ethnicity, smoking, age of first period, childbirth, and cycle length.

A balanced and understanding approach can make the menopausal transition easier. Appropriate laboratory studies and symptom assessment combined with bioidentical hormone replacement can control many of the more bothersome symptoms and provide critical cardiovascular and neurological protection.

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4. Premenstrual Syndrome/Premenstrual Dysmorphic Disorder

Most common symptoms of premenstrual syndrome:

  • Fatigue  92%
  • Irritability 91%
  • Bloating  90%
  • Anxiety/tension 89%
  • Breast tenderness 85%
  • Mood lability 81%
  • Depression  80%
  • Food cravings 78%
  • Acne 71%
  • Increased appetite 70%
  • Oversensitivity 69%

PMS will be experienced by upwards of thirty per cent of women with regular cycles (roughly 75 per cent will have at least one of the above symptoms in any given cycle). A more severe form of PMS, premenstrual dysphoric disorder (PMDD), is experienced by roughly five percent of women wherein symptoms of anger, irritability, and internal tension are prominent.

In making a diagnosis of PMS or PMDD, the relationships of symptoms relative to menses is critical. Symptoms should be present BEFORE menses and relieved within a few days AFTER menses. That is symptoms typically occur late in the cycle and the patient should be symptom-free at some point early in her cycle (this is in the absence of medications including birth control pills).

While the exact cause of PMS is unknown, the very cyclical nature of the syndrome suggests strongly that hormones are involved. The two primary "female" hormones, estradiol and progesterone, undergo an elegant, orchestrated dance during a normal menstrual cycle with estradiol being the dominant hormone during the first half the cycle and progesterone being dominant in the second half. While little progesterone is produced in the first half, estradiol is still present in significant concentrations in the second half.

The balance of estradiol and progesterone in the second half of a normal cycle (just the time when premenstrual symptoms begin to occur) is thought to be important in the development of PMS. This is probably the reason that birth control pills often give significant relief from PMS symptoms. In addition, the balance of steroid hormones also affect the brain signaling compounds known as neurotransmitters. One of these neurotransmitters, serotonin, has been implicated in PMS which may explain the efficacy of the serotonin-enhancing antidepressants in the the treatment of PMS. In addition, the levels of serotonin can be depressed by a variety of vitamin and amino acid deficiencies which may, in part, explain the efficacy of supplementation in some patients with PMS.

Relief from PMS/PMDD can be obtained through a balanced approached emphasizing appropriate supplementation, diet, bioidentical hormones, and/or pharmacological treatment (if necessary).

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5. Weight Gain: Why can't I lose weight?

You hear it all time.

"I used to be able to eat like a horse and not put on a pound"

"If I so much as look at a piece of cake, I put on weight"

"I go to the gym every day and can't lose a pound."

What is it about growing older (not growing old) that changes our ability to keep off the pounds? If you were like me as a teenager, a double-double burger, fries, and a shake would melt off like a snowball in the desert sun. Now the shake and fries are long gone and half the bread on the burger is given to Chloe, my golden retriever.

There are a multitude of factors that make us fatter and keep us fatter. Genetic, hormonal, environmental, and cultural influences can all conspire to keep the adipocytes (fat cells) nice and plump.

Here are a few of the major causes:

1. Resting metabolic rate goes down with age.

Resting metabolic rate (RMR) is the energy expenditure your body uses for maintenance (it is basically the calories that you are burning when not moving and not digesting). RMR decreases slowly with age to the point where a 60 year old may have a RMR that is 75% of a twenty year old. This translates to nearly 300 calories a day. That is, the twenty year old can burn a lot more calories just standing or laying around. To me, that is 60 minutes on the treadmill. Every day.

2. You are female.

The gender differences between men and women conspire to make it more difficult for women to lose weight. Women tend to store more fat in butt, hips, and thighs while men tend to store it around the midsection. Upon vigorous exercise, abdominal fat is preferentially recruited for burning, making fat loss in those "problem areas" difficult.

In addition, women have less muscle mass than men. Muscle being more metabolically active burns more resting calories and more calories during activity. Therefore, men can burn more calories just being a couch potato.

3. You are eating the wrong foods.

I won't even begin to go into efficacy of different diets, however, a few basic guidelines can be agreed upon by just about anyone in the nutrition field. That said, much of diet lore is simply myth and has no scientific basis.

In any diet you should:

  • Eat protein at every meal (protein helps build/maintain muscle which causes more calories to be burned)
  • Take good quality supplements to help your metabolism

4. You can't lose weight by dieting alone

Recent studies have confirmed what has been suspected for many years. Both diet AND increased movement are necessary to lose weight. Neither alone helps you lose weight. You may have put on the extra pounds by overeating and under-exercising, so is it really surprising that you need to both diet and increase movement to lose weight?

5.  You may not be sleeping enough

Here is some good news. A good night's sleep helps burn calories. A good, uninterrupted7-9 hrs a night is needed for this benefit.

6.  You may be sleeping too much

However, sleeping too much can result in excess weight gain. Though the mechanism is unclear, more than nine hours of sleep is associated with weight gain.  Again, the sweet spot is 7-9 hours of uninterrupted sleep.

7. Your hormones are out of balance

All the major hormones (and some of the minor ones) can affect weight. The big three, thyroid, cortisol, and insulin, must be in balance to maintain a lean body.

8. You have an unrecognized food sensitivity

Food allergies and sensitivities can contribute to weight gain by altering the permeability of the gut.

9. You may have the wrong genes.

There is clearly a genetic component to excess weight. Very rare mutations can result in massive obesity and more common ones can lead to a propensity to excess weight. Many of these "fat genes" can now be identified by commercially available genetic testing.

10. You are getting bad advice about weight loss.

A balanced approach to weight loss can lead to long-lasting results. It doesn't need to be years of torture. Identifying and correcting misconceptions about diet and exercise are just a start. Adding food choice, hormone optimization, and pharmacological support can help the pounds disappear for good.

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