Endometriosis is a condition that affects many women.  It is estimated that about 10% of females ages 15 to 49 are affected.  I think this percentage of women with endometriosis is much higher than 10%.  That is because the only sure way to be diagnosed with endometriosis is to have laparoscopic surgery.
There are many signs and symptoms of endometriosis, but they tend to overlap with other hormonal imbalances.  Often it is confused with fibroids, ovarian cysts, and painful, heavy periods to name a few. And like I said, the only sure way to know is having surgery and finding endometriosis in the pelvic cavity.  

What is Endometriosis?
Endometriosis is the lining of the uterus has seeded itself elsewhere in the body.  The top lining of the uterus is called the endometrium. It is the cells of this lining (endometrium) that is found outside of the uterus.  Common places endometriosis is found:
-Fallopian tubes: Sometimes it can cause scar tissue on the fallopian tubes reducing fertility or can contribute to an ectopic pregnancy (which is a health emergency).

Ovaries: commonly it can cause ovarian endometrioid cysts.   
Colon
Cervix
Vagina
Bladder
Some rare reports have shown in the lung cavities and other organs

Why is there Uterine Tissue Not in the Uterus?
There are many conflicting theories on why the endometrium lining that is supposed to be in the uterus is elsewhere in the pelvic cavity.  A long-held theory is in utero when cells are developing; uterine cells are seeded in other areas outside of the uterus. A more recent theory is there is a  retrograde of flow during a period. The blood backs up and out of the uterus causing uterine cells to plant themselves anywhere in the pelvic cavity.
New hypotheses are endometriosis is an extension of autoimmune and inflammatory diseases. But plenty of people do not have endometriosis.  Why some do and not others? Like mentioned above it could be genetic, autoimmune, lifestyle, retrograde mechanical flow, etc.
The old-school theory of developing in utero has pretty much been put on the shelf.  Endometriosis often comes back after laparoscopic surgery. Sometimes it comes back slightly, moderately or its back with a vengeance after surgery.  Which is why many women with endometriosis have had more than one surgery.

The big question: What Does Endometriosis Feel Like?
Pain: Pain is the number symptom that women with endometriosis are seeking answers.  There are several types of pain that are experienced in endometriosis. And the pain is no reflection of how much endometriosis they have in their pelvic cavity.  Some women have minimal endometrial lining seeded outside of the uterus. But report debilitating pain. Other women have stage fo

What Are Liver Enzymes?
Liver Enzymes are made by cells throughout the body but are found in highest concentrations in liver cells. These enzymes are found inside liver cells, so when the concentration is elevated in the blood, usually indicates liver cells (hepatocytes) are inflamed, damaged for dying. Below is a list of the four common liver enzymes that are routinely tested on an annual basis or monitored due to certain medications, such as Statin drugs and acetaminophen.

Liver Enzymes: 

Alanine transaminase (ALT) / Serum Glutamic-Pyruvic Transaminase (SGPT) 
Aspartate transaminase (AST) / Serum Glutamic-Oxaloacetic Transaminase (SGOT) 
Alkaline phosphatase (ALP)
Gamma-glutamyl transpeptidase (GGT)

Liver Enzyme Reference Range: (Quest Diagnostics)

Liver Enzyme Test

Male
Female

AST

10 – 40 U/L
10 – 35 U/L

ALT

9 – 46 U/L

6 – 29 U/L

ALP
40 – 115 U/L

33 – 130 U/L

GGT

3 – 95 U/L

3 – 70 U/L

 
What Does Slightly Elevated Liver Enzymes Mean?
Something we have consistently observed with our patients over the past ten years is slightly elevated liver enzymes. Specifically, a slight elevation to AST and ALT.   

For example, on a routine Comprehensive Metabolic Panel (CMP), a woman will have an AST level of 54 U/L and an ALT level of 47 U/L. Both enzymes are slightly outside the normal range, but this often gets blown off by the primary care physician because the liver enzyme levels are not high enough to indicate major a concern. However, if the enzymes levels were in the hundreds, then the doctor would do some follow-up testing for some liver disease like Hepatitis.

Does progesterone make you tired? It is a lot more complicated than a yes or no answer.  In this episode, we are going to explain this question in full detail.

We are going to talk about:

Types of progesterone replacement: creams, capsules, sublingual, troche
Why progesterone is used to balance hormones
When you usually take progesterone
How much progesterone is a typical dose for treatment

Progesterone is a common type of hormone replacement and is an excellent treatment for many of the symptoms associated with hormone imbalances that occur during Premenstrual Syndrome (PMS), perimenopause and menopause.

We are also going to talk about how progesterone can help with symptoms of hormone imbalance.  One of the most common symptoms is insomnia. Progesterone is fantastic for sleep.  It is particularly helpful for helping women both fall asleep and stay asleep throughout the night.  

Many women complain of waking multiple times during the night or are awake for hours in the middle of the night.  We are going to talk about how progesterone can help with healthy sleep.

We are also going to talk about what forms and doses of progesterone help the most with sleep, mood, and energy.  How some forms of progesterone do not affect energy or sleep quality, and other forms of progesterone can make you tired or sleepy.

Why progesterone is used to balance hormones:
Many of the symptoms associated with PMS, perimenopause, and menopause are related to an imbalance or a decline of progesterone.

Types of progesterone:
Of the different dosage forms of progesterone, we prefer to use bioidentical progesterone sustained release capsule with our patients. We have found this form to provide the most consistent results with our patients. In some cases, we might use a transdermal cream, but it depends on the situation.  We rarely use sublingual tablets or progesterone troches.

Capsules (either immediate or sustained release) 
Transdermal cream
Sublingual tablet
Troche

How much progesterone is a typical dose for treatment?

A common starting dose for women in menopause is 100 mg progesterone sustained release (SR) capsule. This amount can be increased or decreased depending on the response.  For menstruating women, the dose can be as low as 25 mg and go up from there.  

When you usually take progester

It may not always be obvious, but hormones have a significant influence on how we feel and our behavior on a daily basis. It is not something that is given enough thought to in medicine; however, it is something we pay a great deal of attention to because we understand the connections.  

Hormones dictate everything from eating to sleeping and just about anything else in between.  When hormones are balanced, then our behavior normal. If hormones are not balanced, then emotions and behavior will suffer. For example, if someone is under heavy stress, cortisol will rise. Over time, the rise in cortisol can negatively impact the sleep process, resulting in chronic insomnia.

Below are a few more examples of behaviors/emotions that are influenced by hormones:

Sleep
Hunger / appetite / food cravings
Sex Drive (libido)
Addiction
Motivation/drive/ambition
Focus/concentration
Anxiety/depression
Irritability
Emotional/weepy
Sad/melancholy
Grumpy

The relationship between hormones and behavior is a very complicated topic and one we will dive deeper on in the future. For now, hopefully, this gives you a bit more insight into how hormones influence our behavior. If you think that your hormones are having a negative impact on your behavior, please send us an email to [email protected].
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Triiodothyronine also is known as T3 is the active form of thyroid hormone.  T4 also known as thyroxine is made in the thyroid gland.  T4 is then sent peripherally through the system, and mainly the liver will convert T4 to T3.  You can have all the T4 in your body, but if your T3 is low, then you will have symptoms of low thyroid.    
If suspecting a case of low thyroid, thyroid disease, hypo or hyperthyroid your conventional doctor is going to run a TSH blood test.  The TSH (Thyroid Stimulating Hormone) is a signal from the brain monitoring thyroid disease and the thyroid levels in the body.  
To put it simple:  

If the thyroid levels are high, then the TSH is low.  
If your thyroid levels are low, then TSH is high.

As mentioned above the thyroid mainly makes T4, which is released into the blood and will travel in the body and be converted to the active form of thyroid, T3.  Approximately 60% of this conversion occurs in the liver, about 20% is converted by gut flora and about 20% is converted by peripheral tissues, such as muscle.  

As we have always talked about before, your primary care doctor is looking for a ‘disease.’  If you have a ‘disease,’ your GP, internist, or endocrinologist can save your life.  In the case of thyroid, your conventional doctor is going to run a TSH and perhaps a T4.  That is because they are looking for thyroid disease, not low levels of T3.   
Many people with Low T3 get missed by their doctor because their TSH is in the normal range.  They are told, “you are fine,” even though they do not feel fine.     

How do you know if you have Low T3?  You can do a blood test for Free T3.  Free T3 is the bio-available thyroid hormone ready for use.  In checking for Low T3, you want to check the free T3 levels, not the Total T3 levels. Total T3 levels in the blood represent all Free T3 and bound T3 levels.  Testing for total T3 levels is not going to be accurate enough to find out if you have Low T3.

You may need to request blood testing for Low T3 from your doctor, or you may need to order it yourself if your doctor will not order it.  
Blood tests checking for Low T3 Level:

TSH
Free T4
Free T3

This is where it gets a bit confusing.  The reference range for Free T3 is broad.  

Free T3 Reference Range:

2.3 to 4.4 (depending on the lab).  
If your Free T3 is under 3.0, we would consider this to be a Low T3 level.

Testing results we commonly see in patients with Low T3:

TSH: normal range usually between 1.0-3.5 (reference range is .45-4.5)
Free T4: 1.1-1.4 (reference range is .8-1.8)

Here is a typical scenario:
I don't know what to do I have all the symptoms of low thyroid.  My hair is falling out.  I am exhausted, no energy whatsoever.  I have gained weight, even though I try to eat well and exercise.  But honestly, I am too tired to exercise.  Sorry for the TMI, but I am constipated, bloated and fiber makes it worse.  I am feeling pretty low mood wise and so tired.  My skin is really dry, and all I want to do is sleep.  
I went to my general practitioner, and she ran my blood work for thyroid.  My doctor says my thyroid is fine.  But I don't feel fine! Then she just told me to go on a diet and gave me a prescription for an antidepressant.

I cannot tell you how many times I have seen this scene.  That is because your general practitioner, endocrinologist, internist, PCP are looking for disease or if something is broken.  But what if there is not a disease (thank goodness)?  They really do not know what to do with you.  To check for thyroid disease, your doctor will run a TSH (thyroid stimulating hormone).  
The TSH is a signal from the brain monitoring the thyroid status.  If you have thyroid disease causing an underactive thyroid, the TSH will be elevated. And if you have an overactive thyroid, the TSH will be very low.  But the TSH is checking for thyroid disease.  We have a lot of patients that do not have thyroid disease but still have a subclinical, ‘hypofunctioning’ of the thyroid.  
Trying to keep this relatively simple, your thyroid gland makes T4 thyroxine, which is a very stable molecule and will travel in the system and mainly your liver will convert T4 to T3.  Triiodothyronine (T3) is a very unstable molecule but is the active thyroid hormone.  In Subclinical Hypothyroid, you will often see a normal TSH, normal T4 and a lower Free T3.
Subclinical Hypothyroid:

TSH reference range is .45-4.5 = see anywhere from .45 to 2.5
FreeT4 reference range is .8-1.8 = will see .8 to 1.1
FreeT3 reference range is 2.2-4.4 = will see 2.0 to 2.9

Again, your conventional primary care doctor, endocrinologist, GP, internist are looking to make sure you are not going to die of a disease.  They are not going to check your Free T3.  And rarely they may check your Free T4.  But if they do, they do not know what to do if the TSH is normal.  
We find by optimizing your T4 and especially your Free T3; the Subclinical Hypothyroid symptoms go away.  We still keep the TSH in the normal range but try to optimize the Free T3 to 3.5-4.4.  
This is done in many ways based on the patient's personal and family health history, their symptoms and goals.  We might implement a combination of vitamins, minerals, glandulars, medication and lifestyle factors to treat subclinical hypothyroid.   

Hopefully, this has been informative and helpful to you. If you have any questions or personal stories, please feel free to email us at [email protected].

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Our bodies make three different forms estrogens:

Estrone (E1)
Estradiol (E2)
Estriol (E3)

Estrone is usually considered an unhealthy estrogen.  It is still bioidentical, but you do not want loads of estrone around when you are balancing the hormones.  Estrone is common in young girls when they first get their periods and after menopause.  Estrone metabolites can raise the risk for cancer.  This is why you do not want a high level of estrone, which can also cause moodiness, feeling munchie, puffy and grumpy.  With bioidentical hormone replacement therapy (BHRT), we do not use estrone for the above reasons mentioned.

Estradiol is the strongest of the three bioidentical estrogens.  Estradiol is common in conventional hormone replacement in the form of oral, patches or transdermal.  Premarin and Prempro are not estradiol and are not bioidentical.  Because estradiol is the strongest of the estrogens, it has pros and cons to use.  

Pros of Estradiol:  

Great for keeping bones strong
Eliminating hot flashes and night sweats
Neuroprotective for the brain
Great for short-term memory and memory recall
Helpful for libido and sex drive

Cons of Estradiol: 

Estradiol likes to grow things.   (i.e. grow the lining of uterus, which can cause a risk of uterine cancer)
Can cause spotting, bleeding, periods
Grow breast tissue
Cause breast tenderness
Enlarge breasts which can be a risk factor
Moody (weepy, irritable, anxious) 
Can be similar to a 24/7 feeling of PMS
Weight gain

Many women report gaining on average 6 to 8 lbs when taking conventional estradiol hormone replacement.  It is primarily in the breasts and stomach.
   
So how do we get the positive benefits of estradiol without the negative side effects? The best way to properly balance estradiol is to take estriol with it.

Estriol (E3):
Estriol is the gentlest form of estrogen.  Some people refer to it as the weakest form, but I think that is a misnomer.  When you combine estriol with estradiol you can get the beneficial effects of estradiol and estriol, without the negative side effects of estradiol.

What is pregnenolone? It is a steroid hormone but is not a reproductive hormone like estrogen or testosterone.  Pregnenolone is also made from cholesterol, which makes it a steroid hormone. It is also considered to be a pro-hormone,’ because it can convert into other hormones depending on the needs of the body. Recently, it has been discovered that pregnenolone is also produced in the brain and spinal cord, which makes it very potent on stimulating the central nervous system and having an impact on the brain.
Pregnenolone is helpful for memory. It is stimulating to the brain for memory and learning, but at the same time, it is also neuroprotective.  The brain is very complicated, and pages could be written on the process of memory foundation and degradation. What we are trying to say here is, pregnenolone helps with learning and also preserving memory by protecting brain cells.
Other helpful uses for pregnenolone:

Memory: short-term
Brain fog
Mental energy and mental motivation
Helpful for learning new information
Mood
Focus

Pregnenolone, like most hormones declines with age. However, pregnenolone can also drop in response to high levels of chronic stress.  Whether that stress is mentally induced such as dealing with a family member's illness, PTSD or a stressful high paced life. Or physical stress such as intense daily cardiovascular exercise can diminish levels of pregnenolone.  
This is also known as ‘pregnenolone-steal.’  In times of chronic stress, the body will shunt the production away from the other steroid hormones to produce more cortisol.  For women, the body will shunt production away from progesterone to make more cortisol.  
You can test for pregnenolone levels in the blood, but the lab reference ranges are so vast that most everyone will fall in normal ranges.  Quest has a reference range of 22-237 ng/dL, and LabCorp’s is anything less than 151 ng/dL.
Both are broad reference ranges. I like to see pregnenolone 80-100.  If a pregnenolone blood test is less than 80 ng/ dL, I will treat the patient with pregnenolone.  And after being on the pregnenolone for 1-3 months, I will retest the blood work to see where their levels are and how they are feeling.  
As we all know, too much of a good thing' is not-so-good.  Taking too much pregnenolone can have side effects.  There is not a lot of research on pregnenolone.  There are some animal studies but not any real prolific human studies. For the layperson, there is not a lot of information about pregnenolone online. There are some contradictory statements on dosing, side effects, and safety.

What I can tell you from my experience with patients, there are relatively little side effects with pregnenolone, as long as you keep the dosage uniquely prescribed for the patient based on their symptoms and the blood work readings.  
Pregnenolone is available over the counter/online without a prescription.  Many pregnenolone doses are just way too high.  I have had new patients walk into my office, and they are on 100mg or more of pregnenolone per day.  There are a few exceptions based on

Painful intercourse is a very common complaint I get from patients going through or have gone through menopause.  They do feel awkward speaking of vaginal dryness, especially with their male gynecologists.  This is one of the most common symptoms of menopause, second to hot flashes and night sweats.
Menopause is an inevitable course of life that all women will go through.  In menopause, the ovaries are going to reduce and ultimately stop making estrogen and progesterone.  The average age of menopause is 51.5 years of age.  Also, commonly some women have had a complete hysterectomy and oophorectomy which is complete removal of the uterus and ovaries.
This can be due to many health conditions such as Endometriosis, heavy/frequent bleeding, or fibroids.  These women will go through what is called, surgical menopause,’ but either way, menopause can have a variety of symptoms.
Unfortunately, dry, painful sex commonly occurs before, during and after menopause.  A female may opt to take hormone replacement during menopause, or she might not choose to take hormones because she may not be a good candidate.
This can be due to personal reasons, health conditions, family history, physician recommendations.  Whether taking hormones or not for menopause, painful dry intercourse is a common symptom.
It should also be noted that perimenopausal women can also have vaginal dryness.  As we get older, our hormones inevitably decline.  Even women as young as the late 30’s to early 40's can have pain with intercourse due to the slight drop in estrogen.
Why is there painful dry intercourse due to menopause?
Estrogen feeds the vaginal cells.  Immature vaginal cells are called Parabasal cells.  Having estrogen in the system will help convert the parabasal cells into mature vaginal cells.
If you have vaginal atrophy, that means you have mainly parabasal cells in your vagina.  If you have ever gotten the full report from your last pap smear, you will notice the report will say there is predominantly parabasal cells.  The lack of estrogen in menopause is the culprit for painful intercourse and/or dryness.
Options for vaginal dryness and painful intercourse:
Personal lubricants are the first line of choice for painful intercourse, which can be helpful.  However, in vaginal atrophy, the walls of the vagina can become narrow.  You still might experience pain even with the lubricant, or the vaginal tissues are very fragile, and the lubricant cannot protect from the tearing.
The next level of treatment is using estrogen topically.  Your ObGyn may give you estradiol or Premarin cream/inserts for vaginal dryness.  The problem with this is estradiol and Premarin are both very strong forms of estrogen.
They usually enter the bloodstream if you use them vaginally.  Estradiol is ‘bioidentical,’ but it is the most potent form of estrogen we make.  So estradiol may not be appropriate for you or intended to be used long term.
Premarin is made from pregnant horse urine and is not bioidentical. The entire ethical implications behind horse/animal treatment and Premarin is a whole other topic itself.
For the appropriate candidate using estriol (E3) vaginally can help hydrate the vaginal cells and make them more resilient to tearing.  Estriol is the most gentle estrogen that our bodies produce.  Estriol is bioidentical and very helpful for skin and mucous membranes like the vagina.
Unfortunately, your conventional doctor or ObGyn is not going to prescribe estriol for you. Now, this is where I am supposed to tell you: this information is intended for information only.  It does not replace medical advice and it just at the disclosure of the reader.
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