Sharon: Hormones and dizziness

Sharon first came to me at the age of 50, when she was experiencing acute-onset severe attacks of vertigo (dizziness), accompanied by ringing in the right ear, and loss of hearing. These attacks were debilitating, preventing her from even leaving her house at times, and certainly prevented her from her work as an artist. She also gradually felt depressed and discouraged, not surprisingly. She had been a generally healthy woman up until this time, other than slightly overweight, with low HDL (good cholesterol) and high triglycerides. Coincidentally, these attacks first manifested while going through menopause. Along with her intermittent vertigo attacks, she was also experiencing the typical symptoms of menopause, including hot flashes, night sweats, low sex drive, etc. She was evaluated by an ENT physician who, after reviewing normal brain MRI results, diagnosed her with a basilar migraine variant, since her symptoms responded very quickly to typical anti-migraine medications such as Imitrex. Even though Sharon never experienced head pain, we began treating her migraine variant with various conventional preventive medications, including Pamelor (original approved use as an anti-depressant), Corgard (original approved use as an anti-hypertensive medication), and Topamax (original approved use as an anti-seizure medication), as we knew she did not want to have to take abortive medications like Imitrex frequently. None of these medications helped take away her symptoms, but they sure did cause numerous side effects, necessitating their discontinuation.

Sharon came to me early in my work with hormone balancing, but it struck me that this generally healthy woman never had any of these vertigo attacks until going through menopause, which is a time of great hormone fluctuation. I had also been familiar with, and even experienced myself, the typical pre-menopausal woman's cyclical migraine headaches, which usually occurred at the time of a menstrual cycle, obviously also related to hormone fluctuation. From that point on, Sharon and I embarked on a journey to see if we could balance out her hormones in order to relieve her debilitating symptoms. After some early research into the hormone literature, we began using topical Triest (natural bio-identical estrogens) cream along with natural progesterone cream. When these creams did not seem to help with her symptoms, we briefly also tried bio-identical estrogen patch, but this was discontinued very quickly after triggering several episodes of vertigo attacks.

I referred her to another ENT physician, for a second opinion, but she was told that her symptoms were classic for Meniere's disease. Sharon always felt deep down inside that there was a definite hormone connection, and felt discouraged that this second ENT physician was not willing to explore this with her further. Sharon's situation very much intrigued me, and propelled me to read much further into the hormone literature. After much research, we started her on oral Estrace (bio-identical estrogen), along with Prometrium (bio-identical progesterone) in continuous combined low doses, but enough to get her hormone levels closer to that of a mid 40's year old woman's levels. We went as far as to have her keep her levels of estrogen as even as possible by having her break her total day's dose into four divided dosages. Sharon felt great! For about a year, she had dramatic improvement of quality of life, and was able to work on her lovely paintings again. All of her menopausal symptoms also disappeared, as expected, and her sex drive was back!

Along with balancing out her hormones, we also talked extensively about nutrition and metabolism. She read every book I suggested, and completely changed her diet, with dramatic positive results regarding her weight, cholesterol, and overall energy level.

She came in to see me later, after doing some reading of her own, and was wondering if she should switch over to the cyclical way of administering her hormones. It certainly made sense to me that what existed in nature was not continuous low doses of hormones, but cyclical ups and downs of the menstrual cycle, so we decided to give it a try using her current medications. Unfortunately, every time she went off the progesterone with the cycling method, her vertigo attacks came back, so that after 3 months of trying to "cycle" her, we put her back on continuous combined therapy and with time, she was able to get back to feeling great again. I asked Sharon to see a neurologist at this point, and possibly to have repeat brain MRI done, just to make sure that we were not missing something. Despite the huge clue regarding the response of her symptoms to hormone manipulation, once again, she was told that her symptoms were classic for Meniere's disease, and that she should try medications such as Topamax again!

Sharon's situation shows first of all, that hormone fluctuations can lead to migraine equivalents, which biologically are related to changes in multiple brain neurotransmitters, which then lead to a state of brain "hyperexcitability", which then leads to changes in regulation of brain blood flow. In Sharon's situation, the areas affected centered around the vessels which provide blood flow to the right ear, and without adequate blood flow, she experienced acute vertigo and hearing symptoms. This would also explain why her brain imaging studies and thorough ear examination never led to any abnormalities. The other main point of education in her case is that each person's situation is different, and that there is NOT a "one size fits all approach" to hormone balancing. Each of the hormone manipulation methods we tried were all bio-identical, yet clearly the formulation and method of delivery to her made a world of difference. I credit a lot of what I now know about hormone balancing to Sharon, as she kept me searching for the right answer and did not give up when her situation seemed discouraging.

Addendum 11/26/08

It has been nearly 3 years since the posting of Sharon's case history, and both she and I have decided to update her progress due to the tremendous response it has generated.

Sharon last saw me in the office on 11/6/08, and was feeling "fabulous". She had elected to switch her low dose continuous combined oral estrace and prometrium over to rhythmic cycling (aka Wiley ProtocolTM) in February of 2006, because it always made sense to her that her body should have the normal cyclical rhythm of the menstrual cycle. We began her cycling on day 14, so that we could introduce progesterone at the same time in order to minimize any rapid fluctuations of estrogen. The first 3-4 months of the protocol required some adjustments, as she did not have normal menses even though she felt good. She experienced several vertigo attacks until we determined that her consumption of flax seed oil several times per day was interfering with the protocol, given its effects as a phytoestrogen, effects on liver metabolism of estrogens, and/or its ability to make the cell membrane more porous to the hormone. After the adjustments, however, she has had tremendous improvement in quality of life. At our recent visit, she told me that "the protocol has made all the difference in the world...I could not survive if someone took it away from me". She has had virtually no vertigo attacks since we adjusted her protocol in the first few months. She still experiences very minor dizziness periodically when she is stressed, eating excess sugars/junk food, and/or there is a barometric pressure change, but told me that it's not anywhere to the degree of what she experienced prior to starting the rhythmic cycling protocol. She wishes to stay on the protocol indefinitely. In fact, she recently accidentally got off track with her protocol and used the wrong doses for several days, and noticed immediate flares of vertigo. They resolved just as suddenly when she realized her dosing error and corrected it.

Sharon and I also addressed other issues at her last visit: recent hair loss, tendency to overindulge in simple carbohydrates, which is tied in to stress in her life and which affects her cholesterol profile, and lack of improvement of hearing in her affected ear. I have now started her on rhythmic testosterone replacement on top of her protocol, to see if it improves her hair thinning. I also began her on treatment for insulin resistance with metformin, and will await follow-up from her. Unfortunately, her hearing is the one aspect that has never changed with any of the hormonal treatments we have tried. We are thankful it has not worsened at least, but remain puzzled at this point as to what more we can do to try to improve her hearing in the right ear.