Jan 2025 | Volume 20 | Issue 1 N : simplebooklet.com

Clinical pearlsCase management/case studiesNaturopathic philosophyPractice building and business managementCurrent trends and issues that affect naturopathic physicians in your areaNews, announcements, and event noticesDevelopment of new techniques or protocolsAbstracts and reviewsDiscussions pertaining to diagnosticsPublic/media relations and networkingUsing technology to make practices more efficient and profitableEducational and grassroots programs that further the naturopathic causeAny other trend, event, or development you believe is pertinent to theprofessionFor more information regarding article submission, or to receive a copy ofsubmission guidelines, please contact editor@ndnr.com or scan the QR code formore information. Opinions expressed in Naturopathic Doctor News & Review do not necessarilyreflect those of this publication and its publishers.Copyright © 2024 Naturopathic Doctor News & Review. All rights reserved. No portionof this publication may be copied, reproduced, or redistributed without express writtenpermission from the publisher. Reprint information is available by contactingpublisher@ndnr.com.Naturopathic Doctor News & Review reserves the right to edit or reject any submittededitorial or advertising. Opinions expressed by contributors and advertisers are notnecessarily the opinions of Naturopathic Doctor News & Review or its principals.Naturopathic Doctor News & Review is published and circulated as an annualsubscription (12 issues) to licensed naturopathic doctors (NDs) and students andgraduates of CNME recognized naturopathic colleges in North America, and certainsuppliers to the profession. Annual subscriptions (12 issues) are available to other healthcare providers and NDs outside of North America: $199 USDINSIDEPhytoestrogens and Hormonal Modulation: Applications inMenopause Management and Breast Cancer Prevention Artemis Morris, NDExploring the benefits of phytoestrogens in managing menopausesymptoms and reducing breast cancer risks.Understanding and Reducing Breast Cancer Risk ThroughIndividualized Screening and PreventionErin Rurak, NDExplore the latest insights into breast cancer risk factors,screening advancements, and prevention strategies, highlightingthe need to transition from age-based to risk-based screening forimproved outcomes and personalized care.Migraines and Menopause: Two Case StudiesJillian Finker, NDExplore how naturopathic approaches effectively addresshormonal migraines in menopausal women through real-lifepatient case studies.Rewiring Fear and Worry: A Holistic Approach to ConqueringAnxiety in the Female Patient Jonathan E. Prousky, ND, MSc, MAExplore integrative strategies for overcoming anxiety disorders inwomen, emphasizing hormonal insights and evidence-basednatural treatments.The Importance of Self-Care in Mothers: A Flurry of Controversy Lillea Hartwell, NDA deep dive into the importance of self-care for mothers and itslong-term effects on both mental health and child development.Menopause as InitiationMelissa Sophia Joy, NDExplore the transformational potential of menopause beyondphysical symptoms like hot flashes, fatigue, and brain fog. Case Study: Pseudoangiomatous Stromal Hyperplasia (PASH) ofthe BreastMolly Jarchow, NDUnderstanding PASH, its diagnosis, and holistic approaches tomanaging hormonally sensitive breast conditions.Sleep and Menopause: How to Overcome Sleep Disorders inPostmenopausal WomenMona Morstein, NDDiscover how menopause impacts sleep, common sleep disordersin postmenopausal women, and practical solutions to restorehealthy sleep.Autoimmunity, Women, and Relationship to Self Nicola Dehlinger, ND Exploring the unique connection between autoimmunity andwomen’s health, delving into cultural, emotional, and physiologicaltriggers for self-healing.Differentiating Perimenopause: Avoiding Diagnostic PitfallsThara Vayali, NDExploring the complexities of perimenopause, its clinicalchallenges, and how naturopathic physicians can differentiatesymptoms and address root causes.Integrating BioIdentical Hormones and Herbal Protocols:Naturopathic Clinical PearlsJannine Krause, ND Explore a naturopathic method that combines bio-identicalhormones and herbal remedies to help women navigate hormonalchanges during peri-menopause and menopause.Article Submissions: Articles should be original,previously unpublished, and should cover aspecific topic, protocol, modality, diagnostic,philosophy, commentary, or case study pertainingto naturopathic medicine rather than a generaloverview. Illustrations, photographs, charts, andprotocols are encouraged. Naturopathic DoctorNews & Review does not reprint articles fromother publications except under unusualcircumstances. Typical word requirements are 700 to 2000 words per article. Topics of interestinclude:Differentiating Polycystic Ovarian Syndrome andNon-Classical Adrenal HyperplasiaDifferentiating Polycystic Ovarian Syndrome andNon-Classical Adrenal HyperplasiaTOLLE TOTUM31117212733414752JOIN THE CONVERSATION06Kelly Simms ND, CNS, FABNEExplore the clinical overlap between Polycystic OvarianSyndrome (PCOS) and Non-Classical Congenital AdrenalHyperplasia (NCCAH), providing diagnostic criteria, labevaluations, and natural treatment options. JAN 2025 - VOLUME 20 | ISSUE NO. 01364557

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Turn the page to 2025Dear Readers,As we turn the page to 2025, it gives me greatpleasure to address you in the landmark 20thyear of the Naturopathic Doctor News & Review(NDNR). Two decades ago, NDNR embarkedon a mission to serve as a voice and resourcefor the naturopathic community. Today, weproudly continue that tradition, bolstered by anunwavering commitment to provide our readerswith insightful, authoritative, and timelycontent.Reflecting on the past 20 years, it's clear thatour journey has been as transformative as it hasbeen enriching. We've witnessed and reportedon the significant strides in naturopathicmedicine—from advancements in treatmentsand research to notable shifts in publicperception and regulatory landscapes. Ourplatform has grown into a respected repositoryof knowledge, empowering naturopathicpractitioners and students with informationcritical to their practice and professionaldevelopment.In this celebratory year, we are excited tointroduce some new features. Expect more in-depth analyses, a series on emerging trends innaturopathy, and enhanced multimedia contentdesigned to bring you closer to the heart of thestories that matter. We're also expanding ourcommunity outreach to foster even strongerconnections within this vibrant field.Empowering naturopathic practitioners and students with informationcritical to their practice and professional development.4NATUROPATHIC DOCTOR NEWS & REVIEW20YEAREST. 2005ANNIVERSARYThe essence of NDNR’s success lies in the richnessof our community. Your contributions, whether asauthors, readers, or advocates, fuel our collectiveendeavor. We cherish the dialogue between us andstrive to keep it flourishing. As we move forward, Iencourage each of you to continue sharing yourinsights, research, and stories with us.Thank you for your trust, support, and engagementover the years. It has been an honor to growalongside you and your practices. Here's tocelebrating the past 20 years and to forging aheadinto a promising future of continued excellence innaturopathic reporting.In Health, Razi BerryPublisher NDNRWOMEN'S HEALTH

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PCOS Diagnosis Criteria To diagnose PCOS, the patient must meet two of the threepossible criteria: Irregular or absent menstrual cycles: Ensure that thepatient is not on hormonal birth control or an IUD,which can also cause irregular or absent bleeding.1.Symptoms or laboratory evidence of hyperandrogenism:Symptoms may include acne, hair loss, and/orabnormal hair growth. Laboratory evidence is elevatedtestosterone, DHEA-S, dihydrotestosterone, orandrostenedione levels. 2.Multi follicular appearing ovaries: When a transvaginalultrasound is done in the late follicular phase on awoman not taking hormonal birth control of any type,multiple follicles may be present. 3.Note that the criteria for PCOS do not include insulinresistance or increased BMI. Although both can beassociated with PCOS, it is not diagnostic.Laboratory Evaluation and Imaging: For a woman who is not cycling, the following hormonelabs may be collected at any time, early morning preferred:FSH, LH, testosterone (free and total),dihydrotestosterone, androstenedione, estradiol, DHEA-S,17-hydroxyprogesterone (17-OHP), prolactin, TSH, andanti-mullerian hormones. For a woman who is cycling regularly, defined by a cyclelength ranging consistently between 25-35 days betweenmenses, a cycle day three lab draw will more accuratelycheck the FSH: LH ratio. The ratio should be 2:1 on cycleday three, and in PCOS, it is often reversed to be 1:2. Idealestradiol on cycle day three is between 30-50 pg/mL. 7Androgens cannot be measured while on oral contraceptivesbecause sex hormone binding globulin is elevated andGnRH signaling is altered. Note that progesterone should not be checked as a part ofthe workup, especially in amenorrhea. Progesterone is onlymanufactured after ovulation. Therefore, checkingprogesterone and advising that someone is “low inprogesterone” is essentially the nature of the condition dueto anovulation. In the case of irregular ovulation, theywould produce progesterone, but not on a regular monthlycycle. When looking at hormones, consider relative ratios.The GnRH signal is sent to the pituitary to produce bothFSH and LH. LH then targets theca cells in the ovary,leading to androgen production, and the FSH signal targetsestrogen production and follicle development. Consider thatif a woman is anovulatory, the levels of estrogen andtestosterone may be high or even laboratory normal. Still,symptoms may be due to the relative excess of thesehormones relative to progesterone.Transvaginal ultrasound (TVUS) is advised in cases wherepatients do not meet the other two criteria, and thediagnosis is in question. Some literature suggests AMH maybe a substitute marker for multi-follicular ovaries and aTVUS if a woman is 8 years post menarche. 2 AMH issometimes elevated in PCOS. NCCAH Diagnosis and Distinguishing FeaturesNCCAH is clinically indistinguishable, as the most commonsymptoms among adolescent and adult women werehirsutism (59%), oligomenorrhea (54%), and acne (33%).¹NCCAH is due to P450c21 (21-hydroxylase) deficiency, acommon autosomal recessive disorder due to mutations inthe CYP21A2 gene. In labs, 17-OHP is elevated in basal andACTH-stimulated 17-OHP when tested in the earlyfollicular period.³ 17-OHP is best collected early in themorning, and early morning baseline values of 17-OHPgreater than 200 ng/dl should prompt further evaluation.⁴In addition, the multi-follicular ovaries, observed in 75% ofthe PCOS population, are also seen in 40% of the NCCAHpopulation, especially in the ovulation disorder subgroup.Therefore, ultrasound does not help with differentialdiagnosis. Hence, the sole approach for distinguishingNCCAH patients from PCOS patients is to assess 17-OHPlevels.³“At her first follow-up five weekslater, she reported that this wasthe first period where she had nopain during her menstruation andwas able to continue her day.And she “cannot remember lasttime menses were this easy.” JAN 2025 - VOLUME 20 | ISSUE NO. 01NATUROPATHIC DOCTOR NEWS & REVIEW

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The patient shared labs from an outside provider: Cycle day 11 labs, collected at 10:28 AM, around the sametime as her initial intake with me: Testosterone: 55 (9-55 ng/dL)Free Testosterone: 4.7 (0.8- 7.4 pg/mL)Sex Hormone Binding Globulin 91 nmol/L (25-122)Aldosterone 11.8 (4.0-31 ng/dL)Renin activity 0.9 (0.5 -4.0 ng/mL/hr)Aldosterone/Renin Activity ratio 13.1 (<25)17-Hydroxyprogesterone: 142.36 (<206. ng/dL)-NORMALDHEA- S 221 (91-240 ug/dL)Complete Metabolic Panel - WNLCycle day 5 labs; unknown collection time, done in a foreigncountry about a month after her initial intake, so referenceranges are different: 17- Hydroxyprogesterone 3.73 (1.06-12.25 nmol/L)-NORMALEstradiol 122 ( Follicular Reference Range: 71.5-529pmol/L)TSH 2.985 (0.55- 4.75 mIU/L)Free T3 4.3 (3.5 -6.5 pmol/L)Free T4 13 (11.5 - 27 pmol/L)FSH 6.20 (Follicular Reference Range: 2.5- 10.2 IU/L)LH 4.90 (Follicular Reference Range: 0.5-16.9 IU/L)Prolactin 427.6 ( 59-619 MIU/L)Progesterone < 2 (Follicular Reference Range: 0.48-4.5IU/L)Testosterone: 1.40 (0.29-1.21 nmol/L) - HIGHVitamin B12: 312 (156-672 pmol/L)Folic Acid 29.2 (>12.2 nmol/L)Since most recent 17-OHP readings were not elevatedcompared to her initial diagnosis, she will follow up with herendocrinologist for an ACTH-simulated 17-OHP test. Natural Treatment Plan for NCCAH and PCOSSince PCOS and NCCAH have overlapping characteristics,natural treatments that can be used in PCOS cases can beimplemented in NCCAH. The conventional treatments forNCCAH are not always indicated unless the individual issymptomatic. In symptomatic cases, treatment may includelow-dose glucocorticoids, androgen-lowering medicationslike spironolactone, and birth control pills. Women with NCCAH may also be more likely to presentwith oligomenorrhea rather than amenorrhea. Moran et al.examined 220 women with NCCAH. Between the ages of10 and 19 years, the prevalence of oligomenorrhea was ashigh as 56% compared to only 9% of adolescents whoexperienced primary amenorrhea.⁴In addition to 17-OHP, the acute ACTH stimulation testremains the gold standard to confirm decreased 21-hydroxylase activity. Synthetic ACTH (Cortrosyn, 0.25 mg) is administered after collecting a blood sample tomeasure baseline hormone concentrations. A second bloodsample is collected 30–60 minutes later. The correlation ofhormone concentrations with genetic analyses hassuggested that mutations will likely be identified on bothalleles when the ACTH-stimulated 17-OHP value exceeds1500 ng/dL. However, a few NCAH patients, particularlyif older, will demonstrate ACTH-stimulated 17-OHP levelsbetween 1000 and 1500 ng/d.¹Case Study: Ruby’s ExperienceRuby is a 29-year-old female with a history of irregularmenses. Within the past year, her menses have been moreregular, averaging 35-37 days, which categorizes her asoligomenorrheic. In the past, cycles were spaced 50-80days. She has dysmenorrhea, which disturbs her activitiesof daily living. A few hours after getting her menses, she isunable to work or stand up; she cries in bed and vomits.She had been prescribed Magnesium Phosphoricum 30Cby another provider and found the benefit in taking thatacutely for pain. The pain resolves after 10-12 hours. Shewas seen by a gynecologist, who recommended oralcontraceptives and spironolactone. She desires alternativetreatments. She has a normal bleeding pattern. Premenstrualsymptoms include significant breast swelling, abdominalbloating, occasional cramping, fatigue, and mood changes. She has notable androgenic symptoms: hair loss andthinning, excess hair on her nipples, and acne on hershoulders and back. She was initially diagnosed with NCCAH in 2000 due tomulti-follicular ovaries and oligomenorrhea. She does nothave the labs from the initial diagnosis but shares that her17-OHP was significantly elevated. There are no other significant medical diagnoses orfindings in her intake. 8WOMEN'S HEALTH

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NutritionAlthough the patient is not overweight or has signs of insulinresistance, I recommended a high protein and veggie diet,with lower fruit, grain/starch, and sugar akin to theMediterranean diet with less emphasis on carbohydrates. Partof the underlying mechanism for androgen overproduction isovarian, and in her case, also adrenal. To treat ovarian insulinresistance, the Mediterranean Diet combined with a lowcarbohydrate is a good choice.⁵I recommended the following initial treatment plan: Adrenal: Ashwagandha root 500 mg per day. One casestudy report showed a 66% reduction in 17OHP aftertreatment with ashwagandha for six months.⁶1.Restore FSH/LH signaling: Vitex2.Reduce androgens: Saw Palmetto, Pygeum, and Nettles 3.Acne: liver support herbal containing Berberine, MilkThistle, Burdock, and Chicory, and skin supportmultivitamin4.Anti-inflammatory and pain management: magnesiumglycinate and fish oil5.9NATUROPATHIC DOCTOR NEWS & REVIEWAt her first follow-up five weeks later, she reported that thiswas the first period where she had no pain during hermenstruation and was able to continue her day. And she“cannot remember last time menses were this easy.” Breastswelling improved, and lower back pain also improved. Thesecond period, which came 39 days later, was more painfulthan the previous “easy” period, but PMS symptoms werestill improved. She was consistent with her treatment plan,so this may be due to the natural course of healing andmonthly hormone fluctuations. She had an endocrinology visit, and the provider was unsureif NCCAH was still the correct diagnosis. 17-OHP wassignificantly higher at initial diagnosis, and at subsequentlab draws, 17-OHP was much lower. Her providerrecommended genetic counseling for fertility purposes.Those with NCCAH are at increased risk for havingoffspring with the classic form of the disorder.⁴ As a resultof her genetic counseling, she was advised that she is acarrier, so she will not have the full expression of 17-OHPelevations as in a more fully expressed genotype. Herbaseline 17-OHP is normal, but ATCH-stimulated 17-OHPdoes surpass 1500 ng/dL. JAN 2025 - VOLUME 20 | ISSUE NO. 01

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The longer-term treatments for NCCAH depend on thepresentation. The conventional treatment recommendationis glucocorticoid therapy, reserved for those individuals withsymptomatic hyperandrogenism. Depending on cyclecharacteristics, oral contraceptives may be necessary,especially if regular menstruation cannot be achieved withnatural support options. Prescription anti-androgens mayalso be a consideration. The estimated infertility incidence is11% among NCCAH women 10, and glucocorticoid therapymay increase the chances of conception and reduce the riskof miscarriage for women with NCCAH. This highlights theimportance of working up for NCCAH in infertility cases. Her ACTH stimulation testing showed lab values: Baseline 17- hydroxypregnenolone: 203 ng/ml (reference<226 ng/dL)- NORMAL, but suggests NCCAH due to >200 ng/mLATCH stimulated 17- hydroxyprogesterone: 1548.57(<206. ng/dL)- HIGH, consistent with NCCAH, lesssevere presentation, retaining some 21-hydroxylaseactivity.Other lab results: Ferritin 30 (16-154 ng/mL) - SUBOPTIMALVitamin D,25-OH, Total 29 (30-100 ng/mL)- LOWBased on her other labs and feedback from her visits, weadded vitamin B12, vitamin D, iron, and myo-inositol4000mg to her plan. Inositol is an insulin sensitizer andreduces clinical and laboratory symptoms ofhyperandrogenism. Inositols reduce serum total and freetestosterone and androstenedione levels, increase SHBGlevels, and normalize cycle length compared to placebo.⁷Vitamin D has been shown to lower testosterone in PCOSpatients and improve folliculogenesis, leading to more regularcycles.⁸ Low iron stores are a contributing factor in hair loss.Ferritin should be optimized to be at least 40 ng/dL andoptimally 70 ng/dL.⁹ In her case, future naturopathic testingconsiderations include anti-mullerian hormone and cortisol.This patient is continuing her care plan. 10NATUROPATHIC DOCTOR NEWS & REVIEW1 Moran C, Azziz R, Carmina E. 21-hydroxylase-deficient nonclassic adrenal hyperplasiais a progressive disorder: a multicenter study. American Journal of Obstetrics andGynecology. 2000; 183 (6): 1468-1474. Nonclassic Congenital Adrenal Hyperplasia |International Journal of Pediatric Endocrinology | Full Text (biomedcentral.com)2. Dason ES, Koshkina O, Chan, Sobel M. Diagnosis and management of polycysticovarian syndrome. CMAJ. 2024; 196 (3): E85-E94. Diagnosis and management ofpolycystic ovarian syndrome | CMAJ3. Yesiladali M, Yazici MGK, Attar E, Kelestimur F. Differentiating Polycystic OvarySyndrome from Adrenal Disorders. Diagnostics (Basel). 2022; 12(9):2045. DifferentiatingPolycystic Ovary Syndrome from Adrenal Disorders - PMC (nih.gov)4. Trapp CM, Oberfield SE. Recommendations for treatment of nonclassic congenitaladrenal hyperplasia (NCCAH): an update. Steroids. 2012; 77(4):342-6 Recommendationsfor Treatment of Nonclassic Congenital Adrenal Hyperplasia (NCCAH): an Update -PMC (nih.gov)5. Mei S, Ding J, Wang K, Ni Z, et al. Mediterranean Diet Combined With a Low-Carbohydrate Dietary Pattern in the Treatment of Overweight Polycystic Ovary SyndromePatients. Front Nutr. 2022; 9: 76620. Mediterranean Diet Combined With a Low-Carbohydrate Dietary Pattern in the Treatment of Overweight Polycystic Ovary SyndromePatients - PMC (nih.gov)REFERENCES6. Kalani A, Bahtiyar G, Sacerdote A. Ashwagandha root in the treatment of non-classicaladrenal hyperplasia. BMJ Case Rep. 2012 Ashwagandha root in the treatment of non-classical adrenal hyperplasia - PubMed7. Greff D, Juhász AE, Váncsa S, Váradi A, et al. Inositol is an effective and safe treatmentin polycystic ovary syndrome: a systematic review and meta-analysis of randomizedcontrolled trials. Reprod Biol Endocrinol. 2023 Jan 26;21(1) Inositol is an effective and safetreatment in polycystic ovary syndrome: a systematic review and meta-analysis ofrandomized controlled trials - PMC (nih.gov)8. Mohan A, Haider R, Fakhor H, Hina F, et al. Vitamin D and polycystic ovarysyndrome (PCOS): a review. Ann Med Surg (Lond). 2023. 85(7):3506-3511. cc 9. Almohanna HM, Ahmed AA, Tsatalis JP, Tosti A. The Role of Vitamins and Mineralsin Hair Loss: A Review. Dermatol Ther (Heidelb). 2019. 9 (1):51-70. The Role of Vitaminsand Minerals in Hair Loss: A Review - PubMed10. Livadas S, Bothou C. Management of the Female With Non-classical CongenitalAdrenal Hyperplasia (NCCAH): A Patient-Oriented Approach. Front Endocrinol(Lausanne). 2019. 10:366. Management of the Female With Non-classical CongenitalAdrenal Hyperplasia (NCCAH): A Patient-Oriented Approach - PMCDr. Kelly Simms is a Board-CertifiedNaturopathic Endocrinologist and a CertifiedNutrition Specialist® (CNS). She holds adoctorate in Naturopathic Medicine and is aFellow of the Board of NaturopathicEndocrinology (FABNE). Dr. Simms isaffiliated with the American Association ofNaturopathic Physicians (AANP), IllinoisAssociation of Naturopathic Physicians(ILANP), and Endocrinology Association ofNaturopathic Physicians (EndoANP). She hasserved as President of the Naturopathic MedicalStudent Association (NMSA) and has presentedon health topics to both professional and publicaudiences. Dr. Simms lives in Wilmette, IL withher family and enjoys cooking, yoga, and travel.www.kellysimmsnd.comWOMEN'S HEALTH

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Is Soy Good or Bad for Me, Doc? Most of us have had this question from our patients: How werespond can impact their health, hormones, and the menu oftheir plant-based diet. There is a lot of misinformation, evenamong holistic healthcare practitioners, about phytoestrogensand, in particular, soy. Soy (Glycine Max) is complex- it is the most well-knownplant food containing phytoestrogens; its production in theUS is mostly genetically modified (GMO), it's in most animalfeed, a common food allergy, contains a high nutrient profileof complete protein, is the most widely consumed vegansource of protein worldwide and has multiple health benefitsincluding in women’s health.¹ Phytoestrogens, including soy,are plant-derived compounds that mimic the hormoneestrogen and has potential benefits in managing hormonalimbalances, alleviating menopausal symptoms, osteoporosis,cognitive health, and preventing hormone-related cancerssuch as breast cancer.What Are Phytoestrogens?Categories and Sources of PhytoestrogensThere are three main categories of plant-derivedphytoestrogens: mycotoxins, phytoalexins, and the non-estrogenic compounds (equol and enterolignans) requiringgut microbes for their estrogenic effect.² Phytoalexins, such asisoflavones from soy and lignans from flax seeds, areproduced as part of a plant's defense mechanism and,therefore, can vary in concentrations depending on the plant'sresponse to stress, infection, or physical injury.²Phytoestrogens are also characterized by the phytochemicalsin various amounts of many plants consumed as food, spices,and teas. The chemical constituents called phytoestrogensinclude coumestans, resorcylic acid lactones, isoflavones,flavanones, and enterolignans. For example, Red Clover is aplant that contains multiple phytoestrogenic components,including coumestans, resorcylic acid lactones, isoflavones,flavonoids, and enterolignans.²'³How Phytoestrogens WorkThe endocrine activity of phytoestrogens depends on theiraffinity for estrogen receptor binding—both the nuclear andmembrane receptors—and on their ability to induceestrogen-dependent gene transcription. In addition, they canalso act on other cell physiological pathways that exhibitother health properties that vary in health effects dependingon the dose, subject, gender, age, and physiologicalstatus.2,3The Gut Microbiota’s Role in PhytoestrogenMetabolismThe gut microbiota plays a role in enterolignan, isoflavonemetabolism, and phytoestrogen compounds.² It wasproposed that people consuming soy with gut microbescapable of converting the isoflavone daidzein into equol aremore likely to benefit from soyfood consumption.² Equol, ametabolite with a stronger binding affinity for estrogenreceptors than its precursor daidzein, may enhance thehealth effects of phytoestrogens, including potential benefitsfor bone, cardiovascular, and menopausal health.Approximately 50% of Japanese individuals can produceequol compared to 30% of Westerners, with vegetariansbeing more likely to be equol producers than non-vegetarians. However, both equol and isoflavones havephytoestrogenic properties, and it remains unclear whetherequol confers additional benefits independent ofisoflavones.²Phytoestrogenic plants have unique phytochemical,nutrient, physiological, and energetic properties that varydepending on their environment and how they interact withtheir consumers' unique and estrogen-binding variables. Themechanisms by which phytoestrogens exert theirphysiological effects and interact with estrogen receptors arecomplex, and research in this area is ongoing.Estrogen PrimerTypes of EstrogenEstrogen, primarily produced in the ovaries and othertissues depending on the stage in a woman’s life, includesthree forms: estrone (E1), estradiol (E2), and estriol (E3).Estradiol (E2) is the most potent, regulating reproductive,bone, and cardiovascular health, while estrone (E1)predominates post-menopause and can enzymaticallyconvert to estradiol. Estriol (E3), significant duringpregnancy, may have protective benefits in non-pregnantwomen against estrogen-sensitive conditions such as breastcancer. ³'⁴12WOMEN'S HEALTH

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While the affinity of phytoestrogens to the three estrogenreceptors ((ERα, ERβ, and GPER1) is relatively low, andtheir structure is different from that of natural estrogens,research is still uncovering the mechanism by which theirvarying effects occur.3,4 Phytoestrogens, like isoflavonesfrom soy, interact with estrogen receptors favoring ERβ,associated with anti-inflammatory, anti-proliferative, andpotentially cancer-protective effects. Receptor SpecificityERα (Estrogen Receptor Alpha) is found in reproductivetissues and is implicated in estrogen receptor-positivebreast cancers, promoting cell proliferation. ERβ(Estrogen Receptor Beta), expressed in many tissues likethe brain and immune system, often acts as a protectivefactor, inhibiting the pro-growth effects of ERα.8 GPER1(G-protein-coupled estrogen receptor 1) is involved invarious cancers, including breast cancer. It displays a dualrole as both an estrogen agonist and antagonist, offeringpotential as a target for cancer prevention andtreatment.⁵'⁶'⁷'⁸'⁹Phytoestrogens, such as isoflavones (from soy) andlignans (from flaxseed), mimic natural estrogens bybinding to these receptors with lower affinity, acting asnatural selective estrogen receptor modulators (SERMs).⁹This dual activity—estrogenic and anti-estrogenic—positions soy as a potential dietary ally in breast cancerprevention and management. Unlike synthetic endocrinedisruptors, phytoestrogens are associated with beneficialhealth effects, offering a natural, safe approach tomodulating estrogen function in hormone-sensitiveconditions.⁹In preclinical studies, genistein was shown toreduce tumor growth in breast cancer models,likely by modulating the activity of ERβ anddecreasing the inflammatory environment inthe breast tissue.13The interactions between estrogen types, the enzymesinfluencing their production (aromatase, 17β-hydroxysteroid dehydrogenase (17β-HSD), and theirreceptor interaction are key to understandingphytoestrogens' potential effects and uses. Thebiosynthesis of human and animal hormones can beimpacted by factors such as diet (e.g., nutrient deficiency),genetics, and stress. In contrast, stressors, ultraviolet light,and climate variation also impact the biosynthesis ofphytoestrogens.⁶Three commonly studied phytoestrogens are isoflavones,lignans, and coumestans. Isoflavones (e.g., Genistein andDaidzein) are found primarily in soy-based foods and canpotentially manage menopausal symptoms and reducebreast cancer risk. In preclinical studies, genistein wasshown to reduce tumor growth in breast cancer models,likely by modulating the activity of ERβ and decreasingthe inflammatory environment in the breast tissue.¹⁰The gut microbiota metabolizes lignans in flaxseeds,whole grains, legumes, and vegetables into enterolignans,such as enterodiol and enterolactone. Lignans haveantioxidant and anti-inflammatory properties, which helpreduce oxidative stress—an essential factor in cancerdevelopment. Lignans have been shown to lower the riskof hormone-related cancers, including breast cancer.¹¹Coumestans are in alfalfa and other legumes. Coumestanshave weaker estrogen-like effects compared to isoflavonesand lignans. Coumestans can potentially contribute tocancer prevention and hormone balance inpostmenopausal women.¹² JAN 2025 - VOLUME 20 | ISSUE NO. 01NATUROPATHIC DOCTOR NEWS & REVIEW

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Phytoestrogens in MenopauseRelieving symptomsPhytoestrogens can aid in managing menopausal symptoms,such as hot flashes, night sweats, mood swings, vaginaldryness, and other menopausal symptoms associated with thenatural decline in estrogen production and cessation ofmenstruation. Phytoestrogens, with their mild estrogen-likeactivity, have been explored as a natural, safer alternative tosynthetic hormone replacement therapy (HRT). A meta-analysis confirmed that soy isoflavones, such asgenistein, significantly reduce the frequency and severity ofhot flashes and other menopausal symptoms.¹³ By interactingwith estrogen receptors, particularly ERβ, in tissues that aresensitive to hormonal fluctuations, such as the hypothalamusand breast, phytoestrogens may alleviate symptoms withoutthe adverse effects and risks typically associated withsynthetic HRT.¹³Bone HealthPhytoestrogens also have beneficial effects on bone healthand postmenopausal osteoporosis. Phytoestrogens,particularly isoflavones, have been shown to help maintainbone density by interacting with estrogen receptors in bonetissue, thereby reducing the risk of fractures.¹⁴Phytoestrogens and Breast Cancer PreventionProtective MechanismsThe potential of phytoestrogens in breast cancer prevention isthe subject of ongoing research. Since many breast cancers areestrogen receptor-positive (ER+), a primary concern has beenwhether phytoestrogens might stimulate estrogen receptorsand promote cancer growth. However, research suggests thatphytoestrogens may offer protective benefits against breastcancer.³'¹⁸Isoflavones, particularly genistein, have been shown to inhibitthe growth of estrogen-dependent breast cancer cells.Phytoestrogens also possess antioxidant and anti-inflammatory properties that help protect cells from DNAdamage and prevent chronic inflammation, which is essentialin cancer development¹². A cohort study in Asia found thatwomen who consumed higher levels of phytoestrogens,particularly from soy, had a significantly lower risk ofdeveloping breast cancer. ³'¹⁸14Research HighlightsObservational studies in the U.S. and China, summarized inmeta-analyses published in 2013 and 2019, further confirmedthese findings, showing protective effects in ER-positive andER-negative patients. This suggests that phytoestrogens mayoffer protective effects by modulating estrogen receptoractivity and reducing the impact of environmental estrogens.¹⁵Several major health organizations, including the AmericanCancer Society, the American Institute for Cancer Research,and the World Cancer Research Fund International, haveconcluded that women diagnosed with breast cancer cansafely consume soy.⁷⁻¹⁰The European Food Safety Authority (EFSA) concluded in2015 that isoflavone supplements do not affect breast tissue inpostmenopausal women. Beginning in 1999, clinical trialsconsistently showed that neither soy nor isoflavoneconsumption affected markers of breast cancer risk, includingmammographic density and in vivo breast cell proliferation.¹⁸Research supports the idea that phytoestrogens have a saferprofile than synthetic hormone replacement therapies incancer prevention.WOMEN'S HEALTH

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15NATUROPATHIC DOCTOR NEWS & REVIEWPhytoestrogens and Uterine CancerSoy isoflavones at doses above 20 mg/day have been shownto increase endometrial thickness through endometrial cellproliferation. However, there is no compelling evidence tosuggest that these effects lead to an increased risk ofendometrial cancer. This contrasts with hormonalreplacement therapies, which are known to have differingeffects on breast and uterine cancers.²One possible explanation for this difference is that theuterus, ovaries, and vagina are rich in estrogen receptor beta(ERβ) subtypes, to which isoflavones have a greater affinitythan estrogen receptor alpha (ERα). ERβ is involved in celldifferentiation, which may counteract the cell proliferationinduced by ERα. Studies in postmenopausal women suggestthat isoflavones may have a vaginal effect, while noapparent endometrial effects have been demonstrateddespite numerous trials.²Phytoestrogens have been suggested as hormonal substitutesor complementary in breast cancer treatments.¹⁹ Researchindicates that GPER1 may be involved in dual effects ofphytoestrogens, where they may act protectively in sometissues while promoting cancer growth in others. Thisunderscores the complexity of phytoestrogens' interactionwith estrogen receptors and the need for further study intotheir role in breast cancer prevention and treatment.¹¹ In gynecological cancers, selective estrogen receptormodulators (SERMs) and Aromatase Inhibitors (AIs) controlhigh estrogen hormone production. However, the SERM-based endocrine therapy using Tamoxifen has been shown toresult in tumor resistance to the drug and relapse into thedisease. Phytoestrogens are an exciting area of research incancer as they act as natural SERMs. ¹⁹'²¹New research found that treatment with estrogens elicits anti-cancer effects in ~30% of patients with advanced endocrine-resistant estrogen receptor alpha (ER)-positive breastcancer.²¹ Phytoestrogens offer a new territory of nutritionalpotential with anti-proliferative benefits that may serve ashormonal substitutes or complement conventional breastcancer care.¹² JAN 2025 - VOLUME 20 | ISSUE NO. 01

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Phytoestrogens: A Natural Ally for Women’sHealthPhytoestrogens, such as those found in soy, offer a natural,low-risk approach to supporting hormone balance andwomen’s health. These plant compounds can alleviatemenopausal symptoms, lower the risk of estrogen-sensitivecancers, and provide antioxidant and anti-inflammatorybenefits, making them a valuable alternative or complementto synthetic hormone therapies.Their potential to regulate estrogen levels and reduce therisks of hormone-related conditions—including menstrualirregularities, Polycystic Ovarian Syndrome (PCOS),Menopause, osteoporosis, and cancer risk—highlights theirrole in women’s health throughout life. Phytoestrogen-richfoods like soy influence hormone activity and contributeessential nutrients and bioactive compounds that promoteheart, bone, and brain health.Considerations for the safety and effectiveness of soy andother phytoestrogens include quality (non-GMO, organic),preparation, nutrigenomics/ nutrigenetics, microbiome, andindividual factors. Moderation and personalization are key—making these foods a cornerstone of a holistic,Naturopathic approach to hormone balance and wellness.In answer to the question, "Is soy good for me?" the bestresponse remains: “It depends.” But when thoughtfullyincorporated into a balanced diet, soy and phytoestrogensare a safe and beneficial ally, especially for womennavigating hormonal changes or seeking preventive andcomplementary care.Dr. Artemis Morris is the founder andmedical director of Artemis Wellness Centerin Milford, CT, an integrative familypractice that focuses on women’s health andwellbeing, chronic diseases, holistic breasthealth and transformative healing throughpersonalized care. Artemis was the academicdirector of the Master's in IntegrativeHealth at The Graduate Institute, professorof functional nutrition at the University ofBridgeport, and co-author of The Anti-inflammatory Diet for Dummies. She is aNaturopathic Physician, LicensedAcupuncturist, educator, author,international public speaker, researcher,local TV personality and Mediterraneannutrition specialist with over 20 years ofclinical experience.1. Rolands MR, Hackl LS, Bochud M, Le KA. Protein adequacy, plant proteinproportion, and main plant protein sources consumed across vegan, vegetarian,pescovegetarian, and semivegetarian diets: A systematic review. J Nutr. 2024.doi:10.1016/j.tjnut.2024.07.033.2. Laveriano-Santos, E. P., Luque-Corredera, C., Trius-Soler, M., Lozano-Castellón,J., Dominguez-López, I., Castro-Barquero, S., Pérez, M. (2024). Enterolignans: fromnatural origins to cardiometabolic significance, including chemistry, dietary sources,bioavailability, and activity. Critical Reviews in Food Science and Nutrition, 1–21.https://doi.org/10.1080/10408398.2024.2371939 3. Wang X, Ha D, Yoshitake R, Chan YS, Sadava D, Chen S. Exploring thebiological activity and mechanism of xenoestrogens and phytoestrogens in cancers:Emerging methods and concepts. Int J Mol Sci. 2021;22:8798.doi:10.3390/ijms22168798.4. Chen P, Li B, Ou-Yang L. Role of estrogen receptors in health and disease. FrontEndocrinol. 2022;13:839005. doi:10.3389/fendo.2022.839005. 5. Bacciottini L, Falchetti A, Pampaloni B, Bartolini E, Carossino AM, Brandi ML.Phytoestrogens: Food or drug? Clin Cases Miner Bone Metab. 2007;4(2):123-130.6. Palacios OM, Cortes HN, Jenks BH, Maki KC. Naturally occurring hormones infoods and potential health effects. Toxicol Res Appl. 2020;4.doi:10.1177/2397847320936281. 7. Mauvais-Jarvis F, Lindsey SH. Metabolic benefits afforded by estradiol andtestosterone in both sexes: Clinical considerations. J Clin Invest.2024;134(17):e180073. doi:10.1172/JCI180073. 8. Huang S, Qi B, Yang L, et al. Phytoestrogens, novel dietary supplements for breastcancer. Biomed Pharmacother. 2023;160:114341. doi:10.1016/j.biopha.2023.114341. 9. Jeitler M, Ortiz M, Brinkhaus B, et al. Use and acceptance of traditional,complementary and integrative medicine in Germany—An online representativecross-sectional study. BMC Complement Med Ther. 2021;21(1):69.doi:10.1186/s12906-021-03493-7. 10. Vaquero MP, Alvarez C, Barbosa B, and López-Hernández F. Estrogenicphytoestrogens and prevention of osteoporosis. Nutrients. 2022;14(9):1771.doi:10.3390/nu14091771. 11. Tighe S, Weiner S, Lee E. Phytoestrogen intake and breast cancer: Evidence andmechanism. J Natl Cancer Inst. 2023;115(4):381-389. 12. Smith MR, Bush I, Bhattacharyya S, et al. ERβ modulates hormonal resistance inbreast cancer cells. Cancer Res. 2022;82(9):2002-2013. 13. Thompson EA, Xu L, Revenson T. Estrogen receptors, breast cancer, and healthoutcomes: A molecular approach. Mol Endocrinol. 2021;35(6):576-589. 14. Kwon YJ, Lee J, Han J, et al. Phytoestrogens as modulators of the PI3K/AKTpathway. J Cancer Prev. 2023;28(1):16-23. 15. Chan T, Chou H, Wang C, et al. Soy isoflavones, tamoxifen, and breast cancerrecurrence: A meta-analysis. J Cancer Res Clin Oncol. 2022;148(8):1989-1997. 16. Canivenc-Lavier MC, Bennetau-Pelissero C. Phytoestrogens and health effects.Nutrients. 2023;15(2):317. doi:10.3390/nu150203.17. Hendrawati TY, Audini K, Ismiyati I, et al. Effects and characterization ofdifferent soybean varieties in yield and organoleptic properties of tofu. Results Eng.2021;11:100238. doi:10.1016/j.rineng.2021.100238.18. Messina M, Duncan A, Messina V, Lynch H, Kiel J and Erdman JW Jr (2022)The health effects of soy: A reference guide for health professionals. Front. Nutr.9:970364. doi: 10.3389/fnut.2022.97036419. Lecomte S, Demay F, Ferrière F, Pakdel F. Phytochemicals targeting estrogenreceptors: Beneficial rather than adverse effects? Int J Mol Sci. 2017;18(7):1381.doi:10.3390/ijms1807138120. Traphagen NA, Schwartz GN, Tau S, et al. Estrogen Therapy Induces Receptor-Dependent DNA Damage Enhanced by PARP Inhibition in ER+ Breast Cancer. ClinCancer Res. 2023;29(18):3717-3728. doi:10.1158/1078-0432.CCR-23-048821. Mukherjee AG, Wanjari UR, Nagarajan D, et al. Letrozole: Pharmacology,toxicity and potential therapeutic effects. Life Sci. 2022;310:121074.doi:10.1016/j.lfs.2022.121074REFERENCES16WOMEN'S HEALTH

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Non-Modifiable Risk FactorsHereditary Breast Cancer MutationsCertain genetic mutations significantly increase breastcancer risk.2 These include BRCA1, BRCA2, PALB2,CHEK2, and ATM, among others.2 Unfortunately, onlyabout 10% of women with hereditary cancer mutationshave been identified, highlighting a critical gap in geneticscreening.² Expanding access to multigene cancer panels isessential for identifying women at high genetic risk andimproving early detection efforts.Age and EthnicityAdvancing age is a well-established risk factor for breastcancer.³ However, incidence rates are rising amongyounger women, with disparities across ethnic groups.Non-Hispanic white women have the highest breast cancerincidence overall, but non-Hispanic Black womenexperience the highest mortality rates.⁴ Additionally, Blackwomen are more likely to develop aggressive triple-negativebreast cancer and have higher incidence rates before age40.⁴ Given that screening often begins at age 40 or later,these disparities underscore the need for earlier and moretailored screening protocols for at-risk populations.Reproductive FactorsReproductive factors such as early menarche (before age12) and late menopause (after age 55) are associated withincreased breast cancer risk5. Early menarche, inparticular, has become more common, with the averageonset age decreasing from 17 to 12 years since the mid-19thcentury.³'¹² Factors such as childhood obesity, exposure toendocrine disruptors, and psychological stress are likelycontributing to this trend.⁶'⁷ Helping young womenmaintain a healthy body weight through a whole foods diethigh in plant protein and fiber, as well as physical activity,are ways in which clinicians can empower women as earlyas in childhood to lower their risk of future breast cancer.⁸ Childbearing also influences breast cancer risk. Whileparity offers long-term protection if the first full-termpregnancy occurs before age 35, the risk of breast cancertemporarily increases in the years following childbirth.⁹This is known as pregnancy-associated breast cancer and islikely due to hormonal and inflammatory changes duringbreast remodeling to its pre-pregnant state.⁹’¹⁰Reproductive factors in breast cancer occurrence areessential, as is present society. Women are undergoingmenarche earlier, going through menopause later, bearingfewer children, and beginning their families later thanever, all likely factors contributing to the increasedincidence of breast cancer worldwide. Breast DensityBreast density, categorized by the BIRADS scoringsystem, plays a critical role in stratifying women’s risk ofbreast cancer.11 Dense breast tissue, classified as aBIRADS C or D, is found in 50% of women.¹¹ Densebreast tissue poses two significant concerns. Denserbreast tissue is a known risk for breast cancer, with aBIRADS D increasing the risk of breast cancer bytwofold.¹² Density also impacts mammographicsensitivity, with mammograms being less sensitive inidentifying abnormalities in denser breast tissue.¹¹'¹²Breast density highlights the need for tailored breastscreening. Mammography remains the gold standard forreducing breast cancer mortality, performing well inwomen with fatty breast tissue but less effectively inwomen with dense tissue.¹³ Individualized approaches,such as breast tomosynthesis, contrast-enhancedmammograms, or MRIs, will benefit women less suited tomammographic screening alone.¹³Some women seek breast thermography for its non-invasive nature, avoiding compression and radiation.¹⁴Unfortunately, it lacks the specificity and sensitivityrequired for effective screening and is not endorsed byany significant breast screening authority.¹⁴'¹⁵ It is up toclinicians to educate women on its limitations and guidethem towards more evidence-based breast screeningoptions. Breast Biopsies Previous breast biopsy incurs another risk for breastcancer.¹⁶ High-risk breast biopsies of locular cellcarcinoma in situ impose a 30% lifetime risk ofdeveloping breast cancer and atypical hyperplasia of 20%lifetime risk.¹⁶A thorough history asking patients ofprevious breast biopsies and ideally getting the pathologyreports of these biopsies is imperative in supportingwomen's breast health advocacy. 18WOMEN'S HEALTH

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Modifiable Risk FactorsRisk RatioNon-Modifiable Risk FactorsRisk RatioSmoking²⁴1.2Breast DensityBIRADS C:1.2BIRADS D: 2.11Obesity⁵1.5LCIS/DCIS115-8Alcohol¹²1.2-1.7BRCA 1/BRAC ²¹¹10Processed Diet¹1.2Nulliparity⁵1.2MHT (E+P)²²1.2Early Menarche⁵2.1Late Menopause⁵1.3Family History BC¹¹1.519NATUROPATHIC DOCTOR NEWS & REVIEWModifiable Risk FactorsNutritionApproximately one-third of breast cancers are linked tomodifiable lifestyle factors, making prevention through dietand behavior crucial.¹⁷ There are roughly 350,000 newdiagnoses of breast cancer annually in North America.1 It istherefore believed that over 100,000 breast cancers could beprevented through lowering modifiable risk factors.Unfortunately, many women are unaware of modifiable riskfactors.¹⁷ Diets rich in plant-based proteins and fiber,alongside reduced consumption of red and processed meats,have been shown to lower breast cancer risk.¹⁸ Fiber, inparticular, helps reduce intestinal estrogen reabsorption,moderates glucose release, and decreases inflammation.¹⁸Alcohol consumption is the leading modifiable risk factorfor premenopausal breast cancer, contributing to anestimated 13% of cases.¹² Risk increases with higher intake,making moderation a key prevention strategy. Womenshould be advised to limit consumption to no more than twostandard drinks per week.¹²Weight ManagementExcess body weight, particularly after menopause, poses asignificant risk for breast cancer.5 Weight gain duringmenopause is often accompanied by increased visceral fat,which promotes inflammation, insulin resistance, andelevated circulating estrogens—all of which are potentialdrivers of tumorigenesis in the breast.⁵’²⁰ Helping womenbe proactive in maintaining their body compositionthrough mindful whole foods, eating, and sufficientexercise are important strategies for women to lower theirbreast cancer risk.⁵StressIn our generation, there is what can be considered a silentpandemic of stress impacting women. Through the never-ending stressors ranging from work, parenting, finances,wars, and natural disasters, which are the latter more thanever before are available through constant access to socialmedia, all of these factors are leading to a rise in chronicstress which appears to influence women more so thanmen.²¹ Stress through its activation of the hypothalamic-pituitary-adrenal axis and the sympathetic nervous systemcan promote tumorigenesis, inflammation, andimmunosuppression.²² Addressing an individual's stresswill inevitably improve health through a variety ofdifferent ways, including lowering the risk of cancer,including breast cancer.²² JAN 2025 - VOLUME 20 | ISSUE NO. 01

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Menopausal Hormone Therapy (MHT) MHT using a combination of both estrogen andprogestogens is linked to an increased risk of breast cancer.²³This risk appears predominantly mediated throughformulations containing synthetic progestins such asmedroxyprogesterone acetate.²²’²³ When prescribing MHTconsidering breast cancer risk, micronized progesterone islikely the safest progestogen to prescribe.²³ It is advisable toavoid progestogens in situations where they are notnecessary, such as for women who have had a hysterectomyor have a levonorgestrel IUD.Individual Risk Assessment and ScreeningRisk Assessment ToolsValidated tools such as the Tyrer-Cuzick model (version 8)allow clinicians to estimate a woman’s 10-year and lifetimebreast cancer risk.¹² These tools integrate personal andfamily history, genetic factors, and reproductive data toestimate individualized risk.¹² This personalized approachcan guide prevention and screening strategies beyond age-based protocols.Screening for High-Risk WomenWomen with a lifetime risk more significant than 20%should consider screening beyond standard mammography.¹Options include breast ultrasound, contrast-enhancedmammography, and breast MRI.¹³ Education on thesealternatives is vital for empowering women to advocate forappropriate screening based on their unique risk profiles.Moving Toward Risk-Based ScreeningCurrently, age-based breast screening fails to address thevariability in individual risk. By integrating tools for riskassessment, personalized prevention strategies, andadvanced screening methods, clinicians can improve earlydetection and reduce mortality. While not all breast cancerscan be prevented, it is estimated that one-third could beavoided through lifestyle modifications.¹⁷ For those whocannot, identifying and addressing individual risk factorswill lead to earlier diagnoses and better outcomes.Transitioning to risk-based screening represents a criticalstep forward in breast cancer prevention and care. Througheducation and empowerment, we can support women inunderstanding and managing their risk, ultimately reducingthe burden of breast cancer in our communities.Dr. Erin Rurak is a licensed NaturopathicPhysician who graduated from the BoucherInstitute of Naturopathic Medicine in 2014.She holds a Bachelor of Science inMicrobiology and Immunology from theUniversity of British Columbia and is acertified clinician through the MenopauseSociety. With a focus on cancer andmenopause-related hormonal changes, Dr.Rurak specializes in supporting womennavigating cancer and menopausesimultaneously. Alongside managing a busyclinical practice, she speaks at conferencesand writes to advance the naturopathicprofession and educate fellow clinicians.Farkas AH, Nattinger AB. Breast cancer screening and prevention. Ann Intern Med.2023;176(13):ITC361-ITC176. doi:10.7326/AITC202311210. Epub 2023 Nov 14. PMID:37956433.1.DeFrancesco MS, Waldman RN, Pearlstone MM, et al. Hereditary cancer riskassessment and genetic testing in the community-practice setting. Obstet Gynecol.2018;132(5):1121-1128. doi:10.1097/AOG.0000000000002916. PMID: 30303907.2. Cuthrell KM, Tzenios N. Breast cancer: updated and deep insights. Int Res J Oncol.2023;6(1):104-118.3.American Cancer Society. Breast cancer facts and figures 2019-2020. Published online.Accessed at: https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/breast-cancer-facts-and-figures-2019-2020.pdf.4.Collaborative Group on Hormonal Factors in Breast Cancer. Menarche, menopause,and breast cancer risk: individual participant meta-analysis, including 118,964 womenwith breast cancer from 117 epidemiological studies. Lancet Oncol. 2012;13(11):1141-1151. doi:10.1016/S1470-2045(12)70425-4. Epub 2012 Oct 17. PMID: 23084593.5.Rochester JR. Bisphenol A and human health: a review of the literature. ReprodToxicol. 2013;42:132-155. doi:10.1016/j.reprotox.2013.08.008. Epub 2013 Aug 30.PMID: 23994667.6.Zhang L, Zhang D, Sun Y. Adverse childhood experiences and early pubertal timingamong girls: a meta-analysis. Int J Environ Res Public Health. 2019;16(16):2887.doi:10.3390/ijerph16162887. PMID: 31412531; PMCID: PMC6720214.7.Kaplowitz PB. Link between body fat and the timing of puberty. Pediatrics.2008;121(Suppl 3):S208-S217. doi:10.1542/peds.2007-1813F. PMID: 18245513.8.Nichols HB, Schoemaker MJ, Cai J, et al. Breast cancer risk after recent childbirth: apooled analysis of 15 prospective studies. Ann Intern Med. 2019;170(1):22-30.doi:10.7326/M18-1323. Epub 2018 Dec 11. PMID: 30534999; PMCID: PMC6760671.9.Schedin P. Pregnancy-associated breast cancer and metastasis. Nat Rev Cancer.2006;6(4):281-291. doi:10.1038/nrc1839. PMID: 16557280.10.Bodewes FTH, van Asselt AA, Dorris MD, Greuter MIW, de Bock GH.Mammographic breast density and the risk of breast cancer: a systematic review andmeta-analysis. Breast. 2022;66:62-68. doi:10.1016/j.breast.2022.09.007. Epub 2022 Sep26. PMID: 36183671; PMCID: PMC9530665.11.Brit KL, Cuzick J, Phillips KA. Key steps for effective breast cancer prevention. NatRev Cancer. 2020;20(8):417-436. doi:10.1038/s41568-020-0266-0. Epub 2020 Jun 11.PMID: 32528185.12. Kuhl C, Weigel S, Schrading S, et al. Prospective multicenter cohort study to refinemanagement recommendations for women at elevated familial risk of breast cancer: theEVA trial. J Clin Oncol. 2010;28(9):1450-1457. doi:10.1200/JCO.2009.23.083913.Kennedy DA, Lee T, Seely D. A comparative review of thermography as a breast cancerscreening technique. Integr Cancer Ther. 2009;8(1):9-16. doi:10.1177/153473540832617114. Mainiero MB, Lourenco A, Mahoney MC, et al. ACR Appropriateness Criteria BreastCancer Screening. J Am Coll Radiol. 2016;13(11S):R45-R49.doi:10.1016/j.jacr.2016.09.02115.Tice JA, Miglioretti DL, Li CS, et al. Breast density and benign breast disease: riskassessment to identify women at high risk of breast cancer. J Clin Oncol.2015;33(28):3137-3143. doi:10.1200/JCO.2015.60.886916.Clinton SK, Giovannucci EL, Hursting SD. The World Cancer ResearchFund/American Institute for Cancer Research Third Expert Report on Diet, Nutrition,Physical Activity, and Cancer: impact and future directions. J Nutr. 2020;150(4):663-671. doi:10.1093/jn/nxz26817.Rohrmann S, Overvad K, Bueno-de-Mesquita HB, et al. Meat consumption andmortality—results from the European Prospective Investigation into Cancer andNutrition. BMC Med. 2013;11:63. doi:10.1186/1741-7015-11-6318.Rose DP, Goldman M, Connolly JM, Strong LE. High-fiber diet reduces serumestrogen concentrations in premenopausal women. Am J Clin Nutr. 1991;54(3):520-525.doi:10.1093/ajcn/54.3.52019.All References Available on NDNR.comREFERENCES20WOMEN'S HEALTH

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It is crucial to address the root cause of migraines, and inmany cases, balancing hormones is an essential step inachieving true healing. Two significant patient cases Ihave seen stand out in my mind. The first case we’lldiscuss involved one of my earliest patients, who visitedme in 2004. To this day, she remains one of my strongestsupporters and a key factor in my ability to helphundreds of migraine sufferers. This patient only wantedminimal intervention and no testing. So, this case is apleasant reminder that basic naturopathic medicine cansometimes work wonders. The second patient is morecurrent, but like in the initial case, she also didn’t want touse bioidentical hormone replacement therapy. Since westill cannot use this therapy in most states; I like toeducate the public on a more natural means of healing. Case Studies: Real-Life Success StoriesCase One: Jennifer’s Journey to Migraine ReliefFirst VisitFirst Visit: “Jennifer,” a 45-year-old female, came to see me withsevere debilitating migraines when she was 44 years old.The pain she described was a 10 out of 10 sharp, stabbingpain over her entire head that lasted for three days,followed by relief for a few weeks. She would lie on thefloor, often crying in debilitating pain. The migraineswere worse after drinking red wine, crying (which shecouldn’t stop), and taking “too many vitamins,” aprescription multivitamin, which had also given her arash. She hesitated to try any remedy, including naturaltherapies and opposed HRT because of her mother’sexperience with melasma while using it. The patient had asensitive stomach with many GI complaints, includingbloating, constipation, and irritation from foods. Jennifer felt her migraines were hormonal. Prioritizingpatient perspectives is crucial; their intimate knowledgeoften reveals the underlying issue through intuition orreason. With no menses for over a year, the patient’smedical history included fibroids, polyps, and ovariancysts. Despite visiting multiple gynecologists in the pastyear, none agreed to test her hormones and dismissed anyhormonal connection to her migraines. The patient had tried “many medications,” includingTopamax, Imitrex, and Inderal, along with IV medication(Reglan, etc.), during several hospitalizations, and per thepatient, nothing medical was helping at all. She had gone tothe chiropractor regularly, had gotten massages, practicedyoga, and changed her diet. This helped slightly, but notnearly enough. She came to the office with her extendedfamily, who also had no hope since nothing had helped thusfar, and they were anxious about vitamins since she hadissues with the prescription multiple. Jennifer was in excellent shape, with an optimal BMI.Before the migraines, she had little to no health complaints.She actively took part in local community affairs andowned a nearby gym. I strongly desired to assist this patientbecause she advocated for health and wellness in my town.Since Jennifer was a patient in an unlicensed state, Ideferred her physical exams and diagnosis to her primarycare doctor and gynecologist. The only diagnosis she hadreceived was menopause and migraines. Based on herextensive history and the onset of migraines withmenopause, I concluded her migraines were most likelybecause of hormonal imbalances.The patient and her extended family declined furthertesting, and she was hesitant to take anything.22WOMEN'S HEALTH

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To address her hormonal imbalances, probableinflammation, and nutritional deficiencies, I convinced herto take the following: Hormonal Support:Green Tea 1 cup before breakfast and 1 cup beforelunch to modulate estrogen metabolismFlax seed oil taken with each meal to normalizeestrogen levels Black currant seed oil to balance estrogen levels Inflammatory Support:Fish Oil to decrease inflammation and help withmigraines Nutritional Support:Magnesium citrate before bed to help with constipationand migraines before bed dosed to bowel tolerance Dietary Changes:Avoid processed foods, seed oil, and gluten to bringdown inflammationIncrease vegetable intake to bring down inflammationand increase her micronutrient levelsSecond Visit (3 weeks later):Jennifer was feeling slightly better. Her headaches were lesssevere, with 8/10 pain, shorter duration lasting only twodays. She also was happy that she hadn’t reacted to thesupplements I had given her. The patient still refusedfurther testing. Since she felt the headaches had started withthe cessation of her menses and along with the positivefeedback from her taking the flax and black current seedoil, I further addressed her hormones with supplements andlifestyle changes. Hormone Support:Calcium D-Glucarate helps with estrogen metabolism Dietary Changes:Avoid dairy to help with her GI symptoms and to avoidxenoestrogensEat only organic red meat to avoid estrogenic hormoneinjected beef Lifestyle Modifications:Daily relaxation to modulate her cortisol levels andincrease her progesterone levelsAvoid xenoestrogens by staying away from plastics andto stop touching receipts23I also increase her magnesium and the fish, flax and blackcurrant seed oils she was currently taking.Third Visit (1 month later):The patient is thrilled. She is doing so much better.Jennifer only had one migraine that was short andtolerable. I gave her a natural anti-inflammatorycontaining fever few, rosemary and curcumin to takeacutely if she had any headaches in the future. At the sametime, we continued to work on healing her body. Thepatient, delighted, readily agreed to future testing andrequests. My patient has been looking younger for almosttwenty years now, and she “feels better now at 60 than shedid at 40.”I always love reviewing this case because it’s such apleasant reminder that simple, natural therapeutics canreally transform a person’s life. Case Two: Lorna’s Path to RecoveryFirst Visit: “Lorna,” a 54-year-old female, came to see me with ahistory of migraines in her 20s that were manageable andbecame severe in her 30s. When the patient was in her 40s,she managed the migraines with a whole food-focused dietand exercise. Then, the migraines started again in her 50sand became much worse. Migraines are severe three tofour times a month, lasting one day. They are worse withweather changes, stress, and smells. The pain is severe overher entire head, 10/10 throbbing pain, noises bother her,mild nausea, and lights make it worse. The patient feelsbetter with Nurtec 75mg disintegrating tablet and rest. The patient has a history of menopause for one monthwith many severe symptoms for about one year induration ranging from: hot flashes, night sweats, vaginaldryness, insomnia with waking three times a night, jointpain, no libido, weight gain, low blood pressure, dry skin,dry eyes, anxiety, and trouble concentrating. A gynecologist in Lorna’s 20s told her that her migraineswere hormone-related, along with her currentgynecologist, but he refused to order blood work or runany other tests. JAN 2025 - VOLUME 20 | ISSUE NO. 01NATUROPATHIC DOCTOR NEWS & REVIEW

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Final Visit (2 months later)The patient feels like her old self again. She is exercising,sleeping better than ever, feels amazing and is overall sohappy with everything. Lorna is headache-free, calm, andback to her pre-menopausal self. I always enjoy determining the underlying hormonal issuesthat contribute to most of my patients who experiencemigraines and treating them accordingly. I’ve observedhundreds of similar cases over twenty years; these aremerely two examples. I find it hardest to convince patientsthat their migraines can heal, sometimes even with minimalintervention. Third Visit (1.5 months later)The patient feels healthier than she has felt for years. Allher menopausal symptoms are almost totally better,including the migraines. She is still having occasionalmigraines, some anxiety, and slight insomnia. However,everything listed above, from vaginal dryness to bloating,etc. is all completely better. I switched her magnesium to abetter complex with dimagnesium malate, citrate, albionminerals, and lysinate glycinate chelate before bed and totake as needed if she felt a headache coming on. I alsoadded in a proprietary blend of inositol, l-theanine,magnesium l-threonate, sunflower lecithin, and glycine totake before dinner and bed. 26Peikert A, Wilimzig C, Köhne-Volland R. Prophylaxis of migraine with oralmagnesium: results from a prospective, multi-center, placebo-controlled anddouble-blind randomized study. Cephalalgia 1996; 16:257.1.Wider B, Pittler MH, Ernst E. Feverfew for preventing migraine. CochraneDatabase Syst Rev 2015; 4:CD002286.2.Sun-Edelstein C, Mauskop A. Foods and supplements in the management ofmigraine headaches. Clin J Pain. 2009 Jun;25(5):446-52. doi:10.1097/AJP.0b013e31819a6f65. PMID: 19454881.3.Kargozar R, Azizi H, Salari R. A review of effective herbal medicines incontrolling menopausal symptoms. Electron Physician. 2017 Nov25;9(11):5826-5833. doi: 10.19082/5826. PMID: 29403626; PMCID:PMC5783135.4.Abdi F, Mobedi H, Roozbeh N. Hops for Menopausal VasomotorSymptoms: Mechanisms of Action. J Menopausal Med. 2016 Aug;22(2):62-4. doi: 10.6118/jmm.2016.22.2.62. Epub 2016 Aug 30. PMID: 27617238;PMCID: PMC5016504.5.Fuhrman BJ, Pfeiffer RM, Wu AH, Xu X, Keefer LK, Veenstra TD, ZieglerRG. Green tea intake is associated with urinary estrogen profiles inJapanese-American women. Nutr J. 2013 Feb 15;12:25. doi: 10.1186/1475-2891-12-25. PMID: 23413779; PMCID: PMC3584908.6.Nowak W, Jeziorek M. The Role of Flaxseed in Improving Human Health.Healthcare (Basel). 2023 Jan 30;11(3):395. doi: 10.3390/healthcare11030395.PMID: 36766971; PMCID: PMC9914786.7.Nanashima N, Horie K, Maeda H. Phytoestrogenic Activity of BlackcurrantAnthocyanins Is Partially Mediated through Estrogen Receptor Beta.Molecules. 2017 Dec 29;23(1):74. doi: 10.3390/molecules23010074. PMID:29286333; PMCID: PMC6017224.8.Ramsden CE, Zamora D, Faurot KR, et al. Dietary alteration of n-3 and n-6 fatty acids for headache reduction in adults with migraine: randomizedcontrolled trial BMJ. 2021;374:n1448.9.von Luckner A, Riederer F. Magnesium in Migraine Prophylaxis-Is Therean Evidence-Based Rationale? A Systematic Review. Headache. 2018Feb;58(2):199-209. doi: 10.1111/head.13217. Epub 2017 Nov 13. PMID:29131326.10.REFERENCESDr. Jilian Finker, Naturopathic Doctor has a privatepractice in Bellmore, New York. She specializes inwowomen's health and is an expert in naturalmedicine. Dr. Finker has been selected as the bestAlternative Doctor on Long Island for 2011, 2012,2013, 2022, and 2024. She has been on varioustelevision programs, radio shows, and she is afrequent lecturer nationwide. She was the technicaleditor for Boosting your Immunity for Dummies,Adrenal Fatigue for Dummies, and is in the processof editing other health books. Her work has beenhighlighted in First for Women's magazine severaltimes, along with other major journals andpublications. It's about Wellness, Naturally her latestpublication is available on Amazon.WOMEN'S HEALTH

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A report noted an increase of 300% or more in theprescription rates of psychotropics, hypnotics, and analepticsamong women between 50 and 55 years of age.² This increasein medication use among perimenopausal women is linked tothe influence of progesterone and its metabolites onneurological and psychological functions. Duringperimenopause, women undergo significant hormonalchanges, significantly declining progesterone levels.Progesterone and its metabolites interact with the centralnervous system, notably through GABA receptors (as notedabove). These interactions can affect mood, anxiety, andneurological conditions, resulting in a heightened need formedications to address these symptoms.² The perimenopauseduration eventually passes into menopause, culminating intopostmenopause, which is associated with lower ALLO andprogesterone levels compared to premenopausal women.⁵ Integrative Treatment Approaches A holistic approach to managing anxiety in women includesbioidentical progesterone, specific nutraceuticals, botanicalmedicines, and key mind-body techniques. This sectionreviews evidence-based integrative treatments and theirmechanisms of action, focusing on studies withpredominantly female subjects and highlighting only anxietyoutcomes. Adverse effects will not be discussed in detail, asthey were generally insignificant in the cited studies.Bioidentical Transdermal Progesterone Cream(BTPC)Progesterone is converted into ALLO via a two-stepenzymatic process in the brain.⁶ Therefore, BTPC plays anessential role in managing anxiety in women. BTPC'smetabolite, ALLO, a potent positive allosteric modulator ofthe GABA-A receptor,1 helps regulate emotion, promoteneurogenesis, and modulate the hypothalamic-pituitary-adrenal (HPA) axis.⁷Even though high doses of progesterone exhibit anxiolyticand sedative effects,⁸ physiologic doses of progesteronedelivered via BTPC may serve as an effective treatment foranxiety, especially in premenopausal and postmenopausalwomen. When using BTPC among premenopausal females, itshould be taken at bedtime for 15 days each month at a doseof 20 mg/day on days 12 to 26 (i.e., day 1 being the onset ofmenses).9 In premenopausal females with longer cycles,taking BTPC for a longer duration on days 10 to 28 of themenstrual cycle is usually necessary. Sometimes, the dosemust be increased to 30 mg/day for more durable therapeuticeffects.⁹Hansloo and Epperson also discussed the roles that hormonalfluctuations have in the development and exacerbation ofanxiety disorders in women.¹ The hormonal changes thatinitiate puberty are linked to the etiology of anxiety disorders,and this period is also marked by increased psychosocialstress. Puberty represents a vulnerable developmental windowfor the occurrence of anxiety disorders, with higher ratesamong girls as they enter adolescence. Ovarian steroids andtheir metabolites are neuroactive, and hormonal changesduring the menstrual cycle, pregnancy, and menopausesignificantly impact anxiety levels. For instance, some 80% ofwomen experience at least one physical, mood, or anxietysymptom in the luteal phase, and 20% experiencepremenstrual symptoms. Women with anxiety disorders mayalso experience an exacerbation of their symptomspremenstrually. Additionally, 5% to 8% of women experiencepremenstrual dysphoric disorder (PMDD), which has asignificant anxiety symptom component. Is Progesterone Insufficiency, Deficiency, or Defectsto Blame?Progesterone and its metabolite, allopregnanolone (ALLO),can bind to the gamma-aminobutyric acid type A (GABA-A)receptor.² This binding enhances the receptor's sensitivity toGABA, increasing the influx of chloride ions into the neuron,which further hyperpolarizes the cell membrane anddiminishes neuronal excitability. Moreover, in the amygdala(i.e., a deep part of the brain that processes fearful andunpleasant stimuli), GABAergic neurotransmissionattenuates the production of unhelpful emotional andbehavioral responses, thereby lessening fear and anxiety.³Consequently, this mechanism contributes to the sedative,anticonvulsive, and anxiolytic effects of progesterone,effectively moderating excitation within the nervous system.²Altered interactions between ALLO and the GABA-Areceptor contribute to anxiety disorders.1 Broadly speaking,dysfunction in the synthesis of ALLO may further impairGABAergic function, thereby increasing the risk of allpsychiatric disorders.4 During the premenstrual luteal phase,if progesterone is low and the estradiol level is high, forexample, there can be an associated increase in smoking,alcohol consumption, and body dissatisfaction.⁴ Research hasshown an increase in anxiety symptom exacerbationpremenstrually and increases in anxiety that results fromstressful life experiences premenstrually.⁴ State and traitanxiety were associated with daily anxiety reports during theluteal phase.4 Additionally, the acoustic startle response,heightened among individuals with anxiety disorders, iselevated in the late luteal phase.⁴28WOMEN'S HEALTH

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JAN 2025 - VOLUME 20 | ISSUE NO. 0129The dose of BTPC for postmenopausal females is 20 mg/day(i.e., taken at bedtime) based on studies that have shownreductions in menopausal symptoms.⁹⁻¹² Postmenopausalpatients should take a rest day, so the application is 6 dayseach week, except on Sundays.⁹ The late physician Dr.Jonathan R. Lee, when discussing the therapeutic applicationof BTPC, noted that it results in more restful sleep, withpatients feeling more refreshed in the morning while helpingto modulate stress.⁹5-hydroxytryptophan (5-HTP)Like fear, worry is another salient construct implicated inGAD and other anxiety disorders, especially when reconcilinguncertainty becomes too tricky to manage emotionally.¹³Serotonin (5-HT) circuitry is widely implicated in GAD. Thepositive results from selective serotonergic reuptake inhibitors(SSRIs) upon GAD symptoms strongly suggest thatserotonin moderates worry and other symptoms. Evidencefrom functional brain imaging studies has shown thatmidbrain serotonin transporter (SERT) density is negativelycorrelated with symptom severity in GAD, suggesting thatlower SERT density is associated with more severe anxietysymptoms.¹⁴Given the importance of reducing worry in female patients, 5-HTP is worth considering due to its ability to enter thebloodstream, cross the blood-brain barrier, and increaseserotonin levels.¹⁵ An open-label pilot study involved 15 adultwomen with major depressive disorder who did not respondto SSRIs or serotonin-norepinephrine reuptake inhibitors(SNRIs).¹⁶ They took 200 mg/day of 5-HTP and five g/day ofcreatine monohydrate alongside their standard antidepressantdoses for 8 weeks. Results showed a significant reduction inmean Beck Anxiety Inventory (BAI) scores, from 22.7 ± 9.2to 9.3 ± 6.4 (p<0.00001), indicating over a 50% decrease inanxiety. The treatment was well-tolerated, with no seriousadverse events reported. A slow- or timed-release formulationof 5-HTP is recommended for optimal results, as it providesmore consistent elevation of brain extracellular 5-HT levels.¹⁷My clinical experience suggests a daily dosage of 200-800 mgof 5-HTP is effective in alleviating worry and anxietysymptoms.Proprietary Blend (PB) Containing Extracts of Magnoliaofficinalis and Phellodendron amurense The PB was studied in a pilot randomized controlled trial(RCT) involving healthy, overweight premenopausal women(ages 20-50) who reported increased eating in response tostress and elevated anxiety scores.18 Participants received 500mg of PB twice daily for 6 weeks. While PB did notsignificantly reduce long-standing anxiety or depression, theaverage decrease in the Spielberger STATE AnxietyQuestionnaire score was nearly double in the PB groupcompared to the placebo group. STATE Anxiety is atemporary emotional state marked by physiological arousaland feelings of apprehension, dread, and tension. InitialSTATE Anxiety levels were 32.5 ± 7.6 for PB and 29.4 ± 6.7for placebo. The average reductions were -14.3 ± 12.1 for PBand -7.6 ± 9.8 for placebo, with a significant differencefavoring PB (p=0.045).Another RCT examined the effects of the same PB on cortisollevels and mood in moderately stressed individuals, involving56 participants (35 men and 21 women).¹⁹ Subjects ingested500 mg/day of PB for 4 weeks. At the trial's end, the PB groupshowed a significant reduction in salivary cortisol levels(−18%) compared to placebo. Additionally, the PB groupreported lower overall stress (11%), tension (13%), depression(20%), anger (42%), fatigue (31%), and confusion (27%),along with higher vigor (18%) and global mood state (11%).These improvements were statistically significant (p<0.05),indicating a positive impact of PB on mood and well-being.The therapeutic effects of PB likely involve the modulation ofneurotransmitters and stress-related pathways, contributingto its anti-stress and anxiolytic properties. In my clinicalexperience with this PB, daily doses of 500 to 1000 mg arenecessary to achieve observable therapeutic effects.Saffron Extract as Monotherapy or in Conjunctionwith Rhodiola ExtractA pilot clinical trial investigated the efficacy of Crocin, themain active component of saffron extract, as an adjunctivetreatment for major depressive disorder (MDD).²⁰ Crocininfluences levels of key neurotransmitters in the brain,including dopamine, norepinephrine, and serotonin, whichare vital for mood regulation and mental well-being. It is alsoreported to have anticonvulsant, memory-enhancing, andsedative properties, contributing to its potential therapeuticeffects on central nervous system disorders.NATUROPATHIC DOCTOR NEWS & REVIEW

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30WOMEN'S HEALTHThe study involved 40 MDD patients aged 24 to 50 years(34 females and six males), with a mean age of 36.2years.20 The treatment group received 30 mg/day ofCrocin (15 mg twice daily) alongside an SSRI, while theplacebo group received placebo tablets with an SSRI. Thestudy lasted 4 weeks. Initial baseline scores for the BeckAnxiety Inventory (BAI) were shown in the figures, withthe Crocin group averaging 38 and the placebo groupaveraging 36. After the trial, the Crocin group showed asignificant improvement in BAI scores, with an averagedecrease of 12.7, compared to a decrease of 2.6 in theplacebo group (p<0.0001).An RCT evaluated the therapeutic efficacy of Saffron as atreatment for both anxiety and depression. The studygroup comprised 22 women and eight men, while thecontrol group included 20 women and ten men. Theaverage age of the study group was 42.8 years, and theaverage age of the control group was 43.6 years. The studygroup received a 50 mg Saffron capsule twice daily for 12weeks, while the control group received a matched placebocapsule. The study found a significant difference in anxietybetween the Saffron group and the placebo group at the12-week time point (p<0.001). The Saffron groupdemonstrated a statistically significant improvement inBAI scores compared to the placebo group. The differencein BAI scores at the endpoint (week 12) compared tobaseline was -8.65 ± 2.59 for the Saffron group and -5.46 ±2.82 for the placebo group. Unfortunately, baseline or pre-treatment scores were not provided in the study.In another study, participants were supplemented with afixed combination of Rhodiola and Saffron extracts in adietary supplement containing 154 mg of Rhodiola Extractand 15 mg of Saffron Extract per tablet.²² The mechanismof Saffron Extract was noted earlier when discussingCrocin. Rhodiola Extract helps the body adapt to stresswhile promoting resilience, and it also modulates the levelsof neurotransmitters such as 5-HT, dopamine, andnorepinephrine. The recommended dose of this supplementwas two tablets per day for 6 weeks. The study included 59patients screened and enrolled by 16 general practitionersbetween November 2016 and March 2017. The study hadthe most female participants, comprising 82.2% of thesafety population and 81.1% of the per-protocolpopulation. There was a significant decrease in HospitalAnxiety and Depression Scale (HADS) anxiety scores after6 weeks of supplementation with the combination ofherbal extracts. The reduction in anxiety scores was noted starting from 2weeks of supplementation and continued until the end of thestudy, indicating a decrease in anxiety symptoms andseverity among participants. The reduction in HADSanxiety scores was 31.3%, from 12.0±3.1 on Day 0 to8.0±3.2 on Day 42, with a mean difference of 3.9 ±3.3(p<0.0001). When using Saffron Extract as monotherapy orcombined with Rhodiola Extract, the recommended dailydose for Saffron Extract is 30 to 50 mg. The daily dose forRhodiola Extract should be 300 to 500 mg.Lavender (Silexin) ExtractA 6-week randomized controlled trial (RCT) compared theeffectiveness of Lavender Extract (Silexan) to Lorazepam.²³78 male and female patients participated, but the specificgender breakdown was not provided. The treatmentscompared were Silexan (80 mg), a lavender oil capsulepreparation, and Lorazepam (0.5 mg), a benzodiazepine.Both Silexan and Lorazepam target the GABA system,which is crucial for regulating anxiety and stress responsesin the brain. The Hamilton Anxiety Rating Scale (HAM-A)total score was 25±4 points for both groups at baseline. At 6weeks, HAM-A scores decreased by 11.3±6.7 points in theSilexan group and 11.6±6.6 points in the Lorazepam group,with all results being statistically significant (p=0.04). Theresponder rate, defined as a reduction of the HAM-A totalscore by at least 50%, was higher in the Silexan group(52.5%) than the Lorazepam group (40.5%). The remissionrate, defined as a HAM-A total score below 10 points, wasalso higher in the Silexan group (40%) versus the Lorazepamgroup (27%).A 10-week RCT compared the effectiveness of LavenderExtract (Silexan) to Paroxetine (i.e., an SSRI) in 523patients with GAD, comprising a much higher percentage offemale subjects.²⁴ Silexin was chosen since it regulatesneuronal excitability in the hippocampus, a key limbicstructure linked to emotions and stress, where abnormalitiesare associated with anxiety disorders. Baseline HAM-Ascores were 26.0±4.5 for Silexan (160 mg/day), 25.8±4.8 forSilexan (80 mg/day), 25.8±4.9 for Paroxetine (20 mg/day),and 25.1±4.7 for placebo. By the end of the study, HAM-Ascore reductions were -14.1±9.3 for Silexan (160 mg/day),-12.8±8.7 for Silexan (80 mg/day), -11.3±8.0 for Paroxetine(20 mg/day), and -9.5±9.0 for placebo, with all resultsachieving statistical significance (p<0.001). The resultsshowed convincing anxiolytic effects from 160 mg/day ofSilexin, comparable to Paroxetine. The results alsodemonstrated that Silexin can be terminated abruptly at theend of 10 weeks without any symptoms of withdrawal.

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31My clinical experience has shown that the only effectivedose of Lavender Extract for alleviating anxiety symptomsis 160 mg/day. However, I have used daily doses as high as640 mg with good clinical results with several patients. Maca (Lepidium peruvianum) ExtractA clinical trial (Trial II) on postmenopausal womenexamined the effects of Maca capsules (2000 mg daily) foreight months.²⁵ Results showed hormonal improvements,including decreased follicle-stimulating hormone (FSH),increased luteinizing hormone (LH), progesterone, andestradiol. Menopausal symptoms are significantly reduced,such as fatigue, muscle and joint aches, night sweats, sleepdisturbances, and decreased libido. Greene's MenopausalTest Score indicated a decrease in excessive alertness andsudden anxiety, with the latter change being indicative ofan improvement in state anxiety. While these findingssuggest Maca's potential to alleviate menopausal symptomsand anxiety, further research is necessary to confirm itsefficacy.A randomized, crossover trial was conducted on 16 healthypostmenopausal women aged 50-60 to assess the effects ofsix weeks of Maca supplementation on psychologicalsymptoms, sexual function, and hormone levels.²⁶Participants consumed either 3.5 grams of Maca powder ora placebo daily for six weeks, followed by a two-weekwashout period. The Maca powder, provided in individualsachets, was mixed with water or juice and taken oncedaily. This dosage was based on previous human studies.The study measured serum levels of estradiol, FSH, LH,and sex-hormone binding globulin but found no significantchanges between baseline, Maca treatment, and placebo.Using Greene's Menopausal Test Score, significantreductions were observed in psychological symptoms,including anxiety, depression, and sexual problems. Macasupplementation significantly reduced anxiety anddepression symptoms compared to baseline and placebo.Specifically, there was a 30.8% reduction in anxietysymptoms and a 28.9% reduction in depression symptoms.The anxiety subscale, which includes items like heartpalpitations, nervousness, sleep disturbances, and panicattacks, showed a significant improvement. All thesechanges were statistically significant (p-values<0.05). I typically recommend 2000 mg daily to achieve sufficienttherapeutic outcomes with MACA supplementation. Red Clover Extract (RCE) This was a 180-day RCT involving 109 postmenopausalwomen (average age 53.5 years).²⁷ Participants wererandomly assigned to receive either RCE or a placebo for 90days. Participants in Group A received two daily capsulescontaining 80 mg of RCE, while Group B received aplacebo. This treatment regimen lasted for 90 days, followedby a 7-day washout period, and then 90 more days of theopposite treatment. RCE is believed to work through theirestrogenic actions, antioxidant properties, and anti-inflammatory effects. The isoflavones in RCE can weaklymimic estrogen, potentially alleviating menopausalsymptoms. Before treatment, participants had elevatedlevels of anxiety and depression, as measured by the HADSand the Zung Self-Rating Depression Scale (SDS). After 90days of RCE treatment, participants experienced asignificant reduction in anxiety and depression symptoms.The HADS total score decreased from 16.89 to 3.91, theanxiety subscale score from 9.98 to 2.40, and the depressionsubscale score from 6.91 to 1.50. Similarly, the SDS scoredropped from 12.24 to 2.37. Overall, RCE treatmentresulted in significant reductions in anxiety and depressionsymptoms. The total HADS score decreased by 76.9%, witha 76% reduction in the anxiety subscale and a 78.3%reduction in the depression subscale. These findings suggestthat RCE may be an effective treatment for reducingmenopausal symptoms related to anxiety and depression.I commonly recommend 80 mg of RCE at bedtime toachieve therapeutic results among postmenopausal anxiouspatients. I often combine RCE with BTPC to achieve betterclinical outcomes. Mindful Self-Compassion (MSC)MSC is associated with positive psychological outcomes andreduced psychopathology.²⁸ Research indicates thatindividuals who practice self-compassion tend to experiencelower levels of depression, anxiety, and stress. Additionally,MSC is linked to positive psychological strengths likehappiness, emotional intelligence, optimism, wisdom,curiosity, and initiative and has been shown to protectagainst eating disorders and body dissatisfaction. Toenhance MSC, I often guide patients through its three corecomponents: self-kindness, common humanity, andmindfulness. Self-kindness involves treating oneself withempathy and understanding, much like a caring friend. JAN 2025 - VOLUME 20 | ISSUE NO. 01NATUROPATHIC DOCTOR NEWS & REVIEW

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REFERENCESAlthough I do not use EFT in my naturopathic mentalhealth practice, I provide patients with information on itand advise them to download the app The TappingSolution (https://www.thetappingsolution.com/). This appoffers free guided EFT sessions that can be used severaltimes daily to improve emotional regulation. Many patientsfind EFT to be a helpful tool for managing stress andanxiety alongside their naturopathic treatment plan. ConclusionAnxiety in women is a serious issue that requires amultifaceted, integrative approach to treatment. Byunlocking the power of nutraceuticals, botanical medicines,bio-identical hormones, and mind-body techniques,healthcare providers can help female patients overcomedebilitating anxiety. By rewiring the brain to become moreresilient against persistent fears and worries, these practical,evidence-based tools can empower patients and guide themtoward lasting wellness and freedom from anxiety. Common humanity acknowledges that everyoneexperiences suffering and imperfection. Mindfulnessentails recognizing emotions without judgment andavoiding overidentification with them. For instance, whena patient named Jennifer feels overwhelmed, a clinicianmight encourage Jennifer to say the following to herself,"Jennifer, it's understandable to feel overwhelmed. We allhave moments like this. Remember, you can get throughthis, and I'm here to support you." Patients canincorporate physical self-soothing techniques, such as agentle arm squeeze or a hand on the heart, to enhance thebenefits of this brief MSC exercise.²⁹ This simple act cantrigger the release of oxytocin, promoting feelings of trust,calm, safety, and connection. This practice should berepeated multiple times daily to maximize the therapeuticimpact, especially when emotions feel overwhelming.Emotional Freedom Technique (EFT)EFT combines acupuncture and psychology to releaseemotional pain and create positive self-beliefs. It involvestapping on specific acupressure points while focusing onthe issue and using verbal affirmations. A study involving203 participants, primarily women over 50, underwent 6EFT workshops.30 This mental health intervention led tosignificant improvements in anxiety (-40%), depression,PTSD, pain, and cravings while also increasing happiness(all p-value 0.000). Additionally, physiological markers ofhealth, such as blood pressure (systolic blood pressure-6%, p=0.001; diastolic blood pressure -8%, p<0.000) andsalivary cortisol levels (-37%, p<0.000), significantlydecreased after EFT treatment.A study involving 22 German-speaking anxiety patients(15 female, seven male) compared the effects of EFT andprogressive muscle relaxation (PMR) on emotionalprocessing.31 Both interventions reduced the Late PositivePotential (LPP) in the brain's left centro-parietal areaswhile processing negative emotions. However, the specificeffects differed: EFT primarily modulated the processingof angry stimuli, while PMR mainly affected theprocessing of fearful stimuli. These findings suggest thatboth interventions can enhance emotion regulation byreducing arousal in response to negative emotions.Hantsoo L, Epperson CN. Anxiety Disorders Among Women: A Female LifespanApproach. Focus (Am Psychiatr Publ). 2017;15(2):162-172.doi:10.1176/appi.focus.20160042 1.Gruber DM, Sator MO, Wieser F, Worda C, Huber JC. Progesterone and neurology.Gynecol Endocrinol. 1999;13 Suppl 4:41-45. doi:10.1080/gye.13.s4.41.452.Jie F, Yin G, Yang W, et al. Stress in Regulation of GABA Amygdala System andRelevance to Neuropsychiatric Diseases. Front Neurosci. 2018;12:562. Published 2018 Aug14. doi:10.3389/fnins.2018.005623.Handy AB, Greenfield SF, Yonkers KA, Payne LA. Psychiatric Symptoms Across theMenstrual Cycle in Adult Women: A Comprehensive Review. Harv Rev Psychiatry.2022;30(2):100-117. doi:10.1097/HRP.00000000000003294.Kimball A, Dichtel LE, Nyer MB, et al. The allopregnanolone to progesterone ratio acrossthe menstrual cycle and in menopause. Psychoneuroendocrinology. 2020;112:104512.doi:10.1016/j.psyneuen.2019.1045125.Guennoun R, Labombarda F, Gonzalez Deniselle MC, Liere P, De Nicola AF,Schumacher M. Progesterone and allopregnanolone in the central nervous system: responseto injury and implication for neuroprotection. J Steroid Biochem Mol Biol. 2015;146:48-61.doi:10.1016/j.jsbmb.2014.09.001 6.Schüle C, Nothdurfter C, Rupprecht R. The role of allopregnanolone in depression andanxiety. Prog Neurobiol. 2014;113:79-87. doi:10.1016/j.pneurobio.2013.09.003 7.Morssinkhof MWL, van Wylick DW, Priester-Vink S, et al. Associations between sexhormones, sleep problems and depression: A systematic review. Neurosci Biobehav Rev.2020;118:669-680. doi:10.1016/j.neubiorev.2020.08.0068.Lee JR, Hopkins V. What your doctor may not tell you about menopause: Thebreakthrough book on natural progesterone. Time Warner Company; 1996.1(6):36-38.9.Remaining References can be found on NDNR.comDr. Jonathan Prousky (ND, Bastyr University;MSc, University of London; MA, YorkvilleUniversity) has over 25 years of experience innaturopathic mental health. He focuses onevaluating and managing mental health issues withevidence-based integrative methods and advocatesfor complementary therapies. He received the“Orthomolecular Doctor of the Year” award in2010 and was inducted into the OrthomolecularHall of Fame in 2017. Dr. Prousky has authoredover 60 scholarly publications and several books,including Anxiety: Orthomolecular Diagnosis andTreatment and Textbook of Integrative ClinicalNutrition.32WOMEN'S HEALTH

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The Role of Self-Care in Maternal Mental HealthHumans are a product of both nature and nurture. Ourgenes provide biological potential, but our environmentdetermines how that potential is realized. This interplayis evident in traits like language acquisition—our brainsare hardwired for language, but environmental exposureinfluences our mastery of it.This concept extends to humor, aggression, and evencriminal behavior. Children raised in high-crime areasmay develop more active aggression centers in theirbrains. Research shows that most inmates experiencedunstable childhoods between the ages of zero and six.While genetic predispositions influence behavioraltendencies, they do not predetermine them. ² The same istrue for self-care in mothers—environmental stressorsand cultural norms can determine how mothersprioritize their well-being, affecting themselves and theirchildren.Psychological Conditions and the Impact ofMaternal Self-Care on ChildrenThe first six years of life are crucial for development,with children undergoing rapid physical, emotional, andcognitive changes. Concepts like the "Terrible Twos"highlight how certain developmental phases areuniversally recognized. Children build on genetic“blueprints,” relying on emotional and physical carefrom parents to achieve optimal growth. Babiesinstinctively seek food, protection, and care, establishingattachments with caregivers—especially mothers. ³Emotional and physical development are interlinked.Children need emotional security to grow physically;strong parental attachment fosters that security. Self-care in mothers plays a vital role in this process, as itsupports the emotional availability that children require.The nature vs. nurture debate is especially relevant whenconsidering psychological disorders like schizophrenia.Abnormal brain activity, neurotransmitter imbalances(like dopamine), and prenatal viral infections can allincrease the risk of schizophrenia. Evidence shows thatchildren with biological parents diagnosed withschizophrenia are at greater risk themselves. Factors likeparental age and environmental stressors furthercomplicate this equation. ⁴ ⁵34WOMEN'S HEALTH

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REFERENCESMothers' mental health can significantly influence theirchildren's development. Research highlights that depressivesymptoms in mothers correlate with increased depressivesymptoms in their children. Separation from parents, birthcomplications, and maternal mental health challenges likeschizophrenia can all increase the likelihood ofpsychological issues in children. ⁶The Need for Personalized Self-Care PlansSelf-care for mothers requires a personalized approach.Research suggests that self-care activities like stressmanagement, sleep hygiene, mental health support, andhormonal balance can help improve both maternal well-being and child outcomes.One study found that housewives often experience mentalhealth challenges because of irregular sleep patterns,emotional fluctuations, and the overwhelmingresponsibilities of managing household chores. ¹ Thesestressors leave little time for self-care, which impacts notonly the mother’s mental well-being but also her caregivingcapacity.¹¹As a naturopathic doctor, I have found that co-creating self-care plans with patients is far more effective thanprescribing a one-size-fits-all approach. When a self-careplan is too complicated, time-consuming, or costly, itbecomes impractical for mothers with demanding schedules.Personalized self-care strategies, therefore, must beadaptable to the individual’s unique needs and constraints.ConclusionThe nature vs. nurture debate will likely persist indefinitely.Each new psychological theory presents an opportunity toreexamine the interplay of genetics and environment, andthese shifts in perspective influence the way societyapproaches mental health care. From nativism tobehaviorism to cognitive psychology, prevailing ideologieshave shaped public discourse and the understanding ofhuman development. For mothers, the impact of nature andnurture extends to their children. 35NATUROPATHIC DOCTOR NEWS & REVIEW JAN 2025 - VOLUME 20 | ISSUE NO. 01Myers, David G. Psychology. 8th ed. New York City: Worth Publishers, 2007. Print.Chapter 1.1.Myers, David G. Psychology. 8th ed. New York City: Worth Publishers, 2007. Print.Chapter 1.2.Myers, David G. Psychology. 8th ed. New York City: Worth Publishers, 2007. Print.Chapter 1.3.Myers, David G. Psychology. 8th ed. New York City: Worth Publishers, 2007. Print.Chapter 16.4.Myers, David G. Psychology. 8th ed. New York City: Worth Publishers, 2007. Print.Chapter 16.5.Myers, David G. Psychology. 8th ed. New York City: Worth Publishers, 2007. Print.Chapter 16.6.Wu Q, Slesnick N. Substance Abusing Mothers with a History of Childhood Abuse andTheir Children's Depressive Symptoms: The Efficacy of Family Therapy. J Marital FamTher. 2020;46(1):81-94. doi:10.1111/jmft.123647.Kaplan, V. Mental Health States of Housewives: an Evaluation in Terms of Self-Perception and Codependency. Int J Ment Health Addiction 21, 666–683 (2023).https://doi.org/10.1007/s11469-022-00910-18.Firoz Wagla Wala, S. (2021). The Psychological Aspects of Home-Makers and Womenduring Pandemic. IntechOpen. doi: 10.5772/intechopen.976879.Lillea Hartwell, ND, RH (AHG) is a graduate ofSonoran University of Health Sciences. Sheobtained a BS in Plant Sciences, with a minor inEnvironmental Sciences at the University ofArizona. Dr Hartwell has earned the distinction ofRegistered Herbalist with the American HerbalistsGuild. She teaches at the college level and practicesmedicine at her private practice, Saguaro BlossomMedical Center, in Tucson, AZ. Dr Hartwell has apassion for general medicine, especially in urgentcare settings like wound care and minor surgery, aswell as rheumatology and other autoimmuneconditions. For more information, visitdrlilleahartwell.com.When a mother prioritizes self-care, she supports heremotional well-being, which benefits her children. Withoutthis care, both nature (genetics) and nurture (environment)can influence a child’s psychological development,potentially perpetuating cycles of intergenerational trauma.Research underscores the need for mothers to prioritize self-care—not only for their own sake but also for the well-beingof future generations.

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In contrast, cultures that honor aging and revere thewisdom of elders offer a radically different perspective. Forexample, in some Indigenous communities in NorthAmerica and Australia, menopause is celebrated as atransformative "change of life," symbolizing liberation fromthe reproductive cycle and a step into profound authorityand spiritual depth.² This empowering perspective shifts thefocus from loss to growth, reducing stress and easingsymptoms, making the transition smoother and moreharmonious.By helping our patients reclaim menopause as a naturalphase in their lives, women can move beyond outdatednarratives of decline. In my 24 years as a naturopathicdoctor working with women navigating perimenopause andmenopause, I have observed that a woman’s mindset andlife experiences significantly influence her journey. Whenmenopause is embraced as an initiatory process—apowerful rite of passage—it enables women to reclaim theirsovereignty, wisdom, and inner strength. By shifting thenarrative from decline to evolution, the menopausaljourney becomes one of profound empowerment, growth,and self-discovery, aligning closely with these morepositive, culturally rooted perspectives.Yet, for many women, menopause is shrouded in mystery,often accompanied by fear of aging, illness, and the loss ofbeauty. This lack of education creates anxiety andconfusion about what is happening in their bodies, leadingto a negative experience. This is where we, as naturopathicdoctors, can offer guidance. It’s crucial to educate womenabout the nuances of menopause, not only addressingphysical symptoms but also viewing this transition as aspiritual, mental, and emotional initiatory journey oftransformation.Stepping Into the Dragon’s Nest ofPerimenopauseFor many women, the first sign of perimenopause is a risein estrogen, leading to more intense PMS symptoms—heightened anxiety, irritability, and agitation. This surge inestrogen can feel like a fiery, activating energy, forcingwomen to confront aspects of their lives that they may haveignored or suppressed. As estrogen rises, women areenergetically pushed to engage with their inner worlds moredirectly and potently. This process, though uncomfortable,can accelerate spiritual growth and self-awareness. It’s apathway to higher consciousness and freedom, with thechallenges of perimenopause serving as a transformativecatalyst.37Case Study: Rebecca's Healing Journey fromAnxietyRebecca sought my help for severe anxiety that had recentlyworsened. During our initial session, it became clear that heranxiety was linked to hormonal imbalances, specifically highestrogen levels. Her primary care physician had prescribedadditional estrogen without conducting proper lab tests, butmy evaluation revealed her estrogen levels were alreadyelevated. She didn’t need more estrogen; she needed supportto metabolize and eliminate the excess. I recommendedestrogen conjugators like Di-Indole Methane (DIM) andCalcium-D-Glucorate alongside a custom-formulatednervine tincture containing Piper methysticum, Valerianaofficinalis, Scuttelaria laterifolia, Verbena officials, andEscholizia californica to use as needed. These interventionssignificantly reduce her anxiety symptoms.However, her hormonal imbalance was only part of thestory. Together, we explored deeper emotional andpsychological trauma that her high estrogen had activated.This hormonal imbalance became an opportunity forRebecca to confront and heal past wounds, turning herstruggle into a transformative experience. As her estrogenlevels stabilized and she healed emotionally, her anxietybecame a thing of the past.Riding the Dragon: Embracing ChangeOne of the words that best describes the perimenopausalexperience is "change." Perimenopause and menopause aremarked by constant transformation, with symptomsfluctuating dramatically over time. For many women, theentire process of perimenopause and menopause can span adecade, during which their physical, emotional, and spirituallandscapes undergo continuous shifts. I have oftenexperienced finally getting a perimenopausal patient stable.Yet that stability only lasts for a few months before a newphase of symptoms comes on the scene.The shifting tides of the menopausal journey stronglyresemble initiatory rites, where the energy of change canoverwhelm us if we resist it. However, it empowers us whenwe recognize it for what it is and harness its transformativepower. By navigating the waves of transformation thisjourney presents, we can access the more profound wisdomwithin our bodies, minds, and spirits. This is the essence ofmenopause as an initiatory journey—embracing change as acatalyst for growth and transformation rather than letting itoverpower us. JAN 2025 - VOLUME 20 | ISSUE NO. 01NATUROPATHIC DOCTOR NEWS & REVIEW

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Case Study: Susan's Changing MenopausalTransformationSusan, in her early 50s, came to me deeply fearful ofmenopause…influenced by societal views of aging, shebelieved menopause would strip her of beauty and identity.Her early perimenopausal symptoms –-—extreme PMS andestrogen surges—had left her anxious and feeling out ofcontrol. While she had used her own herbs and progesteronewith some success, the emotional toll of her anxiety and fearof losing her femininity was profound. Over time, I supported Susan in reframing her fears, helpingher see her beauty as rooted in wisdom, not youth. Alongsidethis emotional work, we addressed menorrhagia withsublingual progesterone, high Capsella bursa-pastoris, andiron supplementation. During somatic healing sessions, sheuncovered ancestral trauma stored in her womb. Releasingthis energy not only alleviated her menorrhagia but alsobrought emotional relief. Menopause also coincided with significant life changes forSusan: her marriage ended, and her children left home. Theseshifts mirrored her internal transformation, pushing her toredefine her identity. By the time she entered full menopause,Susan had described the experience as running a constantlychanging marathon. Yet, the experience left her with anewfound strength and sovereignty, feeling more empowered,wise, and deeply connected to her inner wisdom.Heat: Becoming the DragonHot flashes, often associated with menopause, are more thanjust physiological symptoms. While they arise from thechanging physiology of a woman’s body, they carry deepersymbolic and transformative meanings. Physiologically, hotflashes are linked to the hypothalamus' response tofluctuating hormones, including estrogen, progesterone,luteinizing hormone, and norepinephrine, which play keyroles in their etiology.³On a deeper level, hot flashes can also be seen as a primalforce rising through the body, activating old patterns,traumas, and energies that require healing. The surge of heatcan be understood as a form of kundalini energy –a spiritualforce– rising through the body, igniting discomfort andtransformation. It pushes unresolved emotions andexperiences to the surface, ultimately helping women stepmore into their wise-woman power. Case Study: Selena's Journey Through Hot Flashesand Trauma HealingSelena came to me struggling with severe hot flashes andinsomnia. She often woke up drenched in sweat,accompanied by vivid, unsettling, and stressful dreamswhere she ran endlessly. Initially, we addressed herhormonal imbalances with a combination of phytoestrogenand phytoprogesten herbal protocols. When those providedonly partial relief, we introduced low doses of bio-identicalhormones: Bi-Est (1.5 mg daily) and sublingualprogesterone (20 mg daily). This approach significantlyreduced her night sweats and helped her sleep, butbreakthrough episodes continued– particularly during themost intense periods of her dreams. Through mind-body counseling and somatic work, Selenauncovered repressed childhood traumas that were correlatedto her dreams. She felt that the recollection of thesememories had been triggered by the intensity of hersymptoms of menopause, especially the correlation of nightsweats and intense dreams. The hot flashes and night sweatswere not just hormonal responses; they were acting as agateway for deeply buried memories to surface. As wecontinued to explore and heal these memories through deepemotional and somatic work, Selena experienced profoundrelease and peace. By the end of our work together, nightsweats and hot flashes rarely occurred, and she sleptpeacefully. She also felt free from the chains of her past,having integrated her trauma, and found a newfound senseof emotional balance.Melt Down-Breakthrough: The Call for Inner RestAs women progress through perimenopause into fullmenopause (which occurs at 12 months of amenorrhea, or iflooked through the lens of the wise woman way—13months), three symptoms often stop them in their tracks:fatigue, insomnia, and brain fog. These disruptive symptomsdeeply affect a woman’s ability to engage in daily life. Thenow decreased hormonal levels of estrogen andprogesterone during this time can severely impact energylevels, cognitive function, and sleep. Fatigue often persistsdespite adequate rest, leaving women unable to completeroutine tasks. Insomnia, made worse by night sweats andhot flashes, further exacerbates daytime tiredness.Additionally, cognitive fog, often characterized by memorylapses and difficulty concentrating, is common during thistransition.⁴38WOMEN'S HEALTH

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Case Study: Carol's Shift Toward Inner Worthinessin MenopauseCarol sought my help during her transition into fullmenopause, having stopped menstruating 15 months prior.She was overwhelmed by extreme exhaustion, rating herenergy level at a 2-3 out of 10. No amount of sleep or coffeeseemed to make a difference. Recently, she also had difficultythinking clearly. Initially, we focused on improving herlifestyle and sleep hygiene and supporting her with adrenaland cognitive supporting herbs, such as a custom-formulatedtincture of Eleutherococcus senticosus, Withania somnifera,Cordyceps sinensis, Rhodiola rosea, Ocimum tenuiflorum,Centella asiatica, and Ginkgo biloba: three dropperfuls/TID.I also recommended a B-Complex, Vitamin C, cognitivesupport through phosphatidyl choline supplementation, andthe Adrenal Rebuilder's glandular support at varying highdoses. I also recommended a rotating protocol of differentinsomnia supplements, which would need to shift accordingto how her sleep would respond. These were Melatonin,Glycine, PharmaGaba 100 (which I have discovered clinicallyis absorbed through the blood-brain barrier and drasticallycan impact insomnia), and Valeriana officinalis. Over the next few months, these efforts led to shifts where shebegan to sleep more soundly, slowly regaining her energy (herenergy shifted to a 6 out of 10) and increasing her cognitivefunction. We also explored more profound emotional workaround her sense of self-worth, which brought her hugebreakthroughs. Through our sessions, Carol began to connect with her innatewisdom and tap into her inner "Wise Woman." As sheexpressed in a heartfelt email to me, “I am not the same person with the same energy I was just 5years ago. I have less of the “go” hormones. And this forces meto stop getting my reflection of worthiness from outside ofmyself. I am discovering that what is needed now is my owninner worthiness, my innate wisdom, and my inner WiseWoman to lead my life. I no longer have a choice to get myinner needs met from the outside, and I must get them met fromthe inside.” This profound shift in her self-perception allowed Carol toembrace her menopause journey as an initiation, whichhelped her gain a sense of empowerment and a newfoundsense of self.Walking Through the Initiatory ThresholdThe hormonal shifts of menopause allow women to connectmore deeply with their true selves. This transition is not justphysical; it’s emotional, mental, spiritual, and energetic.Menopause invites us to ride the dragon of change, to listento its lessons, and to claim our sovereignty. It calls forwomen to articulate what no longer serves, break throughtheir internalized limitations, and step into their full power. Naturopathic doctors can help patients embrace menopauseas a transformative initiation by creating a safe andcompassionate space for their journey. By normalizing theprocess and framing it as a natural experience that impactsnot only the physical body but also offers opportunities foremotional healing and spiritual growth, we can gentlyintroduce the idea of menopause as an initiation. Usingsimple metaphors, storytelling, and supportive dialogue, wecan help patients reframe their perspectives and recognizethe profound potential of this transition. Additionally, wecan provide resources such as support groups or women’scircles to help them know they are not alone and createspace for connection, renewal, and empowerment duringthis transformative phase. We can also encourage personalrituals, particularly as they step into full menopause, to helpthem honor and step through this initiation with awareness,power, and grace. Ultimately, we can empower women toview menopause as a gateway to renewal, self-discovery, andthe freedom to step into their true selves with wisdom andgrace.A variety of somatic and mind-body practices can alsosupport menopausal women on their initiatory journey andfoster healing. Grounding exercises, body scans, and gentlemovement practices like yoga or tai chi help anchor andregulate the body, while self-massage and dancing releasetension and stored emotions. Restorative mindfulnesstechniques, such as pausing during anxiety or overwhelm toreconnect with the breath and body, can slow the hurriedpace and promote presence. Guiding patients through bodyscans—inviting them to close their eyes, tune into theirbodies, and notice areas needing attention—can be a simpleyet powerful practice. Allowing these parts to "speak"fosters deeper awareness and connection. Additionally,introducing or referring patients to somatic healingmodalities such as Somatic Awakening® or SomaticExperiencing® provides transformative tools for processing,stabilizing, and addressing somatic, emotional, and spiritualchallenges. These approaches nurture self-compassion andsupport profound growth through this transitional phase.39NATUROPATHIC DOCTOR NEWS & REVIEW JAN 2025 - VOLUME 20 | ISSUE NO. 01

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REFERENCESMenopausal JourneyThe menopausal journey ultimately aligns women with theprimal forces within, allowing them to break through thebarriers of the proverbial glass ceiling and embrace theirauthentic, powerful selves. It also allows every woman tocome into contact with the queen within, who is waiting torise in strength and wisdom. The more we help our patientsapproach menopause with this awareness, support, andreverence, the more transformational potential it holds forthem. It’s up to us as healthcare providers to help womensee and embody this truth.Charity M. Cultural differences in Menopause. The Menopause Charity.https://www.themenopausecharity.org/2021/04/24/cultural-differences-in-menopause/.Published May 14, 2021.1.Kimani M. Menopause across cultures - NabTA Health. Nabta Health.https://nabtahealth.com/article/menopause-across-cultures/. Published September 12, 2024.2.Freedman RR. Menopausal hot flashes: Mechanisms, endocrinology, treatment. The Journalof Steroid Biochemistry and Molecular Biology. 2013;142:115-120.doi:10.1016/j.jsbmb.2013.08.0103.P. M. Maki & N. G. Jaff (2022) Brain fog in menopause: a health-care professional’s guide fordecision-making and counseling on cognition, Climacteric, 25:6, 570-578, DOI:10.1080/13697137.2022.21227924.Dr. Melissa Sophia Joy is a Naturopathic Doctor,Founding Director of Sophia Healing Academy,and Founder of the healing modality and spiritualpractice Somatic Awakening®. She is a specialistin mind-body-spirit counseling and energymedicine. She is also a spiritual teacher andmedical intuitive. She loves supporting others intheir deep healing and evolution as they rememberwho they truly are and shift from disease tohealing, freedom, and sovereignty. She is locatedin Sebastopol, CA. You can find out more abouther work at www.somatic-awakening.com andwww.sophiahealingacademy.com at Facebook athttps://www.facebook.com/melissa.sophiajoy.108/40WOMEN'S HEALTHMenopause is far more than a biologicalevent—it is a profound initiation, asacred passage that beckons women intodeeper wisdom and power.

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Her personal medical history included polycystic ovarysyndrome (PCOS) and Hashimoto's thyroiditis, both well-controlled with a lower-carbohydrate and gluten-free dietand an active lifestyle. She was homozygous for the MTHFRA1298C mutation. She had not used hormonalcontraceptives for over 20 years. Still, she had applied high-dose bioidentical progesterone cream for many years in her20s to induce withdrawal bleeds due to PCOS-relatedanovulation. This use ceased more than a decade ago afterher cycles became regular. She had never been pregnant andtook no medications. Her supplements included intermittent use of an active Bcomplex, NAC, inositol, Rhodiola, fish oil, and vitamin D.She had no prior mammograms, but a breast ultrasound 22months earlier was normal. Family history revealed breast cancer in her maternalgrandmother (diagnosed in her 70s) and paternal aunt(diagnosed in her 40s with recurrence in her 50s). Herpaternal grandmother died from colon cancer in her 70s. Presenting SymptomsOn physical examination, a 1cm, smooth, firm mass waspalpable in the left breast approximately 2 cm from thenipple at 1 o’clock position. There were no skinabnormalities, nipple discharge, or palpable lymph nodes.The patient was referred for a diagnostic breast ultrasound. Diagnostic EvaluationImage findingsBreast ultrasound revealed a 1.2 x 1.7 x 1.3 cm suspicious,vascular, hypoechoic mass in the left breast with strongposterior shadowing and irregular borders, corresponding tothe palpable mass... No lymphadenopathy or fibrocysticchanges were noted. The right breast ultrasound was normal. A breast surgeon confirmed these findings on repeatultrasound, describing a 1.25x1.16x1.36cm hypoechoic,vascular, solid mass with shadowing. An ultrasound-guidedcore needle biopsy was recommended. The patient declinedthe placement of a metallic clip (which can be made oftitanium, stainless steel, or gold), which is standard in suchprocedures, citing her preference to avoid foreign objects inher body. The clip is utilized for easy identification in futureimaging.Despite the concerning ultrasound findings, several featuressuggested the mass was benign pseudoangiomatous stromalhyperplasia (PASH). The mass was vaguely palpable andnot hard, could “disappear” on ultrasound when the probeangle changed, and tissue samples from the biopsy lackedvisible blood, which is uncommon in vascular cancers. Due to her family history, the patient underwent genetictesting with an expanded hereditary cancer panel assessing77 genes.Biopsy and Genetic Testing ResultsThe final diagnosis from the biopsy revealed “benign breastparenchyma with focal fibroadenomatous change with mildusual ductal hyperplasia and associated pseudoangiomatousstromal hyperplasia, negative for atypia and malignancy.”Genetic testing showed no pathogenic variants.Final Diagnosis & Understanding PASHCharacteristics of PASHPseudoangiomatous stromal hyperplasia (PASH) is a benignstromal proliferation in the breast that mimics vascularlesions due to slit-like pseudospaces in the stroma, devoid ofred blood cells.1 First described in 1986, it is still considereduncommon, although it is an incidental finding in up to 23%of breast biopsies.² PASH often presents as a non-tender thickening or nodule,similar to a fibroadenoma, and is believed to be hormonallyinfluenced. Pre- and peri-menopausal females are mostcommonly affected, though cases of PASH have beendocumented in men with gynecomastia, postmenopausalwomen on hormone therapy, and adolescents.¹Histological staining shows high levels of progesterone andestrogen receptors in PASH stromal cells, and the conditioncan recur after excision. OCP use, hormonal stimulation,and certain medications, including those that interact withthe cytochrome p450 enzymes influencing estrogen andprogesterone detoxification, may increase the incidence ofPASH.³42WOMEN'S HEALTH,

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Differential DiagnosesPASH may be mistaken for mammary angiosarcoma orphyllodes tumor¹, but histological confirmation via coreneedle biopsy rules out malignancy... PASH does not increasebreast cancer risk but can coexist with malignant lesions,warranting further evaluation if a lesion grows rapidly.In 2018, The American Society of Breast Surgeonscollaborated with the American Board of Internal Medicineon their “Choosing Wisely” campaign, creatingrecommendations for benign breast disease, including PASH.They concluded that surgical excision is not recommended forPASH if it is not bothersome to the patient as long as itremains stable without suspicious findings on the ultrasound.⁴Although reassuring when a breast mass is confirmed asbenign, a hormonally sensitive condition like PASH providesan opportunity for the prevention of future health issues byinvestigating underlying hormonal imbalances.Hormonal Testing and Key FindingsBloodwork ResultsBloodwork was ordered for 7 days post ovulation to assessluteal hormones, which revealed an elevated estradiol of 218pg/mL (56-214 luteal), normal progesterone of 19.1 ng/mL(2.6-21.5 luteal), and an elevated AM cortisol of 22.1 mcg/dL(4-22 for 7-9 AM). Her total and free testosterone, fastingblood sugar, insulin, HgbA1C, Vitamin D, and completethyroid panel were all normal.Urine Hormone Metabolite TestingA urine cortisol and hormone metabolite test was alsoordered for 7 days post ovulation. It showed elevated 24-hour free cortisol that followed a normal daily pattern ofelevated estradiol with much higher 2-OH-E1 levels than 2-Methoxy-E1 levels, indicating poor phase 2 detoxification,likely in part due to her MTHFR mutations. Androgens,progesterone, melatonin, nutritional and oxidative stressmarkers were normal.Treatment Approach and LifestyleRecommendationsStress Reduction StrategiesStress reduction techniques were recommended for herelevated cortisol levels, including replacing some of thehours of high-intensity exercise each week with yoga,eliminating caffeine, and switching to Ashwagandha ratherthan Rhodiola to lower high cortisol levels. Supporting Estrogen DetoxificationShe was encouraged to take her active B complex daily andto add magnesium glycinate and trimethylglycine to supporthealthy methylation and phase 2 detoxification. Sheincreased her brassica vegetable intake to two large servingsdaily and added other fiber-rich foods to encourage healthyestrogen detoxification.⁵ She also researched her personalcare products through the EWG skin-deep website,purchased an advanced water filter, and stopped using non-stick pans when cooking to decrease xenoestrogen exposure.43NATUROPATHIC DOCTOR NEWS & REVIEW JAN 2025 - VOLUME 20 | ISSUE NO. 01, ,,

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Follow-up and Ongoing MonitoringAlthough her breast mass remained palpable but stable, hercyclical mastalgia resolved within 3 months. Ultrasound ResultsSix months later, she had a follow-up ultrasound with herbreast surgeon, which revealed no growth of her PASHmass and no additional areas of concern. Long-Term Hormone OptimizationAnnual screening breast ultrasounds were recommendedfor ongoing monitoring in addition to a baselinemammogram. Luteal serum and urine hormonemetabolism tests will also guide diet and supplementrecommendations to optimize hormone detoxification asshe moves deeper into perimenopause.REFERENCESYoon KH, Koo B, Lee KB, et al. Optimal treatment of pseudoangiomatous stromal hyperplasiaof the breast. Asian J Surg. 2020;43(7):735-741. doi:10.1016/j.asjsur.2019.09.0081.Bowman E, Oprea G, Okoli J, et al. Pseudoangiomatous stromal hyperplasia (PASH) of thebreast: a series of 24 patients. Breast J. 2012; 18 (3): 242-7. doi:10.1111/j.1524-4741.2012.01230.x2.Hattingh G, Ibrahim M, Robinson T, Shah A. The effect of hormones on an uncommon breastdisorder pseudoangiomatous stromal hyperplasia: a case report and literature review. J SurgCase Rep. 2020;2020(12):rjaa514. Published 2020 Dec 26. doi:10.1093/jscr/rjaa5143.Rao R, Ludwig K, Bailey L, et al. Select Choices in Benign Breast Disease: An Initiative of theAmerican Society of Breast Surgeons for the American Board of Internal Medicine ChoosingWisely® Campaign. Ann Surg Oncol. 2018;25(10):2795-2800. doi:10.1245/s10434-018-6584-54.Fowke JH, Longcope C, Hebert JR. Brassica vegetable consumption shifts estrogen metabolismin healthy postmenopausal women. Cancer Epidemiol Biomarkers Prev. 2000;9(8):773-779.5.Dr Molly Jarchow is a Naturopathic Doctor andLicensed Midwife. She attended Bastyr Universityin Seattle for her naturopathic and midwiferytraining and has been practicing in Los Angeles for15 years. After co-founding LA Midwife Collectiveand welcoming 400 babies into the world sheretired from births in 2017. Dr Molly is the founderof Sage Naturopathic Medicine in Santa Monicawhere she provides whole person care for womenand children through all phases of life includingpuberty, pregnancy, and menopause.https://www.facebook.com/MollyJarchowNdLm/44WOMEN'S HEALTH

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The benefits of sleep are enormous throughout all the stages.In non-REM sleep, the brain works to convert short-termmemories into long-term memories, while in REM sleep, thebrain innovatively takes that learning and converts it intonovel and creative applications. Sleep is also vital for bettermoods, a healthier heart, controlled appetite, and bloodsugar, improved mental function and immune system, stressrelief, enhanced athletic performance, and rest/recovery fromdaily activities. Getting poor sleep allows the exact oppositeof those benefits: poor mood, poor learning/memory, poorappetite control, weight gain, reduced energy and motivation,and cardiovascular disease. It also increases errors, injuries,and illnesses.The amount of sleep a person needs changes throughout thelifespan. Babies will sleep for 14-17 hours, teens should get 8-10 hours, and adults ideally should get around 7-8 hours. ⁴A few main chemicals that induce and maintain sleep in ourbrains include serotonin, melatonin, acetylcholine, andGABA.Interestingly, numerous chemicals are needed for a wake-upprocess in the morning: histamine, acetylcholine, orexin,dopamine, norepinephrine, and serotonin. If 2-3 of thosechemicals are low, a person can feel sleepy throughout theday. Also, morning sunlight produces adenosine, whichinitiates waking and signals earlier sleep time.Unfortunately, 30% of adults do not get 7 hours of sleep anight due to various conditions.Common Sleep Disorders in PostmenopausalWomen (PMW)There are three main sleep disturbances post-menopause:Obstructive Sleep Apnea (OSA)OSA is a sleep-related breathing disorder characterized byintermittent episodes of breathing cessation or completeairway collapse. OSA is associated with intermittent hypoxia,sympathetic overactivity, oxidative stress, increasedcardiovascular mortality and morbidity, depression, type 2diabetes, weight gain, and increased inflammatory markers.Estimates are that up to 47-67% of PMWs experience OSA. ⁵46WOMEN'S HEALTHIn premenopausal women, estrogens and progesterone helpkeep the upper airway less collapsible, and there’s lessinflammation and oxidative damage. Progesterone seems tostimulate better ventilation during sleep. ⁶Women with OSA have lower levels of progesterone andestrogen after menopause and tend to gain abdominalweight more easily—both of which increase the likelihoodof a collapsible upper airway. Dosing hormones (HRT),particularly progesterone, may help reduce OSA in PMW. ⁷Testosterone may also be helpful, as this hormonepromotes waking ventilation and CO2 sensitivity duringsleep, and it may be decreased in menopausal years as well.Restless Leg Syndrome (RLS)RLS is a condition whereby there is an uncontrollable urgeto move one’s leg. RLS is also a problem in menopause andis aggravated by medical comorbidities (hypertension, type2 diabetes, kidney disease), certain medications, andchanges in the 24-hour sleep cycle. It is seen more in womenwho had RLS during pregnancy. RLS usually worsens atnight and is associated with low dopamine and elevatedglutamate in the brain.RLS is also associated with iron deficiency, as iron isneeded to make dopamine and GABA. Other low nutrientsassociated with RLS include magnesium, vitamin D3, andfolic acid. ⁸Oddly, estrogens seem to worsen RLS—RLS increases inpregnancy with elevated estrogen levels (especially withlower iron levels) and seems to affect women who have hadmore pregnancies. Dosing estrogen doesn’t help RLS inPMW. ⁹InsomniaInsomnia is defined as chronic dissatisfaction with sleepquantity or quality. Problems falling asleep, wakingfrequently, difficulty falling back asleep after awakening,and waking up too early are all considered aspects ofinsomnia. ¹⁰

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NATUROPATHIC DOCTOR NEWS & REVIEWSupplements, Hormones, and Other InterventionsThere are many supplements to help with sleep: melatonin,magnesium glycinate or threonate, tryptophan or 5-HTP, l-theanine, and phosphatidylserine to address elevated eveningcortisol are oftentimes helpful. Numerous botanicals for sleepinclude lemon balm, valerian, hops, kava, oats, skullcap,passion flower, ashwagandha, and lavender. ¹⁶As for using hormones for sleep disorders in PMW, estrogenscan be highly beneficial when vasomotor imbalance isoccurring. Around 75-85% of PMWs suffer, at least for a fewyears, from night sweats, which often cause multiple episodesof waking during sleep. Dosing bioidentical estrogens hasbeen shown to improve sleep quality, reduce awakenings,increase total sleep time, and affect norepinephrine,serotonin, and acetylcholine neurotransmitters. Typicaldosing is a base formula of estriol and estradiol 80/20percentage, from 0.3 to 2.5 mg/gram daily.Progesterone is also highly beneficial. Oral micronizedprogesterone is the best dosing method because most of it ismetabolized in the liver to form allopregnanolone (AP),which works on GABA receptors more effectively thanbenzodiazepines. Typical dosing is 50-200 mg at night.DHEA and Testosterone do not seem particularly helpful forsleep disorders in PMW. Insomnia is a serious concern inPMW and needs to be addressed. Working comprehensivelycan be safe and effective in helping women sleep well.Britannica.com1.https://openwa.pressbookspub/nursingfundamentals/chapter/12-2-basic-concepts/ andhttps://baillement.com/sleep-neurobio.html 2.Sleepfoundation.org3.National Sleep Foundation4.https://doi.org/10.1016/j.maturitas.2019.02.0115.PMID: 34970158 Gender differences in OSA6.PMID: 7386511 Sleep disordered breathing in post-menopausal women7.Neurology: Vol 78, #1, 4/23/128.Why are women prone to RLS: PMID: 31935805, PMID: 8363978 and Sleep. 1998;21:501-5059.International Classification of Sleep Disorders book by the American Academy of SleepMedicine10.https://tinyurl.com/mwp5wf3m11.National Institutes of Health12.doi: 10.1093/ajcn/nqz275 WHI study13.The National Sleep Foundation14.doi: 10.7759/cureus.4359515.Sleep Botanicals VA.gov and doi: 10.1155/2012/74081316.J Menopausal Med. 2019 Aug; 25(2): 83–87 PMID: 3149757717.Sleep Disorders and Menopause: doi: 10.6118/jmm.1919218.Effects of progesterone on sleep: PMID: 1716872419.PMID: 31780185 A/P ratio across the menstrual cycle and menopause20.DHEA-S: Six-month oral DHEA-S supplementation in early/late menopause PMID:1110997421.REFERENCESDr. Mona Morstein has been a naturopathicphysician for 36 years. She has a practice in Mesa,AZ, and makes in-office and telemedicine visits.Dr. Morstein specializes in gastroenterology, allhormonal conditions, and chronic disease. She wasChair of Nutrition, gastroenterology professor,and outpatient clinical supervisor at a naturopathicmedical school for eleven years. She is a frequentlecturer at the SIBO SOS Summits and otherconferences each year. Dr. Morstein is the authorof the well-regarded book “Master Your Diabetes:A Comprehensive, Integrative Approach for BothType 1 and Type 2 Diabetes”. Dr. Morstein hasreceived an award for her gastroenterologycontributions to the field of naturopathic medicineand an overall award for benefiting thenaturopathic profession as a whole. Dr. MonaMorstein has a website, Instagram, and Youtubechannel. 47 JAN 2025 - VOLUME 20 | ISSUE NO. 01

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The Role of X Chromosomes and Xist MoleculesThe mystery of why autoimmunity affects womendisproportionately, approximately 4 in 5 autoimmunediagnoses are found in women, has been a subject of researchfor decades.The most recent theory has to do with the fact that femaleshave two X chromosomes, while males have an X and a Y.⁷Xist molecules are only found encoded on X chromosomesonly when there are two X chromosomes. These long Xistmolecules help to inactivate the X chromosome to ensurethose cells won’t produce too many proteins encoded on Xchromosomes because that would cause deadly biologicalsequelae. These Xist molecules have been found to increasethe formation of unusual clumps of RNA, DNA, and otherproteins that can trigger autoimmune responses.B Cell Dysfunction and Autoimmune DiseaseOther theories have looked to B cell dysfunction as a triggerof the autoimmune process.⁸ Peripheral B lymphocytes play ahuge role in immunity—activating T cells and epitopespreading to regulate the autoimmune process.⁹ B cells havebeen identified as having a critical role in the progressionfrom autoimmunity to the manifestation of autoimmunedisease.Hormones and the Immune ResponseFinally, reproductive hormones, such as estrogen,testosterone, and progesterone, have been implicated in mostsex-biased immune response differences.¹⁰¹¹ Recently,estrogens and androgens have been found to directlyinfluence whether a Th1- or Th2-type immune responsedevelops by interacting with hormone receptors on immunecells.¹² To this day, there is no direct link, and themechanisms of impact of the sex hormones and autoimmunediseases are still unclear.Naturopathic Philosophy and Autoimmune HealingSo, where does that leave us? As a naturopathic doctor withmore than two decades of practice, I am reminded to look toour Naturopathic Philosophy as a guide that goes beyondmechanistic science. What I love about our philosophy is thatit encourages us to go beyond the distractions and venturedeeper as we explore the roots of dis-ease in ourselves and ourpatients.Tolle Totum: Treating the Whole PersonWhen I look for the root causes of why autoimmune diseaseis significantly higher in women, I start by looking at thecultural lessons, beliefs, and expectations women areexposed to. I also consider the stories of female patients andthe struggles and internal conversations they have to face asthey embark on their healing journey. Finally, I havereflected on my own experience as not only a woman but assomeone who has healed from Hashimoto’s Thyroiditis andthe process that allowed me to arrive with negative thyroidantibodies.The concept of being a “good girl” comes up withfrequency. Associated messages commonly imprintedinclude not being too loud or too big and not doinganything that might rock the boat. Many women are taughtto defer to the needs of others and not to be seen as selfish.This creates a pattern of repression of self (desires,inspirations, and pleasures) and a belief that we must do andbe what we think others need us to be. We end up losing orsuppressing our voice and becoming highly self-critical.Tolle Causum: Treating the CauseIf negative self-talk and judgment are at the root of ourpatterns, this is a constant trigger to the nervous system.When the nervous system is activated, more cortisol isdedicated to the fight-or-flight pathway, leaving lessregulation of the inflammatory response.Through our harsh or negative relationship with ourselves,we can start to identify “self” as the enemy. How can thatnot impact how our immune cells perceive other cells in ourbody?Years into my journey with Hashimoto’s, I had “triedeverything.” Restrictive diets, homeopathic remedies, herbs,and supplements are too numerous to count. One day, I washiking, and I noticed my inner voice. It was then I realizedthat it didn’t matter how “clean” I was eating or how hard Iwas trying to reverse this disease process. What matteredmost was how I was treating myself and to what extent Icould show up for myself with unconditional love andcompassion.49 JAN 2025 - VOLUME 20 | ISSUE NO. 01NATUROPATHIC DOCTOR NEWS & REVIEW

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Stimulating the Vis and Removing Obstacles to CureWhen we clear away the limiting beliefs we carry in ourcellular memory, we allow our physiology to be less burdenedand, therefore, more efficient. The nervous system can regulateby creating more compassion and releasing emotionalburdens, and healing begins. Once these obstacles of traumaand criticism are addressed, “the dynamic that animates thematerial body (organism) rules with unbounded sway andretains all parts of the organism in admirable, harmonious andvital operation…”¹³Case StudySusan’s Journey with Rheumatoid ArthritisSusan, a 64-year-old Caucasian female, presented with suddenonset of variable, debilitating joint pain, causing a reduction inquality of life and activities of daily living. She immediatelycame to see her primary care provider, who offered apreliminary diagnosis of Sjogren’s and referred her torheumatology. She also came to see me in the clinic, and thelab results indicated some other disease process. I told her Isuspected Rheumatoid Arthritis and asked her to follow upwith more bloodwork.Waiting for more lab results, we began treatment with high-dose fish oil and concentrated turmeric, a specifichomeopathic and B vitamin injection to help reduce overallinflammation and pain. Over the following weeks, she noticeda mild improvement in her symptoms, but she still feltmoderately impacted on some days.Susan had her initial consultation with the rheumatologist,who diagnosed Polymyalgia Rheumatica—a different type ofautoimmune disease affecting the joints. He recommended shestart Prednisone, which we discussed at length. After her initialresistance, she decided to begin pharmaceutical treatment andcontinue naturopathic support.At her first rheumatology follow-up, her doctor changed herdiagnosis based on new labs to Rheumatoid Arthritis. Basedon that, he prescribed Methotrexate in addition to Prednisoneand supported her continuing with her supplements. Curiousto see if this new medication would bring relief, she reluctantlystarted the second pharmaceutical.After a month on both medications, Susan wasn’t noticingmuch change in her symptom picture—her pain was verymuch up and down. As the weather was getting colder, shenoticed increased overall pain.Tolle Totum: Treating the Whole PersonWhen I look for the root causes of why autoimmune diseaseis significantly higher in women, I start by looking at thecultural lessons, beliefs, and expectations women areexposed to. I also consider the stories of female patients andthe struggles and internal conversations they have to face asthey embark on their healing journey. Finally, I havereflected on my own experience as not only a woman but assomeone who has healed from Hashimoto’s Thyroiditis andthe process that allowed me to arrive with negative thyroidantibodies.The concept of being a “good girl” comes up withfrequency. Associated messages commonly imprintedinclude not being too loud or too big and not doinganything that might rock the boat. Many women are taughtto defer to the needs of others and not to be seen as selfish.This creates a pattern of repression of self (desires,inspirations, and pleasures) and a belief that we must doand be what we think others need us to be. We end up losingor suppressing our voice and becoming highly self-critical.Tolle Causum: Treating the CauseIf negative self-talk and judgment are at the root of ourpatterns, this is a constant trigger to the nervous system.When the nervous system is activated, more cortisol isdedicated to the fight-or-flight pathway, leaving lessregulation of the inflammatory response.Through our harsh or negative relationship with ourselves,we can start to identify “self” as the enemy. How can thatnot impact how our immune cells perceive other cells in ourbody?Years into my journey with Hashimoto’s, I had “triedeverything.” Restrictive diets, homeopathic remedies, herbs,and supplements are too numerous to count. One day, I washiking, and I noticed my inner voice. It was then I realizedthat it didn’t matter how “clean” I was eating or how hard Iwas trying to reverse this disease process. What matteredmost was how I was treating myself and to what extent Icould show up for myself with unconditional love andcompassion.50WOMEN'S HEALTH

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At this point, observing her mediocre therapeutic responseto both naturopathic and pharmaceutical interventions, Ispoke to her about my theory that all autoimmuneconditions were rooted in our relationship to ourselves andthat until we addressed that fundamental issue, anytreatment would most likely be limited. A light went onwithin Susan, and she shared that she’s always been hard onherself and has pushed herself beyond the limits of her body.She shared that she only felt valued when she wasproductive, and since her retirement 3 years ago, she hadbeen feeling even worse about herself and was consideringreturning to work—not for financial reasons, but simply tofeel worthy again.During Susan’s session, her system led us to a “part” of herthat is six years old—the time in her life when her motherdeveloped severe mental illness and her father asked her totake on the care of her mother and brother. We uncoveredhow this situation created another part of her who becamehyper-responsible and pushed away the little kid part whojust wanted to have fun and play.At the end of her mind-body session, Susan stretched herarms and was surprised to find a full range of motions onboth shoulders. She could stand from seated with more easeand noted less pain throughout her body. She was thrilled.At her follow-up 2 weeks after the session, she reportedfeeling mentally “great” and in a new frame of mind. Whilestill feeling some pain and stiffness in her body, shecontinues to report a significant decrease in symptoms andincreased quality of life. 51Dr. Nicola Dehlinger, ND, is a board-certifiednaturopathic doctor and expert in treatinganxiety, depressio,n and insomnia. Moreimportantly, she is a human who hastransformed her relationship with herself,accessing experiences that were beyond whatshe thought was possible. Dr. Dehlingerreceived her B.A. in International Healthfrom Brown University in 1997, graduatingwith honors. She graduated from theSouthwest College of Naturopathic Medicinein Tempe, Arizona in 2004. Dr. Nicola is the founder of Pura VidaNatural Healthcare in Durango, CO whereshe sees people locally and on-line. In additionto seeing patients, Dr. Nicola leads group andprivate retreats. She also teaches a variety ofon-line classes. In her free time, you can findher in the mountains or the kitchen, enjoyingtime with her husband, son and their dogs.ConclusionIn conclusion, this human body is nothing short of a miracle.When the body presents symptoms, rather than jumping toour minds to figure out how to stop the symptoms, let us firstbecome curious. Let us assume that each and every symptomis a divine messenger intended to bring our awareness tounderlying imbalances and patterns that need to be broughtinto the light, presence, and integrated so the nervous systemno longer trips over them, creating inflammatory-basedsymptoms.As naturopathic doctors, we are uniquely poised to movebeyond the constraints of modern medicine and look at ourpatients as a unique, divinely orchestrated system that doesn’tmake mistakes—and is certainly not broken.1. The American Autoimmune Related Diseases Association. autoimmune.org AccessedDecember 10, 2024. 2. Regner M, Lambert P-H. Autoimmunity through infection or immunization? NatureImmunology. 2001;2:185–8. 3. Fairweather D, Rose NR. Type I diabetes: virus infection or autoimmune disease? NatureImmunology. 2002;3:338–40.4. Fairweather D, Kaya Z, Shellam GR, Lawson CM, Rose NR. From infection toautoimmunity. Journal of Autoimmunity. 2001;16:175–86.5. Walsh, S. J. , & Rau, L. M.. Autoimmune diseases: A leading cause of death among youngand middle‐aged women in the United States. American Journal of Public Health. 2000; 90(9):1463–1466.6. Fairweather, D, Rose, N. Women and Autoimmune Diseases. Emerging Infectious Diseases.2004;10(11): 2005-2011. 7. Dou DR, et al. Xist ribonucleoproteins promote female sex-biased autoimmunity. Cell. 2024;187(3): 733-749.REFERENCES8. Dörner T, Lipsky PE. The essential roles of memory B cells in the pathogenesis of systemiclupus erythematosus. Nature Reviews Rheumatology. 2024; 20(12): 770-782. 9. Salinas GF, Braza F, Brouard S, Tak PP, Baeten D. The role of B lymphocytes in theprogression from autoimmunity to autoimmune disease. Clinical Immunology. 2013; 146(1): 34-45. 10. Friedman A, Waksman Y. Sex hormones and autoimmunity. Israel Journal of MedicalSciences. 1997;m 33(4):254-7.11. Klein SL. The effects of hormones on sex differences in infection: from genes to behavior.Neuroscience Biobehavior Review. 2000;24:627–38. 12. Da Silva JAP. Sex hormones, glucocorticoids and autoimmunity: facts and hypotheses.Annals of the Rheumatic Diseases. 1995;54:6–16.13. Hahnemann, Samuel. Translated from 5th Ed by RE Dudgeon. Organon of Medicine:Philadelphia, PA: Boericke and Tafel; 1901:52. JAN 2025 - VOLUME 20 | ISSUE NO. 01NATUROPATHIC DOCTOR NEWS & REVIEW

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The clinical challenge of this attention is thatperimenopause has a gold standard, scientifically accepteddefinition within research,³ as awareness grows, even withinresearch, the nomenclature varies.⁴ This has left mediasources to broaden the definition as it suits their narrative.Coupled with the fact that perimenopause does not have apathognomonic biomarker, there is a risk of overdiagnosiswhen female patients above age 35 present withsymptoms.⁵⁻⁸ This I refer to as the ‘PerimenopauseProblem.’ As the term perimenopause is now coming intothe office from patients themselves, it becomes increasinglyimportant for clinicians to have a keen knowledge of thedefinitions related to the reproductive stages and theirdifferential diagnoses.Defining Reproductive StagesThe gold standard in defining menopause and related stageswas developed at the Stages of Reproductive AgingWorkshop (STRAW) in 2001 with experts from 5 countriesevaluating the best evidence available, and it was laterexpanded on in 2011.³ The STRAW 10+ updates describefemale reproductive life in three broad phases:Reproductive, Menopausal Transition, andPostmenopause. These phases are divided into specificstages, providing a comprehensive framework forunderstanding women's reproductive aging progression.The stages orient around the day of confirmation ofmenopause, which could be considered Stage 0: the date awoman has not had an ovulatory cycle for 12 consecutivemonths after age 45, also called the final menstrual period(FMP).³'⁶⁻⁹ Before age 45, this length of time with non-ovulatory cycles would be considered premature ovarianinsufficiency (POI) or amenorrhea.⁸ Because perimenopauseincludes all stages from Stage 3b to Stage -1 with widevariations in symptoms and signs, it is critical to knowwhich stage your patient is in to validate symptoms ifappropriate and trigger further investigation if symptomshave a mismatch with reported ovarian function. Below, I outline the relevant stages and their signs andsymptoms, as defined by the STRAW 10+ updates and TheStudy of Women’s Health Across the Nation (SWAN).³'⁶The terms menopausal transition and perimenopause areinterchangeable terms:Late Reproductive Stage (Stage -3):Subdivided into Stages -3b and -3aStage 3b: Regular menstrual cycles, normal FollicleStimulating Hormone (FSH), a potential decrease inAnti-Mullerian Hormone (AMH) and Antral FollicleCount (AFC)Stage -3a: Subtle changes in cycle length (1-2 days),increased early follicular phase FSHEarly Menopausal Transition/Perimenopause (Stage -2) Menstrual cycles begin to shift by up to 7 days for somecyclesHigher FSH only on extended cyclesEstradiol remains relatively stableFew noticeable symptomsThis stage, on average, occurs approximately four yearsbefore the FMP. The distribution expands to 7.5 yearsin 2.5% of the studied population.Late Menopausal Transition/Perimenopause (Stage -1)Ovulatory cycles missed for 60 days or moreFSH level fluctuations between the reproductive rangeand menopausal rangeThe sudden drop in estradiol levels correlates withcommon documented symptoms.This stage, on average, occurs approximately two yearsbefore the FMP. The distribution expands to 4 years in2.5% of the studied population.MenopauseOvulatory cycles have ceased for 12 monthsFSH levels rise, estradiol levels remain lowEarly Postmenopause (Stage +1):Subdivided into Stages +1a, +1b, and +1cReflects continued changes in FSH and estradiol levelsfor approximately two to ten years after the finalmenstrual period¹⁰ The longitudinal SWAN data set has shown that the clinicaland research assumptions that the menopausal transitiononly occurred in the 12 months before the FMP weremisguided.⁶ The data shows that 2 years before the FMP, wesaw a drastic drop and surge in estradiol and FSH,respectively.⁶ This is consistent across race, ethnicity, andBMI.⁶53 JAN 2025 - VOLUME 20 | ISSUE NO. 01NATUROPATHIC DOCTOR NEWS & REVIEW

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The criteria to note here is that the strong and compellingdata on the symptoms of menopause and perimenopauseare related explicitly to Stage -1 (late perimenopause),which occurs on average in the 2 years before menopause. Itis critical to understand that therapies, such as estrogenicherbs and hormone replacement therapy (HRT), which maybe appropriate for late perimenopause and menopause,should not be first-line treatments during the latereproductive and early perimenopausal years. Despitecommonly referenced sources frequently citing the incorrectstatistic that symptoms of perimenopause can start 10 yearsbefore menopause, there is no substantial evidence tosupport this claim.3,6-9 However, because there are manyoverlapping symptoms in late perimenopause to othercommon female-related conditions,11 the 10-year spanvalidates and identifies that women from age 35 up untillate perimenopause are indeed suffering. As naturopathicphysicians, we can do the detective work required to treatthe cause rather than assume perimenopause. Symptoms and Risk Factors of PerimenopauseCommon Symptoms of Late PerimenopauseVasomotor symptoms are defined as hot flashes andnight sweats¹²⁻¹⁴Sleep disturbances¹²⁻¹⁴Cognitive and short-term memory concerns¹⁵⁻¹⁸Depression and anxiety¹⁸⁻²³Musculoskeletal pain syndromes²⁴Risk Factors Associated with Estradiol Declines2.6 fold increased risk for CVD when estradiol levelsreach menopausal levels,²⁵⁻²⁸Significantly increased risk for osteoporosis due toincreased osteoclastic activity in the 5-10 years postmenopause²⁹An important caveat is that the above definitions andsymptoms have a population to whom these definitions maynot suit due to their masking of ovulatory symptoms.Individuals with POI, chronic illness with irregularmenstrual bleeding, endocrine disorders such as polycysticovarian syndrome (PCOS) or endometriosis, and long-termhormonal contraceptive use.³⁰⁻³³The Importance of Differential DiagnosisConditions Mimicking Perimenopause SymptomsGiven the variability in symptoms during the latereproductive stage into the menopausal transition (ages 35-60), our task as naturopathic physicians is to differentiateperimenopause from other conditions within the nutritional,endocrine, and immune systems. The six conditions that may be presenting as aperimenopausal picture are mild dehydration, irondeficiency, long covid or similar chronic post-viral illnesses,autoimmune/inflammatory conditions, hypercortisolism,and hypothyroidism.The symptoms of fatigue, weakness, and brain fog cross allsix diagnoses. In addition, long covid, autoimmuneconditions, hypercortisolism, and hypothyroidism, whichoccur primarily in women 34-40, may affect menstrualcycles and cause weight gain, joint inflammation, cognitiveconcerns, and mood changes.⁴¹⁻⁵² The cross-talk betweenthese conditions and estradiol is emerging, where thesesymptoms have been shown to worsen during the lowestradiol phases of the menstrual cycle.⁵³⁻⁵⁵Emerging Research on Estradiol and Chronic IllnessRecent research suggests that COVID-19 and autoimmuneconditions like systemic lupus erythematosus, myalgicencephalomyelitis/chronic fatigue syndrome, andrheumatoid arthritis may trigger early menopause.⁵⁶⁻⁵⁸While the mechanism is unclear between any of theseassociations, these emerging associations put clinicians in aposition to differentiate new mechanisms and the best routesto care. The Perimenopause Problem arrives with a triad of patientdemand, lack of a laboratory diagnosis, and a clinical focuson declining or oscillating estrogen as the main culprit ofsymptoms. While pharmaceutical or herbal estrogenaugmentation may improve symptomatology, they maymask underlying issues that deserve attention.54WOMEN'S HEALTH

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Core Principles of Perimenopausal CareFoundational Clinical AssessmentsIn a clinic, when a patient presents with typicalperimenopausal symptoms, the differential diagnosis beginswith clinical assessments that naturopathic physicians arebest suited to. An astute naturopathic approach to addressing theseinterwoven conditions is to start at the foundations ofneuroendocrine health and work systematically towarddownstream outcomes. Ensure adequate hydration, not simply water intake,but water absorption through scientifically balancedoral rehydration solutions 1.Assess for micromineral deficiencies of iron, zinc,selenium, iodine2.Rule out thyroid issues that can mimic perimenopausesymptoms3.Fat-soluble vitamin (Vitamins A, D, E, and K)assessment and support4.Support methyl donors5.Regulate cortisol secretions6.Address inflammation7.Assess ovulatory hormone patterns8.The ‘Peri-Panel’: Comprehensive Baseline Lab WorkA complete blood count (CBC)Iron studies (Ferritin, Total Iron, TIBC) with B12Thyroid panel (TSH, T4, T3, Anti-TPO, Tg-Ab)Vitamin DHigh-sensitivity C-reactive Protein (hs-CRP)Anti-nuclear Antibodies and Rheumatoid Factor (ANAand RF)Salivary Diurnal CortisolDay 3 Serum FSH and Luteinizing Hormone - Betweenthe ages of 30-45, these tests are often less helpful ascycles may be variable or affected by hormonalcontraception. Aside from fertility, this test should onlybe performed in suspected PCOS, late perimenopause,or premature menopause due to known risk factors59.Salivary Progesterone and Estradiol 10 days before thepredicted menstruation date. Similar to serum FSH andLH markers, these results should not be relied on as adiagnostic for perimenopause and instead be used insuspected luteal phase deficiency, endometriosis, orestrogen dominance.⁶⁰55ConclusionThe Perimenopause Problem is characterized by increasingawareness and misinformation, leading to potentialmisdiagnoses and an over-reliance on hormonal therapies toaddress common presenting symptoms in this age range.This presents a significant challenge for both women andhealthcare providers. The lack of a universally useddefinition in messaging and the absence of specificbiomarkers for perimenopause complicate the clinicallandscape, making it essential for practitioners todifferentiate between perimenopause and other healthconditions that may mimic its symptoms. The STRAW 10+framework offers a structured approach to identifying thevarious stages of reproductive aging, emphasizing theimportance of differentiating symptoms, signs, and timingof early versus late perimenopause. Naturopathicphysicians are well-equipped to investigate underlyinghealth issues that may contribute to symptoms oftenattributed to this phase, such as chronic illnesses,autoimmune conditions, and nutrient imbalances. Byemploying a comprehensive assessment strategy, including aPeri-Panel of relevant tests, clinicians can tailorinterventions that alleviate symptoms and address rootcauses. Ultimately, a holistic approach that considers theinterplay between hormonal health, lifestyle factors, andindividual patient needs will ensure that women receiveappropriate care during this demanding period andempower them with body literacy and personalizedsolutions before falling prey to narrow perspective solutionspresented by the burgeoning interest in women’s health. Dr. Thara Vayali is a naturopathic physicianwith over a decade of experience in women'shealth, specializing in endocrinology, gut andimmune health. She holds undergraduatedegrees with honors in Nutritional Sciencesfrom UBC and a Master's in EnvironmentalEducation from Royal Roads University. Dr.Vayali graduated from the Boucher Instituteof Naturopathic Medicine in 2011. She hasserved on the boards of arts-based educationalorganizations and taught yoga andmindfulness for over 20 years. Dr. Vayali isalso a speaker, educator, and writer, focusingon integrating empathy, technology, andskillful diagnostics in healthcare delivery.Currently, she serves as the Chief MedicalOfficer and Co-Founder of hey Freya,revolutionizing women's healthcare throughethical, science-driven supplements. JAN 2025 - VOLUME 20 | ISSUE NO. 01NATUROPATHIC DOCTOR NEWS & REVIEW

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561.U.S. Census Bureau. Age and Sex Composition: 2020. Census Brief C2020BR-06; May 2023.Accessed November 28, 2024.https://www.census.gov/library/publications/2023/decennial/c2020br-06.html 2. Hill K. The demography of menopause. Maturitas. 1996;23(2):113-127. 3. Harlow SD, Gass M, Hall JE, et al. Executive summary of the Stages of Reproductive AgingWorkshop + 10: addressing the unfinished agenda of staging reproductive aging. Menopause.2012;19(4):387-395.4. Ambikairajah A, Tabatabaei-Jafari H, Cherbuin N. Heterogeneity in menopause definitionsand criteria: a systematic review. Climacteric. 2022;25(3):237-245.5. Santoro N. Perimenopause: From Research to Practice. J Womens Health (Larchmt).2016;25(4):332-3396. El Khoudary SR, Greendale G, Crawford SL, et al. The menopause transition and women'shealth at midlife: a progress report from the Study of Women's Health Across the Nation(SWAN). Menopause. 2019;26(10):1213-1227.7. Gracia CR, Sammel MD, Freeman EW, et al. Defining menopause status: creation of a newdefinition to identify the early changes of the menopausal transition. Menopause.2005;12(2):128-135.8. Peacock K, Ketvertis KM. Menopause. In: StatPearls. StatPearls Publishing; 20249. Santoro N, Epperson CN, Mathews SB. Menopausal Symptoms and Their Management.Endocrinol Metab Clin North Am. 2015;44(3):497-515.10. Gartoulla P, Worsley R, Bell RJ, Davis SR. Moderate to severe vasomotor and sexualsymptoms remain problematic for women aged 60 to 65 years. Menopause. 2015;22(7):694-701.11. Lega IC, Fine A, Antoniades ML, Jacobson M. A pragmatic approach to the managementof menopause. CMAJ. 2023;195(19):E677-E672.12. Gatenby C, Simpson P. Menopause: Physiology, definitions, and symptoms. Best Pract ResClin Endocrinol Metab. 2024;38(1):101855. doi:10.1016/j.beem.2023.10185513. Khan SJ, Kapoor E, Faubion SS, Kling JM. Vasomotor Symptoms During Menopause: APractical Guide on Current Treatments and Future Perspectives. Int J Womens Health.2023;15:273-287. Published 2023 Feb 14. doi:10.2147/IJWH.S36580814. Santoro N, Roeca C, Peters BA, Neal-Perry G. The Menopause Transition: Signs,Symptoms, and Management Options. J Clin Endocrinol Metab. 2021;106(1):1-15.doi:10.1210/clinem/dgaa76415. Metcalf CA, Duffy KA, Page CE, Novick AM. Cognitive Problems in Perimenopause: AReview of Recent Evidence. Curr Psychiatry Rep. 2023;25(10):501-511.16. Maki PM, Jaff NG. Brain fog in menopause: a health-care professional's guide for decision-making and counseling on cognition. Climacteric. 2022;25(6):570-578.17. Weber MT, Rubin LH, Schroeder R, Steffenella T, Maki PM. Cognitive profiles inperimenopause: hormonal and menopausal symptom correlates. Climacteric. 2021;24(4):401-407.18. Weber MT, Maki PM, McDermott MP. Cognition and mood in perimenopause: asystematic review and meta-analysis. J Steroid Biochem Mol Biol.19. Bromberger JT, Epperson CN. Depression During and After the Perimenopause: Impact ofHormones, Genetics, and Environmental Determinants of Disease. Obstet Gynecol Clin NorthAm. 2018;45(4):663-678.20. de Kruif M, Spijker AT, Molendijk ML. Depression during the perimenopause: A meta-analysis. J Affect Disord. 2016;206:174-180.21. Maki PM, Kornstein SG, Joffe H, et al. Guidelines for the Evaluation and Treatment ofPerimenopausal Depression: Summary and Recommendations. J Womens Health (Larchmt).2019;28(2):117-134.22. Terauchi M, Hiramitsu S, Akiyoshi M, et al. Associations among depression, anxiety andsomatic symptoms in peri- and postmenopausal women. J Obstet Gynaecol Res.2013;39(5):1007-1013.23. Jagtap BL, Prasad BS, Chaudhury S. Psychiatric morbidity in perimenopausal women. IndPsychiatry J. 2016;25(1):86-92.24. Lu CB, Liu PF, Zhou YS, et al. Musculoskeletal Pain during the Menopausal Transition: ASystematic Review and Meta-Analysis. Neural Plast. 2020;2020:8842110.25. Kannel WB, Hjortland MC, McNamara PM, Gordon T. Menopause and risk ofcardiovascular disease: the Framingham study. Ann Intern Med. 1976;85(4):447-452. 26. Kamińska MS, Schneider-Matyka D, Rachubińska K, Panczyk M, Grochans E, CybulskaAM. Menopause Predisposes Women to Increased Risk of Cardiovascular Disease. J Clin Med.2023;12(22):7058.27. Zhu D, Chung H-F, Jansen E, et al. Age at natural menopause and risk of incidentcardiovascular disease: a pooled analysis of individual patient data. Lancet Public Health.2019;4(11):e553-e564.28. Woods NF, Mitchell ES, Smith-Dijulio K, et al. Menopause transition and cardiovasculardisease risk: implications for timing of early prevention: a scientific statement from theAmerican Heart Association. Circulation. 2020;142:e506–e532.29. Ji MX, Yu Q. Primary osteoporosis in postmenopausal women. Chronic Dis Transl Med.2015;1(1):9-13. Published 2015 Mar 21.30. Kim H, Kim J, Lee Y, et al. Use of combined oral contraceptives in perimenopausalwomen: benefits and risks. Clin Exp Reprod Med. 2018;45(2):49-56.31. Secosan C, Balulescu L, Brasoveanu S, Balint O, Pirtea P, Dorin G, Pirtea L. Endometriosisin menopause: renewed attention on a controversial disease. Diagnostics (Basel).2020;10(3):134. REFERENCESWOMEN'S HEALTH32. Jakson I, Hirschberg AL, Gidlöf SB. Endometriosis and menopause-management strategiesbased on clinical scenarios. Acta Obstet Gynecol Scand. 2023;102(10):1323-1328.33. Cho MK. Use of Combined Oral Contraceptives in Perimenopausal Women. ChonnamMed J. 2018;54(3):153-158. doi:10.4068/cmj.2018.54.3.15334. Conrad, N., et al. Incidence, prevalence, and co-occurrence of autoimmune disorders overtime and by age, sex, and socioeconomic status: a population-based cohort study of 22 millionindividuals in the UK. Lancet. 2023;401(10391):1878-1890. 35. Fairweather D, Frisancho-Kiss S, Rose NR. Sex differences in autoimmune disease from apathological perspective. Am J Pathol. 2008;173(3):600-609.36. Angum F, Khan T, Kaler J, Siddiqui L, Hussain A. The Prevalence of AutoimmuneDisorders in Women: A Narrative Review. Cureus. 2020;12(5):e8094. 37. Cohen J, van der Meulen Rodgers Y. An intersectional analysis of long COVID prevalence.Int J Equity Health. 2023;22(1):261.38. Bai F, Tomasoni D, Falcinella C, et al. Female gender is associated with long COVIDsyndrome: a prospective cohort study. Clin Microbiol Infect. 2022;28(4):611.e9-611.e16.39. Perlis RH, Santillana M, Ognyanova K, et al. Prevalence and Correlates of Long COVIDSymptoms Among US Adults. JAMA Netw Open. 2022;5(10):e2238804.40. Gao Y, Gao Y, Jiang Y, et al. Sex Differences in Hypercortisolism and Glucose-MetabolismDisturbances in Patients with Mild Autonomous Cortisol Secretion: Findings From a SingleCenter in China. Front Endocrinol. 2022;13:857947.41. Pizzorno L, Pizzorno J. Subclinical Hypercortisolism: An Important, UnrecognizedDysfunction. Integr Med (Encinitas). 2022;21(3):8-15.42. Iacopo Chiodini. Diagnosis and treatment of subclinical hypercortisolism. J ClinEndocrinol Metab. 2011;96(5):1223-1236.43. Braun LT, Vogel F, Nowak E, et al. Frequency of clinical signs in patients with Cushing'ssyndrome and mild autonomous cortisol secretion: overlap is common. Eur J Endocrinol.2024;191(4):473-479.44. Fairweather D, Beetler DJ, McCabe C, Lieberman S. Sex differences in autoimmunedisease: mechanisms and implications. J Clin Invest. 2024;134(9):e180076.45. Tedeschi SK, Barbhaiya M, Malspeis S, et al. Obesity and the risk of systemic lupuserythematosus among women in the Nurses' Health Studies. Semin Arthritis Rheum.2017;47(3):376-383.46. Harpsøe MC, Basit S, Andersson M, et al. Body mass index and risk of autoimmunediseases: a study within the Danish National Birth Cohort. Int J Epidemiol. 2014;43(3):843-855.47. Mishra A, Shang Y, Wang Y, Bacon ER, Yin F, Brinton RD. Dynamic NeuroimmuneProfile during Mid-life Aging in the Female Brain and Implications for Alzheimer Risk.iScience. 2020;23(12):101829.48. Chukur O, Pasyechko N, Bob A, Sverstiuk A. Prediction of climacteric syndromedevelopment in perimenopausal women with hypothyroidism. Prz Menopauzalny.2022;21(4):236-241.49. Mattioli AV, Coppi F, Nasi M, Pinti M, Gallina S. Long COVID: A New Challenge forPrevention of Obesity in Women. Am J Lifestyle Med. 2022;17(1):164-168.50. Belchior-Bezerra M, Lima RS, Medeiros NI, Gomes JAS. COVID-19, obesity, and immuneresponse 2 years after the pandemic: A timeline of scientific advances. Obes Rev.2022;23(10):e13496.51. Dyrek N, Wikarek A, Niemiec M, Kocełak P. Selected musculoskeletal disorders in patientswith thyroid dysfunction, diabetes, and obesity. Reumatologia. 2023;61(4):305-317.52. Angum F, Khan T, Kaler J, Siddiqui L, Hussain A. The Prevalence of AutoimmuneDisorders in Women: A Narrative Review. Cureus. 2020;12(5):e8094.53. Newson L, Lewis R, O'Hara M. Long Covid and menopause - the important role ofhormones in Long Covid must be considered. Maturitas. 2021;152:74.54. Averyanova M, Vishnyakova P, Yureneva S, et al. Sex hormones and immune system:Menopausal hormone therapy in the context of COVID-19 pandemic. Front Immunol.2022;13:928171.55. Navas-Otero A, Calvache-Mateo A, Martín-Núñez J, et al. Characteristics of Frailty inPerimenopausal Women with Long COVID-19. Healthcare (Basel). 2023;11(10):1468. 56. Desai MK, Brinton RD. Autoimmune Disease in Women: Endocrine Transition and RiskAcross the Lifespan. Front Endocrinol (Lausanne). 2019;10:265.57. Li K, Chen G, Hou H, et al. Analysis of sex hormones and menstruation in COVID-19women of child-bearing age. Reprod Biomed Online. 2021;42(1):260-267.58. Grygiel-Górniak B, Limphaibool N, Puszczewicz M. Clinical implications of systemic lupuserythematosus without and with antiphospholipid syndrome in peri- and postmenopausal age.Prz Menopauzalny. 2018;17(2):86-90.59. Le MT, Le VNS, Le DD, Nguyen VQH, Chen C, Cao NT. Exploration of the role of anti-Mullerian hormone and LH/FSH ratio in diagnosis of polycystic ovary syndrome. ClinEndocrinol (Oxf). 2019;90(4):579-585.60. Schliep KC, Mumford SL, Hammoud AO, et al. Luteal phase deficiency in regularlymenstruating women: prevalence and overlap in identification based on clinical andbiochemical diagnostic criteria. J Clin Endocrinol Metab. 2014;99(6):E1007-E1014.

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Hormone Needs During Peri-MenopauseHormone needs vary throughout the month, particularlyduring the erratic hormone phase of perimenopause. I mightprescribe estradiol patches post-ovulation combined withblack cohosh, sage, and Schisandra berry during other phases.This allows for symptom relief while considering the body’snatural fluctuations in estrogens at this time.Micronized progesterone is often micro-dosed orally at 10-25mg² and used post-ovulation or the last week of the lutealphase combined with evening primrose oil³ throughout theentire luteal phase to support fatty acid production. Addressing Libido, Fatigue, and Vaginal DrynessFor low libido and fatigue, I may add DHEA and/ortestosterone in cream form,⁴ depending on the patient's freetestosterone and fatigue levels. For some women, oral DHEAsupplementation⁵ may work better than in a vaginal cream.Daily topical-based testosterone supplementation is my go-to;however, I do have some clients who use injectable formsweekly. It’s not uncommon for me to use DHEA the entiremonth orally and add vaginal testosterone cream startingafter the period ends in peri-menopausal women. Compounded estriol cream is my go-to for treating vaginaldryness and signs of aging skin. Estriol’s versatility anddecreased impact on blood estrogen levels⁶ allow it to be usedon various skin areas, offering aesthetic and functionalbenefits⁷. When used vaginally, after an initial loading dosenightly for 2 weeks, I often recommend a maintenanceregimen, applying estriol vaginally 1-2 nights a week and tothe face the rest of the week. Estriol has even been used inbreast cancer patients to counter vaginal atrophy.⁸For many women experiencing a decrease in sexual interestdue to dryness and reduced libido in peri-menopause, DHEAand testosterone can be combined with estriol cream forvaginal use. Clients who desire an anti-aging, non-toxicapproach to skin care can combine estriol with Vitamin Cpowder, hyaluronic acid, and Vitamin E, formulated bycompounding pharmacies to support skin health whileaddressing deeper hormonal needs.Hormonal Adjustments During Menopause andBeyondAs women transition into menopause, their hormone needsshift. Treatment may include continuous estradiol patches orbi-est cream formulations (a blend of estriol and estradiol)with varying ratios. Depending on symptom severity, I recommend periodicbreaks from hormone use to allow the body to reset. Thisis particularly relevant for women who have been usinghormones for over a year and have stable levels. Thisbreak can support detoxification and prevent hormonaldependency.In my practice, I’ve found that women 10 years pastmenopause often require lower hormone doses than thosenewly transitioning. Adjusting hormone levels throughtapering and micro-dosing can maintain a balance thatsupports the body’s changing needs while minimizingsymptoms. However, it is important to recognize thatsome women continue to experience symptoms and mayrequire sustained hormone support for longer. This is why I’m a huge fan of testing and not guessing, aswell as taking a break from hormones for a week or so tosee how you feel. Importance of Hormone Testing andDetoxificationMonitoring DHEA-sulfate levels and understandingsymptoms are key to determining whether a patient willbenefit more from bioidentical hormones or herbalsupport. The transition of hormone production from theovaries to the adrenal glands involves assessing adrenaland nervous system health. This process helps determinethe best combination of herbs and hormones for eachclient. Liver function, gut health, and methylationcapabilities must also be assessed before introducinghormone support.A comprehensive understanding of a client’s ability todetox hormones through liver function, the gutmicrobiome, and cellular methylation is crucial.Identifying detoxification bottlenecks can prevent sideeffects and enhance treatment outcomes. Additionally,evaluating nervous system health is vital. Integrating Nervous System and HormonalHealthHormonal changes can be more challenging for thosewhose nervous systems are in a chronic state of fight,flight, or freeze. A protocol addressing hormonal andnervous system balance—including adaptogens,breathwork, and lifestyle modifications—can improveoverall results.58WOMEN'S HEALTH

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A whole-body approach to hormone balancing isnecessary, and many naturopathic and functionalmedicine practitioners have realized this and havecompleted programs to address all aspects of hormonehealth. It is concerning how some mainstream sourcesportray hormones as universally "safe" despite thepotential risks from pharmaceutical formulationscontaining parabens and phthalates—chemicals knownto disrupt hormones. This becomes especiallyproblematic when combined with daily habits that mayimpair detoxification, like alcohol consumption.Understanding a client’s exposure to toxins, lifestyle,and family history, especially concerning cancers suchas breast, uterine, or ovarian cancer, is imperative.While cancer history was once seen as acontraindication for hormone use, new insights intodelivery methods and absorption rates of hormonessuggest that personalized hormone support is possibleeven in such cases.⁹ Research has shown that breastcancer survivors have been able to use testosteronecream successfully, and many are using estriol forvaginal atrophy.⁹ I’m currently seeing a 47-year-oldfemale who was diagnosed with breast cancer at 40 andhas been using 0.3% estriol cream vaginally as well ason her face for the last 5 years without anycomplications or excessive rises in her estriol orestradiol levels in her blood or urine on testing. A core aspect of my practice is educating clients abouttheir hormonal cycles, the influence of lunar phases,and the benefits of herbal and hormonal interventions.Encouraging clients to track their cycles—even aftermenstruation has ceased—provides valuable insightsinto their needs and helps fine-tune protocols.Journaling enables clients to understand physical andemotional fluctuations and better informs them whentesting should occur.Urine hormone metabolism tests, now accessible forhome use, offer a practical way to monitor hormonelevels throughout the month. Knowing when to useblood versus saliva tests also helps refine treatment.For clients struggling with hormone metabolism,combining herbs with hormone therapies can reduceside effects like acne, puffiness, and lethargy.Customizing progesterone dosage, sometimes as low as10 mg, can be effective for sensitive clients.59 JAN 2025 - VOLUME 20 | ISSUE NO. 01NATUROPATHIC DOCTOR NEWS & REVIEW

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60Dr. Jannine Krause is a naturopathic doctor,acupuncturist, and host of The Health FixPodcast specializing in optimizing mental andphysical performance for women over 40. Shehas a doctorate in naturopathic medicine,master’s in acupuncture, and bachelor’s inbiology. Her work has been featured in outletsincluding Authority Magazine, NaturopathicDoctor News & Review, SheKnows, HoneHealth, “True Health with Ashley James”podcast, “The Gutsy Health Podcast,” and“The Less Stressed Life Podcast.”Understanding a client’s emotional landscape, stressors, andpast trauma is critical in creating effective hormone support.Adaptogens, alongside education about lifestyle factors likethe moon cycle and personal rhythms, empower clients toparticipate actively in their healing process.A Whole-Body Approach to Hormonal BalanceCombining bio-identical hormones with herbal treatmentsoffers a flexible and practical approach to supporting womenthrough hormonal transitions. A personalized method,grounded in naturopathic principles, considers each woman’sunique needs and evolving biology. By educating andinvolving clients in their healthcare, practitioners can guidethem through the complexities of hormone balancing,ensuring they feel supported and empowered throughouttheir journey.1.Clark, James H. "A Critique of Women’s Health Initiative Studies (2002-2006)." NuclearReceptor Signaling, vol. 4, 30 Oct. 2006, e023, https://doi.org/10.1621/nrs.04023.2.Dolitsky, Shelley N., et al. "Efficacy of Progestin-Only Treatment for the Management ofMenopausal Symptoms: A Systematic Review." Menopause, vol. 28, no. 2, 12 Nov. 2020, pp. 217-224, https://doi.org/10.1097/GME.0000000000001676.3.Mahboubi, Mohaddese. "Evening Primrose (Oenothera biennis) Oil in Management of FemaleAilments." Journal of Menopausal Medicine, vol. 25, no. 2, 5 Aug. 2019, pp. 74-82,https://doi.org/10.6118/jmm.18190.4. Islam, Rakibul M., et al. "Safety and Efficacy of Testosterone for Women: A Systematic Reviewand Meta-Analysis of Randomised Controlled Trial Data." The Lancet Diabetes &Endocrinology, vol. 7, no. 10, Oct. 2019, pp. 754-766, https://doi.org/10.1016/S2213-8587(19)30189-5.5. Rabijewski, Michal, et al. "Supplementation of Dehydroepiandrosterone (DHEA) in Pre- andPostmenopausal Women - Position Statement of Expert Panel of Polish Menopause andAndropause Society." Ginekologia Polska, vol. 91, no. 9, 2020, pp. 554-562,https://doi.org/10.5603/GP.2020.0091.6. Rueda, C., et al. "The Efficacy and Safety of Estriol to Treat Vulvovaginal Atrophy inPostmenopausal Women: A Systematic Literature Review." Climacteric, vol. 20, no. 4, Aug. 2017,pp. 321-330, https://doi.org/10.1080/13697137.2017.1329291.7. Schmidt, J. B., et al. "Treatment of Skin Ageing Symptoms in Perimenopausal Females withEstrogen Compounds: A Pilot Study." Maturitas, vol. 20, no. 1, Nov. 1994, pp. 25-30,https://doi.org/10.1016/0378-5122(94)90097-3.REFERENCES8. Sánchez-Rovira, Pedro, Angelica Lindén Hirschberg, Miguel Gil-Gil, Begoña Bermejo-De LasHeras, and Concepción Nieto-Magro. 2020. "A Phase II Prospective, Randomized, Double-Blind,Placebo-Controlled and Multicenter Clinical Trial to Assess the Safety of 0.005% Estriol Vaginal Gelin Hormone Receptor-Positive Postmenopausal Women with Early Stage Breast Cancer inTreatment with Aromatase Inhibitor in the Adjuvant Setting." Oncologist 25 (12): e1846-1854. doi:10.1634/theoncologist.2020-04179. Glaser, R., and C. Dimitrakakis. "Testosterone and breast cancer prevention." Maturitas, vol. 82,no. 3, 2015, pp. 291-295, doi: 10.1016/j.maturitas.2015.06.002.10. Amarakoon, Darshika, Wu-Joo Lee, Gillian Tamia, and Seong-Ho Lee. 11."Indole-3-Carbinol: Occurrence, Health-Beneficial Properties, and Cellular/MolecularMechanisms." Annual Review of Food Science and Technology 14 (2023): 347-366.https://doi.org/10.1146/annurev-food-060721-025531.12. Chen, M-N, C-C Lin, and C-F Liu. "Efficacy of Phytoestrogens for Menopausal Symptoms: AMeta-Analysis and Systematic Review." Climacteric 18, no. 2 (2015): 260-269.https://doi.org/10.3109/13697137.2014.966241.13. Greff, Dorina, Anna E. Juhász, Szilárd Váncsa, Alex Váradi, Zoltán Sipos, Julia Szinte, SunjunePark, Péter Hegyi, Péter Nyirády, Nándor Ács, Szabolcs Várbíró, and Eszter M. Horváth. "InositolIs an Effective and Safe Treatment in Polycystic Ovary Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials." Reproductive Biology and Endocrinology 21, no. 1(2023): 10. https://doi.org/10.1186/s12958-023-01055-z.14. Zeng, Ling-Hui, Saba Rana, Liaqat Hussain, Muhammad Asif, Malik Hassan Mehmood, ImranImran, Anam Younas, Amina Mahdy, Fakhria A. Al-Joufi, and Shaymaa Najm Abed. "PolycysticOvary Syndrome: A Disorder of Reproductive Age, Its Pathogenesis, and a Discussion on theEmerging Role of Herbal Remedies." Frontiers in Pharmacology 13 (2022): 874914.https://doi.org/10.3389/fphar.2022.874914.15. Chan, Shun-Wan. "Panax Ginseng, Rhodiola Rosea and Schisandra Chinensis." InternationalJournal of Food Science and Nutrition 63, Suppl. 1 (2012): 75-81.https://doi.org/10.3109/09637486.2011.627840.WOMEN'S HEALTHThe Importance of Differential DiagnosisWhen hormone detoxification is challenging, dietary andherbal supports can be effective. Supplements like DIM (di-indole methane), sulforaphane, and cruciferous vegetables10are beneficial for estrogen detoxification. Herbal optionslike sage, red clover, and black cohosh can complementhormonal therapies.¹¹ For testosterone detox, I use sawpalmetto, inositol, and licorice.¹²'¹³Balancing the gut microbiome to reduce beta-glucuronidaselevels also plays a critical role in hormonal health.Probiotics, Calcium-D-glucate (CDG), and gut-liningsupport can assist in this area. A deeper microbiomeanalysis can guide treatment adjustments if testing indicatesgut imbalances.Hormone protocols must evolve as clients age. In their 30s,women's protocols focus on supporting ovarian function,while later strategies shift to emphasize adrenal health.Personalized adaptogenic herbs are often essential duringthis transition, and I’ve found in my practice thatashwagandha and Schisandra berries benefit youngerwomen. At the same time, Siberian ginseng, Rehmanniaroot, and Rhodiola are better suited for older clients.¹⁴

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