Nicole: Early perimenopausal symptoms

Nicole is a 46 year-old mother of two who first consulted me 2 years ago (at the age of 44) for severe migraines, heavy, erratic menstrual bleeds, severe low back pain due to herniated disc in the lumbosacral region, and perimenopausal symptoms. She had already been experiencing night sweats since the age of 39, and over the past few years, also began to experience recurrent bladder infections, achy joints, hair loss, palpitations, and dry vagina. Her back pain was of great concern to Nicole, especially given that she had already undergone a previous anterior cervical fusion at the age of 42 for a herniated disc in her neck due to a skiing accidents. She was now in chronic pain due to her lower back herniated disc, despite taking multiple narcotic pain medications, along with muscle relaxants, anti-inflammatory medications, and a physical therapy program. In fact, her lower back pain was so pronounced that her neurosurgeon recommended surgery again.

Nicole was evaluated by her gynecologist for her perimenopausal symptoms, and was placed on a trial of ortho-evra patch first, followed by nuva ring, both birth-control hormone manipulation methods, in trying to suppress her migraines and heavy, irregular bleeds. At one point, she was told to use her nuva ring every 3 weeks, continuously, in an effort to stop all menstrual cycles. Despite these courses, Nicole continued to have severe migraines to the point that it impacted negatively on her work schedule, and she was requiring multiple abortive migraine medications. She also tried an anti-depressant as a migraine preventive medication, but it only gave her slight relief of the headaches, and furthermore, caused weight gain.

After our first meeting, I asked Nicole to have a pelvic ultrasound done, which showed only 2 small, benign fibroid tumors. It was clear that many of Nicole's symptoms were related to perimenopausal hormone fluctuations and/or deficiency. I placed her on a rhythmic cycling hormone regimen using bio-identical estrogen and progesterone. At her first follow-up appointment several months later, she stated that she was had been doing much better. Her monthly menses were now normal, and occurring on-time. Her night sweats, vaginal dryness, achy joints, and recurrent bladder infections had all resolved, and her palpitations were only occasional now. Her migraines were much improved, and she was only experiencing them during low estrogen and/or high progesterone days. Her low back pain had also improved so much that she was able to taper off all of her pain medications!

I made a few more hormonal adjustments to Nicole's program, and at her most recent follow-up visit in July of 2008, she stated she was doing extremely well. In fact, she also recently had a follow-up appointment with her neurosurgeon, and relayed to me that he was "absolutely shocked that I was able to avoid surgery, and to be able to get off all of my pain medications!" Her migraine headaches were now occurring no more than once per month, as opposed to previously, when she was experiencing 7-10 headaches per month prior to her hormone program. She was back at work as a teacher, and planned to have a follow-up pelvic ultrasound within the next few months to monitor for stability of her fibroid tumors.

Nicole's situation demonstrates that perimenopausal symptoms can begin fairly early in some women, even in their late 30's, and that synthetic birth control hormone manipulation methods do not always work. In fact, they can exacerbate certain symptoms, such as headaches, depending on their estrogen to progestin ratios. Her previous migraines were likely related to estrogen deficiency and/or fluctuation, which, in turn, affects the levels of multiple other neurotransmitters in the brain generated during a migraine inflammatory complex. The dramatic improvement in her low back pain was likely related to improved hydration status in her discs, along with anti-inflammatory and neuroprotective effects of the estrogen, coupled to progesterone's ability to facilitate myelination of her nerves.