If you actually listened to the “side effects portion” or TV ads or read through all the side effects of every single drug you ever put in your mouth, I guarantee you; you’d think more than twice. Fatigue, headache, nausea are mentioned constantly, and while “sexual dysfunction” might not be listed, do you think you’ll be “in the mood” if you have nausea from a pharmaceutical? Meanwhile, there are commonly used pharmaceuticals that specifically lead to a loss of libido. Here are some of the “big players.”

Antidepressants, oddly enough, are one of the main culprits. I say “oddly enough” because depression often causes a lack of sexual interest. So when you take a depressed person and give them antidepressants that make them even less interested in sex, you’re not doing them any favors. So here are the ones to watch for.

Serotonin and noradrenaline reuptake inhibitors (SNRIs) are the most popular category of antidepressants currently prescribed. Many of them will lower the sex drive in women and men. These drugs include venlafaxine (Effexor), desvenlafaxine (Pristiq), and duloxetine (Cymbalta).

Running a close second and prescribed more by primary care practitioners are the selective serotonin reuptake inhibitors (SSRIs). These drugs and even a couple of drugs noted above are also used for menopausal symptoms (groan). Popular drugs in this category include escitalopram (Lexapro), citalopram (Celexa), fluoxetine (Prozac, Sarafem), sertraline (Zoloft), fluvoxamine (Luvox), and paroxetine (Paxil).

Non-functional doctors use tricyclic antidepressants (TCAs) to treat depression, some types of anxiety, fibromyalgia, and certain types of chronic pain. Examples include desipramine (Norpramin), doxepin (Sinequan), amitriptyline (Elavil), amoxapine- clomipramine (Anafranil),nortriptyline (Pamelor), imipramine (Tofranil), protriptyline (Vivactil) and trimipramine (Surmontil).

To round out the list without naming every drug on the market, let me mention (while we’re on the subject of mental health) that some medications used in Schizophrenia will raise prolactin levels and therefore depress libido. Then there are the very commonly used medications finasteride and dutasteride used for prostate enlargement. Next, as I’ll get into more, oral contraceptives might be a problem. Finally, many medications that lower blood pressure also results in low libido. A prime example of a blood pressure medication used to lower blood pressure, calm tremors, and even decrease anxiety is a beta-blocker such as metoprolol.

Lastly, alcohol or recreational drug use can cause low sex drive in women and men. And, it’s a bit of a mixed bag when it comes to “weed,” which will be discussed later.

Emotional and psychological factors

Most people do not have a so-called “psychiatric diagnosis.” But that doesn’t mean none of us have “issues”- in fact, most of us do deal with emotional and psychological factors that can hinder our desire for sex. Let’s start with relationship problems. A lack of trust, poor communication, any form of abuse, or stresses from financial, parental, or child-related issues can lower sexual desire on the part of one or both sexual partners. In addition, mental health issues resulting from undiagnosed depression, anxiety, eating disorders, poor self-image, or even prior sexual abuse can diminish a person’s interest in sexual activity.

Depression, Anxiety and other Mental Health Issues

Sexual disorders are prevalent problems in patients who have been diagnosed with psychiatric disorders.  As mentioned previously, medications such as antidepressants and antipsychotics will induce sexual dysfunction. A comprehensive review article looked at sexual disorders in psychiatric diseases such as bipolar disorder, schizophrenia, depression, obsessive-compulsive disorders, anxiety,  and eating disorders.

Panic disorder and obsessive-compulsive disorder are both correlated with less frequent sexual contact. Decreased sexual desire and sexual aversion are strongly associated with all types of anxiety disorders. The diagnosis of bipolar disorder significantly increases the risk of sexual dysfunction. In the manic phase, there is an increase in libido associated with risky sexual behavior. Depressive phases of this disorder or frankly depressive disorders are associated with low libido and dissatisfaction with sexual activity. In patients with eating disorders, libido and the level of sexual activity decreases, and the level of sexual satisfaction decreases as well.

The prevalence of sexual dysfunction in patients with schizophrenia is quite high among both those treated and untreated. Women who have schizophrenia have anorgasmia, decreased libido, vaginal dryness, and therefore dyspareunia (painful intercourse). Men who have schizophrenia have a decreased sex drive, difficulty maintaining an erection, and delayed orgasm.  The bottom line: if you are seeing a mental health professional, make sure to discuss your sexual needs with them.

Too much exercise

Lack of studies in females means just that: there is a lack of studies. However, it is well-documented in men that those who exercise at higher levels tend to have lower libidos. Thus, in men, higher levels of intense and greater durations of endurance training regularly are significantly associated with decreased libido scores.

Sleep deprivation

Most adults need  7 to 8 hours of good-quality sleep per night. Good quality means that the “sleeping hours” don’t include frequent arousals and are long enough for the individual to feel refreshed upon awakening. Yes, there are some (very rare) individuals who (genetically) require less than 7 to 8 hours of sleep each night. Lucky them. Most of us, when sleep-deprived, are simply pushing ourselves to sleep less. When we do this, we struggle to stay awake during the day, tend to have bouts of fatigue, and definitely suffer from a lower libido than if we were well-rested.

High cortisol

The hormone cortisol increases under stress-a good thing for your body in the short term. However, long-term high cortisol levels can lead to all sorts of physical problems. Physical problems, including immune system dysfunction, cognitive impairment, and much more, make this one of the most correctable and common functional medicine issues we see. High cortisol can also cause you to feel fatigued because the resultant decrease in mitochondrial ATP production interferes with regular sleep patterns. You can see where this is all going, right? Obviously, low libido is part of the end-game of this issue as well.

Fatigue can result from the two things discussed above: inadequate sleep and/or too much stress. Of course, many conditions interfere with sleep and many situations that may cause you to be stressed. If one of these issues is causing your fatigue, you need to address them before you regain your sex drive. If you have a “fatiguing illness,” that’s an entirely different story. I’ll explain.

Fatigue due to Mitochondrial Dysfunction 

Mitochondria (the organelles of respiration throughout the body) produce energy in the form of ATP, which your body then uses for fuel. Your brain, muscles, and heart cells contain more mitochondria than other organs such as the lungs, kidney, or liver. When your mitochondria are working “full tilt,” your energy levels are high, your brain is focused, and your muscles and heart are at peak performance. The creation of new mitochondria (mitochondrial biogenesis) is required for optimal aging and health. As you would predict, mitochondrial dysfunction tanks your energy and contributes to numerous symptoms and diseases. So-what causes this problem?

Mitochondrial dysfunction, characterized by a loss of efficiency in the synthesis of ATP, is a hallmark of aging, and essentially, of just about all chronic diseases. Loss of mitochondrial function can cause fatigue and even other symptoms in just about every chronic disease you can imagine. Examples of fatiguing illnesses with mitochondrial dysfunction include all toxin-related illnesses such as mold mycotoxin illness, anything lumped into the “wastebasket” of chronic fatigue syndrome, fibromyalgia, and autoimmune diseases, for starters. As a “side note,” when I treat these diseases, I also “treat the sick mitochondria” so patients regain energy quickly.

Bedroom Boredom

We’re all adults here. I put this header here so you’ll think about this topic and perhaps even discuss it with your partner. You don’t need me telling you what this means. You know.

Low Sex Drive in Women 

Causes of low libido in females can include anything that alters or interferes with the normal production of “female hormones” associated with libido, including estrogen, progesterone, testosterone, and possibly (but not probably) oxytocin. Let’s start by discussing the possible role of “the pill.”

Birth Control Pills

Common sense would tell you that when you interrupt normal hormonal functioning, you’d have sexual dysfunction. Not so fast! How about the psychological factors associated with knowing that sexual activity, using good oral contraceptives will generally not result in pregnancy? Do anxiety levels about pregnancy play a role? Studies have not examined that, but I suspect that it’s a factor. One very comprehensive study examined the libidos of women taking oral contraceptives in 30 studies. The results were basically “all over the place” as follows.

Menopause 

Most women experience a decrease in sex drive during menopause due to initially- drops in progesterone, then estrogen, and then testosterone. When a woman’s estrogen drops low enough, it not only suppresses her sex drive but also causes vaginal dryness and painful intercourse. In addition, a decreased production of testosterone has been linked in many studies to a decrease in female sex drive.  Conversely, replacement of these hormones with bio-identical equivalents (BHRT) can often restore a woman’s normal libido.

Pregnancy 

Hormonal changes that occur during and after pregnancy can affect a woman’s sex drive. These changes affect everyone differently. Some women may have an increased libido, while others might have little to no interest in having sex. Women’s hormones usually fluctuate during the postpartum months, which may affect sex drive during this time. Factors such as body image, breastfeeding, and fatigue all play a role in post-pregnancy sex drive.

Gynecological Issues

Medical conditions such as endometriosis, causing gastrointestinal cramping, pelvic cramping, or other symptoms can certainly dampen sex drive. In addition, post-menopausal women experience increased bladder infections due to the loss of lubrication of the bladder-also due to low estrogen levels. This type of burning pain, coupled with the other symptoms of bouts of cystitis certain dampen sex drive. In fact, any pelvic muscle problems or chronic pelvic pain will obviously result in low sex drive in women.

Causes of low libido in males 

Low testosterone 

Testosterone is the well-known sex hormone that males produce in their testicles. Testosterone is responsible for a range of male characteristics, including facial hair, muscle mass, libido, sperm production, erectile function, and bone mass. Low testosterone can be caused by trauma to the testicles, tumors, chemotherapy, and/or radiation for prostate or testicular cancers. In addition, anterior pituitary adenomas or toxins and pituitary damage due to traumatic brain injury can cause low testosterone in men. Furthermore, prior testosterone or anabolic steroid use can disrupt the testicular-pituitary axis, causing low T in later life. Lastly, any sort of chronic illness or heavy medications can lower testosterone levels as well.

Low estrogen

If a male has his testosterone replaced and is being treated too vigorously with aromatase-inhibitors, giving them virtually “no” estradiol levels, this can negatively impact male libido. In addition, occasionally, we find that a low progesterone level in a man will lower his libido and disrupt his sleep.

High Estrogen

On the other hand, testosterone which is endogenously produced but shuttled via the enzyme aromatase into estradiol as a conversion product, will impact libido when it gets too high. This is also found when testosterone is prescribed by inexperienced doctors who fail to check and then control estradiol levels.

Doesn’t everyone Know about Low Testosterone Treatment by now?

In a word: no! As a Functional Medicine doctor, about 2/3 of the “hormone therapeutic requests” I receive involve either menopausal symptoms or symptoms of low testosterone. Women read Suzanne Somer’s books. Men don’t seem to have a “go-to” for good information, so, from what I hear, they seem to have many misconceptions about testosterone treatment.  In this article, I’ll discuss testosterone replacement therapy risks and benefits, including:

• How testosterone works
• What are the signs/symptoms of low-T A.K.A. male hypogonadism?
• Why do testosterone levels decline?
• What’s the latest on testosterone and heart disease?
• What should my testosterone level be?
• What’s the best way to replace testosterone?
• What about raising testosterone levels without using testosterone?
• Testosterone replacement and future fertility
• Erectile dysfunction
• Libido

How does Testosterone Work, and What does it do?

Testosterone is the male sex hormone, just as estrogen and progesterone are the primary female sex hormones. Although women do indeed produce testosterone (and at some point might need replacement), this article will focus on men.

In men, testosterone is the main hormone produced in the testicles and secreted by the testes. It promotes libido (sex drive), aggressiveness, and sexual desire. It also stimulates the growth of certain organs, producing sperm, and nourishes all the tissue of the male urinary and reproductive systems. In addition, testosterone promotes protein anabolism which is the use of protein to build muscle, skin, and bone, and mitigates against protein catabolism or breakdown. It also regulates the production of prostaglandins, which (research shows) seems to keep prostate growth under control. 

The effects of testosterone are most pronounced during puberty. In fact, it brings on the enlarged larynx, thicker vocal cords, new body hair, increased muscle mass, and increased oil-gland secretion by the skin commonly associated with puberty.

Some telltale signs of hypogonadism (“Low-T”)

Testosterone deficiency can cause memory, mood, and sleep issues, usually resulting in interrupted and unrefreshed sleep and next-day brain fog. Energy is also impacted, with an all-day feeling of sluggishness, which often includes lack of drive, inability to start an exercise regimen, and loss of muscle mass.

In addition, libido is down, and erectile dysfunction is possible, but (believe it or not) E.D. is usually not due to having a low testosterone level. More on this topic to come. Here are the symptoms laid out as bullet points.

• Irritability
• Depressed mood
• Aches and pains in the joints
• Poor sleep
• Cognitive impairment
• Decreased energy
• Decreased libido with or without erectile dysfunction
• Osteoporosis if it goes on for a while
• Loss of weight due to muscle mass loss and fat gain
• Mild regression of secondary sexual characteristics

If you are experiencing the symptoms described above, there is always the possibility of a testicular or pituitary issue. This is the main reason I implore you not to “cheap out” and go to an online source or a “hormone mill” for your testosterone replacement. Now, these two reasons aside, I’ll discuss why (typically) men develop low testosterone levels, which include other primary causes of hormone deficiency syndromes.

What causes low testosterone?

Low testosterone can also be caused by previous use of testosterone for (oftentimes) bodybuilding purposes. Further, a permanent interruption of the pituitary-testicular axis with “unresponsive testes” may be present after normal dosing for only a few months. Again, let me emphasize that a great form of natural hormone balancing is to fix the underlying cause of the hormonal issue(s). When underlying problems are properly addressed, we can assess whether or not testosterone replacement is actually needed.

After a good medical check-up and a visit with a Functional doctor specializing in bioidentical hormones, it’s time to discuss testosterone replacement therapy. What most men think about when they think “Low-T” is “andropause,”; the gradual waning of testosterone levels usually occurring in men in their 50’s, but sometimes as early as the late 30’s. But are there cardiac risks to using HRT? Should men worry about an increased risk of heart disease if they replace their testosterone? Let me show you the data on that.

Testosterone and Heart Disease Risks

Several years ago, there was a big stir with editorials in the Wall Street Journal and New York Times, reporting on a study showing a correlation between testosterone replacement and coronary artery disease. That particular study was farcical, as the diagnosis of low testosterone was based on symptoms, not lab testing, and replacement was performed by primary care doctors who didn’t check post-treatment testosterone levels. Furthermore, cardiac risks pre-testosterone treatment were poorly documented. Indeed, a lot of chaos was created by one study which should not have been published. Here’s the reality.

Positive Cardiac Effects of testosterone replacement

Hundreds of studies since the 50’s show that adequate testosterone helps prevent heart disease. For example, a recent comprehensive study reviewed men who had existing heart disease. Researchers studied 755 male patients, 58-78 years of age, who all had severe coronary artery disease and low testosterone levels. They were separated into three different groups, receiving various doses of testosterone, administered intra-muscularly or by a gel.

At the end of the first year, 64 patients who weren’t taking any testosterone supplements had severe adverse cardiovascular events. This included only 12 who were taking medium doses of testosterone and nine who were taking high doses. After three years, 125 patients who had not received testosterone therapy suffered severe cardiovascular events, whereas only 38 medium-dose and 22 high-patients did.

Patients who were given testosterone as part of their follow-up treatment did much better than patients who had not been given testosterone supplementation. However, the non-testosterone-therapy patients were 80 percent more likely to suffer an adverse cardiac event. This study also confirms the findings of a previous study from the same researchers, which found that testosterone therapy did not increase the risk of experiencing a heart attack or stroke for men with low testosterone levels and no prior history of heart disease.

Mayo Clinic’s Review of the Effects of Testosterone Replacement

The Mayo Clinic published a large 2018 review of the effects of testosterone replacement based on numerous studies. Here is a summary of their summary.

Randomized controlled studies confirm that testosterone replacement improves cardiac blood flow in men with chronic stable angina (chest pain) and chronic heart failure. These effects persist for at least one year. Testosterone is a coronary vasodilator as well as having other positive vascular actions on other arteries.

The same well-done studies have consistently shown that testosterone replacement therapy reduces fat mass and increases lean mass. In addition, the effect of testosterone on BMI plus waist circumference shows that benefits gradually accrue over several years. Testosterone is also beneficial for regulating carbohydrate and lipid metabolism, positively affecting metabolic pathways, all of which contribute to cardiovascular risk benefits. Further, testosterone replacement in men with type 2 diabetes and hypogonadism improves all-cause (including cardiac) mortality.

Results of a 2020 and a 2021 Analysis

In 2020, a large study concluded that testosterone replacement therapy posed no increased cardiac risk in men with no prior coronary artery disease and men with coronary artery disease. In addition, a retrospective, large-scale study published in 2021 showed a far greater risk of low testosterone causing COVID deaths in men than any cardiac risk to all testosterone-replaced men. The bottom line: testosterone “done right” with aromatization (estradiol conversion) controlled properly is (sum-total) “good for you!”

Endocrine and Urological guidelines for replacement of testosterone

There is a consensus of who needs treatment from the Endocrine and Urological medical communities. In short, they recommend therapy for men with symptomatic testosterone deficiency to either induce or maintain secondary sex characteristics such as muscle development, deep voice, and hair distribution on the chest and face and correct symptoms of hypogonadism. They (of course) strongly discourage starting testosterone treatment in patients who have fertility plans. Contraindications to therapy also include prostate cancer, palpable prostate nodule(s), a prostate-specific antigen level in all men of over 4 ng/mL, or a PSA level greater than 3 ng/mL in men at increased risk of prostate cancer without further urological evaluation. Included in the restriction on therapy are an elevated red blood cell count, untreated sleep apnea, uncontrolled heart failure, and even (per Endo guidelines) stroke or heart attack within the last six months.

Regarding actual testosterone levels, it is suggested in the “conventional literature” that treating Physicians aim for testosterone concentrations in the mid-normal range. That would be 590 ng/dL of total testosterone and 12.35 pg/mL of free testosterone. However, most scientific articles don’t discuss free testosterone and recommend a total testosterone level of 350 ng/dL. Wow, that’s a low-ball recommendation in the opinion of most hormone-replacement experts. After prescribing testosterone replacement therapy for many years, I will tell you that men get symptomatic with a Free testosterone of 12 or less as a rule of thumb. So let me clear things up here regarding “how much” testosterone you need.

Adequate Levels of Testosterone

As clinicians, we seek to replace testosterone to levels where our male patients will have good sleep, energy, libido, optimized moods, and optimal metabolic results from testosterone replacement. Too little yields inadequate clinical results; too much might compromise glucose control; the whole “roid rage thing” involves huge doses, which is a lot more than a legitimate doctor would prescribe. Those of us in the Functional Medical community look at symptoms and aim for a free testosterone of about 15-18 pg/mL. 

We also take into account a man’s albumin and SHBG (sex hormone-binding globulin) levels, as these will affect the amount of “free and unbound” testosterone, which is the best number to calculate if we’re looking for “the magic number.” Unfortunately, there is not always a good correlation between total T, free T, and free and unbound T, which is why I always say you need a hormone specialist to do any hormone replacement correctly. 

What’s the best form of treatment?

There are two types of hormones available for hormone replacement therapy: synthetic hormones and bioidentical hormones. This is important to know because of potential side effects.

Various formulations of exogenous testosterone replacement therapy exist, including oral, buccal, intramuscular, transdermal, subdermal, and nasal preparations. Bioidentical hormones are made to yield products that are biological replicas of the substances produced by our bodies. This is why they do not produce undesirable side effects when administered correctly.

In contrast, synthetic hormones are not biologically identical replicas. As a result, their use can result in severe side effects, as evidenced by clinical studies. Furthermore, bioidenticals have been shown by most clinical studies to be protective when administered properly. This can only be accomplished by a physician who has specialized in this field.

The most commonly prescribed forms of testosterone replacement therapy including commercial gels or compounded creams, injectables, and pellets. Commercially available gels are synthetic but will get men to testosterone levels which are “generally medically acceptable” but not to the levels of optimal symptomatic control as described above. Compounded bioidentical topicals come with the “hassle” of having to air dry plus the concerning factor of transfer to other humans (children and spouses) and even pets. However, this hassle factor has been reduced recently with the advent of special topical compounding formulations, so it’s still a good option.

Then there is the weekly IM or sometimes sub-q injection which is my preferred delivery system. I choose to use testosterone cypionate because after one biochemical “cleavage,” it is considered one of the most bioidentical hormones we use. Lastly, there are pellets, which generally last 3 months. The pellets are implanted into the subdermal fat of the buttocks, lower abdominal wall, or thigh with a tunneling technique using a local anesthetic.

The benefits of this method include guaranteed compliance and lack of transference to persons who may come in contact with it. Adverse effects include pellet extrusion, infection, and fibrosis. Due to the need for a surgical procedure for implantation and the sequela of side effects, this form of HRT is not recommended as a first-line treatment. Now, that said, some doctors want to “make a buck,” and they offer pellet therapy as their only choice. But we don’t always need to use testosterone, either.

What if I have low T and want a family?

First, you will need a sperm count performed, and if you are lucky enough to have a normal one, you need to deep freeze your sperm. However, if your count is low, then we try to increase your count with Clomiphene citrate and HCG (human chorionic gonadotropin), as discussed above. If you respond favorably, you’ll have a decent count or a “combinable samples count,” and you can freeze your sperm then.

To emphasize, do not start taking testosterone if you are planning to have children. Despite the findings just mentioned, a sizeable percentage of men who are given SERMS or Gonadotropins along with their exogenous testosterone is never able to have their pituitary-testicular connection re-established and are therefore unable to conceive. Therefore, I will not prescribe testosterone to a young man who has not frozen his sperm.

E.D. and the Role of Testosterone

Contrary to popular belief, low testosterone is less of a cause of erectile dysfunction than diabetes, pre-diabetes, or vascular disease. If you have E.D., a thorough check-up and lab testing are necessary. Once the metabolic issues are cleared up, we can focus on erectile function. Chances are, if you are in the age group that is more at risk for metabolic issues, you will also have low testosterone. In this case, testosterone replacement will obviously be of benefit, too. But if it’s “not enough,” what then? You’ve heard about viagra, Cialis and might have even tried one of these drugs. But I’ll bet you haven’t heard about PT-141, which I’ll bet you’ll find quite interesting!

PT-141

How to tell if you have a Hormonal Imbalance

A hormonal imbalance is having too much or too little of any of the myriad of hormones I’ll be discussing in this article. Out-of-whack hormone levels can cause just about any symptom imaginable. You can have weight gain or weight loss, hair loss, or excess hair growth. You can become lazy or anxious, sleep too much, or have insomnia! It’s no wonder people scratch their heads trying to self-diagnose. When you receive a diagnosis, you often don’t receive a full explanation, right? Bottom line: If you think you need hormone replacement therapy, seek a physician specializing in hormone replacement. To begin, let’s define “hormones.”

What are Hormones?

Hormones are the body’s “chemical messengers” that transport information from the brain to the “target glands,” The target glands secrete their hormones to affect their target cells.

Next, the cells send their messengers back to the brain to regulate how much message the brain needs to continue or not continue sending. Our bodies contain about 60 trillion cells that must communicate to carry out hormonally based functions. For hormones to be in balance, everything needs to work together, much like a symphony orchestra.

Hormones enter the cells through receptor sites. This can be thought of as akin to a key unlocking a door. Once inside, they flip the switches that control growth, development, and mental and physical functions throughout life.

As we age, the hormones that work to keep us healthy begin to decline. Hormonal balance is lost, causing unwanted symptoms, disorders, and even diseases. In other words, the hormonal symphony plays out of tune and out of cadence.

The A-Z of Where Hormones are Made

• Adrenals: Produces the hormones that control sex drive and the stress hormone cortisol, which controls salt and fluid in the body; aldosterone. DHEA is produced here too.
• Hypothalamus: Responsible for body temperature, hunger, moods, and the release of hormones from other glands. Controls thirst, sleep and is the “master supervisor” endocrine gland.
• Ovaries: Secrete estrogen, testosterone, and progesterone, the female sex hormones.
• Pituitary: The other “master control gland,” which controls other glands and makes the hormones that trigger growth. This is what happens in the anterior pituitary. The posterior pituitary produces ADH, controlling thirst and urination. It also provides pain-relieving endorphins.
• Pancreas: Produces the insulin that helps control blood sugar levels. Glucagon is secreted here too.
• Parathyroid: Controls the amount of calcium in the body.
• Pineal: Produces derivatives of melatonin, which affects sleep and more.
• Testes: Produces the male sex hormone, testosterone, and produces sperm, obviously in males.
• Thyroid: Produces hormones associated with metabolism.
• Thymus: Plays a role in the immune system’s function and the thymus’s maturity and is the primary source for immune “fighter” T-cells early in life.

I’ll cover each of these hormones in alphabetical order, preceded by some basics about hormone replacement therapy and followed by the questions you will be asking yourself about whether or not replacing your diminishing hormones is a good choice for you.

Correct Hormone Replacement Therapy

A little known but important fact about hormone replacement is there are two types of hormones available for hormone replacement therapy: Bioidentical hormones and synthetic hormones. This is extremely important because of the side effects. While some non-functional doctors will “argue” and even publish books touting their opinion that “only FDA approved” hormones-the synthetic ones-are the only ones that should be used, those same doctors are (correctly) touting the effectiveness of the non-FDA-approved mRNA COVID vaccines. It’s a matter of common sense that you, my reader, have or you wouldn’t be reading this article. Here’s why.

Bioidentical hormones are made from natural substances using a compounding process that results in an exact biological replica of the substance produced by our bodies. This is why they do not produce undesirable side effects when administered properly.

In contrast, synthetic hormones are synthesized from a variety of chemicals and, although these molecules resemble those produced by our bodies, they are not biologically identical replicas. As a result, their use can result in severe side effects, as evidenced by the warnings on the labels and research and clinical studies.

Furthermore, in addition to avoiding the risk of side effects and thus being safe, bioidenticals have been shown by most clinical studies to be protective when administered properly. Meanwhile, the latest studies (many of which are listed in the references) refute prior claims that synthetic and bioidentical hormones are “the same.”

I did specify “when administered properly” because hormone replacement therapy is a complex and delicate balancing act that needs to be individually tailored to each patient, often requiring a combination of hormones in conjunction with other mitigating compounded medications. I cannot tell you how often I “clean up the mess” made by unqualified doctors prescribing hormones to patients who “want to save a buck.” Let’s explore whether or not your symptoms sound as if hormone issues cause them.

Do you have Hormone Imbalance Symptoms?

I receive new patient inquiries all of the time, with complaints listed such as decreased energy, sleep disruption, brain fog, and reduced libido. This is usually (at least partially) due to an imbalance (usually too little; not too much) of one or more hormones. However, to determine the problems, I have to “think through” every hormone and organ system—tying everything together like the symphony metaphor I used above. Rather than explain why you can’t self-diagnose your own hormonal imbalance issue or issues, below you’ll find a synopsis of hormone function. This will prepare you to ask the right questions when you see a specialist. As promised, I will go from A to Z, which means we’ll start with aldosterone.

What the heck is Aldosterone?

Calcitonin

Calcitonin is a hormone released by the C-cells in the thyroid gland. It opposes the action of the parathyroid hormone, which you’ll read about further down our list. Both hormones regulate the blood’s calcium and phosphate levels. While it can be used to treat severe osteoporosis, I choose to use the Parathyroid hormone instead. Calcitonin is also used to treat Paget’s disease of the bone.

Cortisol

You have heard about the fight or flight hormones cortisol and adrenaline, right? Cortisol increases under stress which is a good thing for your body in the short term. However, long-term high cortisol levels can lead to increased coronary plaquing, a depressed immune system with associated risks for an increased risk of cancer, and measurably impaired cognitive function, just for starters! In the intermediate term, high cortisol levels can zap your energy by interfering with mitochondrial function. It can make you feel fatigued, and it’s not just because high cortisol levels interfere with regular sleep patterns.

Cortisol causes symptoms I’ll call “annoyances” only because that is how individuals treat them. High cortisol can trigger sugar cravings. It can be the main “driver” of menopausal belly fat. If you are trying to build muscle, it does just the opposite: “catabolic.” It not only can decrease muscle mass, but it also reduces bone mass and can slow down your metabolic rate by interfering with thyroid function too. Lastly and disastrously, it can trigger leaky gut syndrome, a leading cause of systemic inflammation.  This is the only hormone that actually (for the most part) increases as we age.

It is necessary to bring cortisol levels down for people under constant stress and most individuals over 55-65 years of age and older for all of the reasons mentioned above. I usually do this with a combination of adrenal adaptogens (containing ashwagandha, rhodiola, siberian ginseng, and astragalus) as well as an adrenal glandular preparation. Sometimes I use peptides, integratives, or liposomal GABA. There is even a role for some scientifically proven aromatherapy blends. This is the one “hormone arena” where people who read about HPA axis dysfunction (popularly termed adrenal fatigue) can generally self-diagnose much of the time. Please note that you need a medical workup if you self-diagnose and supplement and do not get better within a couple of months.

DHEA (Dehydroepiandrosterone)

I don’t know why this hormone gets a weird “rap”—for instance; it’s linked to anabolic steroids. This wonderful hormone is either not well known or is unfairly demonized, in my opinion. DHEA will amp up your immune system and help calm inflammation. Studies show “older Americans” with good DHEA levels have less depression than those with low levels. Lastly, it’s super important for bone thickness and the prevention of osteoporosis. You wouldn’t detect a DHEA hormone imbalance or deficiency symptomatically, which is why everyone needs key hormones checked as they age. Recent “brain studies” show that DHEA causes brain stem cell stimulation (to produce new neurons), another reason I insist all patients have this hormone normalized.

This hormone is safe to take unless you have a male who has had a “male cancer” or a female who has had “female cancer” or PCOS. DHEA metabolites might be a problem. But, you can safely take the 7-keto form of DHEA, which has the added benefit of being a bit of a metabolic stimulant.

Since when is Vitamin D a hormone?

Vitamin D is a pro-hormone the kidneys produce, which helps control blood calcium concentration and immune system function. The amount of Vitamin D made when sunlight hits the skin and is converted to the active substance called calcitriol by the kidneys is insufficient for most people. Recent studies reveal many cancers are linked to low vitamin D levels.

A low vitamin D level is also related to other issues such as heart disease, autoimmune disease, and even depression. This loosely translates into a minimum of 5000 IU’s per day of vitamin D, which should be consumed with vitamin K for optimal absorption. This is another lab test that should be checked (at least) annually. Recent guidelines recommend levels of 75-80 ng/dl as ideal. If you have an autoimmune disease, the literature strongly suggests higher vitamin D levels as optimal.

Estrogen

Estrogen is responsible for the development of “female pubertal changes.” Most women who contact me are interested in what to do when they have symptoms of estrogen deficiency due to menopause. But please take note that night sweats can be from estrogen deficiency, cortisol excess, mold toxin illness, or infectious diseases, meaning don’t just assume your “hot flashes” are due to estrogen deficiency.

If you have gained “the menopause 25,” it is due to an imbalance of several hormones, including estrogen deficiency. Losing the menopause weight without bioidentical hormone replacement is hard. Poorly done estrogen replacement (and yes, I have seen this) causes weight gain. Estrogen replacement, replacement of other hormones, and balancing cortisol levels make weight loss much easier. Estrogen counters most of the signs and symptoms women find bothersome about menopause.

However, that’s not the only reason to replace your missing estrogen. Estrogen helps your heart, bones, skin, and brain. I don’t know why “length of treatment” remains a controversial topic—likely because dangerous synthetic hormones have clouded the collective thinking on bioidenticals.

I would be remiss if I didn’t touch on two not-uncommon “female illnesses” which are now totally controllable with functional medicine treatment. PCOS (polycystic ovary syndrome) can cause metabolic issues, menstrual abnormalities, symptoms of high testosterone, and generalized inflammation. It can be well controlled, and if hormone replacement therapy is utilized, it is most efficacious if bioidenticals, not synthetics (such as “the pill”), are used for treatment. It is filed here under “estrogen” because often, estrogen levels are low, and cycles are anovulatory.

On the other hand, endometriosis tends to be a disorder associated with high, sometimes super-high estrogen-particularly estradiol levels. The endometrial tissue secretes estradiol, independent of ovarian estrogen secretion, and control of this disorder is also well done in functional medicine therapy, where estrogen levels are brought under control, and new endometrial tissue formation is blocked. Further discussion of these two disorders will be done elsewhere. Now, let’s move on to the pancreas.

Glucagon

This hormone is secreted by the pancreas and directly impacts the liver to control blood sugar levels. Glucagon prevents blood glucose levels from dropping to dangerously low levels. It does this first by stimulating the conversion of stored glycogen to glucose in the liver. It also keeps the liver from consuming glucose. This allows more glucose to enter the bloodstream when needed. Lastly, glucagon is essential for a process called gluconeogenesis: the production of glucose from amino acids.

HGH (Human Growth Hormone)

This is another hormone that gets “maligned”—likely due to its misuse in professional sports. HGH is necessary for many bodily functions. It helps heal injuries. Remember how quickly a sprained ankle healed when you were younger? That’s due to human growth hormone. An M.D-patient of mine had been to several well-known medical centers because he had such fragile skin. He bruised or bled with even a touch from someone else. When he contacted me, he had the lowest HGH markers I have ever seen. Therefore, he had incredibly fragile skin, and that was why he had the problem. Within three months of hormone replacement therapy, his symptoms vanished.

The FDA approves HGH for treating specific problems. The “side effects” are what have made this hormone notorious. It hastens the shedding of body fat and the development of lean muscle mass. It increases bone density and improves immune system function, according to most studies. Overall, it gives people a better sense of well-being. In clinical studies, it increases the dermis thickness—the layer of skin that contains the building blocks of skin called elastin and collagen. In fact, HGH users report they look younger.

Human growth hormone is not to be used in active or recent (within 5 years) cancer cases, as it causes existing tumors or remnant cells to grow. Despite the controversy over whether it does or does not cause cancer, no studies show that it (de novo) causes cancer. But, I need to emphasize this controlled substance should only be used under FDA guidelines. mTOR is one of the pathways stimulated by a marker of HGH called IGF1, and “too much MTor stimulation” might be related to adverse health outcomes. That’s why it’s always a good idea to counteract mTOR stimulation with good health practices such as exercise, intermittent fasting, and correct supplementation. When we stimulate the anterior pituitary to release more HGH by prescribing peptides, we see the same benefits as prescribing HGH for a fraction of the price. Now-back to the pancreas!

Insulin

The pancreas secretes insulin. People with type 1 diabetes have insufficient secretion. It’s an autoimmune disorder, and some cases are completely reversible. People with Type 2 diabetes have inadequate or unresponsive receptors for glucose uptake. Most individuals with Type 2 diabetes are overweight or obese. The entity most doctors call pre-diabetes is as having a fasting blood sugar of 99 ng/dL. What is normal blood sugar? Your fasting blood sugar should be 75-85 ng/dL, or you are “glycating” (stiffening) your body’s cells-all of them.

Insulin is responsible for getting blood sugar into all cells. By doing so, it increases muscle mass and fat storage. However, if insulin levels are too high, there is an increased risk of diabetes, heart disease, Alzheimer’s disease, and cancer. We use insulin as a biomarker for inflammation tied to most if not all disease states and aging in general. This is one hormone you want to keep at a nice, low level—around 2-3 uIU/ml. If applicable, you can get this level down with weight loss, curcumin, omega-3 fatty acids, green tea, and toxin removal. Now, I’d like to discuss a hormone most people think is simply “for sleep.”

Melatonin

Melatonin is one of the most underrated hormones. Most of us need supplementation by the time we’re 30 to have profound, restful, and restorative sleep. You can protect your natural melatonin secretion by maintaining a good circadian rhythm which includes blocking blue lighting as the sun sets. There are apps for tablets and phones you can set to dim your screen at sunset, and I suggest you do so. I recommend slightly higher doses of melatonin than you may be used for patients and families based on research that I find exciting. Here is just a sampling of “what else” melatonin can do for your health.

It reduces oxidative stress (free radical damage), thereby decreasing inflammation. Research shows it also helps block the process, which shortens telomeres, likely affecting genetic aging. It further reduces inflammation by reducing pro-inflammatory cytokines.

It augments immune function by increasing CD4 cells and also increases what is known as natural killer cells. Doing so helps us fight infections and was recently made a part of most good functional medicine COVID protocols.

Melatonin helps preserve brain mitochondria, slows age-related cognitive decline, and inhibits beta-amyloid formation in the brain. In addition, an exciting discovery is that we still have stem cells in our brains, even as adults. And guess what? Melatonin turns on these stem cells. Due to all of the brain-healthy effects, inexpensive but powerful melatonin makes it to my must-have hormones list for everyone.

Oxytocin

In women, oxytocin is responsible for signaling contractions of the womb during labor. The hormone stimulates the uterine muscles to contract, so labor begins. Because of this effect, synthetic oxytocin is sometimes used to induce a woman to start labor if she cannot begin naturally. Once the baby is born, oxytocin promotes lactation by moving the milk into the breast. When the baby sucks at the mother’s breast, oxytocin secretion causes the milk to release so the baby can feed.

At the same time, oxytocin releases into the brain to stimulate further oxytocin production. Once the baby stops feeding, the production of the hormone stops until the next feeding. Oxytocin function is less important for men, but it does appear to affect testosterone production in the testes.

Recent studies show oxytocin is an important hormone that controls some human behavior and social interaction. Oxytocin triggers the bond between a mother and an infant, and it may also play a role in recognition, sexual arousal, trust, and anxiety between partners and friends. It is released when we interact with a loved one, including our dogs; yes, our dogs. A 2017 study proves that you can bond your dog more to you and you- to your dog by staring into your dog’s eyes. And there is leftover oxytocin for you to use with your partner, family, and close friends!

Other fascinating research reveals that oxytocin hormone may affect addiction and stress levels. It also helps people overcome sugar habits with varying success. Recent studies show that it may be useful in pain management regimens as well.

Parathyroid Hormone

In the intestines, parathyroid hormone helps with vitamin D metabolism. This allows the body to absorb more of the calcium it digests from food. The hormone stops calcium release in the kidneys through the urine (stones!) while also increasing vitamin D production. This is one of the hormones where excessive amounts are more common than a deficiency when we are younger, but as with every other gland, the parathyroid glands can fail as we age. Anatomically, these four glands are found on the flip side of the thyroid gland, in the neck.

Pregnenolone

This is another hormone you might not have heard about, but if you’re anxious, you’ll certainly want to see if you’re deficient. It helps repair brain and nerve tissue, decreases anxiety, improves sleep quality, improves general well-being, and is probably brain-protective too. Self-medication with small amounts is generally fine.

Progesterone

Low progesterone complaints are often mistaken for psychological symptoms as all-too-many progesterone-deficient women are handed prescriptions for pharmaceuticals to treat anxiety and depression. Lack of progesterone causes PMDD symptoms, anxiety, irritability, depression, and more. Peri-menopausal sleep issues are generally the result of a dip in progesterone—the first female hormone “to go.”

Adding oral progesterone to the nightly regimen helps with sleep initiation and maintenance. I said “oral” because progesterone creams don’t pass the blood-brain barrier. Please check the referenced article for details on low progesterone symptoms and treatment.

Regarding the role of progesterone replacement in menopause, note that the menopausal weight gain referenced in an earlier section is partially due to the loss of progesterone.

Lastly, if you are on bioidentical estrogens, you must also be on progesterone, whether or not you have had a hysterectomy. You must protect not just your uterus but also your breasts from “unopposed estrogens.”

Testosterone

Testosterone is the most important of all male hormones. We know what happens in puberty, so we’ll skip that part. In adulthood, testosterone is a major energy hormone for men. It increases bone density and is responsible physically for libido and quite a bit of sexual function. The right amount (not too much) is good for cholesterol levels, improving cardiac health.

Bad publicity based on poorly done studies about testosterone supplementation causing heart disease has been completely debunked; testosterone doesn’t cause heart disease. If you take it in massive doses, who knows? But that shouldn’t happen. It also helps prevents prostate enlargement (if aromatization is controlled) and probably helps prevent prostate cancer. It is neuroprotective and decreases the incidence of Alzheimer’s disease in both men and women. Further, it increases muscle mass and bone density in men and women as well. The testosterone that is available on the black market requires self-diagnosis and trust that the substances are safe. Please consult a hormone specialist and don’t treat yourself for “low-T.”

A side note about testosterone is that if you are young, with a low testosterone level, that needs to be investigated, not just replaced. As an example, young men with CIRS will have low testosterone levels due to anterior pituitary involvement. HCG or Clomid is a much more appropriate choice for those patients to augment their testosterone levels while detoxing.

One last thing: if you are a woman who has had estrogen-receptor-positive breast cancer, you should not use testosterone replacement therapy for at least five years after you are done with treatment and considered to be in remission. The reason I’m bringing this up is that I’ve had to repair the damage caused by unqualified doctors who have placed women on testosterone supplementation, not realizing that some of it would be aromatizing to estradiol and then triggering a flare of their breast cancer.

Thyroid hormone

The active form of thyroid hormone (T3) is made from the inactive form (T4), which needs an enzyme (deiodinase)  that requires quite a lot of minerals, so make sure you are on a good multi-vitamin-multi-mineral supplement. I often see labwork where the Free T4 is normal, but Free T3 is low, indicating decreased T4 to T3 conversion the majority of the time. Remember, T3 is the active form of thyroid hormone.

T3 increases energy, fat burning and helps control weight. It increases appetite and heart rate. Too little causes chilliness, a loss of the outer 1/3 of eyebrows, and a decreased morning basal temperature (below 97.3F). If you are looking to self-diagnose before having lab results, you can measure your morning temperature for a week. If it’s lower than 97.3, chances are you’re hypothyroid—no matter what your lab testing shows. Insist on the proper lab testing. Here’s what to ask for: TSH, FREE T3, FREE T4, reverse T3, TPO, and other thyroid auto-antibodies.

Why do Hormones Decline?

However, before jumping into hormone replacement therapy, a good workup is necessary to rule out (or diagnose and treat) weight issues, inflammation, tumors, toxins, food allergies, head trauma, leaky gut, silent autoimmune disease, and excessive stress. A great form of natural hormone replacement is simply repairing the hormonal issue’s underlying cause (s). Once these problems are properly addressed, we can assess what truly needs to be replaced. Here are the basics.

In women, the symptoms of hormonal aging often first appear during early menopause (peri-menopause), when estrogen and progesterone levels begin to wane. Then they continue to decline throughout menopause. The hormone imbalance symptoms can begin as early as age 30.

Men usually experience a more gradual loss of hormones, mainly testosterone, which is called andropause. Unlike the sudden loss of estrogen that women face during menopause, the gradual loss of testosterone happens over time. It is often misdiagnosed or even dismissed as a “male mid-life crisis.” Both men and women usually experience weight gain, loss of energy, sleep disruption, and more during this time of life when (understandably!) most divorces occur.

Is Hormone Replacement Therapy Right for You?

Symptoms of low progesterone   (If you have read this and conclude this is the problem, here is something to hold you until you get to a Functional doctor-use my code:KimCrawford to get a group discounted rate)

You may have “heard” that premenstrual syndrome; PMS, or even the worse premenstrual dysphoric disorder (PMDD) is due to low progesterone. You might have read that one of the common signs of progesterone deficiency is premenstrual bloating. However, this article will review the common symptoms and then the signs of progesterone deficiency that are not often discussed. In fact, many symptoms (complaints) and signs (physical findings) related to low progesterone levels are simply not widely known, even amongst even the most knowledgeable Ob-Gyns or Endocrinologists. Many of the patients I personally see have been to an array of doctors who haven’t picked up on the fact that they are dealing with simple cases of low progesterone symptoms, which, in turn, cause a host of problems. All reversible. And yes, a Functional Internist who is an expert in female hormones is your best bet. Let’s start with the obvious.

Gynecological Issues

Women often attribute all of their premenstrual symptoms to what they call PMS. There are a host of symptoms, with low progesterone as the root cause, but they are not all categorized together. I’ll explain.  You might be having fertility issues. You might develop ovarian cysts. Most women and even most doctors believe that fibroids and endometriosis are estrogen-dependent. Not so. It’s the ratio of estrogen to progesterone that is important, so low progesterone can cause these issues too. Similarly, fibrocystic breast disorder can be caused by low progesterone.

Your libido is (mostly) controlled by your free testosterone level but progesterone also plays a role. Estrogen deficiency isn’t the only hormone that can cause hot flushes. Progesterone deficiency or cortisol excess (early adrenal fatigue) can also cause hot flushes. Lastly, mold and mycotoxin exposure can also cause hot flushes. I won’t go into these other little “nuggets of information” on this article, as they are off-topic. Let’s get started with the major gynecologic issues.

Menstrual Irregularities

During the luteal (second) phase of your menstrual cycle, your uterine lining (endometrium) is building up to receive a fertilized egg. This phase becomes shortened when you are progesterone deficient. Your periods might then be irregular due to progesterone deficiency. You might have some spotting right before your period and then some clots during your period.

The principal cause of irregular periods is the lack of normal ovulation. Lack of normal ovulation, where the egg is not released from the ovary- causes low progesterone because your body is not preparing for pregnancy by building up the endometrium. Other reasons for irregular periods can be PCOS, stress (high cortisol), or simply coming off of oral contraceptives. However, remember that an early “pre-menopause” can mean that you have lower-than-normal progesterone levels, with or without significant symptoms.

Heavy Periods

Approximately 50% of females who report heavy menstrual bleeding, do not meet the requirements of 80 mls (about 1/3 cup)  or more of blood “release” per menstrual cycle. Heavy menstrual blood loss usually includes clotting and having to change pads or tampons every two hours or more. Heavy bleeding is thought to result from imbalances in estrogen and progesterone, and is generally successfully treated with supplemental progesterone. If you are experiencing heavy periods, you will need a full work-up to exclude other causes of heavy menstrual flow such as polyps, endometriosis or adenomyosis (endometrium growing in the uterine wall), as well as other (less common) issues including bleeding or clotting disorders.

PMS

Another one of the signs of progesterone deficiency is premenstrual syndrome- PMS. Premenstrual syndrome is defined as life-disrupting physiological and/or psychological signs or symptoms which occur in the luteal phase of the cycle. Symptoms include headaches, cramps, fatigue, bloating, nausea and mood swings. When menses begins, symptoms will generally disappear. The reason PMS is thought to occur is due to the difference in hormone levels between estrogen and progesterone. Many women respond to progesterone supplementation, while others need a more varied approach-similar to women suffering from the more severe variant- PMDD.

PMDD

Most women are aware of the typical symptoms of PMS. In fact, how many of us have experienced fluid retention (bloating), breast tenderness, or even a little bit of a mood swing? However, women with PMDD (less than an estimated 10% of the female menstruating population) have symptoms that can last all month. Not only that-the symptoms are a gross exaggeration of PMS symptoms. Mood swings are prevalent and severe. Depression brings on “fits” of crying or feelings of hopelessness. Often the most reasonable women experience intense anger and conflict with other people. Tension, anxiety, and irritability. No interest in your usual activities. Trouble concentrating. Fatigue. Appetite changes with binge eating. Not your ordinary PMS. This disorder is associated with measurable drops in serotonin levels, as well as exaggerated estrogen to progesterone dips and drops.  Treatment includes serotonin precursors, progesterone and more.

Breast Tenderness

Another sign of low progesterone is breast tenderness. This is a PMS symptom that will typically occur and then worsen during the mid to late luteal phase. Imbalances in estrogen and progesterone can worsen breast tenderness and pain.

Cyclic mastalgia is not considered as a part of PMS, even though it is indeed related to the menstrual cycle. It is bilateral, diffuse, poorly localized, and generally described as soreness that often radiates to the underarms and even down the arms. It occurs mostly during the luteal phase of the menstrual cycle due to increased water content in breast stroma caused by increasing hormone levels. Cyclic breast pain occurs more commonly in younger women, often will resolve spontaneously, and is classified differently than as being a part of premenstrual syndrome.

Bloating

Bloating is a common sign of low progesterone. Studies have shown that, during the luteal phase, water and sodium retention increase with low levels of progesterone and high levels of estrogen. This occurs because the estrogen lowers what is called the “osmotic threshold,” for which water is reabsorbed in the body. The hormone ADH (arginine vasopressin) is responsible for the reabsorption of water into the bloodstream. When estrogen levels are high, this threshold is lowered, and therefore less water will be excreted through urine. This then causes the body to retain water and creates the sensation of bloating. It could be as little as noticing your rings are tight or as much as being unable to zip up your jeans. This looks and feels differently than the belly fat you start accumulating during pre-menopause.

Painful Periods

Dysmenorrhea (painful periods) is typically experienced as painful cramps before or during menstruation. Secondary dysmenorrhea is due to gynecological issues such as endometriosis or adenomyosis. What we’re discussing here is simply primary dysmenorrhea as a result of “normal” female anatomy. The cramps in the uterus are caused by high levels of prostaglandins.  Prostaglandins are a group of fatty molecules made at sites of tissue damage or infection. They control processes such as blood flow, the formation of blood clots, degree of inflammation, and even the induction of labor. Prostaglandins work in opposition to progesterone, so when progesterone decreases right before menstruation, prostaglandin levels will increase. This then causes uterine contractions, cramps and pain. Treatment is not necessary for “mild cramps”, but more severe cramps usually require prostaglandin inhibition. “Natural” ways to do this are with fish oils and curcumin supplements.

Ovarian Cysts

Ovarian cysts are sacs filled with fluid that are attached to or adjacent to the ovaries. Ten percent of women have ovarian cysts, which can be an “incidental finding” on pelvic exam or ultrasound, or a cause for pelvic pain and other symptoms. Cysts are usually classified according to whether they are a variant of the normal menstrual cycle, referred to as a functional or follicular cyst. Frequent follicular cysts can be one of the signs of low progesterone.

Ovarian cysts are considered “large” when they are over 5 cm and giant when they are over 15 cm.  Most cysts are benign and cause no pain, but others do cause pain as they sometimes don’t resolve with the menstrual cycle and then grow larger over time. Symptoms of an ovarian cyst are heavy cramping with abdominal pain, irregular periods, and pain during bowel movements.  In some studies, progesterone supplementation in the early stages of cyst growth reduced its size, ability to grow and sometimes induced ovulation.

Infertility

Adequate progesterone is necessary for healthy fertility. Progesterone helps to maintain the integrity of the uterine lining so that a fertilized egg can implant. Without optimal progesterone, you are at a higher risk of miscarriage. Many studies have documented the benefits of administering progesterone to patients who are experiencing infertility to increase conception as well as to-term pregnancy rates. This leads us to the next logical topic; miscarriage.

First Trimester Miscarriage

It is critically important to have optimal progesterone levels for a healthy pregnancy. The first trimester of pregnancy is typically when most miscarriages occur. If progesterone levels are low, studies have found that those who are administered progesterone in the first trimester have a better chance of reducing their chances of miscarriage.

Metabolic Issues

Chronically low progesterone levels are often associated with low-grade depression, a topic we’ll cover soon. Low progesterone will lower serotonin levels. If you get sugar cravings, they are often due to low serotonin levels. If you crave sugar and feel happier after you eat an ice cream cone or cookie, this is likely a physiological fact. If you self-medicate your low serotonin levels with too much sugary food, you’ll gain weight, raise your blood sugar, and levels of inflammation in your body.

And it’s not just the serotonin. Low progesterone (in and of itself) is the beginning of the rise in the hunger hormones leptin and ghrelin. Ghrelin is an actual “hunger hormone”, stimulating your appetite but leptin is a bigger problem for most women. As leptin rises, your fat cells will “hold onto fat”, starting often with belly fat. This makes fat loss much more difficult if you are progesterone deficient.

Since progesterone helps to normalize thyroid hormones, it can lower those, causing your metabolic rate to drop. This will often be reflected in a lowering of your morning basal temperature as well as your energy levels. However, fatigue is more likely to occur due to another problem which I’ll discuss next.

Sleep issues

You need two brain chemicals (neurotransmitters) to help you fall asleep and then stay asleep for the night. The fall-asleep brain chemical you need is called GABA, and the stay-asleep chemical is our good friend, serotonin. When progesterone levels fall, so do levels of both GABA and serotonin. This then makes both falling and staying asleep more difficult. When these two neurotransmitters drop, women often get a poor night’s sleep which leads to daytime fatigue and, eventually, all sorts of other problems. Women’s sleep cycles have been studied in depth.

Many studies have found changes in sleep architecture across the phases of the menstrual cycle, with most sleep disturbances occurring in the luteal phase. In the luteal phase, women experience increased sleep onset and awakenings and lower sleep efficiency and quality compared to the follicular phase. Women in the luteal phase have less REM sleep and more non-rapid-eye-movement (NREM) sleep, with an increase in slow wave sleep (SWS) in particular. EEG (electroencephalogram) power density varies throughout the menstrual cycle, with the highest density of sleep spindles occurring in the luteal phase.

The luteal phase is also associated with elevated core body temperature, which could potentially interact with sleep processes to impact sleep quality. During the luteal phase, some women experience nocturnal PMS symptoms of discomfort, such as stomachache, backache, headaches, and nausea. And as a corollary, those with PMS are more vulnerable to sleep disruptions during the luteal phase. Women with PMS report having more unpleasant dreams, nocturnal awakenings, morning tiredness, and increased mental activity at night in comparison with women without PMS.

Several studies have shown that progesterone supplementation has a better ability to restore normal sleep when there was a disturbance in the night compared to the control groups. Progesterone administration seems to enhance sleep duration and sleep quality, mainly by improving slow-wave sleep (SWS). As an aside, let me mention that disturbed sleep and daytime fatigue are very common issues for all  of my women patients. I usually end up giving at least half of my patients integratives to raise their GABA and serotonin levels; not just supplemental progesterone. As a final note in this section; ongoing research is pointing to the increasing role of progesterone in regard to growth hormone and melatonin secretion as well. And yes, both of these carry implications for sleep as well.

Mood issues

We touched on the topic of mood swings during the discussion of PMDD. You might recall that as your progesterone levels drop, so too, do your serotonin levels. Serotonin is one of your happy neurotransmitters, so for some, this drop is enough to cause depressive symptoms. Don’t think that anti-depressants are the answer. Why wouldn’t you want to treat your mood issues more physiologically with progesterone and some serotonin precursors?

We also discussed the diminution of GABA levels in regard to sleep initiation. But GABA levels also control how much anxiety and even panic you’ll have to deal with as you move through peri-menopause and then menopause. However, the degree of symptoms you’ll experience as a result of decreased serotonin and GABA levels is a reflection of your “baseline” levels.

Anxiety is the experience of feelings of worry, fear, or at worst-panic attacks that can completely overpower aspects of your day. Progesterone has anti-anxiety effects due to its boosting relationship with GABA, your natural relaxation mood chemical. If your progesterone is low or you are not producing enough each cycle this can show up as anxiety because you are not producing as much GABA. This is often corrected with supplemental progesterone and pure GABA. A word of warning: if your doctor prescribes an anti-anxiety medication such as Xanax, run, don’t walk, to find a Functional Specialist that won’t give you prescriptions for highly addictive drugs.

Irritability

Pain and discomfort cause feelings of stress and elevated cortisol levels. As described above, there are many ways that having low progesterone levels cause you discomfort- from cysts, to cramps, to PMS, to sleep disruption. Stress will lower dopamine levels, and this then causes irritability and can even contribute to a depressed mood. Low dopamine lowers GABA even further, thus compounding any anxiety issues you might have. We’re talking about close to half of a month of distressing symptoms, all due to a simple lack of progesterone!  Studies have found that there were significant improvements in mood and irritability due to progesterone administration compared to a placebo. And please do note: there are ways to naturally increase dopamine levels as well. Also note: oral GABA is destroyed by stomach acid and rendered ineffective.

Cyclical headaches

Cyclical headaches are defined as recurrent headaches which occur during the same time with each menstrual cycle. They are classified as a complication of PMS, and are one of the less common signs of low progesterone.  When progesterone is low, you are in (by definition) an estrogen-dominant state. Early to mid-luteal cyclical headaches are thought to be caused by the estrogen-dominant effect on cerebral blood vessels. These cyclical headaches are successfully treated with progestins (synthetic progesterone) in clinical studies. It would make sense that the more safe, bioidentical progesterone would be effective for these types of headaches. To make matters just that much more complicated, a small percentage of women get “estrogen-drop” headaches at the very end of their luteal phase, just as menses starts.

Migraines

Speaking of headaches, we must differentiate cyclical headaches from migraine headaches which are also associated with low progesterone levels. Low levels of brain serotonin have been linked to migraines, accounting for the statistical increase in migraines reported by women with documented low progesterone levels. Indeed, bioidentical progesterone is an effective (partial) treatment for a select group of migraine sufferers. Recent studies have shown that, compared to a regular diet, a nutritional ketosis diet might also help to ears to be great for keeping migraines at bay. And speaking of headaches……

Constipation

This is one I’ll bet you didn’t know about. While normal levels of progesterone and indeed the progesterone spike a week before your period can cause constipation which is immediately relieved when you get your period, if progesterone levels are low for your entire luteal phase, it’s a different story. It’s also a different story if you are pre-menopausal, with constantly low progesterone levels or post-menopausal, with inadequate progesterone replacement dosing.

Numerous studies suggest that the interplay between progesterone and the serotoninergic system could underlie altered bowel habits in women. Serotonin (5-hydroxytryptamine or 5-HT) is known to play a key role in the motor function of the GI tract by stimulating smooth muscle contractility. It has been shown that progesterone administration increases 5-HT levels by decreasing the level of  5-HT reuptake, monoamine oxidase mRNA expression, and increasing the availability of 5-HT precursor, tryptophan. This effect of progesterone on the serotoninergic system is not surprising because 5-HT promotes peristalsis. The moral of this story is that curing chronic constipation in women is often a matter of simply restoring progesterone and serotoninergic balance.

Memory issues

It astounds me that so many women who I speak with about hormones think that it is “normal” to start becoming forgetful and foggy-brained at age 40! However, being foggy-brained and having memory lapses can indeed by directly caused by progesterone deficiency. We don’t think of progesterone as a sleep supplement or a brain supplement, but in fact, BI progesterone is just that. As with so many hormonal issues, this is also complex.

Studies demonstrate that increased levels of GABA increase our cognitive performance. Other studies demonstrate that serotonin is important for memory consolidation and storage in the hippocampus.  In fact, there is a higher incidence of dementia in people with chronically low serotonin levels. And finally, progesterone is neuroprotective in animals and women. There is a firm biological rationale for the view that progesterone plays an important role in brain function and there are discernible effects on cognition in animals. Moreover, progesterone exposures are linked to patterns of brain activation during cognitive processing in women.

However, if I am to be scientifically accurate; despite my bias, it remains to be shown that endogenous progesterone or exogenous progestogens exert clinically meaningful effects on short-term or long-term cognitive function in healthy women.

Footnote

Studies are ongoing to investigate the role that progesterone may have in preventing or lessening seizure activity. As noted above, it is thought to be neuroprotective in animals and in women. As such, it is being investigated as a modality to aid in the treatment of traumatic brain injury.

My Flat Belly has become My Menopausal Muffin Top. Help!

You’re a woman in her late 40s. You’ve spent your life watching what you eat, and you exercise regularly. You are not packing on the pounds, but you notice that your previously flat belly pooches out when you look at it from the side. Your pants are getting tight. Worst of all, wearing your skinny jeans, you seem to have some sort of, well, for lack of a better term: menopausal muffin top.

Is this how you are doomed to live the rest of your life? In a word: No. You can get rid of menopause belly fat. I will explain by answering these questions:

• Why is fat collecting, specifically, around your waistband?
• Is this “different fat” than your “younger self’s fat?”
• What are the hormonal conditions causing this fat?
• What can you do by yourself to get your flat belly back?
• How can Functional Medicine help you?

What is the Story with Muffin Top Abdominal Fat?

Is there something unique and mysterious about the pounds we women accumulate just before and during menopause? Mixed evidence favors the opinion that there is more accumulation of harder-to-lose visceral body fat in the belly area during menopause. Elevated cortisol levels, which tend to go up when we are under stress, results in this visceral fat, and those elevated cortisol levels can wreak all sorts of metabolic havoc.

While in this blog, I won’t get into how bad elevated cortisol levels are for your brain, your gut lining (leaky gut), or your microbiome, I will stress that elevated cortisol levels lead to high leptin levels. Leptin, in turn, signals your fat cells to hold on for dear life,’ making it darned near impossible to lose fat, in particular menopause belly fat.

What Exactly causes Menopause Belly Fat?

A total of five hormones are responsible for that muffin top of yours, as well as, possibly, the one sported by your best friend, your sister, and other women around you. Hmmm? Here is a list of the contributing factors, which I’ll examine one by one: reduced progesterone, estrogen and testosterone, and elevated cortisol and leptin.

Low Progesterone

Believe it or not, your cyclic progesterone level may begin to drop in your 20s, which signals the beginning of metabolic changes that favor the deposition of belly fat. When your progesterone is low, the production of the feel-good neurotransmitter serotonin drops.

Low progesterone is the first stage in the rise of the “hunger hormones” leptin and ghrelin. Rather than having a significant impact on hunger, leptin is the hormone that makes you ‘hold onto fat,’ including belly fat. I’ll discuss leptin specifically below and will de-focus on the actual hunger hormone, ghrelin, which isn’t explicitly linked to the accumulation of menopausal belly fat.

The Domino Effect of Low Progesterone on Your Body:

• Low serotonin can trigger sugar cravings
• Eating more sugar causes weight gain and then additional body and belly fat
• Low progesterone can trigger inflammation, which can cause your metabolic rate to drop, which contributes to daytime fatigue
• Fatigue can also be a result of disturbed sleep, as a result of reduced serotonin levels
• Sleep deprivation leads to elevated cortisol levels, and thereby elevated leptin levels
• Fatigue also often leads to excess consumption of stimulant beverages, which in turn leads to increases in cortisoland leptin

Low Estrogen

Most women with a bit of middle-of-the-night awakening due to progesterone deficiency get a whopping dose of sleep deprivation during active menopause. When estradiol levels drop (usually when a woman is in her late 40’s or early 50’s), the drop triggers vasomotor changes, causing the sensation of hot flushing. The vast majority of menopausal women experience ‘hot flushes’ (not flashes) during the night, creating the feeling of being ‘warm’ or ‘dripping in sweat.’ Either way, sleep is interrupted, causing less refreshed sleep, raised cortisol, and, therefore, leptin levels. Low estrogen also triggers ghrelin, leading to increased appetite, which causes non-specific weight gain.

Before I talk about cortisol and leptin, let me mention that estradiol and progesterone oppose the fat-storing action cortisol has on the belly.

Low Testosterone

As a woman progresses through her menopausal years, her testosterone levels will drop. She might notice a decrease in muscle mass, which decreases her metabolic rate, causing weight gain. There are many reasons to love bioidentical testosterone replacement, including its impact on brain health, bone health, and the maintenance of muscle mass. However, a drop in this particular hormone doesn’t cause belly fat per se.

High Cortisol

Cortisol, known as the ‘stress hormone,’ is linked to many ailments, including packing belly fat on men (during andropause) and women during their menopause years. There are so many ways that we create stress and, therefore, high cortisol levels. Here I only mention the ‘big ones,’ or the ‘surprising ones.’

For example, we know that smoking is disastrous for your health, but do you know that as little as two cigarettes can raise cortisol levels for the day? Yes! Seriously.

Everything from excessive noise pollution, disrupted sleep, excessive caffeine or alcohol, any sort of pain and opiate withdrawal, and even some nutritional deficiencies (e.g., zinc and magnesium) can raise cortisol and contribute to the dreaded muffin top. Speaking of nutritional deficiencies, oxidative stress – a pervasive problem that is closely associated with deficiencies of antioxidant vitamins – also contributes to cortisol elevations.

And finally, leptin elevation causes cortisol elevation and vice versa. Now, let me tell you about leptin.

High Leptin

A variety of unhealthy physical factors and habits will increase leptin levels, causing our fat cells, especially our belly fat cells, to hang onto fat no matter what we eat and how much we exercise. As you now know, stress is the most common ‘unhealthy habit’ that raises leptin levels. When stressed, your body releases leptin, and the more leptin you release, the more you will tend to eat comfort foods. And comfort foods tend to be high-carbohydrate, serotonin-producing foods.

Obesity and sleep apnea also increase leptin, as does systemic inflammation caused by being overweight, eating inflammatory foods, or having leaky gut, AKA gut hyperpermeability syndrome, which sustained high cortisol levels can cause! So, what foods are inflammatory? I’ll get into that when I tell you how you can help yourself fix this whole negative hormonal cascade.

If you are one of those women who tells herself, “I just can’t lose weight no matter what I do,” know that certain toxins, especially biotoxins such as mold mycotoxins, can also create sky-high leptin levels. When someone tells me, “I have suddenly put on weight for no reason. I can’t sleep, and I’m tired all the time,” my mold radar goes off big time.

Now I’ll discuss four powerful ways you can do help yourself.

#1. Diet

Muffin top or no muffin top on your belly, real baked muffins are ‘inflammatory foods’ made with sugar, grains, and fat. It is difficult to take the entire anti-inflammatory diet plunge, but if you continue to eat a standard American diet (S.A.D.), you will not lose body fat or belly fat. You simply will not be able to.

Here is a place to start:

Limit or eliminate (ideally) all processed foods, which are typically a significant source of ‘bad’ (starchy) carbohydrates. Processed foods also contain harmful toxins in artificial flavors and colors, preservatives, and a long list of other unhealthy ingredients. Toxic processed food ingredients can hinder your ability to lose body fat, and therefore belly fat.

Live without ‘fast foods,’ unless, of course, you are eating from the salad bar and bringing your own salad dressing

Limiting all sugars and most grains. The bulk of the research reveals that lectins are inflammatory, and high lectin foods include grains (especially those containing gluten), beans, nightshade vegetables, and low-fat dairy. Nightshades are white potatoes, tomatoes, and peppers, for the most part. Eating this way is the basis for the good-old Paleo Diet, but I definitely would not pile on the meat, as is suggested if you “follow Paleo.”

#2. Stress and Cortisol

If you have any doubt, yes, you can indeed be under so much stress that it gives you belly fat. When this happens, your adrenal glands are secreting too much cortisol and adrenaline. This will eventually result in fatigue, sleep issues, and immune system depression.

Here is a list of easy behavioral stress reducers:

• Practice relaxation breathing
• Meditation
• Exercise
• Cut out energy drinks
• Cut down on caffeine
• Cut down on alcohol
• Do not take decongestants (such as pseudoephedrine) for allergies
• If applicable, limit marijuanaconsumption, as marijuana raises cortisol
• Get even more sleep!

If excessive cortisol secretion has ‘gone on for a while,’ you might need adrenal support, usually in the form of herbal mixtures of rhodiola, ashwagandha, astragalus, siberian ginseng, and adrenal glandulars. If you ‘feel stressed,’ you can increase your GABA levels with liposomal (not oral) GABA preparations.

You can also activate your parasympathetic nervous system (your vagus nerve) and decrease cortisol secretion by activating your hypoglossal nerve, achieved by gargling, doing vocal exercises, or singing, which I easily work into my busy schedule. You may know that I have written elsewhere that singing aloud and dancing with abandon to your favorite music is a powerful mood booster.

Aromatherapy also referred to as essential oil therapy, uses naturally extracted aromatic essences from plants to treat various physiological and psychological imbalances. Different mixtures of essential oils are documented to lower cortisol levels. Aromatherapy is also easy to work into your schedule. You can put oils in a diffuser in your workplace or bedroom and then just let the diffuser help you as you go about your day.

The data is particularly astonishing for lavender and lavender oil blends. Clinical studies have found that 8-12-20 weeks of inhaling lavender or lavender blends will improve cortisol levels, self-reported anxiety levels, and sleep quality.

The addition of weekly massage therapy to the use of aromatherapy will further enhance these positive effects.

#3. Sleep

Here are a few things you can try to help you sleep, depending on what is causing the problem:

If sleep initiation is the problem:

• Try taking a hot shower or bath before bedtime, or use a hot tub if you have one.
• Do not watch T.V. in bed and, if possible, do not use your phone or tablet sitting up in bed.
• Instead, read a book with non-blue lighting in the background.
• Try using a liberal dose of liposomal GABA

If you are awakening several times during the night to urinate:

• Figure out what time you need to stop drinking beverages to fix this problem.

If you are awakening during the night with hot flushes:

• Try sleeping with a cold gel pack on your head
• Try a climate-controlled sleeping pad such as a Chilipad.
• Lower the air temperature since a cold room promotes better sleep for everyone, including menopausal women
• Try a black cohosh supplement

If you awake unrefreshed, you need deeper sleep. Try a long-acting melatonin supplement. Try getting more sleep.

#4. Exercise

Your first question will understandably be, “What is the least amount of exercise I can get away with and still lose all my menopause belly fat?” Guess what? You’re in luck! I’ll give you the minimum requirement, based on current research guidelines,

but first, please, let me recommend what I’d like you to also do ‘for your health’ in the category of exercise.

Here is the familiar ‘Check with your doctor first’ list that applies to everything about exercise:

• You need cardiovascular exercise for weight control, metabolic control, and heart disease prevention.
• You need cardiovascular exercise to help your microbiome composition and cortisol levels and decrease your cancer risk. You can achieve this with a brisk 30-minute daily walk, which you can even divide into three 10-minute segments. Your dog needs cardiovascular exercise too, so if you have a dog, do it for your furry four-legged best friend, if not for yourself!
• You need to keep your bones solid and your muscles strong. You can accomplish this in a one-set-to-failure workout per muscle group in about 20 minutes. If you do this twice a week, accompanied by some basic stretches, you are good to go.

Now I’ll tell you how you can cheat this routine and get what you need to help you lose that belly fat.

HIIT

The study results I cite below compared the effect of high-intensity interval training (HIIT) and moderate-intensity continuous training (MICT) for 16 weeks on whole-body and abdominal fat mass in postmenopausal women with Type 2 Diabetes. Cycling full-out in 8-60 second bursts twice weekly was compared to aerobic cycling for 40 minutes twice weekly to see which reduced both visceral and total abdominal fat the most.

Results: Dietary energy (caloric) intake, physical activity level, and total body mass did not vary in either group from the beginning to the end of the training intervention. Overall, total F.M. decreased and total fat-free mass significantly increased over time (by around 2-3%). Total FM reduction at the end of the intervention was not significantly different between groups. However, significant loss of total abdominal (-8.3±2.2%) and visceral (-24.2±7.7%) F.M. was observed only with HIIT.

Easy ways to do HIIT

If you have access to a lap pool or a track, all you need to do is five “bursts” of activity -running or swimming – followed by ‘catching your breath.’ It’s that easy. If you are looking for an easy way to do it at home, just do ‘burpees’ until you’re short of breath, and repeat four times. Or you can do jumping jacks, run in place, or jump rope. You get the idea. The literature suggests that you do this five times per week.

But what if you have tried everything you have read here, and you still aren’t sleeping well? What if you still have some (predictable) brain fog, fatigue, hot flushes, and that blasted menopausal muffin top just won’t budge?

You need help, and your regular Ob-Gyn will not be able to provide it.

How can a Functional Medicine doctor help? Here is what a Functional Medical Doctor like me can do for you:

Functional Medical Doctors are trained to treat our patients as “whole people” and not ‘heart cases’ or “hormone cases,” and so on. This training is the key to good medical care, and, quite honestly, it is only available through Functional Medicine docs who are also Board Certified in Internal Medicine. We use peptides and integratives for energy and sleep, and we can create specialized, personalized eating plans. We explore all of a patient’s hormones, including ‘minor but often significant players’ not discussed in this article. We can replace deficiencies and lower cortisol, leptin, and even ghrelin, using non-pharmaceutical methods.

And finally, we can make sure you lose that menopause belly fat and keep it off for good!