Your Hormone Health Questions

Tikosyn has been reported to have fewer adverse sexual side effects than other anti-arrhythmic medications, sexual side effects are possible on individual basis with all of the medicines in this class used to stop irregular heart rhythms. For this woman, the first “clue” that Tikosyn is the likely culprit in her difficulty having an orgasm is the the orgasmic dysfunction occurred AFTER the last dose increase. Prior to that, at the lower dose, she had not noticed a significant difference in the quality of her orgasms after starting the Tikosyn. Her hormone replacement with testosterone, estradiol and thyroid had been unchanged before and after starting Tikosyn. Medicines to help reduce or stop abnormal heart rhythms are not the only medicines that can cause sexual side effects. I was part of the Sexual Conosultation Unit at Johns Hopkins during my specialty training and we were evaluating the effects on each phase of the sexual response cycle with many medications. Here are some of the most common classes of medicines that can interfere with the normal sexual desire (libido), arousal (erection) and orgasm (ejaculation): antiarrhythmics, anticonvulsants, antidepressants (especially SSRIs), antihypertensives, antianxiety meds, antipsychotics, narcotic (opiod) pain medicines. In addition, regular use of alcohol and marijuana in men decreases testosterone and has estrogen-like effects that can cause low libido, erectile dysfunction and difficulty with ejaculation. Many of the medicines listed above have adverse effects on several phases of sexual response – desire, arousal, and orgasm. SSRIs, antiarrhythmics, and anticonvulsants in particular, dampen down neuronal activity to reduce excess “excitability” of neuronal pathways (brain or heart or other target organ). This how these classes of medicines work for therapeutic effect, which is the opposite of stimulation and arousal needed for normal sexual response (desire, arousal, orgasm). Adverse sexual effects with many of these medicines are affected by many factors: age, absorption, body weight, dosage, duration of action, duration of use, rate of metabolism and excretion, concurrent use of other medications, hormone levels for estradiol and testosterone (optimal levels of both necessary for desire, arousal and orgasm), underlying disorder, and use of alcohol or other drugs. For example, over 60% of patients on long-term SSRIs have difficulty with orgasm, but most docs don’t ask about it, so they don’t realize how widespread the problem is. It is even worse since psychiatrists began prescribing much higher doses of SSRIs, and combining them with the newer atypical antipsychotics – making it a “double whammy.” Over the years, particularly with SSRIs, anticonvulsants, antiarrhythmics, and most other medications I use, I have found that desire, arousal, and orgasm adverse effects are dose dependent. I have been able to help patients have normal sexual response by slowly lowering the dose, which is possible when hormone balance with estradiol and testosterone are restored to optimal ranges. Again, lowering the dose helps improve sexual function IF the hormone balance is kept in optimal ranges for each person. It helps to evaluate each person to see if the hormone levels and other metabolic measures are in the optimal ranges and what other medication side effects need to be addressed. If we can help you with an in-person evaluation or a Second Opinion consult by phone or SKYPE, please contact us at Vive Life Center!
Yes, this is a common problem I have seen since Femring first became available in the US several years ago.  Over the years of treating many patients with Femring, it was clear that the Femring dropped drastically in estradiol delivery after only one month, not the 90 days the manufacturer advertises. When the Femring wears off prematurely, most patients have abrupt return of disruptive menopausal climacteric symptoms that affect quality of life and function, just as you describe and more! I have been able to document a corresponding drop in serum estradiol level concurrent with the return of the above symptoms. Since nothing else changed to cause this, there is clearly less effective delivery from Femring happening to cause this problem on a consistent basis. This shorter-than-advertised drop in estradiol delivery with Femring has occurred in numerous patients over the years I have used this product for women. I recently was informed by an attorney and patient that she had actually researched the data the company presented to the FDA in the approval application, and found that the company itself had submitted data to the FDA showing that they knew that Femring did not last 90 days (as marketed). You may find these documents here, on the FDA website: If you review these documents on the patent information itself, you will see the patent is for a drug delivery device that will deliver the medicine at a substantially constant rate for 3 WEEKS.  NOT 3 MONTHS.  3 WEEKS. Yet the company still marketed the product for 90 days of stable delivery, and the FDA has allowed this.  So now patients and physicians are in a catch-22: the patient needs stable delivery the product was known NOT to provide, yet because the company and the FDA are claiming that it is effective for 90 days, patients are penalized and denied coverage by insurance companies if they need to change the Femring in less than 90 days. Penalizing the patient is even more egregious now that I know the company and FDA actually had the data to show the Femring estradiol level dropped off significantly at 3 weeks. So in fact, the observations from my patients and my own clinical verification of actual estradiol blood levels confirms exactly what the company reported to the FDA at the beginning of their application for approval, but apparently  was never disclosed to physicians, patients, and insurance carriers.  In all the patients I have treated with Femring since it became available, every single one of them has needed to change it more frequently than every 90 days to maintain symptom control and therapeutic benefit. None of my patients have had adverse effects (symptoms or blood levels) of excess estradiol from changing Femring every 4-6 weeks based on their needs. In fact, quite the contrary: their symptoms have been better controlled and estradiol levels remained in the target range for benefits. Based on the information on file at the FDA from the company, it is not surprising that you need monthly replacement, and my opinion is that should be covered as medically necessary treatment to control your symptoms and provide the benefit of estradiol for your quality of life and health.
It used to be that medical professionals thought men having difficulty with erections primarily had psychological factors causing this, but research has now shown that there are over 100 diverse medical causes for men having difficulty achieving an erection for sex, loss of morning erections, loss of rigidity of erections to allow successful sexual encounters, or difficulty sustaining an erection. TV ads are common to describe medications to treat ED, but what about getting to the underlying cause? That is often a little more difficult for patients, since doctors often are not focused on diagnosing the cause as much as they are on just treating the problem. I prefer to do a comprehensive evaluation of my patients to get to the root of the cause, because many causes of ED also have OTHER serious health risks that may cost both quality of life and longevity if not treated. Diabetes is one of the most common medical causes of ED, and in fact, ED is often one of the earliest “symptoms” of untreated diabetes. Approximately 50-60% of diabetic men will develop ED, especially if blood sugar is poorly controlled. The consensus is that ED in diabetes results from both an autonomic nervous system nerve damage and to the micro- and macro-vascular damage caused by the disease itself. Other endocrine disorders such as high prolactin, hyper or hypothyroidism, and the iron overload disorder hemochromatosis (elevated ferritin) can also cause ED. Low testosterone (Low T) commonly causes loss of early morning erections in addition to loss of normal desire for sex. Low T may also contribute to difficulty sustaining erections, and to loss of normal rigidity via effects on nerves and blood vessels. Low T has many causes – side effects of many medicines such as ones for lowering cholesterol and blood pressure, opiods narcotics, antidepressants, mood stabilizers, antipsychotics, antihistamines, diuretics, and others. Alcohol and marijuana (cannabis) both have marked adverse sexual effects leading to loss of sexual desire and loss of erections. Both drugs increase estrogenic effects in men and lead to breast formation (gynecomastia), shrinkage of testicle size, and decreased production of testosterone. Both drugs affect many pathways involved in normal sexual function, including brain effects and adverse effects on blood vessels and nerve function. The most important thing patients can do is have a comprehensive medical evaluation to determine the cause of ED, and decide the correct, combined treatment approaches that may be needed to restore normal healthy sexual function as well as reduce later disease risks. At Vive Life Center, we are here to help you do that!
Optimal ferritin levels are in the range of 90 to about 120. Ferritin levels as high as this patient had are commonly caused by a genetic disorder called hereditary hemochromatosis. Hemachromatosis is also called “Iron Overload Disorder” and it occurs when the daily absorption of iron from the intestines is greater than the amount needed to replace losses. Our body cannot increase iron excretion, so this means that if more is absorbed from our diet or supplements, it will accumulate in body tissues over time. Excess iron deposits build up in various organs – the brain, joints, liver, testicles, ovaries, heart and other tissues. Over time these deposits cause damage to the organs, leading to a variety of symptoms. Women with hemochromatosis typically develop symptoms about ten years later than men do, since women lose iron in menstrual blood each month and not build up iron in body organs as rapidly as men do. Erectile dysfunction in men can be caused by high ferritin and iron deposits damaging blood vessels. Iron deposits in the heart damage the heart muscle and lead to heart failure, palpitations, or irregular rhythms. In the pancreas, iron deposits interfere with insulin production, leading to a decrease in insulin that can lead to Diabetes. Iron deposits in the liver cause liver damage (cirrhosis) and an increased risk of liver cancer. Iron deposits in the pituitary gland, testicles in men, or the ovaries in women lead to decrease in hormone products that we call hypogonadism (low testosterone in men, low estradiol and lack of ovulation in women) that can cause fertility problems and other health risks due to the loss of these critical metabolic hormones affecting hundreds of functions in our bodies. Based on the reader’s symptoms, I think there are several causes for the problems he is having: • Even though his ferritin is still too high, a very rapid decrease in ferritin from a very high level can cause fatigue, headaches, and vision changes. • The extremely high levels he had earlier can certainly have caused damage to various organs • The high ferritin also likely caused damage to the pancreas, which means some of his symptoms may be related to insulin resistance (pre-diabetes), or full blown diabetes. Both diabetes and pre-diabetes lead to blood sugar “swings” that can cause headaches, vision changes, mood changes, dizziness, irregular heartbeats, and other symptoms. Blood sugar problems can be checked with fasting glucose, fasting insulin, a glucose and insulin drawn two hours after eating a normal meal (called post prandial blood test) and a hemoglobin A1C. • Fatigue, headaches, difficulty thinking clearly may also be caused by low testosterone due to iron overload affecting testicular production of this critical hormone. Testosterone is often overlooked in men as well as women, so it would wise to check blood testosterone levels (saliva tests aren’t reliable for this) to determine whether low levels are causing some of his current problems. Testosterone for men should be checked in the early morning for most reliable readings. I will talk in future columns about the benefits…and pitfalls or risks…of various testosterone replacement options for men….and women too! The key to accurate diagnosis is getting the right tests done. I find that these hormone and metabolic factors are often not checked in standard annual blood tests – for men and women! I have booklets on my website,, to provide more information on what tests should be done to answer questions about the possible causes of puzzling or complex symptoms. Remember, this column is for educational purposes only, and is not a substitute for careful evaluation by your personal physician. If you would like more help on this problem, contact our office for a Second Opinion consult by phone for Dr. Vliet to review your symptoms, medical history, lab tests and help you with recommendations for treatment to pursue with your own physician. @ElizabethLee Vliet MD
If so, you aren’t alone. It isn’t in your imagination. And it is not just “stress.” You probably don’t have “attention deficit” either, though that’s what women are often told. It may be simply perimenopause, menopause or long after menopause. Women in all these stages can have memory loss, and the common culprit can be that your brain fuel, estradiol, is on empty! Meet “Ann” and “Katherine,” two of my patients. Ann was 46 when she sat in my consult room in tears, terrified that she might have Alzheimer’s like her mother did. “My mother’s Alzheimer’s began in her early fifties. Now I am having memory problems, and deep inside I’m afraid it’s Alzheimer’s beginning for me too. I can’t seem to focus on my To Do lists like I used to, I forget names, I go to say a word I know and suddenly it’s not there and I feel stupid. I can’t seem to add like I used to, and my mind wanders a lot. I’m really frightened. I just don’t want to end up like my mother. I do everything right, I take care of my health, and there’s just nothing in my lifestyle to cause this memory problem. That’s why I’m so worried it is the beginning of Alzheimer’s.” Katherine, a sixty-one year old writer, was upset by her growing difficulty finding the right words, and trouble keeping her attention focused on getting a story finished on deadline. She said, “My thoughts are fragmented, and I get distracted so easily. I used to be one of the most focused people I know. My husband said I could tune out a freight train coming through the room. Now, the slightest thing distracts me. My mind feels like it’s flying in a million directions. I’m worried I’m developing Alzheimer’s. My other doctors think I’m depressed or tell me I’m under stress. But I’ve always had a lot of stress and used to thrive under pressures of a deadline. I’m frightened. This isn’t me.” Both Ann and Katherine had high FSH levels and low estradiol levels, typical of menopause. Neither woman had considered the memory problems could be related to menopause, and neither woman had experienced the usual menopausal symptoms like hot flashes. Plus, Ann’s doctor had told her she was too young for menopause. I recommended a low dose of an FDA-approved transdermal estradiol for each woman. A month later, Ann sounded upbeat: My memory is better, I’ve got my mind back! I can think of words and remember names again. The brain fog has lifted.” Six months later, she reported, “I’m back to my normal self. I feel great. I was so scared I had Alzheimer’s. I am so relieved to know that what was happening was just the hormone changes of menopause and I could get my memory back with estradiol.” Katherine said “My ability to focus on my writing has dramatically improved. I didn’t realize until I felt better just how much I had been slipping in my concentration. I can keep on track, the problem with words has gone, and I seem to do fine with organizing my thoughts again. I had no idea low estradiol at menopause could wreak such havoc with mental changes. Why doesn’t anyone talk about this?” Research shows estradiol has multiple memory-enhancing effects on brain neurons, memory-regulating neurotransmitters to preserve our critical thinking, memory, concentration and focus abilities. Here are a few: • Promotes growth of new connections (dendrites) between nerve cells • Increases density of connections between nerve cells to allow better flow of information along brain pathways • Enhances nerve cells ability to take in Nerve Growth Factor • Increases production of choline acetyltransferase, an enzyme needed to make the key memory regulating chemical messenger called acetylcholine • Improves blood flow and oxygenation to brain cells • Acts as an antioxidant and anti-inflammatory to help prevent damage to nerve cells as we age If you’re experiencing memory problems, I recommend these five action steps: 1. Reduce use of “memory robbers” like cigarettes, alcohol, marijuana, benzodiazepines, narcotic painkillers, anticholinergic medicines (e.g., Detrol and others), some mood stabilizers, some antidepressants) 2. Read the free booklet on my website, to help you find the right doctor. 3. Read the free booklet on medical tests on my website Ask your doctor to check thyroid, orvarian, adrenal hormones, vitamin D, and others I listed. 4. If your estradiol is low, talk with your doctor about trying an FDA-approved estradiol patch, gel, lotion, spray or pill – start with a low dose and observe what happens to your clarity of thinking and memory. 5. For more information on the hormone connections in memory, read the chapter on ovarian hormones and your brain in my book, It’s My Ovaries, Stupid! 6. Consider contacting our office for a Second Opinion Consult by phone to review your symptoms, medical history and laboratory studies to have Dr. Vliet make recommendations for you to pursue with your own physician for treatment to help memory and overall health! @Elizabeth Lee Vliet MD 2017
GOOD question! I have found that women who have been on the ethinyl estradiol (EE) in birth control pills (BCP) do in fact often need a higher dose of bioidential 17-beta estradiol (E2) for the transition off BCP. This is due to the fact that 17-beta estradiol that is typically used for menopause is much lower potency than the EE needed for contraception. Due to these potency differences, women who have been on 30 to 35 mcg estrogen (EE) BCP may initially need about 2-4 mg of E2 daily – divided into AM and PM doses to keep the E2 blood level steady of 24 hours and prevent the drop in E2 between doses that can trigger return of hot flashes, headaches, mood swings and restless sleep. Then over the first year off BCP, I typically will gradually decrease the dose to a more typical 1 mg E2 AM and PM daily and see if symptoms remain controlled. Each person is unique, however, so I find I am always titrating the dose for each patient to get the desired symptom relief and blood levels ABOVE the threshold needed to preserve bone and provide all the other benefits of estradiol therapy. If you are not finding the help you need locally, you can always schedule a Second Opinion Consult with me by phone to evaluate your clinical history, your symptoms, your labs, and provide a written summary of recommendations for you to ask your local physician to prescribe. Many people find that if I do the “detective” work to find a solution for YOUR needs, then your local physician is more likely to handle the prescriptions. In order to me to prescribe medications for someone, state regulations require that I first see you in person in my office in Tucson or Dallas to establish you as a patient. I hope that helps! Best wishes, Dr. Vliet
Nice to hear from a former patient! But sorry to hear about the struggles you are having. Taking hormones at the “start” of menopause is helpful for reducing symptoms of hot flashes, night sweats, vaginal dryness and the “crazy moods” that all happen with the wildly fluctuating hormones at the beginning of menopause. But it is ALSO important to continue proper hormone therapy over time to maintain the benefits. Many people stop the therapy when doctors mistakenly say “You’re through menopause, you don’t need hormones anymore.” That is NOT what the international research shows! It turns that that research has confirmed what I have been teaching and writing about in my books all along: Keeping hormones in optimal ranges “after menopause” is important in reducing the problems of worsening weight gain around the middle, worsening allergies/asthma, and even diabetes becomes harder to control in women and men with low estradiol and low testosterone. For example, low estradiol in older women increases risk of diabetes, heart disease, bone loss, memory loss and other problems that rob us of our quality of life and even longevity.. Estradiol affects over 400 functions in the body, so it is not surprising that many problems get worse if women stop hormones. Barbara, it sounds like could use a “tune up” and have an in-depth evaluation on all these aspects as I did for you at the “start” of menopause! I am still in practice, happy to help you regain your health and vitality! Call to arrange a Second Opinion Consult for me to provide individualized recommendations for you to discuss with your doctor.
Pellets are surgically implanted hormone delivery systems that are not FDA-approved but being widely touted as “safer” or “more natural” forms of hormone therapy. Pellets may contain either estrogen and testosterone or either hormone alone. They were popular in Dallas area when I started practice there in 1995. I have seen a resurgence of pellet use in the last ten years with the same adverse effects occurring: • excessively high blood levels of testosterone and/or estradiol • excessive testosterone relative to estradiol for women • unpredictable “swings” in blood levels • unpredictable duration of hormone effects. Some people (“slow metabolizers”) may have pellet side effects for up to a year after the last pellet. “Fast metabolizers” have pellets wear off too soon. People have very different metabolic rates for all kinds of medicines. • lack of consistency over time with variation in pellet manufacture Women using pellets typically are given way too much testosterone and practitioners do not monitor them closely enough to avoid problems. I have seen many women with testosterone levels higher than a therapy goal for MEN! Some of my patients had blood testosterone levels over 300 ng/dl as long as a year after their last pellet! Women given excess testosterone typically suffer from insomnia, irritable agitated moods, anxiety, headaches, weight gain around the waist and upper body, excessive body and facial hair, and muscle pain. Sadly, they typically do NOT have better libido. Men using pellets may also have some of the same adverse effects women do from excessively high blood testosterone levels. Men also face the added risk of stroke if high testosterone causes excessive production of red blood cells (erythrocytosis) making the blood too “thick” or viscous, which causes risk of blocking small arteries in the brain, heart and other areas of the body. I prefer to individualize therapy with FDA-approved bioidentical estradiol and testosterone therapy products to allow doses tailored to a person’s needs, and controlled with daily doses that avoid long lasting effects of a pellet that cannot be removed. Once the pellet is put in, you are stuck with it until it wears off – 3 months, 6 months or longer for some. Rx I recommend for my patients typically are metabolized and gone in 12-24 hours if a patient wants to stop due to side effects. In summary, I think pellets are primarily helpful to the practitioner’s revenue stream, and have potentially serious problems for patients.
MANY areas of the brain (especially MEMORY, SLEEP and MOOD regulating areas) are rich in both estradiol and testosterone receptors - so depressed mood in both men and women can occur when the hormones decline - whatever the cause - aging, alcohol use, narcotic pain meds, statin (cholesterol lowering) meds + other causes.
FIRST, take the Hormone Self-Questionnaire for women or men, or the PCOS Self-Questionnaire and the Fibromyalgia Self-Questionnaire contained in the new patient packet available on our website. Based on your scores, these tests will give you an idea whether your symptoms are hormonally related and whether our services will benefit you. NEXT, read Dr. Vliet’s books to give you background on other patients’ stories, the research supporting her clinical approaches, and her philosophy and treatment options. If you find that you identify with the patient stories in the books, and you “reasonate” with Dr. Vliet’s approaches, then we encourage you to schedule an in-depth evaluation or a Second Opinion Consult. Dr. Vliet is the author of these popular books on hormone issues for women from puberty to menopause and beyond: 1. Screaming To Be Heard: Hormonal Connections Women Suspect …and Doctors Ignore (First edition, M. Evans, 1994) 2. Screaming To Be Heard: Hormonal Connections Women Suspect …and Doctors Still Ignore (Revised and expanded edition, M. Evans, 2001). 3. Women, Weight and Hormones: Are Your Hormones Making You Fat? (hardback, M. Evans, 2003) 4. It’s My Ovaries, Stupid! (Scribner, 2003) 5. It’s My Ovaries, Stupid! (Revised and expanded edition, paperback, 2005) 6. The Savvy Woman’s Guide to Testosterone (paperback, 2005 7. The Savvy Woman’s Guide to PCOS. Paperback, 2006