Dr. Weyrich's Naturopathic Functional Medicine Notebook is a collection of information on topics of interest to Dr. Weyrich that may be of interest to the world wide audience. Due to limitations of time, not all information that Dr. Weyrich knows or would like to further research is published here. Dr. Weyrich welcomes financial contributions to support specific research topics, as well as copies of non-free access journal articles for him to review on a topic. Constructive criticism is also welcome.

Overview of Menopause

If a woman is in menopause, it is because her ovarian function has declined (or been medically suppressed/removed) beyond the ability of her pituitary to compensate by increasing FSH hormone levels. Menopause (or andropause) is the first step in the total collapse of body physiology. A patient can choose to accept the progressive collapse as "natural" or they can choose to "Go not softly into the night, but to Rage against the Darkness" as Dylan Thomas wrote.

Anti-aging doctors seek to maximize the area under the curve of quality of life vs quantity of life. Different patients may prioritize these competing parameters differently.

There is a continuum of health care from total lassez faire (let Nature take its course without intervention - we don't need doctors or hospitals at all) at one extreme, to super-heroic technologies (e.g. kidney dialysis, ventilators, artificial hearts, tube feeding, etc) at the other extreme.

Any attempt to add area under the curve (improve quality of life, quantity of life, or both), that Mother Nature did not grant by default, is by definition "un-natural".

The menstrual cycle IS a natural state, that may be extended via the intervention of bio-identical hormones. Whether a woman chooses to do so is her choice. But to call such an extension unnatural simply because it delays the process of dying invalidates the purpose of both allopathic and naturopathic medicine.

Most doctors (conventional and naturopathic) recommend insulin replacement therapy to compensate for declining ability of the pancreas to produce insulin. They also recommend dosing the insulin as close to the natural prandial cycle as possible. Why should gonadal hormone replacement be treated any differently?

Patients come to Dr. Weyrich because their MD told them that all their complaints are just part of getting old, and they should accept (and embrace) the decline. Instead, Dr. Weyrich's approach is to help patients "rage against the darkness" and have the best quality of life for the longest time possible.

Your mileage may vary and batteries not included, but each patient should have the freedom to set their priorities differently regarding the trade-offs between choices along this health care continuum.

Etiology of Menopause

Dr. M.E. "Ted" Quigley M.D states "Estrogen Withdraw Syndrome" is the primary hormonal cause of pain and suffering in women. This can occur during perimenopause, and early menopause, and also during the menstrual cycle, postpartum, or due to drugs (lupron, progesterone, progrestins, clomid, tamoxifen) or surgury. (Estradiol levels are very high before partus, and drop rapidly post partum. Clomid is an "anti-estrogen" that suppresses the tissue effect of estrogen) [Quigley2006].

Dr. Quigley describes the "Women's Estrogen Zone" - amount needed to relieve symptoms:

  • 125-150 pg/mL E2: Relieve cognitive dysfunction
  • 75-125 pg/mL E2: Relieve psych/emotional symptoms, e.g. depression, anxiety, irritability, moodiness
  • 50-75 pg/mL E2: relieve hot flashes, night sweats, palpitations, sleep disturbances

Diagnosis of Menopause

Symptoms of menopause may include:

  • Hot flashes
  • Night sweats
  • Paresthesia of the extremities
  • Muscle pain
  • Headaches
  • Vertigo
  • Vaginitis
  • Recurrent UTI
  • Apathy, depression, anxiety, irritability, moodiness
  • Cognitive dysfunction

Differential Diagnosis of Menopause

Treatment of Menopause

Only giving estrogen without progesterone is NEVER a good idea. A healthy woman btween menarche and menopause produces a monthly cyclical change in her hormones, most notably estrogen, progesterone, and testosterone.

Prescribing both estrogen and progesterone replacement simultaneously without alternation is the current standard of care. However, doing so is like driving down the road with one foot on the gas and the other simultaneously on the brake. This is NEVER a natural solution, even if bio-identical hormones are used. This dosing schedule ever creates anything close to a natural physiologic state.

Varying hormone replacement to match a young woman's (age 25) hormone cycle (e.g. the Wiley Protocol) arguably reproduces a more natural physiologic state, but may have the side effect of producing menses just as seen in a young woman - which some consider to be unatural itself.

Ultimately, each individual woman should have the right and responsibility to choose the hormone replacement strategy that makes most sense to her. Dr. Weyrich is trained in the use of bio-identical hormone creams according to either fixed (conventional) or cyclic (Wiley) protocols, and is happy to discuss the risks and benefits of each protocol.

It has been observed that women being adequately treated for hypothyroidism have far fewer menopausal symptoms than those in the general population [Barnes], [Starr2005, pg 149].

Current medical thought is that it is best to institute hormone replacement therapy (HRT) soon after menopause for maximum benefit at lowest risk.

Some controversy regarding HRT for menopausal symptoms was raised by the Women's Health Initiative Study (WHI) [Rossouw2002], which found a slightly increased risk of heart attack, stroke, and breast cancer for certain groups of women using the non-bioidentical hormones Premarin and Provera, despite considerable benefits and the reduction of risk in other groups. [Quigley2006] has pointed out flaws in the design of the study. In addition, the risks attributed to the non-bioidentical hormones Premarin and Provera may not extrapolate to the bioidentical analogs made endogenously by women and available from compounding pharmacies [Quigley2015], [Starr2005, pg 194], [Brownstein2003], [Vliet2000].

Research has shown that starting estrogen replacement therapy (ERT) in peri-menopausal or early-menopausal women reduces the risk of a heart attack by 30-50%, by protecting against arteriosclerosis. However, if start of ERT is delayed more than 6 years after menopause, this protection is lost. Furthermore, synthetic progestins (but not bio-identical progesterone) reduce the benefit. Furthermore, as shown by the Women's Health Intitiative (WHI), Starting HRT in older (50-79 years old) women causes a SLIGHT increased risk of heart attack, breast cancer, stroke (not statistically significant), and venous thromboembolism. Nonetheless, the benefits of HRT have still been shown to outweigh the risks. For example, in the 50-59 year old Primarin-only cohort, heart attacks were reduced by 44%, invasive breast cancer by 28%, all-cause mortality by 27%). All these benefits more than compensate for the increased risk of thromboembolism (22% increase) in that same cohort. [Quigley2006], [Quigley2015], [Rossouw2002], [Wassertheil_Smoller2003]. The WHI study has also been criticised on a number of points, including:

  • Benefits of HRT were lost by not starting at age of onset of menopause
  • No adjustment of dose for age (rate of drug clearance)
  • Subjects had many co-morbidities but most did NOT have menopausal symptoms
  • Use of synthetic progestin instead of bio-identical progesterone
[Quigley2006], [Quigley2015].

In addition to the benefits of testosterone supplementation in preventing (and treating) breast cancer, [Glasser2011] has shown that testosterone supplementation benefits menopausal symptoms.

However, [Janssen2010] has shown that as estrogen levels drop in perimenopause and menopause, SHBG also decreases, resulting in an effective increase in bioavailable testosterone, which is in turn associated with an increase in insulin resistance and visceral fat. [Dr. Weyrich notes association does not prove cause and effect]. See also [Sutton_Tyrrell2005], [Lee2004], [Zang2006], [Lambrinoudaki2006].

[Golden2007] concludes "of postmenopausal women, endogenous bioavailable T, E2, and DHEA were positively associated and SHBG was negatively associated with insulin resistance."

[Matsui2013] states "SHBG may be a key factor related to insulin resistance independent of estradiol and testosterone" and an "estradiol level that is comparable to that in premenopausal women may be needed for improvement of insulin sensitivity by hormone therapy in postmenopausal women" (in their study, postmenopausal women receiving supplemental estrogen had lower circulating estrogen levels than pre-menopausal women). These authors also raise the question of whether the SHBG is directly involved in insulin resistance, [ORWJr: and free testosterone is simply a marker of low SHBG].

Since the optimum level of estradiol and testosterone to reduce cancer risk and menopausal symptoms without increasing insulin resistance and visceral fat has not been established, testosterone should only be supplemented when free testosterone is below normal physiological levels for premenopausal women, and insulin resistance and visceral fat should be monitored. This begs the question of what optimal hormone levels of estradiol, progesterone, testosterone, and DHEA are for post-menopausal women. Opinions vary from "let nature take its course" to "supplement with the minimum levels necessary to eliminate symptoms" to "reproduce the hormone profile of a 20-year-old woman." The available data clearly shows HRT is superior to letting nature take its course, but Dr. Weyrich finds insufficient data in the literature to evaluate the merits of the latter two options (or more properly, the continuum between the latter two options). The only thing that is clear is the approach to HRT must balance all hormones.

Hypotheses regarding Menopause

The Shorr stain, which was developed by the same research group that developed the Pap smear can be used to judge the adequacy of estrogen levels [Shorr1945]. Using the Shorr stain, [Sonkin1968] found that optimum levels of estrogen supplementation were much higher than conventionally used. In addition, [Sonkin1968] suggested estrogen replacement therapy was protective against breast cancer. This point is further discussed on Dr. Weyrich's web page regarding breast cancer.

References for Menopause