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.
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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  

There are lots of people out there that are worried about not taking enough Vitamin D supplements.  Its more popular than most supplements out there including fish oil, probiotics, and antioxidants. 

​What is all the hype all about and is it real?  Originally, we were told that Vitamin D helps prevent thinning of the bones.  More recently is has been touted to be a panacea for just about everything.  It helps boost the immune system and mood, helps with muscle weakness, fatigue, prevents cancer/heart disease/diabetes and even helps slow down the aging process.  So whenever one supplement does all this, I think we should be a little skeptical. 

What does Vitamin D do?   It helps your intestines absorb calcium.  Without Vitamin d, your intestines can only absorb 10% of calcium from the diet; with it your body can absorb about 40%.  Your body needs calcium to make your bones strong.  Without enough calcium, your bones will start to thin, soften and can bow outward (known as Rickets in children) and can increase fractures in older adults. 

Many vitamins must be consumed from different types of foods because your body can’t make it.  Not Vitamin D.  Vitamin D is made in our skin when exposed to sunlight and then converted in the liver and kidneys to usable forms.  Vitamin D is found in certain specific foods as well.  Since certain states have long winters and less exposure to sunlight, the federal government has required that Vitamin D be fortified in certain foods like milk, yogurt and orange juice to prevent diseases like Rickets.  This disease is pretty much nonexistent in modern times because of fortified foods. 

So why did experts think Vitamin D was so useful for so many things.  Researchers did observational studies where they looked at people who took supplemental Vitamin D and found that they were less likely to have certain cancers, hypercholesterolemia, hypertension, heart disease, fractures and a myriad of other chronic illnesses that are common in our modern world. 

I thought Vitamin D was just supposed to help with bone health, so how did it help with everything else?  In these observational studies, the individuals decided whether they took additional Vitamin D or not.  The people that were more likely to take theses supplements were more likely to be healthy, i.e. exercise regularly, eat healthily, and thus less prone to chronic diseases like heart disease and diabetes.  When randomized controlled trials with Vitamin D were done (the researchers picked who got Vitamin D and who got a sugar pill), the results were quite different. Most of those studies did not show any benefit in the group that received Vitamin D supplementation.  Some even found that Vitamin D supplementation may cause more harm: high levels of Vitamin D could cause weakness (and increase falls causing fractures), vomiting, and kidney stones. 

So, what does all this mean?  First, Vitamin D is not a cure all despite what celebrities may tell you.  Second, the most important way to stay healthy is to get your vitamins and minerals from actual food and not from supplements.  Third, get some sunshine (just not too much!*) and stay active outside.  This will boost your levels of Vitamin D and provide way more benefit than you realize.  Talk to your provider and decide whether you need Vitamin D blood level testing.  Remember 97% of people in the US have adequate levels of Vitamin D (from the sun and fortified foods) when the Institute of Medicine and US Preventative Services Task Force determined that blood levels above 20 nanograms are adequate.  However, more than 50% of individuals were noted to have inadequate levels when certain commercial labs changed the necessary level to >30 nanograms to have an adequate amount of Vitamin D.  Hope this helps to clear up the craze surrounding Vitamin D.  It would be awesome if a single supplement in pill form helped cure everything, but for better or worse, the old adage still holds-if you want to be healthy, balanced diet and regular exercise trump supplements**.  Have a good summer and get your vitamin D the old-fashioned way, by enjoying that Idaho sunshine while it lasts!

 Dr. Pam

*Too much sunshine, particularly without the use of sunscreen, could increase your risk of skin cancer.
**Be sure to talk to your provider before discontinuing any recommended treatments.

As screen time increases, we’ve begun to see a number of health concerns ranging from headache and eye strain to posture issues and obesity to increased anxiety and loss of interpersonal social skills.  Some of the correlation can be more self-explanatory, i.e. hours a day craning your neck to look at your phone can hurt your neck, but some potentially negative health effects, such as those caused by blue light, may be more subtle.  Here we take a look at blue light and how it can affect your health.
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What is blue light?  Taking you back to grade school, a rainbow shows the different colors that make up white light, ranging from red at one end all the way to violet at the other.  Red has a longer wavelength and is less easily scattered whereas blue has a shorter one and is more easily scattered.  That’s why the sky generally appears blue.
Ok, but what does it do?  Blue light is awesome during the daytime because it can boost attention, mood and reaction times.  It’s not so great at bedtime.  Prior to electronic screens, humans essentially evolved to be dependent on the sun for this type of stimulation, and it’s why for however long humans have been around, people tend to be more focused during the day and sleep at night.  Now, with the advent of tablets and cell phones, some people can’t even get out of bed until they get their electronic fix and the blue light that wakes them up.

Um, is that a problem?  It may not be the end of the world to play on your phone a minute or two before getting up, but not being able to sleep at night due to screen time definitely isn’t a good thing.  Blue light decreases melatonin levels, which are responsible for your circadian rhythm, meaning that falling asleep can be harder.  In some cases much harder.  Given that just over 2/3 of the U.S. has trouble sleeping at least one night a week, it’s not unreasonable to think that there may be a correlation, especially as this is nearly an identical number to those in the U.S. with a smart phone.  Those sleep struggles can lead to obesity, heart disease, decreased libido, inhibited immune system, and even contribute to some types of cancer.

Yeah, but I’m not getting rid of my smart phone, so what can I do?  In an ideal world, stopping screen time for at least a few hours before bed is a good idea.  In a practical world, screen settings with warm light or blue light-filtering glasses/screen protectors may provide some benefit.  While some studies suggest these measures can help prevent some of the melatonin decrease associated with sleep disturbances, the data is mixed, so it’s unclear if these measures really make things better or just make us feel better about trying to do something.  The bottom line is that light is good during the day, and sleep is good at night 😊

Dr. Nick

Antibiotics are one of the great advances in medicine.  They have allowed us to treat infections and do surgeries like cesarean sections that would most likely have resulted in death from infection in the past. That being said, there are definitely times when antibiotics can be helpful, but there are also situations in which they aren’t.  To help explain the difference, here’s a quick overview.

First, what do Antibiotics treat?  Germs consist of bacteria and viruses.  Bacteria are living organisms that exist as single cells.  Bacteria are everywhere.  Some cause disease, some do not, and some are even beneficial like the ones that line your intestines and help with breakdown of food.  Viruses are not alive and invade our cells and use them to replicate.  Viruses are generally harmful.  Antibiotics only work against bacteria because they are living organisms.  They do not work against viruses. 

Antibiotics are great at treating bacterial infections that can cause pneumonia, ear infections, or sinus infections, and they can prevent infections during surgery.  However, if these infections are caused by viruses like the common cold or the flu, antibiotics will not help and are only likely to stir up all sorts of issues:

1. First, antibiotics can have lots of side effects!  The most common side effects of antibiotics include vomiting, nausea, diarrhea, bloating, and abdominal pain.  Notice how the most common symptoms are GI related.  The reason for this is there are lots of bacteria in your intestines- some are good and help with the breakdown of food and some are bad.  In the process of killing bad bacteria, antibiotics may inadvertently kill some good bacteria in the stomach as well, and this is what causes these side effects.  Other symptoms include hives (a scaly itchy rash), coughing, and wheezing.  In fact, some individuals even have trouble breathing (this is an emergency that requires an urgent visit to the ER). 
2. The overuse of antibiotics to treat things like the common cold have led to antibiotic resistance.  As bacteria get exposed to antibiotics, they find a way to thwart the effects of the antibiotics on their cells.  This is how they become superbugs.  They find ways to combat the effect of antibiotics and survive despite being bombarded by different types of antibiotics.  What many physicians are worried about is as more bacteria become resistant, we will run out of antibiotics to treat common bacterial infections because they will be resistant to all the antibiotics currently available. 
3. Another side effect of antibiotics is a common complaint from patients to their gynecologist- vaginal yeast infections.  Antibiotics cause yeast infections in the vagina for the same reason they cause GI side effects.  There are many good bacteria in the vagina. Antibiotics can kill off these beneficial bacteria and cause an overgrowth of yeast in the vagina causing a cottage cheese like discharge and severe itching.  Alternatively, they may also contribute to bacterial vaginosis. 
4. Using antibiotics can cause other infections like clostridium difficile (c. diff).  C. Diff is a bacterium that can cause symptoms that range from diarrhea to a life-threatening inflammation of the colon.  When you take antibiotics to treat an infection, it can destroy some of the normal, beneficial bacteria in the intestines and cause an overgrowth of c. diff. 

There are lots of other theories out there as well that frequent antibiotic use in childhood may be a precursor to chronic diseases like asthma and obesity.  While the evidence for this is limited, we should be very wary of taking antibiotics when not necessary.  The best way to prevent these issues is by being a good steward of our current available antibiotics. 

In closing, here are a few quick tips for making the most of your antibiotics.

1. Please take antibiotics if your doctor encourages you to take antibiotics for illnesses or procedures.  Only take antibiotics that were prescribed by your doctor for you, take them as directed and do not skip doses in an effort to save them for later.   This often kills only the weak bacterial cells while leaving the stronger ones, which can cause your symptoms to return with a vengeance AND be harder to treat.
2. Trust your doctor if they feel your symptoms are more consistent with a viral illness and that antibiotics are not necessary. 
3. Consider probiotics foods while on antibiotics to help regenerate the beneficial bacteria of the gut.  This may help decrease the GI side effects, vaginal yeast infections and other issues caused by antibiotics. 

Dr. Pam