Women’s Health Roundtable

Dr.Sima Aidun N.M.D. is a Naturopathic Doctor offering holistic, natural, integrative care to women of all ages. Her main focus is using Bioidentical Hormone Replacement Therapy for perimenopause and menopause. Her Office is located in Scottsdale, Arizona. She also serves Gilbert, Mesa, Tempe, chandler, Cave Creek, Deer Valley, Care free, Fountain hills, and Phoenix area.

September 2009, Women’s Health Round table: Q&A

1. I have a thyroid goiter and was given Synthroid medication, but still have the goiter. Is Bio-identical thyroid medication better?

In clinical practice, some patients respond better to one type of prescription (generic vs. brand name vs. compounded) and some respond the same to all versions. It is just a matter of trial and error, allowing at least 6-9 months for stabilization when calculating the right dosage and type (T4, or both T4 and T3).

If you suffer from goiter, you might also need to pay attention to your Iodine intake. Sometimes in an attempt to absorb more iodine form the blood stream, the thyroid gland gets enlarged. Iodine is used in the making of thyroid hormones.

2. What do you think of using bio-identical HRT in young women? How effective is it in correcting hormonal imbalance, and if so, what is the diet?

Use of HRT in young women is justified if there is evidence of hormonal imbalance. Some examples include: PMS (premenstrual syndrome), PCOS (poly cystic ovarian syndrome), thyroid disease, fibroids, and endometriosis.

Types of food we consume can be a cornerstone of a hormone balancing approach in all ages, especially young women. The perfect hormonal balancing diet should be designed around: •Low glycemic diet to decrease and balance insulin levels: too much insulin can change the ovarian production of hormones toward the direction of imbalance.

-Anti-inflammatory diet: Avoid foods that are pro-inflammatory such as red meat, high fat dairy products, fatty, fried and processed foods. Consume foods high in omega-3 fatty acids (anti-inflammatory effect): oily fish such as wild salmon at least twice a week, walnuts, and flax seed to name just a few.

-Fiber and water: 40 grams a day to help body get rid of excess hormones and toxins metabolized in the liver. Good sources of fiber include fresh fruit, green and leafy vegetables, high fiber cereals (Trader Joe’s has good choices), and ground flax seed

-Avoid Xenoestrogens (external sources of estrogen): eat organic meat and dairy products as much as you can since they do not contain hormones and antibiotics. Try not to drink out of plastic water bottles and do not warm your food in plastic containers. Plastic materials, when heated up, will release toxins that mimic estrogenic effect in the body.

3. How long is safe to stay on Pellet Therapy?

It is suggested to use HRT for no more than five years, regardless of the form of delivery. There is no data specific for Pellet Therapy. Due to erratic release and unpredictable high concentrations of hormones released in pellet form, I would suggest considerably less than 5 years.

4. If I go for blood work before the Pellet Therapy is inserted, do you think the dosage will be correct?

Most probably, yes. One of the purposes of baseline blood work is to identify the dosage. The issue with Pellet Therapy is the unpredictable pattern or release in to the blood stream and inability to change the dosage accordingly.

5. If you have gone through menopause and you still get a cycle well into your 50s (due to Pellet Therapy), should you go off all hormones within 3-5 years?

First, if you are NOT on a cyclic regimen of HRT (10-14 days of progesterone per month) and taking your progesterone every day, the cause of bleeding has to be investigated. The 3-5 year time frame pertains to using hormones in all different delivery systems (pellet, cream, lozenge, tablet, etc.) as well as cyclic vs. continuous regimen of HRT.

*Cyclic regimen of HRT: taking (receiving) estrogen every day, adding progesterone 10-14 days per month to induce cyclic bleeding.

*Continuous regimen of HRT: taking (receiving) estrogen and progesterone every day. No bleeding will occur, unless there is an underlying structural or hormonal imbalance.

6. Alternative to heart palpitation: I am taking Metoprolol due to heart palpitations and am 53 years old. Are there other alternatives?

It depends on the cause of your heart palpitation. If the underlying cause is not of a serious concern, there are natural ways to help with the heart palpitations. I strongly suggest that before you approach an alternative treatment, seek a cardiologist’s approval to do so. Once you get the permission of safety from your cardiologist to replace your medication, make sure the line of communication is open between the cardiologist and the practitioner who is going to help you with “natural” or “alternative” treatment. Remember, not all natural medicine is safe. Due to the liability issues, we cannot provide you with the specific treatment regimens in this manner.

7. There is a diagnosis of breast cancer with my mother, and her mother. I had a lumpectomy when I was 14 years old. Now I am 53 years old and have no libido, but do have vaginal dryness and intercourse with pain. What are your thoughts on taking bio identical hormones with the history of breast cancer? My perimenopause is very difficult to deal with and I am confused as to what action I can take?

I am not clear whether or not you had breast cancer. If you did, I strongly suggest you stay away from HRT containing estrogen as much as you can and use non hormonal therapy. If you are perimenopausal, progesterone has potential to help you with your systemic symptoms such as irregular bleeding, mood changes, PMS etc. For you vaginal dryness and painful sex, you can safely use bio-identical Estriol cream for vaginal dryness.

If you have not been diagnosed with breast cancer, first determine the type of hormonal imbalance (estrogen dominance vs. estrogen deficiency). If your symptoms due to low estrogen level gets intense enough that effects your quality of life considerably, use the lowest dosage of Bio-identical HRT possible, NOT IN A PELLET form. Make sure your hormonal blood levels are checked regularly and follow the recommended mammogram regimen for you, considering your age and family history of breast cancer.

8. I’m a 64 years old female and have been in menopause for more than 14 years. I do not have a history of breast cancer, but my mother was diagnosed in her 80′s. I do have fibrocystic breast and calcifications, which have been checked by mammograms yearly. I have been using HRT Climara + Prometrium. How safe is this combination?

When talking about the HRT and increase risk of breast cancer, it applies to all forms including the patch. The concern is the “hormonal content” not the “method of delivery,” especially in regards to breast cancer risk. Method of delivery becomes an issue if we are concerned about, for instance, increase in clotting factors or high triglyceride levels. Patch and cream do not increase the Triglyceride or clotting factor as much.

Also, women with fibrocystic changes of the breast seem to have denser breast tissues and HRT can add even more breast density. The issue here is that the breast tissue is “white” and potentially cancerous lumps are “white area” on the mammogram as well, making it harder to differentiate. In situations like this, the expertise of the radiologist is most important. Click here to see more information about Dense Breast Tissue.

9. Does HRT increase the risk of breast cancer? What about bio-identical hormones?

These questions seem to be the most common concern for women in perimenopause and menopause. Media’s answer to the question is: Yes, HRT increases the risk of breast cancer. The answer is more complicated. It is a known fact that estrogen can stimulate breast tissue cell division. Prolonged cell division over the course of years has the potential to turn into precancerous and cancerous events. BUT…there are many more factors involved determining the direction of the effect estrogen might have over the breast tissue; such as family history, type of hormones used ( estrogen or estrogen plus progestin or progesterone), genetic factors, environmental factor, and unknown risk factors. To read more visit: Natural Solutions for Women

10. If I can tolerate hot flashes, night sweats, vaginal dryness and insomnia, should I not take HRT? Are there any advantages to taking HRT in some form, such as skin elasticity, heart health?

The main indication in using HRT is to address symptoms of menopause, such as hot flashes and night sweats to the point that effect quality of life, and also to protect bone density. If you can tolerate the symptoms and your bone density is doing well, I recommend that you do not take HRT. But if your bone density is suffering and no other non-hormonal treatments have worked to enhance the bone density, you might benefit from HRT. Even though HRT has many other benefits besides helping with the hot flashes and bone density, those benefits are bonuses (skin health, cardiovascular health below age 60) and are not prescribed for those reasons only. There are other ways to work toward optimal body health. There is one exception: prevention of pelvic floor laxity. Even though you do not suffer from vaginal dryness, you might need to discuss using Vaginal E3 (Estriol) to maintain the pelvic floor tone, hopefully preventing future bladder incontinence and prolapsed of bladder, rectum and uterus.

11. HRT in breast cancer survivors: (more than one person asked this question – here is one example). I am a breast cancer survivor and have had a double mastectomy with her2 neu and estrogen positive breast cancer and positive lymph nodes – can I take hormones safely?

Using HRT seems to be a contraindication in breast cancer survivors. There are many studies looking into the risk of HRT in breast cancer survivors with conflicting results. Amongst these are the two largest:

  1. The HABITS trial: a large, prospective clinical trial on the safety of HRT after breast cancer, showed an increase in the recurrence of breast cancer (relative risk 2.4) in women taking estrogen, estrogen/progestin therapy. The majority of women in the HABITS trial were treated with synthetic progestin, which have consistently been shown to increase the risk of breast cancer.
  2. The Stockholm study: When the use of synthetic Progestins was limited (not used every day of the month) in the prospective ‘sister’ trial completed in Stockholm, the risk of cancer recurrence was not increased (RR 0.82) [93]. In addition, the Stockholm trial showed the risk of death from all causes was not increased with HRT (RR0.5). The Stockholm trial did have a slightly higher percent of patients treated with Tamoxifen.

In conclusion: Since the data is not strong in either direction, we would not suggest HRT to breast cancer survivors, except for Vaginal Estriol for vaginal dryness and painful intercourse caused by it.

12. I have breast cancer and cannot take HRT. Do you have any suggestion to relieve hot flashes?

  1. Sleep habits: Use a down comforter or blanket regardless of time of the year. They are light weight, warm in the winter and cool enough in the summer, especially when the air conditioning or a fan is on. They are light weight and can be tossed off easily. Also, use high quality cotton bed linens, as it will keep you cool.
  2. Dress in sleepwear that isn’t form-fitted around your waist or bust or hips. Keep a thermos of cool water on your nightstand and take a few sips when you are woken up by night sweats. Avoid too much alcohol, and spicy and hot food at night.
  3. Eat foods containing soy such as tofu, tempeh, miso, soy milk, and whole soybeans. Breast cancer patients or patients at high risk of breast cancer should avoid consuming soy products that are “concentrated/processed” such as soy powder, and supplements containing soy and soy protein. Limit the amount of soy Isoflavones to under 50 mg per day. Click here to read more information on this subject.
  4. Exercise at least 30 minutes every day. You can walk, run, ride a bicycle, or do another activity. Just don’t exercise within 3 hours of going to bed to help prevent night sweats.
  5. De-stress! Stress causes your body to produce more adrenaline. This causes blood flow to increase, which as a result, leads to an increase in body temperature.

13. Any recommendation for insomnia?

First, find out the underling cause of your insomnia for the more targeted treatment. Some common causes of insomnia include: drinking caffeinated beverage after 2:00-3:00 in the afternoon, night sweats, sleep apnea, stress, drinking liquid within few hours of the sleep time, and nocturnal drop in the blood sugar.

Some tips:

  • Eat a bed time snack: cheese and cracker, glass of low fat milk, cereal
  • Perform daytime exercise
  • Avoid naps
  • Sleep on a good firm bed
  • Keep your bedroom a place to sleep
  • Get up earlier in the morning and do not sleep in
  • Avoid illuminated bedroom clocks
  • Make a hot chamomile tea: 2 tea bags in one cup and drink two hours before bedtime…or drink Chamomile iced tea throughout the day, with the last cup two hours before bedtime
  • Do not drink caffeinated beverages after 2:00-3:00 pm
  • Visualize something boring!
  • Visualize something relaxing!

14. What are the options for bone health?

  • Calcium supplements:
  • Calcium citrate: High absorption rate, can take with or without meal, less elemental calcium
  • Calcium carbonate: Low absorption, need adequate stomach acid, not a best choice for elderly population or for those on anti-acid, cause constipation, has more elemental calcium
  • MCHC: Type of calcium containing protein molecules present in the matrix of the bone

Make sure your calcium supplement contains magnesium, boron, Vitamin K, Vitamin D3 (at least 1000 Iu). Omega-3 fatty acids taken with calcium increase absorption.

15. I am a breast cancer survivor – I had a lumpectomy, brachytherapy and am on Aromasin since September 2008, I have noticed a difference in my hair – it is thinning and the texture has changed. Is there any vitamin or process that I can do to make my hair thicker?

Aromasin can certainly cause hair loss, but there are so many other reasons why a women going through a breast cancer diagnosis and treatment can be losing hair. First of all, I recommend you speak to your oncologist, as they are familiar with your history and are in a position to narrow down the reasons you are losing hair. Because the treatment depends so much on the cause, it is impossible to recommend treatment options for you.

16. For breast cancer patients whose cancer was estrogen receptive positive – what food should be avoided, if any? Yams, soy, red wine, evening primrose, anything else? How “nutsy” should I avoid trying to avoid things?

We recommend avoiding concentrated supplements, such as soy, that can have an estrogenic affect on the breast. It is probably safe to eat organic soy that occurs naturally such as edamame, to a limited extent, soy milks. Most processed foods contain soy and I recommend avoiding them as much as possible. A glass or two of red wine a week is good for your heart! I haven’t heard that evening primrose oil should be avoided.

17. I have one dense tissue breast. Does that mean I’m a high risk for breast cancer in that breast?

Having dense breast tissue does put you at a slightly increased risk of developing breast cancer because it is more active tissue, typically. But of more concern, it is easier to miss a breast cancer on a mammogram if you have dense breast tissue, because the cancer may not be visible. That is why we stress doing monthly breast self-exam and we are now offering screening breast ultrasound. Click here to read more about dense breast tissue.

18. Do you address the psycho-emotional issues of women with breast cancer? And, do you believe those issues have any connection?

A very important part of the healing process from a diagnosis of breast cancer is addressing the psycho-emotional issues. The more informed and educated women are about their cancer, the easier it is for them to feel confident in their treatment and to develop a trusting relationship with their doctors.

19. Do you think colonoscopy is preferred over colonography?

Colongraphy, including the new modality CT colonoscopy, is very effective at finding small cancers, but the latter has not yet been approved by Medicare as a screening tool. Colonoscopy is more pleasant because you are asleep, but potentially has a higher risk of bowel perforation in inexperienced hands.

20. If I live in a rainy climate (like Seattle), is a light machine safe?

Not all light machines are the same. They are supposed to deliver visible light of certain wave lengths but unfortunately, some of them do deliver UV light. The UV light is usually filtered, but I strongly advise you to check the safety information with the manufacturer and with the doctor that has recommended the use of the lightbox.

To discover your path to wellness and schedule a health assessment, contact us today.