Menopause--Premenstrual Tension Syndrome

Reprinted from Bionutrition Newsletter Jan/Feb 2001

I am dedicating this issue of the Bionutrition Newsletter to the women in the audience. Next to nutritional supplementation, I believe that this is the most difficult problem that I deal with in my office. There is no formula that works for everyone and clinical success is obtained only when you work with these women closely. I am always concerned when a patient brings in a list of hormones that they are taking, which usually includes DHEA and possibly growth hormone or even thyroid products. They state that they just read about them in some book and started taking them. These are all very potent and have the potential to make things worse and not better. There is a delicate hormonal balance that can not only affect how we feel but also can be detrimental to our health. Most of these patients do not feel better in spite of the fact that they have followed these cookbook recommendations to a T. Most of the recommendations are not even from a medical physician or clinician. They may even be from a Ph.D. whose heart is right, but truly doesn't have any clinical experience working with these patients. I am always impressed how very simple and small changes in the use of hormonal replacement can make such a major change in my patients. There are principles that can be applied; however, it is very important that you find an understanding physician who is willing to use natural hormones and phytoestrins to help their patients. This newsletter is going to describe the principles that I use in my practice. However, it must be stated that everyone is quite different and there is no universal approach to these problems. I have patients that go through menopause without as much as one hot flash. I also have patients that come close to losing their husband and family going through this most difficult time. Hopefully, I can give you some encouragement and direction when it comes to dealing with these various problems due to these hormonal changes experienced just before and during menopause.

PERIMENOPAUSE

This is the time period around the menopause. Your ovaries don't just quit working one day. They actually sputter. In other words, your hormonal levels actually vacillate more during this time than they ever have before in your life. It is this great variation in your hormonal levels during this time before your menopause that I believe is the main reason this is such a difficult time for patients. In fact, many patients will have much more difficulty during this period than they will during menopause. Several years ago, I had a patient who I felt was the most mature, well-adjusted lady in my practice who stated that she thought she was going to lose her mind during the 4 years prior to going through menopause. She told me that she felt so much better after she actually went into menopause. She never shared any of this with me until she was doing better; however, it has taught me to really listen to my perimenopausal ladies. They not only can get very emotional, but also they actually may lose the ability to do simple math. They feel depressed and life is not very enjoyable. They can also experience hot flashes, night sweats, and vaginal dryness. However, they are still having good regular periods. What they don't realize is the fact that the underlying changes in their hormonal levels are the cause of all of these emotional and physical changes.

Patients in the perimenopausal period are actually having more vacillations in their estrogen levels and may not even be ovulating. Their periods are actually withdrawal periods from their estrogen levels dropping late in the cycle. Since they are not ovulating during every cycle, they are not producing any progesterone. Progesterone is made from the egg or ovum after ovulation. If your not ovulating, you don't produce the ovum, which is what is necessary for producing the progesterone. Even after your ovaries completely quit working, your adrenal glands still produce estrogen even though the levels drop to approximately half of what they were before menopause. It is important to realize that even though the estrogen levels usually decrease during the perimenopausal period, the progesterone levels are more dramatically affected and may actually go to zero.

In my clinical practice, I recommend to my patients who are having trouble during this perimenopausal time to start taking phytoestrogens (Phytoestrin---3 daily). If their periods are irregular or long, I also recommend they start some natural progesterone cream from their local health-food store. They should use the cream twice daily and in the amounts recommended from the 14th day of their cycle to the 28th day of their cycle. You count the first day that you bleed as day one. If you begin to have your period before the 28th day, I advise my patients to quit the progesterone cream. They can take the phytoestrogens daily and throughout their entire cycle.

These recommendations help a good majority of my patients. However, some patients just do not respond. In these patients, I start using a natural biestrogen cream or tablet along with some natural progesterone. These are natural estrogens that are produced by compounding pharmacists and do require a doctor’s prescription. I have been using Belmar Pharmacy out of Lakewood, Colorado (12860 W. Cedar Dr., Lakeood, CO 80228 - 1-800-525-9473) and Women’s International Pharmacy (5708 Monona Dr., Madison, WI 53716 - 1-800-279-5708). I have also used the Women's Clinic located in Wisconsin. There are also many local pharmacists who are now compounding these natural estrogens and progesterones.

If I am still unsuccessful in helping my patients with these perimenopausal symptoms and they have done everything that I have recommended, I will occasionally have to use some synthetic estrogen. I usually use Estrace or the Climara patch. It is important that you help your patients and not take too long to do so. If my patients are not responding to the conservative natural products, I do not hesitate to use synthetic estrogens. They are usually more potent and the results are more dramatic. It is critical that you get your patients feeling normal. Their lives may depend upon it. You need to remember that the increased breast cancer effects of synthetic estrogens do not occur until the patient has been on these synthetic estrogens for at least 5 years. Once I have gotten my patients feeling better, I keep them on this regimen for 6 months to a year and then try to switch them to the natural estrogens. I can't overemphasize the fact that you must help these patients no matter what it takes. These patients can be very miserable and a doctor needs to work closely with them to be sure they are getting better.

I must mention right now that I always recommend that these patients also take the Usana Essentials, Optomega (of Biomega 3), and 4 to 6 Active Calcium daily. They need to be in a good exercise program (which involves some weight bearing exercise) and be eating a balanced diet such as the Usana Lean Diet.

MENOPAUSE

Once a patient has actually entered menopause, the ovaries have quit making any estrogen. Therefore, the patient is not only not making any more progesterone, their ovaries are not making any estrogen. There are other sources of estrogen production, i.e. the adrenals, which means that the estrogen levels drop by about 50%. Physicians view women who have not had a period in over 6 months as having entered true menopause. In fact, if a patient has a period after not having one for over 6 months, we label this as postmenopausal bleeding and consider it a very serious symptom. This definitely needs to be evaluated to make sure the patient does not have uterine cancer.

Modern medicine views menopause as a disease. Over 90% of the physicians feel this needs to be treated by hormonal replacement. The overwhelming logic is the fact that the good of estrogen replacement outweighs the bad. Physicians are quick to point out that you need estrogen replacement to prevent osteoporosis, decrease the risk of heart disease, decrease the risk of Alzheimer's dementia, and other potential benefits. They usually downplay the well-documented increased risk of developing breast cancer. I was personally offended when the producer of the most widely prescribed hormonal replacement took out a full-page advertisement in USA Today following a major review article in the New England Journal of Medicine. This article in the New England Journal of Medicine warned patients who had been on estrogen replacement for over 5 years increase their risk of developing breast cancer by 46%. However, the USA Today advertisement told only of the positive potential health benefits of taking estrogen replacement.

The truth is difficult to obtain. However, estrogen replacement does not prevent osteoporosis. It only slows down the progression of osteoporosis. Unless you have high risk factors for developing coronary artery disease, you do not gain any health benefits in regards to reducing coronary artery disease by taking estrogen replacement. All of the other potential health benefits of estrogen replacement have been thrown into doubt because of the fact that the overwhelming majority of studies were done with Premarin. Researchers are bringing up legitimate concerns, since it is well known that Premarin has 23 different active ingredients. Which one is giving any particular health benefit? It is reasonable to question all of these studies, since there is no logical way to truly be sure that the health benefits are related to the estrogen portion of Premarin.

I do not believe that menopause is a disease. I do not routinely offer my patients hormonal replacement simply because they have entered menopause. I am very concerned with the increased risk of breast cancer in patients who are on long-term estrogen replacement. One in eight women will now develop breast cancer in their lifetime. Why would I want to increase that risk even more? There are better and safer ways to prevent osteoporosis, heart disease, Alzheimer's dementia, and other chronic degenerative diseases. Osteoporosis is a nutritional deficiency. Women who eat right, exercise (using weight bearing exercise), and take nutritional supplements are not only able to prevent osteoporosis but also are able to increase their bone density. Only when patients have true osteoporosis (not osteopenia---which is just some early thinning of the bone) which does not respond to conservative therapy, will I use medication and variants of hormonal replacement. I follow my patients closely and usually will perform DEXA scans every 3 years or so after they enter menopause. This protects the patient and allows them to be sure they are not developing any serious problems.

If my patients enter menopause and are not having any problems, I will recommend that they take the Usana Essentials, Optomega, and 6 to 8 Active Calcium daily. I also encourage them to get into a moderate exercise program that must include some weight bearing exercise. Eating a well balanced diet that does not spike the blood sugar is also essential. The Usana Lean Diet or the 40/30/30 diet (Dr. Barry Sears---The Zone Diet) is what I recommend. I do not recommend any hormonal replacement unless they are having some definite symptoms related to their menopause. This could be hot flashes, night sweats, vaginal dryness, emotional instability, depression, mental fogginess, etc. I will begin with phytoestrogens and the Usana Phytoestrin (3 daily) along with additional soy protein that contains isoflavones. If this does not correct the problem, I will add natural progesterone cream. Natural progesterone has been shown to actually build bone and reverse osteoporosis. I recommend a natural progesterone cream anytime my patient has osteopenia or osteoporosis. If my patient continues to have problems, I will then add some natural estrogen cream or tablets that are produced by compounding pharmacists. They make it the old fashioned way. I am presently using Belmar Pharmacy out of Lakewood, Colorado (12860 W. Cedar Dr., Suite 210, Lakewood, CO 80228 - 1-800-525-9473) and Women’s International Pharmacy (5708 Monona Dr., Madison, WI 53716 - 1-800-279-5708). A prescription from your physician is necessary. My last resort is to use synthetic estrogens such as Estrace or a patch like Climara. However, I try to use these for only a short period of time--less than two years. I will then slowly try to switch them over to a natural estrogen.

I want to make something very clear. I would prefer that my patients were not taking any kind of hormonal replacement. However, you just have to use them sometimes to help patients get through this difficult time in their life. Once I feel we are well beyond this time and my patients are doing well, I try to get them off all of these medications if at all possible.

The pharmaceutical industry is constantly trying to get physicians to look at menopause as a disease. They are continually in my office trying to convince me that all these patients need estrogen replacement. Your physician is going to put all kinds of pressure on you to start synthetic estrogen replacement. They will actually make you feel that you are going to cause serious health problems if you do not take their drugs. I just have trouble with the logic that the good outweighs the bad. Why would I want to give my patients anything that I know will increase their risk for breast cancer, stroke, blood clots, and other adverse side effects of estrogen replacement, when there is no need to do so? I have been in practice for nearly 30 years and have seen this pendulum of using estrogen replacement swing back and forth. However, I have never seen the influence that the pharmaceutical industry is applying to the physicians. The sad fact is that most of the physicians are buying it.

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