Medical condition: Premature menopause

“I’ve been on Premphase since my doctor told me I was in premature menopause. I’m not sleeping, I can’t concentrate in school, I can’t remember things, I’m gaining weight around the middle of my body, I have NO energy, my sex drive is totally gone, my joints ache… and this is all getting worse. My family doctor said I’m stressed with school and I’m depressed…. He prescribed Zoloft. But I don’t want to take it unless I know that’s what I really need. He did not do any blood tests to check my hormones.”

Former Hormone Replacement Therapy

• Premphase - 0.625mg/5mg (horse-derived mixed estrogens and cyclic synthetic progestin, medroxyprogesterone acetate or Provera)

Lab Data on Former Hormone Replacement Therapy

• Estradiol - 38 pg/ml (too low)
• NTx 65 - (too high, indicating more rapid bone breakdown)
• Cortisol - 17.7 (high, a stress effect from low estradiol, etc.; this contributes to weight gain)

New Hormone Replacement Therapy (bioidentical hormones)

• 17-beta estradiol (Brand name: Estrace) - 0.5 mg AM & PM
• micronized progesterone (Brand name: Prometrium) - 200 mg for 10 days/mo.

New Lab Data

• Estradiol - 112 pg/ml (goal range)
• NTx16 (now normal, indicating no excess bone breakdown)  Cortisol 9.7 (normal)

Shelly’s Comment

“Being off the Premphase has really helped. I feel lots better – have more energy, my sex drive is back, I am not as moody as I was, my memory is definitely better, and I am doing better in school.”

Physician’s Comment

In addition, Shelly did not need antidepressants.

Medical condition: Six years earlier, “Cathy” had a hysterectomy and her ovaries were removed.

Although her daytime hot flashes had improved with hormone replacement therapy, Cathy still had night sweats that woke her up several times during the night. Extreme fatigue was making it hard for her to get through her daily activities. She also complained that her breasts felt full and tender most of the time. She couldn’t remember things well and felt like she had “brain fog” that she had never experienced before. Her complete loss of interest in sex was affecting her marriage.

Former Hormone Replacement Therapy

• Premarin - (horse-derived mixed estrogens) 0.625 mg daily for 6 years

Lab Data on Former Hormone Replacement Therapy

• N-telopeptide (a marker of bone breakdown) = 65, too high (indicating more rapid bone breakdown)
• Estradiol level = less than 30 pg/ml (too low)
• Testosterone level = less than 10 ng/dl (too low)
• A bone density test showed osteoporosis

New Hormone Replacement Therapy (bioidentical hormones)

• 17-beta estradiol (Brand name: Climara patch)- 0.1 mg
• micronized bioidentical Testosterone - 2.5 mg sustained release tablet
• Actonel - 5 mg

New Lab Data (at one year after change in hormone therapy and after adding Actonel)

• Bone Density Test showed improvement, now Osteopenia
• N-telopeptide = 35 (now normal, indicating no excess bone breakdown)
• Estradiol = 85 pg/ml (desired target range)
• Testosterone = 45 ng/dl (desired target range)

Cathy’s Comment

“I am so excited to see how much better my bones are now — I was shocked to think I had been taking Premarin all those years and still losing bone. And I am really amazed how much better I feel on the estadiol patch, it is like night and day difference! My breast don’t hurt, I don’t have those drenching night sweats and I sleep well now. I don’t have that awful brain fog, and I feel like I have my mind back again! I feel like the old me! And since you added the testosterone, my energy is so much better, I feel stronger, and best of all, my sex drive is back. My husband thanks you too!”

Medical condition: Migraines, weight gain

This young woman came in for a consultation because she was having problems with marked weight gain, difficulty losing weight, irregular menstrual cycles, irritability, mood swings, excess body hair, and other issues.

Her diagnosis was PCOS with insulin resistance. She was started on steady dose, low progestin birth control pills: (Ovcon 35) and Glucophage (metformin).

Physician’s Comment

I recommended that Ruby use Your Hormone Power Plan™ and follow the food balance guidelines in my book, Women, Weight, and Hormones. I also suggested that she participate in Weight Watchers for behavioral and emotional support.

Ruby’s Comment

“Today is my 35th birthday, but thanks to you, my body is almost back to what it was at age 21. I’ve lost 2.5 lbs in the last 2 weeks, which has NEVER happened to me before! Not even in the first few weeks of [Weight Watchers]! I now weigh 122, and am only 4 lbs away from my goal of 118. The best part is that I tried on a pair of shorts today that I wore when I met my husband, 14 years ago. They fit! And I probably only weighed 113 the last time I wore them! It’s all because the hormones combined with fixing the [insulin response] have made me capable of building muscle and burning fat like a normal woman! .....I’ve actually been feeling pretty amazing! .....The diet you promote is a leading cause of my new-found health. I’m so excited! ..... “Thank you so much. I am shouting your name from the rooftops right now, because if other women just do some of the things you suggest, I think they’ll find the same success I have!...”

Medical condition: Acne, boils, skin discoloration

Judith had severe cystic acne, skin breakouts, and discoloration of her skin, especially on her face. All this coincided with the luteal (progesterone-dominant) phase of her menstrual cycle. She had tried all kinds of medications and approaches for this “dermatological” problem, without success. No one had ever checked her hormones!

When I analyzed the tests, it was clear that Judith’s estradiol was too low, her progesterone was high in the second half of her cycle, and she was producing excessive levels of androgens (DHEA—a chemical cousin of testosterone and estrogen—and testosterone).

She already feels much better and is enthusiastic about all the positive changes she has experienced since beginning a prescription of Yasmin, a new birth control pill that helps block excess androgen effects and also has some mild diuretic actions.

Judith’s Comment

“The Yasmin has changed my life. I am so much better. The discoloration in my face is gone now, I don’t get those blister-like things or the boils and pimples I did before. My skin isn’t dry like it was before. My parents said I am like new person: my mood is so much more stable, I wake up and am a happy person, I am a lot more balanced, and I feel like emotionally a lot has changed in really good ways. I don’t have any problems I need to discuss today — everything is going really well now and I would like to continue what I am doing. I like your advice and have enjoyed working with you, so I would like to follow up with you every six months and stay on track with this.”

Physician’s Comment

Judith is finally getting good ovarian suppression with the Yasmin. Her DHEA is down to the normal range, and she no longer has the excess androgens that were wreaking havoc with her skin and moods.

Medical condition: Fibromyalgia, Reflex Sympathetic Dystrophy

Ria is an example of the improvement we sometimes witness in women with fibromyalgia when their hormone balance is restored.

Following an automobile accident eight years earlier, Ria developed Reflex Sympathetic Dystrophy (RSD), a syndrome that causes a burning, excruciating pain difficult to relieve even with narcotic medication. Ria had undergone extensive evaluation and treatment by physicians who were experienced in managing RSD.

Two years following her RSD treatment, as she was going through menopause, Ria was placed on a standard cyclic hormone therapy with conjugated equine estrogen (Premarin) and progestin (Provera). Her menopausal hot flashes ceased, and she was sleeping better. Ria felt relieved that her concerns were finally being addressed, even though the pains from RSD continued.

Over the past five years, however, she had developed a new kind of pain, clearly different from the burning pain of RSD. Now she had a dull and aching sensation located in the muscles of her arms, hands, legs, and back. Intermittent sharper pains were accompanied by stiffness in her joints. In the past year alone, the pain had grown to the point that Ria had difficulty walking and had begun using a cane.

Understandably, Ria was becoming more and more discouraged about her health. She observed that the new pain had developed when she began her hormone therapy, and since she met the criteria for fibromyalgia, it seemed reasonable ask her doctors if a hormonal connection could be causing the problem.

But Ria was told there was no way to conduct tests for hormone levels; anyway, her hormone dose was fine because she was no longer experiencing hot flashes. Her doctors recommended physical therapy and anti-inflammatory medication—to be added to the pain medicine she was already taking for RSD. Ria’s pain problems only got worse.

A friend told Ria about the work I was doing with women with fibromyalgia. Ria scheduled an appointment to have her hormone levels checked along with the other blood tests.

Ria was also having problems with weight gain, loss of energy, diminished libido, and restless sleep. She said she just didn’t feel “like [her] old self.” Ria and I spent an hour going over all that she had been through, her lab results, and her treatment options.

Even though she was taking estrogen, Ria’s FSH was still too high in the menopausal range, and her estradiol level was markedly low (less than 30 pg/ml). Her current hormone therapy was clearly not giving adequate levels of the estrogen she needed.

Since she had experienced breast enlargement on the conjugated equine estrogen, I did not want to increase her dosage. I suggested she change to the native human form of estradiol (brand name Estrace), and that she dissolve the estradiol under her tongue instead of swallowing the oral tablet. I knew this would give her a better ratio of estradiol (E2) to estrone (E1). I believed this would help reduce her breast enlargement and weight gain, and still provide optimal levels of estradiol to help diminish her other symptoms.

At her first follow-up visit about two months later, Ria said she felt more energetic, was sleeping well again, and had gone down a bra size. She reported that she did not feel as bloated, her joints were not as swollen and painful, and that she had a better range of movement. Also, to her surprise, her overall pain seemed less intense. When she asked if this improvement could be related to her hormones, I answered yes—that this was the response I had seen in most of my patients, and that there is an important hormonal connection. We agreed that Ria would continue taking the same amount of Estrace, and that she would come back in two months to be rechecked.

Four months later, Ria returned for a follow-up visit. I hardly recognized her when she walked through the door. She looked happy and cheerful, walked more briskly, did not need her cane (although she still carried it), and had more normal, fluid body movements. I commented that I had not seen her in such a long while. I had begun to wonder if she had given up on her new hormone replacement therapy. She laughed and said:

“No, I was just feeling so much better, I forgot to call and make an appointment! After about two weeks after my last appointment, I got up one morning and realized that my joint and muscle pain was completely gone. At first, I was afraid to believe it, but after a few more weeks, I realized that the resolution of that part of my pain was very real, and it has not come back. The RSD pain is still there, but I can cope with that now that I don’t have my joints and muscles hurting so bad all the time. I am even using less pain medicine for the RSD now.”

Ria’s whole countenance just radiated with her newfound release from joint pain and her happiness that she could now do more of the things she enjoyed. Even I was surprised by the marked improvement in her appearance and movements.

Ria talked about the anger she felt towards other physicians who had not taken her seriously when she asked about her pain and the possible link to hormonal changes. She had spent years suffering needlessly, while her ideas and insights were ignored. This is one of the reasons she readily agreed to have her story told. Through tears of frustration, she said: “Maybe other women who read this won’t have to go through what I did.”

Medical condition: Interstitial Cystitis

Odessa is a typical patient coping with Interstitial Cystitis (IC). In excruciating pain, up all night long to urinate, exhausted from lack of sleep and chronic pain, having to urinate forty to sixty times a day, she was dismissed by the urologist in her HMO who told her she didn’t need any more tests and that she just had to “stop drinking so much water.”

Odessa did not give up. She finally found a urologist who knew something about interstitial cystitis, an acutely painful disorder found almost exclusively in women. She began getting appropriate help through a combination of medications and lifestyle changes.

I first saw her two years after her initial diagnosis of interstitial cystitis. She had arranged a consultation to explore the possible hormone connections to her symptoms. Her question was, “I have interstitial cystitis, could it be estrogen-related? I think I may be starting menopause.”

I found that she did indeed have both symptoms of low estrogen and objective signs: thinning of the vaginal lining, diminished breast size, decrease in pubic hair, and low blood levels of estradiol. Her bone mineral density had also dropped below normal for her age. All told, she was a good candidate to begin a trial of low-dose estrogen therapy to help improve her overall health picture, as well as to see what could be improved specifically with her interstitial cystitis.

A year later, her sleep had improved, her energy and concentration was back to normal, her sex drive returned, and she reported that her frequency of urination had decreased by about 50 percent. The intensity of her bladder pain had also decreased. Her interstitial cystitis was certainly not gone, but it was better.

Neither she nor I could determine whether the improvement was due solely to the addition of estradiol, or to the combination of everything she was doing, but Odessa said “it was encouraging to me to have my questions and insights taken seriously and included in my treatment.” Since estrogen has so many direct effects on the bladder lining, nerves, blood vessels and muscles that govern urinary function, it made a great deal of sense to address this issue of her treatment.

Astoundingly, considering that interstitial cystitis is a woman’s bladder disorder, there is almost nothing in the scientific literature about the possible effects of hormone change in triggering it, or on the use of hormones as a part of treatment. Every single interstitial cystitis patient I have seen has asked me this question: “Could it be related to hormone changes?” It seems a logical question, doesn’t it, if the problem is pretty much found only in females! I tell women that it makes a physiological sense that there would be a connection, but there is simply no research available.

Medical condition: Mood swings, headaches

Rya was referred to me by her psychologist who had been concerned about her mood swings and headaches. He thought they might be related to her hormone therapy, although Rya had been told by her gynecologist that this wasn’t likely. Her gynecologist attributed her mood swings and headaches to work stress. (An interesting switch: the psychologist thought the problems were hormonal and the gynecologist thought they were psychological.)

When I met Rya, this was what she had to say:

“I have terrible mood swings and constant headaches, and I have been so frustrated with this because I have always been so healthy. I just want some answers with my hormones and what I can do to take something more natural and feel better. My psychologist heard you speak and feels you are the person I should see. I started out on Premarin and Provera and I just felt horrible on this. I tried it for three months, and I felt agitated, anxious, depressed, and had headaches constantly. Then I was switched to Ogen (a synthetic type of estrone) and Cyrin (a progestin) 5mg for 10 days / month. That’s when I have the worst headaches. I’ve ended up feeling like which do I deal with, my risk of heart attack or feeling lousy every day being on hormones? That’s why my psychologist suggested I see you.”

Rya has a serious family history of heart disease in her mother, father, and her siblings. She expressed a lot of fear about going off hormone replacement therapy because of her risk for cardiovascular disease. I told her I thought we could find hormone options that didn’t produce so many unwanted side effects, so that she would start to feel well on her hormones.

Rya had never had problem with headaches prior to hormone replacement therapy. And she was experiencing yet another menopausal symptom when I saw her: marked insomnia. Most nights, she was waking up at around 2 or 3 A.M. and then having trouble going back to sleep. She took Ogen (0.9 mg) in the morning, and I suspected that her waking up at night could be partly due to the fact that her estrogen was wearing off, or that it wasn’t the best type of estrogen for her. Rya needed the cholesterol-lowering and heart-protecting effects of an oral estrogen, but she had not done well on either of the mixed estrogens she had tried.

I recommended a medication change to oral 17-beta estradiol (Estrace), 0.5mg in the morning and 1.0mg in the evening (which is equivalent to the Ogen dose). Spreading out the estradiol provides better stability in blood levels throughout the day, more closely approximating natural estrogen production by the ovaries. For most women, I find that this approach works much better than a single daily dose, and usually provides marked improvement in sleep. It also reduces the headaches triggered by dropping estrogen levels between doses. I also suggested that Rya try the natural progesterone: 100 mg twice a day for 10 days a month, which would be equivalent to the 5 mg of Cyrin.

At her follow-up appointment she described feeling “like a new person. It’s wonderful not to have daily headaches, it’s like a miracle. My husband has noticed a big change in my disposition, and says I’m not as irritable and short-tempered as I was. My mood feels more even, I feel a real difference in my ability to let things just run off and not get upset by them. I’m not as tired, and I’m sleeping better. This is a big change.”

Medical Condition: Hypertension

“I’m the third girl in a family of four girls. My sisters and my mother had serious medical problems (mostly cardiovascular) while they were alive and they’ve died too soon. I enjoy life, I want to be physically and mentally active. I don’t want to be sickly or to die young. This is the reason for my story.

“In 1984 I was fifty-four years old, a widow for a year, and the mother of four adult children. I was enjoying my work with young people, my family and friends, and life in general; however, I sensed something was wrong with my physical condition. I had been disgnosed as having essential hypertension when I was twenty-nine years old. Over the years, physicians have prescribed a variety of medications which usually kept my blood pressure below the 150/90 threshold. I was taking four different medicines for five or six years and my blood pressure was staying within limits. But I knew something was wrong.

“My body just didn’t feel like me. Everything was taking more effort than it usually did. I felt more like I had to push myself to swim and play golf, my two favorite sports. I would go to aerobic class and really be working out well and never could get my heart rate into the target range. Very frustrating for someone who likes to follow directions and achieve my goals!

“When I mentioned this to friends, they made the usual comments, ‘Remember you’re older now, VR!’ I knew too many active excuses. I went to my doctor whom I’d been going to for seven years. I told him how I felt and suggested that I needed a reevaluation with an up-to-date cardiac stress test (remembering my sisters and their heart problems, it seemed like a reasonable request to me) and then a review of my medications. He looked over my record and said “No, there is no sign that you need a cardiac stress test. Your blood pressure is well-controlled and you seem fine to me.” I believe he thought this was true, but I think he was also influenced by the fact that I was on an HMO insurance plan and this would add to his medical expenses. He had indicated there would be problems justifying the cardiac stress test.

“At this point I did some serious soul searching. I felt something was wrong with me physically. I knew I couldn’t prove it, but I wasn’t going to let a doctor keep me from getting a correct diagnosis! I thought about my mother and sisters: Mother started having heart attacks in her fifties, had two operations on her carotid arteries in her sixties, had strokes in her seventies and eighties, and died in a nursing home at eighty-five out-of-touch with reality. My sister Rae, who was seven years older than I, started having heart attacks in her forties. At forty-eight she had a severely damaged heart, was bedridden, and died at fifty-one. My older sister Anne, who is ten years older than I, started having heart attacks in her fifties, and at sixty-four had a quadruple bypass. She is now very limited in her activities because of her poor health. My younger sister Mary died at age thirty-two of leukemia, so I don’t know what her cardiovascular condition might have been. With this kind of family history, I knew I needed help immediately.

“At the library I picked up a brochure on Preventive Medicine by Dr. Lee Vliet. Could this be the doctor I needed to see? Just walking into her office was a healthy experience: relaxing music was playing, the colors of everything were soothing, the art work was thought-provoking and creative; Dr. Vliet and her staff were obviously interested, caring people. I shared my story with Dr. Vliet. She asked many questions and then ordered a cardiopulmonary exercise test plus some labwork. I had never had such a comprehensive stress test. It was stopped suddenly because condition rapidly declined. The test report stated that I was heavily overmedicated, my heart was blocked so much by the beta-blocker that it couldn’t get to a higher heart rate even though I had already passed the aerobic threshold! The cardiologist’s report said I was in danger of sudden death if I participated in physical activities. And here I had been pushing myself in aerobic classes three times a week. I was flabbergasted with this news. I knew my body had been trying to tell me something, I just didn’t realize how serious it was. Needless to say, Dr. Vliet urged me not to go on my planned wilderness hiking trip, but to take time to get my medication changed and my body in better shape. After the abnormal results, my primary care physician then said, ‘Oh, well, I guess this did need to be done. I’ll send the prescription to the insurance company.’

“I believe Dr. Vliet saved my life. She listened to my concerns and accepted the possible validity of them. She ordered the tests that would give her the factual information she needed to confirm or deny my subjective feelings about my body. Dr. Vliet did a complete reevaluation, and with her colleague, provided me with a new regimen of preventative medicine and appropriate medications.

“Now, eleven years later, I follow the basic tenets of preventative medicine: low-fat foods, regular physical activity, relaxation techniques, caring relationships, and periodical medical checkups with required medications. I have lost weight, yes, but more importantly I have gained good health. My blood pressure is controlled; exercise four times a week. I take only two medications now, instead of five, and I am off the beta-blocker. I work full-time in a high-pressure job I love, I go jet-skiing and swimming with my grandchildren, and have just taken up scuba diving. Good living for a sixty-five-year-old woman! And my younger friends now say, ‘Gosh, VR, I hope I can be like you when I’m your age.’ And my doctor keeps thinking I’m fifty-five instead of sixty-five!”