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Allergies start in childhood. However, in my practice I am seeing more and more patients who present in adulthood, from age 15 and beyond, with complaint of nasal symptoms, asthma symptoms, severe urticaria/angioedema, and even newly acquired food allergy such as shellfish with old bay seasoning. It has been described in the literature that mast cells have a high affinity estrogen receptor alpha (ER-a) and progesterone receptors on their surface. Binding of endogenous and exogenous estrogens to these receptors causes mast cell degranulation with release of histamine and LTC4 that cause the allergy symptoms. I generally inform these patients that their allergy symptoms are not related to environmental allergens and to prove my point I always offer a skin testing and the patient are always surprised to see that their skin testing results are negative. I couple the test with a measure of the endogenous hormones and in most cases, the estrogen is too high. I have been able to give low dose hormone therapy to these patients and their allergy symptoms generally improve. I have several patients who have responded beautifully and the recalcitrant estrogen induced urticaria/angioedema has improved. Xenoestrogens and phytoestrogens play a major role in this process. I therefore give to the patients a list of Xenoestrogens and phytoestrogens to avoid. I also recommend vitamins that help with their overall well-being. Many of steroid dependent allergic patients: steroid dependent asthma, steroid dependent dermatitis, also have important comorbidities: obesity, hypothyroidism, hyperlipidemia, hypertension, insulin resistance, and female menstrual disturbances, such as menstrual irregularity, menorrhagia, metrorrhagia, metromenorrhagia; they often have fibroid tumors and fibrocystic breast disease and have seen multiple physicians, for these conditions; some have had hysterectomies, others have had breast biopsies that have revealed the fibrocystic breast disease. Many of these women are on birth control pills to control their menstrual problems, others are on antidepressants, and some have chronic chest pain due to anxiety that have been evaluated by cardiologists and in some cases cardiac catheterization has been performed without any findings.
These patients most often have estrogen dominance. Estrogen dominance, by definition is normal or high estrogen in the presence of deficient progesterone. The excess endogenous estrogen, coupled with Xenoestrogens and phytoestrogens cause allergic disease by stimulating the non-genomic estrogen receptors on the mast cells and also potentiating the effect of IgE antibody on the mast cells, to release histamine and LTC4. The worse allergic reactions that can occur are the recurrent anaphylactic reactions with foods and also with allergen immunotherapy. I have evaluated several patients who presented with the symptoms of anaphylaxis after ingesting shellfish with old bay seasoning. I can remember a particular case in which the patient, a 60 year-old woman, presented with recurrent anaphylactic reactions after eating crabs seasoned with old bay and drinking beer. After evaluation, her skin testing was negative. She was scheduled to return to clinic with some crab meat for a challenge. She obviously passed the challenge because what was causing her anaphylactic reaction was not the shellfish that she has tolerated for years, rather the old bay seasoning was causing her problem. I now realize that this lady had estrogen dominance. Old bay seasoning contains five phytoestrogens: bay leaves, cinnamon, cloves, celery, and nutmeg. This patient also ingested beer that contains hops and that helped release more estrogen. These phytoestrogens, coupled with her already high endogenous estrogens caused an intense histamine and LTC4 release that led to the anaphylactic reactions. A food challenge that only contained the shellfish itself will therefore not cause the reaction.
The other situation that occurs most often is the anaphylactic reaction to allergen immunotherapy (AIT) that is also more common in women than men. I recently saw a woman who was on AIT and cannot reach maintenance because of recurrent anaphylactic reactions. I reformulated her AIT extracts and started her on a slower injection schedule. She was able to go through the yellow vial and on her second dose of the read vial she had another anaphylactic reaction. This time, instead of reformulating her AIT extracts or changing her injection schedule, I measured her hormones and to no surprise, her luteal phase estrogen level was very high. I started her on low dose hormone therapy and continued her on her AIT. She was also having unexplained syncopal episodes and these symptoms resolved when she started on the new therapy. In this case, the high endogenous estrogen caused a synergistic effect with the IgE on the mast cells that led to her recurrent anaphylactic reactions.
In the case of urticaria, allergists not aware of these estrogen reactions will do their usual standard workups and the results will be negative. The patient is then labeled with “idiopathic” urticaria which means the cause is unknown. Treatment of choice, antihistamines and when the case is desperate, then steroids are used. Allergists should therefore take into account estrogen dominance, phytoestrogens and Xenoestrogens induced allergic reactions when evaluating patients suspected of adult onset allergic reactions (dermatitis, asthma, rhinitis, anaphylactic reactions…). When the actual cause of the symptoms is discovered and treated, both the patient and the allergist are rewarded.
Since learning about the hormones and their relationship to allergic reaction, I have been able to pinpoint the actual culprits in these so called adult onset food allergies. Recently, I saw a patient in my office who presented with urticaria. She was clear about the trigger: she and her husband have recently gone on high protein diet and she was eating a lot of soy protein. She then developed severe urticaria eruptions that improved when she stopped her soy protein diet. She then resumed and the urticaria returned. When she saw me, I confirmed to her that the soy protein was indeed causing her urticaria lesions, by releasing too much estrogen. This patient already had important comorbidities: PCOS, menorrhagia and she was S/P hysterectomy for these symptoms. She was obese and now she was losing weight after her TAH/BSO. Another patient recently presented with similar episodes of urticaria after eating food seasoned with thyme and rosemary, both phytoestrogens.
Another cause of adult onset rhinitis independent of environmental allergens is PNAR. The patients most often will complain of irritants such as cigarette smoke, perfumes, household cleaning agents, and sometimes roses even cause nasal symptoms.
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