Many of us have now assumed certain grandparenting duties with joy and pleasure, especially if we do can them without the duress of becoming the primary care giver … Apparently there have been very few studies on what this role does to our cognitive health. So I read with great interest the article that appeared in this month’s journal of the North American Menopause Society (aptly named Menopause).

The title of the article is “Role of grandparenting in postmenopausal women’s cognitive health: results from the Women’s Healthy Aging Project”. The participants included 186 Australian women from a larger prospective aging study. This portion of the study was meant to examine the disuse hypothesis, also known as ” the use it or lose it” hypothesis that proposes that decreases in activity with age results in the disuse of cognitive mechanisms, which then cause a decline in cognitive abilities. We know that as we get older, large social networks or high levels of social activities can improve cognitive function, help diminish cognitive decline and even lower the risk of developing dementia. So does grandparenting fulfill this function?

A questionnaire was administered to the participants in 2004. They were asked whether they had grandchildren, if they were currently minding their grandchildren, and, if so, how much time they spent minding their grandchildren. Participants were also asked if they felt that their children have been particularly demanding of them in the past 12 month. Cognitive tests were later administered (I won’t bore you with the types and the questions) and their verbal memory and executive function were assessed. There were 131 grandmothers in the sample and those who spent time minding grandchildren (111) were more likely to be employed than those who did not. There was no significant difference in age, number of grandchildren or education between the participants. No significant differences in performance in any of the tests were observed between grandmothers and non-grandmothers; there were also no significant differences between participants who were minding grandchildren and those who were not. The only differences that were found were that participants who spent one day a week minding their grandchildren had the highest cognitive performance in all the tests and those who did so for five days or more per week had the lowest test scores. Frequent grandparenting apparently predicted lower processing speed and working memory performance. Moreover, those who had to perform this “task” almost daily reported more feelings of resentment.

Does this mean that too much of a grandparenting role may not be good for our cognitive health? Although this article was published in a peer reviewed journal, I feel the study is too small to make that assumption. There’s no question that if one has to take care for grandchildren without a respite it can be tiring both physically and mentally. Those in the study who “minded” their grandchildren five days a week or more may have had no choice and indeed minded. Their mood and perhaps fatigue may have adversely impacted their cognitive test results.

I have to stop now and take my granddaughter to her dance class. The drive might be mind numbing but watching her perform is not. This is not a daily “task”, so I assume my cognitive abilities will remain intact.

Last Friday, I delivered one of the keynote addresses for the annual conference of the Academy of Anti-aging and Regenerative Medicine in Las Vegas. It was a huge conference and I was somewhat overwhelmed by the 3500 medical personnel who attended. The topic of anti-aging is certainly one of major concern to medical practitioners and patients worldwide and indeed there were participants from all over the world. As many of you know, I’m a fairly orthodox physician and want evidence-based medical data upon which to base testing, diagnosis, and therapy. So this was not an easy lecture for me to give. Much of the conference dealt with supplements, novel and “new age” testing and procedures and the use of bio identical, compounded medications. So when I PowerPointed my lecture with 35 slides and titled it “Slow Your Clock Down: on label, off label, gray label” I was aware that the topics and information could be controversial and even confrontational for a vast number of the participants.

I am not going to download the entire presentation but I thought I would detail a few of the slides: I started with our universal goal; health span not life span… That we “optimize the minutes and hours of our internal and external clocks so that we can savor our present and future bodies”. I then went on to delineate the issue of labeling and drug use as follows:

On-label (FDA approved): In order to achieve FDA approval drug companies pay for and perform laboratory and animal tests. They test humans to see if the drug works and whether it is safe and it provides a real health benefit. The data is then sent to the Center for Drug Evaluation and Research. A team then reviews the data and proposes labeling. If the review establishes that a drug’s health benefits out way it’s known risks, the drug is approved for sale.
Off-label: Adding additional indications for an already approved medication requires a supplemental drug application; if it is eventually approved the revenue from it may not offset the expense and effort for obtaining approval. Hence physicians often use FDA approved drugs for non-approved indications.
Gray-label: This indicates a non-FDA approved medication or one that has not yet undergone peer-reviewed studies and is not recognized by evidence-based medicine to treat an illness or perhaps positively impact health span.
I then discussed estrogen therapy, something I’m very comfortable with. First, I described on- label use and the North American Menopause Society (NAMS) recommendation that “current data supports initiation of hormone therapy around the time of menopause to treat menopause related symptoms and to prevent osteoporosis in women at high risk of fracture”. The current on-label systemic estrogen indications are moderate to severe vasomotor symptoms. The off-label estrogen indications are the ones that I often see and treat and they include sleep disturbances, skin changes and skin aging, memory issues, skin sensory issues, joint pain, mood changes and sexuality. I then went on to show several other slides, but the one that I want to emphasis on this website is the fact that the follow-up study of the Women’s Health Initiative (WHI) that included 93,676 women followed for up to 13 years found that neither estrogen therapy nor estrogen progestin therapy affected all-cause mortality.

I thought my next slide might cause some issues at the conference; it was titled “Grey-label: bio-identical hormones”. I presented the following NAMS statement.

Bio-identical hormones may offer patients unsubstantiated claims about safety and effectiveness
The term connotes that they are identical to hormones made in the ovaries, but the same is true of many of the FDA approved prescriptions for hormone therapy
These products may contain dyes, preservatives, contaminants, and vary in dose.
Just to be clear, I did go to discuss the fact that certain progesterones for hormone therapy as well as testosterone are not available as FDA or on-label approved therapies for women and when I feel there is an indication to prescribe them I do. (This made the folks at the meeting happier.)

And despite the fact that specialty vitamin companies were sponsoring many of the booths at the expo at the conference, I did put up a slide that stated that “Vitamins are definitely on the no-label list”. I posed the question: “Are antioxidant supplements associated with higher or lower all cause mortality?” The answer was given with the evidence based trials reported in the JAMA clinical evidence synopsis published September 2013. A review of almost 100 studies showed that beta-carotene, vitamin E and higher doses of vitamin A may be associated with higher all-cause mortality and does not lower mortality rates. And of course the media just covered studies and statements that came out (after the conference) that taking a multivitamin does not increase life span.

I just want to mention one more slide which had to do with exercise… I called it the best label of them all! There is ample evidence that exercise lowers risk of coronary heart disease, stroke, hypertension, type two diabetes, depression, osteoporosis and increases lifespan and health span. The national exercise guidelines state that we should get two hours and 30 minutes of moderate intensity exercise a week, or 75 minutes of vigorous activity (or both), and two sessions of muscle strengthening exercises that work major muscle groups.

This is just a part of my talk at the conference. (I would say brief summary, but once I typed it out it seems pretty long.) I’ve discussed all these topics and the studies that led to my statements in previous website articles but I hey, it’s the end of 2013 and a review a can’t hurt. Oh,and I received some positive comments in the end of my presentation…

I searched this last week’s medical journals to find an article to write about. Unfortunately there was nothing I felt would be of interest to most of my patients. My fall back is usually JAMA, but the latest issue dealt with combat casualties, care for mass casualty events, treatment of post dramatic stress disorder and suicide… I pass. So I thought that this week I would write about the recommendations that were published in the Clinical Updates in Women’s Healthcare by the American College of Obstetricians and Gynecologists from April. There was a section dealing with physical activity for “older” adults and I, of course, wondered what their definition of older was… and as usual it encompassed anyone at or over the age of 65. Upon reviewing their recommendations, I realized that these are probably relevant to women and men of any age; so here they are:


  • 30 to 60 minutes of moderate intensity exercise, performed on five days each week or more. This can include walking, jogging, running and bicycling.
  • 20 to 60 minutes a day of vigorous intensity exercise performed on three days a week or more. Higher endurance activities will include swimming, cross-country skiing and aerobic dancing. Team sports such as basketball, soccer and volleyball and racket-sports such as tennis and racquetball included. They obviously can be very vigorous but since they also include intermittent periods of exercise and rest their effectiveness for continuous aerobic activity makes the calculation of duration more difficult.


  • Resistance exercise that involves each major muscle group should be performed on 2to 3 nonconsecutive days per week using a variety of exercise equipment or body weight resistance. This can be done with weight training machines, free weights, elastic resistance ( bands) or body weight resistance activities (push-ups, pull ups, sit ups, stair climbing and Pilates). Most individuals should aim for 10 to 15 repetitions of approximately 8 to 10 exercises to improve strength and power. The recommendations also includes correct breathing techniques… There should be exhalation during the effort phase and inhalation during the lengthening days.( All those exercise coaches were right!)


  • A series of flexibility exercises for each of the major muscle – tendon units, performed two days a week or more for at least 10 minutes is recommended to improve joint range of motion. This should include static stretches, performed by slowly stretching a muscle or tendon group and holding for a period of 10 to 30 seconds. Slow stretching allows greater stress relaxation and generates lower forces on the tendon. Holding the stretch at the point of tightness or mild discomfort for 10 to 30 seconds enhances joint range of motion. There is still a debate regarding the best time to stretch. Current evidence suggests that it is most effective when the muscle temperature is elevated after light to moderate exercise.


  • As we get older, coordinated actions become increasingly important in preventing falls and injuries. Walking on uneven or difficult terrain (try sand) is said to improve balance. The Chinese wellness practices such as can tai chi and qi gong which emphasize posture, breathing and meditation will increase our balance. Regular yoga practice can be quite amazing; it has been shown to be associated with improved gait, balance, flexibility, lower body strength and weight loss. To add to its increasing popularity, it also has been found to be effective in reducing blood pressure, glucose levels and cholesterol levels. Then we come to Pilates which is my favorite… It’s an exercise system focused on improving flexibility, strength and body awareness. It enables us to build core muscle strength and achieve better spinal alignment. One of the more fabulous benefits of Pilates is that it helps us become more aware of maintaining correct posture (I remembered to sit up straight as I wrote this) and activating core muscles in our every day activities.

So there you have it; it’s a fairly inclusive list and perhaps seems to be overly time intensive for many adults. But the impact of exercise (and it can be low-impact) on our health and longevity can be greater than many of the “preventive” medications that physicians prescribe. So I hope you’ll sit up, pay attention and get going.

I know this is the Fourth of July weekend and many of my patients and readers will be busy with family, barbecues and hopefully celebrating the independence of the fabulous country we live in. (And, of course, there are those wonderful sales!). But if you happen to be glancing at this website, I want to take this opportunity to indulge in a modicum of self-congratulation; a committee opinion from the American College of Obstetricians and Gynecologists was just released and it supports what I’ve been telling my patients for years; that hormone therapy does not increase coronary heart disease risk for healthy women who have recently become menopausal. What also makes this committee opinion novel is that it states that if a woman’s quality of life is diminished by menopausal symptoms past the age of 65, extended therapy may be considered. Let me repeat: The American College of Obstetricians and Gynecologists now recommends against routine discontinuation of systemic estrogen at age 65 for women who need HT to manage their vasomotor symptoms (hot flashes and night sweats).

So that’s the summary. And you can go back to your holiday celebrations. But if you want to read further here are some of the studies and facts that the committee used in its announcement:

Much of the controversy about the impact of hormone therapy (HT) on cardiovascular disease came out of the Women’ Health Initiative (WHI) and the Heart and Estrogen/progestin Study (HERS) which seemed to show an increase in heart attack and stroke in women who took hormone therapy. But more recent studies have cast doubt on some of the methodologies used. Many of the women who were in the those two studies were over the age of 63 when they started hormone therapy and already had underlying coronary heart disease, hence they had an underlying increased risk for developing heart attack and stroke, which perhaps was augmented by hormone therapy. But newer studies indicate that when hormone therapy is started at a younger age, in women aged 50 to 59, the opposite occurs. An important study used CT scans to examine the distribution of calcification (plaque) in the coronary arteries in 1064 women who were in that 50 to 59 year range. Those who took estrogen had calcium scores that were lower than women who took a placebo, moreover, those who stayed on estrogen for more than five years had a significant reduction of 40% in their calcification scores.

The committee also looked at other variables of hormone therapy that could affect cardiovascular disease. They stated that synthetic medroxyprogesterone acetate (Provera) causes constriction of blood vessels whereas natural progesterone causes the vessels to relax and therefore may have a positive effect on blood pressure. In addition, unlike synthetic progestins, natural progesterone causes little or no reduction in high density lipoprotein. (Remember, high density lipoprotein is the good cholesterol and works like a rotor router to protect vessels from plaque formation). The committee doesn’t go so far as to state that ET or HT improve cardiovascular outcomes, they simply state that the evidence is as yet insufficient. But they do say that recent evidence suggests that women in early menopause who are in good cardiovascular health are at low risk of adverse cardiovascular outcomes and should be considered candidates for estrogen therapy or combined estrogen and progesterone therapy for relief of their menopausal symptoms. And women over 65 should talk to their doctor. If their symptoms are persistent, it’s OK to consider continuing their hormone therapy.

My final summation: If you develop symptoms that make you miserable – start hormone therapy in the early years of menopause, there is no increased risk of CHD if you are healthy… and continuation beyond age 65 may be an appropriate option if your quality of life is significantly reduced by these symptoms. We still have to discuss risk- benefits (most specifically breast cancer risk…) There is no free lunch or hormone!

I just spent an amazing week at a spa near San Diego where I was able to hike, perform tai chi, yoga, dance, work out in a gym, meditate and even create art. It was a wonderful week of healing and renewal for my body and soul. Upon return, my state of “zen-hood” was altered when I discovered that only 20% of adult Americans meet federal recommendations for aerobic and muscle-strengthening activity.

Although during my spa week, I didn’t have the time nor the desire to read medical journals, once home on Sunday I felt a wee bit guilty (so much for being at peace with my zen-being) and quickly glanced at my favorite journal, JAMA. And there was an article titled “US Adults Are Lax On Meeting National Exercise Guidelines”. And in my current exercise euphoric state, I just had to read the article and feel a sense of exercise superiority as I unpacked. (It was a short article.) Here is what it reported:

Only 20% of adult Americans meet federal recommendations for both aerobic and muscle-strengthening activity. The federal government’s physical activity guidelines for Americans recommend two hours and 30 minutes of moderate intensity exercise or 75 minutes of vigorous aerobic exercise or an equivalent combination of both each week. Aerobic exercise can be walking, running, swimming and bicycling and should be in increments lasting at least 10 minutes spread throughout the week. They state that the health benefits of aerobic exercise include lowering the risk of coronary heart disease, stroke, hypertension, type 2 diabetes and depression. (We also know that it significantly increases longevity, perhaps more so then any medication!) Adults should also get at least two sessions a week of muscle strengthening exercise that works the body’s major muscle groups in the legs, hips, back, chest, abdomen, shoulders and arms. Working with a resistance band, lifting weights, doing push-ups and sit-ups or Pilates are a few of the recommended ways to increase bone strength and muscular fitness. Although the official physical activity guidelines don’t set a defined amount of time for this the exertion, they do state that it should be continued to the point that another repetition would be difficult. (We have all been there, after 10 or 15 reps, lifting that weight one more time or repeating that stretch is just too much of an effort.)

These woeful statistics were gathered through The Behavioral Risk Factor Surveillance System, a telephone survey of adults aged 18 years or older conducted by state health departments. It showed that Colorado did best and 27% of residents met the guidelines for both aerobic and muscle-strengthening exercise. The lowest rate in the country was in Tennessee with about 13% meeting the guidelines.

Although I won’t have a chance to go back for a glorious spa week for another year, I do intend to keep up the daily walking and twice weekly muscle strengthening work out. Statistics are worrisome, but sensing how well one feels as a result of doing the “right thing” is convincing.

As women transition from their regular periods and reproductive stage of life to irregular periods, followed by their absence and menopause, we are likely to experience symptoms such as hot flashes and night sweats. And they are expected… But what we don’t expect is a decrease in our mental abilities or fine motor skills. (As I type this in my iPad, I am watching my fingers to see if they are doing the walking with diminished dexterity!). So I was somewhat alarmed by a recent article in the medical journal Menopause, which of course has a bright red cover. The authors come from the department of neurology at the University of Rochester and the department of psychiatry at The University of Illinois at Chicago. They followed 117 women between the ages of 40 and 60. The women were classified in 4 groups according to their menstrual histories:

  • Late reproductive stage; having subtle changes in menstrual flow, cycle length or both (34 women)
  • Early menopausal transition; persistent cycle irregularity, defined as a difference of 7 days or more at least twice during the previous 10 cycles (28 women).
  • Late menopausal stage; no period for 60 days or longer (41 women).
  • Early postmenopausal stage; the first 12 months after the final menstrual period. (This final menses is also given its own important initials… FMP. I do have to laugh at the acronyms we use in order to sound medical, by the way there were only 14 women in this group… Where have all the postmenopausal women gone?)

These women underwent a battery of psychophysiologic tests that assessed their working memory, verbal fluency, fine motor skills, visual spacial skills, and memory. They all answered questionnaires to help determine their degrees of depression, anxiety (and taking all these tests may have increased the latter), overall health and their menopausal symptoms (specifically hot flashes and sleep disturbances). The researchers then measures the blood levels of estrogen (estradiol) and FSH (Remember FSH is the hormone that is secreted by the pituitary to get the follicles in ovaries to develop and produce estrogen. If there is little or no estrogen, the pituitary works harder and puts out more FSH. The latter will always be high once we run out of follicles and can’t produce estrogen, i.e. menopause has occurred.)

Without going into excruciating detail, what the authors were trying to investigate is whether there was a direct correlation between levels of estradiol, FSH, depression, anxiety, hot flashes and sleep disturbances and cognitive function and whether this function got worse as women progressed through the stages of perimenopausal to menopause.

The results were as follows: Women in the first year of postmenopausal performed significantly worse than women in the late reproductive and late menopause transition on measures of verbal learning, verbal memory and motor function. And depression, anxiety, sleep disturbances as well as hot flashes did not predict cognitive performance.

Okay, this is all rather complicated, so let me come to the conclusion: according to this somewhat small study (and larger ones have not have been as thorough), cognitive function may vary across the menopausal transition, with early postmenopausal being a critical period during which subtle declines in attention/working memory, verbal learning, verbal memory, and fine motor speed and dexterity may occur. The authors (all women) postulated that this may be due to the fluctuating hormones during this transition rather than the total loss of estrogen production that will occur later.

Having brought your attention to this article, I would like to point out that women who were AFTER that first year of absent periods were not tested…they may have reestablished their cognitive ability. (I hope so, otherwise I and most of my friends are in trouble). And just one more comment.. women who took hormone therapy were not allowed in the study. It’s possible that the results would have been different had they been tested. Just a hormonal thought!

We all know that Bacchus was a man. Based on gender stereotypes, most of us assume that women are less likely to excessively imbibe alcohol then men. (For the sake of transparency, the Superbowl was playing while I wrote this and all that celebrated testosterone caused me to make that last statement). But not necessarily so… According to a recent CDC report in “Vital Signs,” more than 14 million US women binge drink about three times a month and consume an average of six drinks per binge. This number includes one in eight women and one in five high school girls! The report states that binge drinking is most common in young women, women who are white or Hispanic, and among women with household incomes of $75,000 or more. Oh…and half of all high school girls who drink alcohol report binge drinking.

A woman’s ability to metabolize alcohol differs significantly from that of a man. When we drink alcohol it is absorbed more quickly, deactivated by enzymes less efficiently, and gets to the brain faster. (Well, we always knew that our brains have rapid and superior circulation. ) We generally weigh less than men so we are also less likely to dilute the stuff. As a result, one drink for a women has the impact of two for a man.

The definition of binge drinking for a woman is consumption of four or more alcohol drinks on an occasion. And an occasion is considered to be 2 to 3 hours. Although binge drinking in high school or college can lead to a higher incidence of alcoholism in later life, most binge drinkers are non-alcoholics and not alcohol dependent. The CDC reports that drinking too much (which of course includes binge drinking) results in about 23,000 deaths in women and girls each year and increases the chances of breast cancer, heart disease, sexually-transmitted diseases, unintended pregnancy as well as other health problems. If a woman binge drinks while pregnant, she risks exposing her baby to high levels of alcohol during its development which can lead to miscarriage, low birth weight, sudden infant death syndrome (SIDS), attention deficit/hyperactivity disorder (ADHD), and fetal alcohol syndrome (facial disfigurement and mental deficiencies). This is where I’m supposed to say it’s not safe to drink alcohol any time during pregnancy.

Aside from giving warnings, the CDC and its Guide to Community Preventive Services recommend certain strategies for preventing excessive alcohol consumption.. These include:  

*Increasing alcohol taxes.

*Reducing the number and concentration of stores that sell alcohol in a given area.

*Continuing government controls over alcohol sales.

*Maintaining or reducing the days and hours of alcohol sales.

*Enhanced enforcement of laws prohibiting sales to minors.

*Electronic screening and counseling for excessive alcohol use.

I know some of this sounds excessive and may go against our sense of what the government should and should not do. (There are no blue laws in California, and according to that wonderful series Boardwalk Empire, prohibition doesn’t work!) To help avoid teenage binging, the best plan might be to make sure that our teens can’t get into our liquor closet and of course, maintain zero tolerance for alcohol use before, during and after school parties. And then we should listen to the anti-binge advice ourselves. Remember abstaining from that second and certainly the third drink may lessen our risk for breast cancer, heart disease, stupid behavior, and worse yet, the wrong sexual and reproductive decisions. We just don’t need that extra glass of wine, cocktail or beer to enjoy the game, the dinner or the party. The salute ” Le Chaim” (translated, for those of you who need it) to “To Life” need not be accompanied by 4 drinks…one is healthier and should suffice.

A quick personal note: I am traveling to Mozambique next week with several women to see the school we built through the LA Associates of Save the Children. I will be happy to share pictures and stories upon my return.


I no longer have to take exams (except for recent on-line traffic school), nor do most of my contemporaries. But we all have to maintain our learning and memory skills in order to live our daily lives and to perform adequately or hopefully, better than adequately, in our professions. Even if we don’t have to take academic tests, our children and grandchildren do. And we all stay up for hours in front of our computers, iPads and tablets trying to get our work done, making sure we have not forgotten something or are not behind in our virtual lives. It seems that everyone crams, often at the expense of sleep. Well, it turns out that the best way to study for an exam, prepare for that next day’s task or keep the necessary data going in our brain’s memory is to get a good night’s sleep. Studies have shown that even a little sleep loss may impair our memory and learning skills.

This was the conclusion of research presented at the Society for Neuroscience meeting in New Orleans this past week, reported in JAMA. A team of researchers from Pennsylvania studied the effects of a single night of lost sleep on 22 healthy adults who agreed to stay in the lab for five days and undergo brain imaging and memory testing. (I’m not sure how anyone could sleep in a lab but hey, research of this nature requires consenting adults who agree to have sleep-overs in strange places.) The participants  were tested after a normal night of sleep and then after a night of sleep deprivation and then once more after two nights of “recovery sleep”. Lo and behold, the participants didn’t perform well on memory tasks after a sleepless night. And when imaging tests were done, their sleep deprived brains had decreased connectivity between the hippocampus (where memory is stored) and other areas of the brain necessary for performance of memory tests and tasks. It was as though parts of their brains had gone to sleep (or strike), in protest of the forced state of sleep deprivation.

The good news is that needed memory connectivity was not lost for long after a night of lost sleep. In the study, the brain connections and the participants’ performance on memory tasks were back to normal after a couple of nights of recovery sleep.

Bottom line: If you get a good night’s sleep you’ll be more likely to remember what you just read and what you should do with the information the next day…I usually write articles telling you to eat right, exercise, maintain a healthy weight, get the appropriate diagnostic tests, therapies, medications and immunizations. This time my advice should be somewhat more relaxing… sleep well.

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.


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:

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There are three ailments that most of us fear as we get older: losing our mental capacities, cardiovascular disease and cancer. In deference to reading time and latest articles, I am only going to deal with one, dementia. As I perused this month’s issue of the Journal Menopause (did I ever mention that its cover is bright red?), I found an article that summarized much of the data on dementia. Over a century ago, Dr. Alois Alzheimer, a German physician, reported on his treatment and subsequent autopsy examination of a female patient (Frau August Deter… there were no HIPAA regulations regarding names at that time) who developed dementia in midlife. Among her symptoms: hallucinations, paranoia, hostility, severe memory impairment, diminished cognition and language disturbance. She rapidly deteriorated, becoming bedridden, incontinent and completely helpless. At autopsy, Dr. Alzheimer found dramatic atrophy of her brain and on microscopic exam the neurons were surrounded by deposits of protein and had degenerated. We now know that the disease named after Dr. Alzheimer (AD) is the preeminent cause of dementia and is one of the most serious public health issues facing baby boomers as we age.

The development of Alzheimer’s disease is now thought to be influenced by many factors that include inherited gene susceptibility, environmental exposures, midlife health status, education and lifestyle choices. We also know, however, that the “older” brain has the ability to form new neurons and improve on the connection of old ones; in other words our brains have “placidity” and “cognitive reserve”. Alzheimer’s is the end result of a spectrum of mental declines and begins with mild cognitive impairment. So are there ways to prevent or delay that decline? And what can we do to maintain our brain fitness? (And if you remember, this is the intent of my somewhat cute website title.)

Here are some of the factors and prevention activities reported in the article:

Cognitive training: We’ve been told in books, magazine articles and PBS specials to engage in stimulating activities. Studies have been done which show that learning to play musical instrument lessons, memory games and learning a second language demonstrate some promise in early AD, but overall the effectiveness of these activities is, according to the authors, equivocal. They point out, however, that it can’t hurt…. (By the way, those of us who are bilingual are less likely to develop AD and lifelong bilingualism appears to delay the onset of dementia by approximately 4 years!)

Social engagement: Here is where I can add that volunteering activities have been found in some research to improve cognitive functions and mental health in seniors.

Health factors: The decidedly negative factors that increase risk of AD are the usual issues every doctor tries to help treat: obesity, atherosclerosis, high cholesterol, hypertension, smoking and diabetes. Diagnosing and treating them at an early stage should help prevent the mental consequences.

Diet: A diet rich in nuts, fish, fruits and vegetables – the so-called Mediterranean diet – is associated with a reduced risk of dementia and AD. One study that is cited in the review found that the dietary pattern that was significantly associated with reduced AD risk was a diet rich in omega-3 and omega-6 polyunsaturated acids, vitamin E, and folate and low in saturated fatty acids and vitamin B12. To get the brain-right nutrients we have to have a diet rich in dark and leafy vegetables, salad dressing, nuts, fish, tomatoes, poultry, cruciferous vegetables, and fruits, while refraining as much as possible from high-fat dairy, red meat organ meat and butter. And although it might seem easier to just take dietary supplements containing antioxidants or the omega fatty acids, know that most randomized controlled studies comparing nutrient supplements with placebo have not consistently found that they protect against cognitive decline. Apparently, we need to actually eat the foods in order to get an interaction of their nutrients to support our brains.

Physical exercise: Greater amounts of physical activity over the course of one’s lifetime are associated with a reduced risk of dementia. And it seems that there are positive effects of exercise in later life. In one study, 130 older adults (mean age 67.7 years) without dementia were randomly assigned to either an aerobic exercise training group of 30 minutes of brisk walking three times a week for 1 year or stretching in the control group. Exercise training actually increased the volumes in certain areas of the brain and memory scores on tests in the exercisers, while the control group had a decrease in the same areas in their brains and a decline in their memory scores over just the 1 year study period. I think that the data on exercise and brain health is extraordinarily convincing. And yes, I went to the gym today!

Bottom line (finally): Keep your brain engaged with mental challenges, don’t let yourself become isolated and if you have free time, volunteer (call me about Save the Children). Moreover, don’t smoke, try to maintain an appropriate weight, make sure you get your cholesterol and glucose levels down to optimal levels, get your brain nutrients through the right kind of diet (don’t rely on supplements to do it), and make exercise a vital part of your daily routine. All this may help prevent loss of a piece or peace of mind.