The last fifty years have seen great changes in medicine, and being a part of the journey since 1961, I would like to offer a perspective. Women’s’ health has been in the forefront of my practice, and there are two issues about which I would like to focus: thyroid health, and hormone replacement therapy.
As we get more and more aware of epigenetics and how everything impacts everything else, we can now almost smugly agree that the dietary, environmental, hormonal, increased toxic load, and emotional connection to thyroid function is real. Yet, the paltry testing and interpretation of those tests have not changed in these last 50 years. It is a given that women experience far more thyroid disease than men: perhaps 10:1. And yet, we continue to measure TSH and occasionally free T4 to assess the health of this power organ located interestingly in the area of the fifth chakra. The testing so essential includes free T3, reverse T3, TPO and thyroglobulin antibodies, ferritin, iodine, vitamin B12, and vitamin D (25 hydroxyvitamin D). And the old values of TSH (0.5-5.5 now in some labs lowering the range to 0.4-4.5) is still absurdly too large a spectrum, the higher the number, the more underactive the thyroid. Those of us practicing functional more integrative medicine desire the range more closely to 0.3-2.0; yet the endocrine world has yet to adopt these more appropriate levels. And even with the ideal TSH without looking at antibodies, and the other aforementioned levels, some 2-3 of every ten women I evaluate have abnormal findings.
Adrenal dysfunction measured in saliva is closely aligned with thyroid function and it, too should be evaluated, because one cannot replace thyroid without addressing adrenal fatigue, which is beyond the scope of this writing. We know that heavy metal intoxication, chronic candida from environmental mold, pesticides, gluten sensitivity all impact thyroid health. Interestingly, the more physiological T4/T3 preparation, known as Armour thyroid, was replaced with Synthroid (T4 alone) with the expectation that the body would know how to take the inactive T4 and convert it to the active T3. Our bodies are magnificent and magical and if left to their own devices could do this, providing we give the necessary cofactors to assist liver detoxification and conversion to the active form. But since we still do not accept the vital role of ingredients provided by pure untainted food and nutrients, we cannot put all the pieces together, and continue the band aid approach to therapy. The important role of compounding pharmacies comes into play here, as Armour thyroid has gone through some struggles with availability and quality, and so many physicians are choosing to have thyroid compounded from porcine thyroid powder under strict regulations, without fillers and additives, often harmful for patients with multiple chemical sensitivities.
Which is my segway into hormone replacement for women. One must remember history so as not to repeat it, said Santayana. Back in the 1960s an infamous book written by then president of the American College of Obstetrics and Gynecology, Robert Wilson, MD, titled ‘Forever Feminine’ extolled the benefits of Premarin (pregnant mares’ urine) an estrogen which became not only the largest selling hormone, but drug in the industry. This well publicized book by the Wyeth Company who sold Premarin was read by millions of women who flocked to their doctors requesting the miracle hormone that would prevent them from becoming dried up sexless hags, aging with little ability to attract a loving partner.
This drug which was produced by torturing magnificent mares and their fouls (that story told most eloquently by PETA (People for the Ethical Treatment of Animals) became so profitable and ingested by hundreds of thousands of women, and because it was ordered as estrogen alone, approximately four per cent of women developed uterine cancer. Back to the drawing board, our astute forefathers realized that if a woman still had an intact uterus, she required the other important hormone, progesterone, to balance the stimulatory effects of the estrogen. Thus was born MPA (medroxyprogesterone acetate) a synthetic progestogen patentable (operative word here) and it was cleverly marketed as Prempro. The issue here is that synthetic progesterone has many side effects (see the PDR) and many women began complaining, such that many albeit unnecessary hysterectomies were performed so that women needed only to take estrogen.
This is where the medieval solution to this problem originated and continues to his day. We now know that synthetic progestin is actually more carcinogenic than estrogen, and to the credit of the pharmaceutical industry, a more bio identical progesterone capsule, named Prometrium, has been added to the tool kit of my colleagues. And if estrogen, and a more gentle plant based form which we now have in pills, patches, sprays, gels were always ordered with the more balancing natural progesterone, I may not be writing this. But this is not the case. Despite the fact that God gave women two major hormones, estrogen and progesterone, and to a lesser amount, testosterone, most physicians stay stuck in the 1970s thinking that if there is no uterus, there is no need for progesterone, especially since we are most familiar with the synthetic version.
My final observation: my profession continues to denigrate bio identical hormones, compounded specifically by pharmacists trained to do so, claiming they can be dangerous, tainted, and found to be dose erratic, according to some critics. Yet for 25 years I have measured hormones in the saliva, and along with a comprehensive thyroid panel, AND most importantly, my patient’s story, I have been able to formulate small, appropriate doses of these hormones, preferably administered through the skin or in the vagina, thus avoiding first pass through the liver and avoiding cytokines and clotting factors which can be affected by estrogen pills. And the one size fits all hormones provided by the pharmaceutical industry cannot come close to addressing each patient’s unique biochemistry.
It is time that we release our egos and righteous indignation about whether we are in the conventional or alternative camps of medical practice. We are here to serve our patients, and when we integrate the best of both worlds, those whom we serve benefit. I just had back surgery: not angel dust or acupuncture, though I certainly gave those attention: this is a metaphor for how we need us all.
Helene B Leonetti, MD