Healthcare and Trauma

This is going to get technical, so if I lose you along the way please feel free to reach out for clarification.

I’m GeorgAnna Wiley, a holistic gynecology APRN, NP, CNM at Rebirth Holistic Women’s Health, with over 25 year’s experience in women’s health and neuroscience. I serve women with histories of trauma and help them heal physically while shifting their negative inner dialogue to one of empowerment and self-love. I specialize in hormones, neurotransmitters, thyroid and adrenal function, as well as full scope reproductive health. I also cofounded a nonprofit for human trafficking survivors and prevention in at risk youth.

People say children are resilient, they’re not, they’re just prelinguistic. Rarely are we taught healthy coping skills or stress management, even counseling is stigmatized in our culture. Self care is thought of as expensive spa days no one can afford. It doesn’t have to be this way.  

Trauma and the medical model

Stress bubbles up inside us, we feel irritable, agitated, our hands shake, our tummy hurts, we get rashes, we can’t sleep. So we distract ourselves, try to suppress it, or numb it classically with pills and alcohol. The 50% of American women with trauma tend to react to stress with a freeze response. Lets try something different. Stand up and give the energy somewhere to go.

Rarely is history of trauma included on intake forms for medical providers, and trauma informed providers, ironically, especially in gynecology, are exceedingly rare. I was in fact repeatedly disciplined for asking about histories of trauma on patient intake visits in a hospital practice as it “wasn’t relevant to gyn” and “made the visit too long”. Interestingly, every woman coming in with vaginismus (involuntary clenching of the vagina causing pain or inability to be penetrated) reported a history of sexual abuse, but none had ever been asked if they had a history of trauma by any provider. In addition, many feel shame and so wouldn’t report it on a written intake form, but might when directly asked. Here is how I ask: “Has anyone ever touched or treated you in a way that wasn’t okay?” And then a gentle pause with eye contact. And then probably handing them tissues. Many are relieved to find this is a huge piece in their health issues.

I saw a 60 year old woman with pelvic pain who, like most uninsured women, was using the ER for her gyn issue. When I asked if she had a history of sexual trauma, she became uncomfortable and said no provider had ever asked her that. I explained it often is a factor in pelvic pain. She began sobbing, and disclosed a life of ongoing rape and assault beginning at age 3. She had never told anyone because no one had ever asked, never sought counseling. She allowed me to perform her first preventative healthcare visit in 30 years, which she had avoided for fear of pain during the exam. This is a common scenario for me. Our medical model is not designed to appreciate mental health, our culture stigmatizes accessing mental health, and rarely can people afford it. 50% of Americans use the ER for primary care, if that gives you any idea of how likely they are to access counseling, which is rarely covered by insurance, for the lucky ones who have insurance.

            Common diagnoses or misdiagnoses that stem from a history of undisclosed trauma include depression, anxiety, bipolar, thyroid dysregulation, IBS, abdominal pain, reflux, GI disturbance leading to prescription of proton pump inhibitors, rashes, hives, chronic fatigue, PMS, obesity, hypertension, PCOS, headaches, hypertension, irritability, insomnia, panic attacks, alopecia, vaginismus, dyspareunia (painful sex), difficulty with intimacy, autoimmune disorders such as achalachia, to name a few. The stress hormone cortisol shuts down systems that aren’t necessary in times of crisis, including the digestive system, we all know what a “nervous tummy” feels like. So why don’t Gastroenterologists ask about our stress levels, histories of trauma, or mental healthcare? When we are stressed and break out in hives, why doesn’t the dermatologist ask about our stress management? The medical mantra seems to be “if pills don’t work, up the dose!” and healthcare often becomes about chasing treating symptoms but missing the root cause – a stressed nervous system that has reset “homestasis” as a state of overdrive that feels like overwhelm, an inability to self soothe, hyperreactivity to mild stressors, and systemic inflammation that also affects the brain. Ultimately, most of us would benefit most from learning self care - not a spa day, but stimulating our own parasympathetic nervous systems and vagal nerves to rewire our circuits to recognize a state of calm as homeostasis.

Psychoneuroendocrinology

Our psychoneuroendocrine system involves the interplay between our neurotransmitters, endocrine system, and hormones. More specifically, stress and trauma impact the hypothalamic-pituitary-thyroid-adrenal (HPA) axis, which regulates the hypothalamic–adrenal–gonadal (HPG) axis – the lynchpin of our stress response cascade is the release of cortisol, epinephrine (aka adrenaline) and norepinephrine (noradrenaline) from our adrenal glands – eliciting the stress response of “fight or flight”, the common analogy of being chased by a tiger in the woods, which has been found to be more of a masculine response to stress. Research has found women have more of a “tend and befriend” stress response tied to oxytocin, the molecule of love, where we response to stress by tending to little ones, seeking connection, befriending others, and pulling loved ones close. Women with histories of trauma tend to have a stronger “freeze” stress response (such as not being able to say no when touched inappropriately and then later not being able to recognize it as rape because she was unable to vocalize “no”), and childhood abuse often leads to the “fawn” response of people pleasing and poor boundaries.

Have you ever wondered why PTSD causes flashbacks? Strong emotional events stimulate the vagal nerve to release norepinephrine into the brain’s amygdala, the specific part that is tied to emotionally arousing events, which deeply etches the memory to later surface as fond nostalgia or reliving torture. Recent studies show that giving propranolol, a beta-blocker blood pressure medicine blocks the actions of norepineprine in the brain, to people who have had traumatic experiences decreases the development of post-traumatic stress disorder symptoms.

Ongoing stress often stems from unresolved trauma, leading to a chronic stress state with systemic inflammation, abdominal weight gain, chronic overwhelm, and burnout, perpetuated by a sense of lack of control, support, and/or safety. The best known anti-inflammatory plant is turmeric, antihistamines such Benadryl can help with inflammation and sleep, omega fatty acids can repair and protect our nervous systems from inflammation. Our cannabinoid type 2 receptors also are anti-inflammatory, and interestingly enough are most concentrated in the vagina, cervix, and uterus and play a role in fertilization, so they may find even more uses for the hemp family and cannabinoids.

The main way to calm our nervous system is by stimulating our vagus nerve – this can be done through listening to binaural beats, breath, singing, gargling, humming, laughing – even nervous laughter, cold water immersion, prayer, meditation. Interestingly, they only recently realized the vagus nerve innervates the cervix, after centuries of human dissection, so sex, masturbation, orgasm, and pelvic floor exercises (Kegels) can now be considered self-care as well.

Adrenal fatigue

Chronic stress burns out our ability to produce cortisol, leading to levels of adrenal fatigue. A hallmark feature of significant adrenal fatigue is waking 3-5am in a state of anxiety, with daytime brain fog, afternoon fatigue but you can’t nap, just lay there with racing thoughts.

Testing is done with saliva 4x/day – cortisol peaks in AM and should progressively lower throughout the day, so pattern shifts can also indicate adrenal fatigue.

Consistent use for 4-6 months of adaptogens such as ashwaganda, Shatavari, Bacopa, or in severe cases also using adrenal glandular products (ground up porcine or bovine adrenals) in addition to rest, meditation, stress management, and restorative practices can help with adrenal repair.

Nervines are herbs that help calm and soothe the nervous system during acute moments of stress, such as passionflower, catnip, lemon balm, chamomile, holy basil, motherwort, milky oat tops, all of which grow well here except chamomile.

Cortisol and thyroid

Our thyroid tells our body how fast to rev its engine – hypo is too slow, hyper is too fast. Hypo is more common with trauma so I’m focusing on that here. Symptoms of hypothyroidism include depression, fatigue, easily feeling cold, weight gain, blood sugar problems masquerading as diabetes, and hair loss. This can be misdiagnosed as PCOS, prediabetes, or depression and mistreated with SSRIs that don’t help because actually they have a thyroid issue. The pituitary in our brain secretes TSH, which tells the thyroid how much T3 and T4 to produce. Prolonged stress leads to excess cortisol production which inhibits TSH secretion thereby affecting T3 and T4, but rarely do providers check thyroid function, and when they do its only with a TSH test. This only tells what the pituitary is doing, not how the thyroid is functioning, which is assessed with a Free T3 and a Free T4 test. A TSH can be within range but a person still have hypothyroidism. 

Most pharmaceuticals for hypothyroidism are simply ground up porcine thyroid, many can heal their thyroid issues with stress management and short term use of thyroid medications. Bacopa and Guggal are herbs that can support the thyroid. Iodine, the leading global mineral deficiency, is the main mineral used by your thyroid. In the old days, young women were made to wear choker necklaces to detect pregnancy out of wedlock – their thyroid would swell to capture more iodine. Undiagnosed hypothyroidism is thought to be the leading cause of infertility and repeated miscarriages. It is common for providers not to test a woman’s thyroid until she meets the definition of recurrent losses, which is 3 miscarriages. Their TSH should be under 2 in the first trimester. Make sure to get iodine daily, granulated kelp mixed in your table salt is my favorite way.

Neurotransmitters

Trauma and chronic stress not only destroy receptors for serotonin, dopamine, and glutamate, they shrink our brain structures in areas of emotion and memory, reduce neuroplasticity, are linked to addiction, cause anxiety and depression, and slow metabolism, among other things.

SSRIs (Lexapro, Zoloft, Prozac) are handed out like candy these days. When I worked in a hospital based ObGyn office, SSRIs were the most common medication asked for as well as that we were encouraged to prescribe. However, these medications were intended to be used with adjunctive counseling to create healthy coping skills while tinkering with our brain chemistry, instead of solely depending on mood stabilizer medications for life. Interestingly, if you check neurotransmitters, many people actually have too high serotonin levels as the cause of their anxiety symptoms so SSRIs exacerbate their mood disorder, yet mainstream medicine does not check neurotransmitters and insurance does not cover testing.

Stress and resultant inflammation prevent the methylation of B vitamins, making the brain unable to use these essential precursors to make neurotransmitters effectively. Adding a methylated B complex can greatly help neurotransmitter function. Interestingly, 80% of neurotransmitters are produced in the gut, so probiotics and addressing gut health are a very real part of mental health and mood disorders.

Sex Hormones

         Hormones are huge part of our mental health. Cortisol shuts down systems that aren’t necessary in times of crisis, including the reproductive system. DHEA is released primarily by the adrenal glands and is the most abundant steroid hormone in the human body. It is a precursor to sex hormones, such as testosterone, and estrogen, and is a crucial source of estrogen for men. DHEA antagonizes the effects of cortisol and is a biomarker for stress – meaning it is elevated by cortisol. Interestingly, exogenous administration of DHEA has been found to improve symptoms of depression. Too high a DHEA level is often found in chronic stress and is a frequent hallmark of PCOS, hair loss, adult acne, abdominal weight gain, metabolic disorders, and hirsutism but levels are rarely checked or addressed by mainstream medicine. Inositol can help, as well as herbs such as Black cohosh, Reishi, Licorice root, Vitex, Saw Palmetto, and Shatavari. For medications, Metformin can help your body use glucose, Spironolactone blocks DHEA and is useful for adult acne and hair loss in women.

And now I am going to step on my soapbox.

Here is a very important overview for anyone who may be fertile, sexually active, and not on contraception: Day 1 of the bleed is day 1 of the cycle, ovulation occurs on day 14 for many women with a 28 day cycle, and progesterone is on board from day 14 until the next bleed. Every woman with a monthly period would benefit by knowing they are fertile the entire week before ovulation. You can buy cheap bulk LH or fertility strips on Amazon and use them to pinpoint your fertile week and exact day of ovulation which is consistent each cycles, and learn to recognize your own fertile window. When you wipe and notice slippery discharge, that is fertile mucus. When you wipe and it feels more dry, you have likely already ovulated. Charting with the Flo app also is useful, but if you are relying on charting cycles for pregnancy prevention I highly recommend LH strips to ensure the app is correct in its algorithm to predict your personal ovulation, as it is not on day 14 for many women. Plan B is basically a high dose of birth control pills that prevents ovulation unless you have already ovulated, and is not an abortifant. It is $50 over the counter, you have to have a walk of shame and ask the pharmacist to have it dispensed but do not need a prescription

Most of us are familiar with PMS or PMDD, which are tied to sex hormones, largely progesterone, released by the act of ovulation and therefore not present in the first half (before ovulation around day 14) of the menstrual cycle. Progesterone is used to make cortisol, so with PTSD or chronic stress causing higher cortisol levels we are depleted of progesterone. Progesterone has sedating, stress relieving, anti-anxiety effects, and promotes sleep, impacts sexual behavior and memory (aka brain fog), all of which are associated with depressive symptoms. Progesterone down-regulates stress and anxiety, and also promotes social contact as a long-term coping strategy. Low progesterone from chronic stress therefore may influence depression partly by decreasing propensity to affiliate with others. This is interesting how it ties into the female stress response of “tend and befriend” – low progesterone from trauma and chronic stress actually would render us unable to seek exactly what we most need to soothe our stress response, social connection, and we are caught in the loop. So when a biologically female friend withdraws in depression, consider offering connection and bioidentical topical progesterone in the second half of their cycle.

Progesterone is our natural form, progestin is the synthetic form used in contraception and not used by our bodies in the same way. For a brief contraception overview - Contraception with only progestin includes Mirena Skyla and Kyleena IUDs, Depo shots, Nexplanon rods, and hormonal contraception with estrogen and progestins includes birth control pills, patches, and Nuvaring. Phexxi is a vaginal gel made of vitamin C that has no hormones and is as effective as pills, and Coso is a testicle bath for men that is also very effective.

Back to hormones…..Hormone balancing does not mean bringing down estrogen, it means bringing up progesterone, wild yam is a bioidentical form of progesterone used to balance hormones that does not work as a contraceptive and can greatly help with fertility. The only prescription progesterone (as opposed to progestin) is Prometrium, which is used to cause menstruation, protect the uterus in menopausal woman on estrogen therapy, and to sustain pregnancies in women with histories of losses.

            Stress also releases epinephrine which blocks oxytocin, the “molecule of love” which is a shy hormone released when you pet your cat, think of a loved one, hug your baby, it peaks in orgasm and childbirth, is key to empathy, trust, bonding, positivity, and feels like love. However, you can now buy nasal oxytocin at Walmart.com so please let me know if you try it!

Remedies and Potions

Here is a brief overview of proven methods to learn to soothe your own nervous system:
The absolute hands down winners are Meditation and mindfulness

Neurofeedback is a hack to learn meditation – such as Muse headbands

Gratitude – reframing the perception of life events

Biofeedback

EMDR type modalities shape your mind to perceive trauma as less traumatic

CRM

Rhythm and flow state which can be whatever gets you there – dancing, gardening, swimming, etc

Tapping, emotional freedom technique

Breath/vagal nerve stimulation

Methylated B, topical magnesium

Touch – petting your cat, massage, hugging, high 5’s

Bird song specifically has been found to calm our nervous system as evolutionarily birds only sang when the environment was safe

432Hz sound frequency

Binaural beats

Fisher Wallace stimulator (headband that delivers low pulses to skull to elicit specific brainwaves)

Plant medicine – herbs such as nervines and adaptogens, mushrooms such as reishi, cordyceps, and lions mane

Research is revealing that psychotropics show great promise as well, including ketamine, psylocybin, LSD, MDMA, ayahuasca, and microdosing.

If you have any questions or want to discuss further, come see me at Rebirth Holistic Women’s Health, or @happy vaginas on social media.

Thank you!

xoxo