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HAPPY HEALTHY HORMONES Daved Rosensweet M.D. HOW TO THRIVE IN MENOPAUSE Daved Rosensweet M.D. HOW TO THRIVE IN MENOPAUSE HAPPY HEALTHY HORMONES Daved Rosensweet M.D. HOW TO THRIVE IN MENOPAUSE This book has been written and published to provide information and should not be used as a substitute for the recommendations of your health care professional. Be- cause each person and medical situation are unique, the reader is urged to review this information with a qualified health professional. You should not consider the infor- mation contained in this text to represent the practice of medicine or to replace consultation with a physician or other qualifiedhealth care provider. The Menopause Method, Inc. Sarasota, Florida 941-366-3768 www.menopausemethod.com [email protected] The Menopause Method: A Woman’s Guide to Navigating Menopause, sixth edition, 2017. Copyright © 2001, 2002, 2006, 2007, 2014, 2017 by Daved Rosensweet M.D. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photo- copying, recording, or otherwise, without the prior written permission of the copyright owner. Sixth Edition 2017 ISBN: 9780999744901 Published in the United States of America Dedication This book is dedicated, first and foremost, to my patients in menopause: for 24 years, woman by woman, moment by moment, molecule by molecule, you have given me what has culminated in these pages. You know who you are, and I do thank you. Writing this dedication has turned out to be a deep and heartfelt experience for me. As I’m sure so many authors have felt, this book has been a monumental project that re- quired a village to complete! As I sit here at my comput- er, writing these very last words, I find myself feeling so much gratitude for so many people. My life is blessed, and has been full of colleagues and mentors who have never stopped contributing to my ongoing medical education… it’s humbling. Many of these wonderful people can be found on page 253. To my editors, Shea Lindner and Sheree Mikulec: you were willing to go into the trenches and have put so much effort and caring into this project. Thank you. Table of Contents Chapter One: Sarah’s Story 3 Chapter Two: Menopause: An Introduction 11 Figure 2a. Variation in Hormone Levels with Age 11 Figure 2b. Cycling Ovarian Hormones 12 Figure 2c. How Much the Female Body Values Progesterone 12 Figure 2d. Earlier More Profound Decline of Progesterone 14 Figure 2e. No Ovulation: Minimal Progesterone 15 Symptoms and Effects of Ovarian Hormone Insufficiency 17 Figure 2f. Symptoms of Too Little Progesterone 18 Figure 2g. Symptoms of Too Little Estrogen 21 Chapter Three: Risks and Benefits 25 Risk: The Bottom Line 25 Benefits 28 Chapter Four: 35 General Principles of Menopause 35 Individuality and Individual Variation Beyond the Ovaries: 37 The Knee Bone is Connected to the Thigh Bone… Chapter Five: 43 Initial Process and Evaluation Table of Contents Your Initial Evaluation is By You 43 Second Step: Finding a Physician or Nurse Practitioner 45 The Next Step: Evaluation by Your Health Professional 48 Other Initial Evaluations 48 Figure 5. Initial Questionnaire: Assessment of Hormones 49 What About Initial Hormone Testing? 50 Chapter Six: Progesterone 53 Why Progesterone First? 53 Biochemistry of Progesterone 55 Figure 6a. Steroid Hormone Biochemistry 55 Figure 6b. Menstrual “Curves” 56 Figure 6c. “Curves” Proportioned 56 Progesterone Treatment 57 Chapter Seven: Estrogens 61 A Family of Hormones: Rx, Bi-Est 61 Chapter Eight: Hormone Dose Determination 73 You’re Evaluated and Ready to Begin 73 Figure 8a. Condensed Summary of Estrogen and Progesterone Deficiency Symptoms 76 Perimenopausal Progesterone 77 Figure 8b. Finding Your Optimal Dose of Progesterone by Titrating Between Symptoms of Deficiency and Excess 79 Table of Contents Menopausal Bi-Est 79 Figure 8c. Finding Your Optimal Dose of Estrogen byTitrating Between Symptoms of Deficiency and Excess 80 Menopausal Progesterone 83 Converting from One Form of Hormone Treatment to Another 87 Chapter Nine: Application Sites and Methods 89 Where and How 89 Illustrations. Applying Bi-Est 90, 91, 92, 93 Illustration. Applying Progesterone 93 When to Apply Hormones During the Month 95 Illustration. Summary of Bi-Est and Progesterone Optimal Application Sites 96 Stopping Hormones Once a Month 96 Figure 9a. Cycling Ovarian Hormones 97 Progesterone Rx During Perimenopause 97 Progesterone Rx During Menopause 99 Bi-Est Rx During Perimenopause 99 Bi-Est Rx During Menopause 100 Stopping Hormones Once a Month and When to Resume 100 To Summarize and Elaborate 101 Steady Dosing vs Variation in Dosing… Plus General Levels of Hormone Dosages 103 “Dermal Fatigue” and Other Possible Locations to Apply Bi-Est and Progesterone 108 A Final Note About Dosages and Testing 111 Table of Contents Chapter Ten: Formulations: Hormones, Carriers, and Dispensing Methods 113 Information Regarding “Carriers” 113 Figure 10a. Organic Oils/Hormones Suspension 113 Dispensing Information: Organic Oils, Rx Dosages 119 Dispensing Methods: Organic Oils, Additional Information 125 Starter Tools 128 Dispensing Methods: Other Carriers and Routes 132 Oral Progesterone: A Common Alternative to Transdermal 134 Transvaginal, Translabial, and Perianal Administration: Carriers and Methods 137 Another Commonly Used Preparation: Vaginal Estriol 138 A Final Note About Dosages and Testing 139 Initial Use of Androgens? 140 Chapter Eleven: Androgens 141 Figure 11a. Finding Your Optimal Dose of Testosterone by Titrating Between Symptoms of Insufficiency & Excess 141 Treatment with Testosterone 144 Figure 11b. Testosterone Hormone Application 146 Treatment with DHEA 146 Figure 11c. Androgen Biochemistry 147 Chapter Twelve: Additional Details About Hormone Treatment 149 Table of Contents Important Variations and Alternatives with Hormones 149 Other Variables 150 If Hormones Are Right, They Feel Right 152 Chapter Thirteen: Treating Elderly Women with Hormones 155 A View from Several Perspectives 155 Medicine Up Close and Personal 157 Chapter Fourteen: Patient Assessment: Initial and Ongoing 161 Figure 14a. Patient Assessment 162 Hormonal Testing: Introduction 162 Hormonal Testing: Some Delightful Details 166 Figure 14b. Menstrual Curves Over Time 167 Figure 14c. Mean Estradiol Serum Levels After Dose Administration 170 Hormonal Testing: Reference Ranges 171 Hormonal Dosing Ranges: Individual Variation 173 Hormonal Testing: Thyroid and Adrenals 174 Hormonal Testing: Time to Test 174 Figure 14d. The Time to Test a Regularly Menstruating Woman 175 Hormonal Testing: More on Types of Testing 175 Sex Hormone Binding Globulin: SHBG 178 Hormonal Testing: More About Thyroid Testing 180 Hormonal Testing: Adrenal Glands 182 Figure 14e. Steroid Biochemistry 183 A Final Note About Dosages and Testing 183 Table of Contents Chapter Fifteen: Patient Assessments: Fundamental Female Evaluations 185 Female Exams: The Basics 185 Breast Self-Exam 185 Breast Health 186 Breast Imaging and Breast Health 188 Mammography 188 Breast Ultrasound 189 Breast Thermography 190 Figure 15a. Effect of Compression and Underwire Bras 190 Figure 15b. Effect of Birth Control Pills on Breast Tissue 191 Figure 15c. Resolution of Breast Tenderness Over Years 195 A Final Word and Caution About Breast Imaging and Thermography in Particular 195 Annual Exam: Breasts, Pelvic, Pap, and Transvaginal Ultrasound 197 Bone Density and Bone Health 199 Chapter Sixteen: Osteoporosis and Restoration of Bone Health 201 Hormones and Bone Health 202 Nutrition and Bone Health: You Are What You Eat—And What You Digest 202 Excessive Cellular Acidity 207 Assessing Bone Health 210 Figure 16a. Example of Bone Density Report 210 Figure 16b. Bone Resorption Test Result 211 Assessing Bone Health: Additional Testing 211 Exercise and Bone Strength 215 Table of Contents Summary of an Osteoporosis Treatment Program 215 Chapter Seventeen: Weight Issues in Menopause 219 Carbohydrates, Glucose, Insulin, Adrenaline, and Cortisol 220 Figure 17a. Insulin Function and Glucose Regulation 223 Figure 17b. Glucose Regulation: Normal Mechanism 223 Figure 17c. Glucose Conversion and Storage Possibilities 225 Hypoglycemia and Adrenaline 226 Gluconeogenesis: Generating Glucose from Muscle Breakdown 227 Figure 17d. Gluconeogenesis: Glucose Conversation from Muscle Protein 228 Glucose Regulation: Not Eating and Not Responding to Hunger 228 Figure 17e. Glucose Regulation: Not Eating and Not Responding to Hunger 229 Glucose Regulation: The Challenge of Simple Carbohydrates 230 Figure 17f. Glucose Regulation: The Challenge of Simple Carbohydrates 230 Excess Carbohydrates, Stress and Insulin Resistance 231 Weight Loss and the Fat Myth 232 Calories, Metabolism, Appetite and Nutrient Rich Foods 234 Neurotransmitters and Appetite 235 More About Hormones and Metabolic Burn Rate 237 Table of Contents Digestion and Assimilation of Food 239 Figure 17g. Protein, Carbohydrates and Fats: Possibilities 241 Summary of Weight Issues 242 Summary of Weight Loss Strategies 243 Chapter Eighteen: 245 In Praise and Honor of the Bladder: Squeeze! 247 Chapter Nineteen: In Closing 251 Acknowledgments 253 Illustration Credits 255 References from Chapters 257 Appendix A: 24-Hour Urine Hormone Test Results: A Common Example of a Treated Menopausal Woman 267 Hormone Test Results of Elderly Women 268 Appendix B: Select References from the Medical Literature 271 Index 307 Epilogue and Summary: This Book in a Nutshell 317 Patient Dose Determination Tool: Titration 326 About the Author 328 HAPPY HEALTHY HORMONES Daved Rosensweet M.D. HOW TO THRIVE IN MENOPAUSE Chapter One Sarah’s Story Not so long ago, I was sitting with an old and dear friend of mine, Sarah, on my porch watching the sun begin to set. We hadn’t seen each other in quite some time and so had spent the day walking on the beach and being together, remembering, rediscovering, and discovering. As we sat, watching the sun wane, we had become more and more si- lent. The day had been sweet, and I felt content and happy. When I looked over at Sarah, however, even in the waning light, I could tell that her brow had furrowed.