It’s amazing to realize that it was just 10 years ago that the Women’s Health Initiative results were released with extraordinary media brouhaha, causing as many as 70% of women who were taking menopausal hormone therapy (usually Prempro) to cease and desist…and in many instances flush, flash and lose sleep. But with time, additional studies and empathy, the experts (members of the North American Medical Society, gynecology department heads at major universities, and editors of the American Society for Reproductive Medicine and The Endocrine Society to name just some) now agree on key points regarding the safety and efficacy of hormone therapy in menopause. And since the following is generally what I tell my patients, I am delighted to recap the recommendations just published in several of the major journals.

In a overview, they agree that systemic therapy is an “acceptable” option for relatively young (up to 59 or within 10 years of menopause) and healthy women who are troubled by moderate to severe menopausal symptoms. There is no one therapy fits all, and consideration should be given to a woman’s quality- of- life priorities as well as her risk factors such as age, time since menopause risk of blood clots, heart disease, and stroke and breast cancer. Their consensus then deals with individual issues

Hormone Therapy Risks

 

Vascular risks Although both estrogen and estrogen with progestogen increase the chance of clots (deep vein thrombosis and pulmonary embolism as well as certain types of strokes) the risk is rare in the 50- to 59- year old age group. Moreover, observational studies have found that transdermal estrogen therapy ( with patches, creams, and sprays) and lowdose oral estrogen therapy have been associated with lower risks of these type of clot caused events.
Breast cancer

An increased risk of breast cancer is seen within 5 years or more of continuous estrogen and progestogen therapy. The risk is not great and risk declines after hormone therapy is discontinued. There is even less risk for women who have had a hysterectomy and don’t need to add progestogen to their estrogen therapy. Use of estrogen alone for a mean of 7 years does not seem to increase risk of breast cancer.
Duration of therapy

This is where everyone sites the same sentence: ” The lowest dose of therapy shouldbe used for the shortest anoint of time to manage menopausal symptoms.” they thenadd that duration should be individualized. I add that if more or longer therapy is neededto achieve quality of life, the patient and her physician should discuss this laststatement. And estrogen therapy alone, allows more flexibility in duration. There arereports of increased risk after 10 or 15 years of use in large observational studies.
Additional information

Evidence is lacking that custom compounded bio identical hormone therapy is safe oreffective. Many medical organizations and societies agree in recommending againsttheir use, particularly given concerns regarding content, purity and labeling. Finally thereis a lack of safety data supporting the use of estrogen or estrogen and progestogentherapy in women who have had breast cancer.

Conclusion

Leading medical societies devoted to the care of menopausal women agree that the decision to initiate hormone therapy should be for the indication of menopause-related symptoms.

Bottom line: there is no question that hormone therapy plays an important role in
managing the symptoms so many women experience during menopause. As usual, we
all recommend that therapy be individualized. So talk to your doctor!

Our new address is:

2080 Century Park East,

Suite 1009 (the 10th floor)

LA, 90067

Yes, we finally did it. You, my staff and I will no longer have to contend with the traffic on the Wilshire Corridor, the difficult parking and the closed exits on the 405. Oh, and my lease is up. So we are moving on September 7th to a better and, for most, a more convenient location. The new office is in The Century City Medical Building on the corner of Century Park East and Olympic Boulevard. There is ample parking under the building, moreover, it’s affordable; nine dollars the first hour and free the second. (I certainly hope that you don’t have to make use of that second hour!) And the suite is lovely…great light, a terrific view and a newly furnished waiting room that is very comfy. We have also gone digital, so your records will be kept in a safe cloud and always be available.

Our phone number remains the same: 310 659 9690.

When you make your appointment, we’ll remind you of the new address. (I am sure one morning, out of habit, I will mistakenly start heading to the old office and I assume others will do the same….) As always we are open to new patients and welcome referrals of friends and family!

It’s amazing how much “stuff” has accumulated in the last ten years in my Westwood office. I could not have made this move without the enthusiastic support of Judy and Deborah. They have been my help mates, as well as my medical soul mates for over a decade. I would be remiss if I didn’t thank them publicly. So thank you Judy and Deborah for the caring attention you have always given my patients… and me.

And thank you, my patients, for your patience and kindness in seeing me through a difficult year of mourning for those I lost and bestowing the gift of confidence in my care.

Our new address is:
2080 Century Park East,
Suite 1009 (the 10th floor)
LA, 90067

Judith Reichman, MD

As a westernized country we can be proud of our climb to higher levels in many achievements, but not when it comes to type II diabetes. The rate of this disease continues to climb and devastate our health.  According to the Centers for Disease Control and Prevention (CDC), 25.8 million persons in the US (8.3% of the population) have type II diabetes. Two million of us will get this diagnosis next year. Diabetes is often stealthy and silent as it causes irreversible complications. Full blown diabetes is usually preceded by a lengthy period in which there are no overt symptoms, (prediabetes). During the “pre” stage, there is a mild elevation of blood glucose levels and insulin resistance. (The insulin is less effective, hence more needs to be secreted whenever there is a sugar load.)  With time, the pancreas begins to have difficulty in fulfilling its glucose balancing role and ceases to appropriately secrete insulin; finally it fails and diabetes II develops. Currently, 79 million Americans are estimated to have prediabetes.

Diagnosis, interventions and early therapy can make a huge difference when it comes to both prevention of type II diabetes and the future health of anyone who is at risk. Hence, I was delighted to see a review article in the August issue of New England Journal of Medicine which detailed the most recent recommendations for diagnosis of prediabetes and diabetes…And as you probably know, blood tests are paramount.  A patient is diabetic if her fasting blood glucose is 120 mg/dL or more, or if her glycated hemoglobin level (Hemoglobin A1c) is 6.5% or more. Glycated hemoglobin measures the level of glycation or attachment of sugar to the most prevalent protein in blood and correlates well with the average blood glucose levels during the previous 2 to 3 months. In other words it “tells” on your blood sugars during the 2 to 3 months prior to the blood test  and is a wonderful indication of how you have been doing glucose-wise.

You are considered prediabetic if you have a fasting glucose level of 100 to 125 mg per deciliter or have a hemoglobin A1c of 5.72 to 6.4%.

So when you should be tested? The American Diabetes Association (ADA) recommends that everyone should begin diabetic screenings at 45 years of age and that if normal, the testing be repeated every 3 years. But they also advise screening earlier for individuals who have risk factors. They state that screening should be done at any age and more frequently if the person’s body mass index is 25 or more and that person has at least one additional risk factor…And there are a lot of risk factors:

  • Family history of diabetes (in a first degree relative)
  • High risk race (Black, Native American, Asian, and Pacific Islander) or ethnic group (Hispanic)
  • History of hemoglobin A1c level of 5.7% or more, impaired fasting blood sugar or impaired glucose tolerance on previous testing (including that done for gestational diabetes)
  • Polycystic ovary syndrome
  • HDL cholesterol level of less than 35 mg%, triglyceride level of more than 250 mg % or both
  • History of cardiovascular disease
  • Physical inactivity…Please note!
  • Severe obesity

Just so you know how important blood glucose levels and glucose tolerance results are, the authors note that individuals with “impaired” i.e. abnormal, fasting glucose  together with an abnormal glucose tolerance have a 10 to 15% chance of developing diabetes per year. Moreover, prediabetic states are associated with increased total mortality.

The article goes on to delineate the advantages and disadvantages of available screening tests:

  • Fasting glucose is widely available but requires (obviously) fasting and can be influencedby acute illness or instability in the test tube.
  • An oral glucose tolerance test which requires fasting followed by ingesting a known amount of glucose and subsequent blood tests over the next few hours. This requires time; inconvenience, costs more and results can vary.
  • Glycated hemoglobin does not require fasting and is stable even during acute illness. It is closely correlated with disease and its complications.

Knowing whether you are prediabetic can have a major impact on your future health. Studies have shown that risk reduction with aerobic exercise for at least 30 minutes on most days of the week and a calorie restricted diet enabling you to lose 7% of your body weight can decrease your risk of developing full blown diabetes over the next 3 years by 58%!  If despite this you don’t achieve the “right” blood sugar levels a medication that improves the way your body recognizes and responds to sugars (metformin) may help prevent full blood disease.

Bottom line: Make sure you are tested for prediabetes and diabetes once you turn 45 and if the test is normal; have it repeated every 3 years. Start sooner if you are at risk; many of us are! Your sugar levels today can have a major impact on your health tomorrow.

Many of my perimenopausal, and menopausal patients request hormone therapy (HT) because they feel it will help treat their sleep disturbances. This is a time in our lives in which we sense that  hormones (or the lack thereof) impact sleep. It appears however, that even during the reproductive years,  the cyclical rise and fall of our hormones during the menstrual cycle can also affect sleep. (Remember, estrogen levels rise during the first half of the cycle, and once ovulation occurs, progesterone levels begin to rise. After 14 days, in the absence of a pregnancy, the levels of both hormones plummet, the uterine lining is sloughed and a period occurs.)

The American College of Obstetricians and Gynecologists publishes a quarterly journal called Clinical Updates in Women’s Healthcare. This July the journal was dedicated to  sleep disorders and indeed  kept me awake during the time it took me to read it.  (Although I have to admit I was watching the Olympics and read during the annoying and frequent commercials). The authors reported the following:

The onset of menstruation is associated with a 2.75 increased risk of insomnia. Premenopausal women who have irregular menstrual cycles (one of the hallmarks of waning ovarian function) are  nearly 2 times more likely to have insomnia symptoms than those in the same age group who have regular cycles. Women aged 18 to 55 years who report having menstrual related problems such as cramping and heavy bleeding are 2.4 times more likely to suffer from insomnia when they get their periods and three times more likely to report daytime sleepiness than women who do not have menstrual related problems.

To add insult to injury, restless sleep and unpleasant dreams apparently are more prevalent for women who suffer from PMS and premenstrual dysphoric disorder than for the more fortunate women who do not have either. There is evidence that women who take oral contraceptives have fewer episodes of sleep arousal compared with those not using oral contraceptives. Therapy with anti-inflammatory medication or SSRI’s to treat some of the severe PMS and/or other menstrual symptoms may also result in improved sleep.

What about those of us who are becoming or have become menopausal? There is a consensus among physicians (as well as my patients) that hot flashes can significantly disrupt sleep. In one study of 521 women who were either premenopausal or postmenopausal, 42% reported some type of disturbed sleep and a significant increase in insomnia. Women who chose not to use hormone therapy had twice the incidence of sleep disturbances compared to women who used  hormone therapy.

Use of estrogen without a progestin has been shown to improve  sleep quality and reduce difficulty falling asleep, nighttime awakenings, as well as morning sleepiness. Those women who take estrogen with natural progesterone have also been found to have greater sleep improvements than women who take estrogen plus synthetic progestin (medroxyprogesterone, brand name Provera). Indeed, I tell my patients for whom I have prescribed natural progesterone or Prometrium to take  the pill at night because it can cause sleepiness.

A good night’s sleep is extraordinarily important to our health. Lack of sleep or inability to maintain a deep and restful sleep is linked to hypertension, coronary artery disease, obesity, metabolic syndrome, insulin resistance, impaired glucose tolerance, and type II diabetes. It’s as important as exercise!

Bottom line: Take the time that you need to get 7 to 8 hours of sleep each night. If your sleep is disturbed at particular times in your cycle or as you go through perimenopause or become menopausal, discuss this with your physician. Medications other than sleeping pills may help you get your Z’s.

The brouhaha has died down and much of the affordable care act, also known as Obama-care will indeed go through. ( I’m not going to discuss all the details and certainly none of those dealing with Medicaid.)

It’s important to know that all new health plans starting on or after August 1, 2012 must include important services that affect women, and it’s about time! Believe it or not until the affordable care act was put in place there was no definitive set of recommendations for preventive services for women. To address this woeful omission,the US Department of Health and Human services asked the Institute of Medicine (IOM) to develop a comprehensive list of services for women.

Here are the recommendations of the IOM for girls and women between the ages of 10 and 65. (Those older than 65 will be covered by Medicare and should, we hope, get age appropriate services; obviously contraception will not be among them.)

  • Gestational diabetes screening between 24 and 28 weeks of gestation or at the first prenatal visit for pregnant women identified to be at high risk for diabetes
  • Testing for high risk human papilloma virus (HPV) for women undergoing cervical cancer screening (PAP smears) and HPV testing beginning at age 30 and every three years thereafter for women with normal PAP results
  • Annual counseling on sexually transmitted infections for sexually active women and girls.
  • HIV infection counseling and screening on an annual basis for sexually active women and girls.
  • Coverage of the full range of FDA – approved contraceptive methods, sterilization procedures and patient education and counseling for women and girls with reproductive capacity.
  • Comprehensive lactation support and counseling and coverage of the cost of renting breast-feeding equipment.
  • Interpersonal and domestic violence screening and counseling.
  • At least one well- woman preventive care visit annually, including preconception and prenatal care for those interested in having children.

Women have always had more out-of-pocket costs for healthcare expenses than men. This will begin to even out once we have affordable health care options. I am especially excited about the contraceptive portion of these options. (OK this does make it sound as if my life is dependent on the IOM, which I admit would be sad!) Because contraceptives approved by the FDA include barrier methods, hormonal methods, emergency contraception and implanted devices; women may now be more likely to select long-acting reversible contraceptive such as the IUD which up to now has been expensive.

The insurance companies may not be happy but we should be; these options will save lives. A study published in the journal Health Affairs estimates that an increase in the use of clinical preventive services in United States could result in saving more than 2,000,000 life years (that’s 1 year for 2 million people or 2 years for one million…you get it) each year that it is in force. The government and yes, the Supreme Court got it right!

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