Wednesday, 6 April 2016

The Menopausal Weight Gain Saga

Recently in the student clinic (8 weeks to go before I finish college!) I have been seeing a patient who I referred (to myself, this is a requirement) who has been complaining of what appears to be menopause-related weight gain. Unfortunately, the menopause/female reproductive health lectures in the theory subjects do not specifically address weight gain and basically ignore it, which makes actually treating it difficult, especially when there are no other menopause symptoms and your patient already exercises plenty.

So what did I do? First I suggested shatavari (Asparagus racemosa), alongside black cohosh (Cimicfuga racemosa). Black cohosh was accepted by the substitute supervisor (SS), but shatavari was not. Black cohosh is a selective modulator of oestrogen receptors, able to protect bone mass but not stimulate growth of the uterus or breasts, so it is a safe alternative to oestrogen replacement. Shatavari apparently only works if a woman still has some eggs left, good for perimenopausal but not postmenopausal women. I eventually replaced this with rehmannia (Rehmannia glutinosa) extract, as this is an adrenal tonic and the adrenal glands are responsible for almost all of a postmenopausal woman's sex hormones.

Tribulus terrestris
Tribulus terrestris. Source: JM Garg
First, however, I suggested tribulus (Tribulus terrestris) extract as a substitute. SS was not happy, as tribulus can increase testosterone levels because of the fact that it raises DHEA, which can convert to either male or female hormones. However, I may have been right to suggest something which can raise both oestrogen and testosterone. In one study on 75 women who previously had to have their ovaries removed, those who received 300ug patches of testosterone "unequivocally" showed significant improvement in sexual function, mood and general wellbeing. This demonstrates that women do lose significant amounts of testosterone after menopause, and that replacing it does have a positive effect. In another, obese women who were given low doses of synthetic testosterone lost more body fat, including abdominal fat, and gained more muscle mass than the placebo group women. After nine months, the women taking "testosterone" lost twice the amount of body fat and gained six pounds of muscle compared to the placebo group; both groups were on a low-kilojoule diet and did not change their exercise habits. SS may be of the older idea that testosterone is not important for women, and does not count menopause/aging as a disease. I will be quite happy if or when aging officially is a disease; it just wasn't something that negatively affected society when women and AFABs like me were able to be forced into motherhood to "replace" the older generation. [My one complaint about that article's argument is that it counts natural medicine as separate from "evidence based" medicine; we are evidence-based, and people prefer us because natural medicines are safer and more effective than our pharmaceutical counterparts.] 

I had also advised this patient to eat regularly, and I learnt today that caloric restriction of at least 50% can increase sex hormone binding globulin, which may be contributing to her weight gain. Depending on her results, this saga may continue as the treatment of menopausal weight gain is considerably overlooked for something that so many people want to address.

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