New Doc 26_2

I’ve been noticing a trend in my practice, which places an emphasis on women’s hormonal health and mental health. Many women are consulting me for treatment of anxiety and panic attacks that have shown up in addition to other hormonal symptoms: painful periods, PMS, headaches, loss of libido, acne and weight gain. It just so happens that these women have also, for either treatment or contraception purposes, inserted a Mirena IUD, an intrauterine device that secretes small amounts of progestin (a synthetic form of progesterone) into the uterus.

The monograph for Mirena—produced and supplied by Bayer Pharmaceuticals—claims that Mirena is 99% effective for preventing unplanned pregnancy. Bayer informs us that Mirena can last in the uterus for up to 5 years and eliminates the need for daily pill-popping or condom use (although it does not protect against STIs). In addition, it is also an effective treatment for heavy menstrual bleeding. This explains why many women with gynaecological conditions, like endometriosis or fibroids, are recommended the Mirena IUD for alleviating symptoms of painful and excessive menstrual flow. Bayer’s claims, which are backed by evidence, make sense, especially when we consider that fibroids and endometriosis are estrogen-dominant conditions—adding more progesterone to the mix should help to “balance” things out. Incorporating a progestin-secreting device that acts on the uterus can help oppose the estrogen dominance that exacerbates the symptoms of these conditions.

The problem (of course there’s a problem, we’re talkin’ Pharma here) with Mirena is this: while the progestin exerts its effects locally, it does not act on the rest of the body. This may not be a “problem” with a capital P, if we understand that oral contraceptives that contain high progesterone are usually responsible for the “crazy” feelings women have when going on birth control—a lot of the “irritability”, weight gain, water retention and depression that women experience premenstrually is due to high levels of synthetic progesterone. However, we also know that progesterone, whose primary job is to maintain the uterine lining during pregnancy, has positive systemic effects. These effects include promoting mental relaxation and opposing estrogen dominance symptoms, which include weight gain, anxiety, panic attacks, fatigue, PMS, breast tenderness, acne, fibrocystic breast changes, cervical dysplasia, infertility, risk for certain cancers including breast cancer and cervical cancer and worsening of endometriosis and fibroids, which ironically happen to be the two conditions that the Mirena IUD is prescribed to treat.

Estrogen dominance is often not about having high levels of estrogen, but normal estrogen levels with insufficient progesterone to oppose some of its effects. Progesterone deficiency can look like estrogen dominance, when we examine a patient’s symptoms.

In my practice as of late, I’ve had a stream of women presenting with anxiety, panic attacks and heart palpitations that I strongly suspect are hormone-related. When I send them for blood work or salivary hormone tests I find that their progesterone levels are very low. They also may have symptoms of painful menstrual periods, stubborn weight gain and acne. And, you guessed it, all of them have the Mirena IUD. Many patients vaguely remember that symptoms began to rear their ugly heads, or worsen, after they got the IUD. Other colleagues have commented on observing the same trend in their own practices. Could the phenomena be linked?

There are several possible explanations for the progesterone deficiency/estrogen dominance phenomenon in clinical practice—these include, but are not limited to, chronic stress, vitamin deficiencies, impaired liver function or bowel function and exposure to exogenous estrogens such as BPA (found in plastic bottles, personal care products, the lining of tin cans and receipts, to name a few). Yet it seems that Mirena is a common factor in the majority of the cases I’m seeing. The possible reason is that, although Mirena provides progestins to the uterus, its hormones do not reach progesterone receptors in other areas of the body, for example the breasts, adipose tissue or brain, where progesterone normally will have an effect. While oral contraceptives act by preventing ovulation (some women don’t even menstruate while using the IUD), which in turn prevents the secretion of natural progesterone from the corpus luteum (formed in the ovary after ovulation), many of them also supply a dose of synthetic progesterone. Since the Mirena IUD only secretes progesterone to local tissues and therefore only acts at local receptors, it may be turning off the body’s ability to secrete natural progesterone—negative feedback loops might instruct the pituitary gland and the adrenal glands to stop making the body’s own progesterone.

As an naturopathic doctor, it can be hard to know where to proceed! I can try to balance hormones naturally with herbs that help promote an increase in progesterone production. I can also treat the adrenal glands so that they are able to produce more natural progesterone, rather than favouring cortisol production. However, not only might my efforts be fruitless, they may interact with the IUD’s contraceptive effects. I can try to promote the healthy excretion of estrogens by promoting liver detoxification and colon elimination, but the practice calls to mind an image of cleaning a dirty river while sewage pipes deposit their waste into it. How can my patients help their bodies clear out excess hormones while we both ignore the fact that the cause of hormonal deficiency may still persist?

While I sympathize with the allure of a hassle-free family-planning method and relief from the symptoms of heavy and painful periods, I can’t help but shudder when I see the often debilitating anxiety that my patients who use Mirena are presenting with. With regards to birth control, I have written in the past about healthy OCP practices and finding the right hormonal fit. There are also other, natural methods of family planning available, copper IUDs (however, there are other issues with the secretion of copper to local uterine tissue as well) and physical barriers. While other options may not be as convenient, or even as effective, they may promote a healthier hormone balance and improved overall health. It’s worth having a conversation with your doctor about options.

With regards to treating heavy menstrual bleeding with Mirena, natural alternative solutions are abundant! Naturopathic medicine offers a large array of therapies and treatment protocols aimed at treating the root cause: promoting healthy detoxification and elimination, supporting adrenal glands and balancing hormones through diet and nutrition. Not only does Mirena pose the potential for furthering hormonal imbalances, it covers up and even potentially exacerbates the underlying cause of why the symptom is happening in the first place, which is likely a case of estrogen dominance.

For treatment of hormonal conditions—endometriosis, fibroids, heavy and painful menstrual bleeding, PCOS, acne, weight gain and so on—I encourage you to explore natural options. In the meantime, I’ll have to figure out how to address my patients’ concerns while navigating against the current of synthetic hormones.

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