If you always do what interests you, at least one person is pleased.
—Katharine Hepburn
When you are putting together your plan for managing wellness in your forties, fifties, and beyond, there are a number of things to keep in mind as you move forward to make that plan effective and empowering.
Cover the Basics
First, let’s start by outlining the basics. These are the items that every woman needs to include in her wellness plan.
RESOLVE THYROID HORMONE IMBALANCES
Get any thyroid imbalances properly diagnosed, sufficiently treated, and optimized. That may require traditional approaches with prescription medications, but more likely it will require a broader, more integrative approach. The best thyroid treatment is the one that safely resolves your symptoms. You shouldn’t be afraid to work with a doctor who is willing to try different approaches and integrate holistic, natural, and alternative medicine into your overall thyroid treatment.
MANAGE REPRODUCTIVE HORMONE IMBALANCES
When reproductive hormonal imbalances are interfering with your quality of life, get them properly diagnosed and sufficiently treated. Because prescription hormones carry some risks, you may want to try natural, holistic, lifestyle, and mind–body approaches first, to see if you lessen the frequency and severity of symptoms, and learn new tools to effectively respond to them. But when symptoms are unmanageable, you should not be afraid to investigate the use of prescription hormones. Right now, the best approach is to go with the safest hormones, at the lowest dose, for the least amount of time needed to resolve symptoms. Which ones are safest is somewhat controversial, but there’s enough evidence to suggest that, whenever possible, stay away from the conjugated estrogens and synthetic progestins, and instead choose estradiol and other bioidentical estrogens, ideally in transdermal rather than oral forms, and natural forms of progesterone if you still have your uterus.
ADOPT A HEALTHIER WAY OF EATING
We are increasingly coming to understand the essential role that diet plays in helping us stay healthy and in helping maintain hormone balance. Many dietary changes were already discussed in Chapter 7, and while we all wish we could pursue a perfect diet, that’s unrealistic. But all of us can try to reduce portion sizes; eat more organic foods so that we can avoid pesticides and hormones; eat more vegetables, fruits, and fiber; eat less processed, sugary, and starchy foods; ensure that we get good fats in our diet and minimize unhealthy, saturated fats; drink enough water; limit alcohol; and learn how to eat to live and not live to eat. We can also commit to trying new foods and learning how to use certain foods as “natural medicine” to help us deal with various symptoms we are experiencing.
EXERCISE
If there is one thing I would suggest to every woman reading this book, it’s to exercise. Chapter 8 talks about T-Tapp, walking, and various other approaches, but in the end, whatever you do, commit to doing it. Slow and steady wins the race, as they say, and they’re right. It’s less important what you choose to do; what is important is consistency and discipline to stick with it. I have a dear friend, Jane, who is in her forties, in perimenopause, and I have watched in amazement as Jane has discovered the wonders of walking. She gets out there every morning, rain or shine, and walks briskly around her neighborhood. Her only fitness equipment is a pair of sneakers and her resolve to walk. In about eight months, Jane, who is a phenomenal cook and still loves to eat, has walked off fifty pounds and walked herself right into a size 6. I have no doubt that it’s her resolve to keep walking that has been the secret to her success.
GET ENOUGH SLEEP
If I told you there was something that you could do every day that would help you lose weight, feel great, have amazing energy, help balance hormones, and help you live a longer life (and, oh, it’s so easy even a baby can do it), would you try it? Of course you would. So put getting enough sleep right up there on your priority list of things to do to take care of your health.
The body is meant to rest, and despite all the improvements of the twenty-first century, we still haven’t figured out a way to bypass the need for sleep. That means, for most of us, eight hours a night. Yes, eight hours.
PRACTICE REGULAR STRESS REDUCTION
Just like brushing your teeth every day is part of good dental health, reducing your stress every day is part of good mental health. What you do to incorporate stress reduction into your life is up to you. Some people pray or go to religious services, others take yoga or tai chi classes; some like breathing exercises; some meditate; some practice self-hypnosis or guided imagery; some use biofeedback; some pursue creative projects. It doesn’t matter which method you choose. Just be sure that you find what works for you, that you find an approach that allows your body and mind to enjoy the “relaxation response,” and make it a habit to incorporate it into your daily life.
FIND THE RIGHT PRACTITIONER
Finding a doctor who can help you with hormonal balance is a challenge. But perimenopause/menopause is an important time in your life to have a doctor who has time for you and who is your partner.
There is no single medical specialty that thoroughly prepares doctors for diagnosing and managing women’s hormones, including thyroid, during the perimenopausal/menopausal period. There are actually many different types of practitioners—including endocrinologists, general practice or family practice doctors, internists, ob-gyns, nurse practitioners, antiaging medicine practitioners, and osteopaths, to name a few—as well as holistic and integrative practitioners, including holistic MDs, naturopaths, herbal medicine experts, and traditional Chinese medicine practitioners, who end up working with women on managing hormones. How do you know which one to choose?
I’ve put together some guidelines and advice to help you find the right practitioner for you, and, once you have that person, how to best communicate with him or her.
Forget Endocrinologists
While endocrinologists have traditionally considered thyroid disease and hormones as areas within the purview of endocrinology, let’s be honest here. Endocrinologists can be essential for proper diagnosis and treatment of serious diseases of the thyroid, such as thyroid cancer and life-threatening thyroid storm, as well as severe endocrine problems, including adrenal conditions like Cushing’s disease and Addison’s disease, osteoporosis, polycystic ovary syndrome, and other complicated endocrine conditions. Diabetes, when improperly managed, can cause blindness, loss of limbs, and even death, is on the rise in the United States. At the same time, there is a severe shortage of endocrinologists. Right now, there are an estimated 4,000 endocrinologists in the United States serving the 25 million to 100 million Americans who might reasonably need to be seen by such specialists. That’s only one for every 6,250 to 25,000 people.
Given such a shortage, where do you think endocrinologists are going to focus their energy? On women who don’t feel well because of hormone imbalances, Hashimoto’s thyroiditis, and symptomatic estrogen/progesterone imbalances? Or on people who have life-threatening endocrine diseases? (I’m not suggesting that hormone imbalances aren’t serious or worthy of attention, of course, just trying to help explain how endocrinologists view them.)
Increasingly, endocrinologists are leaving it to other physicians—general practitioners, internists, ob-gyns, and such—to diagnose and manage what they consider “routine” hormonal imbalances of the thyroid and reproductive hormones, because as far as they are concerned, these patients don’t need the specialized knowledge of an endocrinologist anyway. The American Association of Clinical Endocrinologists (AACE) says that keeping the thyroid in balance requires only “three easy steps”: testing thyroid-stimulating hormone (TSH), taking medication, and following up with a TSH test every six to twelve months.
My advice? Unless you have what an endocrinologist would view as a life-threatening endocrine disease, look elsewhere for assistance in diagnosing and managing thyroid and reproductive hormone imbalances.
If you have an endocrine disease, however, and need to find a qualified endocrinologist, the AACE maintains an online “Find an Endocrinologist” database of clinical endocrinologists, by state. The American Thyroid Association (ATA) also has a “Find a Thyroid Specialist” database featuring doctors who are members of the American Thyroid Association. The Endocrine Society’s Hormone Foundation educational arm maintains a “Find an Endocrinologist” search function. My Thyroid Top Doctors database online also includes endocrinologists who are recommended by thyroid patients.
Consider a Certified NAMS Menopause Practitioner
The North American Menopause Society (NAMS) has a certification process for designation as an NAMS menopause practitioner. To receive this certification, a practitioner must pass a competency exam. The NAMS maintains a state-by-state list of practitioners who have received this certification, which is good for three years. The list includes MDs, osteopaths, naturopathic physicians, physician’s assistants, nurse practitioners, pharmacists, nurses, clinical social workers, and psychologists. Some of the practitioners will clearly have a more conventional focus; the naturopathic and osteopathic physicians on the list may have a more holistic and integrative approach.
The NAMS recommends that you contact doctors in your area to find out what percentage of their practice is devoted to menopause. The NAMS then suggests that you schedule an appointment to see if the practitioner and the practice are a good fit for you.
Information on how to access the list of certified NAMS menopause practitioners is featured in Appendix A.
Use Other Referral Opportunities
There are a variety of referral services, most online, that provide additional starting points to help you identify conventional and integrative practitioners. These include
Contact information for these groups and their referral services is featured in Appendix A.
New York Times health writer and advocate Tara Parker-Pope has other good advice. Says Parker-Pope:
If you are lucky enough to know a nurse, [he or she] can be an excellent resource to help you find the best doctors.
Take an Integrative Approach
While many general practitioners and family practice doctors are called on to diagnose and treat thyroid disease or recognize and treat perimenopausal/menopausal symptoms, they are doing so without a great deal of knowledge or expertise about either issue.
You can’t assume that the thyroid treatment or hormone advice you are getting from a general practitioner (GP) or family practice doctor is reflecting the best and most current thinking on the issue.
Many GPs and family doctors are not proactive about testing the thyroid in perimenopausal/menopausal women, and if they do, they only know how to order a TSH test. These doctors tend to rely on the laboratory report to flag abnormal results, which means that, because most labs are still using the old, outdated TSH range, they are usually not going to be aware that TSH levels above 2.5 to 3.0 may be indicative of thyroid problems.
Frequently, when it comes to what are considered classic menopausal symptoms (that is, hot flashes and night sweats), these doctors don’t test hormones at all, but simply recommend Premarin or Prempro.
There are, of course, terrific doctors who follow a conventional approach. But if you’re trying to find the right practitioner to partner with you for hormonal wellness, my advice is, if you can afford it, see a holistic/integrative practitioner who has experience working with hormone imbalances. By “holistic/integrative,” I mean a practitioner who combines the best of conventional approaches with holistic, natural, and alternative medicine approaches and will help identify the best of all possible worlds for you in terms of your treatment.
The challenges are in how and where to find these practitioners and, given that few of them are covered by health insurance plans, paying for them.
Jacob Teitelbaum, MD, an expert on integrative medicine, says a more broad-minded practitioner is especially important for proper thyroid care:
General doctors don’t do thyroid—they think they do thyroid, but they don’t know how to do it properly. If you want it properly done, go to a holistic physician.
To find qualified integrative physicians, Dr. Teitelbaum suggests starting with the American Board of Integrative Holistic Medicine (ABIHM). ABIHM maintains a physician locator service for more than 1,000 board-certified integrative and holistic doctors around the country. Contact information for ABIHM is in Appendix A.
I’m not suggesting that there are no GPs or family practice doctors who haven’t made an effort to become especially knowledgeable about balancing hormones, because they are out there. But you will have to actively seek them out, either through referrals from their satisfied patients or through directories, such as my Thyroid Top Doctors Directory online.
Communicate Well with Your Doctor
One of the most essential things about communicating with your doctor is to interact professionally. Some women approach a doctor’s appointment as if it were coffee with girlfriends. We go in and we complain: “I feel so fat, I feel like I just inhale chocolate, and I’m gaining weight,” or “I am so totally exhausted,” or “My husband’s going to kill me; I just don’t want sex,” and so on. Doctors tend to hear an informal style of expressing our symptoms as more emotional than physical, which is why these sorts of complaints may be met with recommendations to take antidepressants rather than evaluated as possible thyroid or hormonal issues.
So when you meet with your doctor, be prepared to express your symptoms in a less emotional, more quantifiable way. Quantifying your symptoms is an important way to get doctors to really hear what you’re saying about your concerns. So, for example, instead of saying, “I’m totally exhausted, I can’t drag myself around,” you can say, “I used to manage a busy life—forty-hour-a-week job, caring for an aging parent—on seven hours a night. Now I need nine hours a night, and I am still tired.” Or, instead of saying, “Everything I eat is ending up on my hips!” say, “I was maintaining my weight on about 2,000 calories a day and going to the gym three times a week. Now I’ve actually stepped it up to five times a week, an hour each time, and dropped my calories down to 1,800 a day, and I’m still gaining approximately one pound a week.”
Tara Parker-Pope sums it up this way:
Women need to learn that the doctor visit is not catching up with an old friend. Think about how you’d talk to your accountant or mechanic. Your relationship with your doctor is special, and it shouldn’t be cold, but beyond the warm feelings, you need to be very specific, and help your doctor by giving [him or her] the best information.
One of the most important things you can do to make your doctor’s visits productive is to have an agenda. Some patients find it helpful to put together a simple list of key points to discuss with the doctor, in order of priority, and bring two copies to the appointment. This helps ensure that all your key issues are covered and that you haven’t left the most important questions for the end of the visit.
Another way to get the most out of your visit is to keep a health diary. Says Parker-Pope:
When you start keeping track of things like sleep, events, foods, and symptoms, you start to see patterns. I think before you go to the doctor, you should keep a health diary for at least a few weeks or more. And don’t just keep track of obvious symptoms; write down major things—thoughts, how you feel. Women are smart, we can see changes. And doctors respect health diaries; it takes the emotion out of a doctor’s visit.
During the visit, take notes if necessary, or if you want to concentrate on what the doctor is saying, think about bringing a tape recorder with you. (Easy-to-operate digital audio recorders, which are the size of a cell phone, can record hours.)
Better yet, think about bringing a family member or friend to important doctor’s visits. In fact, bringing a companion with you on a medical visit is associated with improved satisfaction and better communication. Your companion can help by taking notes, asking follow-up questions, and generally aiding in communication.
One of the key challenges in getting properly diagnosed and treated for thyroid and hormone imbalances is finding enough time. It takes time to explore symptoms and review medical history, and often there simply isn’t enough time to cover everything during a regular visit.
Of course, holistic or integrative practitioners, most of whom are not on any insurance plans, often spend more time with their patients, as a hallmark of their care. But many of us cannot afford to go outside our insurance plan. If you are limited to seeing only certain practitioners, how can you get as much time as possible for your hormonal evaluation?
Tara Parker-Pope has an excellent idea: schedule an annual physical. Says Parker-Pope:
Insurance and HMOs give you one annual physical, and that can be a longer appointment that gives you a lot more time with your doctor. During your physical, ask for a complete workup. Tell the doctor you’d like to look at your blood levels for thyroid, hormones, cholesterol, blood sugar, a complete blood count, and so on.
Some doctors debate the value of blood tests for hormones and don’t use them, or they are trying to contain costs and will only test for thyroid hormone if faced with a patient who has serious symptoms. If the doctor refuses to test you or suggests that you start on hormones like estrogen without a test, Parker-Pope suggests that you tell the doctor you’re willing to consider it, but that you’d like to rule out other issues first.
Stay Informed and Connected
Patient advocate and Good Morning America medical correspondent Marie Savard, MD, believes that being informed and connecting with others is essential.
Be informed…. [I]t’s important to understand your body and what to expect. Sometimes just understanding the physiologic changes can help more than other approaches…it puts your mind at ease. Don’t hesitate to share your experience with friends and family who may have gone through the same thing.
Follow the health news. Keep in mind that a lot of coverage of health in the media is sensationalized or oversimplified. In some cases, reporters simply don’t understand what they’re talking about. Here are just a few of the sources I rely on for health news coverage related to thyroid disease and menopause:
I also regularly access the latest medical research on thyroid disease, hormones, and other topics of interest through the National Library of Medicine’s PubMed service online, at http://www.pubmed.gov.
If you’re interested in thyroid disease, you’ll also want to subscribe to my various newsletters on thyroid disease, including a weekly and monthly e-mail newsletter and my bimonthly print newsletter. Information on how to sign up is in Appendix A.
Stefanie Rotsaert, a thyroid patient and founder of a successful patient support group in New Jersey, has found that being informed and connecting with others are part of her overall wellness plan.
Before I had my second thyroid surgery, I was very frustrated. So I started reading everything, looking at alternatives, talking to doctors.
Later, after her surgery, Rotsaert noted in a hospital evaluation form that there were support groups for many issues in her area but not for thyroid disease. The next thing she knew, she was launching a support group through her hospital. The group, going strong for a number of years, is now independent. Through it, Rotsaert books various practitioners to speak to members, and members share information with each other.
Many local hospitals, YMCAs, and community organizations have support groups for women in menopause, so in-person support is always an option. Also, keep in mind that there are wonderful support forums on the Internet for menopause and thyroid disease. I’d encourage you to visit the friendly Minnie Pauz forum, Power-Surge, and my own thyroid forums, for information and support. Links are available online at www.menopausethyroid.com.
When You Don’t Have Access to the Internet
When I speak with folks around the country during phone coaching sessions or in-person seminars, I frequently will suggest checking out this or that Web site. I’m always saying, “You can find that on the Internet at http://www…” but it’s not uncommon for someone to respond, “But I don’t have the Internet at home,” or “I don’t have a computer,” or “I don’t know the first thing about surfing the Web!”
Unfortunately, if you want to stay up on health information, it’s a hardship these days if you don’t have Internet access. There are entire categories of information that are difficult, or unwieldy, or downright impossible to get any other way. There are many online support groups, e-mail newsletters, and Web-based organizations out there ready to meet many of your health care information needs. But these groups do not operate using 800 numbers and regular mail.
If you think there’s no hope for you to get this information because you don’t have access to the Internet, think again. Just head over to your local public library. According to the American Library Association:
Internet access in public libraries is as common as books. Almost all public library outlets offer public access to the Internet. For people without computers at home, work or school, libraries are the number one point of access to the Internet.
Your local librarians are trained to help you find what you need, including online.
Listen to Your Own Wisdom
Who should we listen to when it comes to menopause? Should it be our mothers? Our best friends? Our doctors? Oprah?
I asked many of the doctors I interviewed this question, and I have to say, Tieraona Low Dog’s answer resonated with me. Dr. Low Dog said that, ultimately, we should listen to our own wisdom.
Who do we look to? We should look within. Don’t look outside yourself for experts. When I’m in the quiet, I can hear my own inner wisdom…and that may help me to know how to proceed, and where to find the answer.
Dr. Low Dog then shared a compelling quote from Ralph Waldo Emerson, and I think it’s fitting to end the book with it:
These are the voices which we hear in solitude, but they grow faint and inaudible as we enter into the world.