The Wisdom of Menopause

by Christiane Northrup

  If you decide to seek laboratory confirmation, it is important that you understand what tests are available, and what they can (and cannot) reveal about your current status.

  Hormone Levels: FSH and LH

  The testing method employed by many medical practices is to test FSH and/or LH levels through either blood or saliva. This is based on the fact that at menopause and thereafter, a woman’s FSH and LH levels rise to their highest ever. But there are problems with this method. First of all, it will tell you nothing about estrogen levels, because FSH is controlled by inhibin, not by estrogen. (This is one of the reasons why estrogen replacement doesn’t decrease FSH levels after menopause.)7 In addition, during the five or ten years of perimenopause—before menstruation ceases for good—FSH and LH levels can fluctuate widely. The ovaries may become inactive for a few days or weeks and then resume production of eggs. It is possible, for example, for a woman’s FSH levels to reach postmenopausal levels (greater than 30 IU/1 for blood) while she is still having normal periods. Her LH levels, meanwhile, will remain in the normal premenopausal range. For that reason, a single high FSH/LH level can’t be used to determine whether or not a woman is in menopause. Until a woman has had no periods for a year and has FSH/LH levels well within the postmenopausal range—FSH greater than 30 IU/1 and LH greater than 40 IU/1—it is even possible for her to get pregnant. This is why it’s prudent to use contraception for a year after you think your periods have stopped.

  Hormone Levels: Estrogen, Progesterone,

  and Testosterone

  Another common blood test analyzes the total amount of estrogen, progesterone, and testosterone in the bloodstream. The largest drawback to this method is that most of the hormone so measured is inactive. The healthy woman’s body produces upward of ten times more of these hormones than she can use, so specialized proteins hook themselves to more than 90 percent of the hormone molecules produced, inactivate them, and lock the “doors” that would otherwise allow them to leave the bloodstream and enter the tissues. The biologically active form of the hormone is the part that is unbound or free. This goes quickly into the tissues instead of hanging around in the bloodstream. Thus the standard blood test, which does not distinguish bound from free hormone, will give an irrelevant result, because it measures primarily inactive, unusable, protein-bound hormone.

  Preferred Testing Methods

  With the individualized approach to menopause that has become the new standard of care, many clinicians are finding that measuring hormone levels can provide helpful information for balancing hormones through either nutritional means or bioidentical hormone replacement. Blood tests are now the generally agreed-upon standard for reliable hormone testing.8 However, I believe that there is a place for testing salivary hormone levels if your health care provider is familiar with how to interpret these results. Here’s why: blood levels of hormones do not reflect the level of hormone in the actual tissues of the body, where the hormones have their effects. There is evidence that salivary levels are a more accurate reflection of this activity. In addition, blood tests measure a single value taken at a specific time—even though hormones are secreted in spurts about every two hours. The difference between the highest point and the lowest point can be up to 500 percent!9 Salivary testing, on the other hand, can involve taking a total of five samples throughout the day, about three hours apart, to account for this variability. Salivary hormone levels can also be collected at home without the stress of having to go to a lab and have your blood drawn—an activity that in and of itself can alter hormone levels.

  One challenge with salivary testing is that the tests are not covered by insurance companies, so women who opt for them have to pay the entire expense out-of-pocket (at about $50 per test). Furthermore, the chance for human error in taking the sample is higher because both food residue and blood from bleeding gums or a sore in the mouth can contaminate the sample. That said, there are many clinicians, particularly naturopaths, who use salivary hormone levels with good results. (Laboratories that can do the saliva testing with a doctor’s prescription include Genova Diagnostics, 800-522-4762, www.genovadiagnostics.com; and ZRT Laboratory, 503-466-2445 or 866-600-1636, www.zrtlab.com.) And some research exists to show that salivary levels of testosterone in particular can indeed be useful.10 So the bottom line is this: go with the type of testing that your health care provider is most comfortable with. At the end of the day, he or she is treating you, not a lab test!

  The good news is that more and more research in the area of hormone metabolism is being done. New and improved FDA-approved assays are now available that measure not only biologically active levels of estrogen, progesterone, and testosterone, but also their breakdown products. A growing body of research is showing that hormone balance can affect bone turnover, lipid metabolism, and immune function, as well as hormone-dependent cancers, including breast and uterine. Since blood test results can be modified by changes in lifestyle, including supplementation, diet, exercise, and possible hormone replacement, it is probably worthwhile to have a hormone profile done if you’re having a lot of symptoms or are planning on using hormone replacement. It’s important to work with a health care practitioner who is familiar with this kind of hormone testing. I recommend the Women’s Hormonal Health Assessment from Genova Diagnostics. (See Resources.)

  How and When to Test

  If you’re having symptoms and are actively working with a program to improve hormone balance, I recommend checking your levels both before and after treatment. In an ideal world, it would be good if everyone could get a couple of different sets of hormone tests before embarking on therapy. But in the real world, it’s hard enough for most women to schedule any testing at all before getting treatment. Just remember that regardless of what your tests say, your hormone levels can and do fluctuate widely during the month and even throughout the day. The best time of day to collect a sample is the early morning (especially for testosterone levels), and the best time of the month is between days 20 and 23 of your menstrual cycle, when progesterone levels are apt to be highest.

  Because hormone levels so often normalize or improve with lifestyle changes, it’s also empowering to see how well you’re doing in follow-up testing.

  MENOPAUSE AND THYROID FUNCTION

  The ovaries are the organs that we focus on most commonly at menopause, but the physical foundation of a woman’s menopausal experience actually rests on the health of all her endocrine (hormone-producing) organs. Thyroid problems are very common during the perimenopausal and postmenopausal years. While many women with these problems are completely asymptomatic, others may have a wide variety of symptoms. Among the most common symptoms are mood disturbances (most often seen in the form of depression and irritability), low energy level, weight gain, mental confusion, and sleep disturbances.

  Thyroid problems are intimately intertwined with menopause, and not just because of the epidemiological fact that about 26 percent of women in or near perimenopause are diagnosed with hypothyroidism.11 According to the late John R. Lee, M.D., a noted clinician and author, there appears to be a cause-and-effect relationship between hypothyroidism, in which there are inadequate levels of thyroid hormone, and estrogen dominance. When estrogen is not properly counterbalanced with progesterone, it can block the action of the thyroid hormone, so even when the thyroid is producing normal levels of the hormone, the hormone is rendered ineffective and the symptoms of hypothyroidism appear. In this case, laboratory tests may show normal thyroid hormone levels in a woman’s system, because the thyroid gland itself is not malfunctioning.

  It is no surprise, then, that this problem is compounded when a woman is prescribed supplemental estrogen, leading to an even greater imbalance. In that circumstance, a prescription for supplemental thyroid hormone will fail to correct the underlying problem: estrogen dominance. Estrogen dominance and also glycemic stress (see chapter 6, “Foods and Supplements to Support the Change”) are very often accompanied by high adrenaline levels. And t
his metabolic situation can exacerbate thyroid problems. Here’s what happens. Adrenaline stimulates the sympathetic nervous system, as does glycemic stress. This includes increasing the heart rate and blood pressure, which can lead to palpitations. But it also causes estrogen to be metabolized into substances known as catechols—estrogens that themselves have adrenaline-like effects. The main thyroid hormone, thyroxine, also stimulates the heart and the sympathetic nervous system. To adjust to the already too-high level of adrenaline in the system, the thyroid gland often shuts down a little to lower thyroxine stimulation—which is reflected in slightly high levels of thyroid-stimulating hormone (TSH).

  Hypothyroidism can be confusing because there’s a continuum between overt and subclinical hypothyroidism, with a great deal of overlap between the two. Depending upon which expert you talk with and which criteria are used for the diagnosis, as many as 25 percent of perimenopausal women have some kind of thyroid problem. Most of these are cases of subclinical hypothyroidism. With this condition, although symptoms may be present, tests of thyroid function are only slightly abnormal (TSH of 0.5–5.0, with normal levels of triiodothyronine, or T3, and thyroxine, or T4). According to the American Association of Clinical Endocrinologists, the upper limit for TSH should be only about 3.0, not the higher number of 5.0 or more (although many experts, including myself, are more comfortable setting the limit at 2.5).12 Unfortunately, most labs still report 5.0 to 5.5 as the upper limit of normal. Hence, thousands of women who could use thyroid support, through taking thyroid hormone and/or iodine, are told that their tests are normal when they are not.

  Wilson’s Syndrome

  If your body temperature is persistently low and you have symptoms of hypothyroidism (low thyroid hormones) despite routine thyroid tests showing normal levels, you might have a condition called Wilson’s syndrome (sometimes called Wilson’s temperature syndrome). Although Wilson’s syndrome isn’t recognized by mainstream medicine, naturopathic medical schools are including it in their curricula, and it’s gaining attention from an increasing number of alternative and complementary medicine practitioners around the country.

  Wilson’s usually develops during a period of fairly significant emotional or physical stress, but its symptoms persist even after the stress has passed. Those symptoms include a wide range of seemingly unrelated problems, including fatigue, headaches, migraines, weight gain, irritability, depression, memory loss, anxiety, joint and muscle aches, constipation, irritable bowel syndrome, and many other debilitating conditions. The telltale sign that you do indeed have Wilson’s is a consistently below-normal body temperature.

  Here’s why it develops. Normally, your body converts T4 (one of two thyroid hormones) into T3 (the other thyroid hormone). But when your body stays at a subnormal temperature, it loses the ability to make that conversion. The end result is that cell metabolism is blocked, which encourages weight gain, among many other symptoms. If a person with Wilson’s syndrome is given a standard thyroid medication such as Synthroid, it doesn’t work because these medications contain only T4, which people with Wilson’s can’t convert into T3.

  To see if you may have Wilson’s syndrome, check your temperature for five days in the following manner, using a regular glass thermometer (not a digital one, although digital will have to do if you can’t locate a glass thermometer). Take your temperature first thing after you wake up in the morning, and then take it again in three hours, and again after three more hours. Add all three numbers together and divide the result by three to obtain your daily average temperature. Follow this procedure for five days. (If you’re not yet in menopause, do this only during the first two weeks of your cycle.) If your daily averages are below 98.3 degrees, you may have Wilson’s.

  The usual course of treatment involves taking a pill containing sustained-release triiodothyronine (SR-T3) every twelve hours. You’ll continue to check your body temperature, and once it reaches 98.6 degrees and stays there for three weeks, your health care practitioner will gradually wean you off the medication until you no longer need it at all. One study of eleven people following this protocol conducted by the Friedman Clinic in Montpelier, Vermont, found improvement in all five symptoms that the study measured over a period of three weeks to one year.13 To find a doctor familiar with the diagnosis and treatment of Wilson’s syndrome, visit www.wilsonssyndrome.com/DoctorsListing.

  The Role of Iodine in Thyroid Disease

  Some people with hypothyroidism are deficient in iodine, an essential element that your body needs to produce thyroid hormones. If your T3 and T4 levels are normal but your TSH is elevated, you may indeed be suffering from iodine deficiency. (Other signs of iodine deficiency include apathy, depression, and reduced mental function.) Because the kidneys excrete unused iodine in the body, your doctor can tell if you are iodine deficient by ordering a test that involves collecting your urine for twenty-four hours.

  While iodine deficiency is just one reason for low thyroid levels, it’s one that’s getting more attention lately. The first National Health and Nutrition Examination Survey (NHANES I), performed between 1971 and 1974, found that 2.6 percent of U.S. citizens were iodine deficient. But by the time the third survey was conducted, between 1988 and 1994, that number had shot up to 11.7 percent. It’s currently 13 percent.14

  Experts cite a number of reasons for the lower iodine levels. Environmental concerns such as deforestation and erosion are resulting in lower concentrations of iodine in our soil, which means there’s less iodine in the food that’s grown in that soil. People are also consuming fewer eggs (due to concerns about cholesterol) and fish (because of concerns about mercury), both sources of iodine. Perhaps most significant is the fact that Americans are using less table salt, an important source of iodine, because they’re concerned about hypertension. We’re also cooking less and eating more processed foods, which generally contain a type of salt that has lower levels of iodine.

  Even so, more liberal use of the salt shaker isn’t necessarily the answer, because according to the World Health Organization, the amount of iodine added to salt isn’t always consistent and levels can vary from package to package. Levels of iodine also decrease if salt is stored in open containers, especially in a humid environment. A better way to pump up low iodine levels is by eating sea vegetables (including nori, kombu, wakame, and arame), which have the highest concentrations of iodine of any food available. You can find these vegetables in health food stores, in the Asian foods section of your grocery store (or in Asian grocery stores), or on the Internet. I use Maine Coast Sea Vegetables (www.seaveg.com), which are sustainably gathered and processed from the pristine waters of the Maine coast.

  Ironically, too much iodine in your body can shut down the production of thyroid hormone, also leading to lower levels, so don’t overdo it. Start slow, adding one or two tablespoons of sea vegetables per week to your diet. At the same time, be sure to eat foods high in the trace element selenium (including eggs, meat, fish, cereal, and nuts). If you’re already taking thyroid medication, your doctor will probably want to monitor your TSH levels every eight weeks or so in order to adjust your dose, if necessary.

  WHAT EVERYONE SHOULD KNOW ABOUT IODINE

  Iodide (a type of compound that includes iodine, and the form that is added to table salt) is a chemical known as a halide. Other halides include chloride, fluoride, and bromide. Over the last forty years or so, commercial breadmakers have substituted bromide for iodide, and fluoride has been added to the water supply. (Although the government has recently lowered the recommended levels for the first time in almost fifty years because children are already getting so much fluoride from toothpastes, in addition to tap water, that they’re developing splotches on their teeth.) These halides, which can be highly toxic, can displace iodine from the cells. When you add iodine to your diet or start taking iodine supplements, it can sometimes displace chloride, fluoride, and bromide from the cells. The result is often a rash. This rash is then attributed to iodine, when in fact i
t’s simply a detoxification reaction from the body getting rid of excess bromide or other toxic halides. The solution is to simply cut back on the amount of iodine you are using.

  In those who are taking thyroid hormone, the introduction of iodine often increases the body’s capacity to produce thyroid hormone on its own. Thus women taking thyroid medication who begin taking iodine may well develop shakiness, rapid heart rate, and nervousness—all resulting from too much thyroid hormone. This can be remedied by cutting back on the thyroid dosage slowly and carefully. When adding iodine as a supplement, work with a practitioner who is familiar with the effects of iodine and thyroid hormone so that you can achieve optimal balance. Note that the entire topic of iodine supplementation is highly controversial.

  Once adrenal stress, glycemic stress, iodine deficiency, and estrogen dominance are addressed through modalities such as supplementation, adequate rest, and natural light, thyroid levels may recover. In the meantime, it’s often helpful to take a small dose of thyroid replacement that comprises both types of thyroid hormones (T3 and T4). Armour Thyroid is the most commonly used preparation that includes both hormones. It is widely available at all pharmacies by prescription.