Woman's Health Flashcards

Question

How to Supporting phase II oestrogen metabolism:

Answer 1

* Include: Conjugation pathway support (e.g. cruciferous vegetables, allium vegetables, magnesium, antioxidants incl. glutathione). Methylation support (e.g., folate, B12, B6, SAMe, choline). * Avoid — OCP, high alcohol, high cortisol, mould exposure etc.

Answer 2

The ‘oestrobolome’ = a collection of microbes capable of metabolising oestrogens. * These bacteria produce beta-glucuronidase: — Bacteroides fragilis, Bacteroides vulgatus, Escherichia coli, Clostridium perfringens. * Beta-glucuronidase is an enzyme which deconjugates (reactivates) oestrogens that were already conjugated for elimination. * These deconjugated oestrogens can be reabsorbed via the enterohepatic circulation — increasing oestrogen load in the body. * A healthy gut produces the right amount of beta-glucuronidase to maintain oestrogen homeostasis.

Answer 3

* A dysbiotic microbiome, especially when coupled with low fibre intake and poor bile flow, increases the chances of the entero-toxigenic circulation. Hence why improving GIT function and microbial patterns can help with overall oestrogenic load. * Imbalances in beta-glucuronidase can promote conditions such as: endometriosis, breast cancer. ovarian cancer, PCOS, endometrial cancer

Answer 4

* Endometriosis — may have larger numbers of beta-glucuronidase producing bacteria (↑ circ. oestrogen→oestrogen dominance). * PCOS — lower beta-glucuronidase activity may promote increased androgen biosynthesis and reduced oestrogen levels. Specific group where there is a High fat high sugar diet and a gut issue – maybe a leaky gut => leading to lipopolysaccharides leaking and low grade inflammation adding to any insulin resistance => increase testosterone => add to the symptoms of PCOS. Having a good gut microbiome is really important.

Answer 5

* Optimise the microbiome (probiotics, prebiotics). * If high: ↑ dietary fibre; calcium D-glucarate (a beta-glucuronidase inhibitor) and glucaric acid-rich foods such as mung bean sprouts, apples, cruciferous vegs. Milk thistle, Lactobacilli and Bifidum bacteria. Consider the 5R protocol. * If low: Focus on commensal support (e.g., probiotics). * Consider a stool analysis: look on the beta-glucuronidase levels to help correct any imbalances

Answer 6

Testosterone — an essential hormone for women. We only need a tiny amount. * Produced: In the ovaries and adrenal cortex. That is a reason why to look after you adrenals because they produce testosterone which post-menopausal is very important to maintain things such as sex drive.

Answer 7

* Converted to: E2 via aromatase (most testosterone), and DHT.

Answer 8

Ovarian density, libido, bone strength, stamina, mood, cognition

Answer 9

* Androgen dominance is seen in PCOS. Associated with anovulation, hirsutism and acne vulgaris (on shoulders, back, hairline and face), male pattern baldness. This is driven by insulin resistance (insulin resistance inhibit the production of SHBG by the liver that then allows for the testosterone to be unregulated) so create your client’s plan accordingly. * Low testosterone may be associated with low mood, low libido and cognitive dysfunction, brain fog. This is noted during perimenopause. L-tyrosine may help but also address the cause.

Answer 10

* 5α-reductase enzyme converts testosterone into a more potent form (DHT). This pathway is: * Upregulated by: Insulin, inflammation, obesity. (Seen in PCOS, up regulated by insulin resistance inflammation and obesity) * Downregulated by: Nettle (esp. nettle root), saw palmetto, lycopene (found in cooked tomatoes), turmeric, green tea, zinc, GLA and EPA.

Answer 11

Sex hormone binding globulin (SHBG) — Sex hormones are not water-soluble so need to be transported in blood bound to SHBG. * Produced: A glycoprotein synthesised by the liver. * Functions: Binds to oestradiol, testosterone, DHT. Only unbound hormones are biologically active.

Answer 12

* Lower levels = higher circulating free / active levels of these hormones. Associated with hyperinsulinemia, obesity, metabolic syndrome, T2DM, hypothyroidism, PCOS. High levels of insulin prevents the liver from producing SHBG. * High levels: Seen in anorexia, pregnancy (because the placenta produces SHBG in the 3rd trimester), androgen deficiency, hyperthyroidism, liver disease.

Answer 13

Prolactin = a key hormone controlled by oestrogen and dopamine. * Functions: Lactation, breast maturation, inhibits menstruation.

Answer 14

* Hyperprolactinaemia: Occurs naturally in pregnancy and lactation but can also occur in non-pregnant women (high cortisol levels while elevate prolactin levels to act as a natural contraceptive, could be a pituitary tumour or a deficiency in vitamin D (increases prolactin receptors in pituitary gland), or dopamine antagonist medication).

Answer 15

High levels Associated with: Infertility, menstrual irregularities, low libido, osteopenia, breast pain and vaginal dryness.

Answer 16

Increased by: High cortisol (stress), pituitary tumours, circadian disruption, renal failure, vitamin D deficiency, drugs e.g., domperidone (dopamine antagonists).

Answer 17

Endocrine disrupting chemicals (EDCs) = exogenous agents that interfere with the production, release, transport, metabolism, binding, action, or elimination of bodily hormones. We have no pathway to deal with them in the body so the body retains them. Can interfere with hormonal actions.

Answer 18

Includes: BPA (e.g., plastic bottles / packaging), PCBs, phthalates (e.g., beauty products), heavy metals (e.g., lead, arsenic, mercury), pesticides and herbicides, fire retardants, dioxins, drugs (e.g., NSAIDs). Tap water (contains many of the above).

Answer 19

Mechanisms: * Alter hormone receptor signalling and sex hormone production, secretion and metabolism. * Induce oxidative stress, mitochondrial damage and epigenetic alterations (DNA damage and chromosome alterations).

Answer 20

Adverse health effects: Increased risk of cancer, hormonal disorders such as PCOS, early puberty and gynaecomastia (gynaecomastia = enlargement of male breast tissue); infertility, cognitive deficits and obesity. Critical window of susceptibility: In utero, neonatally, in childhood and puberty. Where the influence can be greater.

Answer 21

Xenoestrogens = a sub-category of EDC that are structurally similar to oestrogen and can bind to oestrogen receptor sites with potentially hazardous outcomes. * Examples: Pesticides, herbicides, dioxins, parabens, BPAs, phthalates, preservatives. Tap water (chlorine, pharmaceuticals etc.) * Bioaccumulation: Build up in the fat of meat / fish, dairy products and in human fat cells with age. * Exposure: Mainly by ingesting via food and drink. Small amounts may be inhaled or absorbed through the skin and mucous membranes

Answer 22

Dairy — commercial milk is mostly derived from pregnant cows, with increased hormone concentrations in the third trimester. * E1, E2 and E3 steroid hormones are found in all milks, with a higher concentration in whole milk. Choosing raw or organic milk will make little difference to hormone content. * Dairy products also contain other hormones, including IGF, PCBs, dioxins, insecticides, bovine growth hormone (use of growth hormones is banned in EU / UK). * Whilst amounts are deemed safe, they add to the overall oestrogen load and, therefore, should be avoided in hormonal imbalances.

Answer 23

Phytoestrogens = naturally-occurring plant compounds structurally similar to 17β-oestradiol (E2). Mimic oestrogen in the body. They are oestrogen modulators. * Produce a weak anti-oestrogenic effect in the presence of a high endogenous oestrogen. Reduces circulating bioavailable E2. Block the stronger oestrogen to binding to oestrogen receptors. * Produce a weakly oestrogenic effect in the presence of low endogenous oestrogen. * Disrupts aromatase — favouring the 2-OH pathway. Raise our baseline levels slightly. * Consider them ‘oestrogen-modulators’. * Health benefits: Lowered risk of menopausal symptoms (because we are losing oestrogen, phytoestrogen can buffer the lowering oestrogen), CVD, obesity, metabolic syndrome, T2DM and breast cancer

Answer 24

Phytoestrogens occur naturally in a number of plant foods: * Flavonoids (isoflavones, genisten, daidzein) — found in soybeans (organic, whole, unprocessed), legumes, lentils, chickpeas. * Lignans (enterodiol, enterolactone) — found most cereals, linseed, fruit and vegetables. * Flavones (apigenin) — found in parsley, thyme, celery and chamomile tea.

Answer 25

* There is a concern that phytoestrogens are contraindicated in oestrogen-sensitive conditions like breast cancer, but their weak oestrogenic effect and selectivity make them oestrogen antagonists in the presence of oestrogen. They are oestrogen modulating and can bring down high levels of oestrogens. Not a concern especially by food. You only get the benefits of them when they are fermented by the gut bacteria, therefore, a healthy gut microbiome is essential! When looking at hormonal balance it is key to consider the guts. Address gut imbalance to make sure they conjugate the hormones properly. Apigenin has been shown to inhibit breast cancer cell growth and is neuroprotective.

Answer 26

* Soybeans are converted using microorganisms to miso and natto (Japan), soy paste (Korea) and tempeh (Indonesia). * Western consumption of soy products typically includes soya oil, flour (breads, cake), protein isolates (textured vegetable protein ‘meat’ products in processed foods), low fat milk and yogurts. Around 1⁄4 of all children in the US receive some soya-based formula (much of which is also GMO). => these don’t have the benefits at all. * If soy products are consumed, they should be fermented and organic (non GMO).

Answer 27

A healthy microbiome is necessary for the fermentation of phytoestrogens by intestinal bacteria. * This can account for large differences in the effects of phytoestrogens among individuals. * Any variation from a healthy gut microbiome will reduce the potential benefits from such foods. * In these instances, phytoestrogens provided in a non-food forms, such as tinctures or teas may be more appropriate * Herbs to consider: Black cohosh, Agnus castus, red clover and Dong quai. Phyto oestrogenic herbs => to obtain from a herbalist.

Answer 28

* Blood glucose dysregulation and excessively high or low body weight or body fat percentage. * Chronic low-grade inflammation. * Poor digestion, microbiome health, detoxification and elimination. * Thyroid and adrenal dysfunction. * High toxic load. * Chronic stress and disrupted sleep. * Nutritional deficiencies e.g., B vitamins, magnesium, zinc etc.

Answer 29

First establish foundations — the CNM Naturopathic Diet (recap): * Avoid processed and microwaved foods, as well as stimulants, refined sugar, table salt, artificial sweeteners and cow's dairy. * Focus on local, seasonal, whole, fresh and organic foods. * Focus on vegetables, fruit, legumes, whole grains, nuts, seeds, water and herbal teas. Include a small amounts of oily fish and meat (organic, grass-fed). * Food-combining principles are followed. * Foods are prescribed according to energetics (hot, cold, dry, moist). * Encourage effective digestion — chew food well, keep fluids away from meals, avoid snacking (stick to three meals / day) etc. You are what you absorb.

Answer 30

Improving blood glucose and weight management: * Avoid processed foods, refined sugars and snacking. * For weight loss, consider time restricted feeding (TRF), consider body composition, * For weight gain, work on macronutrient balance of each meal with particular focus on healthy fats. Reducing inflammation: * Reduce: Pro-inflammatory foods / beverages such as dairy, red meat, alcohol, sugar, processed / deep-fried food; arachidonic acid rich foods. * Increase: Colourful antioxidant-rich foods, oily fish, nuts and seeds, fruits and vegetables. Focus on anti-inflammatory phytonutrients such as quercetin. Make sure 6/3 ratio is good in vegetarian and vegans. Supporting digestion and elimination: * Fat digestion for cholesterol synthesis and absorption of fat-soluble nutrients (bitter foods, lecithin etc.) * Increase dietary fibre and ensure hydration to promote bowel clearance of metabolites. Building the microbiome: * Consider a 5R approach if applicable. * Prebiotic-rich foods (e.g., onion, garlic, Jerusalem artichoke). * Probiotic-rich foods (kefir, kimchi, sauerkraut etc.) Supporting thyroid hormone synthesis and metabolism: * If indicated (selenium, iodine, zinc, tyrosine etc.) Supporting detoxification and reducing the toxic load: * An ‘environmental cleanse’: No smoking, alcohol, caffeine; avoid EDCs (tap water, plastics, skincare, cleaning products, dairy etc.) * Support phase I and II pathways (antioxidant-rich foods, cruciferous vegetables, methylation support — B6, B12, folate, SAMe etc. Managing stress levels, sleep / wake cycle: * Use relaxation techniques (deep breathing, journaling etc.). * Minimise stimulants (coffee, caffeinated drinks etc.). * Establish a healthy sleep-wake cycle (keep to a routine with a regular sleeping pattern. Limit evening exposure to electronics / blue light).

Answer 31

Promote hydroxylation to 2-OH over 4-OH and / or 16 alpha-OH

Answer 32

Reduce the oxidation of 2-OH and 4-OH

Answer 33

Promote the methylation of 2-OH and 4-OH

Answer 34

Increase circulating levels of SHBG

Answer 35

Inhibit the activity of aromatase

Answer 36

Promote the detoxification of oestrogens by up-regulating phase I and II enzymes

Answer 37

Inhibit the activity of beta-glucuronidase

Answer 38

Inhibit the action of 5-alpha reductase enzyme, reducing conversion to DHT.

Answer 39

Modify oestrogen receptor activity

Answer 40

PMS = symptoms affecting many women a week or two before their period. Symptoms can extend into the first few days of menses. * Prevalence: Affects up to 80% of women. Peak occurrence in the 30s and 40s. Approx. 50% state that symptoms followed childbirth — worsening with each pregnancy. * Premenstrual dysphoric disorder (PMDD) — a severe variant affecting 1–10% of women that includes at least one affective symptom e.g., anger, irritability during the second 1⁄2 of the menstrual cycle. * Conditions with overlapping symptoms are often exasperated during PMS e.g., hypothyroidism, CFS, depression and anxiety.

Answer 41

* Over 150 symptoms have been associated with PMS. * Non-physical: Mood swings, irritability, low mood, anxiety, feeling out of control, poor concentration, change in libido and food cravings. Reduced cognitive and visuospatial ability, increase in accidents. * Physical: Breast tenderness, bloating, headaches, backache, weight gain, acne, GIT upset.

Answer 42

PMS subtypes — a woman may suffer from some or all of these with a predominant subtype: * PMS-A (anxiety): Possibly related to high oestrogen: progesterone. Symptoms: Irritability and anxiety. * PMS-C (craving): Blood glucose imbalance, hypoglycaemia and ↓ magnesium. Symptoms: Increased appetite, sugar cravings. * PMS-D (depression): Low oestrogen:progesterone ratio and neurotransmitter imbalances (e.g., low serotonin). * PMS-H (hyperhydration): ↑ water retention secondary to ↑ aldosterone (excess salt intake, excess oestrogen, stress or magnesium deficiency). Symptoms: Weight gain, breast tenderness, abdominal bloating and swelling of hands and feet. Remove excess salt from diet.

Answer 43

Causes and risk factors: * Interactions between oestrogen, progesterone and neurotransmitters: * – Progesterone metabolites bind to GABA receptors and render them resistant to activation. These metabolites are often low in PMS, e.g., due to hormonal contraceptives etc. * – Deficient serotonergic functioning. Progesterone and oestrogen can modify serotonin availability in synapses. Also consider nutritional deficiencies such as tryptophan, gut dysbiosis etc. * The OCP shut down the natural menstrual cycle. They don’t react in the same way in the body and can interfere with key neurotransmitter like GABA. Deficiencies in tryptophan to be looked at for serotonin. 95% serotonin produced in the digestive tract so we need to look at integrity of guts.

Answer 44

* Reduced cortisol awakening response (CAR) — consider high adrenal function / chronic stress and a salivary cortisol test. Causes and risk factors (cont.): * Smoking — nicotine affects neurocircuitry (what regulate neurone activity) increasing susceptibility to environmental stressors. Further declines HPA axis functioning. * Obesity — BMI > 30 is strongly associated with ↑ PMS risk. Any increase in adipose tissue will increase the activity of CYP450 enzyme responsible for the biosynthesis of oestrogen -> we want an acceptable BMI range. * Alcohol — has a negative association with anxiety, mood changes and headaches during PMS. Alcohol can interfere with serotonin levels * High intake of dairy and sugars with a low protein intake can aggravate PMS symptoms. As fluctuation in blood sugar levels will impact PMS symptoms – make sure we got adequate proteins along with good fats (we don’t want to push down inflammatory prostaglandin E2 pathway. Increase inflammation can lead to insulin resistance and direct link to increase in weight. * High omega 6:3 ratio can increase inflammatory prostaglandins and induce aromatisation.

Answer 45

CNM Naturopathic Diet with a ‘Hormone Balancing Approach’, and focus on oestrogen:progesterone balance: * Optimise hormone detoxification (phase 1 and 2), elimination and metabolism (i.e., methylation, GIT health etc.) and hydration. * Minimise xenoestrogen exposure (earlier). * Address chronic stress. Adrenal support. * Restore nutritional deficiencies (e.g., the B vitamins, zinc and magnesium). * Balance blood glucose levels. * Reduce inflammation. Also consider thyroid support if applicable. Natural approach to PMS: 1. Avoid / minimise: * High GI / GL foods, caffeine, alcohol, cigarettes, table salt, dairy, red and processed meats. 2. Balance oestrogen:progesterone ratio: * Support oestrogen detoxification / elimination (e.g., B vitamins, magnesium, high fibre, cruciferous vegetables, broccoli sprouts to help clear oestrogen metabolites out of the body). * Increase phytoestrogens including red clover tea (2 cups / day). * Low saturated fat diet reduces oestrogen circulation. * Remove endocrine disruptors, optimise weight, address stress. * Herbal medicines, e.g., Vitex Agnus castus. 3. Balance blood glucose: * Low GI / GL, plant-based foods, complex carbohydrates. * Alpha-lipoic acid, cinnamon, chromium, magnesium, B-vitamins. => help the body cope with blood sugar fluctuation 4. Reduce inflammation: * Increase omega-3 (especially vegan and vegetarian ensure we balance omega 3 and 6), GLA (EPO, borage oil). Eliminate inflammatory products (dairy, sugar, hydrogenated oils etc.). * Increase antioxidants (e.g., vitamins A, C, E). * Good quality protein (focus on plant proteins, tofu, tempeh). 5. Optimise status of key nutrients: * B vitamins (esp. B6), magnesium, zinc, vitamin D, EFAs, calcium. Supplements in the shorter term can be how we get the results 6. Balance neurotransmitters: * L-Tryptophan (serotonin precursor) or 5-HTP. B6 co factor (also to boost progesterone) * Other key nutrients: Tyrosine, B6, B12, folate, zinc, magnesium, L-theanine (green tea – calming compounds found in green tea). * St John’s wort, saffron — serotonergic effects – similar benefits to serotonin in the body. * Remove alcohol and caffeine; optimise sleep (sleep needs to be refreshing) and exercise (to bring balance in the body). 7. Reduce fluid retention (if applicable): * Reduce sodium and increase potassium-rich foods. * Vitamin B6 to help regulate aldosterone. * Seed cycling (pumpkin and flax in follicular phase / sunflower and sesame luteal phase for water retention) – very good for breast tenderness. * Diuretics — celery, dandelion, parsley, nettle. Nat. sulph. tissue salt. Juice blend of celery fennel, cucumber, mint and apple (for taste).

Answer 46

* B6 is a cofactor for the production of GABA, serotonin and dopamine. * One of the methyl factor – needed for methylation to help metabolise oestrogen out of the body. * Oestrogen-progesterone imbalances can lead to a relative deficiency of B6. ↓ dopamine = ↑ prolactin which affects breast tissue and promotes water retention. * B6 levels are typically low when taking the OCP. Without B6 dopamine not produced at the right level and dopamine is a modulator of prolactin leading to high prolactin levels interfering with ovulation meaning we don’t ovulate. * Vitamin B6 is required for corpus luteum development oestrogen metabolism in the liver. It supports healthy progesterone levels and modulates oestrogen. * Functional testing to see of B6 comes on the borderline deficiency

Answer 47

Magnesium * Important for GABA and serotonin synthesis and various other cell functions. Calcium * Cofactor for tryptophan → serotonin conversion. Vitamin D * Important role in female reproductive health via cyclic sex hormone fluctuations, or neurotransmitter function. Needed for Cholesterol to pregnenolone synthesis Zinc * Zinc is important for the proper action of many sex hormones — in particular, it controls prolactin. Co factor of hormones and neurotransmitters EFAs * Women with PMS have been shown to exhibit EFA and prostaglandin abnormalities (e.g., low GLA). Evening primrose oil. Oil for the brain – PMS ladies have bad 6:3 ration and pushing the proinflammatory prostaglandins

Answer 48

Vitex Agnus castus * Hyperprolactinemia can result in long or irregular cycles and is often linked to low progesterone levels. * Binds to dopamine receptors to reduce secretion of prolactin. * Reduces mood changes, irritability, headache and breast tenderness. Gingko biloba * Effective against congestive symptoms, including breast pain / tenderness and vascular congestion. * Can decrease the overall severity of symptoms. Rosemary — antioxidant effects, neutralising quinones. It downregulates CYP3A4 and induces CYP1A1 – balance oestrogen metabolites — reducing 16-OH-E and increasing the more beneficial 2-OH-E. Ashwagandha — adaptogen, nervine, thyroid support.

Answer 49

* Ginger root — improves blood circulation, reduces congestion / cramping; reduces bloating. * Nervine teas (esp. for PMS-A) — chamomile (also eases bloating) and passionflower. * Green tea — L-theanine to calm the nervous system. * Peppermint — antispasmodic, eases bloating. * St John’s wort (MAO inhibitor, GABA antagonist) — enhances mood.

Answer 50

Polycystic Ovarian Syndrome (PCOS) = an endocrine and metabolic pathology affecting 5–20% of women (reproductive age) worldwide. Because a lot has to do with insulin. Hallmark features: * Ovarian dysfunction (irregular / absent periods). * Hyperandrogenism. * Polycystic ovaries => difference between PO and PCOS is when there is the hormone imbalance (with testosterone increase and DHEA and low levels of SHBG in PCOS

Answer 51

* Amenorrhoea / oligomenorrhoea, weight gain, hirsutism, weight gain / inability to lose weight, thinning hair or hair loss, oily skin, acne and infertility. If severe: ↑ muscle mass.

Answer 52

* T2DM, gestational diabetes, hypertension, dyslipidaemia, NAFLD (NAFLD = non-alcoholic fatty liver disease and metabolic syndrome. * Endometrial cancer, anxiety, depression, autoimmunity, e.g., Hashimoto’s thyroiditis. * It’s not just a hormonal imbalance

Answer 53

* ↑ amplitude and pulses of LH = anovulation and ↑ androgens. * ↑ LH stimulates ↑ ovarian theca cell production of androgens. * Reduced FSH relative to LH reduces aromatisation of androgens to oestrogen leading to anovulation. * Follicular development ceases during maturation = anovulation. Pushed by high testosterone Pathophysiology — insulin resistance is the most common and prominent mediator in the majority of PCOS cases. First line of approach to PCOS is metformin in conventional medicine which is a T2DM medication.

Answer 54

* Decreases hepatic SHBG synthesis = ↑ active testosterone & DHT. * Increases ovarian (theca cell = a group of endocrine cells in the ovary that surround follicles) androgen production => increased DHEA precursor to testosterone . * Increases adrenal androgen secretion. * Leads to leptin resistance, increasing obesity risk. Hypothalamus pick up leptin messages from fat cells and will say I have enough fat cells when leptin is at oprtimal levels and message would be reduce appetite and increased, metabolism to maintain that. Sometimes the leptin message does not make it to the hypothalamus and the interference message are insulin and inflammation because both block the message of leptin. Can increase appetite and reduce metabolism => in obesity find it difficult to get full. * String epigenetics and diet and lifestyle factors IR can lead to weight gain, which can make PCOS symptoms worse. 75% of lean women and 95% of obese women with PCOS exhibit IR. Controlling blood glucose levels is therefore essential therapeutically.

Answer 55

Causes and risk factors — obesity: * Consider factors such as overeating, undernourishment, physical inactivity, poor sleep, intestinal dysbiosis etc. * ↑ IR and compensatory hyperinsulinaemia which in turn ↑ adipogenesis and ↓ lipolysis. * Sensitises thecal cells to LH and ↑ androgen production. * ↑ inflammatory adipokines (e.g., TNF- α) which ↑ IR and inflammation (see next slide). * PCOS symptoms commonly improve with 5% to 10% weight loss. Causes and risk factors ― chronic low-grade inflammation: * Consider factors such as: ‒ A typical Western diet (high in refined carbohydrates, processed foods, trans-fats, a low omega-3 to 6 ratio etc.) ‒ Metabolic endotoxaemia (intestinal permeability / mucosal degradation). ‒ Obesity and a lack of exercise. * This all adds to insulin resistance and impaired ovulation. * High levels of oxidative stress are common in PCOS and considered a risk factor. Studies have shown lower levels of glutathione (GSH), vitamin C and vitamin E in PCOS. Consider hs-CRP testing Causes and risk factors — gut dysbiosis: * Gut dysbiosis can influence inflammation specialy when there is dysbiosis and inflammation => insulin resistance => hormone imbalances * Bi-directional: Gut bacteria may play a role in the pathogenesis of PCOS, and PCOS may lead to composition changes in the gut bacteria as well. Obesity, inflammation * Studies have shown altered microbiota compositions and reduced microbial diversity in PCOS. * Proteobacteria, escherichia, and shigella have been correlated with PCOS in some studies. * Dysbiosis influences the progression of PCOS by altering hormone secretions, gut-brain mediators, inflammatory pathways and islet β-cell proliferation. * HPA-axis dysfunction (chronic stress) — increasing production of adrenaline and cortisol, which increase insulin resistance. Stimulates production of DHEA / DHEA-S and androstenedione, which can convert to testosterone in peripheral tissues. * Genetics — polymorphisms in CYP genes (e.g., CYP11, CYP17 have been linked). * Smoking — linked to hyperandrogenism. * Vitamin D deficiency — vitamin D supplementation ↑ insulin sensitivity and decreases androgen levels in PCOS.

Answer 56

High DHT testosterone High DHEA High oestrogen Low progesterone High LH Low FSH High prolactin High HbA1c High fasting insulin Low SHBG High TNF alfa High anti mullein hormone (AMH) - AMH = is secreted by an ovarian follicle as it matures. It is directly associated with the number of antral (resting) follicles found on the ovary each month – elevated in PCOS because follicles aren’t being released

Answer 57

Therapeutic aims — requires a combined approach to improve overall hormonal balance and regulate ovulation – endocrine and metabolic approach: * Decrease insulin resistance and glucose intolerance to lower androgens. Regular meals balanced with good fats and proteins. * Decrease central obesity and improve muscle composition. Especially if visceral fats because have more of an endocrine influence. * Reduce oxidative stress and inflammation. * Promote optimal liver detoxification and intestinal oestrone clearance. * Support HPA axis; reduce stress and cortisol levels.

Answer 58

Natural approach to PCOS — supporting blood glucose balance, insulin sensitivity and weight loss: * CNM Naturopathic Diet with a ‘hormone balancing approach’ — focus on low GI foods. Low saturated fat, no trans fats and processed foods. Increase fibre. * Limit snacking to improve insulin sensitivity. * Quality protein from predominantly vegetable sources, eggs and fish. * Optimise omega 6:3 ratio (1:1 – 1:3) — wild fish, flaxseeds, chia seeds etc. * Increase chromium rich foods for insulin receptor function (later). Natural approach to PCOS: * Cinnamon — improves insulin sensitivity, downregulates testosterone and insulin; decreases IGF-1 levels. * Berberine — insulin sensitising action (500 mg x 3 daily). * Alpha-lipoic acid — antioxidant, reduces insulin resistance and increasing glucose metabolism (600‒1200 mg / day). * Vitamin D — helps address insulin resistance (test to dose). Test the end of September and again at the end of march to indicate how much and when you need to supplement. * Magnesium — improves insulin resistance (200–500 mg daily). * Omega-3 fatty acids — anti-inflammatory, insulin activity. Cell membrane flexibility and anti inflammatory. * CoQ10 — beneficial effect on serum blood glucose, insulin levels, IR and total testosterone. 60 mg daily researched. The MUFA oleic acid in EVOO has been shown to upregulate SHBG production by the liver. Natural approach to PCOS — supporting hormone balance: * Seed cycling (day 1‒14 1 tbsp each of pumpkin and flax; day 15‒28 1 tsp each of sunflower and sesame). * Saw palmetto — inhibits 5-α reductase and the conversion of testosterone to DHT. * Liquorice — may inhibit the conversion of androstenedione to testosterone. * Spearmint tea — anti-androgenic. * Nettle root — lowers DHT. * Green tea — reduces blood glucose, insulin, testosterone and inhibits COX-1 and 5-LOX. Studies reveal that fenugreek seed extract reduces ovarian cysts. Natural approach to PCOS (cont.): * Support HPA-axis — adrenal adaptogens (e.g., ashwagandha), magnesium, calming nervine teas (chamomile, passionflower, lemon balm), limit caffeine, sleep hygiene. * Microbiome, detoxification and elimination support — prebiotics and probiotics. Fermented foods and polyphenols. Fibre (30–45 g / day) from whole foods. Cruciferous vegetables (1 cup). B complex, magnesium, NAC, silymarin, castor oil packs. * Other nutrients: Zinc (insulin signalling and 5-α reductase inhibition). Carnitine (normalises metabolic profile in PCOS (400 mg / day). Natural approach to PCOS: Promote exercise: * At least 45 minutes of exercise, four times a week to enhance insulin sensitivity. * Tabata training / HIIT has been shown to effectively reduce IR, VAT fat and HbA1C. * Tabata: Each exercise in a Tabata workout lasts only four minutes but is high intensity. The structure of the programme is as follows: ‒ Work out hard for 20 seconds, rest for 10 seconds, complete 8 rounds. Exercise can also increase SHBG. SHBG levels correlate with muscle strength

Answer 59

* Myo-inositol improves insulin sensitivity and supports a healthy body weight. * It decreases LH, androgens and increases SHBG to reduce bioavailable testosterone. * Also improves menstrual cycle regularity, oocyte quality and overall female fertility. * Dosage: 4 g MI alone daily, or MI combined with DCI at a 40:1 ratio, for at least a 6 month period. Food sources: Whole grains, beans, nuts, fresh fruit

Answer 60

Chromium picolinate reduces IR, cardiovascular disease and T2DM. Chromium increases the sensitivity of the enzyme ‘tyrosine kinase’.

Answer 61

ENDOMETRIOSIS Endometriosis = the presence of endometrial-like tissue outside the uterus. Driven by oestrogen. * Endometrial tissue locates in the pelvis (e.g., ovaries, fallopian tubes, rectum, Pouch of Douglas). Extra-pelvic deposits can occur (e.g., lungs) but are rare. * Tissue responds to the natural hormonal cycle causing it to grow, break down and bleed. The blood has no outlet, leading to inflammation, pain, and the formation of scar tissue and adhesions.

Answer 62

* Dysmenorrhoea, heavy menstrual bleeding and deep dyspareunia – (painful intercourse especially around menstrual bleed). * Chronic pelvic pain (minimum of 6 months) and lower back pain. * Period-related or cyclical GI (e.g., painful bowel movements) / urinary symptoms (e.g., dysuria). Painful pelvic area. * Migraines, anxiety and depression.

Answer 63

* Infertility, endometriomas (ovarian cysts containing blood and endometriosis-like tissue), bowel obstruction, ovarian cancer.

Answer 64

* Endometriosis is often associated with a high O:P ratio. * Oestradiol (E2) is central to the endometrial tissue growth. * Mast cells contain oestrogen and progesterone receptors. Oestrogen triggers histamine degranulation, but histamine itself is also able to induce ovarian E2 synthesis (a two-way process). * Oestrogen can trigger histamine response => histamine can then induce oestrogen synthesis => elevated oestrogen levels during the menstrual cycle can trigger that histamine release which contributes to the local inflammatory response driving inflammation, driving angiogenesis and therefore the endometriosis cells proliferation. * High histamine drives inflammation and angiogenesis, and hence endometriosis proliferation. * Progesterone has an inhibitory effect on histamine secretion following mast cell binding but is overridden by oestrogen. Because we are oestrogen dominant the oestrogen override progesterone.

Answer 65

* Immune dysfunction — an inability to recognise and destroy endometrial tissue outside the uterus. Inflammatory mediators, cytokines, macrophages, T-lymphocytes, and TNF are elevated. * Metaplasia — cells found in the pelvic and abdominal area change into endometrial-like cells. * Retrograde menstruation — sloughed endometrial cells flow back from uterine cavity but has now been generally disregarded. * Surgical scar implantation — following surgery, endometrial cells may attach to a surgical incision * Endometrial cell transport — cells transported via the lymphatics.

Answer 66

* Prolonged oestrogen exposure (e.g., early menarche, nulliparity and OCP). * Low birth weight, prematurity and formula feeding. * Obesity (increased inflammatory cytokine and aromatase activity). * Poor oestrogen detoxification and clearance. * Environmental toxin exposure — (e.g., PCBs, organochlorines, dioxins) such as that consumed via food (plastic packaging, non-organic produce, larger fish, dairy). * Emotional trauma, incl. childhood abuse. * Microbial infections — endometriosis can result from a triggering infection such as a virus (e.g., EBV, CMV, HSV), bacteria (e.g., E.coli) or parasite. – Intestinal dysbiosis can also lower DAO activity — increasing histamine levels. SNIP in DOA will decrease histamine tolerance – and 16% ladies with endometriosis have allergies and also have some form of bacterial overgrowth like SIBO – A compromised mucosal barrier can also increase LPS leakage, contributing to immune-overactivity/inflammation. * High consumption of fats (trans / saturated), red meats and alcohol. Low vegetables / fibre, low omega-3, selenium and vit. D.

Answer 67

Natural approach to endometriosis: * CNM Naturopathic Diet with a hormone balancing approach — adopted to be low histamine. * Normalise the immune response and reduce histamine load. * Reduce exposure to hormone disruptors e.g., dioxin and PCBs. * Optimise liver function to conjugate and metabolise hormones and detoxify endogenous and exogenous toxins. * Support the elimination of oestrogen metabolites. * Promote optimal transit time and optimal intestinal microflora. * Reduce inflammatory processes and oxidative stress. Elevate anti-oxidant status (vitamin C, E, selenium, beta-carotene). Consider hormonal, stool and methylation testing. Natural approach to endometriosis (cont.): * Turmeric — regulates inflammatory cytokines, NFkB and ↓ COX-2. * Microbiome support — e.g., a 5R approach, pro / pre-biotics. * Optimise methylation — folate, B12, B6, choline etc. * Liver support — e.g., B vitamins, magnesium, glutathione etc. * Alpha-lipoic acid — can reduce inflammatory cytokines incl. IL-6. * Ginger — acts to lower CRP and IL-6 levels. * Resveratrol — inhibits aromatase and can reduce inflammatory markers / mediators including CRP, TNF and NF-κB. * EGCG (green tea) — anti-angiogenic and histamine- lowering (inhibits the histidine decarboxylase). Consider including probiotic formulas that can produce DAO Natural approach to endometriosis (cont.): * Optimise the omega 6:3 ratio ― e.g., oily fish, flaxseeds etc. * Aromatase inhibitors ― e.g., cruciferous vegetables, onions, garlic, chives, scallions, EVOO and olives. * Quercetin ― anti-inflammatory / anti-histamine (500–1000 mg / d). * Proteolytic enzymes (e.g., serrapeptase) ― for adhesions; anti-inflammatory, assist drainage. * Vitamin D, vitamin C, magnesium, zinc, vitamin E. * Other herbs: White willow bark, Vitex Agnus castus, echinacea, calendula, valerian and dandelion root. * Visceral manipulation, castor oil packs, dry skin brushing.

Answer 68

Fibrocystic breasts (FB) = A common, benign condition characterised by swollen and tender breasts. * Common among premenopausal women aged 20–50 years old. * A minority can progress to a high-risk and malignant phenotype due to genetic mutations and differing breast microbiome.

Answer 69

Symptoms: * Cyclical breast cysts; ‘diffuse lumpiness’. * Breast pain (often bilateral) often during the luteal phase; improves post menses. Dull / heavy in nature. * Some experience nipple discharge

Answer 70

* Oestrogen dominance / elevated O:P ratio with low progesterone. Stress may be a contributing factor. * Reproductive history ― nulliparity and late menopause. * Obesity and T2DM are both associated with breast changes. * HRT ― increased incidence with oestrogen-replacement therapy. * Iodine deficiency ― shown to contribute to FB. * Methylxanthines ― substances found in coffee, tea, cola, chocolate and some drugs that have been linked with FB. * Low fibre ― ↑ dietary fibre = ↓ risk of benign breast disease. Methylxanthines = substances that occur naturally (e.g. caffeine) or synthetically (e.g. in drugs).

Answer 71

* CNM Naturopathic Diet with a hormone balancing approach (incl. xenoestrogen avoidance etc.). Support oestrogen elimination. * Evening primrose oil (1000 mg 3 x daily) ― GLA forms PG1 which inhibits the arachidonic acid synthesis. * Vitex Agnus castus ― indirectly progesterogenic. * Vitamin E and omega-3 FAs have been shown to relieve FB pain. * Remove methylxanthines and caffeine. Stop smoking. * Seed cycling ― to balance oestrogen and progesterone through the actions of phytoestrogens, zinc, selenium and vitamin E. * Restore iodine balance (consider iodine testing). Castor oil packs.

Answer 72

Uterine fibroids = benign tumours that originate from the myometrium and connective tissue. Affect approximately 30% globally. Occur between menarche and menopause but are most common in women aged 35–49 years.

Answer 73

* 50–80% are asymptomatic. * Heavy / prolonged menstrual bleeds. * Pelvic discomfort / pain. * Abdominal bloating. * Depending on location: Frequent urination and constipation.

Answer 74

* Iron deficiency anaemia, infertility, miscarriage, pre-term labour, obstructed labour, foetal anomalies, postpartum haemorrhage.

Answer 75

* Uterine fibroids are oestrogen dependent. * Oestrogen receptors are over-expressed in fibroid tissue. * Oestradiol concentration increases, which increases progesterone receptor availability. Progesterone completes fibroid development. * Excess aromatisation is also seen. * IGF and cytokines (e.g., TNF, IL-8) can also promote fibroid growth

Answer 76

* Genetics ― polymorphisms: CYP1A1, MED12. * Hypertension ― may cause smooth muscle cell injury and / or cytokine release. * Poor oestrogen metabolism / clearance, EDCs, the OCP, obesity. * Chronic stress significantly increases risk. * Heavy metals ― cadmium and lead activate oestrogen receptors. * Diet / lifestyle ― increased risk with low fibre intake and low physical activity. High saturated fat, refined carbohydrates, caffeine and alcohol linked to an increased risk. * Vitamin D deficiency ― shown to inhibit fibroid cell proliferation.

Answer 77

1. Support oestrogen balance and detoxification: * CNM Naturopathic Diet with a hormone balancing approach. * Avoid xenoestrogens / endocrine disruptors. * Eliminate caffeine and alcohol. * Address stress (reduce cortisol). * Increase phytoestrogen foods / herbs (e.g., chickpeas, sage, flaxseed, red clover). * Green tea extract ― epicatechins shown to inhibit fibroid cell growth. * Increase fibre rich wholefoods to improve oestrogen excretion. * Vitex Agnus castus ― prolactin inhibitor (prolactin has been linked). 1. Support oestrogen balance and detoxification (cont.): * Support liver detoxification ― cruciferous vegetables (I3C), B-complex, magnesium, NAC etc. * Choleretics / cholagogues ― support oestrogen clearance, e.g., globe artichoke, turmeric. 2. Regulate excessive bleeding: * Check iron / ferritin levels: A symptom of iron deficiency is an increased risk of heavy bleeding. Focus on iron-rich foods, e.g., spirulina, apricots, nettle leaf tea. Vitamin C to enhance absorption. * Astringent herbs help to constrict blood vessels and control blood flow (yarrow, cranesbill, shepherd’s purse). 1⁄4 –1⁄2 cup broccoli sprouts per day for its I3C content. 3. Reduce inflammation: * Eliminate all sources of arachidonic acid to reduce PGE2 and reduce other pro-inflammatory foods, e.g., refined sugars. * Introduce natural anti-inflammatory / prostaglandin modulating substances or applications: ‒ Omega-3 (EPA), curcumin, ginger, green leafy vegetables, vitamin D. ‒ Proteolytic enzymes, e.g., bromelain, serrapeptase. ‒ Castor oil packs. * Optimise weight and address any insulin resistance (to reduce inflammation and aromatisation). Introduce regular exercise.

Answer 78

Menopause = the life stage where menstruation and reproductive potential ceases. Stages include: * Early menopause (40‒45 yrs.): Cessation of ovarian function without identifiable underlying secondary cause. Affects 5‒12%. * Perimenopause (around 45‒50 yrs.): Begins from the onset of irregular menstrual cycles and ends 1 year after the final period. * Menopause (50‒55 yrs.): After 12 months of amenorrhoea. * Post-menopause (55 onwards): Periods cease and generally the worst of the hormonal symptoms have subsided. * Premature menopause (<40 yrs.): Permanent (bilateral oophorectomy) or due to ovarian insufficiency (genetics).

Answer 79

Perimenopause = the transition phase of declining reproductive hormones where ovarian follicular activity begins to fail. * Hormonal changes: FSH / LH levels rise due to reduced negative feedback. FSH levels can vary markedly. O:P ratio fluctuates a lot during perimenopause. * Menopause = low oestrogen, persistently high FSH (> 30 iu / L checked 4‒6 weeks apart) and LH levels. Note: FSH is not accurate in perimenopause. * Post menopause = ~65% produce sufficient testosterone in their adrenal glands to sustain libido. Assessing adrenal health pre-menopause is a valuable tool to assist a smoother transition.

Answer 80

* Obesity — can exacerbate menopausal symptoms. * Smoking — linked to an earlier onset. It can be hypoestrogenic. * Chronic stress (HPA axis) — associated with menstrual irregularity. * Gut microbiome changes (the ‘oestrobolome’). * Lead — a long-term cumulative exposure to lead is associated with early menopause. * Family history — women whose mothers entered menopause at an early age are at a high risk of early onset menopause. * Hypertension — at an earlier age is linked to an early menopause.

Answer 81

Signs and symptoms — vasomotor symptoms (VMS): * Hot flushes / flashes — characterised by sudden intense sensation of warmth (affecting the face, neck, chest); often followed by a chill. * 30–70% of women experience VMS during perimenopause. * Negatively affected by obesity, smoking, alcohol, spicy foods, caffeine and stress. * VMS contribute to sleep disturbances. * Women with a plant-based diet appear to experience less menopausal VMS. * Proposed mechanism: Oestrogen is a neuromodulator — changes in levels can impact areas involved in temperature homeostasis. * Weight gain and obesity — due to genetic factors, hormonal factors and exogenous factors (e.g., poor nutrition, low activity). * Sleep disturbance — night sweats and mood changes contribute. * Genitourinary symptoms — dry / sore vagina, dysuria, dyspareunia. Urogenital atrophy. * Mood disturbances — irritability, aggressiveness, mood swings, anxiety and depression. * Other — hair loss, joint and muscle pains, headaches, itching skin, burning tongue, daytime fatigue, low libido. Loss of confidence and reduced self-esteem. Memory / concentration issues.

Woman's Health Flashcards

(105 cards)