In this post, you will learn about the effects of estrogen deficiency to my mental health and and how I am finding ways to cope and heal while in the middle of projects.
Warning: this topic might upset you so please proceed with caution.
Disclaimer: I am no medical expert and what I am recounting here is based solely on my experience and opinion through a bit of self study from medical publications and testimonies of women in similar cases. But if you are a woman approaching your 40’s and an artist—no actually, if you’re a woman of any age and any profession or if there’s a woman in your life that you deeply care about, read this. It might enlighten you about what is in store for our future health or at best help you save someone from dementia or even death.
Unwell
When I began writing this a few months back, I have been unwell for quite a while and have felt like I was going downhill. It was like being at the bottom of a barrel and there was no way out because my mind and body did not want to give a fight anymore. It is menopause and I am only 42, well 43 in a few days. I have been forced into it since I was treated for cancer of the uterus in 2015.
For months I became silent in my newsletters and social media because I wanted to disappear. I did not even want to see anyone. Those months have been difficult—mentally and emotionally. I did not have the energy for anything so I had to reduce any stress and some work load to focus on just a few and priority jobs. I was also going to travel back to my country to visit my family.
The After Cancer Curse
I have been open about my cancer story and how the experience of it has changed the trajectory of my life and career. Do I owe every bit of my accomplishments to the disease? Of course not! It was not a blessing but rather a wake up call for deeper introspection and to better take care of myself. In fact I am still suffering from the after effects of the preventative treatment for uterine cancer: hysterectomy and ovariectomy.
I may be free from it but the suffering continues. To cure me of the cancer I was forced into menopause at 34 years old. It was a rare case because of my age. Nobody explained fully what was to happen after hysterectomy and ovariectomy. Perhaps the health practitioners did explain but I was either just too shocked to comprehend anything in German. The cancer patient's booklet provided by the hospital upon discharge only had a paragraph on how a patient may experience menopausal symptoms.
Immediately hormone replacement therapy (HRT) was initiated. My OB-Gyne that time prescribed Femoston-conti, an estrogen-progesterone combo pill, which contains the active ingredients estradiol and dydrogesterone. Since my cancer operation, I have had a parade of doctors, from 3 GPs in 2 countries, 9 OB-Gynes in 4 countries, a geneticist, 2 orthopedic doctors, 2 EENTs, an endocrinologist and a neurologist, most of which could not give me concrete answers nor could put the puzzle pieces together despite giving them a full narrative of my medical history. I have also been piling up on medications depending on what those doctors would prescribe me, and boy, they were never consistent.
I was becoming a shell of my former self.
My former OB-Gyne, who initiated the HRT back in 2015 with the combo of Femoston-Conti and Gynokadin, an estradiol gel, said it would be good for my skin and the gel would relieve me of hot flushes. I am still finding the right combo of skin care to rid me of callouses, blemishes and dry skin! I never had acne even as a teenager until now. My hair is also falling off, my painting hand could not hold a brush due to tremors, I could not sleep or would wake up sweating in the middle of winter, I would either have hot flushes or cold feet, I have aches all over my body, migraine, weight gain and loss, dental and digestive problems, memory and concentration difficulties, brain fog—the uncomfortable list goes on. On one occasion I was rushed to the ER because I collapsed on a couch while watching TV, was breathless and immobile followed by tremors for over an hour! Good news according to the neurologist that my brain looked beautiful but bad news, he didn't know what caused the dizziness and tremors. I was recently diagnosed with hypertension, osteopenia and depression but was misdiagnosed with vertigo and hyperthyroidism. I would either find myself on many occasions either wandering mindlessly around the apartment or bowling my heart out on the floor. Worst of all I have been having a nagging voice, apart from the constant tinnitus, in my head that was fascinated by death! I was becoming a shell of my former self.
I never smoked, I do not drink alcohol, I maintain a balanced diet and weight (even consulted a clinical nutritionist), I practice yoga and mindfulness daily, but I am alone most of the time with my thoughts, which is equally dangerous. Still, what is happening?
Menopause
Most women will experience menopause for at least a decade at the onset of age 50. There is also such a thing as perimenopause when a woman experiences the symptoms around 40. I have been dealing with the long list of symptoms, alternately or simultaneously, since I was 34 years old and will continue to do so until I am past 50 if they stop at all. My OB-Gyne in Dubai exclaimed, you now have the brain and body of a 60 year old! I laugh at the those YouTube videos about life after hysterectomy, where they only talked about their liberating experiences immediately after the operation or at most a year after. Although those experiences may be valid, the body recognizes the changes a bit slower than that and the symptoms will creep in gradually and the next thing you know is that you are on the floor either semi paralyzed or crying for whatever reason you do not understand. Every woman is different and your experience will be different than mine. My mother claimed she breezed through it. She also had hysterectomy in her 50's then soon after developed asthma, rheumatism, allergies, fatty liver and struggled with her weight. My mother never complained, though, nor did she or any woman of her age recognize menopausal symptoms. It is both a taboo and a joke to even mention it. I am probably one of the unfortunate few who could tick all the menopausal symptom boxes.
The Symptoms
Menopause is not just about ending periods and hot flushes
Prior to my cancer diagnosis, I was rarely sick except for the anemia due to menorrhagia, which I have had since I was 16. I was on and off hormone therapy since then (Premarin, Provera, Diana, Yasmin, etc.). After the hysterectomy and ovariectomy in 2015, I was automatically menopausal. The abdominal pain from the operation lasted over a year. I could not sit for long hours. Imagine this: flying for 11 hours straight three weeks after the operation for my destination wedding in the Philippines. Everybody was in a party mood, while I was suffering in silence. I had to make sure everything went as planned and my guests were happy. I did not have a wedding planner. The migraines and hot flushes began about three months after the op and for that I was prescribed a topical estradiol gel in conjunction with the Femoston-Conti pill.
The moment I realized that all I was experiencing was related to menopause was when on a first time visit to a new doctor in Dubai who is a hormone specialist as well as an OB-Gyne and functional medical doctor for three decades, I had to fill up a 4-page form for new patients. It was like a light bulb moment when I started ticking off all the boxes of the symptoms—those I never would have realized connected to it like tinnitus, brittle nails and bones, allergies, dry skin, hair fall, incontinence, hypertension, crying spells, anxiety, depression… I mean, what the hell?!!! Why was I not asked all of this by any of my former doctors? Why did none of them test my blood for my hormone levels knowing that I was way below the menopausal age bracket? Clearly this doctor's standard practice was different from the others. It was also expensive, which was why I was thankful to my insurance coverage. Nevertheless, she did not even wait to get the blood work to immediately take me off Femoston-Conti, which I have been taking for 5 years, and which she said she would not prescribe even to her worst enemy. Apparently estrogen should not be taken orally, because it might damage the liver over time. Topical body identical estrogen is much preferred and approved by governments nowadays.
And my goodness! Estrogen does insert itself all over the body. Every major organ has an estrogen receptor and the biggest beneficiary is the brain. In order for these organs to function, hormones such as estrogen act like keys that unlock the doors of the heart or the brain.
“Estrogens have traditionally been known to have their effects on reproductive behaviors, such as sexual receptivity and maternal behaviors [2]. However, over the past twenty years of extensive research, both in animals and humans, it is now known that estrogens, via their signaling mechanisms and interactions with multiple neurotransmitter systems in our brain, including dopamine, serotonin, and glutamate, have heavy involvement in cognition and mood.” - The Role of Estrogen Receptors and Their Signaling across Psychiatric Disorders
Misogyny in medicine
One of the unacceptable attitudes of doctors toward my case was their nonchalance and the gaslighting of the situation. They ask you how they could help you and once you explain, if you could verbalize your symptoms at all, they respond as if it is a normal thing because you are a woman in that age. You are destined to suffer.
I am so furious! Why do we have to suffer like this when there are obvious solutions, such as HRT? Some researchers focusing on menopause agree that it should be considered a disease and not a condition. It is after all a deficiency of a crucial hormone—one that transforms into a neurotransmitter that directly affects the brain, heart, bones and so on. If diabetes, a deficiency of insulin, a hormone, is a disease and a big business at that, then why is menopause not a disease? Is it because half of the population on the planet experiences it and therefore a normal phenomenon? Half of the global population is still poor. In certain cultures, whether poor or rich, that treat women’s health as taboo, how are they suppose to access the medical support they need to deal with the drastic changes in their bodies? Women’s bodies have been demonized for the most part of human’s existence. The Bible condemns women to eternal suffering because Eve tempted Adam with the forbidden fruit. Guess what? So does Alzheimer’s, dementia, osteoporosis, and so on.
"Most people think of estrogen as a “sex hormone”. In reality, estrogen serves a multitude of functions that have nothing to do with having children and everything to do with having.. a healthy brain. This hormone is so instrumental for brain health that it’s gained the title of "master regulator" of the female brain - the ultimate orchestra conductor." - Dr. Lisa Mosconi, Neuroscientist
It has been so frustrating even for medical practitioners that there has not been enough studies especially training about menopause to prevent the fatal effects of neglecting the symptoms.
HRT has been introduced since the sixties and became popular in the nineties. Studies from the early 2000s already suggested the psychiatric effects of estrogen deficiency. However it was also a scientific study done in 2002, Women's Health Initiative (WHI) hormone therapy (HT) that prevented women from receiving the aid they needed through HRT. The erratic study pushed any development for women's health decades back due to the misinformation that HRT increased the risk of breast cancer and cardiovascular diseases. The study however was focused on using Estrogen/Progestin HT on older age groups with higher risk to the aforementioned diseases and discounting younger age groups that actually benefit from the protective effects of HRT when administered much earlier. Recent studies show that when HRT is initiated at an early age (i.e. 40's), the risk of breast cancer and heart diseases is significantly reduced but when given much later (i.e. 60's) then the protective benefits of estrogen are foregone and might even exacerbate the growth of cancer cells that are estrogen dependent. The key point is to start the right kind of HRT as early as possible to reap the benefits later in life.
Medical practitioners and researchers that aim to prove the effects of estrogen deficiency as well as provide support to women seeking solutions to menopausal symptom management has been criticizing and debunking in recent years the study for its limitations and inconclusive results. Despite the efforts, the impact of the WHI study still persists.
I am not saying that doctors are incompetent but those that I have dealt with were rather less helpful in the case of surgical menopause. After each consultation I cannot help having the feeling of being dismissed because I was not even pregnant nor will I ever be. In a society that values women more because of their child-bearing capacities, what chance do I have to get full attention for my health concerns? I would just rather go to a more empathetic one and preferably someone who realized the connection between endocrinology and neurology. My advice is to find an OB-Gyne who is genuinely interested in menopause, as is clearly stated in their credentials, and not just in pregnancy cases. Women are not just birthing machines!
“That the child is the supreme aim of woman is a statement having precisely the value of an advertising slogan.” - Simone de Beauvoir, The Second Sex
Brain - Estrogen = Depression
Circling back to my ordeal in the last months, even the past years, indeed I have noticed a gradual and increased change in my mental constitution.
Physically, I would seem “normal” and perhaps that was the reason why no one in my circle noticed. I have also been pretending a lot. Even my husband was surprised when I told him about my episodes. I have been fantasizing jumping off a building since we moved to Johannesburg and back then I did not understand why except that I was upset about something that happened recently or in the past like a bad memory on loop in my head. That was when I turned into creativity and making art. It became my therapy until now when I could not even lift a pencil or clear my brain from the dark clouds that have been hovering. Imagine how frustrating it was to not be able to think clearly or to draw? My hands were shaking all the time, I could not draw a straight line. So I would give up on that task and move on to digital work and maybe that would be much easier. My eyes would then hurt and then the migraine would set in that I would be forced to lie down. In desperate times, I would pop in 600mg of Ibuprofen and/or drink two matcha shots (matcha is know to aid in concentration due to the EGCG content). Even brainstorming was impossible because I could not concentrate on the most simple sentence. There are times that I would be wandering about the flat thoughtless or forgetful why I was standing on that spot in the first place. Making art or even those things that use to make me happy were not helping at all! I worry a lot that I may not be able to work as an illustrator anymore and I was just beginning.
I am so grateful for my established daily routine otherwise I would not function. My depression is still low grade and so I could still stand up and act like a person but when it hits, I will be inconsolable and incapacitated. Either way, I will be paralyzed and then extremely exhausted thereafter that no amount of work will be accomplished that day. The worst attacks happened while I was starting on two new picture book projects, which proved to be too difficult to work on. I sought professional help already so I could carry on living my life and finish my commitments.
Since my diagnosis, I have carved my work schedule to anticipate those possible down days as well my weekly therapy sessions, medical check-ups and travel to the Philippines to finally see my family after 4 years. Fortunately, both my publishers were accommodating with my schedule. I did not have to inform them about my illness, of course, to prevent them from worrying, but I was open about my travel plans wherein I will be bringing my work with me anyway. I added buffer weeks before the deadline and worked my way backwards to determine when I should start each milestone step (cover art, sketches and final art).
My daily routine helped me follow a schedule and also guide me through the day, albeit being on autopilot-mode.
I needed to finish. I have two calendars on my desk that help me plan my task for the week and keep me on track until the respective project deadlines. My therapy sessions have given me tips on how to process my intrusive thoughts and first aid for when I had an episode. Yoga, proper nutrition, hours of classical music and support from loved ones within my immediate environment all helped me cope. I was still able to submit on time and deliver good work. But it left me wondering, could I have done a much better job had I not been sick?
More importantly, belief in myself, my innate resilience and likewise understanding that my depression is highly likely biochemical in nature all helped me get through these difficult times. Moreover, informing myself about my condition, what kind of depression I have and then finding the right health care provider, who is an OB-gyne and endocrinologist, who will help me find the right HRT for me were all crucial to my recovery. A significant improvement in my mental state coincided with my most recent blood work that indicated normalized estrogen levels. HRT is really about finding balance, not a one-size-fits-all remedy. I did not need antidepressants nor did my doctors advise them for me. As you can see, I am actively blogging as well as posting again and singing, too!
Depression has many dimensions, though, and I am no expert yet to discuss the complexities of it but this video might:
Fighting for my life and my art practice
The decisions I have made saved me ultimately from cancer. I just wish I had more time to inform myself and that the closest people around me would believe that I am truly suffering. But until you yourself understood what was happening to your body, no one will. I have gathered as much information I could about menopause. I read books, watched and listened to discussions about HRT and signed up in forums about the topic to join in the conversation. I dared to be vulnerable so I could tell my story so that one or two of my mostly female readers may be enlightened. Realize that you need help because you cannot do this alone. Nobody gets an award for enduring pain and suffering. But there is hope. There are answers to your questions and solutions to your issues. You just need to do the extra work and not rely so much on your health care providers. I always come to a consultation prepared with questions and a list of my observed symptoms related to menopause and my HRT. My doctor will then advise and do the necessary procedures. There are apps that help you journal your symptoms and gather data or testimonies such as Balance by Newson Health.
You just need to do the extra work and not rely so much on your health care providers.
On top of that, I also observe my thoughts and emotions and write them down to discuss with my therapist during our ACT (acceptance and commitment therapy) sessions. And when the dark clouds begin to hover, I apply what I have learned from those sessions as best as I could to ward them off. Examples of harming thoughts are feelings of inadequacy, of not being good enough for my loved ones or my job as an artist, or of becoming obsolete. I counter that by knowing my values and my purpose, one of which is to make art. Arming myself with these tools give me a huge fighting chance to conquer this disease. Knowledge is key here.
My intention in writing this is to simply inform you about the real struggles of women in menopause and why in spite of the medical advances, women's health has always been pushed aside. In a way, I wanted you to know that we are not going crazy. When I went back to the Philippines, I gave my girlfriends books about menopause instead of chocolates. Whenever I met female friends, I broach the topic of estrogen and menopause and the automatic response was that of both openness and relief. I honestly don't know any woman who never had any health issues. To continue the conversation, we must be advocates of this cause.
Women have always been neglected and as soon as we reach the later stage, forgotten. So many female artists have related their own mental health issues. Whether they were related to hormonal imbalance, we would never know. The late Irish musician Sinead O'Connor reportedly underwent hysterectomy in 2015 due to endometriosis but was refused by her doctors HRT. Refused! According to her manager, she never recovered from it and spiraled into increased mental health problems.
“Young women whose ovaries were removed surgically die earlier from other related causes.” -Dr. Walter Rocca, Mayo Clinic
Hystera is Greek for “uterus” or “womb” and the origin of the word “hysteria”, an outdated medical diagnosis only attributed to women, who exhibited ungovernable excessive emotional, psychological and behavioral conditions, from toothache to sexual promiscuity. A hundred years of feminist movement fought to demolish this harmful term but more importantly to bring our rights to the forefront. Today there is an active and progressive movement that advocates for women's health. Scientists and doctors are constantly conducting studies and publishing literature to undo the damages caused by the 2002 WHI report. There is concrete science that proves the effects of estrogen in cognitive functions. Just watch again the YouTube video above by Dr. Lisa Mosconi.
Simone de Beauvoir famously writes, "One is not born, but rather becomes, a woman." Women can no longer be slaves to our biological make up. If we cannot be truly equal then we must fight at least for quality of life.
Some more useful resources in English language:
Balance by Newson Health https://www.balance-menopause.com/
Dr. Lisa Mosconi books - https://www.lisamosconi.com/the-menopause-brain
Dr. Louise Newson books - https://www.drlouisenewson.co.uk/books/
Dr. Mary Claire Haver books - https://galvestondiet.com/the-new-menopause-book/
Surprise: Estrogen as Neurotransmitter by Nicole Branan