A Surprising Menopause Case Study, Part 2

 In Endocrinology, Fertility

Tolle Totum

Deborah McKay, ND

In Part 1 of this case study, published in December 2019, I wrote about a 50-year-old woman who presented in January 2019 with a laundry list of health complaints. Some were chronic, such as recurrent sinus infections, GI disturbances, depression/anxiety, and symptoms of low thyroid function (she had untreated Hashimoto’s). However, a year of severe stress and the onset of perimenopause had added to the pile, including weight gain, a foggy brain, and the feeling that her entire life was crumbling.

One week after our initial consultation, she would depart for Mexico for a 2-week yoga retreat. Meanwhile, I educated her about blood sugar swings and small intestinal bacterial overgrowth (SIBO), recommended some dietary adjustments and supplements, referred her to Dr James Wilson’s book (Adrenal Fatigue: The 21st Century Stress Syndrome), and asked her to get a blood draw for lab tests before leaving for Mexico.

First Follow-up

Dorothy returned to my office in February 2019, 1 month after her initial visit. She noted a “lack of joy” during her yoga retreat, and also caught a Mexican “bug” that gave her debilitating diarrhea. The menu of vegan raw foods had made it worse. She put herself on the BRAT diet (ie, bananas, rice, applesauce, toast) at her first opportunity, which had eased the diarrhea, although a stomach ache had persisted. Activated charcoal was easing her symptoms.

She had scored positive on 15 of 18 traits for adrenal fatigue, listed in Wilson’s book.

Per my request, she had tracked her metabolism (via pulse, temp, mind) after starting on liothyronine (L-T3). Unfortunately, this was the same time that the “Mexican bug” was giving her fevers. Her dosing of L-T3 had been sporadic despite my recommendation of 3 tablets daily (15 mcg total). Instead, she had been taking 4-6 tablets per day, often loading up in the evening to make up for missed doses earlier in the day. She noted some sleep disturbance as a result, but no tachycardia or anxiety. There was palpable sadness in Dorothy’s presence.

Laboratory Evaluation

Prior to her Mexico trip, her labs indicated pretty good health overall, except for autoimmune thyroiditis (see Table 1). In contrast to her 2017 labs, her ovarian hormones measured normal despite the lack of menstrual periods for “many moons now.” We planned to check FSH and LH at her next lab visit.

Table 1. Patient’s Laboratory Results

Lab Marker Result
TSH Higher than optimal (2.18 mIU/mL); 1.0 µIU/L is my target “optimal”
Free T4 Low-normal (0.97 ng/dL)
Free T3 Low-normal (2.4 pg/mL)
Reverse T3 High-normal (17.1 ng/dL)
RT3/Free T3 ratio High (7.1)
Anti-TG antibody High (74.4 IU/mL)
Anti-TPO antibody High (41 IU/mL)
LDL-cholesterol High (145 mg/dL)
HDL-cholesterol Good (94 mg/dL)
Fasting glucose High-normal (96 mg/dL)
Fasting insulin Normal, but poor effect (5.0 mIU/mL)
Glucose x Insulin Borderline insulin resistance (480); insulin resistance = 507.6
HbA1c High-normal (5.5%)
Fibrinogen High-normal (315 mg/dL)
25-hydroxyvitamin D Low-normal (39.8 ng/mL)
Ferritin Low-normal (47 ng/mL)
Hemoglobin Low-normal (13.1 g/dL)
Hematocrit Low-normal (39.1%)
DHEA-S, serum High-normal (225.5 µg/dL)
Progesterone, serum Low-normal (0.3 ng/mL)
Testosterone, total, serum High-normal (30.6 ng/dL)
Estradiol, serum OK (75.0 pg/mL)
Cortisol, 9 AM, serum Low-normal (11.9 µg/dL)

(TSH = thyroid-stimulating hormone; T4 = thyroxine; T3 = triiodothyronine; TG = thyroglobulin; TPO = thyroid peroxidase; HbA1c = hemoglobin A1c)

Impressions

My diagnoses included functional hypothyroidism (ie, euthyroid sick syndrome), hypercholesterolemia, and acute gastroenteritis.

Although she still tended toward hyperglycemia, this was under better control now. In my experience, elevated LDL-cholesterol is mostly associated with high carbohydrate intake. The high-normal fibrinogen suggested systemic inflammation, which I often see along with fluctuating glucose; in Dorothy’s case, it could also be related to Hashimoto’s and GI imbalances.

She clearly still had functional hypothyroidism. I suspected that the Hashimoto’s was impairing her thyroid gland’s ability to respond to TSH, as indicated by low Free T4 in the presence of high-normal TSH. She also had an unfavorable ratio of Free T3 (FT3) to Reverse T3 (RT3). Thyroxine (T4) can convert to either active triiodothyronine (T3) or inactive Reverse T3. I look for an optimal FT3/RT3 ratio of 3.5-4.0. I suspected that Dorothy’s emotional distress and the inflammation resulting from Hashimoto’s and irritable bowel syndrome were contributing to an over-conversion of T4 to RT3. She was trending toward iron deficiency anemia, as evidenced by low-normal levels of Hbg, Hct, and ferritin. I commonly see this in SIBO, due to intestinal malabsorption and/or iron sequestration by dysbiotic organisms. An elevated DHEA-S suggested persistent stress.

Plan

I suspected Dorothy’s sporadic timing of her L-T3 prescription, especially the evening loading, was causing fluctuations in metabolism and sleep disturbances. I thus recommended that she spread out her dosing more evenly throughout the day, with a smaller dose of L-T3 in the evening to aid relaxation. I suggested aiming for 30-40 mcg/day, but to self-monitor body, mind, and metabolism in order to stay comfortable.

For daytime focus and stress management, I prescribed a proprietary adrenal support supplement containing key nutrients and Eleutherococcus senticosus, Glycyrrhiza glabra, and Coleus forskohlii, to be taken early morning (along with thyroid) and at lunch.

It’s always important to support the adrenals when starting a patient on thyroid hormones. This is because normalizing thyroid function will often speed up metabolism faster than the HPA axis is able to re-regulate itself. Not doing so has caused some people with adrenal insufficiency to land in the hospital (not on my watch!).

For the infectious diarrhea and chronic constipation, Dorothy agreed to treatment of probable SIBO/SIFO using 2 proprietary herbal formulations – one containing Thymus vulgaris, Origanum vulgare, and Salvia officinalis; and the other containing berberine HCl, Berberis aquifolium, Coptis chinensis, and other berberine-containing herbs, and a mixture of Chinese herbs to support detoxification and elimination. I suggested taking 2 tablets of each, twice daily, for 4 weeks. Although various herbal protocols are prescribed for SIBO/SIFO, I prefer to follow my classmate, Dr Allison Siebecker’s, recommendations and list of published research.1

I coached her on managing Herxheimer symptoms and using charcoal to adsorb biotoxins (though away from thyroid dosing). I encouraged her to read about and follow a low-FODMAP diet. We would consider a definitive lactulose breath test for SIBO when she was ready. 

I recommended she take a multivitamin/multimineral, including iron bisglycinate, with lunch. I cautioned her about magnesium’s laxative effect.

Finally, I had Dorothy fill out a questionnaire designed by Julia Ross (see her books, The Mood Cure and The Cravings Cure). I hoped to start her soon on targeted amino acid therapy (TAAT).

After she left, I scored her TAAT questionnaire. According to Ross’ guidelines, her #1 need was for catecholamines, in this case both thyroid and adrenal hormones. Not surprisingly, the questionnaire indicated that Dorothy’s #2 need was blood glucose stabilization. I planned to mail her some free samples of a proprietary formulation containing chromium, vanadium, alpha-lipoic acid, Gymnema sylvestre, Opuntia streptancantha, and Silybum marianum. This was to be taken with each meal, along with glutamine, to reduce glucose and insulin surges. Her #3 need, according to the questionnaire, was for GABA, for calmness and relaxation. She was already using ashwagandha and L-theanine, but straight GABA is stronger and would likely give her greater benefit. I suggested taking it only in the evening to avoid daytime drowsiness, until she was accustomed to its effects. Theoretically, GABA shouldn’t cross the blood-brain barrier (BBB). However, almost all of my patients with leaky gut appear to also have a leaky BBB.

In light of the emotional underpinnings of Dorothy’s symptom profile, and to assist her in moving forward toward her goal of self-improvement, I was eager to teach her a proprietary technique of “tapping” in the very near future. This technique can help “erase” an unwanted emotion, and only requires about 30 minutes of an office visit.

In about 3 months, we would re-assess ovarian function and thyroid dosing via lab tests.

Second Follow-up, 1 Month Later

Dorothy was following a low-FODMAP diet and exercising positive internal self-talk. She was enjoying this approach to eating. Her menses had returned unexpectedly the previous month – the first time in 5 months – and it was a bad period with severe cramping and heavy bleeding.

Her symptom survey showed continued fatigue, insomnia, dry skin, and intolerance of both heat and cold, although there were very slight improvements across the board. She was currently taking a total of 35 mcg of (three 5-mcg tablets early morning plus 4 tablets mid-day). Her heart rate was typically in the low 70s; her hands remained cold; and her mid-day temps were still in the 97º range (well below the optimal 98.6º F).

She seemed dejected. She was conversing better – not conspicuously slow any more.

Impressions

Current diagnoses included IBS/SIBO, postmenopausal bleeding, and euthyroid sick syndrome. Today’s issues were mostly psychosocial and emotional. Her TAAT for brain chemistry was going to be important for her well-being.

Plan

I suggested continuing her low-FODMAP diet for now, to reduce SIBO/SIFO symptoms. In case of future dysmenorrhea, I recommended using Viburnum opulus (cramp bark) liquid extract, early and often, to prevent the “wind-up phenomenon” caused by prostaglandins. 

We had a long, heartfelt discussion about SIBO and her dietary choices, and about self-compassion vs self esteem. I referred her to Kristin Neff, PhD,’s book and TEDx talk on self-compassion.

For her thyroid, I encouraged a slow upward titration of L-T3 toward 50 mcg daily, while continuing to track metabolism and body-mind symptoms. Bothersome heart symptoms would be her sign to reduce the dose and call me.

I urged her to throw a party with other women when full menopause arrived, celebrating that she was now queen of her own life. I also suggested she plan on 5 years of well-balanced bioidentical hormonal replacement therapy (BHRT) regardless of menopausal symptoms, for lifetime protection of bone density and her cardiovascular system.

It is now internationally accepted that 5 years of BHRT, starting at the moment of menopause, yields lifetime benefits in these areas.2 Recall the nationwide panic in 2002 when the Women’s Health Initiative was abruptly cut short due to HRT-related deaths from cancers, heart attacks, and strokes.3 Those deaths, we now know, were due to using oral (not transdermal) equine estrogens (not human bioidentical) in combination with synthetic progestins (also not bioidentical). I have been using BHRT since Day 1 of my practice, and until these recent findings were published, I had to calm down a lot of anxious women. It’s now much easier to put their minds at ease.

Third Follow-up, 1 Month Later

Dorothy was feeling good overall, yet noted a strange sensation of “living in a cocoon and fighting to get out.” This sounded to me like mild dissociation. She was going through deep and powerful emotional upheaval; in many ways this was her year of self-renewal.

She brought in questions about ionic silver, zinc, and liquid iodine, all self-prescribed. Her mid-day temps were still in the mid-97s; and her heart rate was often in the 60s, except when stressed.

Dorothy’s posture and presence seemed worn down. At the same time, though, her eye contact, speech, and responsiveness were improved. She was feeling more like “her old self” these days.

She requested more dietary guidance, so I recommended the books The Vegetarian Myth by Lierre Keith, and Primal Fat Burner by Nora Gedgaudas.

Because of her elevated HbA1c and LDL-C and her history of hypoglycemic symptoms, I urged her to limit her fruit intake, favoring vegetables instead.

In terms of supplements, I shared my belief that the popularity of high-dose iodine supplementation is not scientifically based, and suggested she save her kelp drops in the event of nuclear fallout. I also urged restraint with ionic silver, saving it for when it’s truly necessary, so that it wouldn’t lose its effectiveness. I recommended that she start oral methylcobalamin and to hold the tablets in her mouth before swallowing, for better absorption. Dorothy tended toward anemia, and I suspected she also needed more methyl donors due to likely MTHFR genetic abnormalities. I also recommended 15 mg/day of zinc.

We further discussed the importance of optimizing thyroid and adrenal function. I suggested continuing L-T4 at 25 mcg each morning; I also suggested she continue the L-T3 at 25 mcg twice daily (early morning and lunchtime), but to try adding an additional 5 mcg at bedtime to “strengthen” her sleep cycles. Most of my patients report feeling feel more restored in the mornings by doing this. She would continue to self-monitor.

We both felt that she was ready for an emotional breakthrough, so we scheduled another visit for “tapping.”

Fourth Follow-up, 1 Month Later

In March 2019, 1 month later, Dorothy arrived at my office, ready to learn the technique of tapping. She had already connected the dots between childhood abandonment by her father with her adult inability to bond with a long-term mate. At this visit, Dorothy appeared brighter and more present than ever, and showed signs of improved physical and mental health. 

“Tapping” involves a preliminary brisk tapping all 10 fingertips against each other, followed by tapping one’s fingers on acupuncture meridians in a prescribed pattern while concentrating on a particular problem but with an imagined positive outcome. The goal is to clear unwanted emotions. A sentence stating a problem and its resolution is formulated before each tapping routine.

During the warm-up exercise, Dorothy could not perceive her own Qi (typically felt as tingling), which suggested an energetic blockage. When she tried to formulate her first sentence for the technique, she immediately felt distressed. During the tapping technique, Dorothy was unable to get traction until she directly acknowledged her childhood abandonment. Her sentence was, “Even though my father abandoned me, I still love and respect myself completely.” At the start, her self-rated emotional distress was 10 out of 10, with tears flowing. On round 2, she scored 8 out of 10, feeling a tight throat. On round 3, she scored 5 out of 10, with palpable unhappiness. Then, on round 4, her energy shifted visibly and her emotional distress dropped from 10 to 2, and she noted “practically just empty words.” At this point she was smiling and her energy was radiant.

This is the kind of miracle I routinely witness when I am able to talk my patients into doing tapping with me. I love my work!

We ended by discussing the idea of taking drop-doses of Oplopanax horridus glycerite to help support healthy personal boundaries. She declined for now. We also discussed doing Buteyko breathing down the line as another way to keep anxiety under control.

I gave Dorothy a lactulose breath test, to be collected at home ASAP. I suggested another blood draw for labs in a couple of months, or sooner if she was curious.

Email Exchange with Patient, 5 Weeks Later

Five weeks later, Dorothy emailed me to say that she had been having increased hot flashes several times daily for the past several weeks. I recommended Cimicifuga racemosa (black cohosh) twice daily, along with non-prescription estriol cream (0.75 mg per pump), to be taken anytime up to twice daily. I explained that progesterone cream (20 mg per pump) should be restricted to early morning, since transdermal progesterone can increase cortisol, which in turn can increase anxiety.

I also recommended she take additional doses of the stress management formula when needed, to reduce the likelihood of a hot flash.

I suggested we reevaluate her current symptoms and treatment plan at her next office visit. As of this writing, she has not scheduled another visit. She has also stopped requesting Rx refills. It is my hope that high-dose L-T3 did what it was meant to do: restore normal metabolism by chasing out Reverse T3, thereby healing and rebalancing bodily tissues. It is rare for folks to continue on high-dose L-T3 beyond a few months. When they feel like they no longer need it, that’s typically an indication that healing has taken place. 

In summary, it appears that Dorothy got what she came for… but it wasn’t what either of us thought it would be. Her diminished mental functions, which she attributed to menopause, cleared in response to emotional healing and normalizing her thyroid function. Mostly, she was simply ready to heal an old childhood wound at a time when she was restructuring her life. My role here turned out to be a little bit of hormones and a lot of emotional leverage.

References:

  1. SIBO – Small Intestine Bacterial Overgrowth. Site author: Dr Allison Siebecker. Available at: https://www.siboinfo.com/herbal-antibiotics.html. Accessed September 5, 2019.
  2. L’Hermite M. HRT optimization, using transdermal estradiol plus micronized progesterone, a safer HRT. Climacteric. 2013;16 Suppl 1:44-53.
  3. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-333.

Deborah McKay, ND, is a bio-identical hormone specialist in Portland, OR – the heartland of naturopathic medicine. Dr McKay is a 2005 graduate of NCNM, and now a solo practitioner. She’s a Founding Member of EndoANP. She has personal experience with thyroid insufficiency, uterine cancer, surgical menopause, PTSD, and the blood glucose roller-coaster. She is passionate about hormone rebalancing, which she views as one possible approach to whole-person healing.

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