Chief Complaint: Hot Flashes, Poor Sleep, Weight Gain, Mood Changes
Jacquelyn is a 56-year-old female who came into the clinic saying she has had the “worst six months of her life.” She is experiencing uncomfortable hot flashes, poor sleep, weight gain, difficulty concentrating, low libido, and feelings of irritability.
Jacquelyn had her last menstrual cycle 13 months ago, so she is officially in menopause. She had the goal of going through the menopausal transition “naturally” and has been trying various supplements, increasing her exercise, and doubling her water intake.
Despite her best efforts, she remains entirely uncomfortable and would like to start bioidentical hormone replacement therapy.
Additional History:
- Jacquelyn has a history of frequent urinary tract infections and high cholesterol
- She has no personal or family history of breast cancer, ovarian cancer, or endometrial cancer
- She had her gallbladder removed but no other prior surgeries
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Functional Medicine Labs for Menopause: Initial Lab Work
We did baseline salivary hormone labs through ZRT and reviewed the recent blood work she had with her primary care doctor.
Her primary care blood work confirmed
- Thyroid was within the optimal range
- Normal liver and kidney function
- No evidence of anemia
- Optimal Vitamin D and B vitamin levels
Baseline Salivary Hormone Lab Results (ZRT)
- Very low estradiol, progesterone, and testosterone.
Functional Medicine Diagnosis: Menopause
Jacquelyn’s lab results are consistent with menopause due to very low estradiol, progesterone, and testosterone.
Functional Medicine Approach for Menopause
To start, I suggested she consider 200mg of oral micronized progesterone and a 0.05mg/day estradiol patch. Oral progesterone has been shown in studies to support improved sleep patterns in postmenopausal women. It may help decrease middle-of-the-night awakenings, support slow-wave sleep duration, and increase nocturnal growth hormone levels. A topical estradiol formulation was considered due to its supportive safety profile compared to oral estrogen. A large observational study from the UK found an increased risk of venous blood clots in all forms of oral estrogen, with conjugated equine estrogen conferring the most significant risk. They found no increased risk of venous blood clots in patients using transdermal (topical) estrogen.
I asked Jacquelyn to return in 3 months to repeat her hormone labs and see how she was doing.
Functional Medicine Labs for Menopause: 3 Month Follow-up Lab Work
Three months later, Jacquelyn is feeling some improvement. She is now sleeping through the night and has noticed improved energy and mental clarity during the day. Her hot flashes are not entirely gone but are now down to just an occasional hot flash at night. She continues to feel almost no libido, and sex remains very uncomfortable and generally unpleasant in part due to vaginal dryness. She has lost 4lbs in the last few months but struggles to motivate herself to get to the gym.
Jacquelyn’s estradiol level is now back in the low end of the premenopausal range. Her progesterone is significantly improved but remains just under the normal range. Her ratio of progesterone to estrogen has also improved but is not quite ideal. We have not addressed her low testosterone, and it remains quite low.
Functional Medicine Approach for Menopause: 3 Month Follow-up
Since Jacquelyn’s chief concern at this point is her low libido and difficulty enjoying sex, we decided to explore adding transdermal testosterone to her regimen. A large meta-analysis showed that when compared to placebo or hormone replacement therapy without testosterone, the use of testosterone was associated with increased sexual desire, sexual pleasure, orgasm, and improved self-image in post-menopausal women. The only safety concern noted was increased cholesterol with oral testosterone but not transdermal testosterone. Some women did note increased hair growth in the area they applied the transdermal products.
I suggested Jacquelyn try a compounded testosterone cream (1mg/0.5grams) at 0.5 grams a day. I also recommended she consider an estradiol vaginal cream to help support vaginal moisture.
Her response to the oral micronized progesterone was not ideal, and we may need to consider additional progesterone in her regimen in the future. I did not want to make too many changes to her regimen at once, so I had her continue her current regimen of estradiol and progesterone with the plan to repeat labs and see how she is doing in another 3 months.
Summary
Women will spend roughly one-third of their life in menopause. While many women experience this transition with little discomfort, others may notice a significant decline in their quality of life and sense of vitality. The most common symptoms of menopause include hot flashes, insomnia, vaginal dryness, decreased libido, fatigue, and joint pain. In one population-based study, the symptoms were significant enough for 86% of women to reach out to their physician for help with symptom management. While there are a variety of helpful pharmacologic and nonpharmacologic options for managing menopausal symptoms, bioidentical hormone replacement therapy remains a widely used approach to help women feel more like themselves again.
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