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Hormones In Exile
by Diane Dees Tobiason

I was writhing in the dentist's chair, but not for the usual reasons. If the truth be known, I am somewhat of a dental show-off. I get compliments on my tooth and gum care, and I attract spectators by foregoing Novocain during drilling. On this particular morning, I was also attracting attention for not requiring anesthesia while my jaw was painfully stretched to accommodate the necessary drill work to repair an old filling. (This is a matter of family honor: my father pulled his own teeth.)

My discomfort at the moment had to do with what the hygienist was telling me. She had read a book about several hundred 19th century American white women who were banished to Indian reservations because no one knew what to do with them. Their behavior was socially unacceptable and caused problems for their families. In our more enlightened times, it is presumed that these women were either experiencing symptoms of female hormone imbalance or they were just plain uppity, my hygienist told me.

She then launched into a more dental-oriented speech, but it was too late for me: no amount of chit-chat about oral surgery or impaction could ease my anxiety.

I have been uppity since childhood, but I knew that I wouldn't be sent off to an Indian reservation; I'm sure that the 19th century experiment forever cured Native Americans of taking in and marrying neurotic white women. It was the part about the hormone imbalance that was keeping my thoughts centered on exilic consequences.

When I reached the age of forty-five, I stopped sleeping. I don't mean that I had difficulty getting to sleep or woke up too early: I mean that I began to lie in my bed all night long in a state of exaggerated wakefulness. I had never before had any type of sleep disturbance, but I had now begun spending entire days nodding off at my desk or drinking multiple cups of strong coffee. I became depressed from fatigue, and obsessed with my sleeplessness.

So preoccupied was I with my insomnia that it was some time before I noticed that other peculiar things were going on in my mind and body. I was forgetting simple things, like where I had put my wallet or what time I was supposed to be somewhere. When I did notice these things, I just assumed they were byproducts of my insomnia. Then one day, while driving down a familiar street in my small town, I suddenly had no idea where I was.

There was more. My once-perfect skin--the sole focus of my vanity--became bumpy and blotchy. I became significantly anxious, and my moods seemed to have boarded a roller coaster with no switch. My immune system, which had been virtually impenetrable, began to fail me. Bladder and yeast infections started to plague me, and the herpes simplex virus, long dormant in my body, began to attack. I urinated way too often. By the time I recognized the vaginal dryness and the 500-watt light bulb exploded in my head, I had decided that I was probably some serious form of crazy. Since I am a psychotherapist, and inclined toward careful diagnosis, this internal evaluation gave me pause. I called my gynecologist.

"Perimenopause," she announced with little hesitation. She invited me to come in for an evaluation, which she followed with prescriptions for estrogen and progestin. I took the hormone replacement faithfully, but I didn't sleep. She increased the dosage, and I still didn't sleep. She switched the medication, but I remained wide awake.

About this time, I began to read everything I could get my hands on about hormone replacement therapy. I was already aware that it was a highly political issue because of some studies which seem to indicate a link between estrogen replacement and breast cancer. I read the results of these studies, and I read about the functions of the major women's hormones: estradiol, estriol, progesterone and testosterone. My gynecologist did some extra reading, too, and we both acknowledged that we had little to go on because there has been so little research done.

I also learned that blood testing is not an accurate method for determining the available hormones in a woman's body. Saliva testing is accurate, and it has been available for decades, but it is rarely used. I have spat into more bottles than I care to mention (unfortunately, there is no family history of prideful spitting), but my reward has been a series of detailed, highly accurate readings of my hormone levels.

I am fortunate. Both my gynecologist and my primary care physician are up-to-date, open-minded, curious and thorough. My health insurance plan is cooperative. I am also assertive, and if I believed that my doctors weren't meeting my health needs, I would replace them.

This is not the case with many, many women. As a psychotherapist, I see a lot of female patients. Many of my middle-aged patients have symptoms of perimenopause or they are experiencing a complicated menopause. I have met with dozens of these women, and their stories are remarkably similar:

"My doctor said it was a natural part of aging, and nothing could be done."

"My doctor said the symptoms were in my head."

"My doctor said I was too young to be experiencing estrogen loss."

"My gynecologist said that since I'd had a hysterectomy, I couldn't possibly need any progesterone because I couldn't get endometrial cancer."

"I told my gynecologist about this, and she sent me to a psychiatrist."

"I spoke with a psychiatrist and he said: 'You have some deep issues to be worked out.'"

"I told my gynecologist that my hormone replacement wasn't working, and she said, 'Well, it should be.'"

Unfortunately, many women continue to consult with doctors who dismiss, patronize, misdiagnose or ignore them. For their part, American gynecologists and other physicians appear to have both a very narrow view and shockingly inadequate knowledge of female hormone issues. They tend to use a one-size-fits-all style of treatment, and their patients become frustrated when this treatment method fails to work.

Women who receive no relief from their hormone replacement therapy (HRT) sometimes just give up and stop taking it. But often, they consult their doctors, and another round of guessing begins, followed by more waiting and more treatment failure. This less than efficient methodology, when combined with less than accurate reporting of scientific studies of HRT, can also lead to fear of receiving any type of treatment at all. The result is that thousands of women are not only in discomfort but they are, many physicians maintain, at greater risk of developing heart disease, osteoporosis and Alzheimer's disease.*

Women have always suffered socially because of our menstrual periods. PMS is high on the joke list, and even ceasing to have periods is a cause for ridicule. There is no HRT spokeswoman, no femme Bob Dole, to introduce some portion of dignity to the issue. In this environment, denial understandably finds a foothold. Who wants to face getting older and listening to hot flash jokes? "I just don't want to have to think about it," an intelligent woman said to me about her symptoms. But we must think about it, learn about it, and demand that our doctors are educated about it. If we cannot take responsibility for something as basic as our physical and mental health, we become victims.

What are our options? There are several. The type of treatment a woman selects depends on her symptoms, age and disease risk factors. Women in their forties whose bone density is sound may want to treat only those symptoms that cause them discomfort. Many women have used progressive muscle relaxation to achieve relief from hot flashes. Black cohosh--long popular in Europe--and evening primrose oil have also been used.

There are many herbs that are recommended for use, but it is important to remember that herbs, if taken incorrectly, can be ineffective or dangerous. Women who opt to use natural progesterone cream that they buy in a natural food store should be aware that most of these creams contain very little progesterone, and that there is no way to measure a proper dose with these products. Soy products do contain natural estrogen and are healthy supplements for women, as are calcium, magnesium and vitamin B6.

The standard allopathic approach is HRT. The issue of breast cancer looms large in any discussion of HRT. Only a few studies which indicate a link between HRT and breast cancer have been done, and the popular press has done a poor job of presenting these results to the public. The most famous of these, the Harvard Nurses Health Study, done in the mid-90's, purported to show a link between HRT and breast cancer, but it was so poorly designed that no valid conclusions can be drawn from it. It should also be noted that of the few studies done, none of the subjects was using natural hormones. Most women use Premarin or PremPro, and these are the hormone replacements that show up in research projects.

It is also difficult to determine who is at risk for breast cancer. Surely a woman whose mother or aunt has had breast cancer is at risk, and we are all at risk as we get older. But there are now so many identified breast cancer risk categories that it is hard to avoid belonging to one.

HRT can, when used properly, bring significant relief to women suffering from hormonal imbalance. Progesterone, for example, regulates fluid balance, increases energy and sexual desire, enhances mood, balances blood sugar and thyroid function, and promotes sleep. There is evidence that it may even protect against breast cancer. (Beware, however, the oft-prescribed progestin, which is usually given to women to protect them from getting endometrial cancer. It is a very high-potency drug that creates a lot of side effects.) Estrogen is key to maintaining bone density, and there are several natural estrogens, as well as other hormones, available from specialty pharmacies, but for some reason, gynecologists just don't seem to know about them.

Another important thing for women to be aware of: while having a hysterectomy does eliminate the chance of getting endometrial cancer, it does not mean a woman shouldn't take replacement progesterone, despite what almost every doctor says. This standard medical protocol totally ignores the reality that women need progesterone for more than endometrial cancer protection.

As we approach perimenopause or menopause, we also need to realize that diet and exercise are more important than ever, and doing weight-bearing exercise is essential for maintaining bone density. Attention should also be paid to the thyroid gland, and some women may need replacement testosterone, DHEA and melatonin, as well as the lesser known estrogens.

Women's bodies are significantly different from men's, and it is imperative that more and better studies be done if we are to learn everything that we need to know about our health risks and the options available for disease prevention. Heart disease, in particular, is a danger to women: it is the leading cause of death among American women over sixty-five. Just as alarming is the fact that a fifty-year-old woman has a forty percent lifetime risk of developing osteoporosis, or the fact that, in the United States, twice as many women as men have Alzheimer's disease. But it appears that we are not doing a very good job of educating women or their doctors about the high risks of runaway menopause. Women will need to read, study and engage their physicians in meaningful discussions about appropriate, up-to-date methods for dealing with hormone loss. And women who meet resistance from their gynecologists need to find doctors who will listen and learn.

None of us wants to imagine a future in which we are hooked to machines in the cardiac unit, crashed on the floor with a fractured hip, or trapped in the prison of an organic brain syndrome. But that is where we are headed if we do not make informed, responsible decisions about our hormone replacement. And that is a fate more frightening than banishment.

Diane Dees Tobiason is a psychotherapist and writer in south Louisiana. Her work has appeared in a number of publications, including Mississippi Magazine, Eclectica and Quickstorm. She has just been named a regular contributor to Moondance, the official ezine of Women Artists and Writers International. She and her husband are webmasters of http://www.princesscafe.com, a virtual rock and roll restaurant.

*editors' note: Said It recognizes that there are widely varying viewpoints on the benefits, harms, and usefulness or uselessness of hormone replacement therapy. The studies on this subject contradict one other, and are by no means conclusive. No one knows for sure what the impact of hormone replacement has in terms of increasing or decreasing the risks of illnesses after menopause. This is particularly true when it comes to the risks of heart disease.




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