“Rya,” 42 Years Old

Excerpted and condensed from “Screaming to Be Heard,” by Elizabeth Lee Vliet, M.D., Evans and Company, Inc., 1995

Medical condition: Mood swings, headaches

Rya was referred to me by her psychologist who had been concerned about her mood swings and headaches. He thought they might be related to her hormone therapy, although Rya had been told by her gynecologist that this wasn’t likely. Her gynecologist attributed her mood swings and headaches to work stress. (An interesting switch: the psychologist thought the problems were hormonal and the gynecologist thought they were psychological.)

When I met Rya, this was what she had to say:

“I have terrible mood swings and constant headaches, and I have been so frustrated with this because I have always been so healthy. I just want some answers with my hormones and what I can do to take something more natural and feel better. My psychologist heard you speak and feels you are the person I should see. I started out on Premarin and Provera and I just felt horrible on this. I tried it for three months, and I felt agitated, anxious, depressed, and had headaches constantly. Then I was switched to Ogen (a synthetic type of estrone) and Cyrin (a progestin) 5mg for 10 days / month. That’s when I have the worst headaches. I’ve ended up feeling like which do I deal with, my risk of heart attack or feeling lousy every day being on hormones? That’s why my psychologist suggested I see you.”

Rya has a serious family history of heart disease in her mother, father, and her siblings. She expressed a lot of fear about going off hormone replacement therapy because of her risk for cardiovascular disease. I told her I thought we could find hormone options that didn’t produce so many unwanted side effects, so that she would start to feel well on her hormones.

Rya had never had problem with headaches prior to hormone replacement therapy. And she was experiencing yet another menopausal symptom when I saw her: marked insomnia. Most nights, she was waking up at around 2 or 3 A.M. and then having trouble going back to sleep. She took Ogen (0.9 mg) in the morning, and I suspected that her waking up at night could be partly due to the fact that her estrogen was wearing off, or that it wasn’t the best type of estrogen for her. Rya needed the cholesterol-lowering and heart-protecting effects of an oral estrogen, but she had not done well on either of the mixed estrogens she had tried.

I recommended a medication change to oral 17-beta estradiol (Estrace), 0.5mg in the morning and 1.0mg in the evening (which is equivalent to the Ogen dose). Spreading out the estradiol provides better stability in blood levels throughout the day, more closely approximating natural estrogen production by the ovaries. For most women, I find that this approach works much better than a single daily dose, and usually provides marked improvement in sleep. It also reduces the headaches triggered by dropping estrogen levels between doses. I also suggested that Rya try the natural progesterone: 100 mg twice a day for 10 days a month, which would be equivalent to the 5 mg of Cyrin.

At her follow-up appointment she described feeling “like a new person. It’s wonderful not to have daily headaches, it’s like a miracle. My husband has noticed a big change in my disposition, and says I’m not as irritable and short-tempered as I was. My mood feels more even, I feel a real difference in my ability to let things just run off and not get upset by them. I’m not as tired, and I’m sleeping better. This is a big change.”