Patient Success Stories: Part II
It’s Only Menopause! (Part 1 of Lori’s Story)
Although this is specifically Lori’s story, and the details and successes of her journey have been recorded by me, her saga could apply to half of the women I work with in my office. Her accomplishments, however, are unequivocally her own. Lori’s story immediately came to mind when I was asked to write this entry on “Menopause Success Stories,” as I had just seen her for her annual appointment, and she was so proud in her now sized 8-10 clothes!
Lori first came in a year and a half ago. The few words on my schedule were: “NP (new patient): Help w/ menopause.”
That pretty much described it. Lori’s chief complaints were: “hot flashes & night sweats that are ruining me,” and “I crave a good night’s sleep.” Not surprisingly, she was fatigued, overly moody, mentally foggy and forgetful, had achy joints (“OMG! Am I going to have to put up with this for the rest of my life?”). After a little probing, Lori also relayed that she’d lost all of her interest in sex (poor husband Phil!). If Philip persisted, she was dry and it burned afterwards. (“Maybe I should just sew it shut!”) NOT a happy state of affairs.
First Appointment: Careful Analysis, Instead of Hasty Diagnosis
I explained to Lori that my place was not to make a hasty diagnosis and write her a bunch of prescriptions but to listen to her story carefully. I warned her I’d be frequently interjecting and asking questions to make sure I was hearing her right. While listening, I would acknowledge what I’d heard in order to absorb her story, enabling me to make a proper diagnosis. From there, I would basically be her guide to help her to accomplish what she wished in a way that was comfortable for her.
I also asked Lori to complete the MENSI (MENstrual Symptomotology Index), which not surprisingly showed a total score of 21, with 10 “yes” answers in the areas of hot flashes, sleep difficulties, fatigue, anxiety, memory, joint aches, vaginal dryness, diminished libido, and disrupted function both at home and in the workplace.
I asked her to define her goals, so as to have a goal by which to measure her progress. Lori listed the following as goals:
· “to feel normal”
· “to get on top of this”
· “to feel valuable again, both at work and home”
· Oh, and yes- “to lose a few pounds!”
I briefly repeated what I’d heard and my diagnoses: menopausal symptoms, insomnia, loss of sexual desire, weight gain, and fatigue. Lori confirmed my perceptions. I then reviewed alternatives, including herbs and botanicals, hormone therapy, non-hormonal medications including anti-depressants, and, most importantly, lifestyle re-evaluation.
This pretty much used up our first visit time, and I set up another appointment one week later to discuss therapy and order lab. “This will take a little while,” I told her. “Rome wasn’t built in a day; we want to get this right!”
Second Appointment: Tests for Underlying Issues & Therapy Discussion
Lori returned a week later. Although I suspected her fatigue was mostly secondary to changing hormone levels and lack of restful sleep, she had not had any basic blood work in years (certainly not since the 20+ pound weight gain she admitted she’d had in the past two years). Because of this, I elected to run a number of tests:
· Thyroid levels;
· Lipids, using a “VAP” rather than the standard lipid profile that most docs order, so
as to give a more in-depth picture of her true lipid values;
· Diabetes screen;
· Basic fatigue-oriented tests including a blood count, auto-immune screen, and basic
· Because of Lori’s peri-menopausal status and diminished sexual desire, I also
added free and bioavailable testosterone to her panel.
We then discussed therapy. Lori had heard from a friend (as well as “that big study a few years ago”) that estrogens cause cancer and was unenthusiastic about a hormonal approach. I acknowledged her fears, but educated her that all of the negative studies on estrogen were performed with quite high dosages of oral estrogens, plus a particularly strong synthetic progestin (medroxyprogesterone acetate or Provera™) that had been the standard for many years.
I assured Lori I worked only with transdermal bioidenticals (both FDA-approved and compounded) and explained how studies of transdermals both in the US and Europe showed little, if any, increase in breast cancer, plus provided a significant decrease in coronary vascular disease (the #1 killer of women), in addition to bone preservation, better cognition, and other advantages, if therapy is started at or shortly after menopause.
Because Lori did not wish to use the anti-anxiety, anti-depressant medications available to help with hot flashes and sleep, we settled on botanicals and amino acids, including black cohosh, evening primrose oil, phyto estrogens, and the amino acids l-theanine and 5-hydroxy tryptophan. Lori purchased some of these at our office and some at a local health foods store. We then set up another appointment for three weeks to review her lab results and for an initial follow-up on her therapy.
Third Appointment: Review of Lab Results, Some Symptoms Improved
When Lori returned, she was marginally better. The l-theanine and 5 HTP had calmed her and aided with sleep. The other botanicals had lessened her other complaints a bit. Her lab was remarkable, except for her abnormal lipids (high LDL-cholesterol, low HDLcholesterol, both with small particle size, elevated triglycerides, and elevated apoBlipoprotein) as well as modestly low testosterone levels.
The adrenals looked fine, but her reserve was compromised as indicated by a somewhat elevated AM cortisol and low pregnenalone results. We decided to re-check the pregnenalone and testosterone and to perform a cardiac C-reactive protein and 1-hour postglucose serum insulin level to check for “insulin resistance,” because of her fatigue, hypoglycemic-like symptoms, and abnormal lipids.
I scheduled a fourth appointment with Lori to have her return in another two to three weeks to review the new labs and to better evaluate how the botanicals were working for her. We also planned to begin the important task of “lifestyle work.” Additionally, because of vaginal dryness that was putting a damper on her sex life, I prescribed a micro-dose of a vaginal estrogen product to help “revitalize” her vaginal tissues, which were thinned and dried secondary to her falling estrogen levels.
Fourth Appointment: Two Months Later, Initial Short-Term Improvement
Lori returned for her “three-week” visit actually almost two months later. She had not yet had her labs repeated nor had she started the vaginal estrogen, because she reported she was “feeling so much better” from the botanicals.
When we discussed her abnormal lipids and weight gain, she expressed clearly she wanted no meds and would “take care of things” herself with a planned diet and health club membership.” Believing things were under control, Lori decided against any further counseling. Instead, she agreed to return in two to three months to see how she was doing.
Six Months Later: Botanicals Lose Effectiveness, Symptoms Worsen
Lori next returned to the office six months later in a state of panic. Everything was falling apart. Her hot flashes had considerably worsened. Her sleep—when she was able—was not restful. She hadn’t had sex in a month due to dryness and lack of desire, and even had a poor performance evaluation at work, secondary to diminished memory, sleeplessness, and poor attention span.
Lori was flabbergasted: “I don’t know what’s wrong; I’ve even increased the herbs!”
I explained to her that although the botanicals had helped initially, as she progressed deeper into menopause, they were no longer effective. “It’s all about estrogen.” I explained. “Yours has been falling and now is quite low.”
“Can I just tough it out? I’m sure I can do that if it’s only going to be bad for another month or so.”
“I wish that were the case,” I explained. “Unfortunately, it takes many months, sometimes years, for your body to acclimatize.”
To add insult to injury, Lori had gained another five pounds. She was finally ready to listen to my counseling.
A New Game Plan
“Rome wasn’t built in a day,” I reminded her. I outlined a plan for her, and how we’d approach her therapy, and again reviewed the basic safety data on low-dose transdermal HT with micronized bioidentical progesterone at nighttime to both protect her uterus from the effects of “unopposed estrogen” and promote quality sleep. She was now ready to recheck her abnormal labs, test for insulin resistance, and listen to my lifestyle-education approach.
I gave Lori the choice of either a twice-a-week quarter-sized bioidentical estradiol patch, or one of the several FDA-approved bioidentical gels or sprays on the market in addition to compounded products. She choose the Vivelle Dot™ patch (I gave her samples to start to see if she liked them) and micronixed progesterone at bedtime in addition to Vagifem,™ a micro-dose vaginal suppository to be used every other night. We scheduled a follow-up in one week to discuss “lifestyle issues.”
Stay tuned to the blog to read Part Two of Lori’s story coming soon. In the meantime, learn more about menopausal medicine, including safe hormone therapy, at www.drmichaelgoodman.com.