Hypothyroid treatment options: Is Synthroid Your Only Choice?

Ok, so you’ve been diagnosed with Hypothyroidism or Hashimoto’s thyroiditis. 

Perhaps this just happened or maybe you’ve been living with and managing thyroid disease for years or even decades.

What do you do now?

If you’ve had hypothyroidism for years and feel like it’s well managed, you simply need to have a yearly blood check (review the full panel to ask for!) to make sure the medication(s) you are taking are still appropriate and doses don’t need to be adjusted.

If you’re new to this rodeo OR you have had hypothyroidism and are on medication but have never really felt any difference with the treatment you were prescribed, here we go:

What are my treatment options for hypothyroidism/Hashimoto’s?

  1. Medication:

I don’t typically think of thyroid medication as first step therapy, unless a woman is trying to get pregnant or already pregnant or breastfeeding, but I know it’s by far the most common treatment option given so I wanted to discuss your options here first.

The medications available are all, with one exception, replacing the thyroid hormone your body is struggling to make.

Here’s how it works in the body:

Your brain makes TSH (thyroid stimulating hormone) which, aptly named, stimulates the thyroid gland to make mostly T4 and a bit of T3. T4 is then circulated through the bloodstream where it is converted to T3 hormone. 

While both hormones have big actions in the body, T3 hormone is the more active player. It’s important that your body has both.

Both T4 and T3 send signals back to the brain to either turn up the volume on TSH production (which translates to your body needing MORE medication) or to turn it down (which can mean you need LESS medication). 

I like to think of TSH as a volume control. The HIGHER it is, the LOUDER your brain is having to communicate to your SLOW thyroid to make hormone. Your hormone production is SLOW or LOW when TSH is HIGH. And, the MORE thyroid hormone you make or take as medication, the LOWER the TSH will be. It can become too low, which tells your provider that you need LESS medication. 

That can be confusing, but the summary is this:

  • High TSH = low T4 and T3 hormones being made/taken
  • Low TSH = high T4 and T3 hormones being made/taken 

I think it’s important to understand the very basics of thyroid hormone production because it relates to your medication options, which are outlined below.

  1. Levothyroxine = Levothroid = Levoxyl = Synthroid = T4 hormone.

This is, by far, the most common thyroid medication prescribed. It is one of the most common meds prescribed in general, on many Top 5 lists for all pharmaceuticals together. When prescribed correctly and monitored well, it is an extremely safe medication. 

Your body takes in the T4 hormone replacement and should convert it to T3 hormone.

Your body should then tell your brain to make less TSH. 

You should see TSH levels come down to ideal values.

Your Free T4 and Free T3 lab values become ideal.

You should feel better! 

  1. Liothyronine = Cytomel = T3 hormone

I don’t see Cytomel prescribed as frequently by my conventional primary care colleagues in the Seattle area, but I have noticed endocrinologists recommending this med occasionally, and I do as well. 

Why? Some people’s bodies don’t convert T4 hormone to T3 hormone well. 

These folks may be deficient in some nutrients (zinc, selenium) or genetically they may just not be efficient at it.

In these women, using T3 in addition to T4 allows the body to give the proper signals to the brain to lower TSH.

Subsequent lab checks for TSH, Free T4 and Free T3 should show ideal ranges, as previously discussed.

You should feel better!

Bummer: of all the hormone medication options, I see Cytomel (T3) being the most irritating to women’s bodies. Even when labs look good/normal/better, women frequently report heart palpitations and hair loss. I don’t use it much for these reasons. Many women do really well with the addition of Cytomel, I’m just always cautious about adding it. 

In some practices, providers will use higher doses of Cytomel alone. This is called the Wilson’s Protocol. I don’t follow this protocol in my practice for the reasons I mentioned above.

  1. Nature-throid & Armour thyroid & NP thyroid = glandular thyroid 

These are all medications containing both T4 and T3, sourced from pig thyroid glands.

Say what now? It’s true, these are pig gland medications. They are available at your conventional pharmacy. 

Some people believe these are more natural because they come from an animal and are not made in a lab. I don’t think of this medication in this way. It’s still manufactured in a lab. It is still hormone replacement.

So, what’s the difference? The medication contains BOTH T4 and T3 in one pill. That can be great for minimizing the amount of medications you take per day. It also has slightly higher amounts of T3 than T4 and some bodies do really well with that. In my experience, women seem to tolerate the T3 in these gland therapies better than Cytomel. 

Because all pigs are unique (just like us!), the amount of thyroid hormones in each batch of glandular medication varies. Some bodies do fine with that variability. Others really do not and we can see wild changes in lab results and patients report feeling over or understimulated from batch to batch.  That is certainly not every woman’s experience, but it does happen.

I’ve noticed that all of these medication options are just that: OPTIONS for managing hypothyroid and Hashimoto’s. I have not seen one-size-fits-all with any of these. I respectfully disagree with the providers that believe there is one medication that is best for all women with thyroid disease. 

Because it’s the most simple and well tolerated, I usually have women start Levothyroxine (T4). This allows us to not only see how she feels on the new medication but also to track how her body is converting the T4 to T3. If she needs T3, we can talk about Cytomel or a change to Armour or Nature-throid.

  1. Low dose naltrexone (LDN) 

Last but not least, LDN is a compounded medication that can decrease thyroid antibodies in Hashimoto’s thyroiditis (and perhaps in other autoimmune diseases).  You have to have this prescribed by your provider and made at a special pharmacy in the ultra low doses that are effective (1.5-4.5mg).

Naltrexone in its standard dose of 50mg (or more) is a medication that is used in helping people overcome alcohol and opiate addictions. It is an “opiate antagonist”, which means that it works by blocking the activation of opioid receptors. Instead of controlling withdrawal and cravings, it treats opioid & alcohol use disorder by preventing any opioid drug or alcohol from producing rewarding effects such as euphoria.

In smaller/low doses of Naltrexone, the body’s endorphins are released. These endorphins have an effect on the immune system that decreases inflammation and the production of antibodies against the self. It’s pretty cool! I have a very small handful of women managing their Hashimoto’s on this medication alone.

It can have uncomfortable side effects, so I don’t prescribe it very much. Women report sleep disruption, nightmares and headaches. I work with many perimenopausal and menopausal women who are already struggling with these symptoms and very few are willing to make things potentially worse.

It can also cause nausea and worsen constipation or diarrhea. 

LDN is typically started at 1.5mg and titrated up every 1-2 weeks by 1.5mg until the therapeutic dose of 4.5mg is reached.

  1. Eat well 

In my practice I see diet being less of an issue with pure hypothyroidism versus Hashimoto’s. That said, generally a healthy diet is the best course for any chronic disease management. What’s a healthy diet? I like Michael Pollen’s recommendation, “Eat real food. Not too much. Mostly Plants.”

I am a fan of the Mediterranean Diet and appreciate the food pyramid associated with that style of eating.

Now, with Hashimoto’s, which is driven by an inflammatory process in the body, I find it important to dig a bit deeper. I FREQUENTLY see foods creating inflammatory (re)actions in the body and they may not always be the foods you might think. That said, my recommendation is to follow an anti-inflammatory diet approach like the Whole 30 or Autoimmune Paleo diets and then test thyroid antibodies to see if they’ve changed. How long do you need to follow a diet like this? That varies per person, but I’d wait at least a month, if not 2-3 months.

If these extreme diets seem too extreme, then start with the more common inflammatory food: you guessed it, gluten.  As mentioned in previous posts, if you have Hashimoto’s, you have a higher risk of Celiac disease, the extreme autoimmune intestinal reaction to gluten. Before eliminating gluten from your diet, have your provider screen you for Celiac disease!

  1. Manage your Stress

Part of managing any chronic disease or condition *should* involve a focus on managing stress levels. I encourage women to think about rating their stress regularly, in order to do a self-check: on a scale of 1 – 10, how stressed are you now? If you give yourself a rating higher than a 5, I encourage you to think about what you can change to either lower the demands on you (say “no” more, end toxic friendships/relationships) OR experiment with different stress coping skills until you find ones that work for you to do DAILY. Ideas:

  • Deep breathing for 5 minutes 
  • Guided meditation for 5-10 minutes daily (apps I like: Calm, Shine, Insight Timer, Head Space)
  • Put your devices away & observe what’s around you
  • Play with your kids
  • Take a date night with your partner
  • Craft/draw/knit/sew/paint
  • Relaxing (yin) yoga for 10-20 minutes
  • Warm bubble bath with 10 drops of lavender essential oil
  • Read fiction 
  • Take a walk outside
  • Take a walk with friends
  • Call a close friend or family member

Why is it important to keep stress in check? When your mind and physical body are stressed it creates a cascade of hormonal changes that can slow the thyroid down and make the autoimmune response worse. It can be much harder to manage your thyroid disease when stress is unregulated. Plus, you’ll be more fun to be around!

  1. Use Natural Therapies
  • Nutrients

I encourage women to have their zinc, selenium, iron and vitamin D tested. Supplement if needed to bring values up into the high end of the normal range. If a woman is low in these nutrients, I will often wait to adjust medication doses until the nutrients have normalized. Frequently, thyroid hormone production improves when these nutrients are in ideal ranges.

If you have a pure hypothyroidism (no Hashimoto’s antibodies are present), it’s important for you to avoid goitrogens. Goitrogens are foods that decrease thyroid hormone production by interfering with iodine uptake. When not enough iodine is available, the thyroid cannot produce sufficient levels of thyroid hormones T4 and T3. The brain senses the low T4 hormone and produces more TSH. The thyroid gland responds to TSH by making more hormones, but if it can’t keep up with demand, the thyroid grows bigger. A swollen thyroid gland is called a goiter. 

  • Goitrogenic Foods:
  • RAW Cruciferous vegetables: kale, cabbage, broccoli, turnips, brussel sprouts,radishes, collard greens. NOTE: cooking cruciferous veggies decreases the goitrogenic content. **These are such a healthy veggie family that I encourage you to NOT stop eating them, just cook them a little bit before enjoying them.
  • Cassava, lima beans, sweet potato, sorghum, soy, millet 

Interestingly, new studies show by blocking iodine uptake, goitrogens are actually beneficial to those with hashimoto’s thyroiditis. Lowering iodine levels lowers the antibody activity within the thyroid gland. Goitrogenic foods have also been found to increase levels of the antioxidant glutathione, which lowers oxidative stress in the gland to slow the rate of destruction of the thyroid cells.

  • Iodine 

This essential mineral is vital to proper thyroid hormone production.You need small amounts for normal function, but many of us are deficient.  Your body can’t make it, so you must get it through your diet or supplementation. There aren’t great tests for iodine deficiency, so I’ll recommend women regularly incorporate iodine containing foods into their diet. These include:

  • iodized salt, seasoning mixes with iodized salt and onion salt or garlic salt made with iodized salt
  • seaweed (kelp, nori, kombu, wakami)
  • food additives: carrageen, iodides, alginates, iodate
  • egg yolks
  • most seafood except fresh-water fish

It’s important to get enough iodine but not too much. There are iodine replacing protocols that use milligram (mg) doses of iodine when the body only needs around 200 MICROgrams (mcg). Mega doses of iodine can worsen hypothyroidism and autoimmune Hashimoto’s. Balance is key.

  • Herbal therapy

Ashwagandha: this Ayurvedic stress adaptogenic herb has been shown in at least one study to increase triiodothyronine (T3) and thyroxine (T4) levels by 41.5% and 19.6%, respectively, and reduce serum TSH levels by 17.4% from baseline. That’s significant! The dose in the study was 600mg per day, and I usually recommend this dose. You can safely take up to 1000mg per day. BONUS: taking it at bedtime may improve sleep quality. DOUBLE BONUS: it is an adrenal hormone adaptogen, meaning it normalized your body’s response to the stress hormone, cortisol!

  1. Avoid toxins

More and more research is showing a correlation between common toxins in our environment and disease risk. Hypothyroid is one such condition. The chemicals we know affect the thyroid gland are:

  • Flame retardants = organohalogens
    • Furniture, some children’s clothing, children’s toys
  • Alkylphenols
    • Personal care products (shampoo, lotions, cosmetics), detergents, cleaning products, paints
  • PFAs/PFCs = Poly- and perfluoroalkyl substances and perfluorinated ompounds
    • Found in textiles, food packaging and firefighting foam
  • Phthalates
    • Personal care products (shampoo, lotions, cosmetics), food packaging, soft plastics, vinyl flooring, vinyl products, old toys

WOW. These chemicals are everywhere. What’s a gal to do? Do your best. Reduce your exposures to these chemicals. Use the Environmental Working Group’s wonderful catalogue of databases to help you find safer options for you and your family:

How often should I get tested?

 When you first start thyroid medication and each time you change the dose, you’ll want to get retested again in 6-8 wks. This is the length of time it takes your body to assimilate the medication and for labs to change. 

Once you’re on the best dose of medication or the best natural treatment regimen, you’ll want to get tested at least annually.

Have more questions? Want to work together to optimize your health and thyroid? Call or email the office and schedule a telemedicine visit. If you live in Washington state, your insurance may cover our visit!

Stay well!

Email me with questions: perimenopausenaturally@gmail.com

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I have Hashimoto’s. Now what?

Have you recently been diagnosed with Hashimoto’s thyroiditis? 

Take a deep breath. Now, do it again.

Let me tell you, it’s going to be OK.

Hashimoto’s is a unique autoimmune condition in that it is not often associated with long term health complications (including COVID 19 risk) and can usually be well managed with a combination of lifestyle change, diet improvements, herbal therapies and often medication.  I do not regard my patients with Hashimoto’s as being very sick. It DOES take a lifelong commitment to living a healthier lifestyle, so there’s that, but as long as it is well managed, it is NOT associated with major organ damage or disability as we see with other autoimmune diseases.

What is Hashimoto’s thyroiditis?

Let’s talk about this VERY common (the most common, in fact) cause of hypothyroidism. Hashimoto’s is a condition caused by inflammation of the thyroid gland. It is an autoimmune disease, which means your body forms proteins that attack your own thyroid gland, as if it was foreign tissue. Hashimoto’s actually typically starts as HYPERthyroid function and then, at varying speeds, the gland slows down thyroid hormone production and becomes hypofunctioning.

The term “autoimmune disease” is scary! You probably think of yourself as a healthy person, and now you have a DISEASE? A disease that you’ll have to manage for the rest of your life? This is life changing. How did this happen? What did you do wrong? What does this mean about life moving forward? Am I at greater risk of COVID 19? How do I treat it? What are my options?

Take another deep breath, friend.

Why do I have Hashimoto’s? Where did this come from?

Hashimoto’s, like other autoimmune diseases, seems to run in families. It is most common in middle aged women (hi there!) but we also diagnose it in younger and older women as well as in men and kids, too. According to conventional literature, the underlying cause of the autoimmune process remains unknown 

I often see Hashimoto’s diagnosed around times of big life events or stressors like pregnancy, perimenopause and trauma to name a few. There is some interesting info that it can be triggered by chronic infections like Lyme or EBV, by certain dental procedures, like root canals, and even by certain breast implants. 

Most physicians don’t put much work into understanding why the autoimmune process has started. I have to admit that I often overlook this, too, as it seems like the important piece is helping women feel their best while managing the condition. In my practice, I may think about the underlying cause when the treatments that should work aren’t working. Admittedly, I should do better. 

What tests should I ask for?

Most GP’s and PCP’s run a TSH screening test to diagnose hypothyroidism. Antibodies are rarely run. If the TSH is normal, you will be told that you do not have thyroid issues. 

Many naturopaths, functional medicine practitioners and endocrinologists have a more narrow range of normal and see that many women struggle with LOW thyroid symptoms when the TSH, although within the lab’s reference range of normal, is not ideal. Given normal vs Ideal, I’ll take Ideal functioning every time!

It’s important to know, though, that TSH can be ideal and you could still have Hashimoto’s. It’s important to get the whole picture. Ask for the following labs and find a practitioner who will order these, if your provider will not*.

  1. TSH (thyroid stimulating hormone)
  2. Free T4
  3. Free T3
  4. Reverse T3
  5. Thyroid Peroxidase (TPO) antibody
  6. Thyroglobulin (TG) antibody
  7. Celiac disease antibodies (If you have Hashimoto’s, you have a higher risk of having Celiac disease, the autoimmune disease in which the body attacks the lining of the small intestines whenever the protein, gluten, is eaten. Gluten is found in wheat, rye, barley, spelt, kamut and products made from these. It’s important to know if you have the Celiac disease antibodies before attempting to follow a gluten free diet as blood tests become normal when you stop eating gluten. Many of my patients start this diet on their own prior to meeting with me, and then we have to decide if reintroducing gluten is a good idea. You have to be eating substantial amounts of a gluten-containing product like breads, pastas & crackers DAILY for a minimum of 2 weeks prior to this test in order for it to be accurate. Women often feel improvements in their health from taking out this potentially inflammatory food and the thought of reintroducing it can be down-right scary. Having a Celiac disease test done while you are not eating gluten is NOT going to work; you must be eating gluten when the test is done. Ok, I hope I’ve made my point.)

What thyroid lab values should I aim for? What’s ideal?

This is a recap from a previous post

  1. TSH: you want a value between 1-2 uIU/mL. This varies per person, but you definitely want a value less than 2.5. (NOTE: this is still within the lab’s reference range for normal).
  2. Free T4: a value of 1.25 ng/dL or greater (up to the top of the normal range, and not to exceed that or you risk becoming HYPERthyroid). Some lab ranges have a normal of .6 – 1.2; for these labs, I recommend a value of 1.0 or greater.
  3. Free T3: a value of 3.0 pg/mL or greater (up to the top of the normal range, and not to exceed that or you risk becoming HYPERthyroid).
  4. Reverse T3: a value less than 15 ng/dL (NOTE: this is still within the lab’s reference range for normal).
  5. TPO antibody: within the reference range of normal. 
  6. TG antibody: within the reference range of normal.
  7. Celiac antibodies: all should be within the reference range of normal.

Ok, so in a conventional medical practice, If TSH is abnormal, OCCASIONALLY (but really, rarely) thyroid antibodies are then ordered. If the antibodies are positive, you have Hashimoto’s. 

Thyroid peroxidase (TPO) antibody is the most common antibody elevated in Hashimoto’s.

Why wouldn’t doctors want to know if the cause of your hypothyroidism is Hashimoto’s? Conventionally, treatment options do not change. The option you’ll be given is medication and the most common medication recommended is Levothyroxine (generic) or Synthroid (brand).

Next time, we’ll discuss both conventional and naturopathic treatment options for Hashimoto’s thyroiditis, including other medication options (and a hint: we may talk about gluten again…). 

* resources for finding help: Naturopathic Physicians and Functional Medicine Providers.


Let’s Talk Thyroid

Why is everyone talking about thyroid?

Ok, maybe in your world people do not always talk about this important hormone, but in my world it comes up a lot! Let’s review this precious hormone and see why it gets a lot of attention, especially amongst women.

What does my thyroid gland do?

The thyroid gland is one of your main metabolic hormone producers. It makes two hormones called T4 and, to a lesser extent, T3. These hormones energize every cell in your body (woo hoo!), in all of your organs from your brain to your uterus. Being HYPOthyroid means you have less of those energizing hormones being produced (boo). 

What are the symptoms of Hypothyroidism?

Less thyroid hormone means things sssslllllooooowwwww down. Women will often admit to  noticing::

  • Fatigue
  • Lethargy
  • Lack of motivation
  • Depression
  • Easy weight gain
  • Difficulty losing weight
  • Constipation
  • Swelling or puffiness in the face or around the ankles
  • Irregular periods
  • Infertility
  • Miscarriage and/or recurrent pregnancy loss

And this is the SHORT list!

It’s important to know that these common symptoms overlap with MANY other medical issues, so just because you have one or two (or most) of the symptoms on this list does not mean you have thyroid disease. Even though it’s common, hypothyroidism is not always the right answer.  At some point every year, I swear I have a slow thyroid. I get my thyroid panel run and it always looks excellent. This is great news, but I’m always secretly disappointed. I know, that’s weird. It would just be so easy!! Women tell me this a lot. I understand.

Anyhow, there is a tendency to overdiagnose hypothyroidism, especially in the alternative medicine community. This can be dangerous, especially if women are put on thyroid medication unnecessarily. Being overstimulated on thyroid meds can damage the heart and accelerate osteoporosis (bone thinning). 

What are the causes of hypothyroidism?

The most common cause of hypothyroidism is an autoimmune disease called Hashimoto’s thyroiditis. That sounds scary. Don’t worry, it’s not. We’ll break that down in the next post. 

Other common causes include genetics (it is very common to see thyroid disease in families, particularly amongst the female line) and big hormone changes like puberty, pregnancy and menopause. Unregulated stress and poor nutrition can decrease your thyroid hormone production and another common cause is simply aging. 

How is hypothyroid diagnosed?

A simple blood test is used to diagnose hypothyroidism. In conventional medicine (this includes most General Practitioners and Primary Care Providers), a TSH is run as a screening test for thyroid dysfunction. 

An elevated TSH is considered abnormal. This is confusing–why would the TSH be HIGH if I have LOW thyroid function? TSH is Thyroid Stimulating Hormone and comes from the brain. It literally stimulates the thyroid (hey, great name!) to make thyroid hormone. I like to think of TSH as a volume control. If the brain and thyroid are communicating in a healthy way, the volume is on the low end. If the thyroid gland is starting to struggle to produce hormone and is slowing down production, the brain turns the volume of TSH up (it stimulates the thyroid MORE) and the TSH goes up. The brain gets louder and louder and sometimes yells for the thyroid to keep up. We detect elevated TSH in these cases.

What tests should I ask for?

As noted, most GP’s and PCP’s run a TSH screening test only. If it’s normal, you will be told that you do not have thyroid issues. 

Many naturopaths, functional medicine practitioners and endocrinologists have a more narrow range of normal and see that many women struggle with LOW thyroid symptoms when the TSH, although within the lab’s reference range of normal, is not ideal. Given normal vs Ideal, I’ll take Ideal functioning every time!

It’s important to know, though, that TSH can be ideal and you could still have Hashimoto’s. It’s important to get the whole picture. Ask for the following labs and find a practitioner who will order these, if your provider will not.

  1. TSH (thyroid stimulating hormone)
  2. Free T4
  3. Free T3
  4. Reverse T3
  5. Thyroid Peroxidase (TPO) antibody
  6. Thyroglobulin (TG) antibody

What thyroid lab values should I aim for? What’s ideal?

  1. TSH: you want a value between 1-2. This varies per person, but you definitely want a value less than 2.5. (NOTE: this is still within the lab’s reference range for normal).
  2. Free T4: a value of 1.25 or greater (up to the top of the normal range, and not to exceed that or you risk becoming HYPERthyroid).
  3. Free T3: a value of 3.0 or greater (up to the top of the normal range, and not to exceed that or you risk becoming HYPERthyroid).
  4. Reverse T3: a value less than 15 (NOTE: this is still within the lab’s reference range for normal)
  5. TPO antibody: within the reference range of normal 
  6. TG antibody: within the reference range of normal

I regularly talk to women who have had hypothyroid symptoms for YEARS, sometimes decades, and their labs have always been “normal”. When we recheck, or I review the labs they just had their GP/PCP run, and tell them they ARE, in fact, hypothyroid, there is a mix of emotions and responses: disbelief, anger at having been dismissed, fear at having a new diagnosis, feeling justified and occasional joy at finally finding the answer to why they’ve felt so crappy for so long.

Ready to have a second opinion about your recent thyroid labs? Need a thyroid panel ordered and reviewed?

Give my office a call! 206-525-8012

I’m offering telemedicine (video or phone) visits for all patients, so distance is not a concern.

(If you’re in Washington state, there’s a good chance your insurance will cover our visit!)


Next time we’ll discuss treatment options for Hypothyroid and it’s most common cause, Hashimoto’s thyroiditis. 

Stay tuned~

’Tis the Season to Be…Sad and Irritated? Mood & Perimenopause, Part 2

I’ve written before about my challenges with my mental health following my second child, while entering the perimenopausal hormone landscape. To be honest with myself, I have struggled with intermittent depression and anxiety since I was a kid. It’s taken me years to fully recognize and admit that. My family is riddled with mental health challenges, from your garden variety anxiety and depression to full blown schizophrenia, and that’s just on one side of the family.  It’d be crazy if I DIDN’T have a mental health issue, and I appreciate that now as a wiser adult. However, as a younger adult it pained me to think I was struggling with the same issues my family members were—how could it be so? I was not like them at all. I was just “sensitive” and “irritable” and “shy”. I had been using various supplements for years and years to manage these symptoms, but was I treating depression? No way. Anxiety? Nope. Not me. I was just fine, thank you.

I am still sensitive, irritable and shy sometimes, by the way, but it got to the point after my second child, Max, that I found myself constantly looking for ways to avoid my family. And if I was in the same room, I would be intensely irritated and overwhelmed at their behavior or the noise or the state of (un)cleanliness that comes with living with 3 males.

I wanted to run away.

I realized that all of the supplements I had been taking were not working as well as I needed them to. I owed it to my family to step it up a bit. And so, I talked to my doctor about antidepressants. I got a prescription and sat with it for a while (2 months, I think) and then I did it. I started medication for my depression and I was SO SCARED—What was going to happen? What if I went crazy? What if I had horrible side effects? What if it didn’t work?

Do you know what happened?

I felt amazing (but not too amazing, which can be a problem). I felt like my best self. I was present with my kids, I wanted to be around them. They weren’t (quite) so annoying any more. I wanted to be with my husband. He wasn’t (quite) so frustrating any more. Did you hear that? I FEEL LIKE MY BEST SELF.

I am ashamed to be on these, though. I am a naturopath, for God’s sake. I use alternative therapies and avoid medications when possible. I am sweating bullets as I write this because I’m afraid of what you’ll think of me! I had been trying for years, for decades, with natural therapies and for the most part they did me very well. I got to a place, though, that for me and my family was not okay and so I tried them and they worked and they continue to do so.

I am grateful for this tool. I am grateful that I started it when I did as my life quickly took some stressful turns as I lost my father, went through a lawsuit with my husband and his company and then recently lost my mother. I did not feel numb through these experiences. I felt very deep & raw feelings & emotions and was able to cope beautifully (I’m patting my own back right now).

I do NOT think antidepressants are the right answer for every woman.

I DO think they are one of the many tools that Naturopaths can use for treating anxiety and depression.

I DO think they work sometimes and are worth considering in specific situations, like mine.

I DO think they can be a game changer for women who’ve tried lots of things but are still struggling.

I do NOT receive any kick-backs from antidepressant pharmaceutical manufacturers.

I want you to know that these may be helpful to consider and I’m SO happy to talk to you about ALL of your options for managing your mental health. I want you here! I don’t want you to run away.

Thanks for listening and supporting me through this wonderful and challenging life.


“Waah, Blah, Boo Hoo Hoo”: Mood and Perimenopause, Part 1

One of the most difficult aspects of perimenopause for me has been the effect on my mood. I am comforted knowing that many women struggle along with me. I talk to women every day who are having a harder time during this transition period. Hormones play such a big role in stabilizing our mental health and our hormones are wonky (a medical term) right now! Add to that the increasing demands of children, partners, aging parents and career that frequently occur around this same time and it’s no wonder that antidepressant medications are one of the most commonly prescribed drugs for women in this age group. I do not have any beef against antidepressants, and we’ll discuss that in more detail in a future post, but today we are going to review some natural ways to elevate and/or stabilize your mood through perimenopause.


Start with the basics~

First, though, go back through the previous posts about PMS and sleep and the foundations of health. The lifestyle factors I’ve already gone through and the few supplements mentioned in these posts are KEY in keeping our brains happy.


Can a brain be happy when it is sleep deprived? No.

Can a brain be happy if it is not getting good blood flow and oxygen from exercise? No.

Can a brain be happy if it surrounded by negative, toxic people or a toxic environment? No.

Can a brain be happy when it’s intoxicated? Maybe initially & briefly, after the first glass, but ultimately all of the research says No.

Can a brain be happy if it is fed crap food and processed chemicals? You guessed it, Nope.


We all know these things. When you are struggling with depression or anxiety, though, it is extremely difficult to make the lifestyle and diet changes you know will help you. I know I just recommended reading those past blog posts to learn what foundational things you should be doing, but I often tell patients who are moderately or severely depressed to forget about their lifestyle and diet choices for the moment while we work on finding the treatment (sometimes an antidepressant, FYI!) that will bring back their motivation to make these changes.


Evaluate with labs~

It’s helpful to have some basic and sometimes more extensive lab work done to rule out potential underlying causes of anxiety and depression. Here’s what to ask for:


* Iron and ferritin

* Vitamin B12 and/or MMA

* Vitamin D (25-OH)

* TSH, Free T4, Free T3, Reverse T3, TPO antibody

* DHEA-sulfate (ideally in the morning before 9am)

* Testosterone, free & total (ideally in the morning before 9am)

* Estradiol (ideally timed during your period or 1 week before your next period)

* Cortisol (ideally in the morning before 9am) OR 4-point salivary cortisol test (a better test)

* MTHFR gene mutation

* COMT gene mutation


With these labs, you can catch anemia, vitamin deficiencies, genetic predispositions, hypo or hyperthyroidism and other hormonal changes that can cause or exacerbate anxiety and depression. Your specific treatment will vary depending on what lab results look like.


Begin supplementation~

Let’s say you did these labs and all were normal (that happens a lot!).

What are some alternative treatments for anxiety and depression?

Here are a few of my favs:

* Therapy, therapy, therapy! There are great studies showing that therapy can be as effective as antidepressant medications for mild to moderate depression. This is huge! I have many patients who do not want to be on medication, so starting here is key. Don’t be afraid to “shop around”, too, if you feel like your first visit or two was not the best fit. Know that it can take time to both find a therapist who fits and to build the bond of trust. I have a colleague who recommends each of her patients find a therapist, even when they’re feeling well. This is a wonderful idea, as we know life gets hard sometimes and often unexpectedly. Having someone on your team waiting for you can save a ton of time when you really need them the most. While you are working on finding your person, talk to your Naturopath about other strategies (perhaps based on your lab results), or start with the following recommendations.

* Happy light or Light box: This is obviously not a supplement, but the research on these is very clear. 15-45 minutes of use of a light box each morning decreases depression. This is especially important for patients living in northern climates because our sun exposure is so low. You have lots of options. You want a box that gives you 10,000lux of light and that you can see directly with your eyeballs. The box needs to be in your eyesight, in other words, not just lighting the room. It also needs to be within arms length. Most women do this in the morning before heading out for the day or first thing at work. Place the box on your dining table, couch arm, bathroom sink or work desk. Use it by 9am; later than that and your sleep can get disrupted. I do have some patients whose anxiety is worsened when they use these lights, so use caution if anxiety is more your jam.

* Fish oil: I have mentioned this in past posts, but the dose for depression/anxiety is much higher than for general health. You want to take 6000-9000mg of EPA + DHA daily for at least 3 months before you decide if it’s helpful. I have patients that feel this immediately and most that notice it after a month. There are DOZENS of options here as far as brand and type of oil. For this high dose, the liquid oil is the most cost effective, although it is an oil and kind of weird to take. They don’t taste like fish, which is awesome, but taking a spoonful of oil can be odd no matter what the taste is. You want to be careful with where the fish is sourced and how it is processed. My go-to brands are Pharmax, Douglas Labs, Nordic Naturals and Carlson’s.

* Saffron: Studies have shown that taking 30mg of saffron extract or 100mg of saffron herb daily for 6-12 weeks improves symptoms of major depression. This herb is very well tolerated, but should be used with caution in folks who are also on blood pressure medications or barbiturates.

* Rhodiola: A few studies have shown that this herb in doses of around 340mg daily (up to twice per day) decreases anxiety, depression and symptoms of “stress”. I LOVE this herb. I think we should all be on it. It’s one of our most effective adrenal adaptogens, which is to say it normalizes your response to stress via the hormone cortisol. I think about this herb for women who are having mental health challenges and feeling less resilient to stress (again, all of us). This herb has the potential to interact with many medications by slowing down how your body processes or detoxes the medication, so take care and ask your (Naturopathic) physician for support here.

* 5-HTP: This amino acid is one of the ingredients your body needs to make serotonin, the feel good brain hormone or neurotransmitter. The studies on this are positive but the dose is variable, ranging from 150mg to 900mg. I recommend taking this at bedtime and starting with a dose between 100-200mg. I read a study that showed taking 200-300mg per meal was effective, which tells me there is room to experiment with dosing and timing of those doses. If you are already on antidepressant medication, you MUST work with your medical provider if you want to use 5-HTP with it. You risk having too much serotonin in the body, a situation called serotonin syndrome. That said, I’ve used these in combo for many women and often do so when trying to wean women off of antidepressant meds and to minimize the side effects of doing so.

* Therapy, therapy, therapy! It’s so good, I’ll say it again. Reach out to your provider if you need help finding a therapist.


The goal in this life is to be your best self.

I’m hopeful these ideas can help. If not, please reach out so we can talk about other options available to you.

Vaginas matter.

I recently bought some feminine hygiene products from a company called Sustain Natural. They make condoms, tampons and pads that are organic and non-toxic and delivered to your door! My box arrived with a little purple card inside that said, “Vaginas Matter.” YES, I thought, they do! Rarely do we talk about vaginal health as we age, but today we’re gonna do it.

Women in my practice fill out symptom questionnaires for me when they come in for their annual physical exams, and more than 50% have concerns about low libido. When I press further, much of the time the libido is related to vaginal discomfort or pain during intercourse. Vaginal changes are incredibly common as hormones shift in perimenopause and menopause. Some women sail through without a problem, but most women have concern.

Estrogen is the key player for vaginal tissue. It keeps the tissue elastic or stretchy, well lubricated and plays an important role in maintaining the strength of the muscles that support the vagina (the pelvic floor). As Estrogen starts to decline with age (typically in a woman’s 40s), the vagina loses much of its lubrication and stretch power and pelvic floor muscles get weaker. Without treatment, these symptoms can worsen, making sex downright painful and for some women, impossible. It can also increase your risk for vaginal and urinary tract infections.

We don’t want that to happen! What can we do?

Vaginal lubricants

There are a few oils that can improve vaginal tissue integrity or health. None of these oils are safe to use with Latex condoms, as they may degrade the latex (not great; remember you can still get pregnant in perimenopause!).

* Vitamin E—try using 400IU of Vitamin E vaginally each night for 2 weeks and then 2-3x per week thereafter. You can use softgels (pierce them with a clean needle to allow the oil to release quicker) or find a liquid from a brand like Carlson’s.

* Coconut Oil—this oil loves the vagina! I have many women that use it as a lubricant during sex. It also has a healing effect on the tissue and can be used in the same way as Vitamin E—every night for 2 weeks, and then 2-3/week thereafter. Coconut oil is messy. A patient pointed me in the direction of this clever website which helps you make your own coconut oil suppositories: www.luckyvagina.com

* CBD—I’ve mentioned CBD in prior posts as a tool to improve sleep when used orally. This amazing oil is also available to use vaginally and will improve libido, lubrication and orgasm. It also reduces anxiety and pain. You use this as needed, or when you are going to have sex. It’s amazing stuff! The brands I recommend are “Bond Oil” and “Velvet Swing” (I know, the names…). In Washington State, you can find one or both of these at most of the Cannabis dispensaries around. Outside of our beautiful state, Privy Peach is a great option.

Vaginal Hormones

* Estrogen

This is the most important hormone for vaginal tissue and is often recommended as a treatment to improve symptoms caused by low levels (things like painful sex and frequent UTIs). The most common form of estrogen prescribed is Estradiol, but Estriol is also available. These are prescription medications that come in creams, tablets and a ring. Dosing depends on the type you use. Several strengths are available.


Some women are not good candidates for estrogen therapy (for example, women who have had certain types of cancers or who have a strong family history of certain cancers). DHEA can be a safer alternative. It is a precursor hormone to both estrogen and testosterone, and when used vaginally, can have similar effects to the tissue as estrogen. It also improves libido in many women (bonus!). It does not increase estrogen systemically, it’s effects are localized to the vagina. This hormone is typically prescribed and compounded into a cream or suppository.

Vaginal Tools

These tools are awesome, as many women do not find benefit from the lubricants and can’t tolerate or don’t want hormone treatments

* Vaginal Weights…Wait, What? Yes, there are various weights available whose purpose is to strengthen the pelvic floor muscles. When these muscles are weak, women notice less sensation during sex and often some urinary incontinence. Options here are the Intimate Rose system of weighted tampons or Kegel Balls (also called Ben Wa Balls). There are many different styles of Kegel balls available, and most adult toy stores have several (we like Babeland in Seattle). If you choose the weighted tampons, you use these daily for 15 minutes and advance through the increasing weights as you get stronger.

* Vfit+

This is a vaginal device that uses a combination of red light LEDs and light vibrational therapy to stimulate healing of the vaginal tissue, restore normal cell function and decrease pain and inflammation. The vibration also recruits and strengthens the pelvic floor muscles. It is used at home several times per week for 8 weeks and then weekly for maintenance. The success rates for this device are incredible: 89% of women experienced more confidence and improved sensation with sex after the 8 week period. I have one patient noticing these benefits after 3 weeks! This device is only available in physician offices. Here’s a link to more info. We now have this available at the clinic! I’m happy to talk to you more about this in person or via a telemedicine visit.

* Pelvic Floor PT

Usually when I recommend this therapy, women are dumbfounded that it is actually a “thing”. These very important, typically female, physical therapists are skilled at identifying and treating pelvic floor issues that may be making sex painful. This is particularly helpful after childbirth or pelvic surgery. Typically, a physician refers you to one of these specialists after you’ve discussed if it’s a good option for you.

What I’ve learned from working with women is that our bodies are high maintenance. It takes a lot of work to feel good! We have to eat well, move often, get good rest, brush and floss…ugh. Our vaginas also need their own maintenance, if we want to prevent common infections and maintain a long and healthy sex life.

Want to chat more about your own personal struggles and which of these options may be the best for you? Call the office to make a phone or in-person visit. My practice is open to new patients again. Please tell your girlfriends!

Do you have a favorite vaginal treatment that wasn’t mentioned? Please let me know so I can share with other women! You can send me a private email to perimenopausenaturally@gmail.com.

Rise & Shine!

That’s how my mom used to wake me up as a kid, “Rise and shine, sweetie!”. Such a sweet way to start the day! Now I wake up to a snoring husband, a demanding kiddo (or two) and/or a long-limbed dog kicking me out of bed. I have to find my own sweet way to wake up…and I have! Along with an hour of quiet time in which I do a mix of yoga, meditation, embroidery and reading (mostly reading!), I make a delicious smoothie. And here it is:

Rise and Shine Smoothie


This is my go-to morning smoothie. I make this most mornings, but always on my workdays. I let it sit for an hour or more while I drink coffee and commute to work. The chia seeds thicken the smoothie during that hour and make it SO filling that I am good-to-go until lunch. I don’t feel hungry after drinking this smoothie. I feel awesome, energized and proud of myself for starting the day with vegetables!

  • 1 cup vanilla flavored Almond Milk (unsweetened)—or your favorite non-dairy milk
  • 1 heaping TBSP chia seeds
  • 1 scoop organic greens powder
  • 1 TBSP organic cocoa powder
  • 1 scoop of plant-based, organic protein powder
  • 1-2 handfuls of greens (I use a mix of Kale and spinach and put as much as my blender will hold)
  • 1 cup frozen blueberries
  • 1 TBSP nut butter, coconut oil or ¼ avocado for a dose of healthy fats

Add each to your blender (the high-powered ones mix this in to a SMOOTHie). Normal blenders may have trouble really grinding down the greens so the end result may be a little chunky; start with a smaller amount of greens at first to see what your blender can do and consider investing in a high-powered one!

Not sure where to find these ingredients? Start here!

I buy the food ingredients in bulk at Costco–they have an impressive supply of organic ingredients these days. Our local farmer’s markets, co-op natural food store, Whole Foods and Trader Joe’s are other great resources. If you live in a place without good, organic food options, a few of my patients use thrivemarket.com.

Have a favorite smoothie? Share it!

What’s your favorite way to start the day?

(Supplemental) Foundations of Health

Each day I’m in practice, women ask me what supplements they should be taking. While I don’t consider myself a “supplement pusher”, I do think we should all be taking a few specific nutrients to stay healthy, age well, and, ideally, prevent disease.


Here are my Top 5 Supplements for (Perimenopausal) Women:

  1. Food-based, organic multivitamin
    • Choose one specific to your age (I like the brand Garden of Life, but New Chapter and Rainbow Light are also good ones). Take the recommended dose each day.
  2. Fish oil or algae oil
    • These are important sources of omega-3 fatty acids, which our bodies can’t make. You MUST either eat fatty fish several times per week or supplement. You want 1000mg of EPA +DHA per day, minimum (reputable brands include Nordic Naturals and Carlson’s as well as the professional lines on this link)
  3. Probiotic
    • We continue to learn more about the “good bacteria” in our gut (the microbiome) and the roles they play in our health. These bacteria improve our immune system, make certain vitamins and improve absorption of other vitamins, have impact on our brain hormones, decrease risk of diabetes and are key to keeping the bowels moving regularly. You want a refrigerated product that is at least 20 billion units in potency and contains 10 or more strains of bacteria. Rotate the brand you use at least every year. Double up for a month after a course of antibiotics.
  4. Vitamin D3
    • If you live in the Pacific Northwest, you should take 5000iu (125mcg) of Vit D3 daily, year round. Have your levels tested periodically to make sure you are absorbing your supplement; your lab goal is 60-80 ng/mL.
  5. Medicinal mushrooms
    • These powerhouse foods are so valuable for our immune systems. They are cancer fighting, improve your ability to fight bacteria and viruses and prevent infections. Many mushrooms also have a normalizing effect on our stress response. My favorite product is “Mycommunity” by Host Defense. You take 1 daily and increase to 2 if you are ill or know you’ve been exposed to an illness like the flu, strep, etc.


This is a long list, especially if you are starting from scratch. You’ll feel like an old lady taking all her pills (really step in to this granny role and buy a pill organizer that you put together each week!).


Why do we need to take so much stuff? It’s a cruel world out there, ladies. We are living longer than ever, exposed to more environmental pollutants and social stressors, trying to be super moms/super wives/super daughters/super professional career women…Our bodies need support if we are going to make it through this.


Although I consider these the basics, I’m always impressed by the changes women notice by starting these simple steps.


Of course, and I hope it goes without saying but I’ll say it anyway—none of these recommendations are replacements for healthy living! I’ve noticed though, that once the habits of taking nutritional supplements is established, and a woman is feeling a bit perkier, the really important diet and lifestyle changes become easier to tackle.


Oh, and check with your doc to make sure these suggestions are safe in combo with your med list and in your specific health condition. Want my opinion? I do phone and email visits! Call for information and to schedule: 206-525-8012.

Gimme some zzzzz’s

One of the most common changes in perimenopause is in how women sleep (or don’t, rather). I regularly hear from patients that they struggle and the struggles vary from difficulty getting to sleep, to sleeping lighter in general to waking at 3am every night unable to get back to sleep. Many perimenopausal women suffer from the consequences of poor sleep including fatigue and irritability, which lead to poor lifestyle choices (i.e. drinking more caffeine and eating more sugar to perk yourself up) which can aggravate mood and worsen anxiety and depression, which affect sleep…it’s a vicious cycle that can be very difficult to get out of.

Where to start?

Stress reduction. Perimenopausal women are under a tremendous amount of stress. We have children, spouses, aging parents, pets, careers and/or stressful jobs all requiring our attention and care. It is very easy to focus on the needs of the important people in our lives and not our own. Our cups overfloweth.

Create boundaries to protect your valuable time: say NO more often (and not just to your kids and spouse/partner), leave work by 6 and don’t check your work email until the next morning and dedicate a moment to yourself each day, for self-care. This could be as much or as little time as you want, but I challenge you to carve out 30 minutes EACH day to bring the focus back to you.

  • Meditation: I see and feel the biggest eye-roll when I talk to patients about this one, but you get the biggest bang-for-your-buck here. Most people think you have to sit in silence for an hour every day in order for it “to work”, but good news! Only 12 minutes a day and your body begins to reap the benefit of meditation. There are many apps and You Tube channels dedicated to this. I use the app Calm.com, but have also enjoyed Stop, Breathe and Think and Head Space. Each of these sites and apps offer guided meditations that are as short as 2 minutes, so you have no excuse! Try one at bedtime and again in the night if/when you wake.
  • Journaling: Get those thoughts and lists out of your mind at bedtime and on to paper. Tell your brain that you’ll come back to the list the next day.
  • Time with girlfriends: hash things out, get things off your chest, find out what they are struggling with (I bet it’s the same stuff you are!), get ideas about problem solving, see what your friends are doing to cope day-to-day. Our women friends are VITAL parts of healthy aging and stress release and these are probably the first relationships to be pushed back when we are busy and need them the most. Make it at least a monthly event to get together with your lady friends. Your soul will thank you for it.



“Sleep Hygiene”

This is a term that insomniacs know well, but few practice these simple strategies that can have a huge return. Terri Gross on NPR’s Fresh Air recently interviewed a professor of sleep science from UC Berkeley named Matthew Walker about his recent book, Why We Sleep: Unlocking the Power of Sleep and Dreams. I haven’t read the book, but listened to the interview in which he talks about these sleep strategies and also reminds us of the effects of short and long-term sleep deficits (they are HUGE).

  • Get 8 hours of sleep, no less. Each night. You can’t make up for lost sleep on the weekend…sorry to burst that bubble!
  • Schedule your to-bed and waking times and keep to that schedule as much as possible, even on weekends.
  • If you are awake for more than 30minutes in bed, get up and go to another dark, quiet room. Our brains learn very quickly to associate the bed with being up and alert if you lie awake in it. You want the bed to be associated with rest, not stress.
  • Screens off! Turn your phone and TV off the hour before you should go to bed (not when you want to go to bed).
  • Exercising too late in the day will make it hard to get to sleep. Ideally you would exercise in the morning or at least by 6pm. I have friends and patients that wake up extra early to get to that class they love at the gym (you would schedule this in to your sleep schedule to ensure you are still getting your 8hrs of beauty sleep). I met a woman recently who goes later in the morning to a gym near work and her employer allows her to work from home those mornings and arrive at the office after her work-outs (and her company pays for the gym membership!). If you can’t get to a gym, there are tons of videos and online exercise programs available. My favorites are the 7-Minute Workouts by Johnson & Johnson (a free app for your tablet or phone; no gear required!) and Betty Rocker’s free 30 day challenge.
  • Listen up! I’ve referred patients to sleep specialists and have noticed the advice to listen to audiobooks if you wake in the night. Apparently, it turns the volume down on the part of the brain that can become stimulated and stressed in the night. I use Amazon’s Audible as it syncs to the books I’m reading on my Kindle (so cool!), but your local library is an excellent source of free audiobooks. The key here is to have the book ready to go, so all you have to do is push play (the last thing you want to do is be fumbling with your phone, finding that app, searching for the book…all of which wake your brain up even more).
  • Track your cycles. I’ve said it before, but because I use the Clue app, I know when I should be ovulating and when to expect my next period. I’ve learned, too, and have heard from many other women, that sleep patterns can change during your cycle. I know to expect 1-2 nights of very early wakings per month, no matter what I do. They always happen a week or so before my upcoming period and I’ve learned to notice them, get out of bed and start the day. That’s often when I’m writing to you! I feel less stressed about these days because they are predictable and I know my good sleep will return soon.
  • Alcohol. Ugh. I love a glass of wine at the end of the day but studies consistently show, I hear it daily in my practice and experience it personally that drinking even a small amount disrupts sleep. Your sleep is lighter and you are more likely to wake in the night with trouble getting back to sleep (the 3 am wake up!). I also hear from women that when they tune in to this one factor, they notice an increase in night sweats and sometimes disturbing heart palpitations and anxiety on nights they drink. For some reason that I do not understand, red wine is the worst offender. Again, ugh…
  • Caffeine will disturb your sleep. Try not to ingest any (coffee, green or black teas, energy drinks, chocolate) after 2pm.

What’s a girl to do without chocolate and red wine at the end of a long day?? This is your challenge, to explore ways of filling up your bucket doing things for yourself that are not sabotaging your sleep and affecting your health. Cuddle with your honey, call that friend you haven’t spoken to in a while, write a letter, have sex, journal, do something crafty, take a class to learn that thing you’ve always wanted to learn, get together with girlfriends for a walk, take a bath, do some yoga, start a blog…

Okay, so you’ve started exercising in the morning, forego that 3pm Pumpkin Spice lattè for a walk around the block and have traded your evening wine for a cuddle and an episode of Stranger Things (so good!) but you are still struggling to snooze. Here are some natural therapies that may help (check out the Resource page for links on where to find these):

  • Magnesium powder. I’ll probably mention Magnesium in every post I write. I love magnesium. It is so safe, so cheap, so effective and most of us are deficient. It is extremely relaxing to our muscles and brains and many folks notice a deeper, cozier sleep once they start taking Magnesium at bedtime. I like the Natural Calm Magnesium powder, but am intrigued by Garden of Life’s Relax and Restore as it contains no sweeteners. Start with the recommended dose on the bottle. You’ll know you’ve taken too much mag if you have diarrhea the next day, so take a little less the following night to find your sweet spot. If your belly can’t tolerate mag citrate, try mag glycinate or mag threonate.
  • Calms Forte by Hylands. This is a homeopathic blend that promotes a peaceful mind and restful sleep without interacting with your medications. Chew 3 of these at bedtime and again in the night if you wake.
  • Melatonin (for getting to sleep only; melatonin will not help you stay asleep). Try 1mg under the tongue and increase if needed. Typical doses vary between 1-5mg. You may feel groggy the next morning; try taking less to see if you get improvement in sleep without the foggy brain.
  • Cortisol Manager by Integrative Therapeutics. This is a great formula for reducing cortisol levels that are too high. You may have trouble getting to sleep or your brain may wake you in the night with that list of things you need to do or forgot to do. Take 1-2 at bedtime; even better, have your cortisol values evaluated by your naturopath!
  • Progesterone cream. I don’t use this cream all that often, but it can be helpful for improving sleep quality in perimenopause especially if you find you consistently get your worst sleep from ovulation to your period (the time when we should be making the most progesterone, but don’t because that’s what happens in perimenopause). Progesterone is relaxing to the brain and occasionally the low-dose creams are enough for an effect (sometimes oral works better). I like the Protocol and Xymogen brands as they are metered pumps of bio-identical progesterone; each pump is 20mg. You rub it on your inner arms at bedtime.
  • CBD. Did you know this chemical in Cannabis (marijuana) is legal in all 50 states? On its own it has no hallucinatory effects but is a powerful sleep aid. I like the liquid forms as you can better manipulate the dose to get as much or as little as your brain needs. It doesn’t work for everyone, but has been hugely helpful for women in my practice (myself included!).

I am frequently asked if over-the-counter pharmaceutical sleep aids are safe? Maybe not. A recent study showed an increase in dementia risk in older folks using Benadryl long term at night for sleep. Try to find another option and if the strategies above are not quite cutting it, go see your Naturopathic physician for a more tailored approach. Now, put down your phone, close your laptop and get some sleep. Sweet dreams~

PMSing through Perimenopause

I wrote before about what’s happening with the two major hormones in a normal monthly menstrual cycle. Estrogen is the Queen of the first two weeks (when the period starts to ovulation), and Progesterone is Queen of the second two weeks leading up to the next period (the classic PMS time). This hormone is the first to get wonky and trigger many perimenopausal symptoms.

Why? Our bodies have a set number of eggs at birth. This number drops steeply at puberty and then decreases each month with ovulation until there are no eggs remaining and a woman is in menopause.

As we age, not only does the number of eggs we have decrease but also the quality of the eggs declines. What does that mean? Remember that we make progesterone after ovulation? If the eggs we are ovulating as we age are less healthy, we make less progesterone. This is one of the first changes in perimenopause. Progesterone levels start to decline in the 2nd half of the menstrual cycle. This creates a natural state of “estrogen dominance”, something many of my patients are curious about. I tell all women over 35 that they are almost positively estrogen dominant. There’s no need to test this in most women; it’s the natural state of affairs in early perimenopause.

This lowered progesterone during this time translates to heightened PMS symptoms for many women. PMS symptoms vary woman-to-woman in intensity and severity and length of time. Most women think of PMS as being the increased emotional sensitivity right before a period, but PMS technically includes ANY symptom that occurs in that 1-2 weeks prior to a period and goes away once the period comes. Common symptoms are breast tenderness, fatigue, headaches, bloating, cramping, intense cravings, insomnia, night sweats, acne. What an awesome way to feel…

PMS tends to increase in length for many women during perimenopause, sometimes starting immediately after ovulation and lasting the full 2 weeks before the next period.

Many women I work with experience most of the symptoms I mentioned for the full 2 weeks of the month– Yuck! These women feel terrible half of the month. Their period starts and PMS symptoms finally go away (hooray!), but then many struggle with extremely heavy bleeding and intense cramping and more headaches. Lots of women I talk to have a few days after their periods in which they feel their best. This is crazy! Many of us only feel well for 1-5 days per month.

Listen, ladies: This is common but is NOT normal! You do NOT have to live like this.

What to do?

  1. Sleep—this is a priority. This is your number one goal. Start your efforts here if you are not getting at least 7 restful hours each night. If so, move on down the list.
  2. Manage your stress—you are more sensitive to stress and it’s impact on another hormone called Cortisol. This hormone is HUGE and deserves it’s own post, so stay tuned.
  3. Eat well—what does that mean? Well, this is another big can of worms and a big part of my healing philosophy so we’ll spend whole posts on it for sure! The big picture: plant-based diet, lots of healthy fats (think avocado, grass-fed butter, coconut oil, nuts & seeds), whole foods, minimal to no processed foods, minimal to no sugar (right when you want them the most, I know, I’m mean), very little if any alcohol, very little if any caffeine.
  4. Are you still reading?
  5. Exercise—more is not always better, but try to move your body daily. Walking, stretching and yoga are perfect starts. Try to find a buddy to make it more enjoyable, keep you motivated and committed, and give you some girlie time to get stuff off your chest. This is an important daily routine, but is also SO helpful during those PMS days. You may find it feels best to go for longer & slower walks, jogs and swims rather than shorter more intense workouts during the PMS phase.
  6. Keep track of your cycles and your symptoms. There are many, many period tracker apps out there. My favorite for simple tracking (not for fertility purposes) is Clue (it’s free!). Look around, though, and find what works for you. The benefit of these apps is that you can start to see patterns and understand if certain symptoms are cyclical or hormonal. They are also excellent for reminding yourself that when you start to feel the PMS symptoms start, they are temporary and will be leaving soon(ish). Many trackers can send you reminders that PMS may be starting, once the app has a good history of the symptoms you enter each month. I cannot downplay the benefit of this knowledge. Many women tell me they feel crazy for days, they don’t know why, they get their period and feel better and then think, in retrospect, “Oh! I had PMS, that’s why I felt terrible!”. Knowing in advance gives you a little bit more control of the situation; this control and knowledge is very powerful and can prevent the PMS from taking over your decision-making processes.

If you’re doing all of these and feeling confident about your efforts and still struggling, or find yourself so stuck in the PMS haze that you can’t find the energy to make the efforts, it may be helpful to try a few supplemental nutrients.

  1. A high quality, food-based multivitamin: All multis are NOT created equal. I recommend the food-based brands like Garden of Life/Vitamin Code, Rainbow Light and New Chapter, because the nutrients are sourced from fruits & veggies (and organic versions are available and preferable). The nutrients from food are readily absorbed and used by the body, minimizing the extra steps needed to activate them or make them useful. This means you actually absorb the vitamins and minerals instead of peeing them out. I recommend finding the Women’s formula specific to your age range, too (that may mean a prenatal).
  2. A high-quality fish or krill oil: I recommend we each get a total of 1000mg per day of EPA and DHA combined per day. More may be better, especially if you struggle with more mood change with PMS.
  3. Magnesium citrate or glycinate: This mineral is amazing! It is needed to relax muscles, it calms the brain, improves sleep, promotes bowel regularity and decreases PMS symptoms. You cannot get a toxic dose orally. If you take too much, your stools will be looser and you may have some abdominal cramping. I recommend taking this to “bowel tolerance”; in other words, take as much as your body can tolerate without causing diarrhea (the glycinate form is easier on more sensitive bellies). This is usually in the range of 300-600mg. Take it at night to promote a blissful slumber.
  4. Vitamin D3: I do recommend having your Vitamin D levels tested. Optimal is to be in the 60-80 range, but normal is above 30. If you live in the Pacific Northwest, I recommend 4000iu daily. You DO want to have levels monitored, as excess levels can increase your risk for kidney stones.
  5. Vitamin B6: This B-vitamin is a necessary precursor or ingredient in making many hormones in the body, including serotonin (the happy brain hormone) and progesterone. Levels are depleted with long-term oral contraceptive use and are often low in women with PMS. Start with 100mg each morning with food; better yet, take it with the other B-vitamins as part of a B-complex. I like the B6-Complex from Pure Encapsulations. You CAN get too much B6, so be careful—it can cause numbness and tingling in the hands and feet.

If you are trying these recommendations and not seeing results after at least 3 months, it’s time to get more aggressive. This could mean lab tests for hormones and nutrient deficiencies, or experimental diets to uncover food sensitivities, or the use of more specific herbal therapies, etc. See your local naturopathic physician for more individualized care recommendations! Find a naturopath in your area here.


No, I don’t have PMS. I’m just a b*tch

Michelle Wolf

 I know that’s a racy way to end this post, but I love the subtext of what Michelle is saying here (she’s a very funny comedian I’ve seen periodically on The Daily Show with Trevor Noah). More often than not, girls and women are taught to be kind, sweet and submissive and we are rewarded for being so. Being bold, aggressive and questioning others is not and the thought is that a woman must have PMS when she behaves this way. Let’s all be b*tches, I say!