The truth about the biology of menopause

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The truth about the biology of menopause from a lifestyle medicine perspective

I watched with bated breath the documentary on the ‘Truth about menopause’ https://www.bbc.co.uk/iplayer/episode/b0bt4c3m/the-truth-about-28-the-menopause.

As I think about menopause, I want to acknowledge how much we women have achieved in the last few years, juggling childcare and effortlessly moving from boardrooms to the trading floor, to running homes, we so wanted to have it all! And sometimes I wonder how much we ended up actually doing it all and what impact this had on our health and the transitioning process of menopause.

I appreciate that our bodies are complex and optimizing health works best when we really understand the biology of mind and body and the complexity of this interaction.

So, back to biology! Even us doctors, we have long forgotten the biology of sex hormones and even if we didn’t, it seems of little relevance as we look at disease with a ’ name it, shame it and tame it approach’, as we go about fixing things in one part of our bodies by giving a drug that suppresses one symptom as quickly as possible. And although this works in the acute medical model, in the chronic disease model it often gives side effects and risks and benefits have to be carefully considered. Moreover, in our expectation for a quick fix, we are often frustrated when the medical establishment does not deliver it. We approach ageing with fear and dread and usually overlook the process of conscious transformation that life entails, the wisdom and love that we could still be passing on as we age.

Rather than explore menopause treatment options separately, I strive to use a double pronged one, nutrition and hormones where appropriate alongside mapping both physical and emotional needs.

Menopause as a takeover process

My brief view of the biology of menopause is that menopause is, in essence, a takeover process. The ovarian function declines and the ovaries produce less estrogen and progesterone. As women, we also make testosterone and dihydroepiandosterone (DHEA) and we continue to produce these from the adrenal glands after menopause. Our bodies have enzymes that transform testosterone into estrogen and this is an important pathway for well-being once menopause sets in. So, after menopause we rely on adrenals for hormones and there is less flexibility in the system without the ovaries. The stress we take on in the preceding years may affect how well the takeover process unfolds.

The steroid pathway

I believe it is really important to understand the steroid pathway, please stay with me on this one.

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As you can see, cholesterol is at the top of the tree. This is where diet comes in and why it is important to have healthy fats (avocados, nuts, seeds, quality organic meat) as part of your diet as you age and maybe explains why Japanese women suffer less from symptoms of menopause.

Take a moment to look at the chart and appreciate the little arrows that facilitate the ways our body can adjust hormones levels and balance them depending on what the perceived need is at any time point.

The main steroid hormones are pregnenolone, cortisol, progesterone, di-hydroepiandosterone (DHEA), testosterone and estrogen (and several other metabolites in between).

And if scientific diagrams don’t agree with you, we can look at hormones using a circle dancing analogy. There are many interactions between various hormones and the brain and they all ‘dance’ together. If one is struggling, they all respond and have to adjust. If there is an additional stress on the system, for example a bereavement or a conflict at work, cortisol production may increase. This may put some pressure on the pregnenolone/ progesterone system, which would support the body’s priority to cope with stress. And sustained stress may over time lower your DHEA levels and fatigue sets in. Your body is doing this moment by moment. All. Day. Long. And I did not cover here the role of sex hormones in the brain or how they may interact with our neurotransmitters…

However, each tissue has its limits in adjusting its responses to daily pressures.

At menopause, estrogen and progesterone begin to trip over; it can be a bit harder to keep the show on the road for a period of time. Can you keep dancing in a circle when two dancers are really dragging their feet?

Cortisol is King

Cortisol is the ruler of hormones and can influence how we respond to estrogen and progesterone, high levels of cortisol have been shown to make estrogen and progesterone less effective (when you feel that the hormone therapy you are taking isn’t working for you, this may be a contributor). Cortisol may influence thyroid function and lead to symptoms of low thyroid. It can cause high insulin, insulin resistance and diminished ability to metabolise sugars, which in turn may cause weight gain (that extra weight round our middle).

To address high cortisol it usually requires lifestyle changes. I believe that approaches like CBT, as in the documentary, may also work by addressing cortisol. Dietary changes include avoiding processed foods and refined sugars, having more protein and quality fats at every meal, as well as incorporating mindfulness in our daily routines. Cortisol has been the elephant in the room in our menopause conversations, because we did not understand the biology of it; not until recently. I recommend Dr Rangan Chatterjee’s upcoming book “The stress solution”, I trust him to deliver a down to earth approach that is rooted in the latest science.

Hormone therapy

Mariella’s hormone therapy was body-identical, meaning that the hormones she used have the same structure with what our bodies make (estradiol and progesterone). Interestingly, using estrogen alone as hormone therapy in earlier studies resulted in a decrease of breast cancer risk (but increased risk of uterine cancer, leading to incorporating progesterone-like drugs for hormone therapy. There are other synthetic progestins that are not progesterone and it is progestins that have been used in the clinical trials showing an increased risk of breast cancer. There isn’t enough data to confirm that using estrogen and progesterone is safer with regards to cancer risk, however it makes sense to replace like for like if possible and to monitor levels to adjust dose, given that our metabolism slows down as we age.

The spectrum of hormone therapy available is wide. Some doctors remain reluctant to even offer it. For many women, Estrogel (Estradiol) and Utrogestan (Progesterone) is still not always available when it is not part of the NHS formulary and monitoring blood tests is currently not recommended by NICE. At the other end of the spectrum, bio-identical hormone therapy can use a more personalized approach and can replace other hormones we naturally produce, such as testosterone and DHEA in addition to estrogen and progesterone, using dose adjustments and blood testing alongside with lifestyle advice and psychology support. Bio-identical hormones prescriptions are made in compounding pharmacies and are not FDA approved.

As a clinician, I know that, when it comes to menopause, it is not the hot flushes that we fear the most, but rather the changes to our brain and how it can at times feel like depression, dementia and ADHD all at once! And there is nothing more rewarding than to hear a woman saying that ‘I feel more like myself again’.

I admit I loved it when the Dalai Lama said a few years back that ‘… women will save the world’, and I hope that our menopause conversations will bring us closer to ourselves and to each other.

Thank you to Mariella Frostrup for starting the conversation.

Morphing into a functional medicine practitioner

Transitioning

(From conventional to lifestyle medicine doctor)

The last Consultant meeting. Five more working days to go, not that I am counting. I am leaving my substantive NHS Consultant job at Barts NHS and am both terrified and very excited. I feel as though I am coming out of the closet, on a professional level.

There is a ‘last’ every day. The last time I would see a particular patient. There are tears and hugs and understanding and frustrations and at times I let my boundaries down, and I hug my patients or let a little tear loose. I had seen some patients regularly for eight years and beyond the undetectable HIV viral load, I know their children’s names, their pets, hobbies and mostly had the privilege of walking alongside them in their HIV journey, from receiving a diagnosis, the shock and grief and into acceptance and thriving health again, rebuilding relationships and giving back to others and society. I learned so much in 20 years in the HIV/sexual health world.  From working on Broderip ward at the old Middlesex hospital in 1998, when planning for death and discussing living wills was an almost daily routine to then being able to prescribe life-saving antiretrovirals, albeit in handful of pills and nasty tasting liquids to finally now being able to sit in my new air conditioned office in a brand new clinic and explain how you can’t pass it on if your viral load is undetectable and yes, it has a normal life span if you adhere to treatment, mostly one or two pills daily. For all this to have happened in my ordinary doctor career is a blessing and mind-boggling astounding and I feel so grateful to have chosen this path.

Academic learning aside, the biggest gift has been the love and connection that I shared with patients over the years. And whilst I have always encouraged them to live true to their identity- sexual or otherwise and saw them live with courage in uncertain times and I know I can talk a good talk, I feel that now is my turn to walk the walk.

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(The dawn of awareness)

Three years ago, I a rough patch. I had an operation followed by complications that required intravenous antibiotics and delayed healing; serial MRI’s; loose bowels, low blood pressure and last but not least fatigue. I saw the best of the best in the conventional medicine world, but my symptoms were somewhat not fully explained by the tests available to me. The answers were few and yielded even fewer practical solutions. The rough patch turned into a black hole in my universe as I knew it. Was it my hypermobility and ‘funny collagen” structure that came with it or was it peri-menopause, burn out, stress or the deep grief at my mum’s terminal illness? The operation had been the last straw in an otherwise perfect storm. Another grief was that nothing I had learned in conventional training seemed to have prepared me for this, except for my analytical skills, ability to review research and willingness to be my own guinea pig.

It was during this time that I found functional medicine, which held many answers within it. Functional medicine is rooted in the latest science and looks at the biology of our systems.

Take stress, for example. In conventional medicine, you are taught that you need to remove yourself from the circumstances that are causing it. But how can you do it? Bread needs to go on the table, socks need to be paired up and there’s the daily emotional management load to be tackle. In functional medicine, you can break it down in components, based on systems biology (hormones, gut and microbiome, inflammation- to name a few). You measure your salivary cortisol at four time points throughout the day and look at its pattern (circadian rhythm). Is it disrupted from normal, when it is highest in the morning, dropping throughout the day to lowest at bedtime to allow for a good night sleep? How can you hack this from a biological perspective? You may start by balancing your blood sugars better by increasing the protein intake at every meal, tackle inflammation (remove inflammatory foods, such as gluten) or consider phosphatidyl serine – a supplement that helps breakdown cortisol to lower levels before bedtime. Do you know how good your metabolic pathways are for breaking down adrenaline? Are your enzymes in good shape or do you have a polymorphism in one of the enzymes (COMT- cathecol-O-methyl transferase) that may slow down its breakdown? If so, you may benefit from methyl donor supplements. You can also quantify your neurotransmitters, and although the validity of such tests is still being investigated, we also know that most of your serotonin, the happy hormone, is produced in your gut. Your lovely gut has 5 times more the number of nerve cells than your brain, ready at a moment notice to divert blood to your limbs for a fight and flight response in case of danger. The gut also hosts your microbiome, which can work for you or against you and can be characterised by a stool test. And can you still hear the whisper of your gut feelings or has it been drowned under the never ending to do list? Sometimes you can rebalance physical issues, but if there is a longing or an emotional hole in your heart, you may need to listen to it and engaging your right sided creative brain helps connect with it.

What about the astounding discovery of neuroplasticity - our ability to rewire our brains, grow grey matter and strengthen synaptic connections throughout life? What work does this involve and how can you build the determination, focused attention and implement the nutritional changes required?

I have now been back to work for 18 months after that rough patch, and whilst I have been able to help a few patients lose weight or even diminish their fatty liver appearance on liver ultrasound in my brief 20 min appointments, I was left feeling that I wanted to do more of this. I am leaving behind a HIV world that is stable and new diagnoses halved in London last year thanks to preventative therapy (PREP). More can be done to prevent metabolic syndromes, tackle cognitive decline and promote healthy ageing and I wish I was a part of that. For now, I am moving on into functional medicine at the Marion Gluck Clinic. I will also be joining forces with Akesio.com to further deconstruct stress and find personalised solutions for the individual. And if you still think stress it’s all in your head and you are in a rough place, I would love to listen to your story, because the likelihood is, I have already been there.

 

Photo by natamata/iStock / Getty Images
Photo by natamata/iStock / Getty Images