All the adverse effects from the oral route of administration of estrogen as previously outlined in Outliving Your Ovaries can also occur from oral Prempro. However, the addition of the progestin seems to confer additional cardiac risk. Perhaps giving progestins daily instead of in cycles of 14 days each calendar month may be a factor in this increased risk. Earlier observational studies, like the Nurses’ Health Study, predominantly used oral cyclic progestins and did not show an increased risk of heart disease.

While estrogen increases the beneficial HDL cholesterol, adding a continuous synthetic oral progestin lowers HDL by 8 to 18%. Addition of oral, micronized progesterone causes little or no adverse effects on HDL. An animal study showed that adding MPA to estradiol blocks the conversion of estradiol to an important beneficial byproduct made in the liver called 2-methoxyestradiol.

In the Women’s Health Initiative, a randomized, placebo-controlled trial showed no change in the incidence of heart disease in women starting Prempro within 10 years of menopause when compared with placebo. Women starting Prempro 10 years after menopause had an increased risk of heart disease which increased the more time had elapsed since menopause.

The 2009 Danish Study, an observational study of 698,098 women, found those who took continuous combined oral HRT had a 35% increased risk of heart attacks compared to women who did not take hormones. In the women taking topical estradiol plus cyclic progesterone or cyclic progestin, there were 38% fewer heart attacks.

I had an acquaintance, Janet, who became newly menopausal and was exhibiting the typical symptoms. Her physician promptly started her on a daily combination pill containing synthetic estrogen and progestin. Within days of starting that therapy, she developed new onset chest pain sending her to the emergency room (ER). At the ER, Janet was evaluated and sent home and referred to a cardiologist who did stress testing and told her everything was normal. When she continued to have intermittent chest pain, her physician changed her to a combined topical estradiol/synthetic progestin patch. The pain lessened but she still had occasional chest pain. Not until she was finally put on topical estradiol with cyclic oral progesterone did she finally have resolution of her chest discomfort. Imagine the cost savings and the angst that would have been avoided if she had just been put on topical estradiol and cyclic progesterone from the beginning!

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. Dr. Johnson has no financial conflicts of interest or ties to any pharmaceutical company. Her only objective is determining the most effective, safest therapy for patients.

To obtain a copy of "Outliving Your Ovaries" click here

I’m a naturally curious person which greatly affects how I evaluate a patient. I see signs and symptoms as the language of the body. This is how your body tells you and me there is a problem. Symptoms represent a reactive compensation of the body to an underlying process. Once I understand the process that caused the symptoms, I’m in a better position to formulate a plan to correct the problem.

When physicians don’t truly understand the nature of a disease, they’ll often describe it and then add “syndrome” to the end. For example, the cause of Chronic Fatigue Syndrome is not known but there is a typical clinical picture. By giving it a label, everyone understands what we’re describing. This is also the way insurance companies categorize patients to determine payment for physician services. This process can be useful but it is also problematic when the patients become merely labels and all therapy is aimed at simply treating superficial symptoms. For example, giving amphetamines to a patient with chronic fatigue may give them short-term relief but it is rarely a long-term solution and does not address the cause of the symptom.

Betty, a school teacher in her thirties, had an obvious tremor in both hands. She was an attractive, young woman but she was sitting there with a fine tremor that got worse when she tried to do anything with her hands. She had difficulty holding a coffee cup or even writing a check so you can imagine how disabling it would be for a teacher who has to write on the blackboard and grade homework. I was very concerned that someone so young would be having such symptoms. Therefore, I ordered a number of tests to try to determine if there was some underlying disease or unknown exposure to toxins that could be damaging her nervous system. The patient didn’t return for a follow-up so we called to inquire about her. She said she’d gone to another physician who diagnosed her immediately on her very first visit. I eagerly asked what he had diagnosed. With great pleasure, she announced, “I have Essential Tremors Syndrome and I was given a medicine (anti-seizure medicine) that made it go away.” I worried that taking this medicine for years would delay discovery of the underlying process causing the tremors.

I was also concerned because chronic medication use can result in adverse effects. Adverse effects from chronic medications may not show up for years. Most people don’t know that when a new drug is released, it has usually only been tested in a few thousand people for less than three months. It isn’t until the drug has been used in millions of patients for many years that the serious side effects become apparent. Phen/Fen and Vioxx should be keen reminders to us all. However, Betty didn’t want to hear any of this discussion. She had been given a “diagnosis” that completely satisfied her. All I could do was wish her well.

To me, the Endocrinologist is akin to a systems analyst for the body. The body is a highly complex system of interlinked processes constantly changing within a delicate balance called homeostasis. Signs and symptoms often indicate underlying disturbances in that balance so when you correct the underlying problem, you resolve the symptoms. Giving a pill that simply masks the symptom is like “killing the messenger.” I prefer to relieve the symptoms by correcting the underlying process that causes the symptom. Many patients who see me are searching for these kinds of answers. For example, deficiency in thyroid hormone can cause many symptoms including fatigue, dry skin, hair loss, constipation, depression and weight gain. Each symptom can be treated by a myriad of medications each of which carries side effects. However, most of these symptoms are relieved with the right dose of thyroid hormone. What could be more elegant?

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD.
Dr. Johnson has no financial conflicts of interest or ties to any pharmaceutical company.
Her only objective is determining the most effective, safest therapy for patients.

A Prayer for the Women of the World

I quietly stand in awe as I realize the

presence of God in everything.

The longer that I am in medical

practice the more I see the miracle

of the human body.

It is both a work of art and perfection

in form and function. With the right

input of nutrients and care, the body

is programmed to self-sustain and heal.

I have observed that patients who heal

in a remarkable way have an inner

strength of the human spirit

and passion for life.

That pursuit of purpose reveals

to all of us what is most beautiful

in each of us,

the will to endure,

the capacity to fight the darkness

that would surround us,

the strength of spirit to pursue the light.

That is what I wish for each of you.

Dr. Marina Johnson

Hypothyroidism Symptoms

Are you overweight?  Are you saying to yourself, "I feel cold all the time" when everyone else is comfortable?  Are you sleeping more and more and still waking up tired?  Do you feel sluggish and achy even when you have not done anything strenuous?  Are you having constipation or feeling depressed for no reason?  Do you have straw for hair or are you losing your hair?  Is your skin dry and scaley?

The most commonly ordered tests for evaluating these symptoms are tests for thyroid hormones, usually TSH or T4.  If the test comes back low, the patient is diagnosed with hypothyroidism and usually started on Synthroid  therapy.  Oftentimes however, the thyroid tests come back normal or "borderline low". The patient may be given a prescription for thyroid medication just in case it might help.

Other times the patient is told that they are just depressed and should see a therapist for counseling.  Many times they are offered a prescription for an anti-depressant medication.  Other patients are told that they are "just getting older" and just need to accept the fact that they are not going to feel as well as they used to feel.

When the patient has known hypothyroidism and is already on thyroid medications, if he develops any of the above symptoms, the patient often assumes that he needs more thyroid medication and insists that his doctor prescribe a higher dose of thyroid medicine.  This response is reinforced by the fact that often the patient does feel better with the increased dose-- at least for a few weeks -- but then the symptoms come back.  This scenario may be repeated many times until lab tests are eventually done which often show very high levels of thyroid.  At this point, the patient's dose is decreased and then they feel terrible on doses of thyroid that show normal lab results. If the patient is truly hypothyroid, when they are started on thyroid medicine, the symptoms do not come back a few weeks later.

What is really going on in these situations?  Does a person need to settle for having these symptoms just because they are getting older?  Absolutely not! First of all, the above symptoms are very common and may occur in many other endocrine disorders sometimes due to subtle deficiency of testosterone, estrogen, growth hormone and/or adrenal hormones. A patient with known hypothyroidism may develop a second endocrine deficiency, for example, menopause which can mimic some of these symptoms.  If the thyroid tests are truly low, then of course the person should be treated with some form of thyroid replacement.  However, if the tests are not low, rather than taking thyroid medicine that they probably don't need, they should undergo a definitive endocrine evaluation to determine the true cause of their symptoms.

Another factor, which may explain a discrepancy between thyroid tests and symptoms, is related to the particular thyroid hormone, which has been tested. The predominant hormone, which is produced by the thyroid gland, is T4 but T4 is primarily a storage form of thyroid hormone, which circulates throughout the blood stream.  When the tissues get ready to actually utilize thyroid for cellular metabolism, the T4 must be converted to T3. Some individuals may have normal amounts of T4 in their blood but they are unable to convert the T4 to T3, which is the active metabolite. In addition, it is more accurate to test for free T4 and free T3 which enables the physician to see the hormone that is truly available to the tissues instead of that bound up to the carrier protein.

In a study in patients with hypothyroidism, a combination of T4 and T3 was more effective than T4 at relieving symptoms of hypothyroidism in two-thirds of the patients (New England J. Med 340:424, Feb 11,1999). There are many prescription preparations available, which enable the physician to give a combination of these two hormones for those patients who have problems with this conversion.

In a general practice setting, patients are usually tested only with a TSH and occasionally with a T4 blood test, which of course, will not pick up problems with T3.  Interestingly, this problem with poor conversion from T4 to T3 may not necessarily be a permanent genetic problem.  Rather it may be related to nutritional deficiencies in selenium and/or zinc and will often improve with correction of these deficiencies.

So in summary, because the symptoms that occur with hypothyroidism can be similar to other endocrine deficiency diseases, it is important that an appropriate diagnosis be established. It is much better to treat the cause of the symptoms instead of resorting to medications that merely cover up the symptoms only to have them recur weeks later.