HRT Side Effects & Troubleshooting
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This is Dr. Heather Hirsch. She’s a board-certified internist, and her clinical expertise focuses on women’s health, particularly in midlife and menopause, and its intersection with chronic diseases (ranging from things associated with sexual health, to things like osteoporosis and heart disease).
So, what does she want us to know?
HRT can be life-changingly positive, but it can be a shaky start
Hormone Replacement Therapy (HRT), and in this context she’s talking specifically about the most common kind, Menopausal Hormone Therapy (MHT), involves taking hormones that our body isn’t producing enough of.
If these are “bioidentical hormones” as used in most of the industrialized world and increasingly also in N. America, then this is by definition a supplement rather than a drug, for what it’s worth, whereas some non-bioidentical hormones (or hormone analogs, which by definition function similarly to hormones but aren’t the same thing) can function more like drugs.
We wrote a little about his previously:
Hormone Replacement Therapy: A Tale Of Two Approaches
For most people most of the time, bioidentical hormones are very much the best way to go, as they are not only more effective, but also have fewer side effects.
That said, even bioidentical hormones can have some undesired effects, so, how to deal with those?
Don’t worry; bleed happy
A reprise of (usually quite light) menstrual bleeding is the most common side effect of menopausal HRT.
This happens because estrogen affects* the uterus, leading to a build-up and shedding of the uterine lining.
*if you do not have a uterus, estrogen can effect uterine tissue. That’s not a typo—here we mean the verb “effect”, as in “cause to be”. It will not grow a new uterus, but it can cause some clumps of uterine tissue to appear; this means that it becomes possible to get endometriosis without having a uterus. This information should not be too shocking, as endometriosis is a matter of uterine tissue growing inconveniently, often in places where it shouldn’t, and sometimes quite far from the uterus (if present, or its usual location, if absent). However, the risk of this happening is far lower than if you actually have a uterus:
What you need to know about endometriosis
Back to “you have a uterus and it’s making you wish you didn’t”:
This bleeding should, however, be light. It’ll probably be oriented around a 28-day cycle even if you are taking your hormones at the same dose every day of the month, and the bleeding will probably taper off after about 6 months of this.
If the bleeding is heavier, all the time, or persists longer than 6 months, then speak to your gynecologist about it. Any of those three; it doesn’t have to be all three!
Bleeding outside of one’s normal cycle can be caused by anything from fibroids to cancer; statistically speaking it’s probably nothing too dire,but when your safety is in question, don’t bet on “probably”, and do get it checked out:
When A Period Is Very Late (i.e., Post-Menopause)
Dr. Hirsch recommends, as possible remedies to try (preferably under your gynecologist’s supervision):
- lowering your estrogen dose
- increasing your progesterone dose
- taking progesterone continuously instead of cyclically
And if you’re not taking progesterone, here’s why you might want to consider taking this important hormone that works with estrogen to do good things, and against estrogen to rein in some of estrogen’s less convenient things:
Progesterone Menopausal HRT: When, Why, And How To Benefit
(the above link contains, as well as textual information, an explanatory video from Dr. Hirsch herself)
Get the best of the breast
Calm your tits. Soothe your boobs. Destress your breasts. Hakuna your tatas. Undo the calamity beleaguering your mammaries.
Ok, more seriously…
Breast tenderness is another very common symptom when starting to take estrogen. It can worry a lot of people (à la “aagh, what is this and is it cancer!?”), but is usually nothing to worry about. But just to be sure, do also check out:
Keeping Abreast Of Your Cancer Risk: How To Triple Your Breast Cancer Survival Chances
Estrogen can cause feelings of breast fullness, soreness, nipple irritation, and sometimes lactation, but this later will be minimal—we’re talking a drop or two now and again, not anything that would feed a baby.
Basically, it happens when your body hasn’t been so accustomed to normal estrogen levels in a while, and suddenly wakes up with a jolt, saying to itself “Wait what are we doing puberty again now? I thought we did menopause? Are we pregnant? What’s going on? Ok, checking all systems!” and then may calm down not too long afterwards when it notes that everything is more or less as it should be already.
If this persists or is more than a minor inconvenience though, Dr. Hirsch recommends looking at the likely remedies of:
- Adjust estrogen (usually the cause)
- Adjust progesterone (less common)
- If it’s progesterone, changing the route of administration can ameliorate things
What if it’s not working? Is it just me?
Dr. Hirsch advises the most common reasons are simply:
- wrong formulation (e.g. animal-derived estrogen or hormone analog, instead of bioidentical)
- wrong dose (e.g. too low)
- wrong route of administration (e.g. oral vs transdermal; usually transdermal estradiol is most effective but many people do fine on oral; progesterone meanwhile is usually best as a pessary/suppository, but many people do fine on oral)
Writer’s example: in 2022 there was an estrogen shortage in my country, and while I had been on transdermal estradiol hemihydrate gel, I had to go onto oral estradiol valerate tablets for a few months, because that’s what was available. And the tablets simply did not work for me at all. I felt terrible and I have a good enough intuitive sense of my hormones to know when “something wrong is not right”, and a good enough knowledge of the pharmacology & physiology to know what’s probably happening (or not happening). And sure enough, when I got my blood test results, it was as though I’d been taking nothing. It was such a relief to get back on the gel once it became available again!
So, if something doesn’t seem to be working for you, speak up and get it fixed if at all possible.
See also: What You Should Have Been Told About Menopause Beforehand
Want to know more from Dr. Hirsch?
You might like this book of hers, which we haven’t reviewed yet, but present here for your interest:
Enjoy!
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Exercise with Type 1 Diabetes – by Ginger Vieira
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If you or a loved one has Type 1 Diabetes, you’ll know that exercise can be especially frustrating…
- If you don’t do it, you risk weight gain and eventual insulin resistance.
- If you do it, you risk dangerous hypos, or perhaps hypers if you took off your pump or skipped a bolus.
Unfortunately, the popular medical advice is “well, just do your best”.
Ginger Vieira is Type 1 Diabetic, and writes with 20+ experience of managing her diabetes while being a keen exerciser. As T1D folks out there will also know, comorbidities are very common; in her case, fibromyalgia was the biggest additional blow to her ability to exercise, along with an underactive thyroid. So when it comes to dealing with the practical nuts and bolts of things, she (while herself observing she’s not a doctor, let alone your doctor) has a lot more practical knowledge than an endocrinologist (without diabetes) behind a desk.
Speaking of nuts and bolts, this book isn’t a pep talk.
It has a bit of that in, but most of it is really practical information, e.g: using fasted exercise (4 hours from last meal+bolus) to prevent hypos, counterintuitive as that may seem—the key is that timing a workout for when you have the least amount of fast-acting insulin in your body means your body can’t easily use your blood sugars for energy, and draws from your fat reserves instead… Win/Win!
That’s just one quick tip because this is a 1-minute review, but Vieira gives:
- whole chapters, with example datasets (real numbers)
- tech-specific advice, e.g. pump, injection, etc
- insulin-specific advice, e.g. fast vs slow, and adjustments to each in the context of exercise
- timing advice re meal/bolus/exercise for different insulins and techs
- blood-sugar management advice for different exercise types (aerobic/anaerobic, sprint/endurance, etc)
…and lots more that we don’t have room to mention here
Basically… If you or a loved one has T1D, we really recommend this book!
Order a copy of “Exercise with Type 1 Diabetes” from Amazon today!
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Fix Chronic Fatigue & Regain Your Energy, By Science
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Chronic fatigue is on the rise. A lot of it appears to be Long COVID-related, but whether that’s the case for you or not, one thing that will make a big difference to your energy levels is something that French biochemist Jessie Inchauspé is here to explain:
Mitochondrial management
Inchauspé explains it in terms of a steam train; to keep running, it must have coal burning in its furnace. However, if more coal is delivered to the engine room faster than it can be put in the furnace and burned, and the coal just keeps on coming, the worker there will soon be overwhelmed trying to find places to put it all; the engine room will be full of coal, and the furnace will sputter and go out because the worker can’t even reach it on account of being buried in coal.
So it is with our glucose metabolism also. If we get spikes of glucose faster than our body can deal with them, it will overload the body’s ability to process that energy at all. Just like the steam train worker, our body will try! It’ll stuff that extra glucose wherever it can (storing as glycogen in the liver is a readily available option that’s easy to do and/but also gives you non-alcoholic fatty liver disease and isn’t quickly broken down into useable energy), and meanwhile, your actual mitochondria aren’t getting what they need (which is: a reliable, but gentle, influx of glucose).
You can imagine that the situation we described in the steam train isn’t good for the engine’s longevity, and the corresponding situation in the human body isn’t good for our mitochondria either (or our pancreas, or our liver, or… the list goes on). Indeed, damaged mitochondria affect exercise capacity and stress resilience—as well as being a long-term driver of cancer.
The remedy, of course, is blood sugar management. Specifically, avoiding glucose spikes. She has a list of 10 ways to do this (small changes to how we eat; what things to eat with what, in which order, etc) that make a huge measurable difference. For your convenience, we’ve linked those ten ways below; first though, if you’d like to hear it from Inchauspé directly (her style is very pleasant), enjoy:
Click Here If The Embedded Video Doesn’t Load Automatically!
Want to learn more?
You might also like to read:
- 10 Ways To Balance Your Blood Sugars ← this is the longer list she’s referring to in the video!
- How To Unfatty A Fatty Liver ← also relevant
Take care!
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Nasal Hair; How Far To Go?
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t’s Q&A Day at 10almonds!
Have a question or a request? You can always hit “reply” to any of our emails, or use the feedback widget at the bottom!
In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!
As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!
So, no question/request too big or small
❝As a man in his sixties I find I need to trim my nasal hair quite frequently, otherwise it sticks out in an unsightly manner. But I’m never sure how severely I should cut the hairs back, or even how best to do it. Please advise.❞
As you might know, those hairs are really important for our health, so let’s start by mentioning that yes, trimming is the way, not plucking!
In an ideal world, we’d not trim them further back than the entrance to our nostrils, but given the constant nature of hair-growing, that could become a Sisyphean task.
A good compromise, if you’re not up for trimming when you get up and having visible hairs by evening, is to put the scissors away (if you haven’t already) and use a nasal hair trimmer; these are good at a) trimming nasal hairs b) abstaining from trimming them too far back.
By all means shop around, but here’s an example product on Amazon, for your convenience!
- Note 1: despite the product description, please do not stick this in your ear (or any other orifice that’s not your nose, for the love of all that is holey)
- Note 2: we chose that one for a reason; the shape of the head prevents overtrimming.
- In contrast, we do not recommend this cheaper one that has a different shape head for a closer trim, which in this case, is not what we want.
Enjoy!
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Life Lessons From A Brain Surgeon – by Dr. Rahul Jandial
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In the category of surgeons with a “what to put on your table to stay off mine” angle, this book packs an extra punch. As well as being an experienced brain surgeon, Dr. Jandial also does a lot of cutting edge lab research too. What does this mean for us?
This book gives, as the subtitle promises, “practical strategies for peak health and performance”—with a brain-centric bias, of course.
From diet and nootropic supplements, to exercise and brain-training, we get a good science-based view of which ones actually work, and which don’t. The style is also very readable; Dr. Jandial is a great educator, presenting genuine scientific content with very accessible language.
Bottom line: if you’d indeed like to look after your most important organ optimally, this book gives a lot of key pointers, without unnecessary fluff.
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Which Sugars Are Healthier, And Which Are Just The Same?
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From Apples to Bees, and High-Fructose C’s
We asked you for your (health-related) policy on sugar. The trends were as follows:
- About half of all respondents voted for “I try to limit sugar intake, but struggle because it’s in everything”
- About a quarter of all respondents voted for “Refined sugar is terrible; natural sugars (e.g. honey, agave) are fine”
- About a quarter of all respondents voted for “Sugar is sugar and sugar is bad; I avoid it entirely”
- One (1) respondent voted for “Sugar is an important source of energy, so I consume plenty”
Writer’s note: I always forget to vote in these, but I’d have voted for “I try to limit sugar intake, but struggle because it’s in everything”.
Sometimes I would like to make my own [whatever] to not have the sugar, but it takes so much more time, and often money too.
So while I make most things from scratch (and typically spend about an hour cooking each day), sometimes store-bought is the regretfully practical timesaver/moneysaver (especially when it comes to condiments).
So, where does the science stand?
There has, of course, been a lot of research into the health impact of sugar.
Unfortunately, a lot of it has been funded by sugar companies, which has not helped. Conversely, there are also studies funded by other institutions with other agendas to push, and some of them will seek to make sugar out to be worse than it is.
So for today’s mythbusting overview, we’ve done our best to quality-control studies for not having financial conflicts of interest. And of course, the usual considerations of favoring high quality studies where possible Large sample sizes, good method, human subjects, that sort of thing.
Sugar is sugar and sugar is bad: True or False?
False and True, respectively.
- Sucrose is sucrose, and is generally bad.
- Fructose is fructose, and is worse.
Both ultimately get converted into glycogen (if not used immediately for energy), but for fructose, this happens mostly* in the liver, which a) taxes it b) goes very unregulated by the pancreas, causing potentially dangerous blood sugar spikes.
This has several interesting effects:
- Because fructose doesn’t directly affect insulin levels, it doesn’t cause insulin insensitivity (yay)
- Because fructose doesn’t directly affect insulin levels, this leaves hyperglycemia untreated (oh dear)
- Because fructose is metabolized by the liver and converted to glycogen which is stored there, it’s one of the main contributors to non-alcoholic fatty liver disease (at this point, we’re retracting our “yay”)
Read more: Fructose and sugar: a major mediator of non-alcoholic fatty liver disease
*”Mostly” in the liver being about 80% in the liver. The remaining 20%ish is processed by the kidneys, where it contributes to kidney stones instead. So, still not fabulous.
Fructose is very bad, so we shouldn’t eat too much fruit: True or False?
False! Fruit is really not the bad guy here. Fruit is good for you!
Fruit does contain fructose yes, but not actually that much in the grand scheme of things, and moreover, fruit contains (unless you have done something unnatural to it) plenty of fiber, which mitigates the impact of the fructose.
- A medium-sized apple (one of the most sugary fruits there is) might contain around 11g of fructose
- A tablespoon of high-fructose corn syrup can have about 27g of fructose (plus about 3g glucose)
Read more about it: Effects of high-fructose (90%) corn syrup on plasma glucose, insulin, and C-peptide in non-insulin-dependent diabetes mellitus and normal subjects
However! The fiber content (in fruit) mitigates the impact of the fructose almost entirely anyway.
And if you take fruits that are high in sugar and/but high in polyphenols, like berries, they now have a considerable net positive impact on glycemic health:
- Polyphenols and Glycemic Control
- Polyphenols and their effects on diabetes management: A review
- Dietary polyphenols as antidiabetic agents: Advances and opportunities
You may be wondering: what was that about “unless you have done something unnatural to it”?
That’s mostly about juicing. Juicing removes much (or all) of the fiber, and if you do that, you’re basically back to shooting fructose into your veins:
- Effect of Fruit Juice on Glucose Control and Insulin Sensitivity in Adults: A Meta-Analysis of 12 Randomized Controlled Trials
- Intake of Fruit, Vegetables, and Fruit Juices and Risk of Diabetes in Women
Natural sugars like honey, agave, and maple syrup, are healthier than refined sugars: True or False?
True… Sometimes, and sometimes marginally.
This is partly because of the glycemic index and glycemic load. The glycemic index scores tail off thus:
- table sugar = 65
- maple syrup = 54
- honey = 46
- agave syrup = 15
So, that’s a big difference there between agave syrup and maple syrup, for example… But it might not matter if you’re using a very small amount, which means it may have a high glycemic index but a low glycemic load.
Note, incidentally, that table sugar, sucrose, is a disaccharide, and is 50% glucose and 50% fructose.
The other more marginal health benefits come from that fact that natural sugars are usually found in foods high in other nutrients. Maple syrup is very high in manganese, for example, and also a fair source of other minerals.
But… Because of its GI, you really don’t want to be relying on it for your nutrients.
Wait, why is sugar bad again?
We’ve been covering mostly the more “mythbusting” aspects of different forms of sugar, rather than the less controversial harms it does, but let’s give at least a cursory nod to the health risks of sugar overall:
- Obesity and associated metabolic risk
- Main contributor to non-alcoholic fatty liver disease
- Increased risk of heart disease
- Insulin resistance and diabetes risk
- Cellular aging (shortened telomeres)
- 95% increased cancer risk
That last one, by the way, was a huge systematic review of 37 large longitudinal cohort studies. Results varied depending on what, specifically, was being examined (e.g. total sugar, fructose content, sugary beverages, etc), and gave up to 200% increased cancer risk in some studies on sugary beverages, but 95% increased risk is a respectable example figure to cite here, pertaining to added sugars in foods.
And finally…
The 56 Most Common Names for Sugar (Some Are Tricky)
How many did you know?
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Good Energy – by Dr. Casey Means
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For a book with a title like “Good Energy” and chapters such as “Bad Energy Is the Root of Disease”, this is actually a very science-based book (and there are a flock of well-known doctors saying so in the “praise for” section, too).
The premise is simple: most of our health is a matter of what our metabolism is (or isn’t) doing, and it’s not just a case of “doing more” or “doing less”. Indeed, a lot of “our” energy is expended doing bad things (such as chronic inflammation, to give an obvious example).
Dr. Means outlines about a dozen things many people do wrong, and about a dozen things we can do right, to get our body’s energy system working for us, rather than against us.
The style here is pop-science throughout, and in the category of criticism, the bibliography is offloaded to her website (we prefer to have things in our hands). However, the information here is good, clearly-presented, and usefully actionable.
Bottom line: if you ever find yourself feeling run-down and like your body is using your resources against you rather than for you, this is the book to get you out of that slump!
Click here to check out Good Energy, and get your metabolism working for you!
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