As I sat down to write this, I thought about how long it had been since I have added any content. I honestly thought it had only been a couple months but realized it has been over a year! Seriously!? How did that even happen? The honest answer, obviously, is ADHD and perimenopause.
This will be a long one (that's what she said) since this will serve as an update of the goings on of the last 12 months. A lot has happened; a Lot has changed. I can't tell you how many times I have been somewhere and had an idea for this. I have multiple entries in the note's app of my phone, and I am sure many more hand-written entries floating around. The problem is that I always get my ideas when I am not home and not in front of a computer, I can put things on, then by the time I am in a place that I can add an entry, I forgot that I wrote something and/or lost what I wrote, oh yeah and I probably forgot that I wanted to make an entry. I apologize for this.
Enough rambling, here is my update.
Looking back at previous posts, I had posted about peri-specific supplements that I was taking. I ended up stopping taking that supplement as the benefits were not enough to justify spending the money. Afte stopping it I also didn't notice any changes in my symptoms that would indicate that it was, indeed, actually making a difference. I am not going to make any suggestions on taking them to anyone, they didn't work for me, but they may work for someone else, try at your own financial risk, if you so choose.
In February, I was finally able to get an appointment scheduled with the hormone specialist through my job at the time. The appointment was scheduled for March 13th which gave me enough time to get the hormone test kit and do the saliva collection on the appropriate day of my cycle.
I chose to do a saliva test. I have found there to be a lot of controversy around which hormone testing is more accurate. Some doctors back the blood test, saying the saliva test is inaccurate (specifically stated in The Menopause Manifesto) and other sources say the blood test is less accurate than a saliva test. I am not a doctor so I can only speak on my experiences, so, again, the choice is up to you, but I have found no hard evidence that one test is more accurate than the other. I chose the saliva test for a couple reasons. 1. The test was done through a private lab, so the testing was cheaper than going through my doctor's office. The last blood draw at my doctor's office cost me upwards of $600 after insurance. This saliva test was in the range of $250 (without my company discount). 2. I had a discount through my job at the time, so it was even less costly.
The is a catch with going through a private lab and hormone consultant. The consultant isn't a medical doctor either, the person I saw is a pharmacist and therefore cannot prescribe medications. She could only make suggestions based on the results. If you go this route, make sure your doctor is willing to work with the consultant and willing to hear their suggestions. That said, I got my testing kit and collected four vials of saliva on day 21 of my cycle. I mailed the samples back to the lab (the kit comes with a pre-paid shipping label) and waited for my results. It took seven days for the lab to process the samples and get the results back to the consultant, then I had a little under a month to wait for my actual consultant appointment.
The results were not what I expected. I honestly don't really know what I expected, but it was not what I got. My results showed that I was estrogen dominant and had very little progesterone present. The estrogen levels were so high that the consultant thought that maybe I did the test during ovulation (this was not the case, I have tracked my cycle long enough to know). My testosterone and DHEA were in the "normal range" but on the lower side, same with my cortisol (more on this later).
During my appointment, the consultant talked me through the results and what all the numbers meant. it was very informative and I learned a lot. She suggested a topical 40mg/g progesterone cream along with several supplements and supplement brand changes. I do feel like some of her suggestions were biased since her and I both worked for the same compounding pharmacy. She, of course, recommended that pharmacy's brand. I did initially make those changes (again because of the employee discount) but eventually went back to the supplements I had been taking after leaving the company. I did compare ingredients and percentages to make sure they were comparable; I haven't noticed a difference with those changes yet.
There was one big supplement addition that she suggested to help clear the excess estrogen from my body. Something I didn't know was that estrogen dominance can be cause by three thing things; "your estrogen is genuinely elevated, your progesterone is too low (making estrogen relatively dominant even at normal levels), or your body isn’t clearing estrogen efficiently" (scienceinsights.org). The supplement that she suggested was made to help the body metabolize and clear excess estrogens. The supplement contains Indole-3-Carbinol and Diindolylmethane (DIM). "Diindolylmethane (DIM) is a naturally occurring compound derived from the digestion of glucobrassicin, a substance found in cruciferous vegetables like broccoli, cauliflower, and cabbage." (Biologyinsights.com). And "Indole-3-carbinol comes from a substance called glucobrassicin, which is found in cruciferous vegetables such as broccoli, cauliflower, and kale." (webmd.com). The specific brand she suggested also contain vitamin E, but not all similar products do. I am unsure of the benefits of the addition of vitamin E and haven't found anything substantial; to justify its addition.
Along with the supplement suggestions and HRT, she also made several diet changes suggestions, this is where I have struggled the most and have followed the least, so that will be for another post, I guess, once I actually follow those directions.
So, here are all the things that changed after that appointment:
I started a regiment of 40mg/g topical bioidentical progesterone, prescribed directions of "one click cycle day 1 of the
cycle (when a period begins) and continued through Cycle Day 13, then two clicks
applied on Cycle Days 14-25. The cream is not applied on Cycle Days 26-29" (or until start of next cycle). The applicator device is a topi-click device (topi-click.com if you want to see what that looks like). I recently started my fifth cycle using the topical progesterone. I know that it is at least being absorbed and used in some capacity in my body because on my second month using it, I forgot to apply it for several days in the second half of my cycle and started my period several days soon er than I normally would have.
**Disclosure - topical progesterone is another thing that has mixed reviews and some controversy around it, depending on who you talk to. It is hard for me to determine truth vs. paid for results in many studies, so I am only telling you my experiences and thing that I have read. Anything that is not my actual experience, I will include a source for the information so that you can do your own research. For instance, according to Dr. Jen Gunter " Progesterone is not absorbed well through the skin, so it's ineffective even if the product does contain progesterone. If a woman is taking estrogen and relies on a progesterone cream to protect her uterus she could get endometrial cancer." (p 296, the Menopause Manifesto). I am not using an estrogen HRT, so I feel that the topical progesterone is fine for me. If I end up having to use and estrogen HRT in the future, I will likely stop using a topical progesterone, because the increased risk of cancer scares me. At any rate, the choice is yours. do your research and talk to your doctor.
The other suggestions the consult made were; 1. Take a multi-vitamin. I used Hippo-7 Vegan complete. this is not what she recommended but I have used this product for years. Their prices are good and the product is formulated specifically for a vegan diet. The biggest thing here is for me to actually remember to take them. 2. Vitamin D3, 125 mcg. 3. Vitamin B12 4. Omega-V. 5. Magnesium Glycinate. These are honestly things I have had or taken regularly for years but since the increase of peri and ADHD symptoms, it has been more difficult for me to remember to take them regularly.
She also addressed that many of my symptoms are probably associated with sub-optimal thyroid function. I Have not addressed that with my doctor yet, one thing at a time. this was a lot of information and a lot of changes that had to happen relatively close together. Also, my health insurance at the time was an HMO, which means they really only covered preventative medicine and not much that was coded as diagnostic.
In May, I learned that my PCP was leaving the practice, my new adventure is now finding another PCP that will listen to me and is willing to work with providers outside their practice to coordinate care. On top of that change, I changed jobs (in April), so I now have significantly better health insurance. It is a POS (point of service, not piece of shit) plan, so more of my testing and treatments will be covered and I will have to pay less out of pocket. I have an appointment with a potential new PCP in a couple weeks to discuss some medication changes. I should be able to gauge her as a provider during this appointment. hopefully it will be a good match.
This post has become an info dump, so in an effort to let this sink in, I will (try to remember to) make another post with the results of all the changes within the next few days. My results are below so you can see what to expect when/if you decide to do hormone testing. It's a lot of information, which I don't expect anyone to actually read but the charts and graphs of the results are fun to look at. There is a section with some links for who I used for my hormone consult as well as some recommended reading.
A link and a book recommendation
Hormone consultation and saliva testing
Consultations | Hoey Apothecary
*If you schedule a consultation, expect it to be a couple months away. you will need time to get the hormone test kit, complete the saliva collection and send it to the lab, and to get the results back. Hormone testing times are very specific to cycle days
The Menopause Manifesto by Dr. Jen Gunter
This book is available from a lot of places. I have a physical copy, and I listened to it on the Libby app through my library system. Here is the amazon link The Menopause Manifesto: Own Your Health with Facts and Feminism - Kindle edition by Gunter, Jennifer. Professional & Technical Kindle eBooks @ Amazon.com. but I am sure you could find it used somewhere and probably at your local library.
My Results
This is copy and pasted directly from the information the consultant provided me after out appointment. this is a full disclosure of my symptoms, hormone testing results and the observations and recommendations of the consultant. This information is specific to me and should not be used for treatment of any other person.
PHARMACIST'S OBSERVATIONS
These observations are for informational purposes and are neither diagnostic nor prescriptive in nature. Rather, they are intended for educational purposes to guide the conversation between Lyndsey and her medical providers, who are ultimately responsible for all treatment decisions. Lyndsey is a 44 year-old woman experiencing symptoms often associated with imbalances in the
reproductive hormone, thyroid, and adrenal (stress-response) systems. Given her age and symptoms, it is likely Lyndsey is in the perimenopausal phase of hormone production. Her
priorities are to optimize and stabilize hormone levels in order to "feel more normal."
Lyndsey's reported symptoms correlate with lab results:
It's important to recognize that, whether measured in serum, blood-spot, or salivary samples, these measurements provide snapshot results of constantly-fluctuating hormones (especially
during the perimenopausal stage of hormone production, discussed next). This is why it is crucial to also evaluate symptoms, which provide a broader and wholistic view of the impact of hormone levels.
Given her age and symptoms, it is likely Lyndsey is in the perimenopausal stage of hormone production, which is characterized by drastic fluctuations in estrogen production along with a steady decline in progesterone production. The resulting imbalances induce sub-optimal levels within the tissues, where hormones are required to enable optimal function. The imbalances and deficits within the tissues cause many symptoms, some of which are commonly attributed to
perimenopause: hot flashes, night sweats, sleep disturbances, mood swings. For other symptoms, the hormone-component is often overlooked, and symptoms are instead treated as a
stand-alone "primary" diagnosis. Common examples include symptoms caused by hormone deficiencies in the:
Brain (depression/anxiety, foggy thinking, memory lapses, etc.);
Cardiovascular system (elevated blood pressure, poor lipid management);
Muscle and bone tissue (decreased muscle strength, difficulty gaining/maintaining muscle
tone, osteopenia/-porosis);
Skin (thinning or "crepey" skin, incomplete healing);
Eyes (macular degeneration, glaucoma);
Genitourinary tract (frequent bladder/urinary infection, vaginal dryness, sexual
dysfunction, etc.); and
Metabolic function (abdominal weight gain, reduced insulin sensitivity, dysregulated body
temperature).
All these non-uterine tissues still rely upon adequate hormone levels to function as expected; when hormone production begins to change, all these tissues produce symptoms of deficiency and imbalance. Estradiol is significantly higher and progesterone is significantly lower than expected for a
woman Lyndsey's age. This correlates with reported symptoms of estrogen dominance, including (severe)
changes to the menstrual cycle, decreased libido, and irritability; (moderate) anxiety, cravings for sweets,
depression, evening fatigue, mood swings, nervousness, PMS symptoms, and headaches, heavy/irregular periods,
sleep disturbances; and (mild) bloating and breast tenderness. Symptoms of estrogen dominance are influenced by (acutely) high estrogen levels but are even more impacted by (chronically) sub-optimal levels of progesterone that are
insufficient to balance estrogen fluctuations: this is seen quantitatively in the progesterone: estradiol ratio.
Estrogen may have been acutely higher at the time saliva samples were collected due to recent (or attempted) ovulation. Similarly, progesterone levels are more similar to those
expected during the follicular-phase and proximal to ovulation vs mid-way through the luteal phase.
The underlined symptoms, above, are also associated with estrogen deficiency, as are (severe) emotional instability, foggy thinking, and hair loss; (moderate) aches/pains, cravings for salty foods, dry skin/hair, incontinence, night sweats, poor concentration, and vaginal dryness; and (mild) dry eyes, hot flashes, memory lapses, and thinning skin. Since progesterone enhances the effects of estrogens at their receptors, progesterone deficiency exacerbates symptoms of
estrogen deficiency even when estrogen levels are sufficient or even elevated. A compounded cream containing bio-identical progesterone is recommended.
The androgens -- testosterone and DHEAS -- are low-normal/normal. Sub-optimal testosterone correlates with reported symptoms of androgen deficiency, including (severe) decreased libido, decreased stamina, emotional instability, foggy thinking, and loss of motivation; (moderate)
aches/pains, allergies, anxiety, decreased strength, depression, dry skin/hair, evening fatigue, headaches, incontinence and vaginal dryness; and (mild) memory lapses. It is notable symptoms of androgen deficiency can also be caused by sub-optimal thyroid and/or adrenal function (both discussed below); this is especially true when symptoms of low libido are reported
despite adequate testosterone levels.
The roles of estrogens, progesterone, the androgens, and cortisol in bone-health are well understood. Sub-optimal testosterone has been correlated with low bone mass in
peri- and post-menopausal women. The current testosterone level may not indicate replacement therapy, but if levels remain low-normal (or lower), this may be revisited and
bone-density evaluation may be advisable, even before the typical age for screening (65 years old). Optimization of hormone levels would be expected to prevent long-term health
conditions, including osteoporosis and bone fracture.
In women, very low doses of high-quality DHEA supplementation have been found to improve symptoms of androgen deficiency and support testosterone levels. This may be preferable to direct testosterone-replacement therapy since DHEA also supports the adrenal and immune systems; DHEA supplements are often less expensive and more easily adjusted than prescription testosterone therapies. Adrenal function was assessed by measuring salivary cortisol levels 4x throughout a single day. Results are within the middle of the expected range with the exception of the noon level, which is low-normal. Cortisol levels must be interpreted within the context of perceived stress: when stress levels are relatively high (ranked 9/10), cortisol would be expected to be elevated, not
normal/low-normal. This contradiction indicates the adrenal system is over-working but under producing cortisol in response to chronic physical, mental, and/or emotional stressors. Over time, this contributes to symptoms like fatigue (throughout the day but especially in the morning), allergy-type responses and sensitivities, immune suppression, cold body temperature, and cravings. Supporting a healthy stress-response by the adrenal system is best achieved with stress
management lifestyle adjustments. Detailed guidance is included in Lyndsey's Protocol on her profile.
Categorize stressors to identify how to either a) minimize, avoid, delegate, get support, or eliminate stressors that are approachable, and b) prioritize healthy, enjoyable, stress
relieving activities to offset/balance stressors that are harder to impact. Eat to support the adrenal system: eat small, regular meals/snacks throughout the day, emphasizing protein each time. Avoid processed foods, sugars, and caffeine.
Increase hydration. Prioritize good sleep (quantity and quality)
Incorporate gentle exercise, like stretching, walking, yoga, etc.
Utilize nutritional supplements with ingredients targeted at adrenal support (especially high-quality sleep)
Many of Lyndsey's reported symptoms can be associated with sub-optimal thyroid function, including (severe) brittle nails, changes to cycle, decreased libido, decreased stamina, foggy thinking, hair loss, irritability, and loss of motivation; (moderate) allergies, anxiety, cold extremities, cramps,
decreased strength, depression, dry skin/hair, evening fatigue, headaches, mood swings, night sweats, PMS symptoms, poor concentration; and (mild) constipation, morning fatigue, hot flashes, insomnia, low body temperature, memory lapses, puffy eyes/face, sensitivity to cold, and thinning skin. Given this
clinical picture, a more analytical assessment of thyroid labs was discussed:
When insufficient thyroid-hormone levels are detected, the brain produces thyroid stimulating hormone (TSH). In response to the TSH signal, the thyroid gland produces thyroglobulin, which is then converted into levothyroxine (T4). When thyroid-hormone levels are sufficient (or high), TSH production is reduced to avoid excessive production of T4.
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