The ZRT Laboratory Blog

Menopause: Your Most Common Questions Answered

Fri, 14 Feb 2020 09:45:18 -0800

Menopause can be a confusing time for many women and their families, and as a society we tend to steer away from having open, honest conversations about this very important transition in a woman’s life. At ZRT, we aim to change that and equip all women with the tools and resources necessary to maintain optimal health during their menopause transition and after. In this post, ZRT’s Clinical Consultants tackle the most commonly asked questions and misunderstandings about menopause from patients.

What Age Does Menopause Occur?

Menopause is defined as the natural absence of menstrual periods for one full year in a woman over age 40. The average age of menopause is 51, with some time between ages 46 and 56 being the most common. Lab values such as a high FSH may help to confirm, but do not define, menopause.

While a woman may stop ovulating and having periods before age 40, that would typically result from either surgical menopause (removal of ovaries with or without the uterus), or primary ovarian insufficiency (also called premature ovarian failure), a condition that tends to run in families and which may have contributions from autoimmunity, chemotherapy and radiation, viral infections, or genetic and chromosomal disorders.

What Is Perimenopause?

Perimenopause is the period of transition leading up to menopause. During this time the ovaries gradually begin to make less estrogen and progesterone. The average length of perimenopause is 4 years, but it may last only a few months or continue for as long as 10 years. Perimenopause ends once a woman has gone 12 months without a period; she is then said to be postmenopausal.

What Are the First Signs of Menopause?

Early signs of the transition to menopause may include irregular menstrual cycles, hot flashes, night sweats, insomnia, forgetfulness, tearfulness, anger or irritability, anxiety, acne, migraines, weight gain, vaginal dryness and changes in sexual function.

Does Menopause Cause Depression or Anxiety?

The cause of depression and anxiety is often multifactorial but hormone changes in menopause can contribute. Estrogen acts as a neurotransmitter and contributes to mood stability, so fluctuations, declines or imbalances in estrogen may contribute to or aggravate existing mood disorders. Estrogen increases synthesis of serotonin, acts as an SSRI and MAO inhibitor, and sensitizes serotonin receptors. The progesterone metabolite allopregnanolone acts as a neurosteroid that influences inhibitory processes centrally by binding to GABA receptors in the brain, and its decline can affect the excitatory/inhibitory balance. Estrogen and progesterone also act on dopamine. Anxiety is a common early feature of menopause for many women. It may occur as a part of the hot flash experience, but can also occur by itself and be hard to recognize as part of menopause, especially at first when there may be no other menopause symptoms.

Can You Get Pregnant During Menopause?

During the transition to menopause a woman’s likelihood of becoming pregnant decreases, although statistics on unintended pregnancies in midlife women are essentially non-existent. One recent study estimates that over 75% of women aged 45-50 were at risk for unplanned pregnancy due to their low use of contraception, despite the ACOG guidelines which recommend family planning counseling and contraceptive protection for women at risk for pregnancy until they are 55 years old [1]. After a year without a period and/or a follicular FSH above 13, pregnancy becomes very unlikely.

Can Menopause Cause Weight Loss?

Unintentional weight loss during menopause would be considered somewhat unusual, and in fact may be a cause of concern worth bringing up to your physician. Fluctuations and ultimately decreases in estrogen, along with declines in muscle mass, physical activity level, quality sleep, and insulin sensitivity can all contribute to gradual weight gain during the time around menopause, as well as a shift in fat storage from the hips and thighs to the abdominal area. Stress and high cortisol levels related to disrupted sleep can also contribute to these body composition changes, which are in turn associated with higher risk of metabolic syndrome, type 2 diabetes and heart disease. Most of these factors are modifiable, but intentional weight loss during menopause typically requires commitment, patience, and often different strategies than what may have been successful before menopause.

Does Menopause Make You Tired?

While menopause, per se, may not cause fatigue, the associated changes in serotonin and sleep disruptions caused by hormone changes and night sweats very well may. Dysfunctional uterine bleeding, heavy or frequent periods, or fibroids can also lead to iron deficiency anemia; perimenopausal women with fatigue should have hemoglobin and ferritin checked to rule out anemia as a contributing factor. Additionally, diurnal dysregulation of inflammatory mediators in the body such as IL-1β, IL-8, TNF, and IL-20 can all contribute to symptoms of fatigue. This type of inflammatory dysregulation is not an uncommon occurrence during the perimenopausal transition and may be related to hot flash frequency and severity.

What Causes Painful Intercourse After Menopause?

Vaginal atrophy is the thinning of the vaginal tissue as a result of decreased estrogen production in menopause. This thinner vaginal mucosa tends to provide less lubrication, lose elasticity and become more fragile, which can lead to difficult, painful intercourse or even light bleeding with intercourse. Without treatment such as lubricants, vaginal moisturizers, vitamin E suppositories, or vaginal hormones such as estriol or DHEA, this condition often understandably contributes to decreased libido. Even with systemic hormone replacement, vaginal application of hormones may be needed to provide relief.

Is Discharge Common After Menopause?

Atrophic vaginitis is the term for the burning, itching and discharge that results from vaginal thinning and dryness. This discharge tends to be thin, watery, yellowish or gray. Changes to the vaginal pH and microbiome caused by decreased estrogen levels can also predispose to bacterial vaginosis, which tends to present with discharge having a characteristic ‘fishy’ odor.

Is It Normal to Have Bleeding After Menopause?

Although it may be relatively common, bleeding after menopause cannot be presumed to be normal. Use of any combination estrogen-progestogen contraceptive will result in withdrawal bleeding even after menopause. It’s also common if starting a new hormone replacement or if a woman hasn’t reached a full year without a period. But any bleeding after a full year without a period requires medical investigation to rule out endometrial cancer or hyperplasia.

Can Menopause Cause Hair Loss?

At menopause the levels of estradiol and progesterone drop dramatically, but testosterone remains about the same, or even increases with increasing LH. During premenopause estradiol keeps the bioavailable level of testosterone low by increasing SHBG, and suppresses the expression of androgen receptors in tissues. Progesterone also plays an anti-testosterone role by competitively inhibiting the enzymatic conversion of testosterone to DHT (dihydrotestosterone), a potent metabolite of testosterone. DHT binds androgen receptors in the skin and hair follicles causing scalp hair loss and increased facial/body hair. Testosterone and DHT levels may be higher during menopause due to sustained high levels of LH.

Why Does Menopause Cause Skin Itching?

Estrogen plays an important role in skin health and moisture at the receptor level, as well as impacting the microbiome of mouth, gut and skin [2]. Microbiome changes related to menopause may increase intestinal permeability, which increases the likelihood of food intolerances and atopic dermatitis. Factor in vaginal dryness and atrophy, sweating from hot flashes, and hives (discussed below) – and it’s understandable why many menopausal women complain of itchiness.

Can Menopause Cause Hives?

Hives, also called chronic urticaria, is approximately twice as common in women as in men and may be associated with hormonal changes such as the menstrual cycle, pregnancy, menopause, hormonal contraceptives or hormone replacement therapy. Although the exact mechanism is not well understood, sex hormones appear to modulate immune and inflammatory cell functions, including mast cell secretion of histamine. One study also suggests that patients with chronic urticaria have lower levels of serum DHEA-S (dehydroepiandrosterone sulfate), an adrenal hormone that tends to decline with age [3]. In addition to the drop in sex hormones, stress is commonly elevated during menopause, leading to high output of cortisol and adrenaline which are frequently associated with hives.

Can Menopause Cause Acne?

Unfair as it may seem, acne can flare up around menopause just as it does during puberty, due to hormonal fluctuations. Acne is often androgen driven, and rising LH levels during the transition to menopause may increase testosterone production. As estrogen and progesterone levels decline, testosterone and its more potent metabolite dihydrotestosterone (DHT) become the more dominant hormones in perimenopausal women, which can show up as acne or new hair growth on the body or face.

Can Menopause Cause Dry Mouth?

Women have estrogen and progesterone receptors throughout the body, and when these hormone levels decline, there can be a loss of moisture not only in the skin and vaginal mucosa, but also in the mouth, eyes and other areas that express receptors for estrogens. In addition, recent research has begun to shed light on how female sex hormone levels influence the composition of the microbiota in many sites of the body, including the mouth. Changes in microflora along with reduced salivation may contribute to oral conditions such as gingivitis, periodontitis and oral candidiasis (thrush) in menopausal women [2].

Can Menopause Cause Headaches?

Headaches can be triggered by declining as well as elevated levels of estrogen, or an imbalance between estrogen and progesterone. The often-dramatic hormone fluctuations during perimenopause and the onset of menopause, and the dilating or constricting effects of these hormones, can contribute to headaches.

Can Menopause Cause Dizziness?

Women commonly report feeling dizzy during menopause, which may be related to middle ear changes, menopause-related fatigue, or hot flashes. However, there are many other possible causes of dizziness which are best discussed and ruled out by your primary care provider.

Can Menopause Cause Bloating or Nausea?

Digestive symptoms such as bloating and nausea may be related to gut microbiome changes in menopause, fluid retention, or the loss of the effect that progesterone had on GI motility during the menstruating years. However, if these symptoms become chronic they should be discussed with your primary care provider to rule out other possible causes.

Can Menopause Cause Hypothyroidism?

Menopause and hypothyroidism have some symptoms in common, including fatigue, weight gain, increased blood lipids, dry skin, and hair loss, which is why comprehensive hormone testing is important to help establish whether a woman is experiencing one or both of these conditions. Estrogen is known to have both direct and indirect actions on the thyroid gland and thyroid hormone metabolism, as well as on modulation of autoimmunity, which is a leading cause of hypothyroidism in the form of Hashimoto’s thyroiditis [4].

Women have many questions about menopause both before it happens and during the process. Working closely with a good practitioner and laboratory can help diagnose and treat many of the common and annoying symptoms of menopause that can severely impact a woman’s quality of life.

Related Resources

References

[1] Johnson-Mallard V, et al. Unintended pregnancy: a framework for prevention and options for midlife women in the US. Women’s Midlife Health 2017;3:8.

[2] Vieira AT, et al. Influence of Oral and Gut Microbiota in the Health of Menopausal Women. Front Microbiol. 2017;8:1884.

[3] Kasperska-Zajac A, et al. Sex hormones and urticaria. J Dermatol Sci. 2008;52:79-86.

[4] Santin AP, Furlanetto TW. Role of estrogen in thyroid function and growth regulation. J Thyroid Res. 2011;2011:875125.

What the ZRT Docs Are Reading

Thu, 06 Jun 2019 11:04:49 -0700

Here at ZRT, we clinicians are always reading. When we aren’t on the phones or completing laboratory reports for you, we are constantly researching and reading. We read everything from the books that some of you are writing to articles on Pubmed and Medscape. We thought that it might be fun to tell you what is currently on our reading agenda.

Dr. David Zava

When asked to write in brief about what I am reading, the only thing that came to my mind was, “a lot”. I’m always reading scientific journal articles related to the tests and research (R of ZRT) we are actively engaged in with many different research groups around the globe, which include mostly organizations with NIH grants, as well as sports organizations and the military. I serve as a consultant for these research organizations to help interpret the tests we are asked to perform in saliva, dried blood spots, and dried urine. The science articles that have the greatest stick to my neurons these days are those involved in providing a deeper understanding of stress and circadian rhythms of cortisol and melatonin, as well as norepinephrine and epinephrine. In my breast cancer research over the past 40 years, and diurnal cortisol/melatonin testing we have done on breast cancer patients, it is crystal clear that cortisol and melatonin do not have normal circadian rhythms in many of the patients we have tested who indicate a history of breast cancer, or who are at high risk for it and possibly harboring an occult tumor. The journal articles I have gleaned the most knowledge from as regards the brain-adrenal feedback systems related to stress, and diseases like cancer, diabetes, and cardiovascular, include those by Nicolaides NC, Frontiers in Endocrinology, 2017 [1]; Bahrami-Nejad Z, Cell Metabolism, 2018 [2]; Champaneri S, Metabolism, 2012 [3]; Yehuda R, Endocrinology, 2011 [4]. For the scientist geeks, of which I’m proudly in that camp, I’m also reading “The Innovators” by Walter Isaacson, which is a historical account of scientific innovators such as Steve Jobs and Bill Gates, among many others, that created the digital age, software, and computers as we know them today. And then there’s a book I’m currently reading entitled “American Moonshot: John F Kennedy and the Great Space Race” by Douglas Brinkley, which takes us back to the beginning of the Second World War when Kennedy was just a young man, his father was working for Roosevelt’s administration, and Von Braun was making V2 rockets for Hitler that were raining terror on England. There is mention of the Manhattan Project that took place in part in Oak Ridge Tennessee, where my father was sent to work on this secret project, and where I was born into this mecca of scientists. Growing up in Oak Ridge, the science city, is what sparked my interest in science and probably why I’m doing what I’m doing today.

Dr. Kate Placzek

I recently read “PCOS SOS, A Gynecologist’s Lifeline to Naturally Restore Your Rhythms, Hormones, and Happiness” by Dr. Felice Gersh. The book completely absorbed me, I couldn’t put it down. I finished it in just one day. Dr. Gersh draws from nearly 40 years of clinical experience in gynecology, to write beautifully and reveal extraordinary ways in which the body can heal itself from PCOS. In this book, Dr. Gersh brings forth the protocol that prioritizes supporting the body’s normal rhythms and processes. PCOS SOS is a culmination of years of work, the product of real passion and commitment to understand the underlying mechanisms behind PCOS, transcending conventional approaches. It blends clinical innovation with a clear and powerful writing style to achieve perfection in combining cutting-edge research publications with a clinically actionable road map to create comprehensive, inspiring and practical health strategies that patients can implement immediately.

PCOS SOS is a ground-breaking work that will endure as a paramount read for anyone who wants to understand, approach and heal from PCOS. I hope this book is as widely read as it deserves to be. I expect the number of transformative success stories will be remarkable.

Dr. Sherry LaBeck

On the heels of Dr. Kate’s beautifully, expressive review of Dr. Felice Gersh’s new book, and contrary to Dr. Smith’s assertion that “we can’t all talk about the same book,” I present my review version.

In her new book, PCOS SOS, A Gynecologist’s Lifeline to Naturally Restore Your Rhythms, Hormones, and Happiness, Dr. Felice Gersh encourages women with polycystic ovarian syndrome (PCOS) to try to “live in sync” with their body’s natural rhythms, as well as in harmony with their environment. She goes on to explain in very realistic, practical terms how to accomplish this. Thus, Dr. Gersh has written step-by-step chapters for managing the symptoms and health consequences of this often-misunderstood condition.

PCOS SOS is an exceptional guidebook for a patient to navigate her individual PCOS journey and the health concerns she encounters. Yet, the information presented would benefit any health care practitioner presented with a patient or patients with a possible PCOS situation.

Each information-packed chapter has a troubleshooting section where Dr. Gersh answers common questions specific to the chapter. A “quick summary” then follows as a reminder of the important points covered. Chapters conclude with a list of “healthy habits” to be checked off with implementation. Each section includes natural options, along with conventional medications that can be advantageous. All in all, I found Dr. Gersh’s book to be insightful, accessible and engaging.

Dr. Allison Smith

I had to chuckle because we’ve all most recently read Dr. Gersh’s book in the clinical department here at ZRT, so eloquently reviewed by Dr. Kate, but we can’t all talk about the same book. As anyone who does any writing in the Health and Wellness space knows, you read tons more than you actually write – but you don’t always have time to digest a book while you’re wading through medical journals. So, what I’m reading right now actually isn’t a book at all – it’s something I’ve been keenly interested in for the last few years (lecturing on it, writing about it) and rather than a book, is more a collection of studies and reviews on the topic of the circadian rhythm’s association with disease. I’ve picked one and would love to share a couple of neat tidbits you might find applicable to your practice.

The article piquing my interest, Diurnal Variation of Circulating Interleukin-6 in Humans: A Meta-Analysis [5], published in PLoS One a couple years ago teases out important details on the diurnal rhythm of IL-6. IL-6, best known for its role in modulating the immune response as an inflammatory cytokine that works with IL-1β, TNFα, and IFNɣ, peaks at night and troughs in the mornings. Did you know that at night, cytokines help regulate sleep and contribute to sleep architecture? When the circadian rhythm of IL-6 is disrupted – loses its variation or phase shifts to higher levels during the morning – the result is daytime fatigue and/or sleepiness. Talk about tired and wired!

What struck me the most when reading this article was how similar it felt to reading about cortisol and how our understanding of its relationship to health and disease has evolved beyond 24-hour highs and lows into a much more comprehensive territory, where we scrutinize the daily slope just as much as the individual highs and lows. Regarding IL-6’s similarity to what we’re finding with cortisol rhythms, a recent study in the Journal of Atherosclerosis and Thrombosis: Interleukin-6 Level among Shift and Night Workers in Japan: Cross-Sectional Analysis of the J-HOPE Study [6], found elevated IL-6 levels in night workers and a positive relationship to cardiovascular disease, although the study design did not control for time of day for IL-6 draws (darn!). I just know more research is forthcoming as researchers have already expressed interest in overnight and diurnal IL-6 levels in PTSD, insomnia, and depression – and these are cohorts known for their altered cortisol patterns. The overlap intrigues me!

Dr. Katrina Wilhelm

What Your Doctor May Not Tell You About Breast Cancer

The seminal work written by John Lee, MD, our very own David Zava, PhD, and Virginia Hopkins, highlights the pivotal role natural progesterone can play in protecting women from developing breast cancer.

Among the steroid hormones, progesterone tends to drop first for women who are moving into their perimenopausal phase and can even decrease cell sensitivity to thyroid hormones, as well, creating symptoms of thyroid deficiency when free T3 uptake drops.

While natural progesterone is readily available as an OTC cream, products often come in a squeeze tube asking you to apply a “pea” sized amount of cream, never really assuring a specific dose per application due to volume variability.

I recommend looking for a professional brand with a metered dose dispenser –- that way you and your patient both know exactly what dose is being delivered. My favorite topical progesterone cream delivers 20 mgs per pump, which works excellently with the ZRT saliva testing topical ranges, which were developed for use with 10-30 mg of topical progesterone per day.

Dr. Alison McAllister

Overcoming Overwhelm by Dr. Samantha Brody

Sadly, reading this book won’t magically take you away from your stressors, give you a million dollars or put you on a beach in Tahiti where you eat amazing fruit while engulfed in the scent of local flowers. If only managing stress was so easy. This book is a workbook and I think it’s a great one to get people to look at what they want in their lives, the energy, the values, and their choices. One of the things we know about the physiology of stress is that our responses, and the feeling that we can respond, help decrease stress. Dr. Brody’s workbook is about taking control of what stresses we allow in our lives, what our life priorities are and how we choose to respond to them. I think that in this world where things are constantly coming at you, it’s really nice to have a tool that encourages people to just stop and say – How are you spending this life? Is this what brings you happiness? Are you getting what you want and then making choices to adapt to things that you can’t change? This book isn’t written for doctors/healthcare practitioners, but boy, I can’t think of a group of people who really need it more as a profession facing overwhelming burnout rates. This is geared to be a workbook talking about practical approaches, understanding some physiology and then some deeper questions I think we all need to ask ourselves. I recommend checking it out; if it doesn’t speak to you, I’m sure that you will have at least one person in your life who needs it.

Related Resources:

Book References:

Isaacson W. The Innovators.

Brinkley D. American Moonshot.

Gersh F. PCOS SOS: A Gynecologists’s Lifeline to Naturally Restore Your Rhythms, Hormones, and Happiness.

Lee JR, Zava D, Hopkins V. What Your Doctor May Not Tell You About Breast Cancer: How Hormone Balance Can Help Save Your Life.

Brody S. Overcoming Overwhelm.

Article References:

[1] Nicolaides NC, et al. Stress-Related and Circadian Secretion and Target Tissue Actions of Glucocorticoids: Impact on Health. Front Endocrinol (Lausanne). 2017;8:70.

[2] Bahrami-Nejad Z, et al. A Transcriptional Circuit Filters Oscillating Circadian Hormonal Inputs to Regulate Fat Cell Differentiation. Cell Metab. 2018;27:854-868.e8.

[3] Champaneri S, et al. Diurnal salivary cortisol and urinary catecholamines are associated with diabetes mellitus: the Multi-Ethnic Study of Atherosclerosis. Metabolism. 2012;61:986-95.

[4] Yehuda R, Seckl J. Minireview: Stress-related psychiatric disorders with low cortisol levels: a metabolic hypothesis. Endocrinology. 2011;152:4496-503.

[5] Nilsonne G, et al. Diurnal Variation of Circulating Interleukin-6 in Humans: A Meta-Analysis. PLoS ONE 2016;11:e0165799.

[6] Amano H, et al. Interleukin-6 Level among Shift and Night Workers in Japan: Cross-Sectional Analysis of the J-HOPE Study. J Atheroscler Thromb. 2018;25:1206–1214.