A Surprising Menopause: A Case Study, Part 1

Tolle Totum

Deborah McKay, ND

I view the menopausal transition as “puberty in reverse,” complete with shifts in hormones that dictate bodily changes. In some cases this hormonal shift can hijack the brain. Personally, I remember looking in the mirror and saying, “Who are you? I don’t even know you.” This happened twice in my life – first during adolescence, and again at menopause.

I’ve heard it’s possible to sail through the menopausal change of life with no muss and no fuss. Just skip a period here and there, then stop menstruating altogether – and on your 14th moon-cycle of no menses, it’s time to throw a party celebrating your arrival into Revered Wise Elder status, queen of one’s own life from now on. That’s the concept, right? But do you actually know anyone so privileged? I’ve met a few, but most American women appear to be too toxic, too unsupported, and too often flooded with false expectations from faulty advice.

One of my new patients last year appeared at first to be a typical menopause case, with ovarian, thyroid, adrenal, glucose, and digestive deregulation (it’s always a package deal at menopause). She ended up happily rebalanced, but by way of a surprising twist that I didn’t see coming. In this article, I share my thinking as a holistic hormone doc seeking “optimal whole-person” health, as opposed to operating with the notion that “lab reference range is good enough.” This will be a 2-part story.

The Patient

First Visit

“Dorothy,” a career-minded 50-year-old woman, came to my office in January 2019 and told me that it felt like her entire life was crumbling. Her wake-up call occurred the previous year with the sudden recognition of her burden of financial debt, followed by the “firing” of her dysfunctional significant other, and then the shocking recognition that her body was no longer her own – an extra 15 pounds had piled on for no apparent reason. Even her brainpower had suffered. She ate well, was devoted to yoga, and studied health; she seemed to be doing everything right, but somehow wasn’t getting traction. She had recently peeled off 5 pounds with great difficulty.

Dorothy told me about a “foggy brain” and easy overwhelm; chronic tension, stress, and an anxious sense of impending doom; non-restorative sleep; decreased libido; constant chilliness; poor memory (especially recently); hair loss; recurrent sinus infections (for which she had been prescribed courses of antibiotics); loss of smell; difficulty breathing during stress; multiple sensitivities (foods, chemicals, inhalants), and malaise. Her mainstream primary care physician would typically address only 1 symptom at a time, and appeared to ignore altogether her sense of dread and impending doom. She suffered from chronic constipation (often 48+ hours between bowel movements) that was worsened by fiber, which she found confusing. Stools were typically Bristol #1-2 (“marbles” or “caterpillars”). She thought her GI symptoms might have started 20 years prior, when she experienced a food poisoning that seemed to shift her entire system. She was currently using OTC meds to achieve Bristol #4-5 (normal), but this required daily attention. Menstrual cycles had recently become irregular, with menses often skipping 1 or 2 months. Finally, she complained of some chronic irritation around her urethra and introitus.

Her goals in seeking my services were to feel better and thrive; determine appropriate nutritional supplementation; amend her diet if necessary; and lose another 10 pounds. Above all, she wanted to ease her menopausal transition. Meanwhile, she planned to depart the following week for a 2-week women’s yoga retreat in Mexico.

History included “many” childhood ear infections. This led to the removal of tonsils and adenoids at age 4 or 5, with a resulting partial loss of hearing in her right ear. She was abandoned at birth by her father, who suffered from depression. Her mother’s menopause was surgical – she had a hysterectomy after 4 babies. Dorothy was born when her mother was just 20 years old. Her mom has borderline personality disorder. As the first-born, Dorothy worked long and hard to raise her 3 younger siblings – the source, she felt, of her habitual self-criticism. She reported past nervousness and depression. Another doctor had previously diagnosed Hashimoto’s thyroid disease, based on positive anti-thyroid peroxidase (anti-TPO) and anti-thyroglobulin (anti-TG) antibodies; however, she was never prescribed thyroid hormones. She had been a sporadic self-prescriber of various nutritional supplements over time. Currently, she was taking daily B-complex vitamins, vitamin D3 drops (dose unknown), and ashwagandha (intermittently).

Here are her laboratory test results from February 2017, ordered by another naturopathic physician:

TSH: High-normal (3.88 mIU/L); 1.0 mIU/L is my target “optimal”
Free T4: Low-normal (1.04 ng/dL)
Free T3: Normal (3.2 pmol/L)
Anti-TG antibody: High (520)
Anti-TPO antibody: High (56)
LDL-cholesterol: High (140 mg/dL)
Fasting glucose: High-normal (94 mg/dL); 85 mg/dL is my target maximum
Fasting insulin: High-normal (7 µIU/mL); 5 µIU/mL is my target “optimal”
HbA1c: High-normal (5.4%)
25-hydroxyvitamin D: Very low-normal (28 ng/mL); 50 ng/mL is my target minimum
Ferritin: Low-normal (37 ng/mL); 50 ng/mL is my target “adequate”
Cortisol, serum (AM): Low-normal (16.7 µg/dL)
DHEA-S, serum: High (315 µg/dL)
Pregnenolone, serum: High-normal (143 ng/dL)
FSH: High, but normal for menopause (27.8 mIU/mL)
Progesterone, serum: Low-normal, but in range for ovulation or luteal phase (0.65 ng/mL)
Estradiol, serum: High-normal, but in range for ovulation or luteal phase (258 pg/mL); she couldn’t recall her menstrual phase
Testosterone, serum: High-normal (36 ng/dL)

Examination

Objectively, Dorothy was bright and articulate but had obvious slow mental processing. I was aware of having to slow down my speech and allow extra time for her to make choices or process new information. BMI was 23.1 (optimal). Body fat content was 30.3% (“acceptable” but disproportionately high compared with her BMI). Muscle tone was average, and her posture was slouching; she appeared unfit despite all the yoga. Her hands were cold to the touch despite wearing 2 sweaters inside a warm clinic. Diffuse thinning of all scalp hair was apparent. Facial expression suggested worry. She would often hold her breath during our interviews. I would find myself unusually tired by the end of her appointments; I attribute this to breath-holding, since I tend to mirror my patient’s body language.

Impressions

My chief diagnosis was perimenopause. Additional diagnoses included: hearing loss, right ear; anxiety; some adrenal over-activity (high DHEAS); functional hypothyroidism (ie, euthyroid sick syndrome); Hashimoto’s disease; hyperandrogenism; vitamin D deficiency; hypercholesterolemia; insulin resistance; and irritable bowel syndrome (IBS), constipation-predominant.

My reasons for suspecting chronic hypothyroidism were based on Dorothy’s constant chilliness, thinning of hair, weight gain, constipation, and slow mental processing. Although Dorothy’s TSH in 2017 was “within range,” she felt and functioned poorly. Something was clearly wrong. I prefer using a TSH upper limit of 3.0 mIU/L. I have also come to adopt Dr Kent Holtorf’s mistrust of TSH altogether,¹ primarily because many different factors can trigger the anterior pituitary gland to suppress TSH, but also because the deiodinase enzymes within the anterior pituitary occur in starkly different ratios from deiodinases in other bodily tissues. This causes the anterior pituitary to “feel satisfied” in the presence of a barely-adequate Free T4 level, even when Free T3 is running low and/or Reverse T3 is running high. Any TSH value, even a seemingly low one, must be handled in light of all of the patient’s signs and symptoms. This approach takes time and patience, which most naturopathic physicians are willing and able to do. The patient’s functional quality of life should always come first. We are treating a treating a person, not a set of lab values.

I suspected that Dorothy’s conspicuously slow mental processing was probably multifactorial, including perimenopausal hormone swings, thyroid imbalance, and her social/emotional/financial stressors. Hearing loss had also increased her baseline level of stress, causing her to be chronically hypervigilant. I hoped her 2-week yoga retreat would help restore her body, mind, and spirit.

I suspected that her IBS was related to chronic SIBO/SIFO (small intestinal bacterial overgrowth/small intestinal fungal overgrowth), based on her chronic and severe constipation. Her sluggish bowel was likely caused initially by low thyroid, but by now was probably fostering bacterial and fungal overgrowth and excessive gut fermentation. In particular, her hallmark symptom of “constipation worsened by dietary fiber” suggested fermentation. (For the record, she was already consuming ample amounts of water each day.)

Based on her previous lab results, I suspected insulin resistance, despite her devotion to yoga and other physical exercise. My truncated HOMA-IR formula for estimating insulin resistance involves simply multiplying Fasting Glucose (mg/dL) by Fasting Insulin (μIU/mL). Optimal would be 405. Using this calculation, Dorothy’s HOMA-IR was 658, indicating mild insulin resistance. Common effects of insulin resistance (even as mild as this case) include disproportionally high body-fat percentage, a tendency toward reactive hypoglycemia (with carbohydrate cravings, irritability, and disturbed sleep), and mood swings due to rapid blood-glucose fluctuations.

Initial Plan

In order to get an up-to-date laboratory assessment, I recommended that she get a blood draw before departing for Mexico.

Meanwhile, I suggested that she “climb off the blood sugar roller coaster.” I explained insulin resistance and how it can trigger hypoglycemia, swiftly and erratically. I advised her for now to keep a “foods & mood” journal for 10 days.

Because the gluten protein can induce anti-thyroid antibodies in susceptible individuals (via molecular mimicry),² I suggested a gluten-free diet.

For her chronic constipation, I gave her my handouts explaining SIBO/SIFO and its treatment. I asked her to skim them and bring her questions to her next visit. Launching treatment of SIBO is a project to be done only with adequate patient education and preparation. Only after that would I offer her the option of baseline breath-testing. If she declined, we would move ahead with treatment, but then do follow-up breath testing afterward.

I recommended additional vitamin D3 to help support her mood and immune system, and help regulate blood glucose. I explained to Dorothy that vitamin D is “the sunshine vitamin” whose production begins in the skin, and suggested immediate sun exposure during the next week as a way to start replenishing her vitamin D3 stores.

To address her recurring sinus infections, I recommended she utilize her pseudoephedrine prescription (a controlled substance in Oregon) on days of air travel to keep her sinuses “bone dry.” At the same time, I educated her to keep her nasal mucosa “wet and flowing” on most days by using steam, N-acetylcysteine, and guaifenesin. Free-flowing mucus would help facilitate the shedding of microorganisms. I taught her hydrotherapy for the sinuses (ie, the “Granny Steam Bowl,” using a big bowl of boiling water with a large towel draped overhead to make a tent), along with visualization of steam-cleaning the nose, sinuses, Eustachian tubes, bronchi, etc. I directed her to follow the steam treatments with the swabbing inside her nostrils of an essential oil blend (grapeseed oil with essential oils of thyme, eucalyptus, lavender, and peppermint). I have found this blend to be highly effective for preventing and treating even full-blown sinus infections, as well as protective against contracting viruses during air travel.

For her mildly inflamed urethra and introitus, I recommended Lactobacillus acidophilus capsules, to be used as vaginal suppositories (1 per day for 1 week). This was based on the likelihood that her vaginal flora had been compromised by antibiotics taken for recurring sinus infections.

To help her stay asleep at night, I recommended she take a proprietary oral combination of Withania somnifera (ashwagandha), L-theanine, phosphatidylserine, Magnolia grandiflora, and Epimedium. I also suggested she purchase a book by our esteemed elder, Dr James Wilson: Adrenal Fatigue, 21st Century Stress Syndrome, and to start with Chapter 5, which contains 18 cartoons depicting the look and feel of adrenal fatigue. Many of my patients describe both laughing and crying with recognition as they look at these cartoons. Dorothy didn’t have “adrenal insufficiency” according to the conventional definition; however – functionally, holistically, naturopathically – she appeared to fit the “resistance phase” of Hans Selye’s stress model, ie, functional lack of adrenal reserve. This pattern can include a constellation of imbalances such as high DHEA, low or normal cortisol, susceptibility to opportunistic infections, depression, and insulin resistance.³

Although new thyroid results would soon be available, she was heading out of town and I wanted, in the meantime, to reduce the amount of time she suffered by starting her on conservative doses of hormone – although only after her blood draw. I instructed her to take 25 mcg/d of levothyroxine (L-T4) and a starting dose of 5 mcg/d of liothyronine (L-T3). Assuming tolerance, I suggested gradually increasing the L-T3 dose every few days (T3’s half-life is only 1.5 days⁴), with a target dose of 3 times daily (15 mcg/d), but also decreasing the dose if necessary. I coached her on tracking her bodily responses to thyroid status, including heart rate, mid-day oral temperature, blood pressure, and sleep quality.

Many doctors are uncomfortable prescribing L-T3, understandably so because it is perhaps the single strongest hormone in the human body, acting to speed up metabolism of every tissue, organ, and gland. Mainstream state medical boards also frown on doctors who prescribe this bioidentical hormone – another reason for doctors’ hesitancy. However, after 2 decades of working with endocrinology, I’m willing to prescribe L-T3 after assessing the patient’s ability and willingness to follow my detailed instructions, which include substantial self-monitoring.

I decided against supplementing glandular products due to Dorothy’s high anti-thyroid antibody count. In my clinical experience, I’ve seen glandulars trigger increases in antibody counts in about 50% of cases.

Finally, I urged baseline DEXA bone density testing before her 51^st birthday.

At some point, I hoped to run some genetic testing on Dorothy. My suspicion of genetic abnormalities, particularly for MTHFR, was based on the combination of her multiple sensitivities, her pull towards negative emotions, and her intense family history (eg, bipolar disorder) suggestive of neurotransmitter imbalances.

Part 2 of this case study will be published in the February 2020 issue of NDNR. Spoiler alert: Dorothy caught a GI infection in Mexico, we adjusted her hormones, and genuine healing took place rapidly when we addressed her underlying trauma.

References:

Holtorf K. Peripheral Thyroid Hormone Conversion and Its Impact on TSH and Metabolic Activity. J Resor Med. 2014;3(1):30-52. Available at: https://restorativemedicine.org/journal/peripheral-thyroid-hormone-conversion-and-its-impact-on-tsh-and-metabolic-activity/. Accessed September 5, 2019.
Friedman M. Fundamentals of Naturopathic Endocrinology. Toronto, Ontario: CCNM Press; 2005: 117-120.
Centers for Disease Control and Prevention. Laboratory Procedure Manual. Free Triiodothyronine, T3. 2007-2008. CDC Web site. https://tinyurl.com/y3tz29zm. Accessed September 5, 2019.

Deborah McKay, ND, is a bio-identical hormone specialist in Portland, OR – the heartland of naturopathic medicine. Dr McKay is a 2005 graduate of NCNM, and now a solo practitioner. She’s a Founding Member of EndoANP. She has personal experience with thyroid insufficiency, uterine cancer, surgical menopause, PTSD, and the blood glucose roller-coaster. She is passionate about hormone rebalancing, which she views as one possible approach to whole-person healing.