MARCH 1998 MEETING
TOPIC: "MENOPAUSE AND HEADACHES"
The East Bay Headache Support Group met on March 10, 1998 to hear John C. Arpels, M.D., a well-known gynecologist from San Francisco, talk about menopause, hormones, and headaches. The meeting was held in the Ball Auditorium at John Muir Medical Center, with 53 people in attendance (naturally mostly women, but a few men were present).
Dr. Arpels said headaches can be caused by a woman’s menstrual cycle and hormone replacement therapy (HRT), as well as other triggers. Menopause is the pause of menses which is a natural aging process. At about Age 38 the hormones produced by a woman’s ovaries reach their peak, and then there is a gradual decline. Even with regular menstrual cycles, one can have uneven levels of estrogen.
The peri-menopausal period may take from 2 to 7 years (when the hormones secreted by the ovaries are declining), and then when menstruation ceases the woman is said to be menopausal. A woman who is post-menopausal can suffer from dementia, osteoporosis, dryness, heart disease, etc.
We are on the cutting edge of preventive medicine. Americans spend $30 billion dollars per year treating women with hip fractures, $60-80 billion per year on complications of heart attack and stroke, and over $100 billion per year on dementia/Alzheimer’s.
25% of women will never need hormone replacement therapy, but 75% of women will need some HRT.
Even those who don’t need HRT to relieve the symptoms of menopause should be concerned with other diseases brought on by reduction of estrogen:
• Bone health. There is now a basic urine test to detect bone loss (cost: $48 versus $150 for a bone density test (which is not as good anyway because it looks at a person’s bone health over the past fifty years, not just at present).
• Cardiovascular disease.
• Dementia.
Estrogens have an impact on the following health problems. For women taking hormone replacement therapy, there is a reported:
80% reduction in osteoporotic fracture.
50% reduction in hip fracture.
45-60% reduction of fatal heart attacks and stroke.
30-60% decrease in dementia.
Taking estrogen may cause breast cancer, but how much is not clear yet. There is currently a 35-center study going on now following 174,000 women. Scientists are trying to determine the relationship between HRT and heart attack, dementia, and breast cancer. The study will end in 2003, with published results expected in 2004.
What does estrogen do for the female body? Estrogen increases the blood flow in every organ, including affecting the middle cerebral artery and ocular artery (this causes migraine).
Estrogen increases the blood flow by decreasing resistance in the blood vessel. When the muscle is relaxed, blood flows easily. Estrogen gets the muscles to relax, thus increasing the blood flow.
Some effects of lack of estrogen in the female body:
Skin: dryness, bruisability, feeling of ants crawling on skin (the medical name for this is formication), thinning, Reynaud’s disease,
Hair: brittle or dry, thinning, loss,
Nails: brittle, ridged
Gums: bleeding, gingivitis
Ears: tinnitus, dysequilibrium
Estrogen brings oxygen to the organs, and takes out byproducts.
By studying many women with migraine vascular headaches, doctors have found that a decrease in blood flow will bring on the headache.
The most common time to suffer a hormonal headache:
4-5 days before the menstrual flow (pre-flow migraine).
Second most common time for headache:
Day 14 of menstrual cycle. There is a drop in estrogen that lasts a day and a half.
When doctors first started prescribing hormone replacement therapy, using a 30-day cycle, they would give a woman estrogen on Days 1-25, and then no estrogen for five days. This commonly brought on a migraine headache. Also, women who use birth control pills are instructed to take them every day for 21 days, and then take a week off. This also would frequently bring on a headache.
Dr. Arpels talked about HRT and arterial blood flow: There is a 20% increase in blood flow when using an estrogen patch.
Progesterone is an anti-estrogen. When a woman still has her uterus and she is taking estrogen, in order to reduce the chance of developing uterine or endometrial cancer she must take progesterone certain days each month to bring on a period (i.e., to slough off the endometrial lining that has built up with the daily use of estrogen). During the days progesterone is taken, there is a 12% drop in the woman’s blood flow. Dr. Arpels said when progesterone is taken, one should counteract its effects by taking extra estrogen.
The administration of these hormones needs to be smooth. Oral doses cause a rise and fall, whereas estrogen and progesterone administered with a skin patch give a smoother application. Dr. Arpels stated that women migraine sufferers tend to do better when their HRT is administered with a patch. There are four hormone patches on the market. In case you find you are allergic to the adhesive used to affix a certain patch, try the others until you find one that works for you.
24-48 hours before a hormonal headache is expected (Dr. Arpels said a migraine headache develops 1-2 days before you experience the pain), try this: Add extra estrogen so your estrogen level doesn’t fall as fast or as deep, and keep taking extra estrogen during the days you take progesterone and even 1-3 days later. This is called finessing. A doctor treating a woman going through menopause will try to figure out her pattern and play to it. Dr. Arpels said, "We’re not always successful, but we have a bag of tricks to try."
Scientists have developed an ultrasound-type machine to show decrease in blood flow. It is so sensitive that they can administer estrogen sublingually (under the tongue) to a woman and within 60 seconds the machine can pick up an increase in her blood flow.
For hormonal headache sufferers, there is a possible 65-80% decrease in intensity and frequency of headaches when one adds estrogen on certain days (finesses).
Dr. Arpels stated, "HRT is under our control--easily anticipated."
The Future of HRT: According to Dr. Arpels, in the past year we entered an exciting era where doctors may be able to give patients alternatives to standard estrogen. There are two estrogen receptors. Scientists are working on designer estrogens, where molecules have been designed using computers. Scientists can manipulate the way estrogens work in different tissues by controlling the receptors. They could tell the estrogen receptor to work more on the bones, heart and brain, but less in the uterus and breast, thus reducing the risk of cancer. Dr. Arpels told us this was called "SERMs, or Selective Estrogen Receptor Modulators." The first SERM released was in January 1998, and was called EBISTA.
Scientists are studying the women of Japan. Did you know there is no word in the Japanese language for menopause? Only 25% of older Japanese women report experiencing hot flashes, whereas that figure is 85% in the U.S. There is also little osteoporosis, less migraine headache, and Japanese women have the lowest incidence of heart attack, stroke and breast cancer. Actually, there is also little uterine cancer; and Japanese men have a low incidence of prostate cancer.
There appears to be a relationship to the diet of the traditional Japanese women and their low incidence of heart attack. stroke and cancer as they grow older. A diet rich in tuber roots, legumes and grains, like the foods eaten by early man, gives the body lots of phyto-estrogens. These are powerful anti-oxidants that increase blood flow, reduce bone loss, and maintain a good/bad cholesterol ratio. In the Japanese, when a woman’s estrogen level drops as she ages, the plant estrogens fill in the gap.
To approximate the phyto-estrogen intake of the traditional Japanese diet, one would have to consume 3-5 pounds of tofu, misu, soymilk, or soybeans (or take two scoops of powder).
Scientists have developed a pill to provide phyto-estrogens, called "Promensil." It will be released in April/May 1998 as a food supplement for the American public. Last year tests were conducted with 100,000 Australian women, and 80-85% of them are still taking it because they saw beneficial results. Promensil is made of concentrated extracts of field clover, and provides one with the equivalent of an average daily soy intake of a traditional Japanese diet. Dr. Arpels said that phyto-estrogens have anti-cancer properties also.
He believes standard estrogen therapy is good, but there are expanding alternatives. He mentioned St. John’s Wort, which can be helpful for mental function.
There are quality of life issues and preventive care issues.
After Dr. Arpels formal presentation he opened it up to questions from the audience.
Dr. Arpels was asked about women who suffer from menstrual headaches, but once they go through menopause they find their headaches are different, or non-existent. He said that at menopause the incidence of vascular headaches (migraine) tends to go down, and that tension headaches increase. It is the drop in estrogren that triggers the headache. Once a woman is menopausal, her hormones are smoother, unless she begins hormone replacement therapy which then makes the hormones go up and down again.
Dr. Arpels said you don’t have to be menopausal to benefit from HRT. Doctors are supplementing the body’s natural hormones with HRT during the peri-menopausal years.
He was asked if Promensil would fill the need for supplements pre-menopausally, and he answered, "More than likely." Promensil works subtly pre-menopausally and has a bigger effect on post-menopausal women.
There are four main phyto-estrogens, which need to be broken down (metabolized) by enzymes in the gut. Some people don’t have these enzymes.
No one plan fits all. A woman may need to take Promensil 4-6 weeks before seeing an effect.
Larger bodies will need a larger dose. Dr. Arpels said a woman over 155 pounds would need to take one pill twice a day, but a smaller woman would take a pill only once a day (with a meal). He said the dose could be increased if needed on certain days.
Dr. Arpels was asked if Promensil could be taken by teenage girls. He said he couldn’t answer that question as he hasn’t studied teenagers.
There are four female ovarian hormones:
Estrogen
Progesterone
DHEA
Testosterone
Testosterone works along with estrogen to promote psychological well-being, female aggressiveness, libido and sexual fantasy. Too much testosterone in skin results in acne.
25-50% of testosterone is made in the ovary and the rest is made in the adrenal gland.
Cells that make estrogen age first, progesterone second, and testosterone last.
When a patient comes to Dr. Arpels complaining of low libido, he will add estrogen to bump up her natural testosterone, and then add testosterone if necessary. But testosterone can cause side effects if too much is added or if it is added too fast. Dr.Arpels said the "rapidity of rise is what causes side effects." Some women don’t mind the side effects (extra hair, etc) because they like what it does for them.
Dr. Arpels was asked to comment on the anabolic effect, which is the muscle building effect of androgens (male hormones). He said 100,000 males and females play with anabolic steroids. It is bad on the liver and lowers good HDL cholesterol level. But he said an abusive dose is 20 mg and up, whereas a 5 mg dose may be prescribed by a physician for HRT.
What about topical estrogen creams? Dr. Arpels said the estrogen absorbs nicely through the skin, and the creams work as well as a skin patch. He did mention, though, that topical progesterone creams don’t protect a woman from uterine cancer as an oral dose does.
What about too much estrogen? Dr. Arpels said one can get a vise-like headache from taking too much estrogen.
There are two switches in the brain: on and off. Estrogen activates the on switch (on one side of the brain) and progesterone activates the off switch. If the brain is in the off mode and you add a tranquilizer, you’ll be even lower.
A neuro-steroid is progesterone made elsewhere.
The incidence of prostate and breast cancer are very close--same high death rate. Phyto-estrogens may help to reduce colon, prostate and breast cancers.
Promensil is not on the market yet, but at the health food store now you can find a phyto-estrogen powder called Supra which is made by Protein Technology International, a subsidiary of DuPont.
Dr. Arpels was asked about blood tests and saliva tests to determine if a woman needs HRT. He said they were very unhelpful. Doctors really need to know the woman’s range from about age 30 as well as her present range. "The best blood test is a woman who’s taken good notes," said Dr. Arpels.
There are three estrogens: Estradiol, estrone, and estriol. Estradiol is secreted by the ovaries, and stays in the receptor 20-24 hours. Estrone stays in the receptor 12-14 hours, and estriol only 2 hours.
If you’re going to use DHEA a blood test must first be taken.
Dr. Arpels was asked what hormones a woman who had a hysterectomy and oopharectomy (removal of uterus and ovaries) at age 36 should be taking. He said she doesn’t need progesterone, but needs estrogen, testosterone and DHEA. "When you’re not given hormones, it’s like not giving drugs to a drug addict--the body screams at you."
He would advise a woman about to go through this operation to have a blood test taken before the surgery. Measure the hormone level during Days 1-3 (lowest days of cycle) before the hysterectomy so afterwards the doctor can know how much hormones to add back.
The slower the estrogen, testosterone, and DHEA levels drop, the easier the body can get used to the drop.
Dr. Arpels was asked about postpartum depression. He told us the ovaries go to sleep as soon as you get pregnant. But then, after delivery when you are sleep-deprived and are experiencing the stress of caring for a newborn baby, plus you experience a 100-fold drop in estrogen in the brain, postpartum depression can set in. Your estrogen is also low during the period you are breastfeeding.
Dr. Arpels mentioned a vicious cycle that some woman have had to contend with. Women with migraine tend to have decreased fertility, and so they have to take fertility drugs to get pregnant. But fertility drugs can increase your risk of ovarian cancer, so doctors prescribe the Pill in an effort to prevent ovarian cancer. The Pill, though, gives the women more migraines.
There is a theory that the more times a woman ovulates, the higher the risk of ovarian cancer. Therefore, if a woman is on the Pill for 12+ years her risk of ovarian cancer decreases by 80%. The risk of ovarian cancer is 1.4% over a woman’s lifetime.
One member of the audience told Dr. Arpels that she started getting migraine headaches only after she went through menopause. Dr. Arpels suggested she might have an arthritic spur in her neck, or she could be getting extra estrogen in a beauty product, or the headaches could be caused by something else.
Dr. Arpels was asked if a woman took HRT for years, would she get headaches when she went off HRT? He answered that if you go off HRT you need to do it very slowly--over a period of 3-4 weeks. Don’t stop it cold, even if you’re diagnosed with breast cancer.
Once Promensil is available and you want to try it, Dr. Arpels suggested that you increase the Promensil slowly while you gradually decrease your replacement hormones.
The most common replacement estrogen is Premarin, which is made from pregnant mare’s urine. There is also a Mexican wild yam which can be made to look just like estrogen made by the ovaries. Estrace is estradiol, but then the gut converts it to estrone. Dr. Arpels said if you are taking estrogen for your brain (better memory and problem solving abilities), it is best to take estradiol.
Hormone replacement therapy administered with a patch was then discussed. Dr. Arpels has seen lots of brittle patients. He recommends the skin patch because of its smooth, 24-hour dosing. They are like band-aids which you can cut into any size so you can take whatever dose is necessary on a particular day. When you take HRT orally you never know how much is actually absorbed into the bloodstream. The downside of the patch is that 15-25% of patients experience skin irritation, and if one’s skin is oily the patch won’t stick well.
If you take too much estrogen your brain is over-revved and you are buzzed, and not enough estrogen will cause you to wake up at night.
Dr. Arpels was asked about the rumor that natural estrogens (used in Europe) are less likely to cause cancer. He said that has been disproven. Premarin is the only estrogen that is not natural. Estradiol comes from the Mexican wild yam and testosterone and DHEA come from soy.
What does Dr. Arpels recommend for a woman who suffers from headaches? He said for vascular headaches he would give estrogen (if your headache responds to Imitrex it is a vascular headache). If it is a prostaglandin headache he would give anti-prostaglandin medicine. Dr. Arpels says he has a good track record with patches and he would recommend a patch for administration of estrogen.
He was asked about his experience with progesterone dosage forms. Dr. Arpels said that 80% of the progesterone taken disintegrates in the gut or liver. Progesterone sits in the estrogen receptor 6-12 hours, and the synthetic Provera sits in the estrogen receptor for 20-24 hours. You have to take three times as much to get past the gut (if taken orally) and 1.25 times if it is injected versus taking it sublingually (under the tongue). Progesterone causes water retention and bloating, especially if taken by mouth or sublingually; water retention is less if given by injection. He said the best new kid on the block is an intra-vaginal dose of progesterone. It is absorbed by the vagina, then goes to the uterus, and then to the gut and the brain. One problem progesterone has is that is only sits in the receptor 4-6 hours.
Now there is a time-release progesterone. Crinone 8% and 4% is the only FDA-approved vaginal progesterone. It is like a skin patch for the vagina. The problem is that it is very expensive and it is only approved by the FDA for the treatment of infertility or secondary amenorrhea, so the HMO’s won’t pay for it. He said that women migraineurs respond badly to every progesterone product except Crinone.
In ending his presentation and question and answer session, Dr. Arpels finished with the statement, "The more tools we’ve got, the better off we are. You just need to try."
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.