26 May 2016
BIOIDENTICAL HORMONES & MENOPAUSE
26 May 2016
Below is a transcription of Dr. Eleveld’s portion of a presentation on Bioidentical Hormones and Menopause. Becky Campbell, a compounding pharmacist at Chiron Pharmacy in Guelph presented on menopause generally and the options available with respect to treatment with hormones. Becky can be reached at 519-824-7887 if you have any further questions. If you have questions for Dr. Eleveld, feel free to contact us through our website: https://naturalchoicemedicalclinic.com/contact-us or book a free 15 minute consultation with Dr. Eleveld by phone (519-265-8035) or online: https://naturalchoicemedicalclinic.janeapp.com/#/staff_member/1
Stay tuned for additional events like this in the future!
“Hello my name is Dr. Harmonie Eleveld and I am a naturopathic doctor. I am the owner of Natural Choice Medical Clinic which is an integrative wellness clinic located on Westmount Rd in Guelph where we have a team of practitioners that can help you address your health concerns. I did my undergraduate degree in Biomedical Computing at Queens’s University and then I did a 4 year naturopathic medical degree in Toronto to do what I do today, which is to help my patients feel well. I especially like working with women who have hormonal imbalances, and the most common hormone imbalance comes along with menopause. If anyone has any questions during the presentation, please feel free to ask or you can write your question down and I can address it at the end.
Does anyone feel like this woman today?
Becky has done a really great job at giving you an overview of menopause and your sex hormones and the options available to you. I’m going to talk a little about why each woman experiences menopause differently and what my approach is in addressing your health concerns in menopause.
First we are going to talk about stress and how that impacts your hormones. Then we will go over sugar and your hormones. I’m going to touch on estrogen dominance, and then I’m going to go into my approach to healthy menopause which includes lab testing, bioidentical hormone replacement therapy, and other natural therapies.
STRESS AND YOUR HORMONES. Becky mentioned that a healthy lifestyle can help to mitigate symptoms of menopause and one of the biggest lifestyle factors that can impact your symptoms is stress. The number one reason that hormones become imbalanced is stress. Stress has such a big impact on hormones that it is estimated that 90% of unexplained infertility is a result of stress. Not that many of you will become concerned about your fertility (in menopause) but it just shows us how impactful stress can be on our hormones. I am going to share with you how this can happen and what we can do about it. Stress used to serve one purpose, to help us run from bears or whatever else that was trying to eat us. And we want our body to have that fight or flight response when we are in a dangerous situation, but what tends to happen is that we are having that fight or flight response, that very stressful response, on a daily basis to things that aren’t particularly dangerous. You’re often exposed to stress at work or at home or sometimes we’re inadvertently exposed to stressors in the environment like pollution or the food we eat. We used to be exposed to stress on occasion but now it’s happening all the time and this is hard for our bodies to keep up with. What does this have to do with hormonal imbalances? Well, if you are running from a bear, your body isn’t very concerned about your sex drive, and your body isn’t very concerned about whether you can reproduce, it has other priorities at that present moment. When you are being stressed all the time that can really impact the hormones responsible for those things.
Bear with me. This chart is a little bit technical but I think it explains the connection about stress.
Stress literally steals your hormones. We either make or take in cholesterol which is the precursor to all of these different hormones here. Cholesterol is made into pregnenolone and then it goes on to produce DHEA which is your anti-aging hormone and then DHEA is the parent hormone for testosterone, all 3 estrogens here, and also goes down to progesterone and cortisol. And cortisol is the key piece here because when we’re stressed, we are producing a lot of cortisol, and when we’re running away from that bear, our body doesn’t care about these hormones over here (estrogen and testosterone) or really progesterone either. Its only concern is cortisol and so this pathway always goes down to cortisol and ignores everything else. So all your other hormones drop off the map and cortisol can become high. If you ever notice that your hot flashes are worse when you’re stressed, this is why. it’s important to note that if cortisol is high for a really long time, your adrenal glands that are used to make cortisol can become tired. If you’re stressed for a very long time, your adrenal glands sort of stop responding to that stress and you can actually end up having low cortisol. There is that high cortisol and low cortisol and both are going to impact your sex hormones. If you’re ever wondering why a friend of yours might be flying through menopause without symptoms, it could be either that she’s managing her stress very well or that she hasn’t had significant stress in her life. Her adrenal glands are actually coping better and they’re able to produce some hormones after menopause. What happens (in menopause) is that the ovaries stop producing your sex hormones, but your adrenal glands can produce a little bit if they’re functioning optimally. If you’ve been exposed to chronic stress, they’re not functioning optimally and they can’t take over for your ovaries and that’s where you run into hormone imbalances.
Stress has other additional negative impacts on the body aside from stealing your sex hormones. It also causes muscle breakdown because despite the fact that your need to use your muscles to run away from that bear, your body thinks that you need fuel more, so it’s actually going to breakdown your muscles to provide fuel for your body to run from that bear. So when you’re experiencing chronic stress, you’re breaking down muscle as well. When you are running away from that bear, your body is not concern about the cut on your arm that might lead to an infection, so it suppresses your immune system and you’re more prone to infections. Have you ever noticed that after you’re run down and you’ve gone through a stressful week, right afterwards you get a cold? That’s because your immune system has become suppressed by that stress and that high cortisol. It (stress also) reduces the production of dopamine. Dopamine is the feel good neurotransmitter that gets released when you consume fatty foods, salty food, sugary food. It’s that addictive neurotransmitter. And when you’re stressed, dopamine isn’t secreted as much and that makes you crave those things more because you’re looking for that satisfying dopamine surge. It(stress) also causes a disproportionate amount of food to be stored as fat because when you’re running from that bear your body doesn’t know when the next meal is coming because it’s in this high stress (state). It doesn’t know when you’re going to be eating again soon so it’s going to store that fuel so you can use it later. It (stress) also triples your insulin release from all grains, starches, fruits, sweets and alcohol. We’re going to get more into how insulin is related but one of the take homes I want you to leave with today is that all the hormones are connected. We were talking about cortisol, now we’re going to talk about insulin, we’ve talked about estrogen, progesterone, testosterone, they’re all interconnected. And when one is out of balance, all of the others can be imbalanced as well.
We’re going to move into SUGAR AND HORMONES. But just before I wanted to stress that stress is very important and that when cortisol is out of balance this is also going to impact your weight, it’s going to decrease your hormones, it’s going to worsen symptoms of menopause including sleep, and it’s going to increase your risk of diabetes, so it has many far reaching implications.
On to sugar. There is no doubt that as a society we eat far too much sugar. It’s estimated that we consume 20x the amount of sugar compared to what we may have eaten in 150 years ago, and while you may classically relate sugar consumption to conditions like diabetes, it also plays a role in impacting your hormone imbalance. And here is how:
When you’re eating sugar or a refined carbohydrate (a refined carbohydrate is any white carbohydrate, so you’d be thinking white pasta, white bread, white rice, white potato, they all act like sugar in the body so your body is able to convert that carbohydrate into sugar very quickly so your body doesn’t really know the difference between those things or sugar) Insulin is released when you consume those foods and then insulin allows your cells to use that sugar as fuel or energy. So insulin is kind of like a key to open your cells to allow that sugar to go in. That’s what happens normally. When you overeat on refined carbohydrates or sugar, you release too much insulin and that’s where you can end up in insulin resistance. Your receptors on your cells become less sensitive to insulin so you may need 5 keys to unlock to get that glucose into the cell and you end up with insulin resistance, high blood pressure, and diabetes. And in addition to that, insulin resistance can also lead to cravings, fatigue, weight gain, increased risk of Alzheimer’s disease, anxiety and depression. It prevents you from using that fuel, that glucose that’s floating around in your blood, which is why it can result in all these problems. It (insulin resistance) eventually leads to diabetes but also hormone imbalance. The reason that it leads to hormone imbalance is because insulin, when it is high, it’s also telling the fat cells to take in glucose. So these fat cells are growing and creating more fat. More fat equals more inflammation, which is resulting in more cortisol because when insulin is released, cortisol is also released. It also results in the ability to store more estrogen in your fat tissues. So instead of metabolizing your estrogen after you’ve used it , you’re actually going to store it in your fat cells and to top it off, your body sees these fat stores with estrogen in menopause (when youre not producing a lot of it) and thinks that I should conserve that. So it tries to conserve your fat cells in menopause. So this is a perfect storm for hormone imbalance and dysfunction.
Question: So what happens when someone starts to detox and start to release that fat with this high amount of estrogen in it?
Women can end up in estrogen dominance if that’s happening. But you can also try to promote healthy metabolism of that estrogen so it goes out to the body more quickly.
Question: So how do you do that?
Diet, lifestyle, certain supplements can help with that.
So this fat stored with estrogen is the reason why overweight or obese women typically don’t experience as many symptoms of estrogen depletion in menopause or hot flashes specifically because they’ve got all that extra stored estrogen. But what that can result in is estrogen dominance. And I see estrogen dominance in many women that are overweight and obese, but I also see it in women who are in the ages of 30 and around 45 that are around perimenopause, and this is because as Becky was mentioning, progesterone falls quite precipitously as you age and estrogen doesn’t fall quite as quickly. The gap between the two actually increases as we approach menopause and that ratio of the two hormones, they are(should be) a match. We need balance between the two and when the ratio is off when the estrogen is higher than the progesterone, that leads to symptoms. You can have normal values on lab work of progesterone and estrogen but estrogen is at the high end of the range and progesterone is at the lower of the range, and you’re having symptoms of estrogen dominance, which are symptoms here…
- Low libido
- Irregular periods
- Heavy periods/flooding
- Bloating (water retention)
- Breast swelling, tenderness and/or fibrocystic breasts
- Headaches (especially before your period)
- Mood swings
- Sluggish metabolism
- Brain fog
- Ovarian cysts
- Uterine fibroids
Alright, moving on to my healthy approach to menopause. While we may have accepted that menopause is a normal part of aging, it is in fact unique to humans. Other primate species like monkeys and chimpanzees do not experience menopause like we do. Because of advancements in society and medicine we live a lot longer than our ancestors did and it was thought that they didn’t live long enough to go through menopause. Now, it is expected that a woman can live up to a third of her life without her sex hormones. I do what I do because I believe in challenging the status quo of health and healthcare. Aging can be done gracefully and it’s not a reason to feel like your body is falling apart.
As Becky mentioned, there is more to menopause than hot flashes so all of these symptoms can be experienced as a result of hormonal fluctuations and menopause.
Most often I do see women struggle with hot flashes and secondly with sleep. Sometimes it is sleep as a result of hot flashes but sometimes sleep on its own. Sleep, to me, is probably the most important single symptom to treat in menopause because if you have insufficient sleep (and a good sleep is getting 7-8 hours of sleep fairly soon after you go to bed and not having interruptions) it can lead to a variety of chronic diseases from obesity, to cancer, to diabetes. It actually increases your mortality risk, just your general risk of dying is increased if you’re not sleeping well and it will also result in lower productivity and poor quality of life. Sleep is when you heal, so you really do need a good quality of sleep.
(Overview) Alright so we were talking about the quality of life, we’re going to get a little into lab testing and I’m going to talk to you about stress management and improving sleep, (we will get into) bioidentical hormonal replacement therapy and a little of bit on natural therapies as well.
I don’t like guessing. I like to do lab testing with my patients. I like to test all hormones, including cortisol, estrogen, progesterone, testosterone, and DHEA. This gives us a comprehensive look at what your hormone levels are and how they are interacting. Because if we only do one hormone, we may know that that one is low, but why is it low? Is your cortisol high? Is that why it’s low? Doing all the different hormones can help to figure out the whole picture. Then we address these hormones directly, what needs raising, what needs lowering.
There are a few different ways to test hormones, we can do blood testing, urine testing, and saliva testing. There’s a lot of different advantages and disadvantages to all of them.
Blood testing – the biggest advantage is that it is less costly. The disadvantages are that it does not test cortisol (it can but it’s not particularly accurate because when someone is coming at you with a needle, your cortisol is going to spike) and also you can only test it once in a day, whereas your cortisol goes up and then falls throughout the day, and you want to see what’s happening in the different points in the day. The other two tests can show you that. It (blood testing) also does not distinguish between bound and unbound hormones (that’s active versus inactive hormone), it’s invasive, and again it’s a single measurement. And with hormones, single measurement is not as accurate as doing a number of measurements.
Urine testing – the biggest advantage of urine testing is that it tests metabolites of estrogen. You make estrogen, you use it, and then you metabolize it to send it out of the body. You can metabolize estrogen in one of three different pathways. One pathway is the preferred the pathway. That’s the one that’s appropriate and doesn’t harm the body, the estrogen goes out as it should. The other two pathways can be cancer-promoting. So if you’re shunting a lot of estrogen through this metabolic pathway then we can see that in the urine test and we can address it by promoting the other preferred metabolic pathway. The urine test tests all your hormones -like your cortisol. The disadvantages are cost, and that contamination is common so I always encourage all of my patients to carefully follow the instructions.
Saliva testing – the biggest advantage is that we can do this for cycling women. We can do a month long test with saliva. It is also great because it can test all hormones except for the thyroid, which we always do with blood. Again similar to the urine, the disadvantages is that it is also costly.
This is an example of a urine test. I wanted to show you, not to get into the details, but to show you that there is a lot of information. It provides us with a comprehensive look at what the different hormones are doing and it provides us different explanations. There are great patient reports you can read if you are interested when you do this (the test). Each little circle is a hormone and it gives you the values in a little graphical representation and then it shows you the normal value in menopause. It shows your cortisol as a curve, which is what we want to see, and then it goes to all different values. If we were looking at a blood test we might have 4 or 5 different lines like that, but there is a lot more information on the urine and salivary testing.
This (the urine test report) goes into the pathways of estrogen metabolism and some more cortisol and other metabolites and then again into the pathways of cortisol metabolism. Lots of information on these tests. So the urine and saliva are more costly but they have really great information.
In menopause as I mentioned earlier sometimes your insulin can be out of balance so it can be indicated to test fasting blood sugar, HbA1C (for an average of 3 months of your blood sugar) and fasting insulin. I also do a comprehensive thyroid panel in many women because as we age the thyroid can become less functional. The typical screening test that is done is thyroid stimulating hormone but I don’t always find that to be the best tool or the only tool to be used. One reason is that the reference change for thyroid hormone is 0.3 to 4 but a lot of the experts and the current research is showing that normal thyroid function should actually fall in between 0.3 to 2.5. I have a lot of women that have been told they have normal thyroid function at 3.5, for example, but they’re experiencing symptoms of low thyroid. That’s one reason that the TSH is not the best value but also because your TSH is like measuring the thyroid function in your brain rather than the thyroid hormone function in your tissues. If you think about this like asking about whether a country‘s people are starving by asking the president if he has enough food. You’re not going to get a good evaluation of what’s going on with the people if you’re going to ask the president. That’s why I test the actual hormones (T3 and T4), anti-TPO (which is an immune response that can happen to the thyroid gland) and reverse-T3 (which is kind of like the anti-active hormone -so if reverse-T3 is high the thyroid can also be low functioning). I also often test melatonin. Melatonin can be low in a lot of menopausal women. One hour of less sleep can lower your melatonin and low melatonin is a risk factor for cancer. So I always make sure to test this one.
What to expect for my patients that would see me: an initial appointment that is about an hour long. We would do any physical exam that is required. We would do a thorough health history to really assess what your health concerns are. Then I would recommend any lab testing or we may go over any labs that were done before and figure out what kind of hormonal imbalances what’s going on. You may have gathered that I typically do the saliva and urine testing. I find that it gives us more of a comprehensive picture and I usually do that testing at the beginning before we initiate any therapy and then as we monitor (at 6 months or a year we will do another round of testing to make sure that the hormones are appropriately dosed and that your metabolizing your metabolites appropriately). As Becky mentioned bioidentical hormones are not the same as synthetic hormones. I use bioidentical estrogen and progesterone. I use the Bi-est estrogen, so the two different types of estrogen.
What I wanted to point out is that if this is our body’s natural hormones and this is our hormone receptors in our cells. It fits perfectly as it should. Bioidentical hormones fit in the exact same way. Synthetic hormones fit fairly well and they are similar. They might be good enough to eliminate your symptoms but that little gap there is what would result in side effects and potential increased risk factors. Historically progesterone was used only for women without a uterus, but progesterone has more than one function and its function is not just to counteract estrogen’s action on the uterine lining. I use progesterone in addition to estrogen typically, especially if we’d done the testing and the progesterone is low, even if you’ve had a hysterectomy.
This is just some side effects of the bioidentical hormones. Becky covered this so I’m going to breeze through these and the risk factors but I just want to emphasize that the bioidentical hormones are not the same as the synthetics. Synthetics are the ones that have more research but the bioidentical hormone research is not showing the same risk as the synthetics. Nothing is without risk but we mitigate these risks by monitoring metabolites and by doing regular screening like mammograms and endometrial ultrasounds and paps. I use transdermal instead of oral because as Becky mentioned the risk for stroke is less when you do transdermal. I also always emphasize that If a woman is doing hormones it’s best to start early as possible because the age that you start hormones completely changes your risk factors. There’s one study that I was recently looking at: If a woman starts (BHRT) before the age of 65, her risk for cognitive decline was lower. If she started hormones after 65, it was the opposite and her risk of cognitive decline was higher.
Now we aree going to talk about stress management. I think I talked about how stress is important and how it can impact your hormonal balance. Stress impacts a lot of areas. Stress management is different for every person; it could look like meditation, yoga, breathing exercises or it could be walking around the park. Whatever it is, it is important to implement something daily so that cortisol can remain in check, and adrenal glands remain healthy.
Supplement: I find that some people come in with a lot of supplements. We do a supplement review and we go over what is important. (I ask) Are you taking that for the right reasons, are you taking the right dose, and are you taking the right form. We go through what they are currently on and I recommend other additional products or supplements for them to take for their health concerns. I may use (supplements) in addition to the bioidentical hormone replacement therapy or instead of, if women choose to not use the hormones or if they have certain contraindications like Becky had mentioned. Here is just a few examples of the ones I use, we’re not going to get into detail. I do emphasize that the correct use and the appropriate dosage of all of these things are very important.
For diet it is very important to balance your blood sugar. That’s where you can impact your insulin. Balancing blood sugar we can do by making sure you consume enough of protein and fat with your meals. Fiber is also a really great way to balance blood sugar. Flax is a great hormone balancer in general and has good omega 3’s in it. Cruciferous vegetables are one of the things that I use to help push estrogen metabolism from the harmful pathways to the more preferred pathways.
The biggest take homes that I want to leave with you today is that hormone balance is very important to health, lab testing is crucial to identifying these imbalances, and bioidentical and naturopathic therapies can help with those imbalances. A lot of women can put up with the symptoms of menopause, but if it’s impacting your quality of life, I would recommend not to put up with them because your quality of life is very important, your relationships are very important, your happiness is very important, and your sleep is very important.
Does anyone have any questions?
Question: How much typically is the urine testing? And how much typically is the saliva test?
They’re both around 400 dollars. The urine test is slightly more than the saliva.
Question: How long can you stay on bioidentical hormones?
Many women stay on them for the rest of their lives. Not that every woman needs to. But if they’re providing relief of symptoms and improving quality of life then women do continue on them. There are certain points where you can try to decrease the dose and see if it is still effective at controlling your symptoms, but it varies from woman to woman.
Question: What is the percentage of women who get their periods back on the hormones?
It doesn’t typically happen because you’re using the hormones consistently. Vaginal bleeding can happen on occasion but I usually only see that when it is sporadic use of the hormones. Vaginal bleeding after menopause should be checked out (via endometrial ultrasound).
Becky: We have another question that was written down. People have posed questions surrounding coverage of medications. So that’s kind of a loaded question because everyone’s drug plan is so different. How we try to handle that at Chiron is that before a compound or the hormone is made we call you with a price and we do a consultation to make sure that you’re comfortable with everything and we’re moving forward. Then we provide you an invoice that you can submit to your drug plan as well as a universal drug claim form. Because bioidentical hormones that we compound don’t have a drug identification number the same way as an antibiotic would or blood pressure medication, you need the supplemental form which gives you a breakdown of each ingredient that is used as well as the quantity that is used. So you would submit both pieces of information to your drug plan to determine if they’re covered or not. If you want to check your drug plan prior to getting your prescription filled, one of the pharmacists would be happy to provide you with that information so you can call your drug plan and see what their formulary covers. The other alternative is to work with drug-identified products that are commercially available. I touched with a few bioidenticals that are commercially available ie the estragel, estrace, Climara. So there are a few options there but we are a little bit limited with the strengths that they provide but again we would work with you throughout that process to try to figure out what works best for you.
Question: What do you use for natural cream base?
Becky: Typically for hormones we use product called versabase so it doesn’t have contain petrochemicals, it doesn’t contain any parabens, it’s fragrance-free, it doesn’t cause acne, it’s hypoallergenic. So it’s a nice well rounded base and a good starting place. We certainly do get patients that prefer a more natural approach so we start to use things like shea butter, emu oil, coconut butter so we can work with those. Oftentimes they do have a little bit of a less cosmetically appealing feel to them, so they are often greasier. It’s certainly an option if that’s something that you want to incorporate. We even have patients that we’ve individualized how much emu and how much shea so we’re using so we can really make it personal as it needs to be.
One of the other questions that came up was… What should testosterone levels be? And that really depends on what labs you are doing. It would be different in blood versus in saliva versus in urine. It also sometimes varies with the lab. If you were to (test testosterone) the labs provide reference ranges – and then typically – but not always, as I mentioned about the thyroid the reference ranges are not always completely accurate – I like to see my patients right smack in the middle of those reference changes to feel the best.
And the other question was, with the risk of using HRT when considering vaginal bleeding, would this be a current problem or a history of bleeding? It depends on why there was bleeding and we would get into that in a consultation and then we’d determine if it increases their risk for endometrial problems later down the line if they were to use hormones.
Question: If you were to find very low testosterone and you’re already low on the estrogen and progesterone, and then found out you’d need to take supplementary testosterone. Is that three different applications or do they combine it any why?
Usually you would keep them separate. You can combine it sometimes but typically I keep them separate, at least to start. If you’re adjusting dosages it can become problematic to adjust (if they are combined) and it becomes costly (to adjust dosages) once you have already compounded it all together. Later on we can put the estrogen and progesterone together and then usually put testosterone separate, but Becky might know better too.
Becky: I agree with Harmonie’s approach. So typically until we know exactly what dose we are going to use, its best to keep it separate. Afterwards, if everything is going to be prescribed once daily you can certainly combine everything to one cream, so its one application. That being said we typically see testosterone being dosed in the morning because it can promote wakefulness whereas for progesterone it’s preferred to be dosed at night because it’s our natural sleep hormone. So those two are best to keep separate just because we wouldn’t want to be counteracting their natural activity by dosing at the wrong time of day. But some women certainly prefer it from a compliance standpoint to use it all at once and they have no issue with it, but that’s when dosage has already been established.
Question: Do you apply it on the same area for all three?
Becky: It really depends on the provider’s preference. Some providers prefer to apply it to the labia tissue, that’s more of a mucosal absorption pattern so more gets absorbed more readily. Other practioners can apply it to forearms, behind the arms here, or inner or outer thighs. It really depends on what they are used to but it’s really important to stay consistent because if you’re always alternating the absorption transdermally versus mucosally it can lead to erratic absorption pattern which kind of throws you off. So its best to pick one and to stay consistent and your dose can be titrated based on that. We’ve had someone go as far as to apply testosterone to the bikini area, because once we get to the higher doses of topical testosterone, some women have reported on having unwanted hair growth to the areas where they are applying it, therefore if you apply it to the bikini area, hair grows where hair growth is already occurring, it’s not as cosmetically cumbersome as applying it to other areas.
Question: There was testing of DHEA. How would you supplement that if you were found to be too low?
There are certain natural supplements you can take to promote DHEA but unfortunately it’s a controlled substance in Canada. So I don’t prescribe DHEA but some other practioners may. And then you can supplement it directly as a bioidentical.
Question: So you can get that through your own doctor?
Becky: Yes so some MDs are able to prescribe DHEA and even testosterone. If you are seeing Harmonie in addition to your healthcare practitioner, sometimes I can be useful to kind of facilitate that process as well as communication to them. So if you run into that in this case I can work with the two of you to work with the physicians to prescribe it.
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