Fabulous Health Before Forty:

Transcription

1 Fabulous Health Before Forty: Fixing Fatigue, Depression, IBS, Irregular Periods and more for good! Aimee Duffy, MD Carolina Integrative Medicine

2 Stressed out Stacy 3 kids, 11, 8, 4 Full time administrative clerk at local college Never lost that baby weight from 4 years ago and has recently gained another 10 pounds Awakens every morning at 6 am (after snoozing for 30 minutes because she was supposed to go to the gym early this morning) wishing she had another hour of sleep 2 cups of coffee, no time for breakfast, grabs a kids left over Pop Tart in the car bathroom x 2 at work Deadlines at work but in meetings all day so no time to accomplish tasks, thinks maybe she will do it tonight at home after the kids go to bed

3 Stressed out Stacy 5:32pm (Hope they don t charge me for being 2 minutes late) Picks up kids from after school care, feels guilty that she is not there to pick them up with fresh milk and cookies at 3:00 like the other moms, I ll grab something at the gas station for them and a Little Debbie cake for me since I didn t have time for lunch Gymnastics at 5:30 for the little one (forgot the leotard again), basketball for the middle, the oldest has homework, wants to stay home ALONE Dinner? Oh right, drive thru again I should get a salad but I can t eat that in the car, so hand held sandwich, fries, and a soda because I need to stay up late 2 glasses of wine, baths maybe, read a book? Not tonight, Mommy s tired. Catch up on Facebook that s important! 10:30 pm, exhaustion I ll do the laundry, make lunches, finish that work assignment, help with homework, make dinner, exercise, eat better, have sex with husband TOMORROW Fall asleep 10:30, awaken at 12:45 sweating (probably the soda), back to sleep 2:20am, toss and turn until alarm at 6:00 (Oh and period started, again, in the middle of the night gotta change the sheets!)

4 Learning Objectives Familiarize yourself with the 7 most common complaints in younger female patients (20 40 years of age): fatigue, irregular periods, depression, IBS, insomnia, infertility and low libido. Become knowledgeable of the adrenal, hormonal and neuroendocrine imbalances which lead to physiologic changes associated with these top concerns of young women Learn to identify adrenal dysfunction, hormonal and neurotransmitter imbalances for each individual so that targeted treatment plans can be generated. Deepen your acumen with clinical pearls Obtain treatment protocols which address these conditions utilizing natural therapies: bio identical hormones, neurotransmitter nutrients, botanical medicine, and nutrition and lifestyle programs.

5 Symptoms of Adrenal Fatigue (adrenal dysfunction) Low body temperature Insomnia Low blood pressure Weakness Moments of confusion PMS Unexplained hair loss Indigestion Craving sweets Nervousness Feelings of frustration Dry and thin skin Excessive hunger Poor memory Headaches Irritability Hypoglycemia Decreased Libido Mental depression Osteoporosis Low blood pressure Lack of energy Apprehension/Anxiety Light headedness Alternating diarrhea and constipation Poor resistance to infections Difficulty building muscle Dizziness that occurs upon standing Inability to concentrate Food / Inhalant allergies Palpitation (heart fluttering) Issues with weight Tendency towards inflammation Wilson JL. Adrenal Fatigue: The 21 st Century Stress Syndrome. Petaluma, CA: Smart Publications; 2001.

6 Symptoms of Progesterone Deficiency Mood swings Irritability Depression Irregular Periods, Heavy Menstrual Bleeding Hot Flashes/Night sweats Vaginal Dryness Water Retention Decreased Libido Headaches Fatigue Sleep Disturbance (Insomnia, less REM sleep) Bone Mineral Loss (Osteoporosis) Short term Memory Loss Lack of Concentration Dry, Thin, Wrinkly Skin Thinning of Scalp Hair Increased Facial Hair Diffuse Aches and Pain Weight Gain: Hips, Thighs and Abdomen Breast Tenderness/Fibrocystic Breasts Uterine Fibroids Infertility

7 Symptoms of Neuroendocrine Imbalances: Mood problems such as Depression and anxiety Low physical energy and stamina Appetite control, insulin resistance Fatigue and sleep disorders Addiction and dependency Low pain tolerance Poor mental focus, or ADD, ADHD Low libido Sexual dysfunction 1. Depression and anxiety symptoms are related to increased 24 hour urinary norepinephrine excretion among healthy middle aged women. Hughes JW, et al. J Psychosom Res. 2004; 57: Blood serotonin levels in postmenopausal women: effects of age and serum estradiol levels. Gonzales GF, Carillo C. Maturitas. 1993;17:23 9.

8 See anything in common? FATIGUE ANXIETY IRREGULAR PEROIDS CARBS CRAVINGS WEIGHT GAIN DECREASED LIBIDO IRRITABILITY POOR SLEEP DEPRESSION

9 Stress Response When a stress response is triggered, the HPA axis is stimulated to produce cortisol and DHEA in the adrenal cortex, and the adrenomedullary hormone system initiates norepinephrine and epinephrine production in the adrenal medulla. Initially, these neurotransmitter levels tend to be elevated often causing a concomitant rise in inhibitory neurotransmitters such as GABA. Additionally, cortisol is required in the conversion of norepinephrine to epinephrine, so a compromise in cortisol levels (as seen with chronic stress) causes an imbalance in the ratio between these two neurotransmitters.

10 Cortisol and Serotonin There is a dynamic relationship between cortisol and serotonin wherein healthy adrenal function is dependent on balanced serotonin and healthy serotonin is dependent upon balanced adrenal function. Serotonin is involved in hypothalamic stimulus to facilitate pituitary release of ACTH, which, in turn, is necessary for the release of cortisol and DHEA. An insufficient supply of serotonin will contribute to an insufficient release of cortisol. As the body continues to demand cortisol there will be a subsequent demand on serotonin to help produce ACTH that may result in depletion of serotonin levels. Furthermore, stress inhibits the conversion of tryptophan to 5 HTP, which is the rate limiting step in the production of serotonin. Head KA, Kelly GS. Nutrients and botanicals for treatment of stress: Adrenal fatigue, neurotransmitter imbalance, anxiety and restless sleep. Alt Med Rev. 2009; 14(2) Heilser LK, et al. Serotonin activates the hypothalamic pituitary adrenal axis via serotonin 2 C receptor stimulation. J Neurosci. 2007;27: Lieberman, Michael PhD, Marks, Allan MD. Basic Medical Biochemistry: A Clinical Approach. Philadelphia: Wolters Kluwer. 2013

11 Testing Before beginning any treatment protocol on the adrenal glands a clinical history should be taken and testing should be done. 8 or 10 panel saliva test Neurotransmitter panel Labs: Thyroid panel (TSH, Free T3, Free T4), Vitamin D, CBC, B12, CMP

12 Testing When assessing a patient for the first time, it is important to get a complete look at their hormone profile. An 8 or 10 panel is best. If appropriate, subsequent testing can focus solely on adrenal health (DHEA and cortisol x 4). However other hormones, such as progesterone levels, can influence adrenal hormones.

13 Steroid Hormone Cascade

14 Integrative Approach to Treatment Balance hormones Women on OCPs do not respond to adrenal treatment protocols as well bio identical progesterone is suppressed by synthetic progestins Test and correct NT imbalances Support the thyroid supplements or T3/T4 replacement if needed Treat vitamin D deficiency goal 60 80, I use 10,000 IU if less than 40 B12 supplementation Address the gut probiotics, eliminate gluten, complex sugars, add veggies, protein

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17 Lab Report Example TSH 1.75 ( miu/l AT) (ideal less than 2, closer to 1) T4, FREE 0.9 ( ng/dl AT) (ideal >1.2) T3, FREE 3.3 ( pg/ml) (ideal >3.5) VITAMIN B ( pg/ml) (ideal ) VITAMIN D, 25 OH, TOTAL 26 L ( ng/ml) (ideal 60 80)

18 Sensory Input

19 Modern Stress Layer upon layer of stress stimulation that does not allow adrenal function to go back to normal

20 Internal Stressors Leaky gut IBS diarrhea and constipation, bloating Gluten (or other food) sensitivity Environmental allergies Prescription medications These send the same stress signals to the body sometimes even in the absence of symptoms

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23 Possible Treatments for Adrenal Dysfunction Hydrocortisone DHEA Melatonin Vitamin C Vitamin B5 Vitamin B6 Vitamin E Phosphorylated Serine 5 HTP L Tyrosine L Theanine Trace minerals Zinc Manganese Selenium Chromium Molybdenum Copper Iodine Rhodiola Ashwagandha Panax Ginseng Siberian Ginseng Adrenal glandulars

24 What I use 2 CAPSULES IN AM OR 1 IN AM AND 1 AT LUNCH 2 IN AM, ADD 2 AT LUNCH IF NEEDED

25 Hydrocortisone 5mg or 10mg Tablets Most common dose is 10mg in am and 5 mg at lunch Other options: 5 in am, 5 at lunch 10 in am 5 in am, 5 at lunch, 2.5 at 3 4 pm 15 in am 10 in am 10 at lunch

26 How Does Cortisol Work?

27 Safe Uses of Cortisol Low dose physiological cortisol supplementation does not produce signs or symptoms of glucocorticoid excess and has not been shown to cause clinically significant adrenal suppression. 20 mg of oral hydrocortisone has far less glucocorticoid effect on bone for example, than 5 mg of prednisone (Jodar 03). Studies have shown that 10 mg and 40 mg of hydrocortisone (the amount increases depending upon body weight) does not cause bone loss, suppression of immune system, weight gain, elevated blood sugar, elevated blood pressure thinning skin, easy bruising or suppression of endogenous cortisol production (Mah 04). Jodar, E et al. Long term follow up of bone mineral density in Addison s disease. Clin Endocrinol. 2003; 58: Mah PM, et al. Weight related dosing, timing and monitoring hydrocortisone replacement therapy ion patients with adrenal insufficiency. Clin Endocrinol. 2004; 61: Jefferies, WM. Safe Uses of Cortisol. Springfield, IL: Charles C. Thomas; 2004.

28 Explaining Safety to Patients

29 Prednisone Mommy

30 Hydrocortisone Mommy

31 Hydrocortisone: Adverse Effects Weight gain/increased appetite Often at the end of the day Actually may need more HC, not less! Can be transient Poor Sleep Stop noon, dose, decrease am dose May return to higher doses later Rash or other reaction Consider gluten allergy Try Brand Rx Can t remember noon dose or symptoms up and down fatigue at 11 am and 3 pm Consider Compounded Sustained Release 10mg SR capsule in am with 5 mg regular tablet

32 Follow up

33 Addressing High Cortisol MM 33 year old Daily headaches Severe fatigue Irritability/anxiety worse in the evening (bathtime for 3 year old is very hard for her) Chronic yeast infections Poor sleep Can t lose baby weight

34 Addressing High Cortisol Labs Vit D: 23 B12: 523

35 Addressing High Cortisol Phosphorylated Serine 90mg 4pm, 7pm, 10pm Cortisol Calm Two vegetable capsules contain: Vitamin D (as cholecalciferol) (D3) 800 i.u. Sensoril ashwagandha 500 mg. (Withania somnifera) extract (root and leaf) Rhodiola (rhodiola rosea) extract (root) 250 mg. (standardized to contain 3% total rosavins and min. 1% salidrosides) Magnolia (magnolia officinalis) extract (bark) 200 mg. (standardized to contain 2% honokiol) l theanine 100 mg. Ascorbyl palmitate (fat soluble vitamin C) 20 mg. Other ingredients: vegetarian capsule (cellulose, water) 1 capsule in the morning and 1 capsule in the evening, with meals. Do not take if pregnant or lactating

36 Other Treatments Progesterone 25mg cream q hs day 7 28 Vit D 10,000 B12 injections monthly Probiotics for yeast Decrease sugar in diet

37 Follow up 4 months later Symptoms significantly improved, headaches not gone completely, but not every day, less irritability, more energy, yeast infection has cleared up Came in for appt due to mild pelvic pain POSITIVE PREGNANCY TEST!

38 Progesterone Deficiency/ Estrogen Dominance Refers to an excess of estrogen relative to progesterone = LOW Pg/E2 Ratio

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40 Symptoms Associated with Low Pg Acne Bloating Breast tenderness Depression Fatigue Food cravings Headaches Irritability Joint pain Poor sleep Decreased libido Irregular periods Infertility Thinning hair/alopecia Weight gain Brain fog/memory issues

41 Low Pg Treatment Considerations Cyclic Bio identical progesterone Start 15 30mg (Kajarin 4 Balance =30mg) topical progesterone cream applied nightly to areas of thin skin (inner arms, behind the knees) Interested in pregnancy: Apply days of cycle (I advise they continue until the next menses) Not interested in pregnancy: Apply days 7 28 Increase to BID at follow up if minimal improvement or residual symptoms Vitamin A, B complex, C GLA (Black Currant, borage oil) Magnesium Manganese Calcium Citrate Ground Flax seeds Indole 3 carbanol or DIM Herbs Vitex(chaste tree berry) Consider Neurotransmitter testing

42 1 3 capsules twice daily or as directed by your health care practitioner. Can be taken with or without food.

43 PMS and Neurotransmitters Dopamine excess leads to prolactin and gonadotropin deficiencies resulting in menstrual irregularities. Low dopamine levels, often influenced by hormonal imbalances, can affect focus and cognition and negatively influence mood. Serotonin levels as well as serotonin receptors are significantly impacted by estrogen levels. Progesterone stimulates GABA, a calming neurotransmitter. Low levels of progesterone then can lead to anxiety, worry, and poor sleep Archer JSM. Estrogen and mood changes via CNS activity. Menopausal Med. 1999;7(4):4 8. Bitran, D. Hilvers, R.J., Kellogg, C.L Anxiolytic effects of 3a hydroxy 5a[b] pregnan 20 one: endogenous metabolites of progesterone that are active at the GABAA receptor. Brain Research, 1991; 561(1): Joffe H and Cohen L. Estrogen, serotonin and mood disturbance: Where is the therapeutic bridge? Soc of Biol Psych 1998.

44 Clinical Pearl Use oral micronized progesterone at night for insomnia mg capsules Progesterone converts to allopregnanolone in liver Stimulates GABA receptors Little to no side effects Occasional complaint of grogginess in am at higher doses

45 Follow up

46 Neuroendocrine Imbalances

47 Interpreting Report The reported cognitive and mood concerns, stress, diminished drive, fatigue and sleep difficulties, cravings and pain issues are consistent with the reported neurotransmitter imbalance(s). Low serotonin may contribute to anxiety/depression and a sense of discontentment. Diminished serotonin may also be implicated in poor sleep quality and subsequent fatigue upon awakening as well as muscle and body aches and over all lassitude. Tryptophan, L theanine, and 5 HTP influence this pathway. Low range GABA may be associated with anxiety, worry, poor impulse control and/or decreased sleep quality. L theanine, GABA, and glutamine influence this pathway, while phenibut exerts GABA like effects. Low epinephrine may be associated with depression and mood changes as well as fatigue, difficulty concentrating, decreased ability to stay focused on tasks and diminished sense of personal/professional drive. L tyrosine, L theanine, and Mucuna pruriens influence this pathway. Low glutamate may be associated with increased addictive tendencies including food seeking behaviors and can contribute to mental fatigue and diminished mental stimulation. L glutamine is a precursor in this pathway. The elevated N/E (norepinephrine/epinephrine) ratio is indicative of poor conversion of norepinephrine to epinephrine. Low cortisol levels may be contributing to the symptom picture (cortisol stimulates the enzyme phenylethanolamine N methyltransferase, which converts norepinephrine to epinephrine). Therapeutic considerations include SAMe and magnesium supplementation. Diurnal cortisol levels may be warranted. Therapeutic considerations include: 5 HTP and/or L tryptophan; GABA, L glutamine, and/or phenibut; L tyrosine, and/or Mucuna pruriens. Additional considerations are nervine and adaptogenic herbs, supportive nutrients, vitamin D, methylation support, and L theanine.

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49 Choosing the Right Supplements The reported cognitive and mood concerns, stress, diminished drive, fatigue and sleep difficulties, cravings and pain issues are consistent with the reported neurotransmitter imbalance(s). Low serotonin may contribute to anxiety/depression and a sense of discontentment. Diminished serotonin may also be implicated in poor sleep quality and subsequent fatigue upon awakening as well as muscle and body aches and over all lassitude. Tryptophan, L theanine, and 5 HTP influence this pathway. Low range GABA may be associated with anxiety, worry, poor impulse control and/or decreased sleep quality. L theanine, GABA, and glutamine influence this pathway, while phenibut exerts GABA like effects. Low epinephrine may be associated with depression and mood changes as well as fatigue, difficulty concentrating, decreased ability to stay focused on tasks and diminished sense of personal/professional drive. L tyrosine, L theanine, and Mucuna pruriens influence this pathway. Low glutamate may be associated with increased addictive tendencies including food seeking behaviors and can contribute to mental fatigue and diminished mental stimulation. L glutamine is a precursor in this pathway. The elevated N/E (norepinephrine/epinephrine) ratio is indicative of poor conversion of norepinephrine to epinephrine. Low cortisol levels may be contributing to the symptom picture (cortisol stimulates the enzyme phenylethanolamine N methyltransferase, which converts norepinephrine to epinephrine). Therapeutic considerations include SAMe and magnesium supplementation. Diurnal cortisol levels may be warranted. Therapeutic considerations include: 5 HTP and/or L tryptophan; GABA, L glutamine, and/or phenibut; L tyrosine, and/or Mucuna pruriens. Additional considerations are nervine and adaptogenic herbs, supportive nutrients, vitamin D, methylation support, and L theanine.

50 What I Use: L theanine 100 mg capsule 1 2 BID TID 5 HTP 100 mg capsule 1 BID TID to start L glutamine mg capsules 1 BID TID Works great with IBS abd pain

51 What I Use: DopaLift Ingredients per 2 capsules: Vitamin B 6 (as Pyridoxal 5 Phosphate) 5 mg N Acetyl L Tyrosine 750 mg Macuna (Macuna pruriens) 425 mg [standardized to contain 60% L dopa (3, 4 Dihydroxyl L Phenylalanine)] Green Tea Extract (Camellia sinesis)(leaf) 100 mg [standardized to contain 98% polyphenols and 45% EGCg] NT Uplift Ingredients per 6 capsules: Vitamin B 6 (as Pyridoxal 5 Phosphate) 30 mg L Tyrosine 1200 mg GABA (Gamma Aminobutyric Acid) 750 mg L Glutamine 600 mg Inositol 600 mg Taurine 600 mg 5 HTP (5 Hydroxytryptophan) 150 mg

52 Vitamin B12 Symptoms of a vitamin B12 deficiency include: Unexplained fatigue or loss of energy Poor circulation Apathy Mental fogginess Unusual mood swings Hair loss Muscle weakness Tingling in the extremities Lack of motivation Memory problems

53 Vitamin B12 Reference Range Optimal Range Supplementation: Compound Methylcobalamin Injections B12 injections weekly monthly Frequency can be subjective : weekly : every 2 4 weeks Sublingual Drops or Chewable Tablets mcg daily Consider Methylation Support Usually contains Methyl B12, Folate (5 MTHF) and other B vitamins MTHFR testing

54 Vitamin D Symptoms Associated with Deficiency Depression Osteoporosis Muscle and bone aches Hormonal imbalances Heart disease Blood sugar fluctuations Supplementation Reference Range: ng/ml Optimal range: ng/ml Less than 40 ng/ml: 10,000 IU daily Retest in 3 4 months and decrease to 5000 IU if 60 ng/ml or greater Do not decrease in the winter months ng/ml: IU

55 Thyroid TSH, Free T3, Free T4 TSH less than 2, closer to 1 ideal FT3 above 3.5 FT4 above 1.0 Treatment Dessicated Thyroid (T4/T3) Armour Nature Throid Start with ½ Grain Supplements Selenium Guggal Iodine

56 Converting from T4

57 Clinical Pearls If TSH high but FT3 & FT4 normal and cortisol is low, treat adrenal/hormones first Revisit thyroid again if not responsive to treatment Low body temperature (< 97.4) can be associated with thyroid dysfunction even though labs are normal TSH will increase with iodine replacement initially, do not retest for 3 months Look for thyroid antibodies (TPO, TgAb, TSI) in patients that have inconsistent TSH TSH high, increase dosage then TSH low decrease dosage They can never get stable, and usually still have symptoms

58 IBS/Food Allergies Consider in patients with symptoms: Abd pain, bloating, constipation, diarrhea Also consider in asymptomatic patients (ie: no GI complaints) not responding to treatment Start with probiotics and modified elimination diet Severe adrenal fatigue patients are typically unable to make many changes in the beginning Consider meal replacement shakes for 1 meal a day

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60 Lifestyle Changes Get a babysitter! Go to the grocery store Get a pedicure Take a nap Find the time to walk outside for 15 minutes at lunch or in the evening twice a week to get started Stock up on healthier snacks Nuts, fruit, carrot sticks, cheese sticks Consider a yoga class

61 Happy Holly AM Adrenal Supplement Hydrocortisone 10mg NT UpLift L theanine Fish Oil Noon Hydrocortisone 5 mg PM NT Uplift Vit D 10,000 Probiotic Progesterone Cream Monthly B12 Injections

62 Happy Holly More energy, awakens even before the alarm sometimes Baby weight is going away Eating a better diet, preparing food from home Finding some time to move, playing with the kids Sleep has improved Mood has improved Periods are more regular, lighter in flow (4 6 months) May, in fact, like her husband! ie improved libido.

63 We All Wanna Feel Good!