I have a 47 yr old client that is overweight (about 40 lbs) and just starting to skip menstrual cycles here and there (clearly perimenopausal), married with 4 children, one of which has an eating disorder which is very stressful for her – and she lost her job a little while back. Her big health concerns are inability to lose and keep weight off and getting rid of her rosacea. She is really eager to learn about her body, how it functions and how to obtain real health. Her current supplements include fiber, a multivitamin, Vit D, probiotic, and cod liver oil.
Her s/s are lack of good sleep, constant need to clear her throat, rosacea, hair loss and hot flashes. She has a rapid heart rate during sleep, IBS, aches in hips and thumbs, water retention in hands and feet, ongoing mood swings, anxiety, irritability, depression and cognitive decline.
SO, WHAT ARE YOU THINKING? What Interconnectedness is likely at play for this client? I encourage you to read over the basic case points above (at SAFM, we call these “puzzle pieces”) and see how you can assemble them into connected dynamics. Challenge yourself before you read on!
THIS PRACTITIONER’S FURTHER NOTES:
She had a thyroid panel done. Her doctor wanted her on medication but refused to give her natural thyroid extract (that she requested); therefore she is not on any thyroid med. I have asked her to share the detailed data. She also would like to have hormone testing done, and we will pursue a DUTCH Complete panel for that purpose.
To get her started I recommended Hyman’s UltraSimple diet, esp to help eliminate the gluten and dairy that I believe may be at play in so many of her s/s. I am thinking thyroid issues with the hair loss and overweight. Also, perhaps cortisol imbalances are contributing to hot flashes, mood swings and anxiety. This was all at the first meeting. I gave her a lot to think about and she asked to work aggressively. Very enjoyable, sincere, sweet woman. What puzzle pieces am I missing?
Excellent client work-up summary. Good for you! I generally find that for women over the age of 45, hormones are a key part of why they might be struggling with their weight. Women’s production of progesterone begins to decline 5-10 years prior to menopause. This means that women other than perhaps those who are very thin) can become increasingly vulnerable to Estrogen Dominance during this timeframe which can promote increases in belly fat. And adipose tissue is endocrine tissue! It also produces estrogen. Excess estrogen can also impair thyroid hormone uptake into cells. And as you obviously well understand, optimal thyroid hormone is vital for metabolism. You will want to do a thorough review of her thyroid labs in order to educate her as she continues to advocate for herself and find a physician she feels comfortable partnering with to support her body. Many peri/menopausal women experience dramatic hot flashes due to highly fluctuating estrogen vs. necessarily aggregate low levels.
Given this particular client’s very stressful life experiences of late, it’s also likely that she has experienced high adrenal demand. Over time, this can dramatically raise and then, over time, drop cortisol, as the coordinated hormone HPATG axis allows a “stress steal”. The Adrenal/Thyroid Myths and Truths Deep Dive clinical course addresses this dynamic in detail. As menopause draws near, women are also more and more dependent on adrenal output for progesterone to balance their estrogen levels. Low adrenal function also impairs cellular thyroid hormone function, as cortisol functions as a “master hormone” in driving the activity of other hormones. Low adrenal function would lower her energy, contribute to water retention, and increase generalized inflammation (cortisol – the primary adrenal stress hormone is a natural anti-inflammatory agent). A DUTCH Complete panel to check both sex hormone and adrenal hormone levels is prudent. I agree her hair loss may just be hypothyroid, but given her obesity, high testosterone levels (especially DHT) may also be at play (and are exacerbated by high insulin levels).
High heart rate over night might be as a result of sleep apnea, so be sure to explore this thoroughly. Certainly there might be other causes (e.g. overnight allergy exposure, low blood sugar), but given her overweight, this seems quite possible. You are going to be working on successive levels of root cause and remedy with her for quite a while; however, to begin, my rapid relief focus areas with her would be improved sleep and reduced hot flashes. She may also be struggling from low blood sugar troughs as a result of very low cortisol that requires adrenaline surges overnight to keep blood sugar at an acceptable level. High fasting insulin from insulin resistance may be making this worse (and contribute dramatically to mood swings and energy ups’n’downs). Given her obesity, I would check HbA1c and fasting insulin levels. Throat-clearing and inflamed airways may also be as a result of a dairy food sensitivity. Your choice to begin with the UltraSimple Diet makes good sense. Achy joints are often caused by the combination of food sensitivities and lower cortisol levels.
This is an excellent write-up on rosacea. And there is an existing Q&A post on this dynamic as well (current students can access this and other links in the Q&A Treasure Chest). As you see in the link, gut dynamics such as SIBO and hypochlorhydria are often involved in rosacea, so I encourage you to explore these both in depth. Make sure fiber supplements aren’t exacerbating her IBS (eliminate for ~2 wks and observe). I would likely do a trial of supplemental “HCl with Pepsin” to see if this is well-tolerated in the middle of a meal. (If she does have insufficient stomach acid, this may be impairing Vitamin B12 absorption and contributing to cognitive impairment.) However, I often find that food sensitivities are the culprit here, so the elimination diet you have begun will be telling. Low adrenal function can also impair gastrointestinal function, especially by causing low stomach acid (hypochlorhydria). If no other GI symptoms are present, I do not necessarily think a comprehensive stool test is merited upfront. However, I would also check her Vitamin D, Vitamin A, RBC Magnesium, and RBC Zinc levels. You definitely want both minerals to be in the upper half of the typical reference range. Cold liver oil brands can have wide-ranging levels of Vitamin A, so it’s important to check to ensure that it (and Vitamin D) are not excessive. Zinc and other mineral level issues – along with chronic stress! – may also be at play in poor conversion of T4 to T3 thyroid hormone. As you gather data, perhaps these more targeted types of supplements make more sense for her than a general “multivitamin”?
Whew! There are VERY rich points of interconnectedness here. Take a look at even a subset of the interconnectedness I am highlighting here. Can you step through this and understand the aggregate point of interconnectedness? This is our passion at SAFM! Remember that the most powerful services we offer our patients and clients are Education, Inspiration, and Empowerment.
I would be sure to get a clean “baseline” hormone sample collection. Then, to reduce hot flashes, beyond the food eliminations you have begun, I would educate her about the role of caffeine, alcohol (especially wines), and red meat (in some) in exacerbating hot flashes. I recommend using two Tbsp of ground flaxseed daily along with chasteberry twice daily. I would also add Evening Primrose oil to her regimen (essential omega-6 fat – an anti-inflammatory one). If she needs more support, assuming her DUTCH results don’t show high testosterone, I would also add maca root (slowwww ramp from 1/2 tsp to as much as 2 Tbsp – in my experience, a very powerful hot flash remedy).
Educating this client about the role of her stress in impairing the immune system, increasing inflammation, impairing sleep, lowering metabolism, etc. is key. Work with her to identify customized, sustainable mindfulness activities and ways of seeing her stress in a new light and releasing its effects.