In a world where so many people suffer from obesity and chronic health related diseases related to obesity like diabetes, hypertension, and cardiovascular diseases, sugar free products have become popular.  Nonnutritive sweeteners are advertised as “sugar free” or “no added sugar.”  Products that contain non-nutritive sweeteners are now so pervasive, that 56% of adults and 80% of children report using products that contain it daily.  Initial uses of these products were confined to tabletop packets and diet soft drinks, but now they are included in condiments, yogurts, fruit cups, baked goods, candies, desert products and the list goes on. 

The first question is- if I consume a product that does not contain sugar, will this help me lose weight or prevent me from gaining weight? This is of course what most consumers looking at packaging that says “sugar free” are thinking.  Unfortunately, this is not true.  These fake sugar products still trigger insulin secretion in humans.  Insulin secretion is what causes us to gain weight.  Non-nutritive sugars also alter the secretion of the gut hormone incretin which increases glucose absorption in the gut.  This means non-nutritive sugars will increase the amount of glucose your body absorbs, and this is how you gain weight.  Nonnutritive sugars also upregulate proinflammatory and adipose promoting pathways (this means it increases your chances of getting fat and developing chronic diseases). Finally, these non-sugar products can change the microbiome or bacteria that line your gut.  Studies in children of normal weight have shown that consuming products with non-nutritive sugars led to higher sugar intake and weight gain.  So, basically these kids did not lose weight but gained weight as they consumed more “sugar free” products. 

In pregnancy, women worry that gaining too much weight and consuming too much sugar increases the chance of developing gestational diabetes and all the problems associated with it.  Unfortunately, these fake sugar products will not save you from developing gestational diabetes.   These fake sugar products are also easily transported through the placenta to the baby and via breast milk.  The metabolites of these products can be found in amniotic fluid and the urine of newborns.  Their safety in pregnancy is not well established.  While the Academy of Nutrition and Dietetics states that non-nutritive sugars are safe in pregnancy, neither the American College of Obstetrics and Gynecology nor the Institute of Medicine have released any statements as to the safety of these products in pregnancy and lactation.  We have lots of animal studies, but very few good human studies in pregnancy to establish the safety of these products in pregnant women. 

The take home message from this is you are not likely going to lose weight or control weight gain with the use of fake sugars.  Also, the safety of these chemicals in pregnancy and breastfeeding are not well established because of the lack of good human studies in pregnancy and lactation.  You are better off moderating your regular sugar intake than you are using these “sugar free” products to control weight and optimize your overall gut health.

Dr. Pam

​The CDC recently provided some updates regarding COVID 19.  These numbers address both how transmissible the virus is as well as the severity of infection.  Keep in mind that these numbers are estimates, and there’s definitely been quite a discrepancy between computer modeling and actual outcomes in the past, although there is now 6 months of data to base these estimates on that wasn’t available before.  That being said, here are the current numbers from the CDC website.

1. Basic reproduction number – this is the number of cases, on average, that result from spread of a single infected person.  The current best estimate is 2.5, meaning that for every one person infected, he/she will spread it to 2.5 others.  The projected range is from as low as 2 to as high as 4.  In more densely populated areas, this number would be expected to be higher than in areas with lower population density.  If immunity develops following infection, this number would decrease over time to the effective reproduction number, which would be lower.  At the present time, there is no data on how masks and social distancing play a role in affecting this number.
2. Infection fatality ratio – the number of deaths from infection divided by the number of people with the infection, regardless of whether or not they have symptoms.  For age 0-19:  0.003% (so survival rate is 99.997%);  for age 20-49:  0.02% (survival rate is 99.98%); for age 50-69:  0.5% (survival rate is 99.5%); and for age >70:  5.4% (survival rate is 94.6%).  There is a caveat for the last age range as the CDC states that the data is only likely accurate for those up to age 79, so there are not specific numbers for those 80 and older, and those less than 2 years old carry the highest risk in the pediatric age group, despite being grouped with those up to 19.  Also, it is important to remember that certain medical conditions may also affect a person’s risk beyond simply the age-related risk so that he/she may be more vulnerable than statics suggest.
3. Percentage of infections that are symptomatic – the current best estimate is 40%, although it may be as low as 10% or as high as 70%.
4. Infectiousness of asympomatic individuals – again, this statistic has large variability with 75% being the current best estimate but a range as low as 25% or as high as 100%.
5. Percentage of transmission occurring prior to onset of symptoms – it is currently projected that 50% of viral transmission happens before the infected person has symptoms.  The range may be as low as 30% or as high as 70%.

This information is definitely a lot of numbers to digest, but it seems to show a virus that is pretty easily spread, and there does also seem to an increased risk as one gets older.  While it looks like for many people, especially a younger population (with 419 deaths in the age range up to age 24 vs 643 deaths from influenza in patients up to just age 17 during the 2017-2018 flu season), medical comorbidities such as obesity, high blood pressure and chronic lung disease may increase that risk.  That being said, according an Oxfam report, over 100 million people worldwide may be pushed to the brink of starvation with hunger-related deaths from COVID 19-related food shortage reaching 12,000 per day (vs peak COVID deaths at 10,000 per day earlier this year), and this doesn’t take into account financial hardships from job loss due to economic shutdown.  This is a tough situation, both from the health effects of the virus as well as the socioeconomic impacts.  Fortunately, investigation continues into potential treatment options (for instance, a new ICAM protocol may have some promise) in addition to vaccination studies.  At the end of the day, the information is there for you to draw your own conclusions, so if you’d like to check out the information yourself, here’s the link to the CDC website used for the statistics above.  https://www.cdc.gov/coronavirus/2019-ncov/hcp/planning-scenarios.html  The numbers are in Table 1.

With such dramatic changes on many people’s lifestyle this year from all the societal changes initiated by Covid, a good night’s sleep has become one of the first casualties.  For some, newfound downtime during the day has led to increased napping and difficulty falling asleep at night.  For others, stress plays a big role in keeping them up late or making getting up in the morning tough.  The temptation is often to try taking a supplement rather than to change behavior (it’s easier to swallow a pill than ignore the siren call of the snooze button), and one of the most commonly used is melatonin.  Here we’ll take a look at what exactly melatonin is and how it works.

What is melatonin?  Melatonin is a hormone produced by the pineal gland (a tiny gland in the brain) that helps regulate the sleep-wake cycle.  Production of melatonin generally increases as darkness increases, which in turn, helps make us sleepy as night approaches.  Production is generally suppressed by light, so we tend to be more awake during the day.  That cycle of sleepy and wakeful is referred to as our circadian rhythm.
​
How does melatonin work?  By signaling the body that it’s time to sleep, the thought is that it may help with insomnia or delayed sleep phase disorder (trouble falling asleep before 2 AM) as well as shift work disorder (those who work night shifts) and jet lag.  That being said, studies have shown mixed results with regards to efficacy.  Perhaps for those who are truly deficient, they may see more improvement of symptoms than those who are able to produce adequate amounts on their own, but for now, there doesn’t seem to be a way to determine which individuals would be most responsive to supplemental melatonin.

Is melatonin safe?  Generally, melatonin is considered relatively safe for short term use, i.e. 1-2 months, although long term safety information is limited.  There are certainly those who should avoid melatonin use such as those on blood thinners, diabetes medications, immunosuppressants, dementia medications, and even birth control pills because melatonin can affect the efficacy of these medications.  Also, use in children should be discussed with a pediatrician as there is a question of whether or not melatonin, as a hormone, can affect hormonal regulation of growth and even puberty or menstrual cycles in those with immature endocrine systems.  As for those who are pregnant or breastfeeding, there is no quality data regarding safety for use of melatonin.  Common side effects can include daytime sleepiness, anxiety, GI distress, dizziness and depression among others.  Because it is considered a supplement in the U.S. (rather than a drug, which would be managed by the FDA), safety and efficacy data is limited.  In fact, a study of melatonin supplements from a few years ago showed that the amount of melatonin listed on the bottle varied significantly from the amount actually in the product in most of those products evaluated, and around a quarter were contaminated by serotonin.

In the end, reviews of safety and efficacy are mixed for supplemental melatonin.  The American College of Physicians recommends cognitive behavioral therapy as a first-line treatment of insomnia.  As for simple changes to make on your own, limiting daytime naps, having consistent bedtimes and wake times, exercising regularly and avoiding electronics (especially those emitting blue light) for several hours before trying to sleep can all be good places to start.  Often, the hardest part of making these changes is avoiding the temptation to catch up on some missed sleep at night with naps during the day, but by being more tired when trying to fall asleep at night, resuming (or starting) a more regular sleep schedule can be within reach. 

Dr. Nick

Since Marijuana has been legalized in many states, there is a general perception that it is a natural and safe drug unlike other drugs.  This perception is reflected in the number of pregnant women who use marijuana while pregnant.  In 2017, a study showed that 1 in 20 women used marijuana while pregnant.  In 2002, the number of women who used marijuana was 1 in 10.    

Now before we talk about marijuana use in pregnancy and autism, let’s review some stuff we already know about MJ use in pregnancy.  First it does cross the placenta.   THC crosses the placenta and can be found in fetal circulation at 10% of the maternal level.  Second, we also know that marijuana can bind to fetal cannabinoid receptors as early as 14 weeks of pregnancy.  Third, studies have shown that exposure to marijuana in pregnancy can disrupt normal brain development.  Children born to women who used marijuana while pregnant are more likely to have low birth weight at birth, hyperactivity, and attention, cognitive and behavioral issues.

So, a couple weeks ago a study out of Canada published in Nature showed that women who used marijuana while pregnant were 1.5 times more likely to have a child with autism. The researchers reviewed 500,000 births between 2007 and 2012 in Ontario, Canada.  They found an association between maternal cannabis use in pregnancy and the incidence of autism spectrum disorder in these children.  The incidence of autism spectrum disorder diagnosis was 4 per 1000 children who were exposed to marijuana and 2.4 among children who were not exposed to MJ in utero. 

So, while this study does not definitively prove that marijuana use during pregnancy causes autism, there does seem to be a strong association.  Based on these findings, as well as ACOG (American College of Obstetricians and Gynecologists) recommendation, we encourage our patients to avoid using marijuana during pregnancy and breastfeeding.  

​Dr. Pam

Just like hormonal changes that can occur during pregnancy, there are also big changes that go on in a woman after delivery.  These changes generally last at least a few months, and hormone levels can be affected in some women for as long as they choose to breastfeed.  These fluctuations can influence everything from hair loss to libido to irregular bleeding, and for some women, the effects can be quite dramatic.  Here’s a quick overview of what goes up and what comes down:

1. Prolactin – prolactin is the hormone responsible for milk production, so for moms who elect to breastfeed, this hormone remains persistently elevated.  Prolactin generally leads to feelings of relaxation and calm, but it directly counteracts dopamine, which plays a big role in sexual arousal and gratification.  Thus, you can feel pretty serene while you’re breastfeeding, but you might be so content that you don’t care about having sex.
2. Oxytocin – during breastfeeding, this hormone increases and causes milk letdown and release.  It’s also associated with bonding both with breastfeeding and sex.  During intercourse, it’s released during orgasm, so it’s not uncommon for milk leakage to happen during sex.  Depending on the amount of leakage that happens, some women can become a bit self-conscious, and in turn, this can decrease desire for intercourse.
3. Estrogen – estrogen will be low for at least the first several months after delivery, and it may continue to be low throughout breastfeeding.  Low estrogen can cause menopausal-type changes within the vagina, leading to decreased lubrication and elasticity with increased tightness, which, in turn, can cause painful intercourse.  That drop in estrogen after delivery also plays a big role in postpartum hair loss.  While this should resolve in few months to year and typically only involves catching up with the normal loss that doesn’t happen during pregnancy, for some women the sudden large amounts of hair loss can be pretty traumatic.  Be sure to continue prenatal vitamins, use gentle brushing and hair car techniques, and remember that this change should be temporary.
4. Testosterone – this hormone plays a role in libido/desire, and it is suppressed in the postpartum period and with breastfeeding.
5. FSH – this hormone is responsible for menstrual cycle regulation, and while levels don’t change much during the postpartum period and breastfeeding, it’s level of activity can.  Change in FSH activity may contribute to anovulation (not releasing an egg).  While change in FSH activity can be helpful in preventing pregnancy for some women (some women can still get pregnant while breastfeeding), it can also be a culprit for some pretty erratic bleeding.  Both menstrual and nonmenstrual bleeding can be very unpredictable for women while breastfeeding, with cycles ranging from completely absent to dysfunctional bleeding nearly every day.  The same irregularity can be present with fertility while breastfeeding as well, with some women who don’t ovulate and can’t get pregnant to those with resumption of normal cycles and fertility to those who become pregnant even before they have their first menstrual cycle after their baby is born.

In short, hormones in the postpartum period and while breastfeeding can vary dramatically from woman to woman and have a variety of effects on their health.  Lack of sleep, a fussy newborn, stress of being a new (or repeat) parent and adjustment to the amount of time needed by your new baby can wreak havoc on everything from mood to uterine bleeding to libido, and the hormonal changes during the postpartum period can add a bit of fuel to this fire.  Sometimes the fix can be as simple as starting a birth control pill to regulate your cycle; other times medical intervention or counseling may be needed for postpartum depression.  While it may feel like your newborn is sucking the life right out of you, these symptoms are common, so be sure to discuss your concerns with your provider, and remember that all of these changes should be temporary, so there is a light at the end of the tunnel 😊

​Dr. Nick

The most common complaint I’ve been getting lately is this- “I’ve gained a ton of weight since this pandemic started.”  Many of us went from working full time to working in our PJ’s at home.  Everything has been closed including the gym.  Fourth of July celebrations and the Rodeo were cancelled. Weddings, graduations, kids’ sports activities and summer vacations were are cancelled.  After being told not to mingle with family or friends and just stay home to be safe, it’s easy to find yourself 19 pounds heavier.  Here are some simple tips on what you can do to lose some of those pandemic pounds while regaining your mental and physical health. 
​

1. Rule #1: No Snacking at all.  Snacking throughout the day causes continuous insulin release.  This tells your muscle and fat cells to store all the fat and sugar you eat.  This is how you gain weight.  Also, more frequent insulin release leads to insulin resistance because your cells stop responding to the insulin produced.  I always tell patients to stick to only 2 to 3 meals a day and no more than that while drinking only water in between.  This is the reason that fasting diets are so successful- they take advantage of decreased insulin release throughout the day, and this is how they contribute to weight loss.
2. Rule #2: Stay Away from Processed Foods.  Anything that can survive in your refrigerator for more than 2 weeks is likely processed.  Again, the emphasis is on refrigerator.  Most things in your pantry other than dried spices are processed.  Most processed foods are high in sugar, salt, and artificial everything.  These foods were made in a laboratory somewhere and have an excessive amount of sugar, salt and flavor enhancers to encourage constant cravings.  They are very calorie dense and nutrient poor.  Start looking at nutrition labels on food and if you see things like MSG, natural flavoring, disodium guanylate, yeast extract, hydrolyzed protein, autolyzed yeast, aspartame, and other long chemical names that you can’t pronounce-don’t buy it or consume it.  This is not real food.  These are mostly chemicals manufactured in a laboratory that are high in calories and artificial flavors and packaged and then sold in a grocery store near you.
3. Rule #3: Try to Cook Your Own Meals.  This will help you stay away from processed foods and allow you to have control over how much sugar and salt you consume.  I know this is time consuming, but this is the only way to have control over your overall nutritional health, and while there are limited social options, now is a good time to learn a new skill that may even become a hobby.  It will also save you lots of money. 
4. Rule #4: Be wary of excessively fatty foods and diet fads.  Diets like the Atkins diet are popular because they allow you to eat fatty foods like bacon and butter.  The idea is that you can eat really yummy fatty foods and as long as you restrict carbs you will trick your body into seeking energy in stored fat.  This sounds awesome in theory- you can eat fatty foods and lose weight.  While patients do lose weight initially, most are unable to maintain such a low carb diet for long.  In addition, eating a lot of fat puts a lot of oxidative stress on your body and is what contributes to metabolic syndrome and other chronic diseases of obesity.  Believe it or not, Dr. Atkins died obese and likely of heart disease.
5. Rule #5: Get outside and get active.  Go for a walk, run, hike, bike ride whatever, but you need to get out of the house.  Studies are beginning to suggest that most contracted the coronavirus at home.  Enjoy the fresh air and get some Vitamin D.  While exercise and activity does not contribute to weight loss as much as dietary changes, it helps maintain weight loss and is overall good for your physical as well as mental health.  Also, especially important right now, is the fact that exercise helps boost your immune system.

Hopefully this helps!  Don’t let the 'Rona get you down.  Eat health and enjoy the outdoors!
 
Dr. Pam

If your family has been isolating together since the early days of the COVID-19 pandemic, tensions may be on the rise in your household. Let’s face it - as much as you love your family, it’s hard not to get on each other’s nerves when you’re cooped up indoors for an indefinite amount of time. As life gradually begins to feel normal again in many areas, you can find new ways to address and alleviate these tensions. If you’re struggling with any of these sources of tension in your household, here’s how to lighten the mood.
 
Avoid Chaos and Confusion
 
Since the COVID-19 outbreak began, your family’s usual routines may have been thrown out of whack. Suddenly, your kids were home from school, you were working remotely, and you had to say goodbye to the old schedule that your family had followed for years. This may have caused confusion and chaos in your household, but establishing new routines can help you feel like you’re in control again. Create morning, afternoon, and evening schedules that everyone can follow so your family can regain a sense of stability throughout the next phase of this pandemic.
 
Address Lack of Exercise
 
Chances are, your family has been spending most of their time indoors for the past few months as a precaution. But according to MetalBladeCycles, a lack of physical exercise can contribute to stress and anxiety, and you’ll likely end up taking these negative emotions out on each other.
 
If you’ve all been feeling a bit moody and sluggish lately, it’s time to exercise outdoors! Try engaging activities like running, hiking, biking, and even rock climbing - all of these sports will boost your family’s overall health.
 
Gaining Quality Time
 
Perhaps your family has been neglecting opportunities for memorable quality time, and because of this, you’re feeling distant from each other. In addition to outdoor sports, your family can also take advantage of time in nature to simply relax together. Try spending a sunny afternoon in your backyard, having a picnic at a nearby park, taking a road trip to a local beach for the day, or even going on a weekend camping trip. Afterward, your family will feel refreshed and rejuvenated!


Make Space for “Me Time”
 
Getting enough “me time” is especially important for people in your household who happen to be introverted, but that can be tough to achieve when everyone is in isolation. According to VeryWellFamily, kids need time alone to develop their imaginations and feel more independent. They might enjoy solo activities like drawing and painting, playing with blocks, or telling stories with their dolls and stuffed animals, which will give you a break! If you want to encourage your children to spend more time reading, consider purchasing a few entertaining graphic novels for them. Before buying a particular book, research the storyline, make sure it’s age-appropriate, and check out a few Amazon reviews to ensure your kids will enjoy it.
 
Self-isolating is the simplest way to protect your family from contracting COVID-19. But there’s no denying that taking these precautions does present new challenges for your household. Many families in isolation feel exhausted and frustrated by the events of this year. However, if you come up with strategies to safely enjoy outdoor activities, find new sources of entertainment for your kids, and give everyone in your family some more time alone, your household will be able to ride out this pandemic with ease!

Guest blog courtesy of Elena Stewart
 
Photo via Pexels

After the long Idaho winter (seriously, snow in June?!) and all of the Covid lockdown, those nice summer rays warming your skin are the last thing you want to block, right?  Unfortunately, while a little Vitamin D from the sun is a good thing, a nice summer tan is a bit less healthy than you might think, and even worse for your skin is that first summer burn.  Even for those diligently applying sunscreen, chances are good that you’re putting it on all wrong.  Here’s what you should know about both the short and longterm effects of all that sunshine and how to enjoy the nice summer weather while protecting your skin.

What happens when you tan or sunburn?  A tan is your first line of defense against the sun.  Skin damage releases melanin, which in turn increases skin pigmentation, i.e. skin gets darker.  While this does provide some protection, this level of protection is only about SPF 3.  Once the level of skin damage begins to cause cell death, an inflammatory process increases bloodflow to the area, resulting in the warm, red appearance of a sunburn.  Tanning is more of a chronic damage whereas sunburn is more of an acute damage.  Even if you aren’t worried about the increased risk of skin cancer associated with this damage, do you really want to look like Magda from there’s something about Mary?  Skin damage from the sun is a BIG contributor to aging.

Don’t I have to get all of my Vitamin D from the sun?  While Vitamin D is important for bone and immune health, not all of it has to come from the sun.  Eggs, milk, and fish are important sources of dietary Vitamin D, and in fact, dietary intake can provide adequate levels of Vitamin D without the need for excessive sun exposure or additional supplements.

How should I put on my sunscreen and what kind should I use?  Sunscreen should generally be applied about an hour before sun exposure, and you should be using a lot more than you probably think.  For the face alone, a nickel-size amount is appropriate, but for the entire body, a shot glass-sized amount (a full ounce) is necessary.  Also, don’t forget to reapply frequently, every 1-2 hours, to prevent sunburn.

As for the type of sunscreen, SPF 15 blocks about 93% of UVB rays, SPF 30 blocks about 97%, and SPF 50 blocks about 98%.  Mineral sunscreen are typically more effective than chemical sunscreens.  Another benefit of mineral sunscreens is that they don’t contain ingredients like oxybenzone or octinoxate that can be harmful to coral and ocean ecosystems.

If you’re absolutely against sunscreen, there are certain clothing lines geared toward SPF protection.  Some long-sleeved shirts, pants and hats can also be effective protection against the sun, but remember that any area of exposed skin will still be vulnerable to UV damage.

So, should you hide in the shade all summer?  Not necessarily.  There’s evidence that some sun exposure may trigger release of nitric oxide and in turn lower blood pressure, but at the same time, there’s no sense in burning until you become a California raisin either.  As with most things, moderation is probably key.  Apply your sunscreen and don’t get sunburned, but go outside and have some fun, too.  It’ll be snowing again before you know it.

Dr. Nick

How does osteoporosis happen?  Our bones are constantly being broken down and replaced.  Whenever the creation of new bone does not keep up with the loss of old bone, they become brittle and weak.  When this happens even minor stresses can cause a fracture.  These fractures most commonly happen in the hip, wrist, or spine.  There are lots of things that contribute to the development of osteoporosis.  Genetics, age, sex, race, nutrition, lifestyle choices and medical conditions can all contribute to osteoporosis.  Unfortunately, White and Asian post-menopausal women are at the highest risk of developing osteoporosis.  However, there are lots of different options to help prevent bone loss or strengthen weakening bones. 
​
There are different medical treatment options available.  The most common of these being bisphosphonates.  Bisphosphonates prevent bone from being broken done. However, this may lead to less new bone formation as it prevents old bones from being broken down.  In addition to this, this class of medications has lots of side effects- muscle aches, esophageal ulceration, osteonecrosis of the jaw, seizures and atypical fractures of the femoral shaft and even esophageal cancer.  Other treatment options include estrogen and estrogen agonists like raloxifene.  While it decreases the chance of osteoporosis, there are many individuals that are not good candidates for this type of treatment because of the increased risk of blood clots and even strokes. 

While we always recommend weight bearing exercises to prevent osteoporosis, recent studies have shown that exercise really bolsters bone mass in the hip and femoral neck decreasing the chance of developing hip fractures.  Studies showed that increases in body mass density at the hip and femoral neck were particularly noticeable in women age 65 or older if exercise training lasted more than 200 days.  Basically, exercise has a huge protective effect on bone mineral density and can prevent fractures without all the side effects that traditional medications like bisphosphonates and estrogen agonists can have.  The thought is that as we age, our bodies produce cytokines that are inflammatory and destroy bones.  Exercise prevents the production of these bone destroying inflammatory cytokines and increases growth factors that help produce new bone.  In women particularly, exercise has also been shown to have a positive effect on estrogen concentrations which helps with bone remodeling. 

With all the innovations of modern society- dishwashers, washing machines, Alexa to turn on our lights and delivery of everything from groceries to dinner, we have become very sedentary.  Unfortunately, our bodies were not built for this.  Our bodies were meant to be active.  Movement and exercise promote the resorption of old bone and the formation of new bone.  This is vital to preventing fractures, back pain from fractured or collapsed vertebra, loss of height over time and stooped postures. 

While it’s important talk to your provider about your risk of bone loss and osteoporosis as you get older to see what options are best for you, don’t discount the importance of lifestyle choices like exercise to help prevent bone loss and fractures. 

Dr. Pam

A very common question at appointments lately is “I think my hormones are out of balance-can I get them tested?”  While society may tell you that an imbalance is the cause for everything from weight gain to mood change to almost any other symptom, it’s not likely the culprit for women with normal cycles, and here’s why:  the amount of sex hormones fluctuates markedly over the course of a menstrual cycle, and in fact, if they didn’t, there would be markedly dysfunctional cycles.  Here I’ll review what happens during the menstrual cycle as well as each hormone involved, how it changes over the course of a menstrual cycle, and also what it does.

What is the menstrual cycle?  The menstrual cycle starts on the first day of bleeding during the period and lasts until the first day of bleeding during the next cycle.  The lining of the uterus is shed and then begins to thicken again in case pregnancy occurs.  Ovulation generally occurs around the midpoint of the cycle (about 2 weeks before the start of the next cycle) in response to hormonal changes, and while the ovum (egg) is present, fertilization and pregnancy may occur.  If there is no pregnancy, then the cycle starts over again.  The length of the cycle can be calculated by using day 1 as the first day of bleeding and then counting days until bleeding starts again.  Typical ranges can be from 24-38 days.  Now that the cycle has been explained, we can move on to the important part – the hormones.
​

1. FSH and LH – think of FSH as the director of a cycle.  Follicle stimulating hormone (FSH) comes from the pituitary gland in the brain and is responsible for the growth of an egg during the menstrual cycle until ovulation is triggered by luteinizing hormone (LH).  FSH is highest just before ovulation and then decreases following the release of an egg until it’s time for the next menstrual cycle.  In menopausal women, levels are consistently very high because the pituitary gland wants to stimulate release of eggs from ovaries that are no longer responding.
2. Progesterone – this hormone is released from the corpus luteum (a cyst formed on the ovary each month).  It increases in the second half of the cycle in order to support a pregnancy should it occur, but if there’s no pregnancy, the corpus luteum goes away and the decreased progesterone triggers a menstrual cycle.  High progesterone levels in the second half of the menstrual cycle are responsible for many of the PMS symptoms experienced by women including acne, mood change, headache, breast tenderness, and everyone’s favorite-bloating.
3. Estrogen – estrogen is produced by the dominant follicle in the ovary and increases as the size of the follicle increases over the first half of the cycle.  Increased estrogen thickens the lining of the uterus in preparation for possible implantation of the pregnancy.  Once estrogen levels are high enough, then the LH surge triggers ovulation and the second half of the menstrual cycle begins.  The decrease in estrogen in the latter part of the menstrual cycle stops the thickening of the uterine lining and works with the decreased progesterone levels to allow the menstrual cycle to start over if there hasn’t been a pregnancy.  Persistently high estrogen levels, such as those caused by estrogen production in adipose tissue in women with PCOS, cause continued growth of the uterine lining.  Continually elevated estrogen can ultimately result in unpredictable menstrual cycles as triggers for bleeding can be suppressed, and these cycles can often be very painful and heavy as several months worth of endometrial lining can be passed at the same time.  Over a long enough time, this type of bleeding can even result in endometrial (uterine) cancer.
4. Testosterone – testosterone, while generally thought of as a male hormone, is present in women, although in much smaller amounts.  Testosterone is a driver for libido and plays a role in developing/maintaining muscle mass and bone density.  There is a slight increase around the time of ovulation (in order to encourage procreation), but otherwise levels are pretty stable.  If testosterone levels get too high, women can experience acne, facial/body hair growth, deepened voice, male pattern baldness, heart disease and increased clitoral size.  While some of those effects are temporary, many of them may be permanent.

Given the natural course of hormonal change during the menstrual cycle, a single hormone test may be misleading.  For instance, progesterone levels prior to ovulation will be lower, but by adding supplemental progesterone to “correct” this imbalance, a woman might then live in a constant state of PMS.  Unopposed estrogen in a woman with a uterus will likely lead to irregular bleeding and could cause endometrial cancer.  Testosterone supplementation at high enough levels could cause permanent hair loss (from the scalp) or permanent hair growth (on the face and body) among other issues.  Many times the good intentions to supplement a natural fluctuation in sex hormones will likely make symptoms worse rather than better, and in turn, this could result in further unnecessary tests and procedures.  For nearly all premenopausal women, the better bet may be some sort of contraception-based hormone management.  That being said, be sure to review your full health history with your provider before starting any hormonal therapy, contraception-based or otherwise, to ensure it’s a safe and medically-appropriate treatment option for your specific symptoms. 

Dr. Nick