Although checking blood levels gives some information, these levels do not register as abnormal until you have been estrogen-deficient for many years. In addition, levels vary dramatically throughout the month. I have found that the best way to tell if a trial of natural estrogen is needed is to ask the simple question: “Are your CFS or fibromyalgia (not PMS) symptoms worse around your period?” If the answer is yes, that is, your fatigue, pain, and brain fog are worse around your period, when estrogen and progesterone levels are lowest, this suggests that estrogen and progesterone deficiency are contributing to your symptoms. In addition, hormone levels drop at midcycle around ovulation. For example, panic attacks, migraines, and palpitations that occur for one to two days around ovulation or around your period are often triggered by dropping estrogen levels. Because of this, it can be helpful to keep a symptom log relative to your periods.
One other point is critical to note. If you have had a hysterectomy, even if your ovaries were not removed, you will likely become estrogen deficient within two years. Though this research was done at Yale, most physicians are not aware of this fact and presume that as long as the ovaries remain, estrogen deficiency will not occur. This is why so many women, even in their twenties, develop CFS/FMS after a hysterectomy. Although it has not been researched, I suspect this may also occur after tubal ligations.
The importance of estrogen deficiency is reflected in research, which shows that 25 percent of women said that their FMS symptoms started with the onset of menopause and 26.4 percent said that the severity of their previous symptoms increased after menopause. Of all the premenopausal females, 45 percent admitted to higher pain severity and 57.5 percent to a higher fatigue severity during their menses, when estrogen levels are the lowest.90
TREATING LOW ESTROGEN AND PROGESTERONE
I strongly recommend that bioidentical hormones be taken in a balance that mimics that found in a thirty-year-old woman. These are made by compounding pharmacies. The form of estrogen that I use in my practice is called BiEst, and 2.5 milligrams daily (containing 0.5 milligram of estradiol and 2 milligrams of estriol) is a good dose for most women.
If you take supplemental estrogen, you must also take natural progesterone to prevent uterine cancer. I usually add natural progesterone even in women who have had a hysterectomy, because progesterone also improves sleep and decreases anxiety. You’ll probably find that a dose between 30 and 100 milligrams a day, taken at bedtime, is best. Higher doses can aggravate the depression that often accompanies CFS/FMS, so it’s important to pay attention to how you feel when you start taking these medications. Taking both estrogen and progesterone every day (instead of cycling hormones by only taking them for the first twenty-five days of each month) will often result in your periods going away after six to nine months, and most women over forty-eight prefer this approach.
The discussion of estrogen and progesterone supplementation is an important one. Although many women are concerned with studies showing an increased risk of breast cancer associated with the use of synthetic estrogen and progesterone, the data suggest that this risk is predominantly associated with the use of Premarin and synthetic progesterones, and perhaps estradiol. Premarin is the brand of estrogen most commonly prescribed for menopausal women. It contains a form of the hormone that comes from pregnant horse urine (pre = “pregnant,” mar = “mare,” in = “urine”). I think it’s medically absurd to prescribe this for human females. There is not likely to be an increased risk with the bioidentical hormones we are recommending (see below). In fact, estriol, the estrogen that goes up most during pregnancy, is likely to actually decrease breast cancer risk. This is reflected in many studies, including those showing that multiple pregnancies are associated with less breast cancer risk. In addition, estriol has dramatic immune-altering effects, which cause multiple sclerosis to improve and which are also likely to help CFS/FMS. Estriol is likely one of several reasons that CFS/FMS improves during pregnancy.
Research and clinical experience show that bioidentical hormones are safer than their synthetic counterparts and leave women feeling better. It is my impression that nonbioidentical hormones have been used mainly because they are patentable and therefore more profitable for drug companies. However, the tide looks to be turning as more and more well-informed doctors are speaking out on the safety and efficacy of natural, bioidentical hormone supplementation.
For more information on the safety of bioidentical hormone replacement, see the article by Dr. Kent Holtorf on the From Fatigued to Fantastic! notes section at www.vitality101.com. Dr. Holtorf is the medical director of the Holtorf Medical Group, Inc, Center for Hormone Imbalance and Fatiguing Conditions, in Los Angeles (310–375–2701). Although highly technical, it will likely leave you comfortable with the safety of bioidentical hormone replacement therapies.
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The Women’s Health Initiative Study and the HRT Controversy
Natural bioidentical hormones for hormone replacement therapy (HRT) are unlike their synthetic versions, often having completely different effects. Thus, it is critical that women be given the information that these natural hormones do not have the negative side effects of the synthetic hormones and in no way pertain to the conclusions reached by the Women’s Health Initiative (WHI) study. Natural hormones are a safe and more conservative approach to hormone replacement therapy and without the risks associated with Premarin and Provera.
Clinically, patients feel much better on the natural hormones, while synthetic hormones do not work as well and cause severe side effects. Medical research confirms our clinical experience 2,50 and shows that HRT with bioidentical hormones is also safer.1–79
HRT and the Risk of Heart Disease and Stroke
The WHI study demonstrated that when synthetic progesterone (Provera) was added to Premarin, there was a substantial increase in the risk of heart attack and stroke. 12–17, 34–36, 49–51, 53, 54, 65, 70–73 Natural bioidentical estrogen and progesterone, on the other hand, have an opposite effect, decreasing the risk of heart attack and stroke.49, 50, 61, 67, 70, 71, 72, 76, 77
One of the causes of heart attack and stroke is blood vessel spasm, which is decreased by natural estrogen and progesterone. 13–15, 68, 69 Unfortunately, synthetic progesterone actually increases spasm and heart attack risk, 13–15, 69 to the degree that researchers noted the following: “We conclude that medroxyprogesterone (Provera) in CONTRAST TO PROGESTERONE increases the risk of coronary vasospasm 13 [emphasis mine].” In women who already had chest pain (angina) with exercise, natural progesterone increased how much exercise the women could do versus how much they could do when taking Provera. This was marked enough that the researchers found that “these results imply that the choice of progestin in women at higher cardiovascular risk requires careful consideration. Provera is expected to increase the risk of heart attack and stroke, while progesterone is not.” 14
For many years, doctors believed that estrogen protected the heart. This is indeed the case, as natural HRT decreases blocked arteries by half.61 However, when Provera is used, this benefit is negated and diabetes risk is increased. 49, 51, 52, 62, 73, 75 Natural progesterone by itself 76,77 or in combination with estrogen 15, 51, 61, 66, 67, 70–72 will protect the heart, while Provera reverses estrogen’s heart-protective benefits. 15, 51, 53, 54, 63–65, 70, 72 In fact, a major review article found that the scientific research “taken together, provide[s] a basis for concern, not about all progestogens, but specifically about MPA [Provera].” 15 Natural progesterone is also more effective than Provera in improving good cholesterol (HDL) levels. 12,34 This effect was so marked that Elizabeth Connor, a cardiologist and researcher on the major PEPI (Postmenopausal Estrogen/Progestin Interventions) study stated: “If I were treating a woman primarily because she was worried about heart disease or…HDL cholesterol, I would probably see if she wanted to take micronized [natural] progesterone. I was quite impressed with the better effect.” 12 In addition, the president of the American Heart Association st
ated that a woman who changes her medication from Provera to natural progesterone would significantly lower her risk for heart disease. 35 Finally, Premarin, an oral estrogen, will increase clotting factors and inflammatory proteins, increasing the risk of blood clots. 16,18 This does not occur with natural transdermal estrogens. 18 Given all this, it is no surprise that the WHI study showed an increased risk of heart attacks and strokes using synthetic hormones. The good news is that bioidentical hormones have actually been proven to protect your heart.
HRT and the Risk of Breast Cancer
The synthetic estrogen Premarin increases breast cancer risk by 23 percent, and adding the synthetic progesterone Provera to the mix increases that risk by 38 percent to 67 percent.9,10,78 This is in contrast to natural estrogens and progesterones, which reduce the risk of breast cancer.
Premarin is made from pregnant horses’ urine, hence its name Pre (pregnant)-mar (horse)-in (urine). It consists of a combination of conjugated equine (horse) estrogens that are much more potent and cancer-causing than bioidentical estrogens.20–22,80
Most compounded bioidentical hormones are a mix of estriol, which is normally present but rises during pregnancy, and estradiol, which is the hormone used in estrogen patches. Estriol is shown to cause much less breast cell proliferation and is felt to be even safer than estradiol 40–48 and much safer than Premarin. 23–27,39 Estriol appears to inhibit breast cancer,24, 26, 39 and the higher your estriol level, the lower your risk of breast cancer. 25, 26, 56, 57, 59, 60 In fact, an analysis of six studies found that there are higher estriol levels in populations with lower risks for breast cancer.26 The protective effects of estriol against breast cancer are so pronounced that a study in the JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION found that 37 percent of women with breast cancer who were given estriol actually had remission, or arrest, of their cancer. The author of the accompanying editorial notes, “Enough presumptive and scientific evidence has been accumulated that we may say that orally administered estriol is safer than estrone or estradiol…. Let us have the estrogen that causes the least risk.”27 Premarin, on the contrary, increases the risk of breast cancer.20–22,80
As one more added benefit, estriol improves multiple sclerosis while other estrogens make it worse, another indication of its profoundly different effects. 28,29 Because of this, the bioidentical estrogen I recommend is called BiEst, a mix of estriol 2 milligrams and estradiol 0.5 milligram a day.
Several studies also show that synthetic progesterones, such as Provera, also increase breast cancer risk,4–10, 19, 33, 55, 78, 79, 81 while natural progesterone is breast-protective.1, 8, 30, 31 In fact, a Johns Hopkins study found that the risk of breast cancer was 5.4 times higher in women with a low progesterone level when compared to those with a normal level.30
Numerous studies indicate that with respect to the risk of breast cancer, heart disease, heart attacks, and stroke, natural hormones offer a safe and more conservative approach to HRT. In fact, a large amount of scientific evidence overwhelmingly demonstrates that natural hormones are safer than the study drugs of the WHI, Premarin, and Provera. Unfortunately, the overwhelming majority of women, and their physicians, do not know that there are safe alternatives to their current HRT or to the one they stopped once the results of the WHI were released. The good news is that bioidentical estrogen (especially estriol) and progesterone decrease your breast cancer risk and protect you from heart attacks and stroke.
Notes for this article follow those for Chapter 4.
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POTENTIAL SIDE EFFECTS
It is important to be aware that using the SHIN protocol will routinely result in your periods becoming irregular for six to twelve months—whether or not you take estrogen. This occurs in part because your hypothalamus cycles back to its normal rhythm as it starts to heal—and this controls the timing of your cycle. The more common side effects of bioidentical estrogen and progesterone (not synthetic, as discussed above) are fluid retention, moodiness, spotting, breast tenderness, and depression resulting from the progesterone supplementation.
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Pregnancy and CFS/FMS
Women often worry about getting pregnant with CFS/FMS. The good news is that most people with CFS/FMS do very well with pregnancy—and even after the pregnancy, given the proper support.
Most of you will actually feel much better during your pregnancy. It is after the pregnancy that you’ll need both nutritional and hormonal support to prevent the CFS/FMS from recurring. I do recommend that, if possible, you follow the treatment protocol discussed in this book for a year before getting pregnant, so you can stop the medications and other treatments that would not be appropriate during pregnancy, without losing the benefits. Although most people with CFS/ FMS do not have problems with infertility, it is more common in this population. The good news is that there are many effective natural treatments for infertility. Because they are not expensive, however, they do not get the attention that in vitro fertilization gets. I have created a section in my Web site notes using a question-and-answer format (adapted from an interview that I’d done) to answer some of the most common concerns. This is followed by general advice for a healthy pregnancy and how to deal with infertility naturally if you are having trouble conceiving. (Visit www.vitality101.com.)
Here’s wishing you a happy and healthy pregnancy, baby, and life.
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Other Hormones
In addition to the more publicized hormones above, others are also important in CFS/FMS.
Low Oxytocin
Research has shown that oxytocin, a neurotransmitter/hormone produced by the hypothalamus, is also low in fibromyalgia sufferers. Oxytocin is recognized primarily for its function in labor and lactation (milk production), but it also appears to play a major role in the day-to-day performance of the hypothalamus, and is an important neurotransmitter in the brain.91 Fortunately, it’s easy to tell if oxytocin will help you feel better by simply taking one injection. People who are pale and have cold extremities seem most likely to benefit from oxytocin treatment. Your doctor may choose to prescribe this injection, and will teach you how to administer the daily dose of 10 international units (1 cc by intramuscular injection). If the oxytocin treatment is going to help, it should do so in thirty to sixty minutes, resulting in increased energy and mental clarity with decreased pain. Oxytocin may cause transient anxiety.
GROWTH HORMONE
Current research suggests that inadequate levels of growth hormone (GH) may be an important factor for some patients with CFS/FMS who do not respond to adrenal hormone, thyroid hormone, oxytocin, estrogen, and testosterone treatment.92 Growth hormone, sometimes called the “fountain of youth hormone,” is synthesized and stored in the pituitary gland, and assists in protein synthesis and bone growth. It is also responsible for stimulating DHEA production, which as we know may be inadequate in those with CFS/FMS. In addition, this important hormone decreases pain and weight and increases stamina. For those who are unable to find relief with other hormonal treatments, suboptimal levels of growth hormone should be tested for with a blood test called an IGF-1 level.
Research studies by Dr. Robert Bennett and others show that people with CFS/FMS have significantly diminished GH levels. Other studies have shown that low GH levels can be associated with significant fatigue and CFS-like symptoms. Getting deep, restorative stage 3 and 4 sleep may well be the best way to raise growth hormone without supplementation; however, these stages of sleep are often missing in CFS/FMS.93 In addition, growth-hormone release during exercise is blocked in fibromyalgia. Dr. Bennett found, however, that growth-hormone release could be restored by prescribing a medication called Mestinon at a dosage of 30 to 60 milligrams, three to four times a day. It may take three to five months to see the full effect of this treatment.
Over the years, I’ve also become much more comfortable with recommending injections of growth hormone for patients with low levels. Unfortunately, it requires expensive daily insulin-like injec
tions, and insurance companies are often unwilling to cover the cost. Nonetheless, for those who are willing and can afford them, the shots can be helpful.
VASOPRESSIN
Vasopressin, which is also known as the antidiuretic hormone (ADH), is secreted by the pituitary gland, and keeps the body from losing too much water by increasing the amount that is reabsorbed by the kidneys. People who are light-headed or drink more water than normal—that is, most CFS/FMS patients—may be low in vasopressin.94 This can cause low blood pressure, dehydration, and secondary fatigue. The simplest treatment to compensate for a low vasopressin level is to increase your salt intake and to drink enough water to keep your mouth and lips moist.
PROLACTIN
Prolactin is synthesized and stored in the pituitary gland, and is best known for stimulating milk production after childbirth. Unlike other hormones, which are usually low in people with CFS/FMS, prolactin levels are sometimes mildly elevated. The hypothalamus normally suppresses, instead of stimulates, prolactin production, but the hypothalamus is often dysfunctional in people with CFS/FMS. To make sure that no (benign) pituitary tumor exists, however, I may order a magnetic resonance imaging (MRI) scan in patients who still have elevated prolactin levels after four months of treatment with the SHIN protocol. The MRI generally shows that everything is normal. Some medications, such as risperidone (Risperdal), can also elevate prolactin levels, as can high-dose melatonin. Taking vitamin B6 at a dose of 200 milligrams a day can lower an elevated prolactin level, and this can be helpful, as excess prolactin can cause both a drop in the neurotransmitter dopamine and infertility.
From Fatigued to Fantastic! Page 14