Polycystic Ovarian Syndrome

March 30, 2018

Polycystic ovarian syndrome (PCOS) is a common health problem caused by an imbalance of reproductive hormones. The hormonal imbalance creates problems in the ovaries. The ovaries make egg that are released each month. With PCOS, eggs may not develop or may not be released during ovulation. Five to ten percent of reproductive aged women have PCOS.  Most often, women find out they have PCOS in their 20’s and 30’s when they have problems getting pregnant – but PCOS can happen at any age after puberty.  Women of all races and ethnicities are at risk for PCOS.  Your risk for PCOS may be higher if you are obese or if you have a mother, sister, or aunt with PCOS.

Conditions Associated With PCOS

  • Diabetes. More than half of women with PCOS will have diabetes or pre-diabetes  before age 40.
  • High blood pressure. Women with PCOS are at greater risk of having high blood pressure compared to women without PCOS. High blood pressure is a leading cause of heart disease and stroke.
  • Unhealthy cholesterol. Women with PCOS often have higher levels of LDL (bad) cholesterol and low levels of HDL (good) cholesterol. High cholesterol raises your risk for heart disease and stroke.
  • Sleep apnea – momentary and repeated interuptions in breathing that disrupt sleep. Many women with PCOS are overweight or obese, which can cause sleep apnea. Sleep apnea raises your risk for heart disease and diabetes.
  • Depression and anxiety. Depression and anxiety are common among women with PCOS.
  • Endometrial cancer. Problems with ovulation, obesity, insulin resistance, and diabetes (all common in women with PCOS) increase the risk of developing cancer of the endometrium (lining of the uterus).

Symptoms of PCOS?

PCOS has many signs and symptoms, some of which may not seem to be related:

  • Menstrual irregularities:
    • No menstrual periods—called amenorrhea
    • Frequently missed periods—called oligomenorrhea
    • Heavy periods
    • Bleeding but no ovulation—called anovulatory periods
  • Infertility
  • Pelvic pain
  • Excess hair growth on the face, chest, stomach, or thighs—called hirsutism
  • Severe, late-onset, or persistent acne that does not respond well to usual treatments
  • Obesity, weight gain, or trouble losing weight, especially around the waist
  • Oily skin
  • Patches of thickened, dark, velvety skin—a condition called acanthosis nigricans

Because many women don’t consider problems such as oily skin, extra hair growth, or acne to be symptoms of a serious health condition, they may not mention these things to their doctor. As a result, many women aren’t diagnosed with PCOS until they have trouble getting pregnant or if they have abnormal periods or missed periods.

Although PCOS is a leading cause of infertility, many women with PCOS can and do get pregnant. Pregnant women who have PCOS, however, are at higher risk for certain problems, such as miscarriage.

Causes of PCOS?

The exact cause of PCOS is unknown. Most experts think that several factors, including genetics, play a role:

  • High levels of androgens. Androgens are sometimes called ‘male hormones’, although all women make small amounts of androgens. Androgens control the development of male traits, such as male-pattern baldness. Women with PCOS have more androgens than normal. Estrogens are also called ‘female hormones’. Higher than normal androgen levels in women can prevent the ovaries from releasing eggs (ovulation) and can cause extra hair growth and acne, two signs of PCOS.
  • High levels of insulin. Insulin is a hormone that controls how the food you eat is changed into energy. Insulin resistance is when the body’s cells do not respond normally to insulin. As a result, your insulin blood levels become higher than normal. Many women with PCOS have insulin resistance, especially those who are overweight or obese, have unhealthy eating habits, do not get enough physical activity, and have a family history of diabetes (usually type 2 diabetes). Over time, insulin resistance can lead to type 2 diabetes.

Polycystic ovarian syndrome (PCOS) is the leading cause of infertility in reproductive age women. Lack of ovulation is generally assumed to be the cause after other anatomic, hormonal, and male factor causes are ruled out.

Diagnosing PCOS

Because there is currently no universal definition of PCOS, different expert groups use different criteria to diagnose the condition. All the groups look for the following three features:

  1. Menstrual irregularities, such as light periods or skipped periods, that result from long-term absence of ovulation (the process that releases a mature egg from the ovary).
  2. High levels of androgens that do not result from other causes or conditions, or signs of high androgens, such as excess body or facial hair.
  3. Multiple cysts of a specific size on one or both of the ovaries as detected by ultrasound.

Having one or more of these features could lead to a diagnosis of PCOS. If your medical history suggests that you might have PCOS, we will rule out other conditions that may cause similar symptoms.

Some of these conditions include:
  • Excess hormone production by the adrenal glands, called adrenal hyperplasia
  • Problems with the function of the thyroid gland
  • Excess production of the hormone prolactin by the pituitary gland, called hyperprolactinemia

After ruling out other conditions and before making a diagnosis of PCOS, we will also:

  • Take a full personal and family history because PCOS tends to run in families.
  • Conduct a complete physical exam. We will look for extra hair growth, acne, and other signs of high levels of the hormone androgen. We will take your blood pressure, measure your waist, and calculate your body mass index, a measure of your body fat based on your height and weight.
  • Take blood samples. Blood tests will include levels of androgens, cholesterol, and sugar in your blood.
  • Do a pelvic exam or ultrasound to check your ovaries.

Treatment For PCOS

  • Losing weight. Changing your lifestyle like having fewer sugary drinks and hog-calorie desserts to help control your weight, exercising each day and avoiding smoking.  These healthy eating habits and regular physical activity can help relieve PCOS-related symptoms. Losing weight may help to lower your blood glucose levels, improve the way your body uses insulin, and help your hormones reach normal levels. Even a 10% loss in body weight (for example, a 150-pound woman losing 15 pounds) can help make your menstrual cycle more regular and improve your chances of getting pregnant.  Consider counseling with a registered dietitian to help you choose healthy foods and lose weight if you are overweight or obese.
  • Removing unwanted facial/body hair. You can try facial hair removal creams, laser hair removal, waxing, or electrolysis to remove excess hair. You can find hair removal creams and products at drugstores. Procedures like laser hair removal or electrolysis must be done by a doctor and may not be covered by health insurance.
  • Slowing hair growth. A prescription skin treatment (eflornithine HCl cream) can help slow down the growth rate of new hair in unwanted places.
  • Medications.  Medicines that contain estrogen and progesterone such as birth control pills, a vaginal ring, or a skin patch; medicines to help your body use insulin better, such as Metformin (for pre-diabetes or diabetes); and/or acne medicine.

Coping With PCOS

Seeing a doctor who knows about PCOS is the first step. Choose a doctor who specializes in hormone problems or a doctor who specializes in women’s health. Remember that the sooner you get help for your PCOS, the sooner you could lower your risk for related health problems such as diabetes. Your doctor can help you find ways to feel better about your appearance. For example, you can ask your doctor about the best way to remove unwanted facial hair. If you feel worried or depressed, ask your parents or your doctor where to go for counseling. You can also go to a support group to talk with others who have PCOS.

Abnormal Uterine Bleeding in Adolescents

March 11, 2018

A female’s first menstrual cycle is an important event during adolescence. For most girls, it marks completion of puberty and the onset of reproductive capability. Menstrual problems are common during adolescence and can last 2-5 years after their first period.

 

Menstrual irregularities are a common gynecologic problem, especially in adolescents. Abnormal uterine bleeding is any form of bleeding that is irregular in amount, duration, or frequency. It can be characterized by excessive uterine bleeding that occurs regularly, by heavy bleeding at irregular times, or a combination of both. It can also be intermittent bleeding or sparse cyclical bleeding. Often the bleeding is not serious, but it can be annoying and disrupt life. The term ‘dysfunctional uterine bleeding’ is a subset of abnormal uterine bleeding and is defined as excessive, prolonged, or unpatterned bleeding from the uterus without an organic cause,  The term is frequently used synonymously with anovulatory bleeding (irregular bleeding resulting from the absence of ovulation). In adolescents, up to 95% of abnormal uterine bleeding is ‘dysfunctional uterine bleeding’. However, because ‘dysfunctional uterine bleeding’ is a diagnosis of exclusion, other potential causes of abnormal bleeding must be considered and excluded.

 

You may have abnormal uterine bleeding if you have one or more of the following symptoms:

  • You get your period more often than every 21 days or farther apart than 35 days. A normal adult menstrual cycle is 21 to 35 days long. A normal teen cycle is 21 to 45 days.
  • Your period lasts longer than 7 days (normally 4 to 6 days).
  • Your bleeding is heavier than normal.

(If you are passing blood clots and soaking through your usual pads or tampons each hour for 2 or more hours, your bleeding is considered severe and you should call your doctor.)

 

The normal menstrual cycle usually consists of an average interval of 28 days (± 6 days) with a average duration of 4 days (±2-3 days). Normal blood loss is approximately 30 mL per cycle, with an upper limit of 60-80 mL. The average age of a first period in the United States is 12.8 years, with the range from 9-18 years.

 

The normal menstrual cycle is divided into three phases. In the first phase, a group of eggs are stimulated to grow in the ovaries, from which one dominant follicle (egg) is selected. The dominant follicle produces increasing amounts of estrogen. Estrogen stimulates the uterine lining to proliferate and develop progesterone receptors. When estrogen reaches a certain sustained level, a surge of hormone is released from the pituitary, causing the dominant follicle to ovulate:  the second stage of the menstrual cycle. Progesterone halts uterine lining growth and stabilizes the lining, which is the third phase. In the absence of conception, there is a rapid decline in estrogen and progesterone. The endometrium collapses and sheds as menstruation occurs, approximately 14 days after ovulation. Menstrual flow stops as a result of the combined effect of prolonged vasoconstriction, tissue collapse, vascular stasis, and estrogen-induced “healing”.

 

In summary, with normal ovulation, there is regular cyclical production of estradiol, initiating ovarian follicular growth and uterine proliferation. Following ovulation, the production of progesterone stabilizes the uterine lining. Without ovulation and subsequent progesterone production, a state of “unopposed” continuous estrogen secretion occurs. This stimulates abnormal uterine lining growth without adequate structural support. The consequence is spontaneous sloughing of the endometrium and unpredictable bleeding. In anovulatory cycles, the estrogen levels can either be high or low. With chronic high levels, there is intermittent heavy bleeding, and chronically low levels may result in prolonged light bleeding.[5]

 

Abnormal uterine bleeding in adolescents is defined as excessive bleeding occurring between menarche (first period) and 19 years of age. During the first 12–18 months after the onset of menstruation, immaturity of the hypothalamic-pituitary axis.  This means that the communication system between the brain, the ovaries and the uterus is immature and not yet communicating properly.  It is believed that this ‘miscommunication’ results in an inconsistent ‘positive feedback’ response, wherein sustained elevations of estrogen occur – which causes progesterone disregulation and prevents ovulation.  The lack of ovulation (called anovulation) is the most common cause of abnormal uterine bleeding during early adolescence. By the third year after menarche, about 75% of menstrual cycles are 21–34 days long, regardless of age at menarche.  The maturation of the hypothalamic-pituitary-ovarian axis occurs slowly in the first 18-24 months after menarche in the adolescent female. Anovulatory cycles may last up to 5 years.

 

Besides physiologic causes, anovulation can also have organic pathologic causes. These include hyperandrogenic states (e.g., polycystic ovary syndrome [PCOS]), hypothalamic dysfunction (e.g., anorexia nervosa and excessive exercise), endocrinopathies, and premature ovarian failure. Occasionally, the bleeding is caused by an anatomic cause (e.g., polyps or fibroids), although this is very rare in adolescents.

 

Girls and adolescents with more than 45 days between menstrual cycles, less than 21 days between menses, bleeding lasting longer than 7 days, having a single episode of 3 months between bleeding, or changing sanitary products more often than every 1-2 hours should undergo an evaluation. Regardless of reported sexual history, it is imperative to rule out pregnancy, sexual trauma, and sexually transmitted infections. Patients should be evaluated for endocrine disorders (such as thyroid disease), stress and eating disorders, and polycystic ovary syndrome (PCOS).

 

Differential Diagnosis of Abnormal Uterine Bleeding in Adolescents

 

Although the majority of adolescents with abnormal bleeding have anovulation due to age, dysfunctional vaginal bleeding is a diagnosis of exclusion.

 

Coagulation Disorder

Blood loss in the normal menstrual cycle is self-limited due to the action of platelets and fibrin. Individuals with thrombocytopenia or coagulation deficiency may have excessive menstrual bleeding.The most common coagulation disorders include thrombocytopenia, due to idiopathic thrombocytopenic purpura (ITP), von Willebrand’s disease, which affects up to 1% of the population, and platelet function defects. Of the adolescents presenting with severe menorrhagia or hemoglobin less than 10 g/dL, 25% were found to have a coagulation disorder. In those presenting with menorrhagia at the first menses, 50% were found to have a coagulation disorder.

 

Pregnancy Complications

The possibility of pregnancy should be considered in any adolescent with abnormal bleeding, and a pregnancy test is mandatory even if the client denies sexual intercourse. Any bleeding in early pregnancy should lead to suspicion of miscarriage or ectopic pregnancy.

 

Reproductive Tract Pathology

Any trauma, infection, or neoplasm can cause abnormal uterine bleeding. Infections, such as chlamydia or pelvic inflammatory disease (PID), may present with abnormal bleeding. Vaginal trauma or a foreign body may cause bleeding that might be assumed by the adolescent to be uterine in origin. Women with a foreign body in the vagina generally present with a bloody, odorous discharge. Cervical polyps, cervical carcinoma, and cervical inflammation can cause bleeding. Cervical cancer is fairly rare in adolescents but may be encountered in those who had sexual experiences at a very early age (including those with a history of sexual abuse). Ovarian estrogen-producing tumors need to be excluded in the adolescent with very heavy persistent bleeding. Finally, although rare, uterine pathology, such as polyps and fibroids, may lead to abnormal bleeding.

 

Endocrinopathies

The most common endocrine disorder to cause abnormal bleeding is thyroid disease. In general, hypothyroidism presents with hypermenorrhea, and hyperthyroidism presents with hypomenorrhea. Hyperprolactinemia caused by a prolactinoma or certain medications, such as neuroleptics, can also cause anovulation and abnormal uterine bleeding. PCOS is underdiagnosed in adolescents and should be suspected in obese teens with hirsutism, acne, and continued irregular cycles. There is some recent evidence that PCOS is more common in women with epilepsy. Other diseases to consider are congenital adrenal hyperplasia, Cushing syndrome, hepatic dysfunction, and adrenal insufficiency.

 

Others Causes

Other causes of abnormal uterine bleeding in adolescents are eating disorders, stress, excessive exercise, and weight loss. In addition, common medications, which increase the cytochrome P450 enzymatic processes in the liver, may induce the more rapid metabolism of steroid hormones, thereby decreasing their bioavailability and result in abnormal uterine bleeding that is secondary to a relative insufficiency of estrogen or progesterone (e.g., anti-seizure medications).

 

Evaluation and Management of Abnormal Uterine Bleeding in Adolescents

 

Laboratory testing should initially include an assessment of urine or serum β-hCG, a complete blood count with platelets, and TSH. Other testing should be performed based on the history and physical examination, and may include androgen levels (free or total testosterone) and prolactin. Adolescents with abnormal uterine bleeding can have a concomitant bleeding disorder. Von Willebrand disease is the most common bleeding disorder in women. Approximately one quarter of adolescents who require hospitalization or blood transfusion may have a coagulopathy. Anemia on initial evaluation should trigger further testing for a bleeding disorder including PT, PTT, and a Von Willebrand panel.

 

The goal of therapy is to decrease excessive bleeding, prevent its recurrence, and improve quality of life. A trial of combined oral contraceptives can serve as a diagnostic and therapeutic approach to the workup of abnormal bleeding in adolescents. In addition to regulating menstrual flow and providing contraception, combined oral contraceptives can provide relief of associated dysmenorrhea, acne/hirsutism, and premenstrual syndrome, prevent menstrual migraine, and potentially reduce pelvic pain associated with endometriosis. In patients who cannot use estrogen due to other existing medical conditions, Depo-Provera or a progesterone-containing IUD can also reliably provide relief for abnormal bleeding, with a substantial proportion of users achieving amenorrhea within 6 months. Rarely, incessant bleeding can become a medical emergency that requires hospitalization and more intense evaluation including a pelvic exam, ultrasound, and treatment including intravenous estrogen, fibrinolytics, and in rare cases, surgical intervention.

 

Consider coming in for evaluation if you have had irregular vaginal bleeding for three or more menstrual cycles, or if your symptoms are affecting your daily life. There are many things we can do to treat abnormal uterine bleeding. Some are meant to return the menstrual cycle to normal. Others are used to reduce bleeding or to stop monthly periods. Each treatment works for some women but not others. We will discuss all the options and find a treatment that is right for you.

 

Differential Diagnosis of Abnormal Uterine Bleeding in Adolescents

  • Immaturity of the HPO axis
  • Coagulation disorders

  Idiopathic thrombocytopenic purpura (ITP)

  Von Willebrand’s disease

  Platelet function defect

  • Pregnancy complications

  Abortion (complete, incomplete, missed)

  Ectopic pregnancy

  Trophoblastic disease

  • Genital tract infection

  Vaginitis

  Cervicitis

  Vaginal foreign body

  Salpingo-oophoritis

  Endometritis

  • Endocrinopathies

  Polycystic ovary disease

  Hyperprolactinemia

  Thyroid or adrenal abnormalities

  Premature ovarian failure

  Hypothalamic dysfunction

  Anorexia, stress, excessive exercise

  • Benign lesions of the genital tract

  Cervical polyp

  Vaginal adenosis

  Endometriosis

  Uterine fibroid

  • Iatrogenic: drugs or hormones
  • Trauma
  • Malignant lesions of the genital tract

Vaginal carcinoma

 Cervical carcinoma

  Uterine carcinoma

  Ovarian tumors

Food Intolerance & Food Sensitivity Testing

February 28, 2018

The terms ‘food intolerance’ and ‘food allergy’ are often confused – although the two are completely different.

 

A true food allergy is rare: only about 2% of adults are affected by a food allergy.  With a food allergy the body’s immune system mistakes a food for a ‘foreign invader’ which results in a rapid allergic reaction often within minutes (and generally within a maximum of two hours).

 

Food intolerances are much more common than food allergies. Researchers estimate that at least 60% of the U.S. population suffers from unsuspected food reactions that can cause or complicate health problems. When foods and drinks are digested the proteins within them are broken down into smaller fragments for easy absorption.  Sometimes the body reacts to the fragments by attacking them using antibodies called immunoglobulins. The symptoms can greatly impact a person’s quality of life, but symptoms are not life threatening.  Symptoms of food intolerance can take up to 72 hours to appear after eating the trigger food.  On average people who suffer from food intolerances usually have between 4 and 8 trigger foods. Many people suffer for years, having formed a coping mechanism to deal with the symptoms but being unable to enjoy a normal work and home life.  Many people don’t realize that there are easy steps to take that could resolve their condition. Studies show that those who eliminate trigger foods based on food-specific immunoglobulin tests have: reductions in weight, body mass index, waist and hip circumference and improvements in all indicators of quality of life that were measured. The quality of life indicators included physical and emotional wellbeing, mental health, social life, pain levels and vitality.

 

Food Intolerance verses Food Allergy

 

Food Intolerance Food Allergy
Reactions up to 72 hours after eating Immediate reactions (2 hours or less)
Multiple foods can be involved Rarely more than 1-2 foods
Any organ system can be affected Primary skin, airways and digestive system
Very common Trace amounts of foods can cause reactions
Difficult to self-diagnose Caused by raised IgE antibody
Symptoms can clear after avoidance (3-6 months) Lifelong

 

Symptoms of food intolerance:

 

  • Abdominal Cramps/Pain
  • Muscle and Joint Aches
  • Acne
  • Bloating
  • Constipation and/or diarrhea
  • Fatigue
  • Dizziness
  • Eczema/Rashes
  • Itching
  • Fluid Retention
  • Headaches
  • Hyperactivity
  • Migraine
  • Nausea
  • Rhinitis/Sinusitis
  • Anxiety/Tension
  • Weight loss/Weight Gain
  • Wheezing

 

In considering food sensitivities, the role of ‘leaky gut’ must be discussed. Leaky gut, or ‘intestinal permeability’, is a condition in which the lining of the small intestine becomes damaged, causing undigested food particles, toxic waste products and bacteria to ‘leak’ through the intestines and flood the bloodstream. The foreign substances entering the bloodstream cause inflammation throughout the body, stirring up trouble everywhere. A vicious cycle of worsening inflammation and worsening leaky gut occurs, which leads to a variety of health issues. This cycle of inflammation triggers an antibody immune response and a whole cascade of inflammatory signals travel to anywhere and everywhere in the body.

 

Inflammation and leaky gut are tied to a variety of conditions, from autoimmunity – like Hashimoto’s, lupus, rheumatoid arthritis, and psoriasis – to depression, anxiety, migraines, irritable bowel, eczema, chronic fatigue, fibromyalgia, PMS, PCOS, infertility, cervical dysplasia and more.  In many cases, leaky gut is caused by your diet. Leaky gut can also be caused by medications including antibiotics, steroids or over-the-counter pain relievers like aspirin and acetaminophen, which can irritate the intestinal lining and damage protective mucus layers.

 

The best way to resolve health issues is to heal leaky gut – the best way to heal leaky gut is to avoid foods that cause it.
To do that, we need to start by doing a food sensitivity panel, so we can determine where we are starting and which foods to avoid.

Transgender Health Issues

February 11, 2018

“Transgender” is an umbrella term used to capture the spectrum of gender identity and gender-expression diversity. Gender identity is the internal sense of being male, female, neither or both. Gender expression — often an extension of gender identity — involves the expression of a person’s gender identity through social roles, appearance and behaviors.

 

Transgender persons are at increased risk for certain types of chronic diseases, cancers, and mental health problems.

If you’re a transgender person, don’t avoid seeing a doctor out of fear of a negative encounter. Instead, look for a doctor who is empathetic and respectful of your specific needs. By doing so, your doctor can help identify ways to reduce your risk of health concerns, as well as identify medical conditions and refer you to specialists when necessary.

 

Health Issues to Consider:

#1: Access to Health Care

Transgender persons may avoid medical care for fear of being rejected. Many have been turned away by healthcare providers or had other negative experiences. Not all providers know how to deal with specialized transgender issues. Often, transgender health services are not covered by insurance. For these reasons, transgender persons may not be able to access the care they need.

Transgender persons should find a personal doctor who understands transgender health issues.

#2: Hormones

Hormone therapy is often used to make a transgender person more masculine or feminine. But the use of hormones has risks. Testosterone can damage the liver, especially if taken in high doses or by mouth. Estrogen can increase blood pressure, blood glucose (sugar), and blood clotting. Anti-androgens, such as spironolactone, can lower blood pressure, disturb electrolytes, and dehydrate the body. Hormone use should always be supervised by a doctor.

Transgender persons wishing to use hormones should only do so under the supervision of a doctor who can prescribe an appropriate dose and monitor its effects.

#3: Cancer

Trans men who still have a uterus, ovaries, or breasts are at risk for cancer in these organs. Trans women are at risk for prostate cancer, though this risk is low. Cancers related to use of hormones are rare, but counseling is still needed.

Transgender persons should be screened for cancers of the reproductive organs.

#4: Injectable Silicone

Many transgender persons use silicone injections to enhance their appearance. The injection of silicon by non-medical persons is a dangerous practice that can lead to serious health problems. Silicone, when administered by someone who is not a doctor, can move through the body and disfigure it. Also, silicone injected outside of a healthcare setting is typically not medical grade, may be contaminated, and is often injected using shared needles, which can transmit hepatitis.

Transgender persons need to be counseled about the risks of injecting silicone.

#5: Substance Use

Transgender persons use substances at higher rates compared to others. Substances used include amphetamines including crystal meth, marijuana, ecstasy, and cocaine. Use of these drugs has been linked to higher rates of HIV transmission through impaired decision making during sex. Although the long-term effects of these substances are unknown, evidence suggests that their prolonged use is likely to have serious negative health consequences.

Transgender persons should be screened for substance use and get appropriate education and risk-based counseling.

#6: Depression and Anxiety

Transgender persons have higher rates of depression and anxiety compared to others. These problems are often worse for those who do not have adequate social support or who are unable to express their gender identity. As a result, teenagers and young adults have an increased risk of suicide. However, culturally sensitive mental health services can help prevent and treat these problems.

Transgender persons should be screened for signs and symptoms of depression and anxiety and should seek appropriate mental health services provided as needed.

#7: Sexually Transmitted Diseases (STDs)

Transgender persons are at risk for sexually transmitted diseases. These include infections for which there are effective cures (gonorrhea, chlamydia, syphilis, pubic lice or crabs), as well as those for which treatments are more limited (HIV, hepatitis A, B, or C, human papilloma virus). Safe sex, including the use of barriers, is key to preventing STDs.

Transgender persons who are sexually active should be routinely screened for sexually transmitted diseases.

#8: Alcohol

Studies have shown that transgender persons have higher rates of alcohol abuse and dependence. Although limited alcohol use, such as one drink a day, may not be unhealthy, any use can be a problem for a transgender person with an alcohol related disorder. Alcohol abuse is a common problem among transgender persons and can increase the risk for being injured or becoming the victim of a crime.

All transgender persons should be screened for alcohol dependence and abuse, and alcohol use should be limited.

#9: Tobacco

Transgender persons smoke and use tobacco products at much higher rates than others. This can lead to a number of serious health problems, including heart disease, high blood pressure, lung disease, and lung cancer.

Transgender persons should be screened for tobacco use and offered tobacco cessation programs.

#10: Heart Disease

Transgender persons are often at higher risk for heart disease because of hormone use, smoking, and obesity. All transgender persons should have their blood pressure and cholesterol checked as generally recommended. Also, transgender persons should learn about the signs and symptoms of heart disease and stroke.

Transgender persons should have their blood pressure checked at least once a year and their cholesterol screened at least every five years.

 

Experts recommend that you take steps to protect your health based on your anatomy, regardless of your gender identity or expression. This might include:

 

  • Age-appropriate screening for cervical and breast cancers
  • Age-appropriate screening for prostate cancer
  • Age-appropriate screening for colon cancer
  • Age-appropriate vaccinations
  • Screening for mental health conditions
  • Screening for substance abuse
  • Screening for HIV
  • Screening for hepatitis

 

Additional issues might need to be considered if you have had feminizing or masculinizing hormone therapy or surgery.

Your health is important — regardless of your gender identity or gender expression. If you’re due for a screening or you have health concerns, don’t put off seeing a doctor. Early diagnosis and treatment help promote long-term health.

 

More About Transgender Hormone Health:

Hormone replacement is also often part of the transition process . Many transgender persons experience dysphoria, or psychological distress experienced in relation to the discrepancy between the sex they were assigned at birth and their gender identity. There is a high prevalence of depression, anxiety and suicidal thoughts.

Hormones help align physical characteristics with gender identity. Many individuals find hormone therapy extremely beneficial because it enables them to maintain a physical appearance that more closely matches their gender identity, thus increasing their comfort with their physical appearance and decreasing dysphoria and distress. Research shows that hormone therapy significantly reduces depression, anxiety, and sensitivity, along with feelings of hostility. Additionally, hormone therapy often has the effect of increasing self-esteem and feelings of attractiveness. During gender transition, people who receive hormones typically experience a second puberty, during which secondary sex characteristics change to align with gender identity.  These hormones help to produce characteristics that align with their identity or eliminate characteristics causing distress/dysphoria.

It is essential to remember that it is not possible to choose which characteristics result from hormone therapy, and hormone therapy will affect people in different ways. Because of this, the initiation of hormone therapy can also increase feelings of dysphoria and distress.  Many transgender patients don’t quite know what to expect.  Often the changes experienced as a result of hormones therapy are not the results that patients anticipated or have side effects that were not considered.  For the reason, it is essential to counsel these patients thoroughly before initiating a regimen.

What You Need To Know About Thyroid Disease

January 10, 2018

The thyroid gland is a small, gland located in the base of the neck. It plays a huge role in our body, influencing the function of many of the body’s most important organs, including the heart, brain, liver, kidneys and skin.

I use this example with my patients to explain the role of the thyroid gland:

Think of your thyroid as a car engine that controls how your body functions. An engine produces the necessary energy for a car to operate in a certain manner. In the same way, the thyroid gland produces enough thyroid hormone to prompt your body to perform functions in a certain manner. Just as a car cannot produce energy without gas, your thyroid needs fuel to produce thyroid hormone. Your thyroid’s fuel is iodine. The thyroid extracts iodine from the bloodstream and uses it to make two thyroid hormones: T4 (contains four iodine atoms) and T3 (contains three iodine atoms). T3 is made from T4 when one iodine is removed, a conversion that occurs mostly outside the thyroid in organs and tissues where T3 is the primary thyroid hormone that is used. When T4 is produced, it is stored within the thyroid as a reserve for later use. A small amount of T3 is also produced and stored in the thyroid. When your body needs thyroid hormone, it is secreted into your bloodstream in quantities set to meet the needs of your cells. Your car engine produces energy, but you tell it how fast to go by stepping on the accelerator. The thyroid gets its instruction from the pituitary gland, which is located in your brain. These instructions come in the form of thyroid-stimulating hormone (TSH). TSH levels rise or fall depending on whether enough thyroid hormone is produced to meet your body’s needs. Higher levels of TSH prompt the thyroid to produce more thyroid hormone. Conversely, low TSH levels signal the thyroid to slow down production.

When Things Go Wrong

Normally, the thyroid produces just the right amount of hormone to keep your body running smoothly. TSH levels remain fairly constant. But even the best systems are subject to interference. When outside influences such as disease, damage to the thyroid or certain medicines inhibit proper communication, your thyroid might not produce enough hormone. This slows down all of your body’s functions – known as hypothyroidism or underactive thyroid. I like to use the term ‘suboptimal’ thyroid function.  Your thyroid could also produce too much hormone which would send your systems into overdrive, a condition called hyperthyroidism or overactive thyroid.  I like to use the term overactive thyroid.  When considering thyroid disease, doctors ask two main questions: First, is the thyroid gland inappropriately producing an abnormal amount of thyroid hormone? And second, is there a structural change in the thyroid, such as a lump (a nodule) or an enlargement (a goiter)? Though one of these characteristics does not necessarily imply that the other is present nor do they diagnose hypo- or hyperthyroidism.

 

Out of Gas

Sometimes the thyroid can’t meet your body’s demands for thyroid hormone, even though TSH levels increase. As your body slows down, you may feel cold, tired and even depressed. You may gain weight, even though you’re eating less and exercising. There could be a number of reasons why your thyroid is not performing well. For example, if your body isn’t getting enough iodine, your thyroid can’t make enough thyroid hormone, but it will try to respond to rising TSH levels by working harder and harder anyway.

Causes of Hypothyroidism
  • Autoimmune thyroiditis:  When your thyroid comes under attack by your body’s immune system. Normally, antibodies protect you from infection or inflammation. But in this condition, called Hashimoto’s thyroiditis, your antibodies mistake your thyroid for a foreign invader. Hashimoto’s generally involves the presence of two types of antibodies called antithyroid peroxidase (anti-TPO) and antithyroglobulin (anti-TG) antibodies. These antibodies lead to destruction of the thyroid by the immune system. Hashimoto’s thyroiditis results from an abnormal immune response are called autoimmune diseases. Hashimoto’s thyroiditis is only one form of thyroiditis —an inflammation of the thyroid—that causes hypothyroidism.  Other autoimmune diseases may be associated with this disorder, and additional family members may also be affected.
  • Central or pituitary hypothyroidism:  Any destructive disease of the pituitary gland or hypothalamus, which sits just above the pituitary gland, may cause damage to the cells that secrete TSH, which stimulates the thyroid to produce normal amounts of thyroid hormone. This is a rare cause of hypothyroidism.
  • Congenital hypothyroidism: An infant may be born with an inadequate amount of thyroid tissue or an enzyme defect that does not allow normal thyroid hormone production. If this condition is not treated promptly, physical stunting and/or mental damage may develop.
  • Medications: Lithium, high doses of iodine and Amiodarone, for example.
  • Postpartum thyroiditis: 5-10% of women develop mild to moderate hyperthyroidism within months of giving birth. Hyperthyroidism in this condition usually lasts for approximately 1-2 months. It is often followed by several months of hypothyroidism.  Most women will eventually recover normal thyroid function. In some cases, however, the thyroid gland does not heal, so the hypothyroidism becomes permanent and requires lifelong thyroid hormone replacement. This condition may recur in subsequent pregnancies.
  • Radioactive iodine treatment: Hypothyroidism frequently develops as a desired therapeutic goal after the use of radioactive iodine treatment for hyperthyroidism.
  • Silent Thyroiditis: This condition appears to be the same as postpartum thyroiditis but not related to pregnancy.
  • Subacute thyroiditis: This condition may follow a viral infection and is characterized by painful thyroid gland enlargement and inflammation, which results in the release of large amounts of thyroid hormone into the blood. This condition usually resolves spontaneously. The thyroid usually heals itself over several months.
  • Thyroid surgery: Hypothyroidism may be related to surgery on the thyroid gland, especially if most of the thyroid has been removed.
Signs & Symptoms of Hypothyroidism

In its earliest stage, hypothyroidism may cause few symptoms, since the body has the ability to partially compensate for a failing thyroid gland by increasing the stimulation to it, much like pressing down on the accelerator when climbing a hill to keep the car going the same speed. As thyroid hormone production decreases and the body’s metabolism slows, a variety of features may result.

  • Pervasive fatigue
  • Drowsiness
  • Forgetfulness
  • Difficulty with learning
  • Dry, brittle hair and nails
  • Dry, itchy skin
  • Puffy face
  • Constipation
  • Sore muscles
  • Weight gain and fluid retention
  • Heavy and/or irregular menstrual flow
  • Increased frequency of miscarriages
  • Increased sensitivity to many medications
Diagnosing Hypothyroidism

Characteristic symptoms and physical signs  can signal hypothyroidism. However, the condition may develop so slowly that many patients do not realize that their body has changed, so it is critically important to perform diagnostic laboratory tests to confirm the diagnosis and to determine the cause of hypothyroidism.

Treating Hypothyroidism

Hypothyroidism is generally treated with a daily medication. There are multiple types of thyroid medication.  Not everyone respond the same to each medication, and not every medication is appropriate for a particular type of thyroid disease  An experienced physician can prescribe the correct form and dosage to return the thyroid balance to normal. Thyroid hormone acts very slowly in some parts of the body, so it may take several months after treatment for some features to improve.

It is extremely important that women planning to become pregnant are kept well adjusted, since hypothyroidism can affect the development of the baby. During pregnancy, thyroid hormone replacement requirements often change, so more frequent monitoring is necessary. Various medications and supplements (particularly iron) may affect the absorption of thyroid hormone; therefore, the levels may need more frequent monitoring during illness or change in medication and supplements. Thyroid hormone is critical for normal brain development in babies.

Since most cases of hypothyroidism are permanent and often progressive, it is usually necessary to treat this condition throughout one’s lifetime. Periodic monitoring of laboratory levels and clinical status are necessary to ensure that the proper dose is being given, since medication doses may have to be adjusted from time to time. Optimal adjustment of thyroid hormone dosage is critical, since the body is very sensitive to even small changes in thyroid hormone levels.

 

Revved Up – Hyperthyroidism

Hyperthyroidism develops when the body is exposed to excessive amounts of thyroid hormone. This disorder occurs in almost one percent of all Americans and affects women five to 10 times more often than men. In its mildest form, hyperthyroidism may not cause recognizable symptoms. More often, however, the symptoms are discomforting, disabling or even life-threatening.

Causes of Hyperthyroidism
  • Graves’ Disease: Graves’ disease is an autoimmune disorder that frequently results in thyroid enlargement and hyperthyroidism. In some patients, swelling of the muscles and other tissues around the eyes may develop. This is characterized by swollen, bulging, red eyes; widely open eyelids; and double vision. In its most severe form, diminished visual acuity may be present. As with Hashimoto’s thyroiditis, antibodies attack the thyroid, but in this case they stimulate the thyroid to overproduce thyroid hormone. The antibodies present in Graves’ disease are generally thyrotropin receptor antibodies (TRAb), including one kind known as thyroid-stimulating immunoglobulins (TSIs). They work by mimicking TSH, attaching to the TSH receptor on the thyroid gland and confusing the thyroid into producing too much hormone. Like other autoimmune diseases, this condition tends to affect multiple family members. It is much more common in women than in men and tends to occur in younger patients.
  • Postpartum Thyroiditis: 5-10% of women develop mild to moderate hyperthyroidism within months of giving birth. Hyperthyroidism in this condition usually lasts for 1-2 months. It is often followed by several months of hypothyroidism, but most women will eventually recover normal thyroid function. In some cases, however, the thyroid gland does not heal, so the hypothyroidism becomes permanent and requires lifelong thyroid hormone replacement. This condition may occur again with subsequent pregnancies.
  • Silent Thyroiditis: Transient (temporary) hyperthyroidism can be caused by silent thyroiditis, a condition similar to postpartum thyroiditis, but is not related to pregnancy. It is not accompanied by a painful thyroid gland.
  • Subacute Thyroiditis: This condition may follow a viral infection and is characterized by painful thyroid gland enlargement and inflammation, which results in the release of large amounts of thyroid hormones into the blood. This condition usually resolves spontaneously over several months, but often not before a temporary period of low thyroid hormone production occurs.
  • Toxic Multinodular Goiter: Multiple nodules in the thyroid can produce excess thyroid hormone, causing hyperthyroidism. Typically diagnosed in patients over the age of 50, this disorder is more likely to affect heart rhythm. In many cases, the person has had the goiter for many years before it becomes overactive.
  • Toxic Nodule: A single nodule or lump in the thyroid can produce more thyroid hormone than the body requires and lead to hyperthyroidism.
  • Excessive Iodine Ingestion: Various sources of high iodine concentrations, such as kelp tablets, some expectorants, amiodarone and x-ray dyes may occasionally cause hyperthyroidism in patients who are prone to it.
  • Overmedication with thyroid hormone: Patients who receive excessive thyroxine replacement treatment can develop hyperthyroidism. They should have their thyroid hormone dosage evaluated routinely and should NEVER give themselves “extra” doses.

 

Signs & Symptoms of Hyperthyroidism

When hyperthyroidism develops, a goiter (enlargement of the thyroid) is usually (but not always) present and may be associated with some or many of the following features:

  • Fast heart rate, often more than 100 beats per minute
  • Becoming anxious, irritable, argumentative
  • Trembling hand
  •  Weight loss, despite eating the same amount or even more than usua
  •  Intolerance of warm temperatures and increased likelihood to perspire
  • Loss of scalp hair
  • Tendency of fingernails to separate from the nail bed
  • Muscle weakness, especially of the upper arms and thighs
  • Loose and frequent bowel movements
  • Smooth skin
  • Change in menstrual pattern
  • Increased likelihood for miscarriage
  • Prominent “stare” of the eyes
  • Protrusion of the eyes, with or without double vision (in patients with Graves’ disease)
  •  Irregular heart rhythm, especially in patients older than 60 years of age
  • Accelerated loss of calcium from bones, which increases the risk of osteoporosis and fractures

 

Diagnosing Hyperthyroidism

Characteristic symptoms and physical signs of the disease can be detected by a trained physician. In addition, tests can be used to confirm the diagnosis and to determine the cause.

 

Treating Hyperthyroidism

Antithyroid Drugs

Two drugs are available for treating hyperthyroidism: propylthiouracil (PTU) and methimazole. Except for early pregnancy, methimazole is preferred. These medications control hyperthyroidism by slowing thyroid hormone production. They may take several months to normalize thyroid hormone levels.

 

Radioactive Iodine Treatment

Iodine is an essential in the production of thyroid hormone. Each molecule of thyroid hormone contains either four (T4) or three (T3) molecules of iodine. Since most overactive thyroid glands are hungry for iodine, it was discovered that the thyroid could be “tricked” into destroying itself by feeding it radioactive iodine. The radioactive iodine is given by mouth, usually in capsule form. Maximal benefit is usually noted within 3-6 months.  Most physicians strive to completely destroy the thyroid gland with a single dose of radioiodine. This results in the intentional development of an underactive thyroid state (hypothyroidism), which is easily, predictably and inexpensively corrected by lifelong daily use of oral thyroid hormone replacement therapy.
Thousands of patients have received radioiodine treatment. The treatment is a very safe, simple and reliably effective. Because of this, it is considered by most thyroid specialists to be the treatment of choice for hyperthyroidism cases caused by overproduction of thyroid hormone.

 

Surgical Removal of the Thyroid

Although seldom used now as the preferred treatment for hyperthyroidism, surgically removing most(or all) of the thyroid gland may be recommended in certain situations. Surgery usually leads to permanent hypothyroidism and lifelong thyroid hormone replacement therapy.

 

Other Treatments

A drug from the class of beta-adrenergic blocking agents (which decrease the effects of excess thyroid hormone) can temporarily control hyperthyroid symptoms until other therapies take effect. In cases where hyperthyroidism is caused by thyroiditis or excessive ingestion of either iodine or thyroid hormone, this may be the only type of treatment required. Also,  iodine drops are prescribed when hyperthyroidism is severe or prior to undergoing surgery for Graves’ disease.

 

How common is thyroid disease?

Thyroid disease is more common than diabetes or heart disease. As many as 30 million Americans are affected by thyroid disease – and more than half of those people remain undiagnosed. Women are five times more likely than men to suffer from hypothyroidism.

 

How important is my thyroid in my overall well-being?

The thyroid gland produces thyroid hormone, which controls virtually every cell, tissue and organ in the body. Untreated thyroid disease may lead to elevated cholesterol levels and subsequent heart disease, as well as infertility and osteoporosis. Research also shows that there is a strong genetic link between thyroid disease and other autoimmune diseases, including types of diabetes, arthritis and anemia. Simply put, if your thyroid gland isn’t working properly, neither are you.

 

How do you know if you have a thyroid problem?

First, you must recognize the symptoms and risk factors of thyroid disease. Since many symptoms may be hidden or mimic other diseases and conditions, the best way to know for sure is to ask your doctor.

 

What are some of the reasons to consider a thyroid evaluation?

  • Family history:  If you have a first-degree relative (a parent, sibling or child) with thyroid disease, you would benefit from thyroid evaluation. Women are much more likely to be thyroid patients than men; however, the gene pool runs through both.
  • Prescription medications: If you are taking Lithium or Amiodarone, you should consider a thyroid evaluation.
  • Radiation therapy to the head or neck: If you have had any of the following radiation therapies, you should consider a thyroid evaluation: radiation therapy for tonsils, radiation therapy for an enlarged thymus, or radiation therapy for acne.
  • Chernobyl: If you lived near Chernobyl at the time of the 1986 nuclear accident, you should consider a thyroid evaluation.

 

Thyroid Nodules

A thyroid nodule is a lump in or on the thyroid gland. Thyroid nodules are common, but are usually not diagnosed. They are detected in about 6% percent of women and 1-2% of men. They are 10 times as common in older people. Sometimes several nodules will develop in the same person. Any time a lump is discovered in thyroid tissue, the possibility of malignancy (cancer) must be considered. Fortunately, the vast majority of thyroid nodules are benign (not cancerous).

 

Causes

Nodules can be caused by a simple overgrowth of “normal” thyroid tissue, fluid-filled cysts, inflammation (thyroiditis), or a tumor (either benign or cancerous).

 

Signs & Symptoms

Most patients with thyroid nodules have no symptoms. Many are found by chance on a routine physical exam or an imaging study of the neck done for unrelated reasons. A substantial number of nodules are first noticed by patients or those they know who see a lump in the front portion of the neck, which may or may not cause symptoms, such as a vague pressure sensation or discomfort when swallowing. Finding a lump in the neck should be brought to the attention of your physician, even in the absence of symptoms.

 

Diagnosis
  • Thyroid Scan: A  picture of the thyroid gland taken after a small dose of a radioactive isotope has been injected or swallowed. The scan tells whether the nodule is hyperfunctioning (a “hot” nodule), or taking up more radioactivity than normal thyroid tissue does; taking up the same amount as normal tissue (a “warm” nodule); or taking up less (a “cold” nodule). Because cancer is rarely found in hot nodules, a scan showing a hot nodule eliminates the need for fine needle biopsy. If a hot nodule causes hyperthyroidism, it can be treated with radioiodine or surgery.
  • Thyroid needle biopsy: A very thin needle takes a small sample of tissue from the nodule.  This is a simple procedure performed in the physician’s office and patients can usually return to work or home afterward. A thyroid needle biopsy will provide sufficient information on which to base a treatment decision more than 75% of the time, eliminating the need for additional diagnostic studies. Use of fine needle biopsy has reduced the number of patients who have undergone unnecessary operations for benign nodules. However, about 10-20% of biopsy specimens are interpreted as inconclusive or inadequate – uncertain whether the nodule is cancerous or benign. In such cases, a physician who is experienced with thyroid disease can use other criteria to make a decision about whether or not to operate. The fine needle biopsy can be repeated in patients whose initial attempt failed to yield enough material to make a diagnosis. Many physicians use thyroid ultrasonography (ultrasound) to guide the needle’s placement.
  • Thyroid ultrasonography: Obtaining pictures of the thyroid gland by using high-frequency sound waves to create detailed images of the thyroid. It can visualize nodules as small as 2-3 millimeters. Ultrasound distinguishes thyroid cysts (fluid-filled nodules) from solid nodules and help physicians identify nodules that are more likely to be cancerous. Thyroid ultrasonography is also utilized for guidance of a fine needle for aspirating thyroid nodules. Ultrasound guidance allows biopsy samples to be obtained from the solid portion of those nodules that are both solid and cystic, and it avoids getting a specimen from the surrounding normal thyroid tissue if the nodule is small. Even when a thyroid biopsy sample is reported as benign, the size of the nodule should be monitored. A thyroid ultrasound examination provides an objective and precise method for detection of a change in the size of the nodule. A nodule with a benign biopsy that is stable or decreasing in size is unlikely to be malignant or require surgical treatment.
Treatment

Most patients who appear to have benign nodules require no specific treatment and can be followed by their physician. Some physicians prescribe thyroid medications with hopes of preventing nodule growth or reducing the size of cold nodules, while radioiodine may be used to treat hot nodules. If cancer is suspected, surgical treatment is recommended. The primary goal of therapy is to remove all thyroid nodules that are cancerous and, if malignancy is confirmed, remove the rest of the thyroid gland along with any abnormal lymph nodes. If surgery is not recommended, it is important to have regular follow-up of the nodule.

 

Testing For Adrenal Fatigue

November 27, 2017

Diagnosing Adrenal Fatigue from a single test or symptom is very difficult. To make an accurate diagnosis, it is important to look at a range of tests, sometimes conducted multiple times, and take note of every symptom. This requires experience and a thorough knowledge of the various systems in your body, as well as patience. It may require two or three visits to the doctor before you can be sure that you have adrenal fatigue.

Testing for adrenal fatigue can take several forms. First we have the standard hormone tests, which include testing for cortisol and various thyroid hormones. Then we have the tests that tend to look at the ratios of various hormones and neurotransmitters, in order to get a better idea of how are feeling. And lastly we have a set of more subjective physical tests, which were mostly developed in the early days of adrenal fatigue diagnosis.

To diagnose adrenal fatigue correctly requires using a combination of lab testing and patient feedback.

The major lab test used to diagnose adrenal fatigue is cortisol. But there is more than one type of cortisol testing, and the correct interpretation of results is also important. Taking a single measurement, or even a 24-hour average, is not enough. The best cortisol tests take 4 individual samples at various points of the day and then map your cortisol levels over the course of a 24-hour cycle. Our cortisol levels vary dramatically, starting high when we wake up and then tapering off until they reach their lowest point late at night. This usually represents approximately an 80% drop, which is perfectly normal. Your healthcare professional needs to see not just your average cortisol level, but also the size of the morning spike and how sharply it drops off afterwards. Interpreting the results correctly can be difficult. The reference ranges supplied by labs are so wide that they only flag up extremely low cortisol levels. Your doctor will need to look at the levels provided and make his or her own judgment. This is where the importance of using an optimal range, rather than the reference range, becomes clear. Lastly, your health care professional should be aware that more than one cortisol test will be necessary during your treatment for adrenal fatigue. Once you have been diagnosed and started on a treatment course, saliva cortisol testing is a good way to monitor progress as your cortisol levels begin to return to normal.

ACTH Challenge

This is another kind of cortisol test that can be very useful. First, your baseline cortisol levels are measured. Then, a dose of ACTH (adrenal corticotrophic hormone) is injected. Finally, your cortisol levels are measured again. The ACTH has the effect of stimulating your adrenal hormone output, just like it would if you were placed in a stressful situation. This test allows you to see the response of your adrenals to stress. If your cortisol exhibits a healthy spike higher (at least double in a blood test), your adrenals are probably in reasonably good shape. If the spike in cortisol is not so large, this suggests adrenal insufficiency.

Thyroid Tests

The complexity of the human body means that one part of the endocrine system cannot exist independently of another part. In reality, there are connections and relationships that exist between every system in the body, and a weakness in one area can easily translate into changes in another. In the case of adrenal fatigue, it has been shown that a weakening in the hypothalamus and pituitary gland can lead to lower thyroid function. In other words, if your blood tests suggest mild hypothyroidism, the underlying problem might actually be adrenal fatigue. There are a number of different tests for thyroid function, all blood tests. As with the cortisol test, your doctor should be looking beyond the reference ranges provided by the lab. In fact, these days it’s very common for someone to be diagnosed with mild hypothyroidism even if all their results are within the range.

TSH

Thyroid stimulating hormone is produced by the pituitary gland in response to instructions from the hypothalamus. As its name suggests, TSH stimulates the thyroid to produce T3 and T4, the two most important thyroid hormones. The level of TSH is inversely proportional to the activity of your thyroid. If your thyroid is producing lots of T3 and T4, your pituitary gland produces less TSH (because the thyroid needs to be stimulated less). Conversely, if you are hypothyroid then your TSH is likely to be high, as your brain is telling the thyroid to produce more hormones. This is the same kind of feedback loop that exists for many other hormones in the body, including cortisol. In the case of adrenal fatigue, the  thyroid is often performing weakly, so they will typically have a TSH reading of above 2.0. Note that the reference range provided by the lab will usually be around 0.50 – 4.50. Once again you can see the importance of looking for an optimal level rather than just blindly following the lab ranges.

Free T3 (FT3)

This is a test that is rarely conducted by doctors, and even then usually only on hyperthyroid patients. However, it can give a useful insight into the overall function of the thyroid. When used in conjunction with the other thyroid tests, this helps to give a complete picture of why the thyroid is underperforming. Optimal values should be somewhere in the 300-450 pg/ml range. However, the typical lab range allows values as low as 230 pg/ml.

Free T4 (FT4)

Similarly to T3, this hormone is produced when TSH stimulates the thyroid. Your thyroid makes much more T4 than T3, but T4 tends to have less of an effect on the body than T3. If your thyroid is producing too little T4, often your TSH level will be higher. This test measures Free T4, which is ‘unbound’ and available for immediate use.

Total Thyroxine (TT4)

This test should be used along with the free T4. While Free T4 measures the amount of unbound and available T4 in your blood, whereas total thyroxine includes the amount of T4 that is bound to carrier proteins (essentially held ‘in reserve’). Using this test together with the free T4 test can tell you how much T4 is available for your body to use, and how much is being held in reserve.

Cortisol / DHEA Ratio

This test tells us which point along the adrenal fatigue pathway the patient might have reached. In the initial stages of a stress reaction both cortisol and DHEA will be high. But as the body begins to struggle to produce sufficient stress hormones, DHEA levels start to fall. Put very simply, this is because the stress hormone production ‘steals’ resources from the sex hormone production. Further on in the development of adrenal fatigue, cortisol levels will begin to drop too.

17-HP / Cortisol Ratio

17-hydroxyprogesterone (17-HP) is a precursor to cortisol, in other words one of the ‘raw materials’ that the body uses to create cortisol. With adrenal fatigue, it is common to see higher levels of 17-HP vs. cortisol, as the adrenals struggle to make this conversion happen.

Neurotransmitter Testing

Neurotransmitters are chemical messengers that transmit messages between our cells and, just like cortisol, they can become depleted after long periods of stress. With recent developments in testing procedures it is now possible to compare a patient’s neurotransmitter levels to a reference range for healthy patients. This test is usually conducted first thing in the morning and is best accomplished via a urine test. It is only available from a small number of labs.

Alternative Tests

When adrenal fatigue was first diagnosed many of these tests did not even exist. To help provide a diagnosis, doctors developed a series of more physical tests that can be conducted quickly in a doctor’s clinic or at home. These tests are clearly much less accurate than the blood, saliva and urine tests mentioned above, and positive results may reflect other health problems besides Adrenal Fatigue. However, they can be a useful diagnostic tool in combination with all the other evidence provided.

The Iris Contraction Test

First described by Dr. Arroyo in 1924, this test measures the contraction of the iris in response to repeated exposure to dark light. In those with weakened adrenal function, the theory goes that the iris will be unable to maintain its contraction for long. To conduct the test, sit in a darkened room, in front of a mirror. Take a flashlight and shine it across your eye, from the side of your face. In a hypoadrenal state, your pupil will not be able to hold onto its contraction for more than 2 minutes and thus will begin to dilate despite light repeatedly shining on it. In those with healthy adrenals, the contraction should last much longer.

Postural Low Blood Pressure

When we stand up, those of us who are in good health experience an almost immediate rise in blood pressure. In contrast, with adrenal fatigue, there is little or no change in blood pressure, or even a slight fall. In very general terms, a larger drop in blood pressure signifies a more severe case of adrenal fatigue.

This is a very simple test to do at home. Use your regular blood pressure monitor and check your blood pressure while lying down. Then stand up and conduct the test again.

Hormonal Mood Disorders

October 17, 2017

FADS AND OVER-DIAGNOSIS

Over the past several decades psychiatric diagnostic acumen has improved significantly. However, more and more people seem to carry psychiatric diagnoses that are inaccurate and have negative consequences. Additionally, it seems that fads in psychiatric diagnosis come and go.  Likely they satisfy a deep-felt need to explain, or at least label, unexplainable human deviance. In recent years, the pace has accelerated and false ‘epidemics’ have come to involve an increasing proportion of the population. We are now in the midst of at least three such epidemics – autism, attention deficit disorder & childhood bipolar disorder. Estimates suggest that in any given year, 25% of the population (almost 60 million people) has a diagnosable mental disorder. A study showed that, by age thirty-two, 50% of the general population will ‘qualified’ for an anxiety disorder and 40% for depression. Imagine what the percentages will be by the time these people hit fifty, or sixty-five or eighty?  In this brave new world of psychiatric over-diagnosis, will anyone get through life without a mental disorder?

What accounts for the upsurge in diagnosis?  It is unlikely that we can blame it on our brains. Human physiology changes very slowly.  Could it be caused by our stressful society? There is no good reason to believe that life is any harder now than in the past.  It is more likely we are a more pampered and protected generation than ever before. Most likely that these ‘epidemics’ are caused by changing diagnostic fashions – in other words, people don’t change, the labels do. There are no objective tests in psychiatry –  no X-ray, laboratory, or exam finding – that say definitively that someone does or does not have a mental disorder.  Other factors contributing to the increase include:

1) DSM manuals being sold to more ‘ordinary’ people than to mental health professions.  This has made psychiatric diagnosis accessible to the general public, allowing self-diagnosis.

2) Definitional thresholds may be set too low. We seem to worry more about missing cases than about casting too wide a net and capturing people who do not require a diagnosis.

3) The pharmaceutical industry over-utilizes marketing. Drug companies are skilled at mounting a full court press that includes ‘educating’ doctors, ‘supporting’ advocacy groups, controlling research, and direct-to-the-consumer advertising.

4) Patient and family advocacy groups call attention to neglected needs (lobbying for clinical, school, and research programs; reducing stigma; and promoting group and community support). Advocating for those with a disorder can spill-over and promote the spread of the disorder to others who are mislabeled.

5) Recent ‘epidemics’ have occurred mostly in childhood disorders.  Perhaps a contributing factor is that the provision of special educational services often requires a DSM diagnosis?

6) The internet provides a wealth of information and creates a network of ‘informed consumers’.  Disorder-focused web-sites provide an attractive forum & support system that draws people who inaccurately self ‘over-diagnose’.

7) The media both feeds off of and feeds public interest. It is not uncommon for the media to become obsessed with one or another celebrity whose public meltdown seems related to a real or imagined mental disorder. An example is the Tiger Woods media frenzy which will likely lead to an ‘epidemic’ of sexual addiction.  Popular movies can also be contagious:  Sybil helped cause a fad in multiple personality disorder.

8) We live in a society that is intolerant of normal individual difference. What was once accepted as aches and pains of everyday life is now labeled a mental disorder. Eccentrics who would have been accepted on their own terms are now labeled Asperger’s and in need of intervention. Criminal behavior has been medicalized (rape as a psychiatric disorder) because prison sentences are too short and such labeling allows for indefinite psychiatric commitment.

Despite all this uncertainty about diagnosis of mental health disorders, a few certainties exist.  There is sufficient research to indicate that a significant subset of people diagnosed with mental health disorders, in fact, have hormone imbalances. The connections between hormones and the brain is undeniable. Hormones impact brain chemistry and circuitry, and hence influence emotions, mood and behavior.

PUBERTY

For many adolescents, the first exposure to the mood-changing impact of hormones is puberty. Pubertal girls and boys can experience significant upheaval due to constant emotional ups and downs, irritability, depression, anxiety, brain fog, and moodiness. Boys can have additional symptoms of anger with rising and fluctuating testosterone. At the beginning of puberty, the brain releases GnRH, which triggers secretion of FSH and LH. In girls, FSH and LH instruct the ovaries to begin producing estrogen. In boys, the same hormones initiate production of testosterone. Many of the mood swings that teens experience are caused by fluctuations in these hormones. These same teen hormones will also affect the way they think about dating and sex. Teens become more interested in sex, sometimes to the point of obsession, as hormones kick into gear. Many adolescents feel that these hormone-related changes are weird or unnatural.

In adolescent girls, hormonal disorders are often overlooked because we tend to focus on the time they begin menstruating.  We forget that long before a girl undergoes menarche, a variety of other changes occur that commence with hormone fluctuations:  thelarche (breast development), pubarche (pubic hair growth), and the pubertal growth spurt. In considering anger, mood swings, and changes in behavior, we must consider their relationship to these other hormone-mediated events.

PREMENSTRUAL SYNDROME (PMS) AND PREMENSTRUAL DYSPHORIC DISORDER (PMDD)

PMS affects up to 85% of women. Irritability, tension, and dysphoria are the most consistently described symptoms. Women whose affective symptoms are especially severe may meet criteria for PMDD, which occurs in 2-10% of women. PMDD is a serious, disabling condition that can rob a woman of her functioning every month. PMS and PMDD are cyclical, with symptoms arising during the luteal phase of the menstrual cycle and lasting until the onset of menstrual flow. Prior to ovulation, estrogen rises, while during the luteal phase following ovulation, progesterone rises. Immediately before the onset of menstruation, estrogen and progesterone both decrease.  The tricky part about PMS and PMDD is that they are not always exactly the week before bleeding, nor do they last exactly a week.  It is further complicated in women who do not have the ‘classic’ 28-day cycle.

Arguably the most frequent, popular and incorrect diagnose associated with puberty is bipolar disorder, in all of its subtypes and flavors. It seems that any adolescent who is moody, angry, or temperamental is labeled bipolar. Bipolar disorder and PMS/PMDD have many similar symptoms. Both are characterized by cycling moods, including severe depression. There are hundreds, if not thousands, of adolescents running around with this diagnosis, yet many of them have never had a manic episode, which is the hallmark of bipolar disorder. Many of these kids have never had anything other than irritability. Load them up with cocktails of anxiolytics, antidepressants or medications like Seroquel, Depakote, Abilify, Lithium, Klonopin & Trazadone and their symptoms go away.  The proof is NOT in the pudding. All that is proven is that one’s affect can be obliterated by harsh medication cocktails.  But being incapacitated by medications does not prove bipolarity. This confusion is tragic because these therapies are often ineffective and more damaging, with serious long-term side effects in the form of obesity, metabolic syndrome, diabetes, sexual dysfunction & movement disorders.

After careful evaluation and consideration, these patients need to be detoxified from their toxic cocktails. Once these medications have worn off, consider a tailored titration onto a pulse pattern of a SSRI or Wellbutrin to control the PMS.  Sometimes Monoamine Oxidase Inhibitors (MAOI’s) are used because it is the surge in MAO that occurs abruptly when a woman’s estrogen drops.  The MAO is the enzyme that degrades all biogenic amines – dopamine, serotonin, norepinephrine, etc. and induces the moodiness and symptoms of PMS/PMDD.  These patients should also be started on therapies designed to suppress cyclical hormonal changes (suppress ovulation). Longstanding ‘bipolar depression’ often disappears when the premenstrual cycle is suppressed.

POLYCYSTIC OVARIAN SYNDROME (PCOS)

The subset of girls who will eventually be diagnosed with PCOS creates an even bigger set-up for misdiagnosis.  Most PCOS patients are diagnosed after menarche – in other words, adolescents diagnosed with mental health disorders, who have PCOS, often haven’t been diagnosed with PCOS yet. PCOS is characterized by irregular menses, elevated testosterones, masculinization, hirsutism, weight gain, metabolic disturbances and many other features. These patients have significant hormone fluctuations without a menstrual cycle. They have florid mood swings, affective dysregulation, depression, impulsivity, suicidal gestures…the whole gamut. True psychotic symptoms are rare.  Most mood medications these girls are started on cause weight gain and some directly increase blood glucose and all of this is quite bad for a PCOS patient.

PREGNANCY AND POSTPARTUM

Pregnancy and postpartum are other key times when mind and hormones intersect. Some women have their first experience with significant moodiness, emotional ups and downs, and frank depression during or after pregnancy. Postnatal depression and psychosis are key mental illnesses that have a major hormonal component to their onset and course. This is thought to be triggered by the sudden, rapid drop in the high levels of pregnancy hormones shortly after birth.

MENOPAUSE

The next commonly recognized — but not well-understood — time, is broadly referred to as ‘menopause’. Broadly, because the term isn’t really used properly. Menopause is a single moment in time when a woman has not had a period for a full year. In the United States, the average age is 51. But most symptoms associated with menopause — erratic periods, hot flashes, mood swings, sleep disturbances, mental fog and decreasing mental focus, weight redistribution, decreasing motivation, diminished exercise endurance, muscle & joint aches, diminished exercise recovery, headaches, and changes in sex drive— take place during perimenopause — the time before menopause — when testosterone, estrogen and progesterone can go up and down erratically. These fluctuations can actually start as early as late thirties.  During this transition, women experience major hormonal shifts. During this time, women are 14 times more likely to experience depression. It affects women differently than other types of depression, causing anger, irritability, poor concentration, memory difficulties, low self-esteem, poor sleep and weight gain. Perimenopausal depression isn’t well recognized and is often poorly treated with standard antidepressants. Women with this type of depression respond better to hormone treatments.

DIAGNOSIS

Diagnosis of hormone-responsive depression should be made through the patient’s history and not through the measurement of hormonal levels, since hormonal levels in premenopausal women are typically normal. Instead, carefully consider the patient’s history that point to hormonally based depression.

  • A history of mild or severe PMS as a teenager
  • Relief of depressive symptoms during pregnancy
  • Postpartum depression, with new-onset or newly recurring depressive symptoms
  • Recurrence of premenstrual depression following resumption of menstruation after delivery
  • Worsening of premenstrual depression with age, blending into the menopausal transition and becoming less cyclical thereafter
  • Coexistence of cyclical somatic symptoms, such as menstrual migraine, bloating, or mastalgia, which are not associated with bipolar disorder
  • Runs of 5 to 20 euthymic days per month
  • Recurrent episodes of depression, often severe and related to menstrual periods, but without episodes of mania

Beyond the patient’s personal history, family history can shed light on the origin of depressive symptoms. If the mother and sisters also suffer from PMS and postnatal depression, it can be suggestive of a familial hormonal basis for the symptoms. Alternatively, a history of bipolar disorder and suicide in male relatives would suggest mixed etiology.

MEN & HORMONES

Low testosterone leads to andropause, which can result in erectile problems, diminished libido, decreased muscle strength and decreased bone mass. To complicate matters, testosterone is converted to estradiol in men (via aromatase enzyme). So, testosterone exerts its effects independently (as itself) and indirectly via conversion to estrogen. Too much estrogen can lead to excess breast tissue, depression or mood swings. Too little estrogen contributes to mood disturbances, low sex drive, decreased motivation and diminished ability to retain muscle mass. Fluctuating estrogen levels, also cause mood swings, which further complicate the picture.  A discernable PMS pattern of behavior is often recognized with these fluctuations. If all this wasn’t complicated enough, the relationship between E and T is also very important, especially with regard to mood changes. Altered estrogen/testosterone ratio (both too high and too low) can cause problems with memory function, depression, irritability, sleep, fatigue and occasionally even hot flashes/sweats.

After seeing a series of men diagnosed with a putative mental health disorder, prescribed all of the usual drugs, there is a discernable pattern of diminished libido, sexual dysfunction, subtle feminization and new/strange sexual thoughts & fantasies.  Initially, these were considered  medication side effects. However, evaluation of hormone levels indicates relative to absolute hypogonadism. Furthermore, these findings are not attributable to psychiatric drugs because this phenomenon is also seen in men who present with similar complaints and no prior treatment with these mood medications. In addition to having low testosterone levels, these men often have high normal or abnormal estrogen levels.  If these men are weaned off mood medications and started on testosterone replacement, their moodiness, irritability, insomnia and other symptoms resolve as they are re-masculinized & estrogen levels fall.

When considering testosterone replacement in men, avoid topical preparations (when possible) if concerned about increased conversion of testosterone into estrogen.  The enzyme that coverts testosterone into estrogen is found in increased quantities in adipose tissue.  Use of injectable long-acting, slow-release testosterone works best for these men.

OTHER HORMONES INVOLVED IN MOOD

In addition to our male & female hormones, there are other hormonal imbalances that can have profound effects on mood.

Thyroid issues are an often overlooked, hormonally-triggered cause of symptoms. When the thyroid becomes overactive – hyperthyroidism — symptoms can include anxiety, insomnia, moodiness, panic attacks, and depression. Some men and women have even been mistakenly misdiagnosed as having panic disorder or anorexia, before properly diagnosed with an overactive thyroid. An underactive thyroid — hypothyroidism — can cause depression, moodiness, fatigue, and anxiety.

While conventional doctors often rush to prescribe antidepressants, it is essential to routinely check patients for thyroid imbalances prior to prescribing any medication for depression or other mood disorders. Interestingly, one symptom of undiagnosed hypothyroidism is depression that does not respond to antidepressant therapy. Thyroid problems are also more likely to show up during periods of hormonal flux – puberty, pregnancy, post-partum, perimenopause, menopause and andropause — which makes it even more important to have a full thyroid evaluation done if you experience depression or anxiety during these times of life.

Adrenal issues — imbalances in the body’s stress hormones adrenaline and cortisol, and the precursor hormone DHEA — can cause a variety of symptoms that seem to be mental health-related, including depression, anxiety, and insomnia. In patients that have experienced trauma or violence, chronically elevated levels of cortisol can result, causing significant mental illness at any time in a person’s life. High cortisol levels have huge impacts on many brain regions, resulting in rage, suicidal thoughts, obesity & infertility. A chronic excess of stress hormones can make you feel jittery, anxious, unable to sleep, and irritable. A chronic deficiency of stress hormones can make you feel sluggish, tired (even after sleep), moody, depressed, and have difficulty concentrating. Daily fluctuations and imbalances can cause a mix of these symptoms.

TRANSGENDER PATIENTS

Hormone replacement is also often part of the transition process for transgender patients. This is, yet, another area where hormones and mood intersect. Many transgender patients experience dysphoria, or psychological distress due to the discrepancy between the sex they were assigned at birth and their gender identity. There is a high prevalence of depression, anxiety & suicidal thoughts.

Hormones help align physical characteristics with gender identity. Many individuals report hormone therapy is extremely beneficial because it enables them to maintain a physical appearance that more closely matches their gender identity, thus increasing their comfort with their physical appearance and decreasing dysphoria & distress. The effects on physical characteristics from HRT can usually be seen in one to three years, but a person receiving hormones will continue taking them for the rest of their life in order to maintain the effects. Research shows that HRT significantly reduces depression, anxiety, and sensitivity, along with feelings of hostility. Additionally, HRT often has the effect of increasing self-esteem and feelings of attractiveness. During gender transition, people who receive hormones typically experience a second puberty, during which secondary sex characteristics change to align with gender identity.

Trans-women receive estrogen in addition to antiandrogens to block testosterone. Trans-men take testosterone, which stops the menstrual cycle, lowers voice, and facilitates facial hair growth, though there may be other effects as well. Non-binary individuals (those whose gender is not specifically male or female) take hormones to produce characteristics that align with their identity or eliminate characteristics causing distress/dysphoria.

It is essential to remember that it is not possible to choose which characteristics result from HRT, and hormone therapy will affect people in different ways. Because of this, the initiation of hormone replacement can also increase feelings of dysphoria and distress.  Many transgender patients don’t quite know what to expect.  Often the changes in hormones they experience from replacement do not yield results that they anticipated or have side effects that were not considered.  For the reason, it is essential to counsel these patients thoroughly before initiating a regimen.

THE TAKE HOME MESSAGE

Before you go down the road of antidepressants and/or anti-anxiety medications, make sure you take a complete medical history, assess symptoms, do a thorough clinical exam, and run comprehensive blood testing to evaluate and diagnose any hormone balances. Unlike most medications and supplements that support and balance hormones, antidepressants and anti-anxiety medications often have significant side effects, and frequently don’t even resolve your symptoms if the underlying cause is a hormonal issue.

Trying to Conceive

August 7, 2017

Infertility is defined as not being able to get pregnant after at least one year of trying. Additionally, (1) women over the age of 35 who having been trying for less than one year and (2) women who are able to get pregnant but then have repeat miscarriages are candidates for infertility evaluation.

Pregnancy is the result of a complex chain of events. Infertility can result from problems with any of these steps:

  • A woman must release an egg from one of her ovaries (ovulation).
  • The egg must go through a fallopian tube toward the uterus.
  • A man’s sperm must fertilize the egg along the way.
  • The fertilized egg must implant inside of the uterus.

Problems with ovulation account for most cases of infertility. Without ovulation, there are no eggs to be fertilized. Irregular or absent menstrual periods are a sign of no (or infrequent) ovulation. Less common causes of infertility in women include:

  • Blocked fallopian tubes due to pelvic inflammatory disease, endometriosis, or surgery
  • Physical problems with the uterus
  • Uterine fibroids

Many things can affect our ability to conceive: age, stress, diet, intense athletic training, being overweight or underweight, smoking, alcohol, sexually transmitted infections, hormone changes.

Sometimes we can find the cause of a couple’s infertility by doing a complete fertility evaluation. The process begins with physical exams and health and sexual histories. If there are no obvious problems, like poorly timed intercourse or absence of ovulation, further tests are needed. Finding the cause of infertility is often a long, complex, emotional process. It can take months to complete all the needed exams and tests.

For a man, we begin by testing semen. We look at the number, shape, and movement of sperm. For a woman, the first step in testing is to find out if she is ovulating each month.

Infertility can be treated with medicine, surgery, artificial insemination, or assisted reproductive technology. Many times, treatments are combined. Two-thirds of couples treated for infertility are able to have a baby. In most cases infertility is treated with drugs or surgery. Many fertility drugs increase a woman’s chance of having twins, triplets, or other multiples. Women who are pregnant with multiple fetuses have more problems during pregnancy. Multiple fetuses have a high risk of being born too prematurely. Premature babies are at a higher risk of health and developmental problems.

Assisted reproductive technology (ART) describes several different methods used to help infertile couples. ART involves removing eggs from a woman’s body, mixing them with sperm in the laboratory, and putting the embryos back into a woman’s body.

There is a small number of causes that are ‘preventable’. Reducing or eliminating life stressors, both emotional and physical, is important to increase the likelihood of conception.  Also, eating healthy can make a difference.  Being overweight or underweight can affect fertility potential.  Also, for women who enjoy intense athletic training, reducing or altering workouts can make a difference in the body’s ability to produce healthy, viable eggs.  Eliminating habits like caffeine, cigarette smoking, alcohol, drugs and even some over-the-counter and prescription medications can increase chance of conception.  If you are using prescriptions medications, do not stop these medications abruptly without consulting your medical provider.  Men and women can optimize their immunity and health by incorporating food or supplements rich in antioxidants, monounsaturated oils and omega 3’s.  Additionally, protecting oneself from exposure to sexually transmitted infections and getting immediate treatment if exposed to an infection, can reduce infertility.

Additionally, if you do not want to have children until later in life, consider freezing eggs.  By doing this, you can eliminate poor egg quality, that comes with advancing age, as a reason for infertility. Likewise, if a man or woman has cancer and requires chemotherapy or radiation, consider freezing sperm or eggs in the event cancer treatments destroy egg/sperm quality and/or quantity.

Being mindful of the above can certainly reduce the likelihood of infertility, but there are so many other causes that are not preventable.  For this reason, it is nearly impossible to ‘prevent’ infertility.

As indicated above, some women will turn to freezing eggs and sperm to increase likelihood of conceiving if planning to conceive later in life or receiving medical treatments that may destroy eggs and sperm.

 

Other infertility treatments include (1) initiating fertility and hormone medications (for both men and women) to correct hormonal imbalances, improve sperm health, enhance the ability to make good quality eggs and ensure ovulation, (2) hysteroscopic or laparoscopic surgical interventions to remove anatomical abnormalities, scar tissue or other blockages that affect females and male reproductive structures, (3) hysteroscopic or laparoscopic surgeries to remove fibroids or polyps or other uterine abnormalities that restrict adequate implantation of fertilized eggs, (4) surgical interventions to reverse vasectomies or tubal occlusions, (5) intrauterine insemination (IUI) to help sperm with decreased motility get to an egg for fertilization, (6) and more complex and technical procedures like in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) where sperm is directly injected into the egg to allow fertilization.  Additional options include sperm and egg donation and using gestational carriers/surrogates.

 

There are a variety of struggles when it comes to infertility. The most obvious hurdle is the financial cost of infertility treatments. Some insurance plans cover infertility treatment, but coverage varies and is often not enough to cover all expenses or treatments.  Out of pocket expenses can often lead to fights or resentments if spouses disagree on cost effectiveness or either is pressured to go through with costly treatments.

 

Couples also deal with emotional/psychological hurdles.  A lot of couples feel shame and don’t want anyone to know they are having trouble conceiving naturally. Also, couples with infertility often feel like others cannot relate to what they are going through. These factors can cause couples to feel isolated as they compare themselves to family and friends who are parents. Because of this, they feel embarrassed and avoid family and friends for fear of judgement or criticism. Additionally, couples often try to avoid being questioned by family, friends and strangers. Insensitive inquires like: ‘Why don’t you have children?’ or ‘Which one of you has the problem?’ can take an emotional toll.  Not to mention unsolicited comments and recommendations that couples are often given.

 

Another difficulty is that couples can undergo many treatments before they achieve success (assuming they ever achieve success).  Fertility treatments have become more advanced, but couples still often face multiple disappointing failed treatments along the way.  Multiple treatments and failures can lead to both physical and psychological stress.  In addition to this, side effects of fertility treatment drugs, hormones and injections can cause mood swings, sleep disturbances, problems focusing, depression and anxiety.  Overall, there is often a rollercoaster of emotions.  It is hard enough when both partners are affected the same way.  Unfortunately, emotional factors often affect each partner differently, which can cause resentment, misunderstanding and arguments that can either bring couples closer together or take a significant toll on the relationship. On top of this, sex often becomes a chore that has to be timed perfectly in order to optimize success.  Sex loses its association with pleasure and intimacy.

 

Infertility has taken on a new face, with added struggles, with the emergence of same-sex couples and single individuals wanting to become parents.

 

At Tree of Life Medical we will perform a thorough evaluation of all the possible causes that are making it difficult for you to conceive.  We will prescribe some medications and make lifestyle recommendations to assist you in your attempt to conceive.  If more in-depth evaluation and management is needed, we will make sure you are referred to the appropriate specialists.  We will help coordinate your care and stand by you as you go through every step of the process.

 

Peri-Menopause, Menopause, Post-Menopause?

June 8, 2017

Peri-Menopause, Menopause, Post-Menopause…What Does This All Mean?? 

Wikipedia definitions: (1) Perimenopause: the period of a woman’s life shortly before the occurrence of the menopause. (2) Menopause:  the ceasing of menstruation; the period in a woman’s life (typically between 45 and 50 years of age) when this occurs. (3) Post-Menopause: having undergone menopause or occurring after menopause.

Hmmm? Still uncertain what this all means??

Reality: what you call it, isn’t all that important!! Perimenopause, Menopause, and Post-Menopause are all part of a continuous spectrum.

Perimenopause means ‘around menopause’ and refers to the time when your body makes the natural transition to menopause, marking the end of reproductive years. This time is also called the ‘menopausal transition’.  Women start perimenopause at different ages. You may notice signs, such as menstrual irregularity, sometime in your 40s. But some women notice changes as early as their mid-30s.

The level of estrogen — the main female hormone — in your body rises and falls unevenly during perimenopause. Your menstrual cycles may lengthen or shorten, and you may begin having menstrual cycles in which your ovaries don’t release an egg (ovulate). This period of time is also marked by decreasing levels of testosterone, another important female hormone. These hormonal changes/fluctuations may cause symptoms, such as hot flashes, sleep problems, vaginal dryness, irritability and mood swings, fatigue, decreased motivation, decreased libido, weight gain or difficult losing mid-section weight, decreased mental focus and decreased concentration.

Once you’ve gone through 12 consecutive months without a menstrual period, you’ve officially reached ‘menopause’…and perimenopause is over. Essentially, this is one, single day in time.

The time of a woman’s life following menopause is called post-menopause. During this time, many of the symptoms experienced before menopause can decrease. However, a lot of women may have persistent or worsening symptoms. **IMPORTANT** — just because your symptoms may decrease or go away completely, this does NOT mean your body is satisfied with its current hormonal state!!!

Postmenopausal women are at increased risk for a number of health conditions, such as osteoporosis and heart disease. Also, depletion of these hormones can exacerbate chronic pain disorders and mood disorders.  Medications and/or healthy lifestyle changes may reduce the risk of some of these conditions, but there is NO substitute for proper hormone balance!!

Menopause And Ovarian Cancer

Ovarian cancer starts in the ovaries and often spreads to other parts of the body. Although it can happen at any age, it is most common in women over age 50. Half of ovarian cancer cases are found in women age 63 or older, according to the American Cancer Society.  Menopause does not ‘cause’ ovarian cancer. But your chances of developing ovarian cancer increase as you get older. When you go through menopause, your risk increases just because of your age. If you start menopause late — usually after age 52 — your chance of ovarian cancer may be higher (because you’ve had more ovulations). Ovulation is when your menstrual cycle triggers your body to release an egg.

Breast Cancer and Menopause

Menopause itself is not associated with an increased risk of developing cancer. However, the rate of breast cancer increases with age.  Age is the single-most important risk factor for breast cancer. About 95% of women diagnosed with breast cancer each year are over age 40, and about half are age 61 and older. Personal risk is also greater if an immediate family member (mother, sister, or daughter) has had breast cancer, particularly if it was at an early age. Also, women who have had a breast biopsy (removal of breast tissue) that shows certain types of benign disease, such as atypical hyperplasia, are more likely to get breast cancer.

Other risk factors include:

  • Having cancer in one breast (may recur or develop in other)
  • Having a history of ovarian, uterine, or colon cancer
  • Having a genetic abnormality in breast cancer genes BRCA1 or BRCA2
  • Late menopause (after age 55)
  • Starting menstruation early in life (before age 12)
  • Having a first child after age 30
  • Never having children

Can I Prevent Breast Cancer?

While there is no definitive way to prevent breast cancer, there are steps you can take to reduce your risk:

  • Maintain a healthy weight
  • Be physically active and get at least 30 minutes of moderate to vigorous exercise five or more days per week.
  • Eat a healthy diet with at least five servings of fruits and vegetables daily; limit the amount of processed meat and red meat eaten.
  • Women should drink no more than one alcoholic beverage daily (men should drink no more than two alcoholic beverages daily).

Menopause and Heart Disease

People who have one or more specific risk factors for coronary heart disease may be at much greater risk of heart disease than people with no risk factors.

Common Risk Factors:

1) High blood pressure:  High blood pressure can strain the heart and increase wear and tear on the blood vessels, making blockage more likely.

2) African-American Race:  African-Americans are more likely than Caucasians to develop severe high blood pressure as well a heart disease. Heart disease risk is also higher among Mexican-Americans, American Indians, native Hawaiians, and some Asian-Americans. This may be partly due to higher rates obesity and diabetes.

3) Post-Menopausal Female:  Men have a higher risk of heart disease than women. However, the risk of heart disease in postmenopausal women increases and becomes similar to that of men.

4) Family History of Heart Disease:  The genetic make-up of some individuals increases their chances of developing heart disease.

5) Over Age 40:  The older you get, the more likely you are to develop heart disease.

6) High cholesterol:  High cholesterol can contribute to the build-up of plaques that can clog blood vessels leading to the heart, narrowing them and potentially blocking blood flow to the heart.

7) Smoker:  Cigarette smoking is a major cause of heart disease. It causes plaque to build up in the arteries and can greatly increase your risk for heart attack.

8) Diabetes:  About three-quarters of people with diabetes die of some form of heart or blood vessel disease. Even when blood sugar levels are under control, diabetes increases the risk of heart disease, but the risks are even greater if blood sugar is not well controlled.

9) Physically inactive, Overweight, or Obese:  An inactive lifestyle is a risk factor for heart disease. Regular physical activity helps prevent heart and blood vessel disease. And people who have excess body fat — especially around the waist — are more likely to develop heart disease even if they have no other risk factors.  Exercise can help control cholesterol, diabetes, and obesity, as well as help lower blood pressure.

10:  Other:  Other factors may also contribute to an increased risk of heart disease. These may include an individual’s stress level and consumption of alcohol. Talk to your doctor about your specific situation, taking all factors into consideration.

Osteoporosis and Menopause

Osteoporosis is a disease that weakens bones, increasing the risk of sudden and unexpected fractures. Literally meaning “porous bone,” osteoporosis results in an increased loss of bone mass and strength. The disease often progresses without any symptoms or pain. Many times, osteoporosis is not discovered until weakened bones cause fractures usually in the back or hips. Unfortunately, once you have a broken bone due to osteoporosis, you are at high risk of having another. And these fractures can be debilitating. Fortunately, there are steps you can take to prevent osteoporosis from ever occurring. And treatments can slow the rate of bone loss if you already have osteoporosis.

What Causes Osteoporosis?

Though we do not know the exact cause of osteoporosis, we do know how the disease develops. Your bones are made of living, growing tissue. An outer shell of dense bone encases a sponge-like bone. When a bone is weakened by osteoporosis, the “holes” in the “sponge” grow larger and more numerous, weakening the internal structure of the bone. Until about age 30, a person normally builds more bone than he/she loses. During the aging process, bone breakdown begins to outpace bone buildup, resulting in a gradual loss of bone mass. Once this loss of bone reaches a certain point, a person has osteoporosis.

How Is Osteoporosis Related to Menopause?

There is a direct relationship between lack of estrogen and development of osteoporosis. Early menopause (before age 40) and any prolonged periods in which hormone levels are low and menstrual periods are absent/infrequent can cause loss of bone mass.

What Are the Symptoms of Osteoporosis?

Osteoporosis is often called the “silent disease” because initially bone loss occurs without symptoms. People may not know that they have osteoporosis until their bones become so weak that a sudden strain, bump, or fall causes a fracture or a vertebra to collapse. Collapsed vertebrae may initially be felt or seen in the form of severe back pain, loss of height, or spinal deformities such as stooped posture.

Who Gets Osteoporosis?

Important risk factors for osteoporosis include:

  • Age: After maximum bone density and strength is reached (generally around age 30), bone mass begins to naturally decline with age.
  • Gender: Women over the age of 50 are at the greatest risk. Women are four times more likely than men to develop osteoporosis. Women’s lighter, thinner bones and longer life spans account for some of the reasons why they are at a higher risk for osteoporosis.
  • Ethnicity: Research has shown that Caucasian and Asian women are more likely to develop osteoporosis. Hip fractures are twice as likely to occur in Caucasian women as in African-American women. However, women of color who fracture their hips have a higher mortality.
  • Bone structure and body weight: Petite, thin women have a greater risk of developing osteoporosis because they have less bone to lose than women with more body weight and larger frames. Similarly, small-boned, thin men are at greater risk than men with larger frames and more body weight.
  • Family history: Heredity is one of the most important risk factors for osteoporosis. If your parents or grandparents have had any signs of osteoporosis, such as a fractured hip after a minor fall, you may be at greater risk of developing the disease.
  • Prior history of fracture/bone breakage.
  • Certain medications: The use of some medications, such as the long-term use of steroids (like prednisone) can increase risk of osteoporosis.

How Do I Know If I Have Osteoporosis?

Bone mineral density (BMD) tests, or bone measurements, are X-rays that use very small amounts of radiation to determine bone strength. A bone density test is indicated for:

  • Women age 65 and older.
  • Women with numerous risk factors.
  • Menopausal women who have had fractures.

How Can I Prevent Osteoporosis?

There are many ways you can protect yourself against osteoporosis, including:

  • Exercise: Establish a regular exercise program. Exercise makes bones and muscles stronger and helps prevent bone loss. It also helps you stay active and mobile. Weight-bearing exercises, done at least 3-4 times a week, are best. Walking, jogging, playing tennis, and dancing are all good weight-bearing exercises. In addition, strength and balance exercises may help you avoid falls, decreasing your chance of breaking a bone.
  • Eat foods high in calcium. Getting enough calcium throughout your life helps to build and keep strong bones. The U.S. recommended daily allowance (RDA) of calcium for adults with a low-to-average risk of developing osteoporosis is 1000 mg (milligrams) daily. For those at high risk of osteoporosis, the RDA is 1,500 mg daily. Excellent sources of calcium are milk and dairy products, canned fish with bones like salmon and sardines, dark green leafy vegetables, and breads made with calcium-fortified flour.
  • Supplements: Calcium carbonate and calcium citrate are good forms of calcium supplements. Be careful not to get more than 2,000 mg of calcium a day. That amount can increase the chance of kidney stones.
  • Vitamin D: Your body uses vitamin D to absorb calcium.  You can get vitamin D from eggs, fatty fish like salmon, cereal and milk fortified with vitamin D, as well as from supplements. People aged 51-70 may need a higher amount of Vitamin D daily.
  • Medications: Actonel, Evista, Fosamax, and Boniva are some of the drugs available to help treat and/or prevent osteoporosis.
  • Estrogen and Testosterone: Estrogen helps protect against bone loss. It is used as treatment for the prevention of osteoporosis. Replacing estrogen lost after menopause slows bone loss and improves the body’s absorption and retention of calcium. Testosterone actually builds bone.
  • Avoid certain medications: Steroids, some breast cancer treatments (such as aromatase inhibitors), drugs used to treat seizures (anticonvulsants) and blood thinners (anticoagulants) increase the rate of bone loss if not used as directed. If you are taking any of these drugs, speak with your doctor about how to reduce your risk of bone loss through diet, lifestyle changes and, possibly, additional medication.
  • Other preventive steps: Limit alcohol consumption and do not smoke.  Smoking causes your body to make less estrogen, which protects the bones. Too much alcohol can damage bones and increase the risk of falling and breaking a bone.

How To Get Calcium If You Are Lactose Intolerant

If you are lactose intolerant or have difficulty digesting milk, you may not be getting enough calcium in your diet. Although most dairy products may be intolerable, some yogurt and hard cheeses might be digestible. You can also eat lactose-containing food by first treating it with commercial preparations of lactase (which can be added as drops or taken as pills). There are also lactose-free dairy products you can buy. You can also eat lactose-free foods high in calcium, such as leafy green vegetables, salmon (with bones), and broccoli.

Weight-Bearing Exercises and How They Help Strengthen Bone

Weight-bearing exercises are activities that make your muscles work against gravity. Walking, hiking, stair-climbing, or jogging are all weight-bearing exercises that help build strong bones. Thirty minutes of regular exercise (at least 3 to 4 days a week) along with a healthy diet may increase peak bone mass in younger people. Older women and men who engage in regular exercise may experience decreased bone loss or even increased bone mass.

Protecting Yourself From Fractures If You Have Osteoporosis

If you have osteoporosis, it is important to protect yourself against accidental falls, which may result in fractures. Take the following precautions to make your home safe:

  • Remove loose household items, keeping your home free of clutter.
  • Install grab bars on tub and shower walls and beside toilets.
  • Install proper lighting.
  • Apply treads to floors and remove throw rugs.

 

The Effects of Testosterone

April 12, 2017
Hormones

Testosterone is often called the “male” hormone. However, both men and women produce testosterone. Hormones are molecules that regulate the body. They are usually produced in one location in the body and travel to other organs.

Testosterone is an androgen hormone. It produces male characteristics in the body.

Testosterone is made in the following locations:

  • testes in men
  • ovaries in women
  • the adrenal glands, located above the kidneys in both men and women

Men have higher levels of testosterone in their bodies than women. In either sex, if testosterone levels become imbalanced, adverse symptoms can occur.

Testosterone is responsible for many actions in the male body throughout a man’s life cycle. It helps the external and internal organs of a male fetus develop. This includes the male reproductive organs such as the penis and testicles.

During puberty, testosterone is responsible for:

  • growth spurts
  • deepening of the voice
  • growth of hair in the pubic region, face, and underarms

Testosterone is also associated with behaviors such as aggression and sexual drive. Men need testosterone to make sperm.

In women, testosterone also contributes to a woman’s sex drive. It also helps to secrete hormones important in a woman’s menstrual cycle.

Testosterone also plays common roles for both sexes. For example, the hormone stimulates the body to make new red blood cells. Testosterone can also affect a man’s bone density, fat distribution, and muscle strength.

Low testosterone in men can cause many physical symptoms.

It can also cause insulin resistance, which can contribute to diabetes. Examples of symptoms caused by low testosterone in men include:

  • decreased sex drive
  • erectile dysfunction
  • higher percentage of stomach fat
  • gynecomastia (development of breast tissue)
  • infertility
  • lack of body hair
  • lack of deepening of the voice
  • low muscle mass
  • slowed growth of the testicles or penis

A boy will typically start puberty at around age 10. If this is delayed, low testosterone levels could be the cause.

Possible causes of low testosterone in men include:

  • chronic health conditions such as diabetes
  • damage to testes, such as physical trauma, alcoholism, or viral illnesses
  • genetic diseases
  • hypothalamic disease or tumor
  • pituitary disease or tumor
  • testicular failure

In women, low testosterone can result in:

  • decreased sex drive
  • infertility
  • irregular or absence of menstrual periods, known as amenorrhea

Low testosterone in women can be caused by:

  • long-term use of oral contraceptives
  • advancing age
  • ovarian failure or removal of both ovaries

In both genders, low testosterone levels can cause mood changes such as:

  • lack of motivation
  • depression
  • difficulty concentrating
  • problems with memory
  • insomnia

Having too much testosterone can also cause health problems.

In boys, undergoing early puberty, also called precocious puberty, can cause development of:

  • facial hair
  • deepening of the voice
  • well-developed muscles
  • growth of the sexual organs

Early puberty can be caused by tumors and a condition known as congenital adrenal hyperplasia.

Potential causes of excess testosterone in men include:

  • congenital adrenal hyperplasia
  • taking anabolic steroids
  • tumors of the testicles or adrenal glands

In women, excess testosterone can cause a condition known as hirsutism. This causes a woman to develop body hair in a male fashion, including on the face. Virilization is another condition caused by excess testosterone. This causes a woman to have a masculine appearance. Symptoms can include male pattern baldness and a deep voice.

Ovary or adrenal gland tumors and polycystic ovarian syndrome are potential causes.

Taking certain medications can increase testosterone levels in both men and women.

Examples of these medications include:

  • anticonvulsants
  • barbiturates
  • clomiphene
  • estrogen therapy

Talk to your doctor before you stop taking any medications.

A man’s testosterone levels will typically peak somewhere between age 20 and 30. After this time, they will gradually decrease for the rest of his life. Testosterone levels are estimated to decrease by 1 percent annually after age 30 to 40. Therefore, lower testosterone levels are more common among older men. This explains some of the age-related changes in men, such as loss of muscle mass.

Women’s testosterone levels peak in their 20s and then begin to slowly decline. When a woman starts to experience menopause, her testosterone levels are half of what they were at their peak. A woman’s adrenal glands will make less testosterone during menopause. The ovaries will continue to produce testosterone after menopause but stop producing estrogen and progesterone.

Treating the condition that is causing high or low testosterone levels can help restore levels. But it’s not always possible to find a cause of testosterone imbalances. Your doctor can prescribe testosterone replacement to correct low levels.

There are several treatments for low testosterone. Examples include:

  • topical gels and creams
  • sublinguals
  • patches
  • injectable testosterone
  • implantable testosterone

Both men and women may take testosterone therapy. A woman may take testosterone to improve sex drive and reduce sexual dysfunction. However, women must have an appropriate level of estrogen before treatment. This is because testosterone can affect a woman’s estrogen levels.

Testosterone replacement therapy can cause side effects, such as:

  • acne
  • breast tenderness or enlargement
  • increased amount of red blood cells
  • infertility
  • small testicles
  • swelling of the low extremities