Women's Bodies, Women's Wisdom (120 page)

H
YPOTHYROID
D
ISEASE

The thyroid—a butterfly-shaped gland located in the area of your neck just below the Adam’s apple—is part of the endocrine system and regulates your metabolic rate, although it exerts a profound effect on the function of nearly every organ in the body. Women with hyperthyroidism make too much thyroid hormone, while the far more common condition is hypothyroidism, which occurs when the body doesn’t make enough thyroid hormone. About 26 percent of women in or near perimenopause have this problem.
¹⁰

There is a wide variety of symptoms of hypothyroidism. The most common include mood disturbances (such as depression and irritability) as well as low energy level, weight gain, mental confusion, and sleep disturbances. Some women have hypothyroidism without any of these symptoms, while others reporting symptoms have normal (or only slightly abnormal) thyroid function tests—in which case subclinical hypothyroidism is often the cause. (By the way, many symptoms of hypothyroidism are the same as those commonly associated with the hormonal fluctuations of perimenopause. So it’s entirely possible to have many of the symptoms of hypothyroidism yet have completely normal thyroid function.)

Low thyroid function can deplete your body of serotonin and other mood-stabilizing neurotransmitters, which is why low thyroid levels are often associated with depression. I suspect these two conditions (hypothyroidism and depression) occur simultaneously. While one does not necessarily cause the other, similar emotional or behavioral patterns—such as learned helplessness or not believing you can have your say—may predispose you to both low thyroid and depression. For this reason, many women do best when their depression and their hypothyroidism are treated simultaneously.

If you suspect you may have thyroid issues, have your TSH (thyroid-stimulating hormone) level checked, along with your free triiodothyronine (T3) and free thyroxine (T4) levels. The TSH should definitely be no higher than 3.0 mIU/L, although many experts, including myself, are more comfortable setting the limit at 2.5. If your levels are higher than that, you have subclinical hypothyroidism. (For information about how to check these levels without a doctor’s visit, see My Med Lab in the Diagnostic Laboratories section of the Resources.)

Iodine supplementation could help (see the section on iodine in chapter 10 for more information). If that doesn’t work, try thyroid replacement. In many cases, supplementing with only T4 (which is the hormone found in Synthroid, one of the most commonly prescribed thyroid medications) is not enough. You also need T3. To get that, you need to take natural thyroid replacement, such as Nature-Throid (
www.nature-throid.com
), Armour thyroid, or a mixture of T3 and T4 made up by a formulary pharmacist.

KINDS OF MENOPAUSE

Natural Menopause and Perimenopause

The average age of menopause is currently about fifty-one, with a range from forty-five to fifty-five. It is possible for some women to experience menopause as early as age thirty-nine. Most women go through menopause at approximately the same age as their mothers, although this is not always the case.

The climacteric is a biochemical process lasting six to thirteen years. During this process, periods may stop for several months and then return; they may increase or decrease in duration and flow. Some women may experience as much as a year-long interruption in periods only to have them resume once again.

When irregularity in the menstrual cycle begins during perimenopause, a woman’s symptoms, such as headaches and irritability, will often be due to increased levels of estrogen relative to progesterone, caused by decreased ovulation. This is known as estrogen dom inance. Women who have experienced a difficult puberty, PMS, or postpartum depression are more likely to experience mood swings and other related symptoms during menopause than those who have gone through earlier hormonal changes comfortably. Women in perimenopause can often be helped dramatically by small amounts of progesterone administered in the luteal phase (second half) of the cycle. The usual dose is 50 to 100 mg of micronized progesterone adminis tered orally one to three times a day from the sixteenth through twenty-seventh days of the cycle.
¹¹
A 2 percent progesterone cream can also be used. (Some women will fare better if progesterone is administered continuously through the cycle.) Progesterone is particularly ben eficial for women with premenstrual migraine headaches.

Many women who begin to skip periods or experience changes in the menstrual flow believe that they are entering menopause. Though the final menstrual period is probably at least five years away, it may be very helpful to order a hormone profile at this time. This establishes your baseline levels of estrogen, progesterone, and testosterone, which may be useful later for prescribing individualized hormone replacement, should you choose that option. (See pages 534–535 for information on hormone testing resources.) Hormone testing is still considered con troversial at this time; more studies are needed.

While menopause is often heralded by the onset of a change in menstrual flow or skipped menstrual periods, some women simply stop having periods and have no symptoms whatsoever. Others experience hot flashes, vaginal dryness, decreased libido, and “fuzzy thinking.” A blood or urine test is often done at this time to “diagnose” menopause. This consists of measuring the levels of the pituitary gonadotropins FSH (follicle-stimulating hormone) and LH (luteinizing hormone), hormones produced by the pituitary gland to stimulate the ovary to produce eggs. During the years of menstruation, FSH and LH peak with ovulation at midcycle each month, producing the emotional and physiological changes discussed in chapter 5. During the climacteric, however, the pituitary gland and the ovaries undergo a gradual change, during which ovulations decrease and FSH and LH levels gradually increase. (The pituitary gland continues to send out LH and FSH because it is not getting the usual hormonal messages from the developing egg to tell it to slow down.) When FSH and LH reach a certain level in the blood, they are said to be in the menopausal range.

I was taught that once a woman’s FSH and LH are in the menopausal range, she was indeed menopausal and would stay that way, but this is not always the case. One forty-year-old woman, for example, who had no periods for six months and had menopausal levels of FSH and LH, later went back to having normal periods for years. A recheck of her hormone levels showed that they also had gone back to premenopausal levels. At this point, I don’t consider FSH and LH levels very reliable diagnostic indicators of menopause, but they can be useful to confirm that a woman is heading in that direction. (It’s also fun to watch this trend reverse sometimes when the ovaries and adrenals get the support they need.)

It’s important for per imenopausal women to know that even though they may be skipping ovulations, they can theoretically still become pregnant up until one year after their last period. For that reason, I recommend that a woman continue to use some form of contraception throughout this time.

Premature Menopause

A small percentage of women—approximately one in a hundred— experience natural premature menopause at age forty or younger. In some cases, this is due to an autoimmune disorder related to poor diet or chronic stress and resulting in the production of antiovarian antibodies.
¹²
Women who undergo premature menopause from any cause and loss of ovarian estrogen supply have been shown to have increased susceptibility to dementia.
¹³
It is important for a woman with this history to pay special attention to those things that promote healthy brain function. (See discussion of Alzheimer’s later in this chapter.)

Artificial Menopause

Currently, one in every four American women will enter menopause as a result of surgery. Hysterectomy with ovarian removal or bilateral salpingooophorectomy (removal of both tubes and ovaries) results in instant menopause in the premenopausal woman, which is very different from natural physiological menopause and should be treated differently. Removal of the ovaries is associated with a dramatic decrease in the production of testosterone and other androgens. Surgical menopause can also result in a major decrease in estrogen production. Symptoms can be severe and debilitating without proper readjustment of hormonal levels.
¹⁴

A startling 2009 study also shows that premature menopause, whether natural or because of bilateral oophorectomy, nearly doubles the risk of lung cancer—even if you don’t smoke.
¹⁵
Bilateral oophorectomy also increases your chances of coronary heart disease, stroke, and dying from any form of cancer—although it decreases the risk for breast and of course ovarian cancer.
¹⁶
In addition to the risks cited above, the Mayo Clinic Cohort Study of Oophorectomy and Aging found that women who’d had their ovaries removed before menopause had a fivefold increase in risk of mortality from neurological or mental diseases. Data from this same study also indicated that women with bilateral oophorectomy before age forty-five experience an almost twofold increase in mortality from cardiovascular disease; an increased risk for Parkinsonism, cognitive impairment and dementia; and an increase in depressive and anxiety symptoms later in life.
¹⁷
Taking hormone therapy after ovarian removal certainly helps to prevent these outcomes, but studies also show that long-term compliance is not sufficient to make up for the impact of hormone deficiency following the surgery.
¹⁸

Because normal menopause occurs at around fifty-one years of age, hormone replacement should continue at least until this age but can be continued longer depending on individ ual circumstances.

Hysterectomy without removal of the ovaries may still result in accelerated menopause, as mentioned earlier. In some cases, the ovaries tem porarily decrease hormone production, causing menopausal symptoms that disappear when normal ovarian function resumes. It has also been shown that progesterone levels decrease significantly for at least six months following tubal ligation.
¹⁹
(This is probably not the case with the new Essure method—See
chapter 11
, “Our Fertility.”)

Women who have had chemotherapy for any cancer or who have undergone radiation to the pelvis are also apt to undergo premature menopause. For women facing chemotherapy or radiation, it has been my experience that undergoing a course of acupuncture and Chinese herbs at the same time as the chemo or radiation often can prevent premature menopause and also will alleviate many side effects of the treatment. Adding together the women who undergo natural premature menopause and those who undergo artificial menopause through drugs or surgery means that ap proximately one in twelve women today faces menopause before the age of forty.

THE HORMONE THERAPY QUESTION

A Brief History of Conventional Hormone Replacement

Premarin, the first and most well-known form of estrogen therapy, was introduced in 1949. It consists of a collection of more than twenty different conjugated equine estrogens mostly made from the urine of pregnant horses.

(Premarin is an acronym derived from the phrase “pregnant mares’ urine.” If you doubt this, just put a drop of water on a tablet of Premarin and smell it.)

For historical and economic reasons, Premarin (taken by itself, along with a synthetic progestin called Provera, or in a pill called Prempro, which is a combination of Premarin and Provera) has been the gold standard against which all other menopausal hormone treatments are measured. In the late 1980s through the 1990s, millions of women were put on this drug because studies strongly suggested that it decreased the risk of heart attack and stroke (the leading cause of premature death in women), increased bone density, and decreased the risk of dementia. Although it was associated with a slightly increased risk of breast and endometrial cancer, these risks paled in comparison to the possibility of saving lives lost to heart disease.

In the early 1990s, the Wyeth-Ayerst company, makers of Premarin, helped fund the huge Women’s Health Initiative (WHI), which was designed to prove that Prempro would save lives by decreasing heart attacks et cetera. The study was stopped in July 2002 when researchers found that Prempro actually increased the risk of heart attack and stroke as well as breast cancer, Alzheimer’s, and dementia. Overall, it was felt that the risks outweighed the benefits.

The news about Prempro panicked thousands of women, many of whom stopped taking hormones cold turkey and ended up with insomnia, intolerable hot flashes, and a greatly decreased quality of life.

Then in early 2006, a reanalysis of the data from both the WHI and the Nurses’ Health Study found that women who started hormone therapy within ten years after menopause did indeed have an 11 to 30 percent decreased risk of heart disease compared with those who didn’t use any hormones. But those who started it ten years or more after menopause had an increased risk for stroke, heart attack, and so on.
²⁰
This added a new wrinkle to the entire HT discussion.

Another closer look at the evidence has shown that hormones that match those found in the female body may not raise the risk of breast cancer the way synthetic hormones do. One of the largest studies to date comparing the risk of breast cancer with the use of natural bioidentical hormones to the risk when using synthetic hormone therapy followed more than 80,000 postmenopausal women in France for more than eight years. Data showed that the natural hormones (including progesterone) had significantly less associated risk of breast cancer.
²¹