Date: 20/08/2024
Location: Fremantle Hospital
Introduction
Talk at a staff education event; delivered by yours truly Dr Purity.
Case: 33-year-old primary school teacher with a history of hormonal imbalance, postpartum depression, and recent symptoms indicating further endocrine dysfunction. This case highlights the importance of a tailored approach to hormone therapy and the potential overlap between hormonal imbalances and conditions such as ADHD.
Case Overview
Patient Profile:
• Age: 33 years old
• Occupation: Primary school teacher
• Obstetric History: G2P2 (two pregnancies, two live births)
• Conception History: ?PCOS, contraception use to regulate periods and mood.
• Past Medical History: Postnatal depression (PND) with her second child 6 years ago.
Presenting Symptoms:
• Anxiety, tearfulness, low libido
• Headaches, excessive crying for two weeks per cycle
• Weight gain, poor sleep, IBS-type symptoms, hot flushes
• Family History: Daughter undergoing ?ADHD diagnosis; other family members with ?ADHD tendencies but no formal diagnosis.
Initial Management Steps
1. Estrogen Therapy:
• Action: I initiated body-identical estrogen therapy, adjusting the dosage to increase during the luteal phase and decrease during the follicular phase to align with her menstrual cycle.
2. Progesterone Therapy:
• Action: Added body-identical progesterone for its GABA-A receptor-mediated calming effects, aimed at reducing anxiety, improving sleep, and stabilizing mood.
3. Continued Use of the Pill:
Advice: I recommended discontinuing the contraceptive pill due to its potential side effects, but the patient chose to continue due to fear of mood dips. She remained on the pill for the next two years.
Symptom Progression and Further Investigation
Recent Symptoms:
The patient began experiencing severe headaches, dizziness, and an overall inability to cope with daily life.
Blood Test Results:
1. Testosterone: Undetectable levels
2. Vitamin D: Low
3. Thyroid Function: Subclinical hyperthyroidism, antibody-negative
4. HS-CRP: Elevated, indicating inflammation
Revised Management Plan
1. Discontinuing the Pill:
• Action: I advised her to stop the contraceptive pill as it was no longer needed for contraception and was contributing to her symptoms.
2. Adjusting Hormonal Therapy:
• Action: Consider increasing the doses of body-identical estrogen and progesterone if needed. Plan to retest testosterone levels in six weeks and consider supplementation if levels remain low.
3. Dietary and Lifestyle Modifications:
• Cholesterol Management: Suggested reducing animal products and incorporating flaxseed meal to lower LDL cholesterol by approximately 15%.
• Inflammation Control: Recommended quercetin to help reduce inflammation.
Understanding the Underlying Issues
1. Fertility and Hormonal Imbalance:
• The patient’s difficulty conceiving likely indicated a pre-existing hormonal imbalance.
2. Worsening PMS with Age:
• Her premenstrual syndrome (PMS) symptoms have progressively worsened, which is common as women age.
3. Postpartum Depression:
• The significant drop in estrogen levels postpartum likely contributed to her postnatal depression, as estrogen levels can drop up to 17 times below baseline.
4. Impact of Oral Estrogen:
• Oral estrogen increases sex hormone-binding globulin (SHBG), reducing free testosterone levels. This reduction in testosterone can affect liver function, cholesterol production, glucose metabolism, and overall psychological well-being.
5. Advantages of Body-Identical Hormones:
• No Negative Impact on Testosterone: Body-identical hormones do not reduce testosterone levels.
• No Increased Risk of Clots: Body-identical hormones, especially transdermal estrogen, do not increase the risk of blood clots.
• Flexible Dosing: Hormone levels can be titrated according to the patient’s cycle.
• Safe for Migraines: Transdermal estrogen is safe for women with migraines with aura because it does not go through first-pass metabolism, avoiding an increase in clotting factors and venous thromboembolism (VTE).
• Progesterone Benefits: Prometrium (body-identical progesterone) stimulates GABA-A receptors, improving sleep, reducing anxiety, and stabilizing mood.
Prognosis and Long-Term Outlook
Prognosis:
The patient’s prognosis is very good with appropriate management. Without intervention, she would likely experience severe menopause and post-menopausal symptoms. Continuous hormone replacement therapy (HRT) may be necessary for her long-term well-being.
Discussion Points
1. Reproductive Depression and ADHD:
• The potential overlap between reproductive depression, perimenopause, menopause, and ADHD.
2. Hormonal Imbalance in Mental Health:
• Consider hormonal imbalances as a possible cause when diagnosing women with psychosis, PMDD, or BPD. Encourage patients to track symptoms throughout the month.
3. Use of MENO-D:
• MENO-D is a valuable tool for assessing and managing menopause-related symptoms.
4. Fibromyalgia and Hormonal Deficiency:
• Often linked with deficiencies in estrogen and testosterone.
5. Autoimmune Conditions:
• More common during peri and menopause, particularly thyroid disorders.
6. Additional Symptoms:
• Alopecia, IBS, severe migraines, insomnia, and weight gain are commonly linked to hormonal changes during menopause.
7. Impact of Antipsychotics:
• Antipsychotics can disrupt the ovarian-pituitary axis, leading to decreased testosterone and estrogen, increased prolactin, and elevated risks of hypercholesterolemia, diabetes, and metabolic syndrome.
8. Sleep and Mental Health:
• Poor sleep is a significant risk factor for suicidality and mental health issues. Non-addictive sleep aids like progesterone can be beneficial without the metabolic side effects associated with antipsychotics.
Take-Home Messages
1. Consider Hormones: Always ask, “Could it be hormones?” when evaluating complex cases.
2. Keep It Simple: Focus on the basics and avoid overcomplicating treatment.
3. MENO-D Tool: Utilize the MENO-D tool for managing menopause symptoms.
4. Individualized Care: There is no “top dose” of estrogen; treatment must be individualized, much like insulin or thyroxine.
5. Body-Identical HRT: Effective for PMDD and perimenopausal mood symptoms with no significant increased risk of breast cancer within the first five years of use.
Other resources:
End of Presentation
By Dr Purity Carr
GP & Menopause Doctor
Harvey, WA, 6220
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