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New Menopausal Client: Where to Begin?

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PRACTITIONER QUESTION:

My client is 53 years old and has just gone through menopause (no period for 1 year).  I would like to clarify what you would advise the first step be, when I speak with my client on our first session.  Here are relevant issues I noted based on info I could find in the database:

  • Menopause – she has gained 10 pounds in the last year
  • She has been running for the last 8 months in an effort to lose weight, but has only seen herself gain more – perhaps excessive exercise?
  • Client drinks alcohol in the evenings (would be hard for her to give up)
  • Drinks coffee every morning
  • Wakes up in the middle of the night with hot flashes
  • Said for the first time in her life she has belly fat

She has fatigue and had a partial thyroidectomy back when she was 28 (overactive, never diagnosed as Grave’s).  I know you recommend ground flaxseeds and chastetree berry.

In terms of education and recommendations, how much can we effectively cover in the first session?   On one hand, I want to take a slow-but-steady approach, but on the other, I just really want her to see results up front so she can get excited about her health.  With your clients, do you usually recommend they wean themselves off of certain items that are contributing to their challenges, or go cold turkey in an effort to heal?   What would you recommend for breakfast? She typically eats either a bagel, toast, or oatmeal so I was thinking of having her start with sticking to the oatmeal and adding the flaxseed as an easy first step.

What would you advise?  I am also interested in learning more about your overall style of running client sessions.  What are key aspects you would mentor me to be aware of in creating an effective session?   And what clinical courses might help me to learn more in depth about this kind of issue?

 

TRACY’S ANSWER:

Keep in mind that women can have drastically different experiences going through menopause, so making detailed note of your specific client’s complaints and needs is critical (vs. any generalized “approach to menopause”).  The Demystifying Hormones clinical course covers this topic in great detail. 

Various clients prefer all sorts of different pacing and detail in their sessions.  I would not cover more than 3 topics in a single session, but I would definitely do more than one, especially right as you begin.   Regardless, check in with them at the very end of your first few sessions until you are well aligned.  Ask, “How did this feel to you?”  Say “Everyone is different.  I want to make sure this pacing feels good to you, as I can easily work more aggressively or more moderately, depending on your needs.  Does what we talked about today feel workable for you to complete in the next two weeks?  Do you feel comfortable? ”  In my experience, it’s best to err on the side of a bit more information (more perceived value), and then it’s key to seek their feedback on pace overtly.

Because rapid relief is critical to galvanizing a new client’s commitment to working with you AND their belief in their ability to feel better, I focus on supporting them with their top complaints.  I also think a focus on education is particularly key overall but especially in the first session.  A key tenet is how much the overall body changes in response to menopause but that menopause is not a “medical event”.  What felt like an optimal lifestyle *before* is likely not going to serve her optimally now at all.  So the body is asking us to be open to change.  We are also moving from an ovary-dominant phase of life to an adrenal-dominant phase of life (more on this below).  Imbalances that women have been ignoring/tolerating in the past may worsen and become impossible to ignore now.  Help to create a positive and powerful placebo effect by positioning this as an opportunity for awareness and growth vs. a frustrating, annoying, disruptive time of life.

Choosing a “weaning” or “cold turkey” approach is highly dependent on the personality and mindset of each unique client.  Don’t guess.  Ask them what they believe works best for themselves in terms of making sustainable change.  I usually start with a cold-turkey proposal and then adjust my approach based on their reaction.

Given what you share, I might focus on all of the following in the first 2 sessions, covering a few topics with a particular focus on education:

In your first session, I would discuss the fact that post-menopause, the adrenal gland is the only tissue that makes notable progesterone.  In fact, the ovaries do continue to produce small amounts of estrogen, and of course, adipose tissue (body fat) is endocrine tissue and continues to provide estrogen.  While overall hormone levels go down in menopause, having a balance between estrogen and progesterone is still important!  So hormone balance in menopause is highly dependent on effective stress management (mindset to prioritize one’s care and ease is key!).  Regular and sound sleep, self-care, having support…all of these aspects become more important, not less.  With ongoing stress,  the HPATG axis will shift hormone balance from the adrenals, providing insufficient progesterone to keep estrogen receptors primed.   Women can indeed have estrogen-dominance due to rock-bottom progesterone (and perhaps overload with xenoestrogens) but still have hot flashes due to dramatic *fluctuations* in estrogenic effects.

Keep in mind that beverages like coffee and alcohol are not necessarily negative lifestyle choices, but in the case of hot flashes, they can both definitely be exacerbating factors.  These are common!  But they can be daunting choices given ongoing “coping” habits.  Remember to focus on education and see what choices are inspiring to this client.

  • Weaning usually works best for coffee (vs. cold-turkey elimination).  See if she is open to switching from coffee to black or green tea.  Exploring a variety of teas can be a run distraction from drinking less coffee.
  • Explore with your client how much and how often she drinks alcohol.   See if she is open to just a 5-day trial of drinking no alcohol at all to observe how it does or doesn’t change her body’s response.  An “experiment” proposal like this often feels much less daunting to a client than the prospect of “maybe you should stop drinking alcohol”.   Or if that’s not acceptable, perhaps a trial of drinking only every third day (to see the contrast) and not drinking beer or wine specifically (which tend to be worse in terms of triggering hot flashes, especially red wine) but rather a lower-sugar drink based on distilled spirits (e.g. vodka with soda water and a splash of cranberry juice).
  • I have had many clients who noticed dramatic reductions in hot flashes simply by drinking less alcohol (or by at least not drinking wine at all) and drinking less coffee.

Blood sugar fluctuations will exacerbate hot flashes.  It’s important that her breakfast include some protein and a good dose of healthy fat.  Indeed, I would eliminate the bagels/toast entirely.  Following your line of thinking on starting with something she likes, perhaps a small portion of oatmeal (with the ground flax  – an easy way to incorporate it) along with 1/4 cup of mixed seeds/nuts is a better choice.  However, I would indeed right away explore if she is also open to experimenting also with a higher protein breakfast (e.g. two eggs with some mixed greens, sprinkle of seeds, and perhaps some avocado and other fruit) for a few days in a row to see if/how it makes her feel better.  Post-menopause, many women find the need to modify their diet to a lower glycemic one in order to retain the metabolism they enjoyed pre-menopause.   I usually recommend eliminating all sweetened beverages and all grain flours with a strong focus on vegetables, nuts/seeds, fruits.  Make sure that she is not choosing dinner foods that are likely to results in a blood sugar crash several house afterward (e.g. pizza, pasta, sugary dessert) further disrupting sleep.  Fasting insulin and HbA1c are straightforward markers which might give her greater insight into any insulin resistance (more in-depth testing such as a glucose tolerance test are an option to characterize it further if issues are indicated by this data).  The Reversing Diabetes clinical course covers this topic in detail.

Yes, I agree with adding 2 Tbsp daily of ground flaxseed.  You mentioned chastetree berry which, I find, tends to help more women in perimenopause than post-menopause (while the ovaries are still producing some progesterone).  In this case, I would recommend maca root (ramping slowly from 1 tsp, 2x/day whisked into water up to as much as 1-2 Tbsp, depending on the individual).  Herbal extracts such as dong quai, red clover, and black cohosh can all be helpful in boosting estrogen; some women need over time to ramp up to use 2-3x the typical dose of these types of supplements in order to see a therapeutic effect.

I would also cover the potential value of lab data, whether you cover that in your own scope of practice or simply want to educate her on the value of advocating with her physician her desire to learn more about her body.  It is typically better for labs to be run soon in order to capture an accurate baseline vs. later after numerous changes have been implemented.

In terms of the big picture, I think it’s absolutely critical to get a current thyroid panel for this client (specifically at least TSH, Free T4, Free T3, Reverse T3, and TPO/Tg antibodies).  With the prior history of (usually autoimmune) hyperthyroid, there may be another AI dynamic at play driving some of her weight challenges.  You don’t mention any medications, but with a partial thyroidectomy, she might be taking some sort of thyroid hormone replacement (typically a synthetic T4-only drug) that may not be working optimally for her now at all.  All hormones affect each other.  Highly fluctuating estrogen levels or net estrogen dominance (a common state for obese women in menopause due to very low progesterone) may now be affecting her previous thyroid stability (e.g. levels of bound vs. free hormones or levels of cortisol that are highly elevated or suppressed).   I am particularly suspicious of these dynamics regarding her weight gain.

I also recommend a urinary hormone test (e.g. DUTCH).  Conventional medicine focuses primarily on estrogen in menopause, but indeed low cortisol (from sustained stress) and low progesterone (also due to menopause, but perhaps exacerbated by stress as well) often play a dominant role in symptoms.   I often find that my clients who struggle with hot flashes almost entirely at night (vs. during the day) have low overnight cortisol (due to low adrenal output), and this is a root cause that must be addressed directly for relief.  Ample cortisol is key for maintaining optimal blood sugar during periods of fasting.   The body may experience a surge of adrenaline (perceived as a “hot flash”) if cortisol is too low in an effort to force the liver to release/convert glycogen to glucose.  If there is insulin resistance and higher fasting insulin, this dynamic will just be exacerbated.  The Adrenal/Thyroid Myth and Truths clinical course covers these topics in great detail.

You are right that aggressive exercise might not be helping her, but I would likely leave this topic to a follow-on session, as it can often be more daunting to give up an activity that contributes endorphins for stress relief (and continuing this regimen may just give her enough support to allow the alcohol elimination trial).  It will be key to have in mind a palatable alternative substitute when you have this discussion (e.g. moderate yoga, weight-training).  Sometimes having adrenal lab data can also help to educate and inspire the client that the body is asking for change.

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7 Questions for “New Menopausal Client: Where to Begin?”

  1. 4
    Ellen Metzger says:

    Is there any reason why a thyroglobulin level would be elevated – repeated twice 69 and 72 (usually a cancer marker for someone WITHOUT a thyroid). All other Thyroid labs WNL (TSH, Free T3, Free T4, Antibodies). May it be related to Iodine – labs from years ago revealed low iodine. Hx of low Vit D as well.
    An additional piece of information is a thyroid ultrasound 5 months ago, revealed
    thyroid nodules, a few less than 1 cm.
    Interested to know why the slightly elevated Thyroglobulin – with an intact Thyroid. And the relationship this findings may have. Treatment recommendations, prevention of modules increasing, further lab work ups, etc?
    Thank you!

    • 4.1
      SAFM Team says:

      Thyroglobulin is a primary protein produced by the thyroid gland in all healthy individuals and it is a precursor to both T4 and T3 thyroid hormones. Normally, its serum levels are low, and elevation in thyroglobulin levels can be pointing to thyroid dysfunction, but it’s not possible to tell what type of dysfunction that is based on just this one marker. This is a good compilation of information on this laboratory marker:
      https://labtestsonline.org/tests/thyroglobulin
      To expand the puzzle that you are building I would check the iodine levels again and make sure that it D is optimal. To ensure sufficient levels of key thyroid-supporting nutrients such as zinc, iron, selenium, vitamins E, B2, B3, B6, C, and D you could choose to run a Spectracell panel and if any these come back low, ask WHY are these low – is it because of poor intake, issues with digestion and absorption, or is there something that’s ‘draining’ those nutrients (high need for running detoxification, for example). I would also be asking if there are adrenal or sex hormone imbalances affecting the thyroid function. Too much or too little cortisol will prevent even healthy thyroid hormone levels from exerting their action on the cellular levels. Similarly, an excess of estrogen will block the intracellular action of thyroid hormones. Last, but not least I would work with a doctor and continue observing the nodules as those are a clear sign that the thyroid needs attention (more nutrients? less stress? less sugar, better fats?) and if those are benign you want to get to the bottom of why they got developed in the first place and protect the thyroid from developing any type of malignancy. In case you haven’t experienced the ‘Adrenal and Thyroid: Myths and Truths‘ course yet, I highly recommend it for a deep dive into all that I Just laid out: https://www.schoolafm.com/clinical-courses/

  2. 3
    Jill McEachern says:

    Hi,

    This is from the Puzzle Piecing Where to Start webinar: “Low vitamin D can cause night sweats. Too much vitamin D, in late perimenopausal or menopausal women, can cause hot flashes. So, it’s a good reminder that there is a sweet spot for vitamin D. “.

    Not having experienced one myself, would a woman waking in the night know if she had had a hot flash (possibly from excess Vit. D) versus night sweats (low Vit. D)?

    All told, menopause sounds like a “hot” phase of life! I’m 50, so here’s hoping!
    Thank you.

  3. 2
    Samantha Hall says:

    To fully understand, is the plan to attempt alcohol elimination specifically because of the sugar content and the clients weight gain issue, or is there something more complex relating to alcohol and its effects on the hormones. Of course I realise alcohol is toxic, specifically for the liver and the brain, and appreciate that nightly dependence, and especially if intake is excessive should be addressed for these reasons regardless of any symptoms, thank you

    • 2.1
      SAFM Team says:

      Yes, you’re mentioning all the right reasons, Samantha why limiting alcohol would be helpful with helping a newly menopausal client balance sex hormones. Another reason for this limit is the fact that alcohol processing takes up precious hormone detoxification pathways in the liver, which in turn can be promoting further sex hormone imbalance that leads to many unpleasant menopause symptoms. This is a good article for a deeper dive on this topic:
      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1949018/

  4. 1
    Linda Delmore says:

    Thank You, Thank You, Tracy for all your passion and knowledge. Great insight for the DUTCH test and how it can help navigate us with our eyes open, instead of guessing. And the importance of metabolizing and excreting hormones properly.

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