How Come They're Happy and I'm Not? (27 page)

While conventional medicine uses synthetic oral forms of hormones, the holistic and natural medicine world tends to use transdermal (absorbed through the skin) and vaginal (absorbed through the lining of the vagina) preparations. These are called bioidentical hormones, for they are identical to the molecules a woman has in her body.

One advantage transdermal bio identical hormones have over oral forms is that the oral forms of hormones pass through the intestinal system and go directly into the liver. The liver tries its best to sop up all the extra hormone by throwing out a lot of sex hormone binding globulin (SHBG), a protein that not only binds up estrogen and progesterone but can also tie up many other hormones, like thyroid hormones. So, in an effort to raise estrogen, oral forms of hormones can mess up thyroid function, contributing to low mood. Transdermal applications of hormones, however, seem to bother the liver much less, for the liver does not see it all come by at the same time.

Limited studies of HRT and bioidenticals have shown

• Estrogen used alone (whether natural or synthetic) increases breast cancer rate by 10 percent.
  
• Estrogen used with progestin (synthetic progesterone) increases breast cancer risk by 40 percent but protects the uterus from cancer.
  
• Estrogen used with natural micronized progesterone decreases breast cancer risk by 10 percent.
  
• Ovarian cancer risk seems about 40 percent higher with any hormonal replacement, natural or synthetic, oral or transdermal.
  

If you are considering using hormone replacement, you and your doctor need to consider your personal risks for cancer. Then think about whether you have already tried all the other natural suggestions in this book. If you have done all you can, then bioidentical hormones may be a reasonable next step.

If you have decided hormones may be worth a try, you might be wondering how to get them. To determine which hormones and the best forms you need, visit your naturopathic physician or other like-minded doctor, who can run the proper tests. Have your doctor check your current levels of estrogen, progesterone, testosterone, DHEA, DHEA sulfate, SHBG, and possibly a few others, depending on what your doctor thinks is appropriate.

The tests you need are

• Serum blood test: Your blood is tested for hormone levels.
  
• Salivary hormones test: You soak a cotton-type sponge with your saliva and send it to the laboratory for analysis.
  
• Urine hormones test: This test requires you to collect your urine for twenty-four hours. It may be the most accurate of all the tests, for it analyzes the sum of hormones that can vary from minute to minute throughout the day. While the saliva and blood tests catch a moment in time, the urine test looks at the whole day.
  

No single test can tell you everything, and because hormones are so complicated, I believe it's better to run all three of these tests to obtain the most accurate picture. As an aside, any doctor who tells you that she understands women's hormones and what you
need is partially lying—no one fully understands this complicated system. The best thing to do is test what you can, look at your symptoms, and then make the best decision possible.

Based on the test results, your doctor may prescribe a transdermal cream with natural estrogens in three forms (estrone, bi-est, and tri-est), testosterone, DHEA, and natural progesterone. My strong advice is to ask the doctor for the lowest doses available of the hormones, monitor how you feel, and retest in one to two months. If your mood does not improve, you can slowly increase one or more of the hormones as indicated by your symptoms and the blood tests. You can visit my website
www.drpeterbongiorno.com/happyhormones
for a list of symptom changes with hormone use.

The overall key while using bioidenticals is to first start the naturopathic suggestions outlined in the other parts of this book, to work closely with your doctor, start slowly using the lowest doses possible, test regularly, and most importantly, see how you feel.

As we age, life can throw out surprises and threats that can affect our mood. In my senior patients, though, I have witnessed an amazing amount of wisdom, courage, and perception that I just do not see in my younger patients. Overall, the strength and resilience in older people is inspirational. Given the trials, tribulations, and difficulties associated with aging, seniors are actually quite equipped to accommodate age-related losses and have shown that in a number of studies. I have seen natural medicines play a role in helping this process.

Any doctor working with seniors should know that this population is less likely to respond to drugs, which already have a paltry 30 percent response rate. Furthermore, more than 60 percent of patients over sixty-five experience moderate or major side effects with first-time antidepressant prescriptions.

But there's some good news: the fact is that seniors actually suffer from depression less than younger people do. One large U.S. study tells us that only 10 to 13 percent of seniors experience depression, while 18.8 percent of people younger than sixty years of age do. Also, among seniors experiencing depression, only about 5 to 10 percent of them had their first episode of depression after the age of sixty. That means that people who have not had depression earlier in life are not likely to get it after age sixty.

If you are a senior and are experiencing low mood or are interested in supporting a senior you know, it is important to keep in mind that the experience of depression and its symptoms will vary for seniors versus that experience in a younger person. As a result, depression in older people might not parallel the strict definition for depression diagnosis and often is not expressed with sadness. Think about the typical curmudgeonly old man. Maybe it's you reading this book. This behavior is more likely a symptom of depression than a personality trait. Common symptoms of depression in seniors include

• Bodily aches and pains
  
• Memory problems or dementia
  
• Irritability and agitation
  
• Hypochondria
  
• Grumpiness and meanness
  
• Feeling obsolete
  
• Unwillingness to adapt to situations
  
• Talking about expecting death
  

My experience with patients has taught me that life circumstances, including living situations, life changes, health challenges, and
finances play a major role in senior mood. Understanding these and identifying the specific triggers for mood change can help patients and doctors focus on creating a plan of action.

Living situations can help predict who is more likely to get depressed. People over age sixty who live in communities show a depression rate of 1 to 4 percent, which is low for any population. Elderly people in primary care settings who live at home report a 6 to 9 percent depression rate. Hospitalized senior patients have up to 12 percent prevalence, and residents of long-term care facilities show a 12 to 20 percent rate of depression. One lesson from this is that it's best to stay healthy and avoid hospitalization and long-term care when possible for best mood.

There are a number of psychosocial factors that may contribute to the onset of senior depression. Low mood may come on with life events such as serious illness, widowhood, entering a nursing home, death or illness of close friends, loss of meaning derived from personal goals and actions, and loss of resources (money, perceived lifetime left, cognitive functioning, or social support).

Studies on the effect of retirement vary greatly. While some studies show that seniors are happier because they no longer work, others show no change, or worsening mood. So whether retirement is beneficial for mood is case by case. I have recommended that some of my patients look for part-time work, which seems to have helped their mood. Couples who retire at different times bring in an added dimension—retired men whose wives are still working are likely to be the least depressed while working men whose wives have retired are often the most depressed. Among couples, financial issues in
retirement are more important to men, while the quality of the marital relationship is more important to women.

Interestingly, researchers examined eighty-seven depressed elderly patients, about half of whom were receiving psychotherapy, antidepressants, or a combination of the two. The best predictor of improvement in this evaluation was not these remedies but instead the “religiosity” of the patient. This gives us a sense that the more people include some type of religion in their life, the more resistant they are to depression.

While the information found earlier in this book can be applied to the senior population, the following research should also be considered for specific treatment of depression in older patients.

Adequate water intake may also play a role in moods of the elderly. PET imaging of older people's brains found that the midcingulate cortex can stop working prematurely and halt the body's thirst mechanism even though their bodies need more water. This discovery helps explain why the elderly are often easily dehydrated. Water is essential for transporting tryptophan into the brain for proper serotonin levels. If you are over sixty years old (or any age), it's important to drink plenty of water.

A known factor in cardiovascular disease, high levels of homocysteine may also play a role in depression with aging. Checking for high blood levels and using the recommendations in
chapter 4
may be helpful for the aging senior who is depressed.

Selected populations may be especially prone to low vitamin D. These include the elderly, who have an increased incidence of low vitamin D. More about vitamin D is in
chapter 4
.

Low magnesium is seen particularly often in the geriatric population, and high calcium and low magnesium intakes are associated with depression. One study checked the relationship between depression and these two minerals and found that the calcium-to-magnesium ratio in the spinal fluid and blood was elevated in depressed patients compared with non-depressed controls. Some literature suggests that higher levels of calcium may create a magnesium deficiency and that magnesium should be supplemented in these cases. Given that concerns about osteoporosis in elderly often influence doctors to pummel patients with extra calcium and vitamin D (which increases calcium absorption), plenty of magnesium should also be included for balanced mood. See
chapter 5
for more about magnesium.

We talked about the benefits of L-carnitine for mood and energy in
chapter 4
. Acetyl-L carnitine is a form of carnitine that can help boost energy in the brain by acting like a neurotransmitter called acetylcholine. As such, acetyl-L-carnitine is useful for patients with depression, especially senior patients.

The supplemented dose used in most studies ranges from 1 to 3 g per day. There are no known toxicities with acetyl-L-carnitine. Mild gastrointestinal upset and vomiting were noticed in a small number of patients.

Clinically, massage has demonstrated benefits by lowering anxiety levels in the elderly.

One trial of qi gong therapy in seniors had two groups do ten minutes of qi gong once a day. This group exhibited reductions in anxiety, depression, fatigue, pain, and blood pressure compared to the placebo group. This was pretty exceptional for such a minimal time commitment. More about qi gong is found in
chapter 6
.