SSRI meds and hormone proglems.

[Guest guest]

Here are some posts by Dr. M about this dam good read and I can't wait until his

book comes out.

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#2 (permalink) 04-08-2009, 03:05 AM

marianco

Doctor of Medicine Join Date: Nov 2005

Location: Monterey, California, USA. See Profile for contact info.

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Re: Post-SSRI anhedonia, sexual dysfunction and fatigue. Need your brains!

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Quote:

Originally Posted by Denmark

Post-SSRI Anhedonia, sexual dysfunction and Fatigue.

I was on lexapro for a year, but discontinued due to constant fatigue, insomnia,

sexual dysfunction and apathy and anhedonia. Problem is now 9 months later,

these problems persist!

I got some testing done to get a look at my hormones. Here goes

Free T4 1.9 Ok range (0.7-2.5)

Free T3 3.6 Ok range (2.5-6.5)

TSH 3.3 H range (0.5-3.0)

TPO 17 Ok range (0-150) 70-150 borderline

Cortisol levels

Morning (7.9) Ok range (3.5-9.5)

Noon(4.7) H range (1.2-3.0)

Evening( 2.4) H range (0.6-1.9)

Night (0.4) Ok range (0.4-1.0)

PSA(2.1) Ok <0.5-4 optimal range(0.5-2.0)

Estradiol (blood spot) 35 Ok pg/ml 12-56

Testosterone (blood spot) 559 Ok ng/dL 400-1200 (Age Dependent)

Ratio: T/SHBG (blood spot) 0.6 L .7 - 1.0

DHEAS (blood spot) 318 Ok ug/dL 70-325

SHBG (blood spot)* 34 Ok nmol/L 15-50

Symptoms generally are

Chronic fatigue

Thin, dry skin, decreased sweating

Sexual dysfunction

Problems emptying bladder

Anhedonia

Poor cognitive abilities, vigilance, articulation, short term memory etc.

Chronic constipation

Furtherly drained by vigourous exercise

Increased fat in abdomnial area and increase in weight, about 30 pounds.

I'm 21 years old

Generally, when a person has mental health problems, one is dealing with a

complex illness involving the nervous system, endocrine system, immune system,

and metabolism - which to me are parts of the mind - along with nutritional

problems.

Psychological problems have to be addressed in therapy whenever they exist since

they also contribute to physiologic changes in the mind. One's environmental

stresses have to be evaluated. Physical activities are an important component in

maintaining health. Note that psychotherapy can have as good a response as any

single psychiatric medication. Thus if one is not engaged in improving oneself

psychologically (e.g. skills in emotional regulation, distress tolerance,

problem solving, stress reduction, relationship and social skills, etc.), then

one is not maximizing the outcome of treatment.

The use of a single medication - such as an SSRI - only addresses a small part

of the complex multi-problem illness. This is why one cannot generally expect

remission of the illness with the use of a single treatment. The other problems

continue. Further, one has to consider the effects of a single treatment on the

other signaling systems and on metabolism. For example, an SSRI, if the dose is

too high, may reduce dopamine excessively and increase norepinephrine

excessively, further causing problems unless measures are done to address these

problems, if a particular dose is necessary.

In research studies, what is interesting is that " remission " is defined often as

half of the lowest score for response. This leaves a person still ill despite

being found to be in " remission " . Thus research studies use weasel words to

define successful treatments - which are not.

It often takes multiple systemic breakdowns to create depression, for example.

If low thyroid is the entry breakdown, then mood is generally maintained by

compensations in the other systems. But when these compensations become

excessive (such as in sympathetic nervous system activity or immune system

activity) or impaired (such as in adrenal anti-stress signaling), then mood

regulation breaks down and the person becomes dysfunctional. Breakdowns in the

dopamine systems may contribute to anhedonia, sexual dysfunction, impaired

memory, impaired attention, impaired drive, movement problems, etc. Breakdowns

in the serotonin systems may contribute to increased stress, anxiety, etc.

Excessive sympathetic nervous system activity can lead to insomnia, paranoia,

vigilance, excessive inflammation, insulin resistance, adrenal fatigue, etc. Low

thyroid signaling may lead to lack of energy, impaired thinking, lack of libido,

increase in stress, as well as physical signs such as dry skin, constipation,

etc. Excessive insulin signaling may lead to weight gain, excessive inflammatory

signaling, which lead to other systemic problems. Each of the signaling systems

strongly interact with one another. Piecing together what is happening then

would require detective work examining the interactions of all these systems.

In regard to lab testing, for thyroid testing, total T4 is important to give one

an idea of how much thyroid replacement therapy can be done.

Thyroid hormone can fall rapidly during the transition from childhood to young

adulthood, contributing to mental health problems and/or physical health

problems, which may be only partially addressed by maturation of the

reproductive system.

When excluding people with Hashimoto's thyroiditis, the average TSH become

approximately 1.0 . Thus, assuming the nervous system is working well and

assuming that TSH is a good measure of thyroid activity, then a TSH far from

1.0, such as 2.0 and above could be considered a sign of low thyroid hormone.

Thyroid hormone interpretation can be complicated because the brain could be

considered a separate compartment from the rest of the body because of the

blood-brain barrier., Astrocytes in the brain convert thyroid hormone from T4 to

T3 at a rate different from the Liver, Kidneys and other organs. In Alzheimer's

disease, this conversion is lower in the brain than the rest of the body, thus

the brain is in a relative hypothyroid state.

Even if one is low in thyroid hormone, thyroid replacement is not always simple.

One has to pay good attention to nutrition otherwise one can get heart problems

from thyroid. One has to attend to the adrenal glands otherwise thyroid

treatment itself may cause adrenal fatigue. Etc. Thus even single treatments can

become complicated when the whole picture / person has to be considered.

Belly fat is a very active organ which can cause significant increases in

inflammatory signals, contribute to insulin resistance, excessive estradiol

signaling, liver problems, etc. Some of these problems are in bad positive

feedback loops. For example, excessive insulin (insulin resistance), can lead to

increased belly fat, which can increase estrogen signaling, which then can lower

thyroid signaling, which can lead to increased stress and insulin resistance,

which then increases insulin signaling, and so on. Additionally, the increased

insulin can lead to lower testosterone production, which increases insulin

resistance and insulin signaling. These positive feedback loops are vicious

biological traps. Addressing one or more links in the chain is necessary to

break it and improve health.

Once the physiologic contributes to mood problems are identified - including

signaling problems in the nervous system, endocrine system, and immune system,

as well as metabolic problems and nutritional problems - then a comprehensive

treatment can be designed to address them. Generally, this can be a more

successful treatment than using single treatments. And it makes sense.

Cheers.

Dr. M

__________________

Any statement I make on this site is for educational purposes only and will

change as medical knowledge progresses. It does not constitute medical advice,

does not substitute for proper medical evaluation from physician, does not

create a doctor/patient relationship or liability. If you would like medical

advice, please ask your doctor. Thank you.

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Last edited by marianco; 04-08-2009 at 03:09 AM.

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#4 (permalink) 04-08-2009, 10:39 AM

marianco

Doctor of Medicine Join Date: Nov 2005

Location: Monterey, California, USA. See Profile for contact info.

Posts: 800

Rep Power: 4

Re: Post-SSRI anhedonia, sexual dysfunction and fatigue. Need your brains!

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Quote:

Originally Posted by Denmark

Yeah, thanks for that. It is very informative. But I need some advice about what

to do based on symptoms and blood tests. I figure that most of of my symptoms

can be explained by downregulated dopamine, testosterone and thyroid hormone.

I'm freaked about having these problems so early in my life.

The problem is that my doctor dosn't believe I have a thyroid problem because my

TSH in within the reference range. So i've ordered some t3 myself as I've been

told I have Rt3 dominance. My free testosterone is low, I don't know what to do

about that, i need professional help for I suppose. I'm hoping that increasing

T3 alone will bring up testosterone and dopamine.

Hopefully one can find a physician who can determine one's status. When there

aren't MDs or DOs who can help or understand one's condition, I think

naturopathic physicians (NDs) are a great alternative when it comes to hormone

and nutritional treatments. There is a fairly inexpensive textbook called

Naturopathic Endocrinology, which explains this point of view. NDs can also

prescribe conventional medications.

Total testosterone is the best measure of testosterone's signaling activity, not

free testosterone.

If the total testosterone is good, I would look at the other signals and

nutrition if problems remain.

In psychiatry, a textbook maneuver is T3 up to 50 mcg a day when augmenting

antidepressant treatment.

However, I usually don't advocate using T3 alone as a sole treatment past this

dose since it can totally shut down T4 production. This would leave a person

vulnerable to episodes of hypothyroidism when T3 doses are missed or if T3

levels fall down too quickly. For a person's safety, some T4 should be present

to help buffer T3 lows.

Thyroid treatment has to include optimizing nutrition - particularly the

B-vitamins to stay out of trouble.

The adrenal glands have to be considered in treatment.

Cortisol alone is not enough to determine how well the adrenals are doing. The

adrenal cortex makes pregnenolone, progesterone, DHEA-s, testosterone,

estradiol, aldosterone, etc. Usually two or more of these signals have to be

considered also in assessing adrenal function.

I usually prefer blood tests rather than spot blood tests for reliability.

Discounts can be obtained through various vendors such as LEF.org for those

without insurance.

When choosing initial thyroid replacement alternatives, I prefer a more balanced

treatment such as armour thyroid to avoid having no T4 or using Levothyroxine

alone (particularly if adrenal fatigue is a huge problem).

Adrenal cortical function has to be optimized since it helps control immune

system signaling. The pro-inflammatory signals of the immune system contributes

to a passive depressive state - e.g. anhedonia, lack of energy, etc. - when in

excess.

A coordinated treatment is often necessary both to help addressed the group of

problems a person has and to avoid adverse effects.

Dr. M

__________________

Any statement I make on this site is for educational purposes only and will

change as medical knowledge progresses. It does not constitute medical advice,

does not substitute for proper medical evaluation from physician, does not

create a doctor/patient relationship or liability. If you would like medical

advice, please ask your doctor. Thank you.

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#6 (permalink) 04-09-2009, 04:18 AM

marianco

Doctor of Medicine Join Date: Nov 2005

Location: Monterey, California, USA. See Profile for contact info.

Posts: 800

Rep Power: 4

Re: Post-SSRI anhedonia, sexual dysfunction and fatigue. Need your brains!

--------------------------------------------------------------------------------

Quote:

Originally Posted by Denmark

The thing is though is that if there is RT3 dominance, adding a medication which

contains T4, even armour, will make a person more hypothyroid instead of

increasing metabolism by converting t4 into rt3 instead of t3.

My total testosterone is within range but in the lower end of normal.

Since the lab tests you give do not give Total T4, Total T3, nor Reverse T3, it

would be difficult to argue that there is " RT3 Dominance. " If Total T3 is good,

then one can't argue that it is a problem with Reverse T3, either. Thus these

other values are important to know.

Using only Free T3 and/or Free T4 as measures of thyroid signaling activity is

flying blind since one doesn't know the actual amount of thyroid hormone

available nor the amount of binding proteins, which can be affected by other

factors. Thus, at least a Total T4 is needed, and a Total T3 would be a bonus.

Having these values would allow one to determine dosing.

Using TSH as a measure also assumes the brain is working well. If a person has

mental illness and possibly other health problems, this assumption is incorrect.

Thus TSH could be very off. Thus, correlating the physical signs and history of

illness with the lab test becomes very important. One has to answer the

question: " Is this patient physically hypothyroid? " This information is more

important than the lab test itself.

If Free T3 is used as a measure of thyroid activity, then a level over 3.3 would

usually mean a person has enough thyroid hormone. But because the brain

conversion of T4 to T3 may be different from the body's levels, a person could

still be hypothyroid as far as the brain function is concerned yet look like

they are good in thyroid hormone elsewhere. This is actually one of my

explanations for the phenomenon of " Thyroid Resistance " that Dr. Lowe

(drlow.com) believes as one contributing cause of Fibromyalgia. He would

advocate adding T3 under this circumstance.

Under " normal " circumstances, about 40% of T4 is converted to T3 and 60% is

converted to Reverse T3. Reverse T3 is very quickly removed from the system. It

is the primary pathway that one gets rid of excess T4. Reverse T3 is quickly

converted to T2 and T1 - which have some thyroid signaling activity - then to

Tyrosine.

When one is fasting, has significant stress, or has significant physical illness

(e.g. serious infection, etc., then TEMPORARILY (for about 1-3 weeks), T4 to T3

conversion is reduced and T4 to Reverse T3 conversion is increased. After 3

weeks, generally, T4 to T3 conversion returns to normal. The slower metabolism

that results from lower T3 levels would also result in reduced elimination of

Reverse T3, leading to the ILLUSION that there is even more Reverse T3 being

created but this is actually due to reduced elimination of Reverse T3.

Note that this is temporary. 's Syndrome is the belief that this is not

temporary - instead that it is stuck - but it can be reverted to the normal

state by temporary T3 treatment. There isn't much evidence for this, but I keep

a open mind though have doubts. However, in psychiatry, the addition of T3 to

augment antidepressant treatment is often a temporary maneuver also. Perhaps the

improvement in mental function that can result from adding T3, reduces stress

signaling enough that T4 to T3 conversion can be returned to normal.

This discussion, however, begs a huge question:

If fasting/starvation/poor nutrition, stress, or physical illness is the cause

of the decreased T4 to T3 conversion, why not address these problems first?

For example:

1. Improve nutrition.

2. Improve one's psychological skills to reduce stress by learning meditation or

participating in psychotherapy

3. Reduce one's environmental stresses (e.g. work, relationships, drug abuse,

etc.)

4. Look for and treat the other physical illnesses or conditions one has which

are not directly related to thyroid hormone, which impair conversion.

5. Improving one's physical health through exercise.

Adding T4 generally does not result in hypothyroidism unless the replacement

dose is too low. It is still converted to T3 and Reverse T3. The question would

be if it works well if the person has other ongoing problems - such as different

conversion rates in the body vs. brain. In the large majority of people, it

works. It is also safer when adrenal fatigue is present, when nutritional

deficiencies are present, etc. And it is cheap - $4 a month on Wal-Mart's and

Target's prescription plans. In some patients, if T4 is used, the dose may have

to be fairly high to obtain the desired results. The main problem is that as the

person's health improves, T4 to T3 conversion improves. The high dose T4 then

increases the risk of hyperthyroidism since it would be an overcorrection. Thus,

I would have to gradually reduced the dose of thyroid hormone used. Using Total

T4 as a top end helps determine this line. One tactic is to reach a target Total

T4 level and then work on the other areas of one's health. As one then improves

by addressing these areas, thyroid activity improves also. One can see

temperature improve, for example, yet the dose of T4 remains the same.

As an aside, I generally would not do testosterone replacement on a man with a

total testosterone of 500 ng/dl and above. What problems the person has are

usually elsewhere and not due to testosterone deficiency. Addressing these other

problems may actually lead to a rise in testosterone production.

Dr. M

__________________

Any statement I make on this site is for educational purposes only and will

change as medical knowledge progresses. It does not constitute medical advice,

does not substitute for proper medical evaluation from physician, does not

create a doctor/patient relationship or liability. If you would like medical

advice, please ask your doctor. Thank you.