EBHSG - SEPTEMBER 1996 MEETING NOTES
TOPIC: "HORMONES AND HEADACHES"
Sondra Altman, M.D., a Walnut Creek gynecologist, spoke at the September 10, 1996 meeting about hormones and headaches. 64 people (almost all women) attended this meeting, which was held in the Ball Auditorium at John Muir Medical Center from 7:30 to 9:00 pm.
Following are notes of Dr. Altman’s talk, with this disclaimer: As these notes were taken by a volunteer who is not a medical professional, and it was impossible to take down every word she said, they may not accurately portray the information she presented to the group. If you have questions about a possible link between the menstrual cycle and headaches, consult your personal physician.
Dr. Altman started out by talking about five situations where hormones may be related to the onset of headaches:
Every month there is a cyclical change in hormones in the adult female. Day one of your cycle is the day your period starts. During the first two weeks of the menstrual cycle the estrogen level rises, and then it dips. When a woman is having her period her estrogen level is at its lowest point. If a woman is still ovulating, progesterone rises to a peak. If you’re having bleeding problems, it means your progesterone is out of whack. 30% of woman suffer from PMS (pre-menstrual syndrome), but it is difficult to find subjects to use for studies on PMS.
There are two types of PMS sufferers:
A. Chocolate-craving, weepy, clumsy, tired, suicidal women. These women experience headaches related to estrogen deficiency. Add a little estrogen to balance things out as the estrogen level drops toward the end of the cycle.
B. Salt-craving, irritable, bloated, homicidal women. Women in this second group have problems with water retention, and therefore headaches. A PMS headache is triggered by excessive water retention, which Dr. Altman calls "water on the brain." She told us about two ways to relieve these "water on the brain" headaches:
The most common headache Dr. Altman has seen in her gynecologic practice is menstrual migraine. She used to prescribe Midrin, Fiorinal, or Naprosyn, but now she prescribes low doses of estrogen to combat estrogen-deficiency headaches she sees in her patients.
Estrace is a pure estrogen (estradiol) available by prescription which Dr. Altman thinks is the best estrogen to combat menstrual headaches. It is the best because it can be prescribed in small doses, and can be cut into even smaller doses if necessary. Also, it can be put under your tongue (sublingual dosing) and absorbed into the bloodstream in only fifteen minutes. Dr. Altman has tried taking Estrace herself when she had a headache she felt was caused by an estrogen deficiency, and was floored with the impressive results.
If you think some of your headaches are caused by a too-low level of estrogen, ask your physician. She suggested taking a ½ mg. of estrace if we experience a migraine during the lowest level of estrogen. You might want to try taking an Estrace sublingually and see if the headache is relieved in fifteen minutes. Some women may need to take estrogen twice a day to get best results, as our bodies absorb it at different rates.
Dr. Altman said that some of her patients complained of headaches twice a month, and she realized that estrogen dips twice during the menstrual cycle: During your period the estrogen level is very low, then it climbs for two weeks, and at midcycle, or time of ovulation, there is also a dip in estrogen.
Dr. Altman learned to listen to her patients. She has had patients taking birth control pills which provided them with estrogen and progesterone for three weeks and then during the fourth week they were only taking sugar pills (placebos). During the fourth week they experienced more headaches, which were probably related to the dip in estrogen on those days. Birth control pills may not cause headaches for some younger women, but older women on the "Pill" frequently complain of headaches. This is because the older body’s natural hormones can’t adjust to the rise and fall of the artificially ingested hormones in the "Pill." She suggested that women in their 40’s who use oral contraceptives take Estrace during the placebo days, or fourth week. Dr. Altman said when it works, it works well.
If you get a headache on the estrogen/progesterone part of the cycle—that’s something different, and raising your level of estrogen with Estrace, or another estrogen, will not help.
When you take a tiny dose of estrogen it doesn’t affect your monthly bleeding cycle.
The common belief is that if you have enough estrogen to make a period, you are fanning the flame if you add estrogen. In other words, if you are still producing enough natural hormones to have a period on your own, it is not good to add additional estrogen. Dr. Altman disagrees with this belief, though. She said, "a happy uterus is not necessarily a happy woman."
The fifth type of headache she mentioned is the menopausal headache, which may be caused by an estrogen deficiency. Sometimes, though, menopausal women can get headaches from their hormone replacement therapy, or HRT. Premarin, the most popular brand of estrogen on the market (made from the urine of pregnant mares), tends to make the body retain water (fourteen times more than Estrace, according to studies done on the subject). Therefore, some headaches may be triggered by the water retention brought on by the Premarin. Dr. Altman said if you’re taking Premarin you might want to consider switching to Estrace or some other form of estrogen.
Sometimes taking an anti-testosterone hormone will make headaches go away. The ovaries make some testosterone. Estratest is an estrogen/testosterone combination, but this one is not good if you get water retention headaches.
Doctors have treated the following statement as law for many years: If you are on hormone replacement therapy, and still have a uterus, you must take progesterone. (Progesterone is the hormone that brings on your period, after estrogen builds up the lining of the uterus each month.) You must not allow the lining to get too built up or the risk of endometrial cancer escalates. Dr. Altman said that doctors are starting to loosen up on this point.
Some women find it hard to tolerate synthetic progesterone, which Dr. Altman said is probably a water-retention phenomenon. There are two progesterones in birth control pills.
Progesterones are available in creams (over 50% don’t work well) or may be taken orally.
Dr. Altman told us that estrogen is good for your cholesterol level. Provera blunts the good that estrogen provides. Natural progesterone, however, doesn’t affect cholesterol.
Surgical menopause requires immediate estrogen replacement therapy. Testosterone-making capability is also lost, and testosterone needs to be replaced.
The stress of surgery may also cause a need for hormone replacement (or an increase). If you don’t take estrogen, ultimately you will end up with more testosterone.
Dr. Altman then fielded questions from the floor. Dr. Stein asked her about her experience in prescribing an estrogen patch versus estrace tablets. Dr. Altman said that with the patch there is no fluctuation in hormone level. However, the week-long patch doesn’t necessarily last all week for everyone. Everybody is different. She also said: If the patch doesn’t work for you, try the pills; or if you’re taking the pills and they don’t work well, try the patch. She stressed that every body is different and it takes some experimentation.
Dr. Stein also asked Dr. Altman about headaches during pregnancy. Dr. Altman didn’t have anything to say about that, so she polled the audience. A large majority of the women at the meeting said they did not experience migraine headaches during their pregnancies.
Dr. Altman said that five of her patients seemed to be cured of their migraine headaches after she performed hysterectomies.
If you have a history of breast cancer, what do you do when you’re told not to take estrogen? Dr. Altman said there is no data relating hormone replacement therapy to breast cancer. She said that women with high blood pressure should be on estrogen for life.
Taking estrogen for migraine only works if the migraine is triggered by low estrogen. It doesn’t make up for drinking wine, etc.
To get to menopause sooner, she said to smoke cigarettes and drink a lot of milk.
What am I doing to myself if I don’t take estrogen during and after menopause? You may be at risk for osteoporosis (loss of bone density), heart disease, and Alzheimer’s disease. The risk of heart attack is reduced by 40% if taking estrogen. There are two non-estrogen alternatives:
Dr. Altman said "the buffet table is filling in—there are more desserts, etc. (i.e., more options for women today). The main symptom of menopause for women in China is shoulder pain, whereas in the United States it is hot flashes. Try changing one thing at a time to see which it is. Getting the right HRT is like buying a new pair of shoes—you have to try it on.
Depo-Provera: once every three months. Try oral Provera first, because once you have the shot, you’re stuck with the side effects for three months.
There are different progesterones, including Agestin, which is similar to the progesterone in birth control pills. The smallest dose is 5 mg. (1/2 tablet). Dr. Altman also mentioned micronized natural progesterone.
Dr. Altman told us about a free community education seminar on Women’s Health in the Middle Years, scheduled for Saturday, October 12, 1996. Dr. Nancy Snyderman is the keynote speaker and Dr. Altman will also give a presentation. Unfortunately, space was limited for this program, and as of this writing, the seminar is filled.
The notes provided above were taken by an East Bay Headache Support Group volunteer and have not been reviewed by the speaker for accuracy. If you have any questions regarding the notes, please contact the EBHSG.
The intention of the East Bay Headache Support Group is to provide information and resources. It does not provide medical advice, which should be obtained directly from a physician.