Depression, Anxiety and Hormones
Depression and anxiety can be caused by hormonal imbalance.
In episode 57 of the BioBalance Healthcast we talk about some of the medical and emotional causes of depression. Last week we talked generally about Depression and Anxiety. This episode focuses more specifically on the role hormone imbalance can play in causing anxiety and how it can often be treated with bioidentical hormone pellet therapy. The discussion is in part based on a chapter of my book, Testosterone, The Secret Female Hormone. Following is an excerpt of the draft manuscript.
Anxiety and Hormones
Anxiety. Worry. Fear. Anxiety is a term most people use loosely to describe “over worry,” but when intermittent worry, turns into constant fear or recurrent episodes of fast heart rate, sweating and/or the feeling of impending doom, that won’t go away with deep breathing or the many anti-anxiety drugs on the market, a true medical condition called Anxiety is the best label. The many and varied symptoms of anxiety are listed below. A patient with anxiety can have one or the majority of these symptoms.
Here are some of the symptoms of Anxiety:
- Fast pulse
- Feeling of impending doom
- Sometimes cyclic, in the last week of a menstrual cycle
- Temper outbursts
- Insomnia waking at 2 am with heart racing
- Lack of ability to concentrate
- Unreasonable worry
- “Flying off the handle” without provocation
- Hyperventilation and chest discomfort
- Flight of ideas
- Mind is racing
There are many causes of the disease known as anxiety. The one cause responsible for anxiety in women over 40, is testosterone loss and after 50 estradiol deprivation. Before using bioidentical hormones to treat the other symptoms of hormone loss, I treated anxiety like any other doctor; with medications like Xanax, or Ativan, to treat the symptom, but never really looking at the cause that began the process. This is the one symptom that I never in my wildest dreams considered to be related to the loss of testosterone or estradiol!
I was trained to replace these hormones in the most natural way, to alleviate many other symptoms, but anxiety was not one of them. Soon after I began to use Bio-identical testosterone pellets, my patients came to report on their success. At the end of the conversation, they would usually add a statement like this, “I thought that the many symptoms of menopause and peri-menopaus would be gone, but it was so weird…I don’t have anxiety attacks, or I don’t have anxious worry anymore! Why do you think that is?”
After going through the research I found papers on the fact that elevated FSH and LH prior to menopause can cause atypical “hot flashes”. They were described in many ways, one of which was an anxiety attack or overwhelming anxiety, and worry all the time. The anxiety attacks were related to brief elevations of FSH and LH from the pituitary that did not feel hot or generally sweaty (although sweating could accompany the anxiety), like a hot flash, but was perceived as an anxiety attach with fast heart rate, fear and jitteriness. The surge of FSH/LH destabilized the neurotransmitters of the brain and instead of stimulating the temperature center, it stimulated the area of the temporal lobe that controls mood, causing a brief but potent anxiety attack. By replacing testosterone and estradiol (after menopause), the surges subsided and so did the anxiety attacks. Even now, some of my patients can tell their testosterone pellets are wearing off because their anxiety attacks start up again!
Just to be complete, other psychiatric and medical illnesses can masquerade as anxiety, and are not responsive to replacement with hormones. The most likely illnesses that appear like anxiety can be, Bipolar disorder, Attention Deficit Disorder, and personality disorders, to mention a few. It takes a physician, lab work and a few sessions in the office to decide which disease is the primary issue.
In the case of long standing anxiety,(appearing earlier than age 40) a genetic component can be integral to the appearance of anxiety in a particular patient. In some cases the cause is a gene that translates into low serotonin and norepinephrine levels. It can also be from genetically low testosterone levels, and in that case the history of a low sex drive is typical as well.
Lastly, a few other hormones can be guilty of hyper-secretion, causing anxiety. Cortisol and Thyroid are the two most likely suspects. Longstanding high cortisol is called Cushings, and increases anxiety, energy, decreases immunity, and allergies, but can exhibit the anxiety with anger and irritability, as well as sleep.essness. If hyperthyroidism is the cause, an auto immune thyroid condition stimulates the thyroid so temperature, pulse, rate of breathing increase as well as anxiety. Most often weight drops rapidly and sleep is not necessary to function.
Now for the women who are dealing with this symptom and have no idea that it could be related to hormones,the characteristics of anxiety caused by testosterone deprivation have some telltale signs that are characteristic to loss of testosterone as the primary cause.
Helen Hormonal is a 43 year old working mother of three who sits down quickly in her doctors office, drums her fingers on the desk and sighs over and over again before she starts to discuss her problem. Helen feels very different than she did a few years ago and her biggest worry is that she feels anxious all the time, punctuated with severe anxiety attacks, especially at night that feel like she is having a heart attack. Helen tells her doctor, “I worry more than ever before, in fact, all the time, but when I try to sleep, or relax in the evenings I get surges of anxiety that come and go, lasting a few minutes at a time. I feel my heart beat quickly, I sweat and get chest pressure and feel like I’m going to die, right there!” Helen is clearly afraid she has heart disease, but she has already had a cardiac work up and it is negative. She is asked about other symptoms that are new; Helen remembers that she wake up at 2 am and can’t go back to sleep, and she is not interested in sex any more. Helen thinks awhile and tells her hormone doctor that she has noticed that the more severe episodes of anxiety occur when she is having her period. She remembers that her mom had the same thing when she was in her 40s, and was given valium. She finally asks her doctor,” None of the anti-depressants or antianxiety pills that my primary care doctor gave me help, and some even made me worse. I don’t get it, my life is great, I have had nothing to be anxious about. What is wrong with me?”
Helen is the typical patient who needs testosterone replacement. She knows there is something physical wrong with her, but the traditional treatments for the symptoms she is having don’t work. Her anxiety is new since she turned 40, and she wants an answer and a treatment for the cause of her symptoms.
Specifically following is the diagnosis of Helen’s symptom list: The hormonal reason behind her symptoms of anxiety are complex, but include surges of FSH and LH stimulated by low testosterone levels causing an increase of these hormones that cause an atypical hotflash. The anxiety attack is cause by the surge of FSH and LH that cause tachycardia, sweating and shortness of breath. The low testosterone decreases the amount of seratoinin and Norepinephrine that is produced in the brain, and in return makes the woman feel depressed and anxious from lack of neurotransmitters. Many women treat their anxiety by having regular sex to improve endorphins, but as libido disappears their unconscious self-treatment goes with it.
- Symptoms that are typical of anxiety caused by Testosterone Deficit include:
- New onset of symptoms after age 38
- Increased episodes at night and during the period
- Lack of life events typical of situational anxiety
- Other symptoms of Testosterone Deprivation
Oh, forgive me but I forgot the most common source of depression in ,my previous chapters…weight gain! The change in our bodies after we turn 40 is the most external sign that we are aging, and if you are a doctor the most obvious symptoms that testosterone has decreased! There are very few women in America who can avoid this physical change without replacing the lost hormones or exercising to excess or both.
Helen Hormonal came to her hormone doctor for her second visit before she had started her hormonal replacement.
“I am so freaked out! I looked in the mirror and my mother looked back at me! I have her sagging double chin, and none of my clothes fit…I have tried every diet and my belly keeps getting bigger! I am so depressed and it is so unfair! If I had a sex drive I would still be too embarrassed to have sex because of my body! I got married at 120 lbs and now I’m 165! Aaagghhh!”
Helen has a lot of company! Her doctor consoles her and tells her that she will give her the missing hormones back and write a script to replace her flagging thyroid, but she has to do her part as well. “Helen, you are going to have to stop eating 6,000 calories of fast food, and carbohydrates a day. You won’t need it to medicate your miseryanytmore.” Helen looks like she lost her best friend…her Cherry Coke! “ Helen, you will feel better in a month or so and then I want you to exercise 3 times a week, no excuses. Exercise means sweating too! I also want you to begin a low carb,6 feedings a day, diet. It took a long time to get here and it will take a while to work your way back to health!” Helen nods and considers her dilemma. Dr. Hormone reassures her that with her replaced hormones she has a chance to regain her health, and her body, and she will soon feel more like exercising when she is not so tired.
Here’s some of what you might be seeing in the mirror:
- Decrease in muscle mass
- Increase in abdominal fat
- Increase in cellulite
- Decrease in skin quality and tautness
- Increase in wrinkles and sagging “waddle”
- Dry and translucent skin with visible veins
- Loss of hair on your head and in the pubic area
When we are young we take our beauty, youth and our hormones for granted. Some of us did destructive things to ourselves, like smoke, drink, and eat too much of the wrong things, but youth protected us. Now everything fails all at once and aging plus our bad habits show up all over our body. What happened and what can we do?
Much of what has happened is the result of declining levels of free testosterone, estradiol, progesterone, and growth hormone, and possibly thyroid, combined with increased levels of estrone and androstenedione from the adrenal gland.
Helen hormonal wants a reason for all of this. She asks her hormone doc why this happens in the middle of our lives?
“ We were built to live about 40 years. Now our intelligent medical minds have given us a longer life, but we were built to last 40 years. When our ability to reproduce decreases after 40 the outward appearance was a sign that we were no longer fertile. Both pregnant and older women lose their waistlines….that is why having a small waist is so important to men and women. It is a sign of youth and fertility. Some things don’t change, but we can outsmart an outmoded system. We can restore our minds and bodies with replacement hormones and give us back a quality life instead of a sick, but long life!”
Helen was so excited to understand the cause of this seemingly senseless mess!
Take a look at the list of functions of estradiol and testosterone do for our tissues:
- Stimulate collagen production
- Reduce cellulite
- Increase dermal (skin) thickness
- Increase skin moisture and natural oil
- Increase thickness of scalp hair and eyebrows
- Accelerate healing
- Increase blood flow to the skin, muscle and connective tissue
- Increase the volume and definition of muscle and support for the skin layer
- Increase lean body mass
- Decrease our waistline
The addition of all three of your missing hormones into your health regimen increases the collagen and the supportive tissues for your skin. This improves your body composition to a more youthful figure over about 12 months. Of course, damage from sun and smoking is not reversible in this manner and must be dealt with in other ways.
Cellulite is a function of a low-oxygen-environment surrounding superficial fat. The largest areas of cellulite on women are the fatty areas covering the large muscles of the thigh, hip and gluteus (buttocks). When testosterone decreases, muscles shrink, and do not demand as much oxygen. The fat lying on top of those muscles are “starved” for oxygen, and they succumb to scarring areas of muscle in response to a low oxygen environment. These scars pull the skin down and “dimple” the skin overlying the hypoxic fat. This is where cellulite comes from. All treatments for treatment of cellulite are aimed at oxygenating the fat. The best oxygenator is replacing the testosterone so blood and oxygen is drawn to the working and growing muscles. This heals the cellulite from the inside out. For severe cases or faster repair, I-Lipo laser or radiowave cellulite treatments help stimulate the bloodflow quickly and helps dissolve the fat as well.
Restoration of our previous youthful body requires patience, time, work, a Mediterranean low carb diet and exercise. First, hormonal replacement restores tissue integrity. Weight remains stable, rather than inching upward, as muscle builds and fat decreases for one year. Clothing size, and waist measurement decreases as muscle builds. Finally, weight begins to decrease after one year of therapy, and continues until you reach ideal weight.
Remember, it took years of hormone insufficiency to get here, it will take at least a year to get back. It will be easier than you think once you get your energy back. It is truly amazing to watch the reformation of your figure after you follow this treatment plan.
Dry Eyes and Testosterone
Dry eye syndrome is defined as a decrease in the production of tears or poor quality of the tears, e.g., tears that break down too quickly to be of benefit. It can also be excessive tear evaporation. When tears are lacking or of poor quality, the cornea becomes dry and vision is distorted. This condition can prevent you from wearing contacts and cause you to have difficulty preventing corneal abrasions. This is not a minor symptom of testosterone deficiency.
There are other causes for dry eyes, but the one cause that is most prevalent is the loss of testosterone that occurs after 45 y.o in women. Every gland that produces “wetness”, like lacrimal ducts (tears), salivary glands (saliva), sweat glands (sweat), among others dry up when the level of testosterone becomes critical. This is a recent finding in the literature and has been discussed and evaluated mostly by opthamologists. Because they don’t replace hormones, and it is kind of tricky, they have used topical drops with testosterone, but they were only mildly successful.
The real treatment for this condition, when secondary to low testosterone levels is systemic testosterone, that is replaced 24/7. Many of my patients have been happily surprised when they could throw away their “cheaters”, and put their contacts back in, after being treated with testosterone pellets for other reasons. Some opthamologists send me their most difficult patients to treat for dry eyes, with testosterone pellets, however there are generally multiple causes in the worst cases, and it has not been as successful as in the patient who presents for some other testosterone deprivation syndrome.
If you think this is a minor problem compared to lost libido and memory loss, then think again. The statistics about dry eyes might surprise you. Did you know that 3.2 million American women over 50 suffer from dry eyes? One point six million American men over 50 do, as well. Hispanic and Asian women are at higher risk than other ethnic groups.
Symptoms of dry eye syndrome:
- Red, scratchy eyes
- New intolerance to contact lenses
- Burning and stinging of the eyes
- Stringy mucous from the eyes
- Blurred vision
- Frequent infections
- Frequent abrasions of the cornea
- Decreased night vision
Testosterone is essential to the health of the lachrymal duct and is crucial to the production of tears. Decreased testosterone causes increase in “cytokines” which are an inflammatory chemical in the blood and tears. Once the lachrymal duct is inflamed it stops producing tears.
There are conditions other than testosterone deprivation that can cause dry eye syndrome, as well:
- Autoimmune disorders like rheumatoid arthritis, Sjögren’s, and Lupus (SLE)
- Dry air
- Contact lenses
- Car air-conditioning ducts
- Medications, e.g., high blood pressure, antihistamines, sleeping pills, some pain relievers
- Lasik, blepharoplasty, and other corneal eye surgery
Pregnancy is a notable cause of dry eyes. “A significant proportion of women report dry-eye syndrome during pregnancy, especially when they have had at least one prior birth.” Joel Schechter, Ph. D., reported, “…In Dr. Evans’ study, symptoms were four times more likely to be worse during pregnancy than before it.” “During pregnancy, androgens are deficient, causing insufficient lachrymal gland function.”
But pregnancy isn’t the only hormonal culprit – there’s also menopause. “Dry eyes occur most frequently in older persons and more often in women than men. The androgens that are released normally by the lachrymal gland help maintain the gland’s structural integrity.”1 This substantiates the connection between dry eyes and the endocrine system.
Women are forced to stop wearing contact lenses just when bifocals are needed! We have noticed for years that patients taking testosterone pellets resolved or improved their dry eyes. Now research has proven that parenteral (IV or IM or pellets) replacement can relieve dry eye symptoms. 2 Testosterone eye drops are also being compounded for patients who cannot take testosterone pellets, but are found to be less effective than pellet therapy.”
1 All from Evans, Jeff, “Study shows dry eyes a problem in pregnancy,” AMA News,
2 0062 Schaumberg DA, et al, “Prevalence of dry dye syndrome among US women,” Am Journal of Ophthalmol, 2003 Aug;136 (2):318-26; Schaumberg DA, et al, “Hormone replacement therapy and dry eye syndrome.” JAMA 2001 Nov 7; 286(17): 2114-9.