There are a slew of over-the-counter products in the pharmacy (and supermarket!) isles that are supposed to help or cure itching, irritation and discharge “down there”, and/or make you feel fresh, smell like a garden and keep you dry. So when an article appeared in the Journal Menopause titled, “Over-the-counter treatments and perineal hygiene in postmenopausal women” I both read it and thought I should summarize it on this week’s website.

The authors who are physicians in the Department of Obstetrics and Gynecology at Brown University questioned 114 postmenopausal women, who were seen for routine gynecological care, on their use of over-the-counter (OTC) products. They grouped the products into five major categories: barrier treatments, powders, topical anesthetics, antifungal (yeast) treatments and topical steroids (hydrocortisone). The women were also asked if they douched, took sitz baths, used soaps with perfumes and/or waxed. (I know this is getting somewhat embarrassingly technical but the percentage of women who used the products or did this was surprising.)

Over 50% of the women reported using at least one OTC vulvovaginal treatment in the last three months, including barrier treatments, topical anesthetics, powders and an antifungals. Women often used more than one OTC product during that time. Eight percent reported douching in the last three months. More than 50% of women used pantiliners, pads or some sort of diaper for garment protection. Half of the women were sexually active and of those almost 50% reported using a product for lubrication with intercourse. (Remember these were post menopausal women.)

The authors then emphasized that some OTC products can cause adverse reactions. For example, topical benzocaine, a common ingredient in OTC products marketed for itch relief has been shown to cause severe contact dermatitis (an allergic skin reaction) of the vulva. Likewise absorbent products for garment protection can have ingredients such as rosins, colophony and methydibromoglutsronitril (I have no idea what these are!) which can also cause severe contact vulvitis.

Besides products that cause allergic reactions other products have been shown to cause harm. The use of talcum powder is associated with an increased risk of gynecologic malignancies. Talcum powder is widely available in United States and they found that 22.8% of postmenopausal women reported talcum powder use within the last three months. Another practice that has been shown to cause harm is douching. Douching leads to a disturbance of the normal vaginal flora and an increase in bacteria that don’t like oxygen (anaerobes). When they multiply, a condition called bacterial vaginosis occurs, which can then cause irritation, discharge and odor. This is the opposite of the freshness that douching advertisements promote…. The authors found that 8% of post menopausal women reporting douching within the last three months. Other medical literature has shown that 25 to 70% of reproductive age women report douching on a regular basis.

So what does this all mean? If you are using any of these products and start to feel irritated the first thing to do is stop. And certainly don’t douche or use talcum powder to ” freshen up”. If irritation or discharge continues make sure you tell your physician about your OTC perineal habits. Contact dermatitis is the most common cause of chronic vaginitis. The products you use to help you feel that all is right ” down there” may be making it wrong.

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 walk my dog every morning for 40 minutes. After we take the required pauses for her to do her outdoor doggy functions, we maintain a fairly brisk pace. On many days this walk is my chief form of exercise. And in my office, during each patient’s visit, I ask about her exercise routine. I’m usually satisfied if she says that she’s walking briskly for more than 30 minutes a day. So of course, I was intrigued by a review article that appeared in the medical journal Menopause titled ” Effects of walking on the preservation of bone mineral density in perimenopausal and postmenopausal women: a systematic review and meta-analysis.”

Brisk walking has been shown to decrease the risk of diseases such as congestive heart failure, stroke, some cancers, type II diabetes, high blood pressure, and high cholesterol. It also burns calories and helps maintain healthy weight. The authors of this review article reviewed over 229 articles that were potentially relevant regarding the association of walking and bone density. They found 90 walking trials which they then evaluated but 80 of them did not have a non-exercise control group, the appropriate age women, bone mineral density data or did not separate walking from other forms of exercise. So in the end they had 10 walking trials that they could review appropriately. (Such is the long and tedious type of statistical analysis that is needed in order to write review articles… Hours and hours of reading, comparing and eliminating not to mention the need to go to the bathroom.)

There were two tables and seven figures that were included in this article and I’ll spare you all of them and get to the conclusions: Walking when done as a singular exercise seems to have no significant effect on BMD (bone mineral density) at the lumbar spine (lower portion of the spine), the radius (bone in the arm) or for the whole body in either perimenopausal or postmenopausal women. However, and this is the good however, the statisticians found that there were significant and positive effects on the BMD of the femoral neck i.e. the hip… if the women maintained this form of exercise for more than six months.

Although the study did not include a report on the incidence of fracture, the results offer “hip encouragement”. (My daughters would hate this last attempt at humor). We know that there is a significant correlation between loss of bone density in the hip and osteoporotic hip fracture. The latter is a major cause for disability and mortality. So I’ll keep walking briskly for my heart, my brain, my dog and hopefully my hips. Weight resistant exercise (Pilates, weight training, workouts with bands etc.) will help maintain muscle and bone in the other areas of our bodies. Once more – exercise, even walking, makes us healthier and stronger!

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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!

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!

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!

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Certain songs play over and over again in our minds…One that haunts me was written by Charles Fox and sung by Roberta Flack; “Killing Me Softly with His Song”. I was humming it while reading an article in the journal Menopause. (Please don’t laugh.) The article was a met- analysis  of studies that measured the mean difference in age of natural menopause between smokers and nonsmokers. Menopause occurred 1.12 years earlier in smokers than nonsmokers, and that difference was significant. Hence the heading for my article this week.

Menopause is defined as a permanent cessation of periods for 12 months. And if wis use this 12 month definition, the only way to date menopause is to do so retrospectively. Before our ovaries run out of the follicles that produce the estrogen and progesterone needed to instigate our periods, they “sputter”. The follicles that have not been used up during our teens through our mid forties are the rejects and they simply do not put out (hormonally) as they should. This period of approaching follicular extinction is termed the menopausal transition. On average it begins at age 47 and lasts 4 years. During this transition, even though periods may come and go, symptoms such as hot flashes, sleep disturbances, vaginal dryness and pain with intercourse can occur.

There are more than 3000 chemicals inhaled in cigarette smoke. Many of them are detrimental to the health and well being of the follicles and can contribute to their early demise. The concerns about early menopause do not solely relate to symptoms. Early menopause increases the risk of cardiovascular disease, venus thrombosis (clots) and osteoporosis. Overall it increases the risk of mortality by approximately 2% per year. And to add insult to smoke injury, the combination of earlier loss of estrogen and current smoking further increases a woman’s risk of cardiovascular disease and death!

For this and so many other reasons, quitting smoking is the best thing a smoker can do for her health. Now would putting a picture of ovaries with a big red X over them help to convince women to stop smoking? I’m not sure … But it can’t hurt to add this to all the other warnings.

As you know when you come for your annual gynecologic visit, the receptionist requests that you update your information, sign a confidentiality form, and she checks on your insurance. The nurse then hands you a small plastic cup and asks you to give a urine sample. So there you are in a cramped bathroom trying to aim the stream into what now seems like an impossibly narrow container and thinking: (a) this is humiliating, (b) why is this necessary, I have no problems with my bladder? and possibly (c) I can’t go, so what am I supposed to do now?

A new article in the Journal Obstetrics and Gynecology aptly titled “In the Trenches” emphasizes the importance of checking your urine.

An immediate urine test can be performed with a “dipstick”, a strip of paper that is specially treated to check for white cells (often present if there is an infection) red blood cells or RBC’s (and the rest of this newsletter will deal with this… if blood is present in the urine, the medical term is hematuria), protein (if elevated, a sign of kidney or even systemic disease), glucose (present in urine if blood levels are high), ketones (elevated with kidney problems or dehydration), bilirubin (elevated in liver disease) and pH (acidity).

The journal article dealt specifically with microscopic hematuria in women. “Microscopic” simply means that there is blood (or red blood cells) in urine but the urine doesn’t look bloody to the naked eye or toilet paper…(I realize this is getting a bit gross!) According to the American Urological Association, “significant microscopic hematuria” means there are three or more red blood cells (RBC’s) per high power field (magnified 40 times) on microscopic examination from two to three properly collected urinalysis specimens. To get a proper sample, the first drops of urine should not be included, just the midstream…all the more difficult to get into that cup. If you have your period, recently exercised vigorously, just had sex or vaginal trauma, obviously blood cells in the urine will not count and the test should be repeated another time.

Once a dip stick test is positive for RBC’s …I (or any doctor) will probably send the urine out for a complete urinalysis. The urine is spun down and the sediment is examined for the number of RBC’s, white cells, and/or bacteria. Often we also do a urine culture to rule out infection. (Most women, however, do know when they have a bladder infection…. they have urinary urgency, frequency and burning.)

So why is it so important to detect microscopic hematuria? Before I relate the possible causes and consequences listed in the journal article, I’ll tell the tale of a patient that I saw a few weeks ago. She was menopausal, had no signs of vaginal bleeding or urinary problems, but a routine urine dipstick test was positive for RBC’s. Her urine was sent out for culture (it was negative) and complete urinalysis. The latter confirmed the presence of a significant amount of RBC’s.. I asked her to repeat the test 2 weeks later and once more it showed RBC’s. I then referred her to a urologic specialist for a complete workup.. This ultimately consisted of cystoscopy and a CT scan of her pelvis and kidneys. She was found to have bladder cancer. It was resectable and curable.. This simple urine test probably saved her life.

The two most frequent causes of microscopic hematuria in non-pregnant women (46% of women do have hematuria during their pregnancy) are cystitis (bladder infection) and kidney stones. Additionally, some women seem to shed RBC’s in their urine without any pathology. But the cause that should be ruled out, especially in women over 40, is cancer. Bladder cancer is the 17th most common cancer in women worldwide. In the United States in 2008 there were 17,770 new cases of bladder cancer diagnosed and 4,270 deaths …that means that there were more deaths annually from bladder cancer in women than from cervical cancer! (A personal aside…. many years ago my paternal grandmother died from bladder cancer.)

The risk factors for urologic cancers in women include age over 40, smoking, a history of exposure to chemicals or dyes, a history of gross hematuria (the “gross” here is a medical term and means that urinary blood is visible), analgesic abuse and a history of pelvic radiation. And here is a fact that seems to appear whenever we discuss most cancers: up to 35% of female bladder cancer cases may be attributable to cigarette smoking!

The recommendations put forth in the article state that a complete work up of microscopic hematuria should include an evaluation of the lower urinary tract (the bladder) and upper urinary tract (the ureters and kidneys) in any “high-risk” patient. Once more, you are at risk if you are over 40, have smoked, have had chemical exposure (hair stylists), have a family history of bladder cancer (I guess that’s me) and/or recurrent urologic disease. The work up should include cystoscopy, x-rays with dye and CT scans.

We all know about the need for Pap smears. It turns out that a urine test is just as important. So please don’t bewail that request to pee in a cup.

I’ve written several newsletters about potential side effects of bisphosphonates medications used to treat osteopenia and osteoporosis (Fosomax, Boniva, and Actonel….just to remind you of some brand names). This time I want to share some potentially good news about this bone density enhancing class of medications. And I am especially happy to share the report because it comes from a study conducted in Israel. (As many of you know, I have taught and worked there and indeed will be in Tel Aviv when this article appears.)

The Israeli researchers conducted a study entitled The Molecular Epidemiology of Colorectal Cancer. It was supported by the National Cancer Institute and published in the February issue of the American Journal of Clinical Oncology. (I hope I haven’t lost most of my readers by this point…just bear with me. So many of you or your relatives take bisphosphonates so that your skeletons can successfully bear your weight without an osteoporetic fracture)

They found that postmenopausal women who had taken an oral bisphosphonates longer than one year had a 59% reduced risk of colorectal cancer. Like the Scandinavian countries, pharmaceutical records in Israel are extremely well documented. (All the citizens have health insurance and most of their prescription medications are covered…I wish I could say the same for us!) The researchers used computerized pharmacy records and identified almost 2000 women who had colorectal cancer.

They found that in these women, compared to controls who were matched for age, weight, and religion, the use of bisphosphonates longer than 1 year, but not less than 1 year, reduced the risk of colorectal cancer by half, even when they adjusted for other factors that could perhaps lower colorectal cancer risk. (Here is where I list these factors to remind you that they too count in our “war on colorectal cancer”…as does screening. They include vegetable consumption, physical activity, and weight control, use of low-dose aspirin, statins, vitamin D and postmenopausal hormones.)

Ongoing research indicates that oral bisphosphonates may exert a cancer-protective effect (including breast and prostate cancer.)  Clearly this study is not large enough to persuade the FDA to approve any official indication that this class of medication will diminish colorectal cancer. So I’ll end with the phrase that is used in the conclusions of most medical articles: “Further studies are needed”. I felt , however, that a bit of good news about the medications that can lower the huge toll of osteoporotic fractures in women (and men) is welcome.

Let’s discuss several hormonal scenarios: (1) You’ve been on hormones for several years and now think you may try to stop. (2) You have just started having hot flashes and you haven’t quite made up your mind as to whether you will want to take hormones during the menopausal transition. (3) You are not yet menopausal but worry about what you will experience when it inevitably develops.

The defining question for most women (at least in regards to quality of daily life) is: “How long will I experience hot flashes?” One would think that since menopause has been around before and since the written word that we could estimate the average duration of this pesky and sweaty symptom. (Well maybe not, 120 years ago the average life expectancy for women was 47 and most did not outlive their ovaries.)

Hot flashes generally begin when estrogen levels plummet in menopausal or during the premenopausal transitions. The ovaries run out of follicles that are capable of responding to pituitary messages to develop and hence produce estrogen. In the absence of said estrogen, the pituitary works harder (it’s trying to get those damn follicles to work), hence it puts out more and more FSH (follicle stimulating hormone). The pituitary gets its signals from the part of the brain called the hypothalamus which produces GnRH or gonadotropic releasing hormone, the master hormone that instigates FSH production. In the absence of “usual” estrogen production, GnRH and FSH levels soar and there is a veritable hypothalamic storm. This then causes a state of confusion in the central thermostat in the brain which begins to “think” that the body’s core temperature is too hot. In order to correct this, the hypothalamus sends out directives to dilate the small blood vessels in the skin (the flush) and causes water to evaporate from the skin’s surface (as sweat, facial and body perspiration) in order to cool the body down. All of this may lower the core body temperature by as much as half a degree. Often subsequent to a hot flash, a woman may shiver as small muscles contract to re-elevate the core body temperature.

Hot flashes are associated with poor sleep, decreased quality of life, may worsen depressive symptoms and even signal the onset of a major depressive disorder. The flashes may also be a clinical sign for underlying cardio vascular disease as well as a risk factor for poor bone heath. Although “natural”, hot flashes are not great to experience and ultimately may correlate with poor overall health.
What we do know is that the peak incidence of hot flashes occurs approximately 1 year after menopause in 80% of women in the US, but (and this is what is so surprising) the overall duration of hot flushes is unclear.

(Sorry that this intro is so long, but now I’ll get to a recent attempt to answer the “how long will this last” question…) A study published in the May issue of Obstetrics and Gynecology tried to assess the duration of menopausal hot flashes and associated risk factors.

The “flushing and flashing” women that were followed were part of The Penn (Pennsylvania) Ovarian Aging Study of 435 women (half white and half African American) that were monitored for 13 years. Hot flushes (they use this term instead of “flash”) were evaluated at 9 -month and 12-month intervals though in-person interviews. At enrollment, the participants’ ages were 35 to 47 (mean age 42.2) and 91% were still premenopausal. The most common age at onset of moderate-to-severe hot flushes was 45-49(35%); 30% were between 40-44years, 21% were older than age 50and 14% were younger than 40 years. Age at the onset was inversely associated with duration of hot flashes. In other words, the younger the women were, the longer they suffered. This totaled 11.57 years for those whose onset of hot flushes occurred before the age of 40; and decreased with onset at older ages: 11.25 years for those whose flushes started at 40 to 44 years; 8.1 years with onset ages 45-59 and 3.8 years duration with onset at 50 years of age or older.

Other independent predictors of the duration of the flushes were race (African Americans had a longer duration) and body mass (thin women also had a longer duration.) It’s thought that obese women convert hormones produced by their adrenals to estrogen-like hormones in their abundant fat and hence have production of estrogen that “saves them” from many years of flushes. It’s interesting that in this study smoking, alcohol use and number of children the women bore had no association with the duration of their hot flushes. (Although in general, the data has shown that smokers enter the menopause at an earlier age than non smokers, simply because the toxins in cigarettes kill off the follicles in the ovaries….my comment in this article against smoking!).

In the discussion portion of the article, the author’s state that “the median duration of moderate-to-severe hot flushes was 10.2 years, well beyond the duration considered in clinical guidelines. When women who reported mild hot flushes were included, the median duration increased to 11.6 years.”

Before all you women who begin to have menopausal symptoms in your early 50′s freak that these will continue unabated into your 60′s, I have to point out that the majority of the women in this study were younger than 50 when they reported moderate-to-sever hot flushes. (Most were 45 to 49.) Hot flush duration was approximately 8 years for this group compared to less than 4 years when onset occurred at ages 50 years or older.

Bottom line: The earlier you begin to have hot flashes (even if you are still getting your period) the longer you can expect them to continue during menopause. Now that you have this information, discuss therapies with your doctor.