The woman who is willing to make that change must become pregnant with herself, at last.
—Ursula Le Guin
Sleep Problems and Fatigue
Even with optimal thyroid treatment, hormone therapy, and diet, exercise, and lifestyle changes, you may still find that your most troublesome continuing symptom is fatigue. You may feel as if you’re waking unrefreshed or as if you can’t get through the day without a nap. What else can you do?
First, you need to be sure that you are getting enough sleep. That means eight hours for most of us—not seven, not six, but at least eight hours. Many women tell me they are exhausted and have no idea what to do about it, but when I ask them about their sleep habits, they are almost always trying to get by while chronically sleep deprived, getting far less than eight hours a night. (According to the National Sleep Foundation, one in three people in the United States get six hours or less per night.) I am one of those people who do not do well on less than seven and a half to eight hours. With young children, I got to a point where I was trying to get by on six hours a night and became exhausted. My first reaction was to blame my thyroid condition, but, no shock, when I made an effort to get back to eight hours a night, my energy dramatically improved. So, while proper treatment for hormonal imbalances is critical, don’t even think about other ways to fight fatigue until you’ve taken this most basic first step of getting eight hours of sleep every night.
Physician and patient advocate Marie Savard agrees.
I have found that making a habit of getting seven to eight hours of sleep is a critical step—this will do far more to help than most things. Once you are sleeping more, you can add more difficult changes in small steps, such as improving your diet, drinking less caffeine, etc.
Dr. Tieraona Low Dog agrees that sleep is essential for women in menopause.
If you’re not sleeping well, everything is worse. Hot flashes are worse, your body hurts more. Helping women sleep better makes so many symptoms a lot more tolerable.
If you are getting adequate sleep in terms of time, you may want to set up a video camera to tape yourself, or ask a partner or family member to do an informal “sleep study,” to see if you are snoring or having episodes of sleep apnea where you briefly stop breathing. If any of these behaviors are observed, you should definitely have a formal, medically supervised sleep study. (Note: Apnea is more common in thyroid patients.)
If you’re getting the hours in, but you’re not getting quality sleep (you have a hard time falling asleep, you wake frequently, and so on), then you should start by practicing good sleep hygiene. This involves not using your bed as a place for work, television watching, or reading; establishing regular bedtime routines and schedules; getting enough exercise; limiting napping; avoiding stimulants before bedtime; avoiding food later in the evening; minimizing noise and light in the bedroom; keeping your bedroom cool; avoiding alcohol, caffeine, and nicotine; and other commonsense techniques.
The North American Menopause Society has some other recommendations to help with sleep:
Ultimately, however, if you are unable to reestablish healthful sleeping patterns, you may wish to try a nonprescription sleep aid. These can include
Prescription sleep aids may also be appropriate for debilitating fatigue. These can include
In addition to adequate sleep, if you are suffering from flagging energy, you need to be sure that you are getting enough B vitamins. Vitamin B12 in particular is essential for energy. To ensure you’re getting enough B vitamins, consider taking a B complex, plus a separate sublingual B12.
Other supplements useful for fighting fatigue are substances that the body naturally produces. Supplements in this category include coenzyme Q10, also known as CoQ10, which supplies energy to muscles; L-carnitine; NADH (the reduced form of nicotinamide adenine dinucleotide), which helps cells convert food into energy; and DHEA (dehydroepiandrosterone) (but be sure to be tested by your practitioner before you start this hormone).
Professor Gayle Greene, author of Insomniac, has found that menopause is a time when hormonal fluctuations can especially affect sleep. Says Greene:
Menopause is a biological as well as psychosocial event, a time when our bodies are adjusting to plummeting levels of estrogen and progesterone. Researchers suspect it may be the fluctuations rather than the depletion of hormones that create the problems, because the other trouble spots for women’s sleep are also times when hormonal levels fluctuate, not only at menarche and just before menstruation, when estrogen and progesterone levels drop, but just after a woman gives birth, when estrogen levels plummet from the high point they were at during pregnancy.
One reason hormonal fluctuations disrupt sleep is that they raise temperature. Body temperature tends to decline as sleep comes on, so anything that keeps it elevated—an electric blanket, a hot room, work or vigorous exercise too close to bedtime—may inhibit sleep. Anything that facilitates a drop in temperature, like a cool room or a hot bath, may bring on sleep. Hot flashes, of course, raise body temperature in a big way.
If sleep problems are a major concern, I highly recommend that you learn more by reading two terrific books: Gayle Greene’s Insomniac and Sleep, Interrupted, by Dr. Steven Park. Both explore the critical role of sleep in health and have practical advice.
Weight Gain
Gynecologist and menopause expert Dr. Jan Shifren sums it up when she says, “To combat perimenopausal weight gain, you have to run to stay in place.” The same can also be said for weight gain that occurs with an underactive thyroid.
One of the most essential steps for weight management is for every woman to start making the necessary dietary and exercise changes to minimize any extra weight gain right away, for example, by their late thirties, or as soon as they have a thyroid disease diagnosis.
I talked about the importance of exercise and some healthy nutritional changes that women can make in perimenopause/menopause, but what do you do if you’re gaining weight or finding weight loss more difficult? Remember that you’re not lazy or lacking willpower, so don’t beat up on yourself. Your body is changing and not working the way it used to, and it does have to do with your hormones. When the thyroid is underactive, the metabolism can become so efficient at storing every calorie that even the most rigorous diet and exercise programs may not seem to work. Add in the hormonal changes of menopause, and things slow down even more. Your friend or spouse could go on the same diet as you, lose a pound or two—or even more—a week, and you might stay the same, or even gain weight, despite working just as hard.
Unfortunately, the combination of thyroid and menopause is a double whammy for women, and you may find that nothing you’re doing will move the scale. But there are some solutions.
EVALUATE YOUR MEDICATIONS
Take a look at medications you are taking. There are a number of drugs that promote weight gain. These include
CHECK YOUR BLOOD SUGAR
Consider getting your blood sugar tested. At a minimum, you can get a glucose level from a home test kit, but preferably, get a fasting glucose test to evaluate whether your blood sugar is normal, high-normal, or elevated. In late 2003, the American Diabetes Association recommended that the fasting glucose range for defining prediabetes be changed, down from 110 mg/dL to 100 mg/dL, meaning that a value of 100 mg/dL or above would lead to a diagnosis of impaired fasting glucose/prediabetes/insulin resistance. If it is high-normal or elevated, this can in part contribute to your difficulty losing weight. It is also a sign that you are becoming insulin-resistant, are prediabetic, or already have type 2 diabetes. If your blood sugar level is elevated, you should discuss going on an antidiabetic medication such as metformin (brand name Glucophage). Metformin, along with diet and exercise, can help prevent the progression of insulin resistance or prediabetes to full type 2 diabetes.
CONSIDER AN ANTIDEPRESSANT
Even if you do not suffer from depression, you might find that you have greater success fighting a weight problem if your doctor tries you on a course of antidepressants. A number of people have written to report that their diet/exercise plan suddenly began to work after their doctor prescribed a short course of antidepressant medication, like Prozac, Welbutrin, Effexor, or Paxil. It’s worth discussing with your doctor. Welbutrin, in particular, is thought to be helpful in curbing cravings and addictions, and is not as likely to cause weight gain, which can be a side effect with some antidepressants.
CONSIDER A LOW-GLYCEMIC DIET
An effective method to combat insulin resistance and the inability to properly process simple carbohydrates is eating a low-glycemic, carbohydrate-controlled, calorie-controlled, fairly low-fat diet. Low-glycemic foods are foods that do not rank high on the glycemic index, which assigns values to foods based on their effect on blood sugar levels.
High-glycemic foods are sugary, starchy substances, like those made with white flour (pasta, bread, and crackers), white rice, many cereals, desserts, and anything else with a high sugar content (drinks, jams and jellies, and snack foods, for instance). You may feel frustrated that there’s nothing left to eat. But you need to rethink your eating habits, shifting to a diet of low-fat protein sources (like chicken, turkey, fish, leaner cuts of other meats, and low-fat dairy products) and nonstarchy, high-fiber vegetables and fruits, along with certain grains.
There are numerous books and Web resources that provide information on the glycemic index of foods and beverages that you can consult. Generally, avoid sugar in all forms and emphasize lean sources of protein, some good fat, nonstarchy vegetables, and limited fruit. When you do eat starches, be sure they’re high fiber, and eat them only in limited quantities.
Researchers have found that thyroid disease and menopause are linked to increased cravings for starchy/sugary carbohydrates. This increased craving for and intake of carbohydrates appears to stem from various changes in brain chemistry and sympathetic nervous system activity. As you eliminate the “bad” carbohydrates from your body, you’ll eventually find the cravings reduced.
EAT ENOUGH PROTEIN
Protein is needed to build muscle and to maintain energy, so your diet should include sufficient levels of protein. Ideally, include a portion of lean protein in every meal and snack, and never eat a carbohydrate, whether vegetable, fruit, or starch, without an accompanying protein, because it helps slow down the digestion of the carbohydrate as it converts to sugar.
GET ENOUGH GOOD FAT
Essential fatty acids cannot be produced in the body, so you must get them through diet or supplements. The key essential fatty acids are
DRINK ENOUGH WATER
Hypothyroidism and menopause can both cause water retention and bloating. Because you feel or look bloated or swollen, you may not be drinking enough water. The body will hold onto even more water more fiercely when you cut back on your water intake. Not drinking at least 64 ounces of water a day is counterproductive, as it will worsen bloating and cause dehydration, which slows metabolism.
Hypothyroidism also slows digestion and elimination, which can impede weight loss. Optimize digestion by making sure you get high levels of fiber every day. If you need help with regular elimination, consider adding a natural supplement, such as ayurvedic triphala, to aid in regularity.
GET ENOUGH FIBER
Fiber is essential to digestion and optimizing your weight loss efforts. It has minimal calories but can fill you up by adding bulk, and when consumed with carbohydrates, it helps modulate the insulin response and normalize blood sugar. There is a fair amount of scientific support for fiber’s ability to increase your feeling of fullness after you eat and reduce your hunger levels. One study found that adding 14 grams of fiber per day was associated with a 10 percent decrease in calorie intake and resulted in weight loss of five pounds over four months. To add fiber, eat more raw vegetables and fruits; they have more fiber than cooked or canned. Limit cereals and breads to high-fiber only. Two slices of high-bran bread, for example, has 7 grams of fiber, compared with only 2 grams of fiber for white bread. Other good sources of fiber are nuts, beans, apples, oranges, broccoli, cauliflower, berries, pears, brussels sprouts, lettuce, prunes, carrots, and yams. Women up to age fifty need 25 grams of fiber per day; those over fifty should get at least 21 grams. If you can’t get all your fiber from food, consider a fiber supplement.
Important warning: If you switch from a low-fiber to a high-fiber diet, be sure to take your thyroid medication at least an hour before eating breakfast, so absorption is not impaired. High-fiber diets can change dosage requirements, so six to eight weeks after starting a high-fiber diet, you may wish to have your thyroid function tested to be sure you don’t need a dosage change.
KEEP TRACK OF WHAT YOU EAT
Studies have shown that people who write down everything they eat lose weight, even if they’re not formally dieting, simply because the act of writing makes you more aware of your consumption and likelier to make better choices. Get a journal or use your cell phone, your BlackBerry, a notepad, your computer, a calendar, or a loose-leaf binder to record what you eat on a daily basis. It doesn’t matter what form your record takes; it’s the action of sitting down and thinking about your goals, what you’re going to eat, and assessing what you’ve eaten that will make the difference.
If you want a more formalized way to keep close track of your nutritional intake and want a supportive community to help you follow your chosen approach, check out tools such as South Beach Diet Online, Ediets, Weight Watchers Online, and Calorie Count, all of which have detailed food-tracking programs, as well as online support communities and forums where you can share information and encouragement with others.
ESPECIALLY FOR PEOPLE WITH HYPOTHYROIDISM
No matter which plan you choose, when you are following a weight loss program, there are some particular considerations you need to keep in mind that apply specifically to you as someone with hypothyroidism.
Don’t expect to lose weight quickly. Celebrate your resounding success if you lose even a pound a week. Do not compare your results with anyone else. And don’t diet with a friend, unless she or he is hypothyroid too, because you’re bound to feel frustrated if you compare your rate of loss to others.
You have to exercise. It’s not optional. Weight-bearing/muscle-building exercise is critical to raising metabolism, and aerobic exercise helps burn calories. Even if you join a weight loss center that says you can lose weight without exercise, it’s not likely to be true for you.
If you add fiber to your diet, have your thyroid function retested about six to eight weeks after you stabilize at your new level of fiber intake. You may need a change in your dosage of thyroid hormone replacement.
If you lose more than 10 percent of your body weight, it’s time to get retested to see if you need to adjust your dosage of thyroid medication.
Many thyroid patients report that only when they dramatically cut down on starchy carbohydrates and sugars—eliminating things like bread, sugar, pasta, sodas, and desserts—and limiting carbs mainly to vegetables, with some fruit, are they able to lose weight. While there are thyroid patients who process carbs with no difficulty and can lose weight on a more old-fashioned food pyramid diet that emphasizes cereals, grains, and bread, they seem to be the exception rather than the rule.
Hopping on a scale to keep track of weight loss is important, but not as important as keeping track of measurements. Particularly for thyroid patients, who may have more early results in building muscle than in losing pounds, keeping track of measurements can provide important feedback and may even provide incentive on those days when you don’t see much movement on the scale.
MY OWN PROGRAM
Many women thyroid patients who are trying to lose weight turn to my book The Thyroid Diet for help. That book outlines in great detail how to optimize your thyroid treatment so you stop gaining, or at least get in the right state of mind to lose weight. Then you learn what actually needs to be done to start losing. As many of us have learned the hard way, if your thyroid is not being fully and effectively treated, even the best diet and exercise program in the world won’t work. Maximizing thyroid treatment, balancing hormones and the endocrine system, increasing a slow metabolism, and determining what to eat to lose weight are all covered in The Thyroid Diet.
I’ve rarely met a woman in her forties or older who has success losing weight on high-carb approaches, myself included. Nor have I found that many thyroid patients do well on an “all you can eat,” steak-and-bacon, low-carb diet that has no calorie or fat restrictions. (Doesn’t work for me!) In The Thyroid Diet, I recommend a low-glycemic (low-sugar) diet that limits carbohydrates overall, emphasizes “good” carbs (vegetables primarily), but with calorie and fat limits, and this is the kind of diet I follow.
If you need a detailed, structured, ongoing program, with weeks of extensive menus and recipes, I also recommend The South Beach Diet, which has an updated version that’s known as The South Beach Diet Supercharged. It’s a healthy diet based on eating the right carbs and right fats, and it’s not difficult to follow. In addition to the book, there is a Web site and online membership program for South Beach that’s not hard to follow and works well for thyroid patients.
As for exercise, I’m a huge fan of T-Tapp, which is discussed in Chapter 8. It works better for me than any other approach I’ve found.
In addition to my prescription thyroid medication, I’m taking several supplements to help with weight loss. There is no miracle diet supplement, but there are some supplements and herbs that may help in your weight loss efforts. I emphasize may, because there are no guarantees. Some supplements may do nothing at all for you; in fact, they may actually do the opposite (you’ll be one of the few people who gain weight on something that’s supposed to help!). Right now, I’m taking glucomannan before each meal. It’s dietary fiber from the root of the konjac plant, and it comes in capsule form. It is believed to help in balancing blood sugar, lowering cholesterol, and creating a feeling of fullness. I know that it makes me feel full when I take it, so I can cut back on my intake. I’m also taking cinnamon with each meal. Cinnamon is thought to reduce blood sugar levels, increase natural production of insulin, and lower cholesterol levels. I also am using FucoThin, a supplement made of fucoxanthin, a derivative of brown seaweed that has reported fat-burning properties.
Some other supplements to consider are alpha lipoic acid, acetyl-L-carnitine, calcium, capsaicin/cayenne pepper, chromium picolinate, conjugated linoleic acid (CLA), glucosol, glutamine/L-glutamine, Hoodia gordonii, pantethine, pyruvate, taurine, vitamin C, and zinc. I have a detailed discussion of these supplements in my book The Thyroid Diet.
Finally, to stay on track, I rely on Dr. Steven Gurgevich’s Self-Hypnosis Diet. You can get the book/CD version or the audiobook format, and both are terrific. For me, it’s a great, relaxing, and very effective way to make sure that the desire to manage my weight translates into action—eating well, exercising, and taking care of myself. Pop in the CD, listen, and help shore up your motivation and desire to do the right thing.
Other issues that can interfere with your ability to lose weight are discussed in various places here and in Living Well with Hypothyroidism, as well as in greater depth in The Thyroid Diet. These include food allergies and sensitivities, candidiasis/yeast overgrowth, celiac disease/gluten (or wheat) sensitivity, parasites, the copper/zinc balance, adrenal imbalances, and estrogen and progesterone imbalances.
Depression/Anxiety
If your depression or anxiety is unrelieved by even your best efforts to treat the underlying hypothyroidism and hormonal imbalances, then it may need to be treated separately. This is not something to be embarrassed about; it’s just an indication that your brain chemistry is interrelated with your endocrine system, and without balance in one, it’s hard to become perfectly balanced in the other. Antidepressant treatments—such as conventional medications, herbal formulations, therapy, exercise, and support—can help balance the brain chemistry and relieve the depression or anxiety.
MEDICATIONS
Antidepressants are frequently prescribed as a treatment for depression/anxiety. They include mirtazapine (brand name Remeron), venlafaxine (brand name Effexor), nefazodone (brand name Serzone), and bupropion (brand name Wellbutrin); selective serotonin reuptake inhibitors (SSRIs), such as paroxetine (brand name Paxil), fluoxetine (brand name Prozac), and sertraline (brand name Zoloft); monoamine oxidase inhibitors (MAOIs), such as phenelzine (brand name Nardil) and tranylcypromine (brand name Parnate); and tricyclic antidepressants, such as sinequan (Adapin), amitriptyline (brand name Elavil), desipramine (brand name Norpramin), and impramine (brand name Tofranil). Your doctor will need to discuss the best option for you. If you are prescribed an antidepressant, it may take a few weeks, even a month or more, to start seeing the benefits. Don’t give up after a week or two if you don’t feel a difference. Remember that some antidepressants can become stronger or weaker in the presence of thyroid hormone, or can interfere with thyroid absorption, so discuss this with your doctor.
Medications to combat anxiety are sometimes prescribed for short periods of time. These include clonazepam (brand name Klonopin), lorazepam (brand name Ativan), and alprazolam (brand name Xanax). Buspirone (brand name Buspar) is a newer antianxiety medication that takes several weeks to become effective. In some anxiety disorders, beta blockers, such as propranolol (brand name Inderal), may also be helpful.
ALTERNATIVE SUPPLEMENTS
Since there are side effects associated with many antidepressants, some people try supplements. While St. John’s wort (Hypericum perforatum) is often a popular choice, some experts believe that it can interfere with thyroid hormone replacement therapy, and so should be avoided. Other supplements used for depression include 5-hydroxytryptophan (5-HTP), an amino acid derivative and the immediate precursor to serotonin, a brain chemical responsible for feelings of well-being. Another supplement some find effective is tyrosine. Tyrosine is an amino acid used to create norepinephrine, a brain chemical that works as an appetite suppressant, stimulant, and antidepressant; many leading-edge researchers are proposing that depression stems directly from a deficiency of norepinephrine. Most people need two to three weeks in order to begin seeing some definite benefits.
Supplements that may help with anxiety include valerian extract, passion flower, and L-theanine. (Note: My favorite sleep aid, Jacob Teitelbaum’s Revitalizing Sleep Formula, contains these ingredients. At lower doses, it can be used as a natural antianxiety supplement.)
OTHER APPROACHES
Other approaches that are helpful in addressing depression and anxiety are
Sexual Dysfunction
As many as 43 percent of women reportedly have some sort of sexual dysfunction, including low desire and/or pain during intercourse. Low sex drive is a common—but not often talked about—symptom of both hypothyroidism and perimenopause/menopause.
In a Red Hot Mamas survey of menopausal women,
Low sex drive/sexual dysfunction is also a symptom that, unfortunately, does not get better over time, despite what doctors deem adequate treatment. Many people, women in particular, still complain of a lack of sexual desire even after their doctors consider the thyroid problem sufficiently treated or put them on hormone therapy.
If you suffer from sexual dysfunction, you need to be sure that you are getting optimal thyroid treatment. You may want to explore prescription hormone treatment, in particular, testosterone, which may help with libido.
Low sex drive may be a result of other health conditions. Diabetes and hypertension/high blood pressure can cause low sex drive in women. You should ask your doctor to discuss the diagnosable symptoms of depression with you, so you can assess whether or not you are depressed.
You should also discuss other prescription drugs you are taking, because some antidepressants, tranquilizers, and antihypertensives, as well as many illegal drugs such as cocaine and marijuana, can reduce sex drive. An estimated 40 percent of patients on antidepressants report problems with sexual function, in particular, tricyclic antidepressants like clomipramine (brand name Anafranil) and some SSRIs, such as Prozac, Paxil, Zoloft, and Lexapro. If you are being treated for depression, you may want to consider asking your doctor about bupropion (brand name Wellbutrin), an antidepressant not typically associated with sexual side effects.
Other drugs you’ll want to discuss with your practitioner are
There is some evidence that appetite suppressants and opioid pain drugs contribute to sexual dysfunction.
Exercise improves blood flow to all body parts. Research has found that people who exercise regularly have higher levels of desire, greater sexual confidence and frequency, and an enhanced ability to be aroused and achieve orgasm, no matter what their age. The best type of exercise is aerobic exercise, because it can trigger the release of endorphins, chemicals in the brain that create a feeling of well-being.
An important thing that you can do to help sexual dysfunction is to lose weight. Excess weight can affect your self-image, making you feel less sexy and less interested in sex. And, medically, being overweight can reduce libido. Some experts believe that a ten- to twenty-pound weight loss in an overweight woman reduces enough body fat to in turn substantially reduce levels of sex hormone–binding globulin (SHBG), which then unbinds (frees up) estrogen and testosterone, allowing them to get back to their regular functions in the reproductive system.
When there are other psychological and self-esteem issues preventing healthy sexual desire, therapy can sometimes help. Traditional psychotherapy may help identify and resolve root causes of problems, improve self-esteem, and teach new skills in self-expression. Communications or couples counseling may help improve the relationship. Sex therapy may help resolve specific dysfunctions and teach techniques that aid in sexual desire and satisfaction.
The prescription drug Viagra has been used with women, but it’s not clear whether it can be used to treat sexual dysfunction. For women, more research is needed on prescription drugs that will help with sexual desire.
Some herbal and natural supplements are considered helpful for low sex drive. But supplements can have various—and sometimes serious—side effects, so you shouldn’t self-treat. Talk to your practitioner regarding these products. Some supplements that may help with libido are
In terms of lifestyle issues, you may need to schedule sex regularly with your partner, and be sure to take time for your relationship. Some practitioners suggest reading erotic literature or using a vibrator.
Menstrual Irregularities
Many women in perimenopause experience a variety of menstrual problems. Erratic, unpredictable periods are a hallmark of the perimenopausal period. But another menstrual issue, menorrhagia (extremely heavy periods), is also a problem for some women during perimenopause.
According to Dr. Jerilynn Prior, scientific director of the Centre for Menstrual Cycle and Ovulation Research in Vancouver, Canada, in perimenopause, approximately 25 percent of women have at least one episode of heavy flow, which usually occurs when cycles are regular and before the onset of skipped cycles. What constitutes a “heavy flow,” or menorrhagia? Says Dr. Prior:
Flow of more than 80 mL (almost 3 ounces) per menstrual period is considered menorrhagia.
Since most of us aren’t measuring, how can you tell if you’re having menorrhagia? According to Dr. Prior:
Each soaked normal-sized pad or tampon holds approximately 5 mL of blood. To calculate the approximate amount of blood loss, multiply the number of soaked normal-sized pads or tam pons in a whole cycle by five to determine the millilitres of blood lost. A maxi-tampon or pad probably holds 10 mL. Sixteen soaked normal-sized sanitary products used in one flow means a blood loss of 80 mL.
In comparison, during a normal period, a woman will typically soak two to seven sanitary products.
Hormone therapy—in particular, going on an oral contraceptive (“the pill”)—can significantly improve menorrhagia. But what other options are there for women who do not want to take hormones?
First, there are some self-care measures. According to Dr. Prior:
Any time you feel dizzy or your heart pounds when you get up from lying down it is evidence that the amount of blood volume in your system is too low. To help that, drink more and increase the salty fluids you drink, such as tomato or other vegetable juices or salty broths (like bouillon). You will likely need at least four to six cups (1.0–1.5 litres) of extra liquid that day. Take at least one tablet (200 mg) of ibuprofen every four to six hours. Nonsteroidal anti-inflammatories decrease the amount of flow by 25–30% by altering the endometrial prostaglandin balance. Also, start taking one tablet of over-the-counter iron (like 35 mg of ferrous gluconate) a day.
(Note: If you are also on thyroid hormone replacement, be sure that you are taking iron at least three to four hours apart from your thyroid medication.)
Some women have found that progesterone can be helpful. You can talk to your doctor about oral or transdermal prescription progesterone (the over-the-counter creams are usually not strong enough to affect heavy periods). Another option is the Mirena intrauterine contraceptive (from Bayer HealthCare Pharmaceuticals), which releases a synthetic progestin and can reportedly reduce total menstrual flow by as much as 94 percent.
There are some procedures that may help with heavy bleeding:
On the herbal and natural front, a number of plants have traditionally been used for heavy menstruation, including
If you are a smoker experiencing menstrual problems, you have to stop smoking. Smoking is linked to many problems, including longer and heavier bleeding. The more you smoke, the more likely you are to have more significant symptoms. Find what works, whether it’s antianxiety medication, antidepressants, varenicline (brand name Chantix), acupuncture, the nicotine patch, or a smoking cessation group, supplemented by exercise, stress reduction techniques, online support groups, and other tactics.
Hair Loss
During menopause, and for women with thyroid issues, the most common type of hair loss is androgenetic alopecia, also known as female pattern hair loss. Androgenic alopecia is affected by sex hormones (estrogen and progesterone), as well as by thyroid, adrenal, pituitary, and pineal hormones.
In androgenic alopecia, testosterone, a type of androgen hormone, is involved. Testosterone metabolizes to dihydrotestosterone (DHT), which causes hair follicles to react by interrupting the hair growth cycle and reducing follicle size. This causes changes in hair texture, diameter, and length.
Androgenic alopecia is characterized by a shortening of the hair’s growth cycle and progressive shortening and thinning of individual hair shafts. It may progress until no hair growth is evident. It is most common in women around menopause. It’s estimated that 37 percent of women experience hair loss and thinning around this time.
Hair can be considered a barometer of health because hair cells are some of the fastest growing in the body. When the body is in crisis, the hair cells can shut down to redirect energy elsewhere. Besides hormonal changes, poor diet and nutritional deficiencies, a variety of medications, surgery, and many medical conditions, noticeably, thyroid disease, can cause hair loss.
Many people notice rapid hair loss as a symptom of hypothyroidism. Some people feel this is the worst symptom of their thyroid problem: thinning hair, large amounts falling out in the shower or sink, often accompanied by changes in the hair’s texture, making it dry, coarse, or easily tangled. Interestingly, some people have actually written to tell me that their thyroid problem was initially “diagnosed” by their hairdresser, who noticed the change.
Proper thyroid treatment, as well as estrogen and progesterone therapy, can help some cases of hormonally driven hair loss. If you’re experiencing hair loss and are just starting hormone therapy, it’s likely that the loss will slow down, and eventually stop, once hormone levels are stabilized and in the normal range. This may take a few months, however. Rest assured, I’ve had many thousands of e-mails from people and have yet to hear from anyone who lost all his or her hair, or became bald, due to hormone imbalances. But many people—including myself—have experienced significant loss of hair volume. In my case, I’d guess at one point I had lost almost half my hair. I had long, thick hair, and it got much thinner for a while.
If you continue to lose hair, you need to make sure that it’s not caused by your particular type of thyroid hormone replacement. Prolonged or excessive hair loss is a side effect of Synthroid and other brands of levothyroxine in some patients. Many doctors do not know this, even though it is a stated side effect in the patient literature, so don’t be surprised if your doctor is not aware of this.
When I have had major bouts of hair loss (despite low-normal TSH and being on a T4/T3 drug), I took the advice of several noted thyroid experts. In his book Solved: The Riddle of Illness, Stephen Langer, MD, points to the fact that symptoms of essential fatty acid insufficiency are very similar to hypothyroidism. Langer recommends evening primrose oil, an excellent source of essential fatty acids, for people with hypothyroidism. The usefulness of EPO, particularly in dealing with excess hair loss associated with hypothyroidism, was reinforced by endocrinologist Kenneth Blanchard. According to Dr. Blanchard:
For hair loss, I routinely recommend multiple vitamins, especially evening primrose oil. If there’s any sex pattern to it—if a woman is losing hair in partly a male pattern—then the problem is there is excessive conversion of testosterone to dihydrotestosterone at the level of the hair follicle. Evening primrose oil is an inhibitor of that conversion. So almost anybody with hair loss probably will benefit from evening primrose oil.
As someone who has had a few periods of extensive hair loss since I became hypothyroid, I can vouch for the fact that after taking EPO, not only did my hair loss slow down, but it stopped after about two months. New hair grew back, and my hair was no longer straw-like, dry, and easily knotted. Now as soon as I notice my hair starting to shed, I start taking EPO again, usually 500 mg, two to three times a day.
If you have extensive or continued hair loss, you should consult with a dermatologist for more intensive treatment. Some of the key treatments are
Without a prescription, you can try minoxidil (brand name Rogaine). This drug, which comes in a topical solution, may slow down hair loss. In some people, it helps trigger hair regrowth after several months. Minoxidil is an FDA-approved remedy for hair loss.
The LaserMax laser comb is the only FDA-approved consumer device to treat hair loss. It’s expensive, usually around $500, and the results are mixed. You might want to try several laser treatments at a salon to see if your hair loss responds before considering purchasing a LaserMax.
In addition to EPO, some other natural approaches that are helpful for hair loss are
Also, be sure that you are not taking a medication that is a known trigger for hair loss. My book The Thyroid Guide to Hair Loss has detailed information on thyroid-related hair loss, prescription, natural, and mind–body approaches, and a detailed list of medications that cause hair loss.
Vaginal Dryness, Urinary/Bladder Symptoms
Vaginal dryness can be a side effect of lower estrogen levels in perimenopause and menopause. Oral and topical estrogen tends to resolve this symptom. In women who choose not to take hormones or use any of the natural herbal approaches to hormone balancing, there are some other options to help with vaginal dryness.
Vaginal moisturizers such as Replens and KY Long Lasting Vaginal Moisturizer can be applied periodically to help maintain moisture in the vaginal area and keep the cells lining the vagina moist. This may help relieve symptoms such as itching and a tendency toward irritation and infection. For sufficient lubrication during sexual intercourse, water-based vaginal lubricants like KY Personal Lubricant and Astroglide may be helpful.
You may also want to avoid antihistamines, as they have a tendency to dry out the mucous membranes, including the vagina.
Some practitioners also recommend Kegel exercises and regular sex to help tone pelvic muscles and improve blood supply to the pelvic area.
Urinary problems, including chronic infections, can be more common in menopause. To help prevent urinary infections, you’ll want to urinate both before and after sexual intercourse, don’t let your bladder remain full for long periods of time, and stay well hydrated. You’ll want to limit alcohol, and be aware that smoking can aggravate bladder infections.
For incontinence, Kegel exercises have been shown to be more effective than many medications.
To perform Kegels, first identify the muscle groups by trying to stop your urine stream while you’re urinating. These are the muscles used in Kegel exercises. Contract these muscles as tightly as you can, count to ten, then relax. You’ll want to do ten contractions a day, three times a day, for maximum benefit. Experts suggest you do Kegels while you’re waiting in line, in the car, at a store, or at your desk. For an extra challenge, try coughing or laughing while practicing.
Sex educator Kim Switnicki has developed a special DVD, The Freedom from Your Leaky Bladder Program, which helps teach proper Kegels and other techniques specifically to treat urinary incontinence. It’s an excellent instructional guide.
For difficult urinary incontinence, talk to your doctor about medical options that can include
Hot Flashes/Night Sweats
Practitioners, from the most conventional to the most holistic, admit that if you are suffering from hot flashes and night sweats, the most effective treatment is some form of estrogen therapy. Studies show that estrogen therapy stops hot flashes and night sweats in 80 percent of patients and reduces their frequency and severity in the rest of women. You can’t argue with those sorts of results.
At the same time, there are some very real issues regarding the safety of estrogen. Some women suffering from hot flashes and night sweats may, based on their own medical history or risk factors or based on concerns about the potential dangers of treatment, choose not to pursue this treatment. In those cases, the value of symptom relief is not worth the potential risks of the medication.
Some phytoestrogens, for example, flaxseed, soy, and black cohosh, may be worth investigating. But again, effectiveness is mixed, and we don’t know if long-term use of phytoestrogens is safe.
Let’s take a look at some other options for hot flashes, besides estrogen treatment.
OTHER MEDICATIONS
Although only hormones are approved by the FDA for treating hot flashes and night sweats, but doctors can prescribe other medications (called off-label prescriptions) for such use. Off-label prescriptions may be covered by some health insurance programs.
The most effective appears to be the antidepressants venlafaxine (brand name Effexor) and paroxetine (brand name Paxil), which, in some studies, have reduced hot flashes by as much as 61 percent at a daily dose of 150 mg. Side effects include dry mouth, loss of appetite, nausea, constipation/diarrhea, headache, dizziness, insomnia, and sexual dysfunction. At higher doses, these medications can raise blood pressure, so they are not recommended for women with hypertension. The FDA requires that all antidepressants carry a generic warning about possible suicide risk for patients taking them. Other antidepressants, including fluoxetine (brand name Prozac) and citalopram (brand name Celexa), have not been found to be effective for hot flashes and night sweats.
Gabapentin (Neurontin) is a medication approved for treating seizures as well as pain associated with shingles. One study found that 900 mg of gabapentin per day for twelve weeks resulted in a 46 percent decrease in hot flashes. Some women have found that a dose of gabapentin at night can help with night sweats. Side effects can include drowsiness, dizziness, nausea, imbalance when walking, and swelling.
Clonidine (brand name Catapres) is a high blood pressure medication. Transdermal use of a clonidine patch may help relieve hot flashes and could be useful for women who have high blood pressure and are not candidates for venlafaxine. Side effects include dizziness, drowsiness, dry mouth, low blood pressure, constipation, and inhibition of orgasm in women.
PRACTICAL CHANGES
Figure out if you have hot flash triggers. Some women have hot flashes like clockwork if they are drinking alcohol, have too much caffeine, or eat spicy food. Try keeping a “hot flash diary” for a few weeks, to learn your triggers, so that you can avoid them during this period of hormonal transition.
There’s nothing worse than wearing a heavy wool sweater that you can’t take off when a hot flash hits. So dress in layers, so that you can add or subtract clothing items as needed, and try to wear breathable cotton as much as possible.
Try to manage the ambient temperature as much as possible. This may mean turning down the thermostat to keep your home or office cooler during the day. Definitely keep temperatures cooler at night for sleeping. Some women like to have windows open or fans running.
It may seem silly, but a personal fan can really help. For summer heat, there are small portable fans that also have a water-misting feature. You can pop out a small battery-operated purse fan anywhere you need it, to help get through a several-minute hot flash more comfortably.
Some women like to keep ice water handy at all times. Carry a sports bottle or travel cup with ice water everywhere you go, and if you feel a hot flash coming on, sipping the ice water may help. You can even freeze a water bottle to keep in your car, or at the office, and as it thaws, you’ll have a ready supply of ice water available.
Your fitness and weight can have an impact on hot flashes, so continuing to exercise may help regulate the nervous system and help with hot flashes. Also, helping reduce the frequency and severity of hot flashes is yet another benefit of losing weight and quitting smoking.
PACED RESPIRATION AND BREATHING
Gynecologist and menopause expert Dr. Jerilynn Prior recommends doing anything that decreases your feeling of stress as a way to help night sweats and hot flashes. In particular, she recommends paced breathing and guided visualization.
Good evidence supports what is called “paced breathing.” It is a kind of meditation or relaxation therapy that uses slow, deep, controlled breathing. Alternate methods of relaxation are to sit in the same quiet place and relaxed way and visualize yourself in the most calm, secure, and lovely place you can imagine.
A study showed that paced respiration, when done twice daily, actually decreased the frequency of hot flashes by 50 percent over a four-month period. Other studies of paced respiration have shown that women who practice it also have lower average skin temperature, which is a way of measuring hot flashes.
Paced respiration is not hard, but it takes some practice. It’s a diaphragmatic breathing technique, which means you need to keep your rib cage still and inhale and exhale using your stomach muscles to lower and raise your diaphragm. You can try it yourself.
To practice, spend ten to fifteen minutes twice a day. When you feel a hot flash coming on, stop whatever you are doing, find a quiet place, and perform paced respiration until the hot flash subsides. You may even be able to prevent the hot flash from developing. A few minutes of paced respiration can also help calm stress during a hectic day.
Another form of breathing that may help for hot flashes is a yoga technique known as alternate nostril breathing. Alternate nostril breathing is thought to provide balance to the body’s temperature, and some women swear by it as a hot flash remedy. To perform alternate nostril breathing,
That is one cycle of alternate nostril breathing. Repeat the cycle, starting with one to two minutes, and working up to several sessions of ten minutes a day.
You might also want to try alternate nostril breathing when you are getting a hot flash, to see if it helps reduce the severity, intensity, or length of the flash.
Finally, I have to share the approach created by holistic physician Molly Roberts. In her work with groups of perimenopausal and menopausal women, Dr. Roberts realized that most women tense up and become very stressed when they are having a hot flash. Many of her patients also described hot flashes as a problem, something to be cured, or evidence that something is “wrong” with them.
Dr. Roberts believes that, like labor pains in childbirth, hot flashes are not evidence of something wrong, or unnatural, but rather are a natural process. Says Roberts:
Our bodies are such a miracle, there must be some constructive reason for hot flashes. I believe, therefore, that at some point, we’re going to find out that hot flashes are actually good for us! What I think is happening is that as estrogen goes up and down, we have more tendency for blood clots. I think the opening of blood vessels during a hot flash may be helping to open up the vessels and perhaps even prevent clots.
Dr. Roberts realized that aspects of the Bradley method, which focuses on relaxation and natural abdominal breathing during childbirth to manage pain, might be useful for women suffering hot flashes. She created a process she calls “The Roberts Method for Hot Flashes,” which she describes here.
When you have a hot flash, take it as a cue that you may be experiencing some stress. Consider a hot flash your body’s way of saying, “Chill out and take a break.” At the same time, recognize that there’s something protective about hot flashes—they are natural and you are having them for a reason. Take a minute or two to do some deep, diaphragmatic breathing, and appreciate your body, appreciate how your body is figuring it all out and getting you through this time.
Dr. Roberts suggested this method to a group of women participating in a menopause workshop, and they tried it for a few weeks. The group then came back together, and most of the women reported that it really made a great deal of difference in the number of hot flashes they were having, as well as the length of time the hot flashes lasted. Dr. Roberts was particularly surprised that some of the women came back saying that they had even come to enjoy their hot flashes. Apparently, the hot flash became a reminder—and, at the same time, permission—to take a few moments to relax and do the deep breathing, which the women found pleasurable.
SELF-HYPNOSIS
A 2008 article in the Journal of Clinical Oncology reported on the results of a study of hypnosis for hot flashes. The women in the study received five fifty-minute sessions each week that involved relaxation and cooling imagery. The group reported a phenomenal 68 percent reduction in the severity and frequency of hot flashes.
As discussed in the section on affirmations and self-hypnosis in Chapter 9, I recommend Dr. Steven Gurgevich’s self-hypnosis resources for perimenopause/menopause, or work with a medical hypnotist who is certified by the American Society of Clinical Hypnosis.
A Special Note: Stop Smoking!
I know that those of you who smoke hear it all the time, but one of the best things you can do to help resolve many symptoms is to quit smoking. Smoking makes thyroid problems worse, it makes menopausal symptoms worse, it makes menstrual irregularities worse, and it can make fatigue worse—not to mention the issues of heart and lung health.
Stopping smoking should be an essential part of your wellness plan.
Even if you’ve tried to quit smoking many times, don’t despair. Keep trying, because eventually, you’ll get good at it. I know, because I smoked for fifteen years, and I was not a social smoker; I was a hard-core, one-to-two-pack-a-day smoker. I tried to quit many times, but I loved to smoke and kept lapsing. Finally, I was able to quit in my early thirties. The only way I was able to do it was with the support of my doctor, some medication, and discovering that crocheting, of all things, could occupy my hands and mind enough for me to battle the cravings. (Five king-size afghans and three months later, I was finally smoke free for good, and I’ve stayed that way for another fifteen years.) While quitting smoking was one of the hardest things I have ever done, it’s also one of the best things I could do. Even while facing the health challenges of thyroid disease and perimenopause, I thankfully do not have the extra risk of heart disease, stroke, lung cancer, emphysema, and a host of other smoking-related problems hanging over me. So find what works for you—antidepressants, antianxiety medications, smoking cessation drugs like Chantix, prayer, meditation, exercise, yoga, breathing, needlework, biofeedback—and get started.