Shmirshky (5 page)

CHAPTER 14
shmirshky numbers

In addition to your yearly Pap smear
²⁴
and mammogram,
²⁵
you need to get some other tests to help you monitor your PM&M. These test results will help give you and your doctor an idea of where you are on your PM&M journey, but they are not definitive indicators. You have to pay close attention to your symptoms and to how you feel. It's not unheard of that a shmirshky's hormone numbers will appear normal while her PM&M symptoms are through the roof, because every shmirshky lives differently, at different hormone levels.

While the suggested test-result ranges I've included in this book can be helpful reference points, they should not be treated as objective benchmarks. Be sure to bring your Shmirshky Daily Symptoms Chart and tell your doctor how you
feel
, because this helps determine what the test results mean for your body and how best to approach your particular situation. Discuss all the different options with your gynecologist and get the tests you need.

Below, I have listed the tests that I found helpful.
²⁶
You can get most of these done with one blood draw. Always ask your doctor's office for a copy of your lab results and keep them in a notebook or folder. You may find you want to refer back to them later. There are lots of numbers here, but don't worry, no long division! Okay, here we go:
²⁷

• Bone density: Bone density is the measure of calcium and other minerals in your bones. The bone density test, also called a DEXA scan, is a great preventative test. It can determine whether you have osteoporosis
²⁸
or even a risk of getting osteoporosis before you experience symptoms. When you go through PM&M, your estrogen
²⁹
levels decline, which can lead to a rapid loss of bone density, so this is important for the PM&M shmirshky to check. The test measures the bone density (strength) of both the hip and spine. It only takes a few minutes and exposes you to very little radiation (technicians are not even required to wear a lead apron). Suggested range:

•
T-score
: greater than -1
³⁰

• CA-125 (cancer antigen 125): This protein is best known as a blood marker for ovarian cancer. It may also be elevated with other malignant cancers, including those originating in the endometrium, fallopian tubes, lungs, breasts, and gastrointestinal tract. Suggested range:

• Less than 35 U/mL
³¹

• Cholesterol: A waxy substance produced by the body. It is needed to make hormones, skin cells, and digestive juices. Your cholesterol changes during PM&M. Too much cholesterol in your body can build up plaque in your arteries, which ultimately narrows the blood vessels and may cause a heart attack. You will need to fast for this test, so don't eat or drink for twelve hours beforehand. Suggested range:
³²

•
Total cholesterol
: less than 200 mg/dL

•
HDL
(high-density lipoprotein, the “good” cholesterol): less than 50 mg/dL generally
increases
your risk of heart disease; greater than 60 mg/dL generally
helps protect against
heart disease.

•
LDL
(low-density lipoprotein, the “bad” cholesterol [too much LDL in the blood can clog your arteries]): less than 100 mg/dL

•
Triglycerides
(molecules of fatty acid): less than 150 mg/dL

•
Cholesterol/HDL
(the ratio of total cholesterol to HDL): less than 5:1 is desirable; 3.5:1 is optimum

• DHEAS: DHEA sulfate is a hormone that is easily converted into other hormones, including estrogen and testosterone. It is the adrenal hormone that triggers puberty and is found in the highest concentration in the body. DHEAS is the sulfated (S) form of DHEA in the blood. DHEA levels increase and decrease throughout the day. DHEAS blood levels are steadier, and therefore more reliable. Suggested range:

•
Age 30–39
: 45–270 ug/dL

•
Age 40–49
: 32–240 ug/dL

•
Age 50–59
: 26–200 ug/dL

•
Age 60–69
: 13–130 ug/dL

•
Age 69 and older
: 17–90 ug/dL

• Estradiol: This is the main type of estrogen produced in the body. It is secreted by the ovaries. If you're still menstruating, be sure to have this blood test done during the first three days of your period. Suggested range:

•
Premenopausal
: 30–400 pg/mL

•
Postmenopausal
: 0–30 pg/mL

• Free and Total Testosterone: Free testosterone is the unbound, metabolically active testosterone. Total testosterone includes both the free and bound testosterone. In shmirshkies, the ovaries produce testosterone. This benefits shmirshkies by helping to maintain a healthy libido, strong bones, muscle mass, and mental stability. Suggested range:

• 30–95 ng/dL

• FSH (follicle stimulating hormone): A pituitary hormone that stimulates the growth of the ovum (the egg and surrounding cells that produce ovarian hormones). This is one of the measures that can indicate if you've entered M (although it's not a definitive determinant because your levels can fluctuate). If you're still menstruating, be sure to have this blood test done during the first three days of your period. Suggested range
³³
:

•
Shmirshkies who are menstruating
: 1.7–21.5 mIU/mL

•
Postmenopausal shmirshkies
: 25.8–134.8 mIU/mL

• Progesterone: This is a hormone that stimulates the uterus and gets it ready for pregnancy.
³⁴
Progesterone also regulates the monthly menstrual cycle. Low levels of progesterone can impact your mood and cause irritability, among other things. Results will vary depending on when the test is done. Suggested range:

•
Pre-ovulation
: less than 1 ng/mL

•
Mid-cycle
: 5–20 ng/mL

•
Postmenopausal
: less than 1 ng/mL

• Thyroid workup: This blood test usually includes checking your TSH (thyroid stimulating hormone). If there is an irregularity with your TSH, you may need to get your Total T3 and Free T4 checked as well. (
Free
means it won't be affected by your estrogen status, not free of charge!)
³⁵
Remember that the symptoms for both PM&M and a thyroid disorder can be very similar. Suggested range:
³⁶

•
Total T3
: 60–180 ng/dL

•
Free T4
: 0.89–1.76 ng/dL

•
TSH
: approximately 0.3–3.0 mIU/L for those with no symptoms of abnormal thyroid function. A much wider range of approximately 0.5 to 5.0 or even 6.0 mIU/L is being used by labs and doctors who are
not
following the latest recommendations by the American Association of Clinical Endocrinologists.
³⁷

• Vitamin D3 (Cholecalciferol): This vitamin, named after my husband's first initial, helps to maintain normal blood levels of calcium and phosphorus, and helps keep your bones nice and strong. Suggested range:
³⁸

• 40–100 ng/mL

Most of these tests are simple blood tests, which is actually a nice break from having lots of things shoved in and out of our shmirshky at the gynecologist. When we go to the gyno for a Pap smear, we're told to get undressed, put on a gown, and put our heels in the stirrups. When I hear
gown
, I start looking for something beaded and satin, but instead I get a paper towel jacket and a giant paper towel tablecloth to drape over my legs. During the exam, I never have a clue what's going on down there. Do you? My gynecologist always tells me, “Just relax.” Yeah, I'll relax when you stop sticking giant Q-tips up my shmirshky. I can't wait to grab that huge paper towel, mop up all the gel they shoved inside me, and get the hell out of there. Doesn't this process sound a bit archaic? At least upgrade the paper towel to two-ply or quilted. I hope the Brawny Man doesn't walk in on me while I'm all saddled up!

CHAPTER 15
to hrt or not to hrt?

Once your test results come in, be sure to make an appointment to meet with your doctor in person to discuss your numbers. Bring your advocate with you on this visit as well. I brought my husband so that he too would become more aware and involved in what I was going through. After all, we were going through it together. The more I included David in my journey, the more knowledgeable, helpful, and supportive he became. Plus, let's face it, by this point I was a total bitchface half the time. David pretty much jumped at any opportunity to get back the wife he knew and loved.

Remember that the results of your lab work are only half of the conversation. At this appointment you need to be sure to bring your shmirshky Daily Symptoms Chart and communicate honestly and openly about how you're feeling. Ask your advocate to help encourage this during your appointment. Make notes before your appointment of all the things you want to talk about. Share this list with your advocate. The more clearly your doctor understands how you're feeling and functioning, the more he or she will be able to help determine the correct course of action for you.

Don't feel rushed. Doctors are often on a tight schedule and they like to move quickly, but don't let that frazzle you or steer you off course. Set the pace of your appointment so that you and your advocate can address all your questions and concerns.

The big question at this stage is whether to HRT
³⁹
or not to HRT. In order to answer this question, we need to have a quick crash course on HRT. Basically, the way it works is that when you go through PM&M, your body begins to produce different amounts (usually smaller) of estrogen, progesterone, and/or testosterone hormones. These fluctuations often result in the symptoms that many PM&M shmirshkies experience. HRT is intended to supplement or moderate these hormone fluctuations and ultimately provide an umbrella for a shmirshky caught in a PM&M storm.

Not all HRT options are created equal. The first distinction you will want to make is whether an HRT supplement is bioidentical or not (see Hormone Therapy Brands on page 156). A bioidentical hormone is identical to the hormone produced in your body. It may not have originated in your body, but it has the same chemical structure and even goes by the same name. Most important, it has the same biological function.
⁴⁰

On the other hand, there are HRT options available that are NOT identical to the hormones in your body. They might be similar, they might even have a similar name, but they are not exactly the same as the hormones produced in your body.
⁴¹

The other important characteristic to understand is whether or not the HRT option is natural and/or synthetic. I say “and/or” here because the natural and synthetic labels are NOT mutually exclusive. Here's how that works. Technically speaking, if a hormone is called
natural
, that means it is originally derived from a plant or animal source. A hormone is considered
synthetic
if the chemical structure was altered in a laboratory. Sometimes hormones are extracted from yams and then chemically altered. In this instance, the hormone is both natural and synthetic.
⁴²

If you're given a prescription for HRT and want to know what you're getting, try asking the following questions:

• Is this HRT option bioidentical? Or, in other words: Is this HRT option chemically identical to the hormone I produce in my body?

• Was this HRT chemically altered in a lab? (If the answer is yes, then the HRT option is a synthetic hormone.)

• Did this hormone originate in a plant or animal? (If yes, then that hormone is technically considered natural.)

If the answer to all three questions is yes, then you have a plant- or animal-derived hormone that was chemically altered to become identical to a hormone found in your body—which means it is natural, synthetic, and bioidentical. I know it's confusing, because natural and synthetic seem like opposites, but with regard to HRT, they are actually referring to two different distinctions. Whoever came up with these terms needs a talking to.
⁴³

These distinctions are important, because just as your body reacts differently to a tablet of Advil than it does to a tablet of Aleve, different hormone therapy options have different potentially positive and negative results. When you take bioidentical hormone therapy, your body may react the same way it would if it produced the hormone itself, because, chemically speaking, it is the same as the hormone your body actually does produce. When you take hormone therapy that is not bioidentical, your body may react differently.
⁴⁴
Learn about how your medication options might affect your body before you decide with your doctor on a particular course of treatment.

Now that you've gotten a handle on your HRT lingo, you need to learn about the WHI (Women's Health Initiative)
⁴⁵
and the studies it conducted. There are many different viable interpretations of these studies, so it is best that you go online to the Women's Health Initiative at www.nhlbi.nih.gov/whi and read about the studies for yourself. To further research what some experts think of the validity of these tests and their findings, do a Web search for “WHI pros and cons.” You can read for hours. Let me caution you right now, this is not fun reading! Many nights, I could have used some toothpicks to prop my eyelids open because the material is so technical and dry.

Here is what I learned: The FDA
⁴⁶
announced its statement on the WHI studies in 2002, which scared every PM&M shmirshky half to death. The agency reported that HRT increases a shmirshky's risk of breast cancer and heart disease. It was all over the newspapers and news shows. So many shmirshkies went off their HRT cold turkey! OMG! That's like stopping a roller coaster on a dime in the middle of the ride. You're left hanging upside down, lucky if you don't fall right out of your seat!

I am not a scientist or a doctor, but let me tell you a few of the problems that I have with these studies. Some of the shmirshkies in these studies had heart disease, were obese, and had elevated cholesterol levels requiring medication. All of the shmirshkies who were studied were in Post-M and were given the same amount of HRT. This was not clear to many PM shmirshkies, who thought the studies applied directly to them. Do you think a shmirshky who is seventy-nine years old should be treated with the same dose of HRT as a shmirshky who is fifty? No, as you get older, you typically require less HRT, and shmirshkies in PM require very different treatments than shmirshkies in M and Post-M.

It is also important to note what kind of HRT was used in the studies. Up until 2002, most shmirshkies on HRT were taking Provera or Premarin (a mixture of estrogens obtained from the urine of pregnant horses).
⁴⁷
Many shmirshkies were on Prempro (which is a combination of Provera and Premarin). The WHI studies were solely focused on these forms of HRT, none of which are bioidentical.

Why didn't they also study healthy, younger shmirshkies while they were in the beginning stages of PM&M and see how they fared with various kinds of HRT? I think we should all demand more studies on HRT and PM&M. We need more hormone specialists, please! We need to keep our scientists studying and researching this. With all the brains in this country, is this the best we can do for shmirshkies? I think NOT!

It is so important to think inside the box and educate yourself on the issues. Be sure to read more about bioidentical hormones and, once again, brace yourself for some new vocab words, not-so-fun terms like progesterone,
⁴⁸
estradiol,
⁴⁹
estrone,
⁵⁰
and estriol.
⁵¹
You'll also need to familiarize yourself with the various forms that HRT comes in. You won't believe how many options there are! (Check out the Hormone Therapy Menu on page 154.) You can wear a patch. These patches are like putting medicine on a piece of Scotch tape. Seriously, that is what it looks like. Then you have the cream version. You can use the cream topically (on your skin) or shoot it right into your shmirshky (this was news to me!). Then there are pills. You can put them under your tongue and let them dissolve, swallow them, or shoot those babies right into your shmirshky too. Then there is the ring. No, I'm not referring to a diamond one; this one does not go on your finger. Guess where it goes? Yep, in the shmirshky. There are also pellets they can shoot right under your skin. Don't forget the sprays, but these, thank goodness, you spray on your skin (not on your hair!).

As I was researching, I started to visualize my carry-on bag at the airport. My allowable toiletry Baggie was already bulging with all the face creams I had squeezed into tiny three-ounce bottles. I definitely could not risk putting my shmirshky creams in the same bag as all of those face creams—what if I got them mixed up? Homeland Security needs to get right on this! We may need a special line at airport security for PM&M shmirshkies.

So many choices! I was overwhelmed!

My mind immediately wandered to my favorite shoe store. I love buying shoes. (FYI, your shoe size is the only size that doesn't seem to change with PM&M.) I can walk around the biggest shoe department and have no problem whatsoever picking out one pair that I love. Too bad they can't administer HRT through a pair of heels.

I began talking to every shmirshky I knew. No matter where I was—in a grocery store, at the cleaners, in a car wash, or at a dinner party—I would bring up the topic. I had no time to be wishy-washy, so I was very direct, asking every shmirshky young and old, “Do you take HRT?” Based on the reactions I got, you would have thought I was talking about a nasty drug habit! It seemed no one wanted to admit that they use or used HRT. It was
taboo.
I think the fallout over the WHI
⁵²
study made a lot of shmirshkies think that being on HRT was wrong, so they sort of went into hiding (back under the bush). But I didn't give up.

 

shmirshky party alert!

Gloria, now seventy-plus years old, was on Premarin and Provera for years for her PM&M symptoms (sleep disturbances and night sweats). Like so many shmirshkies, when the WHI study came out, Gloria abruptly stopped taking hormone therapy. Unfortunately, her symptoms reappeared, so she tried several bioidentical options for a couple years, but her breasts became so tender (a symptom that is often caused by estrogen dominance
⁵³
) that she could no longer sleep on her stomach. The public stir about hormone therapy risks, coupled with her nagging breast tenderness, led Gloria to discontinue her HRT altogether.

Now here is Gloria's
recurring
evening forecast: sleepless with mild to heavy precipitation (those beloved night sweats are back). I feel so bad that Gloria is still suffering. I picture myself at age seventy-three, still sleepless and dripping. Yikes, thank goodness shmirshkies don't get mildew!

In contrast, Patty's response to my “Do you take HRT?” survey was wholeheartedly positive. “HRT is on my list of very positive experiences,” she said. Patty explained that she always had the world's best memory, until, suddenly, during PM&M, it vanished. She was on the verge of tears all of the time and was no longer joyful or a joy to live with. I asked her husband, Mark, what it was like to live with Patty before she went on HRT. He said it was “like a roller coaster ride,” fun when you're five, not so much when you're fifty. Once Patty began bioidentical creams, though, her life turned around. She describes it as an “And then there was light!” moment. She became a whole new person—no more emotional roller coaster rides or night sweats. She slept better, became less forgetful, more focused, more patient, and more present. After HRT, if she found herself in a bad mood, her daughter and son would jokingly ask, “Mom, did you use your cream today?”

My friend Mindy is a whole other story. When she comes into town every August for a week, we like to hit the beach and catch up on shmirshky news. The young, frolicking, bikini-clad shmirshkies run around the beach while Mindy and I sit smothered in SPF 60 under a huge oversized umbrella with our towels draped over our chalky white legs. As it turns out, I envy Mindy's PM&M experience almost as much as I envy how the younger shmirshkies' butts stay politely tucked into their bikini bottoms.

Mindy basically experienced “PM&M light” and never felt the need to take HRT. Her first symptom began at fifty-one when her periods became irregular and then completely stopped for one full year. She had one more “encore” period and then it was gone forever. The show was over. Mindy never had a sleepless night, a dry shmirshky, or memory loss, but she did have some problems with her internal thermometer. Sometimes her husband would find her sitting on the sofa stripped of her top and bra, but before he had a chance to get excited, she would have herself wrapped in a blanket because she was cold. Lucky for Mindy, her temperature fluctuations only lasted for about six months and never resulted in a drop of sweat. She told me, “At fifty-three I became a bitch. Of course, I blamed it on menopause, because with no period, you can't blame it on PMS anymore!” Her PM&M symptoms faded away by age fifty-four, leaving Mindy all out of excuses!

Ultimately every shmirshky has to make her own determination about what course of action is best for her body. For Gloria, it's being HRT free, and for Patty and her family, it's an HRT shrine next to the fireplace. For Mindy, she has to find a new excuse when she's being a bitchface!

 

I was hoping one of my friends would just tell me what to do, but that universal answer didn't exist. Everyone's case was so different and required different solutions. So how was I going to decide? If I were to use HRT, what other side effects would I have? Would I gain more weight? Oh, dear! Would I have more or less risk of cancer? Would HRT prevent osteoporosis or make me more susceptible to broken bones? I kept reading and educating myself so that I could make the healthiest choices. I can't stress enough the importance of research—take responsibility for your body and arm yourself with knowledge. If you decide not to HRT, acupuncture (see chapter 22, “No Needles in My Shmirshky”) can be a tremendous help. Some shmirshkies combine HRT and acupuncture with great success.