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Join Dr. Emma Pollon-Macleod, Naturopathic Doctor and Grace Meehan, Clinical Pharmacist NAMS Certified Practitioner where they discuss over Katherine's 1-month progress and treatment plan.
Emma: Hi everyone, thanks for tuning in today. I am Doctor Emma Pollon Mcleod, Naturopathic Doctor.
Today I have with me Grace Meehan, one of our pharmacists, and NAMS Practitioner. That stands for 'North American Menopause Society Practioner'.
Super knowledgeable in the field of menopause, and that's why I wanted to pull her into this video, so we could talk about the follow up to the case blog that I just posted earlier on in the week.
So, we had talked about a case that I had, 49-year-old women, Catharine, who was coming in with problems with sleep, mood, problems with gaining weight around the middle. I chose this case because it is a good representation of what I see often.
Grace: So common.
Emma: Yeah, really, really common. Sleep problems arise, fairly early on, I find that women would report that they've been sleeping well. Then it's the frequent waking up, 2-3 am in the morning, mind racing, not sleeping well, then they are restless all night, not feeling rested, and refreshed in the morning.
It's starting to really impact on their mood, they're not working out as much because you're sleep-deprived, and then you're gaining weight in the middle.
So, it's kind of this snowball effect that we see really often when women go and see their physician, a lot of the times a solution that's presented to them is sleeping pills.
Grace: Sleeping pills or anti-depressants.
Emma: Yes, exactly. So there is an alternative, and that's what we are here to talk about. Based on that, if you go read the blog, what we have recommended, we did the initial intake, we decided to do a comprehensive blood panel, and we did an anti-inflammatory diet for thirty days.
Today I want to discuss our follow up. So this would have been 3-4 weeks into the diet, and after I have the results for the blood work.
On her blood work findings, let's talk about hormones first because that is really important. In peri-menopause, we do measure hormone levels as a baseline. Yes, they are going to fluctuate.
We know that a lot of people will say, what is the purpose of testing because there are such fluctuations, so, the reason we test is so we do have a baseline and I get a sense of how much estrogen is still releasing.
For Catherine, it hadn't been a full year since she hadn't had a period. So she had had her period, I think I wrote about 6 months prior and before that, it was 3 months. So it's starting to become quite irregular, but again, understanding, if there are surges in estrogen at that point, will guide me to know if it's appropriate to give estrogen or not.
And so for this case, when I looked at her blood work, her ATHSH was in her 50s, her Estroidal was a little, she was still making a little bit, so she was around 95, her ovaries were still releasing some estrogen, and her progesterone was at zero.
Again, this is quite common, so it's telling me that there's still a little hormone released from the ovaries, and giving estrogen at this point might not be the best idea. So what we have decided to discuss today, is the use of progestogen for her.
She is not making any progesterone, she is making a little estrogen. Sometimes, that imbalance in perimenopause, and you see this quite often, when progesterone really dip and they stay low, and then you have this estrogen that is surging and dipping, surging and dipping, and it can really impact mood, body temperature, that sort of thing. You've seen it-
Grace: Oh absolutely, and it's in perimenopause that women will say that they feel their worst, and they feel better post-menopause when things become more stable. So it's kind of like a crazy time, and women wonder what has happened to them.
Emma: Yes, exactly, and when we talk about hormones when we talk about hormone replacement, we really are talking about two, progesterone and estrogen for women.
So with Catherine, I guess I will get into the hormones now because that's what we are interested in and then we will go through the rest of the blood work.
So, because her hormones were really low, her sleep was super disrupted, she is really stressed out in the evenings, she's anxious, we decided to give her a little progesterone, and she is going to take it in the evenings.
Grace let's talk a little bit about that. So I started her on a little really low dose, because, especially with hormones and because we like to use compounding pharmacies, we get to dose very uniquely based on a women's needs.
So we don't need to give tons of hormone if we don't need to. Sometimes it just takes a little bit to get that calming sensation, and really helps kind of regulate mood, and sleep.
Grace: And we've seen this clinically. Progesterone we talking about, good micronized progesterone. Very, very different to hat was used years ago in women which were synthetic.
Micronized progesterone is very calming. Now, there's a commercially available micronized progesterone, which is a great product, but it's in a bit of higher strength, and we found, that someone doesn't need that much.
So starting them off at 25mg, letting them titrate up to their sweet spot, really works well.
Emma: And when we say micronized progesterone; that means bio-identical progesterone. That's the same progesterone that your ovaries are releasing. We can actually measure it as well.
Grace: It is very, very calming. Progesterone is the hormone that dips first in the perimenopause. That's the one that goes down, and that's when sleep becomes a problem and women report feeling irritable, and anxious because progesterone calms the body. It's really necessary to keep us feeling calm.
Emma: Exactly, and the nice thing about, and when we talking about progesterone, progesterone is the pre-curser to adjusting your hormones.
When there is a lot of stress you're running on an empty tank, your body is running on a lot of cortisol, stress hormones, so you will actually utilize more of your progesterone to start making these stress hormones, so, it's another decline in progesterone, and in this day and age when we are just pulling ourselves through, not sleeping, we're just draining that tank of progesterone.
So, we're losing that nice balance between estrogen and progesterone; that a woman needs to kind of, feel calm, and confident, and regulate it--
Grace: And sleep.
Emma: And sleep. Let's talk about the safety of progesterone, in this case, because that is a big question and this is a big reason why I wanted, Grace Meehan, Pharmacist, in on this conversation, because the controversy with hormones is around safety, and a lot of women is very skeptical or nervous because of what they've heard, or because of what their friends or Physicians are telling them.
Let's talk about what you say to your patient about progesterone, and I will say what I say.
Grace: So, progesterone, micronized progesterone is so very very different than the synthetic that was used in the WHI study, the HER studies, many studies, so the synthetic was the one that was really implicated in causing issues in women, meaning, increased number of breast cancer cases, increased heart disease, etc.
It was the synthetic progesterone that was used back then. Micronized progesterone being what our bodies and what our ovaries make, there's a lot of safety information concerning, out there.
It's never ever, micronized progesterone has never been implicated in health risk in women, having said that, if you are in perimenopause, and there might be fibroids growing, sometimes progesterone can help the growth of a fibroid. That's something your clinician would take into consideration.
Emma: Yeah of course, and we do practice with an abundance of caution, you know, not everybody is a candidate for hormones.
What I haven't really discussed is Catherine's family history was clear, there is no family history of hormone-positive cancers or personal history of personal positive cancers. She is in a good weight range, she is a non-smoker… She exercises a lot so there is a lot working in her favor as well.
Another one of the risks that we, I like to say, especially, in the early forties, when we start using progesterone is when ovulation is really sporadic, it's very hard to tell your cycle and we start to get progesterone, which is a bit of fertility-enhancing hormone.
We like to say just use extra caution, and that's kind of the other risk.
Grace: No surprises.
Emma: No surprises, so, we're giving her a little bit progesterone, we're having a safety discussion, we're talking about, even though we are not giving estrogen, even when we start bringing in progesterone, I do like to talk about monitoring methods, looking at breast health, talking about mammograms-
Grace: Because that is women's health, in mid-life. That' all-important.
Emma: Exactly, and so we shouldn't be afraid to talk about these things, to be afraid to scare women off hormones but we should educate people on their breast health, their uterus health, giving a little bit of progesterone when you don’t have any, and you're still producing estrogen, is protective of the endometrium.
Grace: And the breast actually, and you have high levels of estrogen, and low levels of progesterone, that's when you can get more density in the breast and breast density is a risk factor for breast cancer.
Emma: It can be really helpful and protective if you’re starting to just emulate your uterus with estrogen, and you don't have progesterone. You might notice more of a bleed when you first start. That's okay. Because you're helping to shed that lining.
So that's why it's nice you have a pharmacist you can talk to about hormones like Grace who is so knowledgeable.
So we did a little bit of progesterone, we will start with 25mg, very nice and low, taken at bedtime. When we went through the rest of her blood work, we saw that her vitamin D was really low, it was at 50. Ideally, we want vitamin D levels to be around 120.
And then especially for women's' health bone density is a really big thing as you transitioning through perimenopause. Estrogen is very protective of the bones it promotes bone formation and bone strength. When those levels start o decline, you lose that, and that's why women are more at risk for osteoporosis than men.
So, strengthening of the bones, the immune system, it's really, really essential. So for her, we're dosing her around three thousand units per day just to maintain --
Grace: Not to mention that is very important for our mental health as well.
Emma: Yes, for sure. Yeah, mood, mental health, stability. So it's really essential. We also saw that her B12 was quite low. So it was in the two hundred.
I actually ended up giving her a B12 shot because it was so low she was eating animal protein. But often when a B12 is that low and someone's eating animal protein, it's telling you there guts a little inflamed, and it's not absorbing nutrients, and fat-soluble, vitamin D is low as well.
So we really wanted to work on gut health with her. So we gave her a B12 shot. Following up on the anti-inflammatory diet, she actually noticed an improvement in her anxiety, and mood, and energy, just from the diet alone before we even did any hormones or anything at all.
So that was really, really, really eye-opening for her because we hadn't done anything.
Grace: We see this all the time.
Emma: All the time. Yeah, yeah, yeah. So interesting. And it's empowering for women to kind of, as your hormones change, the way you respond to different foods changes.
You know, it's just like sometimes with alcohol, your tolerance changes as you age. Same with sugar and processed foods.
What you used to be able to consume, you might not be able to consume anymore, but you don't even notice that that's what's kind of triggering that really sluggishness, low mood fogginess.
So that's really where diet comes into play. Major League.
Grace: Yeah, yeah. It's not as simple as just taking a hormone. It's so much more than that. And when you do target the guts, everything gets better and the hormones can be just a little adjunct to it to get women over the top where they feeling really good.
Emma: Yeah, that's what we like to say. We call the hormones the sprinkles on top.
Grace: Yeah, right. Sprinkles on top.
Emma: They're not the base layer. You know, you have to bake the nice foundation, then you do the icing on top, which is the other nutritional supplement. So your diet is the base. You have vitamin D or B vitamins. We gave her magnesium as well. Nice and calm in the evening. Great for mood stability as well.
Gave her some B12 and then just a little sprinkle of hormones on top to help really regulate and balance everything. That's really kind of the way that we go about doing it.
So for Catherine, the last thing that we did for her, so we gave her magnesium in the evening. Two hundred milligrams before bed, really nice and calming. It's a really simple protocol that we did for her, but we just really wanted to see what some slight tweaks would do for mood.
And then we go from there, we peel back layers, what's improved, what's gotten better, what hasn't. And then we keep working together to make sure we're getting her into that optimal area where she feels really good, rested, energized, the mood is coming back in, and often this is all it takes.
Emma: It doesn't need to be this crazy, huge, complicated treatment. And then, oh, the last thing I want to talk about, Grace, was, she had also mentioned and it's funny this happens a lot.
It's not only and it's not on the chief concerns, it's not really anywhere on the intake. But I always like to ask about libido, vaginal dryness… Sensation down there. Like, some women don't really find the word 'dryness' clicks with them, more of a discomfort or a lack of sensation down there.
And that can be because your estrogen levels have been declining and estrogen is what allows the vaginal tissue to retain moisture in elasticity. So sometimes women experience pain with intercourse, that sort of thing.
And so, Catherine, we're starting to notice quite a bit of dryness, discomfort, and pain with intercourse. So much so that she didn't want to engage in intercourse with her partner anymore. So we gave her a really nice low dose of vaginal Estriol cream.
Grace: Yes. So important because this symptom is so prevalent amongst peri-menopausal and postmenopausal women. In fact, a recent study in NAMS showed that it's causative for depression and anxiety at midlife.
In women, it's so important and it's undertreated and women forget to mention it to their practitioners or they think it's just, you know, oh, well, that's what happens.
But when we treat this, it restores the vaginal tissue back to how it should be and gets women back their sex lives, their relationship with their partners. And, you know, there's a great window of opportunity to treat women with this.
So like you're saying if you start women with some low dose of estrogen, you know, late perimenopause into post-menopause, it's easy to treat this tissue. But if you wait, it gets worse and worse and worse and worse.
It is harder to get somebody in. The 60s and 70s, back to normal, that tissue is so fragile and irritated. So, yeah, it's a kind of slam dunk when it's done properly and at the right time.
Emma: Exactly. And often, you know, we give an ultra-low dose. I like to a point one percent Estriol, not estradiol, Estriol, which is a more gentle form. I like to pair it with hyaluronic acid, which is a moisturizer in itself.
Often, women, you know, for Catherine, what I would tell her is expect almost immediate relief within the first two weeks. So you use it two weeks every night and then thereafter, like once, twice a week.
And often that's all it takes. And some women, you know, maybe we'll use it once a week, twice a week here and there. They'll forget sometimes and then use it again. But all it is just making sure that we're getting a little bit of consistent estrogen in the area and it can make a world of a difference.
And I'm sure some of you listening are a little bit you might be a little confused being, you know, thinking to yourself, wait, you just said not to give estrogen to this woman. Why are we talking about vaginal estrogen? So when we talk about vaginal estrogen, the doses are extraordinarily low. So we're using it; as a very localized treatment. It is just to treat the vaginal tissue. It is not a hormone replacement therapy.
Grace: Right. So they're not going to do anything for hot flashes.
Emma: No. And so this is very this is a very different conversation. There's a whole bunch of research for low dose estrogen therapy or estrogen therapy vaginally.
This is in Canadian medical guidelines. So it's really not controversial. It doesn't fall into the hormone replacement therapy category. But we like to use, I like to use a cream. So the commercially available one is a tablet, and for it's a tablet that you insert and some women like it.
But I find for a case like this with Catherine and it's bioidentical as well. So we're talking all bioidentical, in a case like Catharine's, we do like to start with the cream because we can actually get some moisturizing, other compounds in it and then you can again type treat up your dose.
You're not having to insert a tablet into a potentially really uncomfortable area. So that could cause more damage.
Grace: And you can take a little bit of the cream and apply it over the labia, too, which can be dry and irritated with that.
So creams have a good advantage over tablets.
Emma: Exactly, exactly. You can start a little bit more externally and work your way internally. And that's often the way that we tell women to start using it. And again, that's often how we got the best results.
So thank you so much for tuning in. Thank you so much, Grace, for doing this for me. I really appreciate it.
If you haven't read the blog, you can go ahead and read it. Otherwise, have a lovely day. And thanks for tuning in here.
Grace: Take care.