Headache Interview
Health and Healing
"Doc, is it my hormones?"
All About Bioidentical Hormones
from the Director of the N.C. Comprehensive Headache Clinic
Q- Dr. Matthews, you have been treating patients at the Headache Clinic for over 25 years. You've said before that patients with headache often have other problems as well, such as fibromyalgia, fatigue, depression, insomnia, weight gain. Can hormones be causing these conditions?
Q- Dr. Matthews, you have been treating patients at the Headache Clinic for over 25 years. You've said before that patients with headache often have other problems as well, such as fibromyalgia, fatigue, depression, insomnia, weight gain. Can hormones be causing these conditions?
Dr. Matthews: That's an excellent question. The answer is clearly yes. For women with migraine, headaches often begin to occur within a few years of when they first begin to menstruate; they often worsen during menses; and may improve dramatically during the second semester of pregnancy, and after becoming adjusted to menopause the headaches often subside. When the historical pattern of headache coincides with the menstrual cycle, weight gain, onset of depression, fibrocystic breast changes, hair or skin changes, or digestive problems- and I know that sounds like about everything- I begin to suspect a hormonal problem.
Q- Are hormonal problems something a family practitioner or endocrinologist, or the GYN doctor, would diagnose and treat?
Dr. Matthews: For most headaches- and most thyroid problems, or GYN problems with menstrual difficulties- your family practitioner, endocrinologist, or Gyn physician can do very well for you. For example, if you are simply depressed, and otherwise healthy, and your "hormones" check out "OK" on the bloodwork, and you feel better on an antidepressant, and you are not having significant side effects, then that's fine. Or, if you have having menstrual problems and the pill or a GYN procedure solves it, that's fine too. For a growing number of people, however, they are ending up on multiple medications that just won't work well, or are causing as many side effects as they are helping. For people on multiple medications, many suspect they have a hormonal problem and that they are not getting attention for it. And it seems more and more people are taking antidepressants, taking something for IBS or reflux, they are dieting and not losing weight and being told that they are lazy, when they suspect there is something wrong with their hormones and metabolism. And this understandably can be very frustrating.
Q- Can you give me an example?
A: Sure, there are many. I am thinking of a patient who ended up teaching me a lot about thyroid disease, because at first I didn't understand what needed to be done. She had been diagnosed with "low thyroid" by an endocrinologist on the basis of an elevation of her TSH (the TSH is a pituitary hormone that stimulates the thyroid, and it goes up if the thyroid is underactive). She was treated with one form of thyroid hormone, her laboratory test came back to "normal", but she still felt terrible. She was dying a Harvard death, as we used to call it in residency- the number was perfect, but the patient felt terrible. She was gaining weight, in spite of eating very little and exercising all she could. She ached all over, she was so tired she spent days on the couch, and she had daily headaches. One day she doubled her thyroid hormone- very much against the advice of her endocrinologist- and felt terrific within a few days. When she refused to reduce the medication, her endocrinologist fired her as a patient.
Q- What do you think was happening here?
Dr. Matthews: This was really the beginning of my curiosity about thyroid metabolism. I began to read the medical literature, first in endocrinology journals, and then even historically, going back to how thyroid disease was treated in the 1800's. This is a very complex subject, but to sum it up, there is an academic controversy over what a "normal" TSH is. It turns out that the statistical definition of normal TSH- the labs will report "normal" with a TSH anywhere from 0.5 to 4.5- is drawn from a population that includes patients with family histories of thyroid disease, patients with antithyroid antibodies, patients who are overweight, patients who have heart disease and high cholesterol, and patients with irregular menses or difficulty with fertility- all potentially symptoms of thyroid insufficiency. If you exclude sick people from the sample, the TSH normalizes to about 1.1. Yes, a TSH of 2.5 is "normal"- but it's normal in this population to be overweight. And one particularly clear example- many women will be infertile until their TSH drops below 2.0, and infertility clinics will use this lower TSH as "normal" because the TSH for the normal population is not adequate for conception in many cases.
Q- Isn't this something an endocrinologist will know about?
Dr. Matthews: if you have the time to do so, and consulted ten endocrinologists, more than half would tell you that making sure the TSH is "normal" is all you need to worry about. There are some very prominent endocrinologists, however- I am thinking of the papers of the Belgian endocrinologist Hertoghe- who disagree, and would say that you have to collect a 24 hour urine sample and measure the "free triioothyronine" (T3) to see the problem. There is much, much more to say about the TSH controversy. A good place to read about this is to Google "TSH controversy" and look at the Thyroid.com link. There is an excellent summary of the medical literature there.
Q-Why don't doctors pay attention to this?
Dr. Matthews: Well, most of the time the basic lab test is fine, and works well for most patients in a medical practice. Doctors are well-meaning people. But, most specialties think of a hormone as just being directed at their particular gland of specialty. A normal TSH may mean the thyroid gland is performing adequately, and an endocrinologist may well say that that's all they have to be concerned with. But, thyroid hormones have brain receptors too; and what is right for the thyroid and pituitary axis, may not be sufficient for a patient with depression, or fatigue. A recent study has shown that 90% of patients with rapidly cycling bipolar disorder have an abnormally low nocturnal secretion of TSH, where their daytime TSH values are "normal". So, what is right for the endocrinologist, may not be right for the patient with a neurological or psychiatric condition. The field is really "neuroendocrinology"- the fancy term allows a neurologist like me to intrude a little bit on the turf of other specialists.
Q- Any other examples?
Dr. Matthews : A good example is progesterone deficiency in a woman who has had a total hysterectomy. GYN physicians will provide estrogen hormone replacement after hysterectomy; but very few will replace progesterone in any woman without a uterus. I recently had a patient who had a total hysterectomy to try to stop her headaches- and became disabled when her headaches became worse. She had "tried everything", and was rapidly gaining weight on medications that were useless for her. Her headaches stopped within days after adding a bioidentical progesterone, and now she is back at work- and losing weight. I was happy to write her GYN doctor, who was very concerned about her, about this interesting response to progesterone in a woman without a uterus.
Saying that a woman doesn't need progesterone because she doesn't have a uterus is like telling a man he doesn't need testosterone if he doesn't want to father any more children. The point is, progesterone is not "just a hormone for the uterus"- it has actions all over the body, including blood vessels and the brain. And actually, a good medical endocrinology text will cover these topics, but the endocrinologists don't see the GYN patients!
So, unfortunately for these patients, they fall between specialities.Q- Are there hormonal treatments that can help headache?
Dr. Matthews: Several years ago a patient said to me, "Doc, don't you get it- it's my hormones!". And she left a copy of a Suzanne Somer's book to read. Sure, I read it, but at that time I felt there was just too little known from a scientific point of view. Over the years, though, the patients have taught me a lot about what works. Oprah began talking about it recently. I had to admit to one of my academic friends that Suzanne and Oprah were better endocrinologists that I was. This lead to a lot of laughter, pointing fingers at me, and attempts to throw fruit. We neurologist geeks sometimes take longer than the rest of us. My hat is off to Suzanne and Oprah.
Q- What changed your mind about treating with Bioidentical Hormones?
Dr. Matthews: There was a dedication in a book written by John Lee M.D. that said, "To the doctor with the honesty to admit when something is not working, the curiosity to figure out why, and the courage to do something about it". I looked at that and thought, OK, I wold be ashamed not to try and learn about this.
Q- What hormone is the cause of hormonal headaches?
Dr. Matthews: Estrogen in many women is the trigger for headaches at onset of puberty. Interestingly, all hormones, including estrogen, are a little addicting for the body. Just like tobacco or alcohol, when a woman's body starts producing estrogen, they feel sick for awhile, like a young person trying to smoke. Early teenage years are rough, not just for getting used to having periods, but for emotional changes as well. Once you become used to the hormone- a process that involves adaptation (the cells and the glands and the brain have to get figure out how to get synchronized)- then when estrogen falls, as it does to trigger menstruation, or during menopause, you feel sick for awhile. Once the estrogen falls to lower, stable levels after menopause, the typical migraine headaches often go away.
Q- Don't some doctors treat headaches with estrogen?
Dr. Matthews- Yes, there is a popular treatment of adding back a little estrogen during the menses. One of my colleagues at UNC published a paper on this a few years back. It works OK sometimes. I don't like the approach, as I think the problem is more often inadequate progesterone, and replacing progesterone to natural levels works much better long term. I feel the estrogen approach is a little like treating nicotine withdrawal with cigarettes. There is substantial evidence that having high estrogen relative to progesterone is a cause of fibrocystic breast disease, uterine fibromas, infertility, endometriosis, and cancers of the female genital tract and breasts.
Q- Why do people have these hormonal problems?
Dr. Matthews: I think there is a lot of fear out there about "toxins"- but some of this is right. When I was a kid, I spent summers wading through creeks in Farmville North Carolina looking for frogs; they are mostly gone now. If you look at the data on the amphibian population, they are rapidly going the way of the dinosaurs. The skin of frogs and salamanders absorbs water-born chemicals easily. Residues of burned hydrocarbons, plasticizers, pesticides, and fertilizer by-products are often hormonally active, and can have an effect like taking extra estrogen. I think it's generally accepted by biologists that these estrogen-like substances (called "xenoestrogens") are the likely cause of the decline in the amphibian population. My guess is that this is the same reason why the average age that menses start has declined form about age 16 in 1900 to about age 11 today, with a rapidly growing population starting menses at age 9. At the same time, women are having less pregnancies and starting them later, and pregnancies reduce the lifetime ratio of estrogen to progesterone (progesterone increases dramatically during pregnancy). So, we have fake chemical estrogens in the environment, and our bodies are overproducing estrogen relative to progesterone because we have reduced numbers of pregnancies. This is another line of thought suggesting that we should be adding natural progesterone, rather than keeping estrogen levels artificially high or using synthetic progestins more appropriate for uterine problems alone (as are found in most oral contraceptive pills and HRT replacement regimens).
Q- How do you treat with Bioidentical Hormones?
Dr. Matthews : 1) You need to have complete hormonal testing first. 2) Regardless of the tests, treat the patient, not the test! 3) Thyroid problems and low progesterone may be commonly under diagnosed. 4) Replace to natural levels with hormones that are what your own body makes when that is the best choice, not what is easy and patentable by a pharmaceutical company. 5) If the bioidentical hormone replacement doesn't allow you to to feel better and to discontinue multiple pharmaceutical medications within a month, you probably don't need it.
Q- Who are good candidates for Bioidentical Hormones?
Dr. Matthews: if you suspect you are having a hormonal problem, regardless of what you may have been told, you are probably right. Also, I follow the "Three Strikes and You're Out" method with patent medications: if you are on more than three pills from pharmaceutical companies, and you are still not feeling well, you may have a hormonal problem. Get it checked.
