Solving the Mystery of Hormone Balance: Experimenting with Minerals
by Patricia Rackowski

After working with estrogen, progesterone and thyroid for three years, I still hadn't solved the mystery of hormone balance. I still wasn't sleeping well, I still had episodes of non-stop hot flashes, and my energy and mood were either very good or very bad. I felt that hormones were only the proximate causes of my symptoms, and I had to look deeper to find the original cause of my hormone imbalances.
About a year ago, in August of 2000, I began to take copper supplements, and after three days my estrogen levels increased enough to give me that high estrogen headache, and I went off of estrogen. My hot flashes disappeared and haven't come back since. This was rather dramatic because I had been having non-stop hot flashes for 4 years unless I used estrogen, and even with estrogen I had episodes of non-stop hot flashes that kept me awake all night. This experience with copper convinced me that minerals are extremely important, not just the "Little Sister" in my Vitamin and Mineral supplement. Perhaps you would be interested to know how I got to copper, and whether it would help anyone else.
I am not a doctor or a scientist. I am a massage therapist. As a bodyworker, I have learned to listen to my body and to trust my inner voice. It doesn't always steer me direct, but it doesn't steer me wrong. Hair analysis had been attracting my attention for awhile.
It's not really the hair analysis that's important, it's the minerals. Minerals are involved in the manufacture and the activities of enzymes, and it's enzymes that carry out almost every process in the body. It's enzymes that build up and break down hormones, enzymes that convert one hormone to another, and enzymes that carry out activities initiated by hormones at receptor sites. It was very possible, I thought, that the hormonal imbalances I was experiencing were caused by mineral deficiencies.
I was wondering about copper, because I had read that premature white hair was a sign of copper deficiency. My hair started turning white little by little since I was 22, at the same time I developed Graves' disease (autoimmune hyperactive thyroid). Premature white hair is a common result of Graves' disease. Copper deficiency is also associated with Graves' disease.
Also, as a menopause consultant, I was wondering about minerals and osteoporosis. I read about all the minerals that are important for bone building: calcium, magnesium, phosphorus, zinc, copper, boron, and manganese. But how much of each should one take? Recommendations varied from author to author. I thought a more important question might be: which minerals was I getting enough of and which ones did I need more of? Although there is a lot of talk about how much calcium one "should" take, there is little discussion of how to find out if your body is absorbing the calcium you are taking. I wanted an assessment tool.
And as an eater, I was wondering about the disappearing minerals in my food. According to the US Dept. of Agriculture, the mineral content of fruits and vegetables has greatly diminished in the past 50 years due to poor maintenance of the soil. For example, the amount of calcium in broccoli has declined by 50% since 1975, and the amount of calcium in corn is down by 33% since 1963. But was I really deficient in minerals in general, or was I deficient in particular minerals? It didn't seem wise to me to start taking large amounts of minerals willy-nilly without any type of feedback system to tell me whether I needed them or not.
Hair analysis is a test that can give you an approximate idea of which minerals your body is absorbing enough of, and which are deficient. It is often used to reveal toxic mineral exposure for arsenic, mercury, aluminum, cadmium and lead. But it can also be used to show nutrient mineral status. It is more useful than a blood test, which only shows the minerals in the blood at the moment it's taken. A hair analysis of one inch length hair shows mineral absorption over about two months for those minerals that accumulate in hair as well as other tissues. And, a hair analysis shows the ratio of certain minerals to their companion minerals, such as the ratio of calcium to magnesium and the ratio of zinc to copper. The ratios can be more important than the actual mineral values when it comes to figuring out what is going on in your body. This is why a trained practitioner is required to interpret a hair analysis.
I found out that in order to get a hair analysis test, I had to see a practitioner, since the testing labs do not deal directly with the public. Although I didn't understand it at the time, I know now that mineral balancing is not a straightforward process, and it's good to have a practitioner's guidance. Lots of different practitioners use hair analysis testing including medical doctors, nurse practitioners, naturopathic doctors, chiropractors, nutritionists, and many others. Each lab instructs the practitioners in interpreting the test results, and interpretation varies considerably from lab to lab.
I went to a nurse practitioner at the Marino Center, a holistic health center in Cambridge, MA. They use Trace Elements lab in Addison, TX. I've gotten other analyses done since then at other labs, but I still prefer the Trace Elements report. If you try to call Trace Elements, however, they will not deal with you directly. They will not even tell you who uses their lab in your area. So you just have to ask around to find a practitioner who does hair analysis, and then ask them what lab they use. If you can't find a practitioner who uses Trace Elements, then Great Smokies Lab is OK and so is Doctor's Data. Those are the three I have used and they were consistent with my mineral values. I just liked the accompanying report by Trace Elements a lot better.
I got my first hair analysis in January, 2000. I was really impressed by the report. Without any other information about me other than from my hair, the Trace Elements report described my metabolic problems and my symptoms quite accurately. All of my minerals were really low, except selenium, which I had been supplementing for a couple of years at 100 mcg/day on the advice of my endocrinologist. All of my electrolytes were low: calcium, magnesium, potassium and sodium, although I had been taking calcium and magnesium for years.
What happened next was a big delay in progress. As I said, my inner voice doesn't always steer me directly. Although the report recommended a great many mineral supplements, being the cautious person that I am, and having suffered a lot already and gotten a little better, I was afraid to start taking them all at once. So I determined to follow the extensive dietary recommendations in the report, what foods to eat more of and what foods to avoid, to see if I could improve my mineral uptake through diet.
The upshot of all this was that after six months I had another hair analysis, and nothing had changed. Nothing! I was not going to be able to improve my mineral levels without taking significant supplementation. During this six months, however, I had learned a lot more about minerals through a website I found at http://www.ithyroid.com. I began to realize how complicated this whole thing is, and perhaps it was just as well that I got into this slowly. If I had gone whole hog in the beginning, I might have made a mistake and discouraged myself from continuing.
In August 2000 I was ready to go up to 6 mg. copper daily. I had learned that copper was probably my most significant deficiency and after that magnesium. I also began to take calcium/magnesium in a 1:1 ratio instead of the usual 2:1 ratio. I switched calcium supplements from a tablet to a capsule (powdered) form, but I was actually taking about the same milligrams I had been taking for years. And I began to take Betaine hydrochloride with Pepsin before dinner (a stomach acid supplement) to help me absorb more minerals from my food.
That's when, in three days, my hot flashes were cured. These hot flashes were characterized by a brief feeling of dread, followed by a shot of adrenaline that would cause palpitations, a sense of heat rising from my chest upwards, and finally the chills. The chills lasted the longest, perhaps 15 -20 minutes, and then the whole thing would start again. These were not funny. These were not power surges. I couldn't live with these hot flashes, and that's why I was on estrogen, although I hadn't missed a period yet. Estrogen greatly reduced the hot flashes.
Is there a connection between estrogen and copper? You can bet your entire plumbing system on YES. Now for some science.

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ESTROGEN AND
COPPER / PROGESTERONE
AND ZINC

Copper levels are related to estrogen levels. Copper is involved in the production of estrogen. Copper accumulates in the liver, and must be available for the metabolism of estrogen. Both excessive copper and deficient copper may cause estrogen imbalance. Adrenaline stimulates the liver to produce ceruloplasmin, the main copper-binding protein. Copper is not bioavailable until it is bound to certain proteins. Thus in cases of adrenal insufficiency there may be a hidden copper excess in the tissues, caused by unbound, biounavailable copper. We see that copper may be deficient, excessive or biounavailable.
In another enzyme pathway, copper removes excess T3 in the body, and thus "saves" estrogen, which also removes excess T3. Copper accumulation in the liver can remove too much T3 and result in fatigue or even hypothyroidism. Hypothyroidism is associated with too much copper and not enough zinc. Low zinc results in low progesterone, PMS and infertility Too much T3 as in hyperthyroidism may deplete the body's stores of copper, causing an estrogen deficiency. Untreated hyperthyroidism will cause menstrual cycles to stop, as excess T3 "eats up" estrogen.
Are you confused yet? Let's look at it another way, by symptoms
According to Dr. Lawrence D. Wilson, author of "Nutritional Balancing and Hair Mineral Analysis", the hormone imbalances of PMS and perimenopause need to be approached differently depending upon the symptoms:
Estrogen-dominant, low progesterone women have PMS characterized by fluid retention, bloating, sore breasts and irritability. These women, who tend to have a heavier build and more body fat, have a slower metabolism, higher copper levels and a high sodium/potassium ratio. They require copper-lowering nutrients such as zinc, B6, choline, inositol, Vitamin C, molybdenum and sulfur, and more potassium-rich foods. Zinc supports progesterone production. Fluctuating progesterone causes blood sugar instability and mood swings. Chocolate and other sweet cravings at the menstrual period help keep blood sugar, and mood, up. A desire for red meat may indicate low iron stores. Salt cravings may indicate a need for trace minerals such as selenium, chromium and iodine. Low zinc, iron, selenium or iodine may result in functional hypothyroidism. Uncorrected hypothyroidism in younger women can cause infertility. This condition can be caused by the birth control pill, which depletes zinc.
Low estrogen, progesterone-dominant women have PMS characterized by anxiety and hyperactivity, or fatigue and depression if adrenals are worn out. These women tend to have a more slender body build, a low sodium/potassium ratio, and low or biounavaible copper. Their metabolism is generally on the fast side. They feel better with supplemental copper, Vitamin E, magnesium, pantothenic acid and other nutrients to assist the adrenal glands. Magnesium may help them sleep better. Chocolate is high in copper. Chocolate cravings around the menstrual period may be due to a need for copper. Copper stores may be so low that the production of estrogen at the menstrual cycle depletes them. At perimenopause, their fast metabolism "eats up" estrogen and causes hot flashes, palpitations, and insomnia. Untreated hyperthyroidism in younger women can cause an early menopause.
The above are not hard and fast rules, and a woman may vary in her symptoms from month to month if all minerals are low. Just by taking a multimineral daily supplement*, symptoms should diminish over time, unless deficiencies are severe, in which case, after a hair analysis, certain individual minerals need to be supplemented at higher levels. Hyperthyroidism, hypothyroidism, hypoglycemia and diabetes indicate that more severe mineral deficiencies exist.
At menopause, both estrogen and progesterone levels fall. Sometimes progesterone falls first, causing symptoms similar to the PMS estrogen dominance symptoms above: fluid retention, bloating, sore breasts, mood swings, headaches and heavy bleeding. Taking natural progesterone can counteract the symptoms and "save" zinc, because zinc is involved in the production of progesterone. But it's also possible that symptoms can be relieved by taking zinc which supports progesterone production, and B complex vitamins with extra B6.
When estrogen levels begin to fluctuate, sometimes high and sometimes low, we can get hot flashes and relieve them by taking estrogen, which "saves" copper. It is also possible that symptoms can be relieved by copper, IF one is copper deficient or low in copper, which in turn "saves" estrogen. If copper is biounavailable, B complex vitamins with extra B12 may be needed to enhance the absorption of copper. B12 level can be tested by a blood test. Be sure to get the numerical results, not just a "you're OK". B12 on the low side of the normal range can be supplemented with good benefit.
In my own case, I was deficient in copper, which is usually the case with Graves' Disease or hyperthyroidism. I had treatment with Radio-Active Iodine in 1976, so my hyperthyroidism had become hypothyroidism, but due to the copper deficiency, I tended to be sort of a hyper/hypo person. I had both kinds of PMS. When progesterone fell at menopause, I had severe estrogen dominance symptoms at first, but when estrogen began to fluctuate too, I had non-stop hot flashes. Basically I was low in all minerals on my hair analysis, but copper was the most significant and underlying deficiency. Onçe I began to replace copper I began to get back into balance. I was able to absorb the other minerals better once the "hyper" side of me was treated.
Copper, zinc and iron are the three minerals most involved in thyroid regulation. If you have too much of any one of these, you will eventually become depleted in the other two. Mineral ratios are as important or more important than mineral levels. This means that even if the copper level is normal, if the zinc/copper ratio is very low, one is likely to experience symptoms of elevated copper.
Thus I recommend that if you do not have a thyroid disease, you try a multimineral daily supplement that has the daily requirement of each mineral in the proper proportion (see list at end of article), but if you have a thyroid disease or diabetes, I suggest you get a hair analysis first before taking supplements. You may need copper and iron, as I did, or you may need just copper. You may need zinc and iron to balance too much copper. Also, your sodium/potassium ratio will be an indication of adrenal health and your calcium/magnesium ratio will give information about glucose metabolism. Low magnesium could explain heart palpitations, waking up startled, insomnia. Low iron could explain feeling cold, cold flashes, chills, and waking up early. Thyroid function could be enhanced by iron, selenium, iodine, manganese and/or chromium. Insulin usage could be assisted by chromium and vanadium. Look for a practitioner in your area who uses hair analysis to help you.

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MORE ABOUT
ZINC, COPPER & IRON

Copper deficient anemia is very dangerous, but even low copper can result in an aneurysm (burst blood vessel). About 4-6% of Americans die from aneurysm . Copper is important for the integrity of the blood vessel walls. Taking large amounts of Vitamin C for a long time can deplete you of copper. Copper is also important for preventing osteoporosis. Altogether it is a very significant mineral. Yet one must not take too much copper, for high copper levels can cause poor memory, depression, insomnia, migraines, and joint and muscle pain. Thus the hair analysis is important to keep track of long term supplementation above 4 mg/day.
And regarding zinc, I have seen recommendations by doctors for very high levels of zinc supplementation, such as 50 or 70 mg/day, for prevention of macular degeneration, without any mention of the fact that this can deplete copper and iron and cause anemia, hyperthyroidism or aneurysm. From what I have learned, zinc should not be taken in such high amounts unless it is found to be deficient through a hair analysis. In that case, more zinc can be taken until zinc is in the normal range, but then the normal 15-30 mg/day is enough. Another way to tell if you need zinc is to suck on a zinc lozenge. If it tastes really bad, you have enough zinc. If it tastes neutral, you need zinc. As with many other things, too much can be as bad as too little.
About iron, I want to mention that it is not wise to take iron without being tested for iron deficiency. Postmenopausal women do not need as much iron as women who are still losing iron each month at menstruation, since iron accumulates and excess iron is not excreted in urine or feces. But if you are experiencing fatigue, feeling cold when others don't, cold flashes instead of hot flashes, or waking up early, you may be low in iron. If you are a vegetarian or have had episodes of heavy bleeding in perimenopause you may be low in iron. Ask your doctor for a blood test, and do not take "You're OK" for an answer. Get the numbers. If you are on the low side of the normal range, you may still take some iron and feel better.

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IS HAIR ANALYSIS RELIABLE?

If you mention hair analysis to your doctor, you will probably be told that it's a hoax, pure quackery. This is because reputable medical journals have attacked hair analysis from time to time with studies that show that there is a great deal of discrepancy between labs in their reports. I read the most recent debunking of hair analysis in the Journal of the American Medical Association, Jan. 3, 2001. It's absurd. Hair samples from ONE "healthy" woman were sent to six different labs for analysis. There were large discrepancies in the reports, mostly due to differences of scale by factors of 10 or 100 in reporting the data, but also due to different testing procedures. Yet there was, by the Journal's own data, enough agreement between labs on all the major minerals to tell you whether the woman was deficient or not. For example, the results for copper were: 13, 15, 14, 11, 12, and 14.93. This was good enough to indicate that copper was in the lower half of normal range. It was probably as close as cholesterol testing from six different labs would be. I frequently read news articles about hair analysis being used to look for toxic mineral levels in people exposed to mercury, lead, cadmium and arsenic. There is no reason why the same technique isn't just as effective with nutrient minerals.
Another problem is that the "normal" range for copper (and all the nutrient minerals) in hair is not well established, and each lab has set up its own normal range based upon testing of "healthy" individuals. I put "healthy" in quotes because people may appear healthy while they are marginally deficient in some minerals. A great deal more study could be done in this area, but it would not be beneficial to any drug company to sponsor one. There is very little profit in selling minerals compared to selling hormones and drugs. Minerals are really cheap.
It's important to remember that the goal of mineral balancing is not to get a "perfect" hair analysis whatever that may be. The goal is to feel better, to resolve difficult symptoms and health problems. If this is accomplished, then that is success. After all, I don't really care how much copper is in my hair, I just want to be able to sleep at night! The hair analysis is just a guide to what might be needed and what needs to be brought back closer to balance. The body does the rest. The body heals itself, given the proper raw materials.

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MORE READING Many studies have been done on mineral deficiencies and diseases in domesticated animals, but they have been done over at the US Department of Agriculture by veterinarians. After all, a pig with diabetes or hypothyroidism is a dead pig, and farmers can't afford too many of those. One such USDA vet became a naturopathic doctor and began to apply what he knew about animals to people. He is Dr. Joel Wallach. He made a tape called "Dead Doctors Don't Lie" which has been passed around extensively by people doing multi-level marketing for colloidal minerals. (Colloidal minerals have too much aluminum. Look for ionic trace minerals.) Now "Dead Doctors Don't Lie" is available as a tape and a book from Amazon.com. I highly recommend it. It's entertaining as well as informative.
"Nutritional Balancing and Hair Mineral Analysis" by Dr. Larry Wilson has the information that Trace Elements Lab uses to analyze metabolism, stress levels and diet. Dr. Wilson says that "Hair analysis is much more than a test for minerals. From a small sample of hair, you can learn about your metabolic rate, stage of stress, immune system, and adrenal and thyroid activity. The test offers accurate information about carbohydrate tolerance, energy levels and tendencies for over 30 illnesses, often years before they manifest. You can also tell if you are eating enough protein, eating too many carbohydrates, and whether a vegetarian diet is working for you. . . . Families can learn why a child has learning difficulties, attention deficit disorder, infections, or difficulty falling asleep . . . Nutrition consultants can
reduce the guesswork in recommending nutritional products . . . Health practitioners can approach each patient as an individual using hair analysis." You can order this book from Dr. Wilson at http://www.drwilson.com.
"The Healing Power of Minerals, Special Nutrients and Trace Elements" by Paul Bergner, a clinical nutritionist, is another good book on minerals and disease prevention with mineral supplementation. He writes about the mineral deficiencies in our foods and the diseases that are resulting in our society today, about each mineral and what it does in the body, how much to take, and about food, herbal and supplemental sources of minerals and trace elements. He has a table that shows how much aluminum (a toxic metal) colloidal mineral supplements have and that is why I warn you about them. He suggests that liquid ionic trace minerals or sea salt are better sources of trace minerals.
"Why Am I Always So Tired" by Ann Louise Gittleman, nutritionist and author of the excellent "Super Nutrition for Menopause", explores the symptoms of copper imbalance. Copper excess is a more common problem than copper deficiency, and may explain your fatigue. Eating too many carbohydrates and not enough fat and protein, a vegetarian diet, taking birth control pills, using the copper IUD, and water high in copper from copper pipes, all contribute to high copper levels.
For an interesting discussion of a "hormones and minerals" case where a woman with two previous postpartum depressions was prevented from having one after her third pregnancy through hair analysis and mineral balancing see
http://www.malterinstitute.com/ppd_1.htm,

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CONCLUSION

In summary, what I have told you here is a GROSS OVER-SIMPLIFICATION. I highly recommend that you thoroughly study the website http://www.ithyroid.com where I got a lot of my information. Credit is due to ithyroid's creator, John Johnson, for putting together a huge amount of information on minerals. As John says, this is an EXPERIMENTAL approach. Be cautious, hyperthyroids especially. Read "Balancing Minerals" first, at http://www.ithyroid.com/balancing_minerals.htm
I don't suggest that people stop taking their thyroid medications or their diabetes medications or even their ovarian hormone therapy. I suggest working with the minerals and little by little working into a better mineral balance. Perhaps your need for medications will then decrease. I am still taking Levoxyl, but my symptoms have much improved with mineral balancing.
"The minerals in our bodies are like precious jewels, rare gifts to us from the Creator. They perform biological functions there that nothing can replace, not conventional or alternative medical therapies, not mind/body medicine, not New Age thinking. To maintain our health, or to regain a higher level of health, we need only turn, open-handed, to receive the gift of natural foods." - Paul Bergner in "The Healing Power of Minerals".
In the more than 30 years that have gone by since I was diagnosed with Graves' Disease in 1970, I have gone to many endocrinologists and other doctors. I have had Radioactive Iodine, thyroid replacement, and hormone therapy. I have had psychotherapy, bodywork, Reiki, acupuncture, Chinese herbs, homeopathy and hypnosis at different times. I learned a little or a lot from these experiences. At times I improved a little or a lot. But I have never had so dramatic and important a result as I have had since I started repairing my mineral balance. I feel that my health and my mental and physical balance are being restored. It's taking some time. I won't bore you with all the ins and outs of my experience. I just wanted to tell you that there is something to taking minerals, and you might want to explore it. You may have tried everything else already, or you might be lucky enough to start here. Either way, it's worth exploring. It's not expensive, it's pretty safe, and good results come along fairly quickly.

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ABOUT SUPPLEMENTS

When choosing a multimineral supplement, you will have to look carefully at the label. Different products are better for different people. For example, if you are postmenopausal you don't want to take more than 10-15 mg/day of iron, unless your iron is low. Don't take more than 30 mg/zinc daily for a lengthy period of time (some multiminerals have more than that). Consider your diet--do you eat seaweed? If not, you should look for a supplement that includes iodine. Do you eat a lot of calcium-rich foods? You don't need to take so much calcium in your supplements.
As a baseline for mineral supplementation, not taking into account foods that you eat, the following are generally recommended for menopausal and postmenopausal women:

Calcium 1000 mg
Magnesium 500 mg
Potassium 99 mg
Iron 27 mg (menstruating)
Iron 10 -15 mg (not menstruating)
Zinc 15 - 30 mg
Copper 2 mg
Manganese 4 -10 mg
Boron 1 - 3 mg
Iodine 150 mcg
Chromium 200 mcg
Selenium 100-200 mcg

A good general multimineral supplement is Bronson Labs'
Mineral Insurance Formula, http://www.bronsonlabs.com. Three tablets daily, one with each meal, contain:

Calcium 324 mg
Magnesium 200 mg
Iron 15 mg
Phosphorus 166 mg
Zinc 15 mg
Copper 2 mg
Manganese 5 mg
Iodine 150 mcg
Chromium 200 mcg
Selenium 20 mcg
Molybdenum 100 mcg

You would have to add more calcium, magnesium, and some Vitamin D for your bones, at least another 100 mcg selenium for your thyroid, and 1-3 mg boron for hormone balance and bones. I recommend 1 or 2 capsules Tri-Boron Plus daily, 1 capsule Tri-Boron three times a week, and selenomethione 100 mcg (any brand). The Vitamin Shoppe has good prices on these.
For those who need to supplement particular minerals more intensively until rebalancing is achieved, you can find individual minerals very cheap at http://www.puritan.com Zinc lozenges are a good way to add zinc. When they start to taste bad, you have enough zinc. Magnesium citrate is probably the most absorbable magnesium. If it gives you soft stools, don't worry, eat more fiber or take psyllium.
If you have a hard time taking pills, look for liquid mineral supplements in your local health food store. For trace minerals such as germanium, lithium, vanadium and all the others, use a generous pinch of sea salt daily, eat some kelp, or take Concentrace Trace Mineral Drops (http://www.vitaminshoppe.com). *

How to Keep Your Menstrual Cycle Regular with Herbs

by Patricia Rackowski

When I was 46 and getting closer to menopause, I began to have irregular menstrual cycles. Instead of my usual 26 day cycle, I was getting my period early, at 19 days or 21 days. I was spotting between periods, and I had terrible PMS for several days a month.

I began to read about herbal remedies for menopause, I went to workshops and talked with my acupuncturist. I learned how to keep my menstrual cycle regular with herbs and natural remedies. After awhile, I had a better menstrual cycle than ever, and I wished I knew about these things years earlier. I began to share what I had learned in a workshop called “A Natural Approach to Menopause”.

A normal menstrual cycle is 26-32 days, with the most fertile cycles averaging 29 days. A fertile and symptom-free cycle is a reflection of perfect health in a woman. If her body cannot support a pregnancy because of starvation, serious illness or stress, even a young woman may stop ovulating altogether.

But in between a perfect menstrual cycle and no menstrual cycle are many variations: short cycles, long cycles, heavy bleeding, fibroids growing, mood swings, irritability, and painful menses. Many women suffer one to several days of these symptoms every month, to the detriment of their relationships, jobs and emotional balance. I did. But between 46 and 47, even so late in my ovaries’ career, I was able to establish a perfect menstrual cycle such as I had never had. Thus proving, by the way, that PMS was not “all in my head”.

Before I describe the herbal regulators of the menstrual cyde, let me mention two common treatments for PMS and irregular cycles. If you complain to your doctor about your mood swings, you will be given an anti-depressant. It may or may not help, but it will probably have the side effect of decreased sexual desire. If you complain about your irregular cycles, spotting and heavy bleeding, you will be given a “low dose” birth control pill. It will control your bleeding, but probably make your moods worse, due to the synthetic progestin in the pill. Perhaps some of you have already tried these
treatments.

Herbs are the best remedy for the menstrual irregularities of PMS and premenopause. Herbs can regulate the menstrual cycle, working with your body and its hormonal signals, without side effects. At the same time, working wholistically, herbs can help to re-establish emotional balance.

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Vitex: the Women's Herb

Vitex (also called ChasteTree Berry) is an herb that has been used for over a thousand years in Europe to help regulate women’s hormones. In modern times, vitex is widely recommended by herbalists in England and Germany for PMS, irregular periods, heavy bleeding, infertility, hyperprolactinemia, poor milk production in lactating women, premenopause, and perimenopause.

Studies in Germany have shown that vitex increases LH and supports progesterone production by the corpus luteum. Progesterone deficiency can be the cause of many problems, including mood swings, food cravings, irritability, fatigue, muscle and joint pain, cyclical migraine headaches, dizziness, decreased libido, bloating and breast tenderness.

In Germany, vitex is generally prescribed in the liquid extract form. 25-40 drops in a little water are taken once a day, first thing in the morning. Don’t eat or drink anything else, except water, for 1/2 hour afterwards. Vitex can be taken as early as 3 AM, if you are up. Vitex is much more effective when taken this way, as opposed to later in the day or after meals.

Young women can take Vitex for the last one or two weeks of their cycle, depending on when their symptoms usually begin. After six months to a year of using Vitex, if the cycle is regular again, Vitex can be discontinued. Women near menopause should take Vitex every day. Often the period will come early during the first month of using Vitex.

Women usually feel a better emotional balance within the first week of taking Vitex, but it takes at least six months for the full benefit of Vitex to take effect, as far as regulating the cycle. During this time, symptoms such as headaches and bloating should continually improve. You cannot improve faster by taking twice as much vitex. Herbs don’t work that way. Once you have taken enough, they either work or they don’t work, but more won’t help. If you have experienced no improvement after three months of taking Vitex, then it is not for you.

Some women whose mood changes in PMS are characterized more by anxiety than irritability can also benefit from St. John’s Wort in addition to Vitex. PMS that is characterized by depression may be more related to low estrogen levels, and can benefit from Dong Quai.

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Dong Quai

Dong Quai is the traditional Chinese herb for women. It’s name has been translated as “compelled to return”, indicating that it makes the menstrual cycle regular. It has been used to help teenage girls establish a regular cycle, to help women after pregnancy re-establish a regular cycle (indicating it could do the same for women coming off of birth control pills), and to help premenopausal women maintain a regular cycle as long as possible.

Dong Quai is usually taken with other herbs that work synergistically with it, such as Rehmannia, Ligusticum and White Peony. Women’s Treasure tablets, by Planetary Formulas, is a good example of such a formula. Women’s Liberty Tea, by Traditional Medicinals, is another good way to use Dong Quai. Drink one cup a day, in mid-morning or mid-afternoon. (This tea, which also contains licorice, is not for women
with high blood pressure. Regular use of licorice can slightly increase blood pressure. Use Women’s Treasure tablets instead.)

Dong Quai tends to support the estrogen side of the equation in hormonal balance. It works to help the ovaries produce estrogen. This is demonstrated by its great effectiveness in relieving hot flashes in premenopausal and early perimenopausal women, when the ovaries are still working, and its complete lack of effectiveness in relieving hot flashes in postmenopausal women and women with ovaries removed.

By using Vitex and Dong Quai together, the menstrual cycle can be completely harmonized. If your cycle does not respond to these herbs, then you may need to consult with an acupuncturist or naturopathic doctor for additional herbal support, or with a medical doctor for hormone testing. There may be an underlying medical condition such as hypothyroidism or a pituitary gland disorder causing the menstrual cycle irregularities. Or, in the case of menopause, you might be too far along in perimenopause for these remedies to help.

As perimenopause progresses, and ovulation ceases, Vitex and Dong Quai become less the herbs of choice. Black cohosh and other herbs are better at relieving hot flashes, and natural progesterone cream will have to be used to support progesterone levels that the body can no longer maintain on its own.

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Some Products with Vitex and Dong Quai

WOMEN’S LIBERTY TEA by Traditional Medicinals (irregular periods) Licorice Root, Orange Peel, Wild Yam Root, Ginger Root, Cinnamon Bark, Dong Quai Root, Clove Stem, Fo Ti, Angelica Root

VITEX AGNUS CASTUS or CHASTE TREE BERRY extract (irregular periods, mood swings, cyclical headaches, infertility)

PMS FORMULA tablets by Pioneer (irregular periods & PMS) Chaste Tree, Dong Quai, Black Haw, Alfalfa, Licorice, Magnesium, Vitamin B6

WOMEN’S TREASURE tablets by Planetary Formulas (irregular & painful periods) Dong Quai, Rehmannia, Peony, Ligusticum, False Unicorn Root, Blue Cohosh, Cramp Bark Atractylodes, Black Cohosh, Ginger Root, Poria Cocos

VITEX/ALFALFA SUPREME extract by Gaia Herbs (hot flashes & mood swings) Chaste Tree, Alfalfa, Night-blooming Cerus, St. John’s Wort, Sage, Wild Oats, Motherwort

WOMEN’S TRANSITION tablets by Pioneer (hot flashes & mood swings) Chaste Tree, Dong Quai, Black Cohosh, Alfalfa, Licorice Root, Motherwort, Rice Bran Oil

Sexual Desire in Menopause

by Patricia Rackowski & Kathleen Gill, Ph.D.

According to the studies of Dr. Barbara Sherwin of Montreal, and others, testosterone is responsible for libido in women as well as in men. While this is generally acknowledged, sexual desire is more complicated than that.

We like the definition of sexual desire proposed by biologist Winnifred B. Cutler in her book, Love Cycles. ¹ She identifies three components of sexual desire: arousal, willingness and libido. Arousal is the physiological response to sexual stimulation during which blood rushes to the pelvic area, the vagina is lubricated, and orgasm becomes possible. Willingness is an attitude. Libido is more elusive because it happens in the brain and throughout the body. Thinking about sex, fantasizing about sex, actively seeking a partner (or planning sexual encounters with a regular partner), even masturbation, are all evidences of libido.

When a woman says that she feels a lack of sexual desire, it’s important to identify which of these aspects of desire is involved.

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Arousal

A woman’s physical capacity to be aroused requires some minimal level of estrogen. As women become postmenopausal and their estrogen levels decline, many experience a thinning of vaginal tissue, insufficient lubrication, and painful intercourse. Estrogen replacement therapy can restore vaginal tissue, but so can lower doses of estrogen in vaginally applied creams. Non-estrogen therapies for vaginal dryness include progesterone cream, flax seed oil, and herbal remedies such as dong quai, motherwort, and chickweed. ²

Dr. Cutler reports studies that show that postmenopausal women who have sex regularly (at least twice a week), including self-stimulation, have significantly less vaginal atrophy. ³ Not all women suffer from vaginal dryness but all men and women need more time to reach arousal as they get older. As Dr. Cutler points out:

“ . . .an unaroused woman tends not to lubricate. Forcing intercourse when a woman is not yet lubricated is the sensual equivalent of having sex with a man who does not yet have an erection . . . Although the use of lubricants is widely touted, I’m not so sure they shouldn’t be used only as a last resort. They do solve the abrasiveness, but I wonder if it wouldn’t serve the couple better to . . . take the time her body needs to promote her own arousal. . . .A woman and a man in their midlife years may require five minutes or more of undemanding stroking or petting to get the blood to flow.
. . .The urge to come and go in a heated rush should give way to a slower, moresensuous pace. ⁴

If a lubricant is needed, many are now on the market. Remember that estrogen cream is not a lubricant! It should be used at a separate time from sexual intercourse or it might have undesirable effects on a male partner. Products such as Astroglide or ID Personal Lubricant are designed for immediate use during sexual activity. If you prefer to mail order your sex supplies, Eve’s Garden in New York City has a delightful catalog. (Telephone 212-757-8651). In Canada, call the Wise Women’s Health Store at 416-962-9473.

Once sufficiently aroused, the majority of women are orgasmic. Orgasm is a reflex response, a muscular contraction triggered by rhythmic pressure on the nerves of the clitoris, vagina and cervix. It can be inhibited, however, by emotions, tensions or mental processes. ⁵

While orgasm is not necessary for satisfying sex, many women who have not been orgasmic can learn to become regularly orgasmic through self-help or sex therapy.

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Willingness

An attitude of willingness towards engaging in sex is subject to many influences, including past sexual experiences of a positive or negative nature, cultural practices and beliefs, physical health, availability of a desireable partner, fear of AIDS or other sexually transmitted disease, repressed anger against the partner, and the ability of the partner to satisfy one’s desires. Some of the issues that come up in midlife to detract from willingness are: fatigue and irritability due to hot flashes and sleep disturbance, negative beliefs about the attractiveness of middle-aged bodies, and lack of privacy with grown children, grandchildren and/or elderly parents in the house.

Sex therapists recommend the same approach to couples of all ages: talk about it. Improved communica-tion between partners can result in greater understanding, joint problem solving, compassion for each other’s weaknesses and more intimacy than ever. Couples who have difficulty communicating might benefit from a therapist’s help.

Interestingly, sex therapists report that the most common problem presented in therapy today is the same for young and old. People don’t have time for sex. Sometimes this is literally true because responsibilities at midlife can be enormous and there is only so much time in the day. For both men and women, as energy and libido lessen with age, sex can easily fall down on the list of priorities. If both partners are satisfied with this, there is no problem.

If, however, we are not happy and feel that we want
to have more sexual activity in our lives, we have to remember that both sex and intimacy require time . . .for relaxation, for feelings to flow, for needs to be felt. Relaxation practices such as meditation, yoga, tai chi, or massage need a place in our schedules, and this can lead to a resetting of priorities as we keep in touch with all of our needs and try to bring our lives back in balance. This is a never-ending process.

Another process that can enhance willingness is to ask ourselves about our conditions for good sex. Remember and visualize some of your best sexual experiences and identify the elements that pleased you the most. Become aware of your own conditions for good sex and communicate these to your partner, not as demands when you’re having sex but at another time. Let your partner in on what you need or like. “I love it when you do the dishes!” works better than expecting your partner to read your mind.

If your partner wishes to have sex and you are at least neutral about it, let your partner begin. You may become aroused after all and enjoy the experience. At midlife, many women say they don’t think about sex often but enjoy it when it happens. Another possibility, although it flies in the face of cultural norms that define sex as intercourse only) is to give pleasure to your partner without receiving stimulation yourself on occasion. It might be fun, even moving, to focus on your partner’s pleasure. At some other time you can be the recipient.

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Libido

At our workshops on sexual desire in menopause, women express a variety of feelings ranging from, “I couldn’t care less about sex right now,” to “I’m so horny, I’m embarrassed”. Most women are just wondering what’s happening in these bodies that they hardly know as their own anymore. They want to know what’s normal at this time of life.

If there’s one thing that most women are unaware of, it’s the fact that testosterone has something to do with libido in women as well as men. Women secrete from 1% to 5% of the testosterone men do, but it has a powerful effect. In women of reproductive age, the ovaries secrete testosterone on a more-or-less regular basis. Thus nature enhances willingness with libido.

But testosterone output becomes irregular, or out of balance with estrogen and progesterone, at menopause. Libido becomes unpredictable, intermittent or--less often--stronger than ever as the other hormones decline in relative influence. Women who have had their ovaries removed, or subjected to chemotherapy and/or radiation, may experience a sudden loss of libido. If they are already several years postmenopausal, they may have already adjusted to new levels of adrenal androgens and estrogens. If they are pre- or peri-menopausal, they may need to combine testosterone with estrogen and progesterone replacement therapy to restore libido.

In her book The Hormone of Desire , Dr. Susan Rako, a Boston area psychiatrist, explores loss of desire at midlife and recounts her own experiences with supplementary testosterone. She advises that most commercial testosterone preparations contain too high a dose for women. She recommends a more physiologic dose that can be prepared at a compounding pharmacist and checked by blood tests. She includes information on the normal testosterone range in women and the various ways of testing for it. ⁶

Dr. Rako adds to the debate about natural vs. synthetic hormones when she points out that natural testosterone (an exact copy of human testosterone made from soy or wild yam molecules) can be converted back to estrogen in the body, but very little methyltestosterone is converted back. This could be an important point for women who wish to avoid estrogen. Methyltestosterone can be used pharmacologically to relieve hot flashes and vaginal dryness, although only short term use is currently recommended. Long-term use of pharmacologic doses of testosterone may result in unpleasant side effects such as lowering of the voice, enlargement of the clitoris, acne, unwanted hair, and even more serious effects such as liver disease. ⁷

If you already have normal levels of testosterone (which can be checked by a blood test), there is no reason to take more. Libido can be lacking for other reasons. Certain drugs--especially some antidepressants and blood pressure medications--suppress libido in men and women, as do depression, hypothyroidism, or simple lack of sleep due to hot flashes. Some women report increased
sexual desire while using natural progesterone cream, possibly because it restores a more normal hormone balance to women who have “too much” estrogen. ⁸

Just as testosterone stirs sexual thoughts, sexual thoughts can stir testosterone. Even after menopause, our ovaries and adrenals make some testosterone. It’s just not on a monthly schedule any more. We can call it up with fantasizing, watching movies or reading books that turn us on, or making a special date, listening to special music. There’s no law that sex has to be totally
spontaneous. A little planning can do wonders for romance . . . as they say, anticipation is half the fun.

Speaking of romance, a new relationship or the re-blooming of an old one can dramatically increase sexual desire. We have heard testimony to this in our workshops. You can read such accounts in the book Women of the 14th Moon . ⁹ It’s proof that libido is initiated in the mind and heart as much as by hormone production.k Cohosh, Alfalfa, Licorice Root, Motherwort, Rice Bran Oil

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Analyzing "The Problem"

A gynecologist consulted about lack of sexual desire in a midlife woman may miss the mark entirely by prescribing testosterone for what is really a relationship problem. A dramatic example is a woman we know who, after mentioning lack of desire along with other menopause symptoms, was given testosterone with her hormone therapy. She was living with a man who physically abused her, but this did not come up in the interview with the doctor. A short time after her testosterone treatment began, she began to experience unusual bouts of anger--wanting to hit other passengers on the subway train who were annoying her. Clearly her aggressive feelings were aroused and displaced.

In contrast, another woman told us that, following a hysterectomy at age 42, she lost all desire for sex with her husband. No one had mentioned that this could be a result of hysterectomy even with ovaries retained. After a year of relationship therapy, it finally dawned on her that the problem might have something to do with the hysterectomy. She then began to do research and to look for a doctor who would work with her in a trial of testosterone.

Another woman felt that she had lost her sexual desire at menopause, but it also coincided with the death of her mother. She was wondering if grief were the true cause of her lack of desire. We suggested a short course of therapy to help her figure out what was going on. Sex therapists are particularly oriented towards this type of problem solving therapy, as opposed to long term analysis. Perhaps all she needed was permission to grieve as long as necessary.

Discrepancies in desire between partners can go either way. It is not always women who have less desire. Men often get depressed when they can’t perform as reliably as they used to. Performance anxiety can make their “failures” more frequent and they may not wish to try so often. Both men and women can benefit from adjusting their definition of “success” from “simultaneous orgasms with intercourse” to something more within reach, allowing for many forms of enjoyment besides intercourse and even without orgasm.

Knowledge of physiology and psychology can be of great help in analyzing problems of desire, but we may also need to rethink our philosophy. What is it, after all, that we desire? As we age, our passion may change its focus. We may no longer desire sex. As we contemplate our bodies’ transition from the “luscious” to the “divine” and follow in our hearts the glimmers and glances of true intimacy in a relationship, we may find new ways to love and new objects of desire. Our desire is for connection and we are never too old for that.

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Conclusion

Thus we see that in the case of lack of sexual desire, it is important to locate the part of sexual desire where our problem lies. Then we can begin to address the problem, if it really is a problem, with hormones, with the help of our partners, with doctor, priest or therapist, whatever is most appropriate to our situation.

Sexual desire is a complicated and sometimes elusive feeling at midlife, and we hope that this article sheds some light into its deep mystery. We believe that by continuing to explore that mystery, and by following our passions wherever they lead us, we will continue to find satisfaction in life.

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Estriol

Estriol is a human estrogen made in large quantities during pregnancy. Estriol is called a “weak”estrogen because it does not strongly stimulate cell proliferation in endometrial tissue. It has an affinity for tissue of the vulva, cervix and vagina. a Estriol cream used vaginally has been shown to improve tissue health in the area without increasing blood serum levels of estrogen. b Thus estriol cream is safer than estradiol cream for women who have had breast cancer. It has also been successful in reducing urinary tract infections in postmenopausal women. b Estriol could be called nature’s own “designer estrogen” because it has some of the beneficial effects of estrogen without strong stimulation of breast or endometrial tissue. Estriol cream is available by prescription from compounding pharmacies. For a free packet of information about estriol, call the Women’s Pharmacy in Madison, WI (1-800-279-5708).

a. Diczfalusy E, “The early history of estriol”, Journal of Steroid Biochemistry 1984, Vol. 20, No. 48, p. 951.

b. Raz R, Stamm W, “A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections”, New Eng J Med 1993, Vol. 329, No. 11, pp753-756.

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Physiologic vs. Pharmacologic Dose

A physiologic dose of a hormone will bring a woman into the normal range for that hormone. Hormones work best, with no side effects, as a physiologic dose which is neither too little nor too much. A pharmacologic dose is a large dose given for therapeutic reasons, as in fertility treatments or as in a shot of progesterone to induce a menstrual period. With a pharmacologic dose of testosterone, a woman will feel libido restored quickly as she passes through the normal range, but, in a few weeks or months, new symptoms of imbalance will develop with masculinizing effects.

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This article is based on the workshop Sexual Desire in Menopause taught by Patricia Rackowski and Kathleen Gill, Ph.D. Pat is a massage therapist and menopause educator. Dr. Gill is a sex therapist in private practice. Pat and Kathy offer workshops on menopause throughout the Boston, MA area. To attend a workshop, see Pat’s Talks & Workshops. If you would like to schedule a workshop for your women’s group at your church, your place of business or your home, e-mail Pat.

You Can Take HRT Without Side Effects!

by Patricia Rackowski

I write today for the woman who truly suffers from hormone changes at menopause. Not the woman sitting with questionnaire and calculator trying to figure out her long term risks of taking hormone therapy -- but the woman crying in her doctor's office right now because she is miserable with HRT and miserable without it.

Can women get relief from hot flashes, night sweats, insomnia, mood swings, vaginal dryness and other menopausal complaints without suffering irregular bleeding, headaches, nausea, bloating, depression and worse mood swings frequently caused by HRT? For many women this question is a lot more pressing than will they get heart disease, osteoporosis or breast cancer in the distant future.

Back issues of AFI are filled with letters from women who have tried to take HRT for symptom relief, and felt worse. Many women have tried a variety of herbal and complementary therapies, but these too have not brought relief. Some have already had their ovaries removed, and they are desperate.

That's the women's side. Meanwhile, Menopause, the Journal of the North American Menopause Society, has an article in almost every issue bemoaning the fact that 80% of North American women still do not use HRT, which the doctors are convinced is almost universally beneficial. The most recent issue (Vol. 5, No. 4, 1998) estimates that up to 54% of women who start on HRT quit within a year. From other surveys we know that as many as two-thirds of women who start stop within two years. Most of these surveys do not explore why. While some authors do acknowledge the need to fine-tune hormone therapy to an individual woman's situation, they rarely examine what this really involves in terms of time, expertise and the quality of care.

This article shares some of what I have learned through personal experience and research about fine-tuning hormone therapy. Standard, one-size-fits-all HRT doesn't work for everyone, no matter how much you explain it, halve it or double it!

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Finding the Right Doctor

Most HRT prescriptions are now given out by internists or primary care physicians, who don't have adequate time to counsel patients about possible problems that may develop. The ob-gyn who delivered your babies, if he's still in practice, may not be up on the latest in menopause. The nice young woman who took his place may be too busy delivering babies and doing hysterectomies to have time to keep abreast of her patients' mood swings. "Nice" is not all that we need when it comes to doctors; what we really need is doctors who know what they're doing.

All too often, women find themselves handed a prescription and told: "See you in three months". There might be a nurse or nurse practitioner to call for advice, but they are rarely hormone specialists. Many women, who are leery of HRT to begin with, stop taking their prescription relatively quickly when unexpected side effects arise. A practice or clinic devoted to menopause can make a big difference in the initial evaluation, counseling, and follow-up.

The woman who is desperate with severe menopausal symptoms -- and many women have other health issues to address as well -- needs a menopause specialist. For this article, I interviewed two such specialists in the Boston area to explore what they consider when they prescribe hormone therapy. By now, most large metropolitan areas in the U.S. and Canada have menopause clinics or practices. If you live in a smaller center or rural area where such services may not be avail- able, you might consider traveling for a consultation -- you're worth it!. If that's not possible, take opportunities to educate yourself, find resources through libraries and the Internet. Then you'll have to educate your own doctor to be what you need her/him to be.

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A Menopause Practice

"Specializing in menopause is not a big money-making practice, but it is professionally rewarding," says Dr. Alan Altman of Brookline, Massachusetts, a gynecologist and member of the North American Menopause Society. It takes time to listen to patients with complicated problems, to explain physiology and treatment plans to baby-boomer patients who want to understand everything, and to return phone calls at night. "This type of practice goes against the current direction of health care," he points out, "but it is satisfying to a doctor who has an independent streak and a desire to be of service. You can't be just a gynecologist-- you also have to be part internist, psychiatrist, sexologist, and social worker, and an empathetic human being".

Dr. Altman sees many women who have already been on HRT, the standard prescriptions of PremPro® or PremPhase®, both combinations of Premarin® and Provera®, and who have difficulties. I asked him to elaborate on the theme "you can take HRT without suffering side effects."

"Patients need to realize that HRT is not one thing," he began. "We start down a road and we don't know where we'll end up. As you go along, your body continues to change, and new products come out that offer more choices than before. Drug companies realize that the baby-boomer menopause is a big market and they are trying to answer the needs. Look at what's out just in the past year--Combipatch®, the vaginal ring and Prometrium®. If the patient is miserable on HRT, then the HRT can be changed". He has a "somewhat systematic" approach which would make for a pretty complicated flow chart.

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Fine-tuning Hormone Replacement Therapy

When Dr. Altman sees a patient who is not doing well on standard HRT, he starts all over again. His approach begins with an evaluation of where the patient is in menopause. Is it perimenopause or postmenopause? How long since the last period? What are the complaints of the patient?

If she is in perimenopause and still getting a bleed, then her body is still making estrogen. He might discontinue the HRT temporarily, test her hormone levels and see what symptoms exist. A woman with heavy bleeding and swollen breasts, who is making estrogen without opposition from progesterone (from lack of ovulation), might be put on Prometrium™, natural progesterone capsules, with no additional estrogen unless she also has a lot of hot flashes. Dr. Altman prefers to use Prometrium™ over Provera® because of its better cardiovascular benefits. [Women usually prefer it because it has fewer side effects than Provera®.]

A perimenopausal woman who has little bleeding but is heavily symptomatic with hot flashes, night sweats, etc. might just take a little estrogen augmentation, either herbally or with a low-dose patch or a formulation called Tri-Estrogen (10% estradiol, 10% estrone, and 80% estriol, a "weaker" estrogen in terms of endometrial stimulation ) Her bleeding pattern would be monitored until she went longer than three months without a period, in which case it might be time to add some progesterone to the regimen to reduce her risk of cancer of the endometrium.

Early perimenopause can also be successfully treated with low dose birth control pills, but despite their "low-dose" name they do contain pharmacologic doses of hormones which are much higher than HRT and some women don't tolerate them well.

Postmenopausal women who have used only herbs such as dong quai and black cohosh, or soy phytoestrogens, up to this point could be given the "progesterone challenge" (13 days on progesterone) to see if they get a withdrawal bleed. Women who deal with menopause symptoms successfully with herbs may have naturally higher estrogen levels than women who couldn't find relief with herbs. But without progesterone, they are at slightly higher risk of endometrial hyperplasia.

Obese women should also get the progesterone challenge, because their own bodies make more estrogen in fat cells. If these patients bleed, they should have an endometrial biopsy. They may need to take progesterone cyclically for awhile, even if they aren't taking estrogen. Obesity by itself is a substantial risk factor for endometrial hyper- plasia and endometrial cancer.

If a postmenopausal (or hysterectomized) woman on HRT has complaints such as frequent bloating and swollen breasts, nausea, weight gain and headaches, this may indicate too much estrogen. Dr. Altman would stop the present HRT and start again with a low .3 mg Estratab® and no progesterone. Transdermal estrogen in the patch, creams or gels, might be appropriate, to give greater freedom in dosage amounts than pills do. Once a woman is comfortable on estrogen, he would add progesterone. If a withdrawal bleed occurs, then cyclic Prometrium™ would be added to the regime. If not, then a continuous/combined regime of estrogen and progesterone can be followed, with no bleeding expected. Some natural progesterone can be given even to a woman who has had a hysterectomy as this may improve mood and energy levels and counteract fluid retention.

If a postmenopausal women on HRT come back with complaints of hot flashes returning, and estradiol and estrone levels measure around 60 pg/ml each, Dr. Altman is likely to add testosterone to the formula, usually with Estratest HS® (Half Strength). He explains that he would add testosterone before more estrogen because testosterone reduces SHBG (sex hormone binding globulin) and estrogen increases it. A lower level of SHBG in the blood means more free estrogen and testosterone, reducing hot flashes and increasing libido. He hasn't seen masculinizing effects from Estratest HS®, such as acne, facial hair growth, or hair loss.

For older postmenopausal women who are tired of having a withdrawal bleed on a cyclic progesterone regimen, or intermittent spotting and bleeding on the continuous/ combined regimen, Dr. Altman has been using a "cyclic/combined" HRT regimen. On this regimen, the other- wise daily progesterone is stopped for five days a month. The explanation for this is a bit too technical for this article, but it works to stop the bleeding. Unexpected bleeding should be evaluated by a doctor.

Some women have vaginal dryness despite taking HRT, because estrogen in the blood simply does not adequately reach the vaginal tissue. Dr. Altman has had good results using the new vaginal ring, Estring®, a low- dose time-release estrogen application.

Dr. Altman depends more on what patients report about their symptoms than on blood test results. He doesn't do a lot of hormone blood levels, although he does some when it seems useful.

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A Hormone Specialist

Dr. Carolyn Shaak, a gynecologist in Needham (Massachusetts), calls herself a "Hormone Specialist". Several years ago Dr. Shaak responded to her patients' complaints about the few choices available in HRT by devoting herself to finding a better way. Now she believes she has found it, with "bio-identical natural hormones" mixed into creams by her pharmacist collaborators at Bird Hill Compounding Pharmacy.

Dr. Shaak now has over 1000 women in her practice using her hormone creams, which are individualized combinations of estradiol, progesterone and testosterone. She is applying for a patent for her formulations, which she will simplify into 5 different commercial products.

I asked Dr. Shaak why she prefers to use the transdermal (through the skin) method of taking hormones. Studies have shown that women are more compliant with hormone regimes that use pills.

"We are not trying to corral women like sheep into compliance," said Dr. Shaak. "Women know whether they feel better or worse taking hormones, and they will not take a pill that causes uncomfortable side effects. I have had tremendous success with women who have tried other hormone regimes and couldn't tolerate them."

"When women understand the benefits of transdermal hormones," added Dr. Shaak, "they gladly use the cream. Some have tried the patch [which also provides natural estradiol] and were allergic to the adhesives. Many women who do not like wearing a plastic patch prefer a cream to taking a pill. They use creams anyway for moisturizing. It seems more natural and less medical than taking a pill for the rest of your life when you consider yourself a healthy person. After all, menopause is not a disease.

"Women also like the creams because it makes them an active participant in their treatment and gives them some control over the dose," she said. "Unlike pills, cream dosage can be adjusted easily. For perimenopausal women who still experience their own bodies' hormone ups and downs, with breasts that are sometimes tender and swollen, the dosage can be cut back for a few days until the tenderness passes."

Dr. Shaak's patients use their cream in twice daily applications to thighs, hips, abdomen--areas where there is body fat to absorb the cream and slowly release the hormones into the blood just as the ovaries do. Most hormones taken in pill form do not reach the bloodstream. They are broken down in the digestive system. Those that make it through the liver are changed molecules, metabolites of the original hormones. According to Dr. Shaak, that is the cause of many side effects women experience in taking hormones in pills. Pills also result in an uneven release of hormones into the blood, peaking shortly after taking the pill and dropping off greatly later in the day. Peaks and falls of hormone levels can cause headaches or nausea.

Dr. Shaak asks all of her patients to read Natural Woman, Natural Menopause by Dr. Marcus Laux N.D. and Christine Conrad (Harper Collins, 1997). This book explains the concepts of hormone balance and the benefits of natural hormones. Natural, when it comes to hormones, means hormones that are an exact molecular copy of human hormones. Usually natural hormones are produced in a lab from a substance in soy or wild Mexican yam called diosgenin. (Premarin®, the most common form of oral estrogen prescribed, could be called "natural" because it is extracted from mare's urine, but is not 100% natural to the human body. It is composed of 11 different estrogens most of which the human body cannot use.)

Bio-identical natural hormones have all the same actions in the cells as our own hormones. Synthetic hormones are different molecules, and do not have all the same actions. Synthetic progesterones such as Provera®, for example, will act more strongly than natural progesterone on the uterus to prevent hyperplasia (excessive cell growth). It will not, however, have all the same good effects as natural progesterone on metabolism and mood.

It wasn't commonly believed, even five years ago, said Dr. Shaak, that all three sex hormones could be effectively absorbed through the skin. Her work has demonstrated, by checking blood levels before and after treatment, that satisfactory levels of hormones can be achieved using her prescription creams.

Her goal is to supplement a woman's own hormones to the levels of Day 17 of a normal menstrual cycle. This puts estradiol at 60-90 pg/ml, progesterone at 3.5-5 ng/ml, and free testosterone at 0.8-1.8 pg/ml. She admits that the targets are somewhat arbitrary in that we do not know what optimal postmenopausal hormone levels are. But she has found these levels, which duplicate average hormone levels before menopause, to be where most women feel comfortable and do not experience side effects, bleeding or hyperplasia. Her office does perform endometrial biopsies to confirm the effectiveness of natural progesterone treatments in preventing hyperplasia.

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Finding the right prescription

The physician is on the front lines of treatment, faced daily by patients who are in distress now. Using current knowledge and tools, he or she often has to go beyond what has been studied and proven, to try to solve complex problems. The two specialists described in this article have done so, courageously I might add, in an area like Boston, which is dominated by conservative, by the book, treatment. They have helped many patients, myself among them, to cope with a very difficult time in our lives.

In seeking the prescription that is right for you, look for a specialist with the expertise and information about menopause that you need. Find someone who will work with you to problem solve and try different approaches, if necessary. Remember that there are many different kinds of hormones and ways of using them, as well as complementary therapies. Don't lose hope!

And remember too, you are paying for your health care, whether directly, through insurance or through your taxes. If you are not happy with your service, seek out another doctor. Ask your friends for recommendations, network, interview doctors over the phone if possible. Do research on your own or with the help of a librarian or friend. Don't be passive; find what you need. It makes the system better for all of us.

Progesterone for Menopause

Surgical Menopause

is caused by the removal of the uterus and ovaries. Women who have had hysterectomies, with ovaries removed or not, usually receive estrogen replacement only. This is because many doctors think that the only role of progesterone in the body is to prevent excess estrogen stimulation of the uterine lining. Why prescribe progesterone, they think, if a woman doesn’t have a uterus?

But progesterone has receptors in many parts of the body—brain, bones, breasts, vagina. Some progesterone is converted to testosterone, estrogen or cortisol if the body finds it necessary, so progesterone has another role as a back-up hormone. Progesterone plays a role in metabolism, sleep regulation and bone-building as well. And we don’t even know all about what progesterone does yet!

After surgical menopause, women who receive estrogen-only replacement may continue to complain about bloating, swollen breasts, fatigue, “crying for no reason”, lack of libido and easy weight gain. Their frustrated and busy ob/gyn doctor sends them back to their primary care physician for anti-depressants, diuretics, diet advice and assurances that “nothing is really wrong with you— you probably just feel bad about losing your uterus—it will pass.”

Some testosterone can help the libido. The estrogen dominance symptoms can be relieved with natural progesterone. I have recommended ProGest cream to women who feel like this, and they have resolved their complaints.

Natural Menopause
During natural menopause many women experience a drop in progesterone levels before they experience a drop in estrogen levels. This is because progesterone is made primarily by the corpus luteum, the remains of a follicle after ovulation. When there is no ovulation, there is no corpus luteum. Only a small amount of progesterone remains, made by the adrenal glands. This would be fine as long as estrogen levels dropped simultaneously, but they don’t always. Sometimes estrogen levels continue relatively high for several years, since some estrogen is still made by the ovaries and an estrogen called estrone is made in fat cells. This is nature’s way of easing us into menopause, but it can get out of balance.

Estrogen dominance symptoms after menopause include intermittent bloating and swollen breasts, fatigue, depression, lack of libido and easy weight gain. Progesterone enhances thyroid metabolism and estrogen interferes with thyroid. Estrogen dominance can mimic hypothyroidism.

The more weight a woman carries, the more likely she is to be estrogen dominant. In fact, obesity is a risk factor for hyperplasia and endometrial cancer, because of estrogen dominance. Unopposed estrogen made by the woman’s own body may stimulate the lining of the uterus and thicken it with blood. For this reason, any unexpected bleeding more than one year after periods have stopped should be checked by a doctor.

Heavy women, who are less likely to be on estrogen because their own estrone relieves hot flashes, may nevertheless need to take progesterone for awhile after menopause to protect their uterus from hyperplasia. One way to check for this is to take the “Progesterone Challenge”. It would probably be better to work with adoctor on this and to take a prescription level of progesterone or progestin. (ProGest cream would be too low a dose.) Progesterone or progestin is given for 10 days and then stopped; if a period or any bleeding results, then there is some blood being built up in the uterus. Natural progesterone should then be used for several months to a year, cyclically, until this withdrawal bleed stops.

For other women, estrogen dominance just doesn’t occur. Instead, periods get lighter, fewer and far between until they disappear. Hot flashes, night sweats, sleep disturbance, anxiety, depression, and vaginal dryness may be their complaints. Their doctor will most likely prescribe standard H.R.T. which is the most commonly prescribed drug in the world—PremPro or PremPhase, combinations of Premarin and Provera. Premarin is a conjugated estrogen (combination of estrogens) derived from Pregnant Mare’s Urine—thus the name. Provera is a synthetic progestin.

Many women feel much better on H.R.T., but others don’t. They have side effects like bloating, sore breasts, fatigue, nausea, depression and headaches.They do not realize that You CAN Take HRT Without Side Effects! It’s just not the standard prescription. Natural estrogen and natural progesterone made from wild yam and soy molecules are exact copies of our own hormones, and they can be prescribed in physiologic doses that result in NO SIDE EFFECTS!

In 1998, Solvay Pharmaceuticals brought micronized natural progesterone capsules to the market in a new product called Prometrium (Trademark). Prometrium capsules contain 50 or 100 mg. of progesterone suspended in peanut oil (beware those who are allergic to peanuts). Prometrium can be prescribed with the estrogen patch or micronized estradiol capsules to provide natural hormone replacement. Natural hormones are made from soy and/or wild yam molecules called diosgenin, which is very similar to human hormones. Natural hormones are made in a lab, and they are an exact copy of our own hormones. When prescribed in physiologic doses, they act just like our own hormones and have no side effects. (Allergy to soy does not seem transferrable to these products, usually.) This regime has been promoted extensively by Dr. Christiane Northrup, author of Women’s Bodies, Women’s Lives.

Another way to take natural hormones is in cream form, transdermally, which results in a time-release effect like the patch, but without the bother of wearing a piece of plastic. Dr. Carolyn Shaak of Needham, MA, my gynecologist, is developing a product line containing several different standardized dosages of estradiol, natural progesterone and testosterone. In the meantime, such creams can be prescribed by any doctor and made up at a compounding pharmacy near you. The Women’s Pharmacy in Madison, WI, can supply such creams by mail order.