FATIGUE, WITH A FOCUS ON WOMEN & HORMONES

by Robert A. Weissberg, M.D. ©2006
IntegMedRW@aol.com

Fatigue is an extremely common complaint, and it is one that conventional medicine often handles poorly. Just about every significant illness, from colds to cancer, has associated fatigue, so it is not a specific help with diagnosis. The conventional approaches to medicine aim at determining a disease diagnosis. The implication is that the diagnosis will determine the treatment. Unfortunately, this is rarely the case with generalized fatigue. When no diagnosis is found, the conclusion is often that nothing is really wrong, the patient is making it up, or has psychological problems. In reality, not in the abstract world of diagnoses, fatigue is most often related to multiple "sub-clinical" areas of dysfunction or sub-optimal function; no one of these would cause much trouble, but adding them up does.

In my Integrative Medicine practice, I frequently find that fatigue is associated with the following factors: diet and activity; excess inflammation; depression; energy imbalances; hormone deficiencies or imbalances. The endocrine glands most often involved are the thyroid, adrenals, and sex glands (testes, ovaries).

Thyroid deficiency is quite common among women, and needs to be considered in all cases. For a long time, the standards used for testing have underestimated thyroid deficiency, and missed many positives, forcing us to rely on basal body temperature measurements. This has been partly corrected, although body temperature is still useful. Very often, just the pituitary hormone, TSH, is tested for, but not the free levels of T4 and T3, the two main hormones. T3 is the activated form., and is made from T4 by enzymes in the cells of the body. If this conversion is not effective, low thyroid activity results. People who have chronically low body temperature are suspects for low thyroid. Sometimes, hormone replacement, with both T4 and T3 is necessary, other times, vitamins and minerals to promote T3 production is used. It is also worthwhile dealing with energetic issues, such as communication difficulties (including not being heard/listened to), and imbalances in the meridians.

Adrenal Fatigue is also relatively common among fatigued people with low endurance and resiliency often with chronic inflammatory problems and sleep disturbance. We often hear a story of chronic recurrent stress, followed by weight gain in the belly area, fatigue, low resistance to further stress. Standard tests do not show severe deficiency, such as in Addison's disease, but often salivary cortisol levels are abnormal, or the pattern of cortisol production is abnormal. Cortisol is one of the main stress hormones produced by the adrenal glands. Dealing with Adrenal Fatigue requires an integrative approach, and the treatment can vary greatly depending on individual differences among patients. We often use selected vitamins, herbs and minerals to stimulate adrenal function and provide the adrenals what they need for healing. Also, use of glandular extracts can help. Body energy related methods such as acupuncture and acupressure are often helpful. For rare patients, use of low dose adrenal hormone, such as hydrocortisone, is needed to jump start the process. Because the adrenal cortex hormones are made from the same cholesterol chemical skeleton as are the sex hormones, we often see inter-connections with sex gland function.

The most common sex gland issue related to fatigue that I see in patients at this point is the menopause, although male andropause is becoming a close second. Many women experience hot flashes, fatigue, sleep problems, joint pains, emotional difficulty, headaches, and other symptoms, while andropausal men may also experience erectile dysfunction, and are not subject to hot flashes. For a long time, this natural stage in a woman's life had been medicalized, considered an age-related female hormone deficiency in women, and treated as a disease. "Replacement" was offered using an easy to obtain mixture of hormones derived from pregnant mare urine (originally marketed as Premarin™), and sometimes a synthetic version of progesterone (originally Provera™) that could be taken in pill form. The intention was that of replacing the deficiency, suppressing the hot flushes, keeping women "young" and "feminine," in spite of advancing years. The thought was that this should keep women healthy longer, and slow the aging process. In spite of this approach being done in a one-size-fits-all fashion since the 1950's, no good quality, large studies showed convincingly that hormones did much more than suppress hot flushes and keep the bones from thinning. The recent Women's Health Initiative, applied to thousands of women, did show these benefits, but many deficits, including greater risk of heart disease, blood clots and cancer. For this reason, the study was terminated early.

The Integrative, Alternative and Complementary medicine sector has known for years about the potential benefits of using bio-identical hormones for replacement or treatment, and the dietary and metabolic factors that relate to bone and cardiac health, hot flushes, and many menopausal symptoms. Use of supplemental hormones is not always needed. It is possible to help women with the discomfort of menopause by: reducing animal protein and increasing soy protein; losing body fat and increasing exercise; taking black cohosh and other herbs; using certain metabolic factors which promote normal sex hormone metabolism. Finally, it is possible to prescribe personalized doses of bio-identical progesterone and estrogen applied to the skin, so as to more closely mimic the gradual steady secretion from the ovaries. Treatment may be monitored by a combination of blood and salivary testing in order to tailor the dose to each woman's needs. Theoretically, this approach should be safer and more potentially effective, but large studies have yet to be done. A key element to this type of treatment is individualizing the therapy, which is, of course an essential principle of Integrative Medicine.