One Woman’s Journey
Rian Shah, ND
Carla came to see me one bright morning as a new patient. Her main complaints were night sweats, hot flashes so bad as to “make me want to strip down naked in the grocery store,” depression, worsening joint pain and osteopenia, weight gain, hyperlipidemia, and insomnia. The hot flashes, night sweats, weight gain, worsening osteopenia, and insomnia had all begun around the time of menopause which had been about 1½ years prior. Her depression had been life-long and refractory to treatment. She was not suicidal, but had gotten used to living in the dark emotionally for as long as she could remember. She hid the depression well under an “overly” smiley face and a very animated affect. But this was contrasted by a distant and somewhat cold energy. She had walls up that were high and thick and appeared to be deeply protecting her.
Carla had come from an emotionally distant family. Her mother seemed to favor her two blond sisters; in her words, she felt like an “unloved stepchild” most of the time. She and her sisters were left alone for most of the day while her mother would go out drinking. Carla never remembers being told she was loved by either one of her parents. She chose to never have children because she didn’t think she would make a good mother, and she married a man who traveled a lot and was emotionally unavailable. Loneliness was her “normal,” and since she had such a hard time reaching out to her community and developing close relationships, she stayed inside most of the time, alone, watching television. She mentioned having a hard time moving through her house, that there were boxes everywhere. I was a bit worried about hoarding, but figured we could cover that at a later date.
Osteoporosis ran in her family, as well as heart disease and hypertension. She had been diagnosed 5 years prior with osteopenia in her femur and lower spine, which had slightly worsened since menopause. Her primary care physician had not given her any suggestions regarding her bone density except to take more calcium. She was taking a 1000-mg calcium tablet once a day and had been for a few years. She was not taking any vitamin D but did take a one-a-day multivitamin once in a while. Her medications consisted of bupropion and omeprazole. She also had a prescription for a statin but was not taking it because she was scared of the possible side effect of muscle pain.
Physical Exam
Carla’s physical exam was all mostly within normal limits. ENT, as well as cardiovascular and pulmonary exams were unremarkable. Her skin was thin and dry. She had significant pigmentation changes, or age spots, mostly on her face. Joints were all mobile and range of motion was normal, though she did have quite a bit of knee pain on palpation. No crepitus was detected and no inflammation was noted. On palpation her thyroid seemed slightly enlarged and boggy bilaterally but without tenderness or asymmetry. Her patellar reflexes were sluggish. Pretibial edema (+1) was noted bilaterally.
I wanted to test her blood, but since it would take about a week for results to come back, I requested that in the meantime she keep a 5-day diet diary so that we could get a head start on nutrition.
Laboratory Evaluation
Carla was sent out for a fasting blood draw. Her laboratory results were as follows:
Total cholesterol: 222 mg/dL (125-200)
HDL-C: 78 mg/dL (> 46)
LDL-C: 130 mg/dL (< 130)
Triglycerides: 127 mg/dL (< 150)
Estradiol: <1 pg/mL (menopausal range is < 31)
Progesterone:<1 ng/mL (menopausal range is < 0.5)
Free testosterone: 0.1 pg/mL (0.1-6.4)
DHEA-S: 76 µg/dL (45-320)
Pregnenolone: 15 ng/dL (13-111)
CBC: wnl
CMP: wnl
TSH: 3.24 µIU/mL (0.45-4.5)
Free T4: 1.0 ng/dL (0.8-1.8)
Free T3: 27 pg/mL (2.3-4.2)
25(OH)-vitamin D: 30 ng/mL (30-100)
Homocysteine: 12.0 µmol/L (< 12)
B12: 364 pmol/L (200-111)
hs-CRP: 2.2 mg/L (< 3.0)
Impressions & Treatment
My feeling was that though her LDL-C was high, it was not statin-worthy. Her HDL-C level was impressive. Given that she was not exercising and was eating junk food and microwavable meals every night (per her diet diary), we needed to start with basic nutrition assessment and guidance, as well as an exercise plan that she would stick to.
I was much more concerned about inflammation and intimal damage due to her borderline-high homocysteine and C-reactive protein (CRP), since these are more significant risk factors for heart disease and stroke in women. Treating her with only diet and lifestyle would likely not be enough to modify these factors. I suggested sublingual B12 (methylcobalamin) at 2500 mcg BID to bring down her homocysteine and improve cognitive function. I also recommended curcumin at 1200 mg BID to reduce her hs-CRP. This would also likely help her joint pain.
Carla also had tremendous emotional stagnation. Her heart was filled with sadness and disconnection. The fact that she was not given much attention or love as a child and was in a loveless marriage, and that she had a hard time connecting emotionally with others, made her the perfect candidate for intranasal oxytocin. I recommended intranasal compounded oxytocin at 40 IU BID.
Her hormone levels were predictably postmenopausal. Not all women are candidates for hormone replacement therapy, but I recommended it to Carla, given her history of osteopenia, refractory depression, debilitating hot flashes and night sweats, as well as the thinness and dryness of her skin, which, she told me later, was accompanied by quite a bit of vaginal dryness and atrophy. I suggested 3 separate compounded creams for her to apply: Two creams included a low-dose bi-est and progesterone, both of which would be applied to face and neck every morning. Applying it here can produce a nice aesthetic effect and would hopefully improve the tone and elasticity of her skin. Testosterone cream was to be applied behind her knees on a daily basis or else applied clitorally 30 minutes before intercourse to improve libido and orgasm.
To further balance out the hormones, I prescribed oral DHEA, as a morning dose, and pregnenolone, to be taken at bedtime. DHEA is crucial for facilitating the body’s endogenous production of estrogen and testosterone. Pregnenolone is not only helpful in stabilizing progesterone, but is also very beneficial for deepening sleep and reducing LDL cholesterol.
In my opinion, her vitamin D level was too low. Optimal levels of vitamin D are between 60 and 90 ng/mL, especially when the goal is to improve bone density and hormone balance. I suggested 20 000 IU of vitamin D3 for 2 months and then to re-measure.
Her thyroid markers were within normal limits, but given her mood issues, dry skin, digestive issues and dry stool, I felt it was worth supporting via a low dose of levothyroxine (T4). I also suggested a balanced multivitamin, 2400 mg of fish oil daily, and a full-spectrum digestive enzyme.
I suggested she go off all gluten and wine, which, after looking at her diet diary, seemed to be spurring the reflux for which she took omeprazole. I talked to her about how omeprazole is not good for bone density and that we needed to get her digestion and absorption functioning again.
I wanted her to come back in 4 weeks to re-measure the sex hormones and thyroid in order to make sure that levels were within their optimal physiological ranges. I then recommended that once her hormones had stabilized and her symptoms were reduced, we should measure every 3 months to be sure we were keeping things within a safe range.
I knew that exercise and emotional work would be difficult until she felt better and had less symptomatology. So I decided to wait until she came back for her follow-up to flesh out those parts.
Follow-Up
Five weeks later Carla returned for an office visit after getting her blood drawn. This was a non-fasting draw, as we were looking specifically at hormone balance. She was feeling much better. Her hot flashes were nearly gone and the one she experienced every morning had decreased in intensity by about 70%. Her night sweats had completely stopped. Her vaginal dryness was gone and she had a visible glow about her that wasn’t there before. She loved the oxytocin and noted a significant boost in mood after just a few uses. She wanted to eventually go off the bupropion and wanted to discuss how to do that responsibly. Her reflux had disappeared and her bowels were regulated. She was finally having bowel movements without strain, and daily, at that.
Her energy was improving and she had already lost a few pounds. She said her clothes were fitting more loosely, although she hadn’t yet weighed herself. And she was smiling a more genuine smile. The over-animation had subsided and she seemed calm, more centered, more present, and less weepy.
Carla’s labs came back showing overall improvements. Her estradiol had come up to 34 pg/mL, progesterone to 1.2 ng/mL, and free testosterone to 2.4 pg/mL. TSH had dropped to 2.0 µIU/mL, and her free T3 had come up to 3.2 pg/mL.
Carla felt a greater libido and stronger muscles. She was excited about working out and was ready to make an exercise commitment.
I told her to keep her hormones at the same dose unless that morning hot flash persisted, in which case she was to increase her bi-est dose by 0.1 ml. I suggested she keep her levothyroxine the same as well. I felt that her TSH was still a bit on the high side; however, her bowel movements had regulated, her skin was less dry, and her pretibial edema was gone. Furthermore, since thyroid hormone and sex hormones are interrelated and she was taking both exogenously, I felt it was wise to proceed cautiously. I suggested she order a weighted vest and wear it daily to help improve bone density in her lower back. I recommended a more absorbable form of calcium, taken at a lower dose but more frequently. I also added magnesium to her calcium, to produce a 1:2 ratio. I suggested that she sign up to the local gym and start weight-training. Most gyms will offer a free trainer on the first visit, to get one started—worth taking advantage of. She agreed and was very excited and motivated, now that she felt so much better.
At 3 months, Carla returned for another blood draw. Her thyroid had sped up a bit more, most likely due to improved nutrition and exercise, so I reduced her dose to one-half of a 25-mcg tablet. She had experienced some mild spotting, so I reduced her bi-est by 0.1 ml and I asked her to reduce it by another 0.1 ml in 2 weeks if the spotting did not stop. Her hot flashes were gone and her mood was so much better that she had weaned herself slowly off the bupropion. She had continued the oxytocin. Carla’s sleep was deep and long after increasing her pregnenolone to 30 mg (up from 10 mg) and adding melatonin. She had titrated up her melatonin from 1 mg to 6 mg per night and was now sleeping through the night without waking.
Carla’s B12 level had increased to 1200 pmol/L and her homocysteine had dropped to 8.2 µmol/L. My goal was to reduce her homocysteine to less than 6.2, so I had her continue for a few more months at the higher dose of B12.
Her hs-CRP had dropped to 1.0 mg/L. My CRP goal is <1.0, so I had her continue the curcumin for a few more months. Her joint pain had improved greatly after going off gluten.
Carla had taken her eating to a new level. I had suggested some wonderful whole foods cookbooks and she had tried a few recipes and realized she really missed cooking. She had segued onto a whole foods diet and was feeling great. I suggested a follow-up blood draw in 3 months, this time fasting so that we could check her cholesterol, cardiovascular inflammatory markers, thyroid function, and hormones.
I find that complicated cases are sometimes a very simple exercise in balance. I tell my patients all the time that we can’t build health on a foundation of sticks and gum. We need to build nutrition, balance hormones, balance exercise, address emotional health and only then can we start to heal.
It was now time to address the hoarding…
Rian Shah, ND maintains a practice (Shah Integrative Medicine) in Sammamish, WA, specializing in anti-aging medicine, bio-identical hormone replacement, thyroid imbalance, and heart disease. She graduated in 2004 from Bastyr University and since then has worked for Doctors Data Laboratory, Longevity Medical Clinic, and in collaborative practice with other specialties. When not seeing patients, she spends time in the mountains with her husband and their 2 young children. For information, consult her website: shahintegrativemedicine.com.
