The patient: Kara, a 51-year-old litigator with debilitating neck and shoulder pain.
Why she came to see me: Kara strode into my office with a confidence characteristic to her profession. Within minutes of our consultation, however, she broke down. Three months earlier, she’d begun experiencing neck and shoulder pain. In recent weeks, it had grown so acute she could hardly fasten her bra. She hadn’t been in a car accident or suffered a major injury. As she put it, the persistent pain “seemed to come out of nowhere.” Her primary care physician had prescribed ibuprofen to little effect, and his next suggested step was a steroid shot in the shoulder. Kara was determined to not only discover the root cause of her pain but to also find a natural route to recovery.
How I evaluated her: Kara and I began with an in-depth look at her personal and medical history. Eight months earlier, she’d experienced her last period. Prior to that, her periods had grown light and irregular, with up to four months between them. Additionally, she’d been suffering from periodic hot flashes, insomnia, fatigue—and more anxiety than she’d had in her life.
Her neck and shoulder pain had started out as seemingly benign—stiffness and aches that she attributed to the long hours she spent at the office and in front of the courtroom. She’d tried a combination of treatments, from purchasing ergonomic office furniture to doing stretches with an app to seeing a well-reputed chiropractor. The pain failed to go away. Indeed, it only grew worse, and most mornings her neck was so rigid she struggled to get out of bed.
Less than a year ago, Kara claimed she’d been living a “much healthier lifestyle”—spending her weekends hiking in the mountains, eating fresh, locally sourced food and working out at the gym three nights a week. But as her work load increased with the arrival of a high-stakes case, and as her symptoms intensified, she’d abandoned her weekend hiking adventures, canceled her gym membership so she could rest immediately after work, and resorted to “convenient food,” such as premade sandwiches, frozen entrees and Thai takeout. “I feel like I’ve gone from hero to zero,” she said, “and my neck and shoulder pain is impacting every area of my life.”
To get to the bottom of Kara’s symptoms, I ordered a 24-hour urine test that would check her female hormones and a blood test to evaluate her thyroid hormones and thyroid antibodies. I also did a simple orthopedic exam on her upper back, shoulder and neck…assessed her for range of motion…and examined her patterns of pain and discomfort.
What my evaluation revealed: As we both suspected, our assessment revealed that Kara was nearing menopause, which is defined as going a full year without a period. The stage she was in was underscored by her lab results: high FSH (follicle stimulating hormone) and low estrogen and progesterone. Further, her thyroid stimulating hormone (TSH) and thyroid antibodies were high, while her T4 and T3 (thyroid hormone) levels were low. All of these are classic indications of Hashimoto’s Thyroiditis, an autoimmune disorder that leads to hypothyroidism (underactive thyroid).
Kara’s physical exam demonstrated significantly decreased range of motion in her left shoulder and tight muscles in her upper back, anterior and posterior neck, and pectoralis (chest muscles). Kara had what are called “trigger points” scattered over these areas—places where the fascia (our thin connective tissue) had become knotted up and severely sensitive to even the lightest touch. Our exam also showed early warning signs of a “frozen shoulder,” which is known in the orthopedic world as adhesive capsulitis and as “the 50-year-old shoulder” in Chinese medicine, in that it frequently occurs in women around menopause.
How I addressed her problem: As I reiterated to Kara, the underlying cause of her symptoms—from pain to exhaustion—was due to a combination of three primary issues: deconditioned muscles and joints…low female hormones secondary to perimenopause…and Hashimoto’s Thyroiditis. Treating her, I explained, would require a three-pronged approach.
First, I had a long discussion with Kara about the pros and cons of hormone replacement therapy in women between the ages of 50 and 60, or within the first 10 years of menopause. Research demonstrates that taking estrogen during the first decade after menopause may help prevent joint pain and deterioration, support bone health, and decelerate the potential progression towards dementia. And yet, at the same time, it may increase a woman’s susceptibility to cancer. Given that Kara had no familial or personal history of estrogen-related cancers, and no history of breast and ovarian cancer, she agreed to try a bio-identical estrogen called Bi-est, which contains a key mix of estradiol (20%) and estriol (80%). I also prescribed natural progesterone. To administer, I asked her to use both as a cream and to apply to her labia, vagina and vulva once a day, as these tissues have a high absorption rate for hormones.
Secondly, we discussed Hashimoto’s Thyroiditis. Also called Hashimoto’s Disease, the condition—which is the leading cause of hypothyroidism in the United States—occurs when your immune system, in essence, attacks your thyroid. In turn, this interrupts hormone function. While sufferers may go years without symptoms, they can also experience muscle aches, tenderness and stiffness, joint pain, fatigue and sluggishness (among other signs)—in short, the very issues Kara was dealing with. What’s more, there is a direct association between frozen shoulder and thyroid malfunction.
In an attempt to remedy this, I put Kara on a natural desiccated thyroid called Nature-Throid, a prescription-only medication that was one of the first available treatments for hypothyroidism. I prefer Nature-throid over levothyroxine (Synthroid) because it contains both forms (T4 and T3) of thyroid hormone. Levothyroxine contains only the inactive thyroid hormone T4. Some people don’t convert T4 to active T3 well, so giving both in Nature-throid guarantees that the patient will get active thyroid hormone.
I also prescribed 200mcg of L-selenomethionine once a day, which has been shown to improve thyroid function and lower thyroid antibodies. Lastly, I strongly encouraged her to ditch gluten altogether, as increasing research reveals a link between Hashimoto’s Thyroiditis and gluten intolerance.
Thirdly, we attacked Kara’s most urgent concern—her chronically-aching shoulder and neck. To provide immediate relief, I recommended a combination of trigger point therapy and prolotherapy. The injection-based treatments utilize a measured dose of sterile dextrose (a sugar derived from corn), an anesthetic such as procaine and nutrients that include Vitamin B and amino acids. The elixir is then injected into specific areas of the body—those aforementioned trigger points—to stimulate healing, in that they block nerve receptors that release proteins responsible for pain and stiffness. When administered in the joint at high doses, the patient experiences a temporary burst of irritation. This is because prolotherapy operates by generating temporary, low-grade inflammation at the injection site, which “tricks” the body into thinking it’s been hurt and rushes a cascade of fibroblasts to the region. The direct exposure to these particular cells ignites new cell growth, collagen deposition and connective tissue repair. (Prolotherapy is also often used for joint inflammatory conditions such as osteoarthritis because it can render joints more flexible, fluid and elastic.) In the end, these treatments would make her tissues stronger and more functional and she would experience less pain.
Trigger point therapy, meanwhile, uses much lower doses of glucose, procaine and nutrients (also B vitamins and amino acids), which are injected into areas of pain and stiffness. In doing so, the technique releases fascial adhesions that may be the underlying cause of one’s pain and discomfort. To allay Kara’s concerns, I explained that trigger point therapy employs a very small needle (about the size of an acupuncture needle) and has been an effective form of treatment for many of my patients. (Many claim that their chronic upper back and neck stiffness melted away after just a few treatments.) After some consideration, Kara was game. After all, unlike ibuprofen and steroid injections, these treatments stimulate the body to heal itself and don’t further weaken the supporting structure and tissues.
Since these treatments are only catalysts for a healing response, I also sent Kara to a physical therapist for strength training. Strength training would help her thwart joint and musculoskeletal problems in the future, particularly further exacerbations of frozen shoulder, in part by developing a layer of muscle over the affected joint. This would then increase joint function, decrease soft tissue and muscle pain, and help inhibit arthritis. Besides, regular exercise bolsters blood and oxygen flow, thus promoting circulation and aiding in the delivery of nutrients to “sore” tissues.
Finally, I referred Kara to an Iyengar yoga class. I see Iyengar yoga as a method of profound self-care—one that combines myofascial release work with mindfulness meditation. (Indeed, I recommend it to all of my patients.) It’s also a safe, accessible form of yoga that utilizes blocks, chairs, blankets and other support systems that allow people to learn the practice at their own pace (and, most importantly, without injuring themselves).
The patient’s progress: Two months later, Kara returned to my office with her signature confidence—only this time, it remained. “I haven’t felt this wonderful in decades,” she claimed as she laid out the details of her recovery. Adopting a gluten-free diet was far easier than she realized—thanks in part to the abundance of restaurants in her neighborhood that served gluten-free foods—and strength training had not only relieved her pain but also gave her toned arms. (“I had no idea I had triceps!” she gushed.) Her neck and shoulder pain was “all but gone” and she was far less fatigued. As with many who come into yoga at the right time in their lives, she’d fallen in love with the practice, and attended a class at least four times a week. Her period had not returned and she was still experiencing the occasional hot flash, but she felt ready and keen for what lay ahead. As for that bra she once couldn’t fasten? She celebrated with a shopping spree at La Perla.
Click here to buy Dr. Laurie Steelsmith’s books, Natural Choices for Women’s Health, Great Sex, Naturally and Growing Younger Every Day: The Three Essential Steps for Creating Youthful Hormone Balance at Any Age.