Endfatigue Home Page Interview with Elizabeth Vliet, M.D. From Fatigued To Fantastic is pleased to interview Elizabeth Lee Vliet, M.D., author of "Screaming to be Heard - Hormonal Connections Women Suspect... And Doctors Ignore." Dr. Vliet is a national expert on the role of estrogen (and testosterone) deficiency in CFIDS/FMS, migraines, PMS, and other illnesses which affect women with far greater frequency than men. She is founder and Medical Director of "HER Place," a comprehensive wellness oriented program in Tucson, Arizona and Dallas, Texas and has served as the chairwoman of the Southern Medical Association conference on preventive medicine. She is on the clinical faculty of the University of Arizona and the University of North Texas Medical Centers. Dr. Teitelbaum: How did you get involved in women's health issues? Dr. Vliet: After years of seeing patients develop fibromyalgia, migraines, "depression", poor sleep and memory, and a host of other symptoms soon after hysterectomies or tubal ligations, or at the onset of menopause, it became clear that there was a connection -- especially with the female predominance of CFIDS/FMS and an average onset in one's early 40s. It is staggering to me that the obvious questions about the role of ovarian deficiency as a trigger for FMS/CFIDS are not being asked. The woman is usually aware that her symptoms cycle with her period, but the doctor usually ignores this information. Dr. Teitelbaum: How common are suboptimal estrogen levels and what response do you see with estrogen therapy? Dr. Vliet: All of my documented CFIDS/FMS patients have had lower than expected (low or low normal) estrogen levels. Over 75% show major improvement after one to six months of restoring estrogen, DHEA, and testosterone to optimal levels. Dr. Teitelbaum: How does low estrogen trigger fibromyalgia? Dr. Vliet: As documented and referenced in my book, low estrogen from any cause, including ovarian decline as in menopause or hypothalamic suppression, will cause poor sleep and can trigger the rest of the cascade. My background in psychiatry at John Hopkins gave me a foundation for understanding the biochemistry of biological changes in the brain. Research shows low estrogen can cause the drop in neurotransmitters, e.g. serotonin and acetylcholine, and the low DHEA and testosterone seen in FMS. As discussed in my book, it can also account for many of the other biochemical changes and symptoms seen in FMS/CFIDS. It is scandalous that this information is being ignored by physicians and pharmaceutical companies. It is critical that we look at estrogen levels, because you won't get optimal improvement until you treat this major piece of the puzzle. Dr. Teitelbaum: What triggers low estrogen? Dr. Vliet: There are a number of causes. A stressful life-style, for example, can cause hypothalamic suppression. Menopause is the natural decline in estrogen, but many women's estrogen levels drop long before their periods become irregular or their FSH and LH blood levels become elevated. These are late findings in the menopause transition, but many women's symptoms may also begin in the one to three years after a hysterectomy or tubal ligation. Dr. Teitelbaum: I was amazed to find out that a hysterectomy will cause early menopause even if the ovaries are left in!. No one told us this in medical school. Dr. Vliet: Amazing, isn't it? The research done by Dr. Phillip Sarrel at Yale shows that 60% of women who have a hysterectomy (leaving in the ovaries) will go into menopause within three years, and often within six months. This has major implications for younger women who have had hysterectomies. Dr. Teitelbaum: How long does it take to see improvement with estrogen therapy? Dr. Vliet: Sleep starts to improve in four to six weeks, followed by mood, energy, and clarity of thinking. Energy starts to improve in about six weeks, and pain starts to improve after three months. I usually see optimal improvement in six to nine months. Dr. Teitelbaum: How do you treat FMS/CFIDS? Dr. Vliet: I see FMS/CFIDS as a trauma to our whole body and spirit. It is important to treat the whole process-hormone deficiencies as well as nutrition, sleep, life-style, etc. For example, who are the "toxic people" in your life? Although I emphasize estrogen therapy, it is important that all the modalities must be integrated for optimal health. Dr. Teitelbaum: How do you approach estrogen and testosterone therapy? Dr. Vliet: 17-beta estradiol is the main form of estrogen in the human female. Unless the woman's ovaries have been removed, I prefer to begin with estrogen therapy for two to three months before adding DHEA or testosterone, as estrogen may stimulate DHEA or testosterone production. If testosterone is raised without first raising estrogen levels, you can worsen the ratio and increase pain symptoms. I find this will also happen if DHEA is added or increased before the estradiol (estrogen) is brought up to an optimal level. Using natural estradiol (e.g. Estrace, or the Estraderm or Climara patch) is preferable. I do not like using the "triestrogen" form though. Horse derived estrogen (e.g. - Premarin) is not natural for women. I do not recommend using Premarin because is frequently aggravates FMS/CFIDS. In younger women who are still cycling, a low dose of progesterone is needed to protect the uterus. Most birth control pills have too much progesterone or too little estrogen. I like to use Ovcon 35. If the woman has side effects, I switch to Estrace or the Climara patch. Climara causes less skin irritation than Estraderm. If estradiol levels are mildly decreased, 1/2 to 1 mg of Estrace per day may be adequate. If the uterus is present, you need to add about 100 mg per day of natural progesterone (Ed. Note: Natural testosterone and progesterone are available from Belmar Pharmacy (800) 525-9473 or Cape Drugs (800) 248-5978), or a cyclic regimen of 200 mg per day for ten days each month. Taking it daily is useful in menopausal woman who do not want to have periods. Their periods will usually go away after nine months on daily estrogen and progesterone. If a woman has had a hysterectomy, she does not need progesterone. One exception is if there is a history of endometriosis. The progesterone then decreases the risk of flaring the endometriosis. If both ovaries are out, or the woman is younger at reaching menopause, 2 mg per day of Estrace may be needed. The dose needs to be individualized for each woman. Dr. Teitelbaum: Can you address migraines and low estrogen. Dr. Vliet: Migraines and other FMS symptoms (such as palpitations) often flare when estrogen levels are dropping. Estrogen levels drop about 15 days after your period during ovulation and again drop sharply the few days around your period. Since it is important for migraine patients to keep estrogen levels steady, I find that using the patch, or dividing the estrogen dose up and giving it two to four times a day can be helpful. Dr. Teitelbaum: What about progesterone deficiency? Dr. Vliet: I feel this is overhyped. PMS and many FMS symptoms are worse in the luteal or progesterone dominant phase when estrogen levels are lower. I find that most of the time, it worsens FMS/CFIDS. Progesterone has sedative brain depressant effects. In high dose, it raises GABA levels and it has a Valium-like effect. Progesterone deficiency is a late occurrence in the menopause transition preceded by inadequate estrogen and testosterone production. Dr. Teitelbaum: Can estrogen be used if there is a family history of breast cancer? Dr. Vliet: If your family members (mother or sister) were postmenopausal when the cancer developed, I feel your increased risk is mild. I feel that estradiol used postmenopausally also poses a minuscule risk of cancer relative to its benefits. This is a decision I have needed to make for myself. I have been on estradiol since 1990. Dr. Teitelbaum: At what blood levels do you see signs of estrogen and testosterone deficiency, and how to you treat low testosterone? Dr. Vliet: Symptoms of estrogen deficiency usually begin with estradiol levels under 100 pg/ml (levels are usually 200-400 mid cycle) and testosterone levels under 40 ng/dl (levels in females are usually 40-60 ng/dl). The "normal" ranges given by the labs do not reflect healthy ranges. If low testosterone persists after three months of estradiol treatments, adding 1-1/4 to 2 mg a day of natural testosterone is usually adequate, although doses of 3-4 mg are sometimes needed. Dr. Teitelbaum: Thank you for your great work and valuable insights!. Dr. Vliet's book is a rallying cry to every woman whose body knowledge has been dismissed as "neurotic" or "hysterical." It validates what women have suspected all along: hormonal cycles DO play a role in many health problems -- migraines, fibromyalgia, chronic fatigue, auto immune illnesses -- which affect women in greater numbers than men. Dr. Vliet explains in a highly readable style the complex connections between hormones and brain messengers that regulate memory, mood, sex drive, appetite, pain, and other body changes. She blends options to help women find a "wholeness" in the fragmented, symptom-based approach of both alternative and traditional medicine. Copyright 2002 by The Annapolis Chronic Fatigue and Fibromyalgia Research Center..