As I sit here worrying about the Middle East and talk to my family in Israel, I’m experiencing hot flashes. Admittedly, they are from anxiety and not a hormonal imbalance, but they have made an editorial I read this week in the Journal Menopause more compelling. It’s titled “Hot flashes: is a hot flash just a hot flash?” The author, Dr. Lila Nachtigall a professor from New York University, has long been an advocate of hormone therapy and has written multiple articles and given many lectures on menopause. Her current editorial highlights issues that may be of interest to many of my patients.

Studies conducted in 1990 have shown that among untreated women, 80% of hot flashes will stop in three years and 90% of hot flashes will be over after six years. A few women, however, can have them for 40 years or more. In more recent studies of women who have hot flashes, 25% reported that the symptoms remained for more than five years and 10% reported that the symptoms continued for more than 10 years. Why? Well, we know it’s lack of estrogen that causes these vasomotor symptoms. The brain has an inner thermostat zone that impacts the body’s ability to heat or cool with minimal temperature changes. There is a hormone; norepinephrine (now aptly called brain norepinephrine) which is released from brain estrogen receptors when they are not receiving estrogen. This hormone sets off responses in the body to impose heat regulation and cool the body though dilation of superficial blood vessels (flushing) and evaporation of fluids (perspiration). Women who are recently or suddenly postmenopausal have more of these used-to-work-estrogen receptors. Estrogen deprivation together with what we call up-regulated receptors cause these women to have more frequent and more severe hot flashes. (I know this doesn’t explain why 10% continue to have significant hot flashes. We do know if the hot flashes were severe from the start they are more likely to continue…perhaps because the estrogen receptors remain robust.)

There have been studies that have shown that the severity of hot flashes is associated with lower levels of health and even work productivity. One study called The Study of Women’s Health Across the Nation has shown that hot flashes are associated with a higher incidence of insulin resistance. Other studies including the Women’s Health Initiative have shown that there are higher risks of cardiovascular disease in women with significant menopausal symptoms. Those experiencing severe hot flashes have an increased risk of coronary heart disease by a factor of five compared with their counterparts who had less or no symptoms. Similarly, the risk of stroke was elevated by a factor of almost 4. Brain PET scans have shown that there is a significant decrease in cerebral blood flow during a hot flash. The author goes on to state that this may explain a woman’s inability to continue her tasks during a severe hot flash.

As a result of some of this data the American College of Obstetricians and Gynecologists has added new clinical guidelines for the management of menopausal symptoms. This directive encourages physicians to treat vasomotor symptoms i.e. hot flashes and not use age as a guideline, stating that the decision to treat should be individualized and there is no need to discontinue medication if a woman is still symptomatic after age 65.

Although it’s clear that estrogen will indeed prevent those brain receptors from releasing vasomotor causing norepinephrine there are other pharmacologic medications that are available to help diminish or stop the hot flashes. One of these is a low-dose SSRI (Paxil) called Brisdelle. A new formulation of gabapentin was found in a recent phase 3 study to statistically reduce frequency and severity of hot flashes.

The pros and cons of hormone therapy, types of hormone therapies, and alternatives to hormones have become a major subspecialty in the treatment of women over the age of 50. It’s difficult to give an assessment of what can and should be done in one article or one exam. Like everything in medicine, symptoms, personal and family history, health risks and of course symptoms have to be properly assessed by both the patient and her physician. New studies and expert insights improve our ability to make more informed decisions. So I thought I would share …and no, I have no ready solutions, despite copious reading, that helps me cope with my Middle East anxiety.

Seventy five percent of women who become menopausal will have hot flashes, night sweats and sleep problems which, although not life-threatening, can certainly impact quality of life. I have spent much of my career writing about this and indeed treating women with these symptoms. For those who have no contraindications, hormone therapy will usually be the “cure” they seek (as well as maintain bone density, vaginal integrity, skin collagen, perhaps impact cognition and focus, and at least initially, help prevent atherosclerosis and decrease abdominal fat distribution). There is, however, concern about the impact of oral estrogen and synthetic progestin on the risk of blood clots, breast cancer and even dementia. There are new ways to prescribe estrogen that maybe safer (transdermal) and alternatives to synthetic progestin. But a considerable number of women have clear contraindications and/or choose not to take hormone therapy. There is also a valid concern about long-term use; after three to five years of successful hormone therapy the question remains, “Is it safe to continue?” Some women will stop and have minimal symptoms but others will return to the same hot, bothered and sleepless condition that caused them to go on hormones in the first place! Until now, there been no FDA approved non hormonal medications to help treat these vasomotor symptoms.

So although I knew about this medication and have already started to prescribe it for appropriate patients, I wanted to mention the new article that was published in the May 8 issue of the New England Journal of Medicine, “FDA Approval of Paroxetine for Menopausal Hot Flashes” Paroxetine is also known as Paxil which is generally prescribed in doses of 10, 20 and up to 40 mg for several psychiatric conditions, including major depressive disorder. And as you may have noted as you watch or read the myriad direct to consumer ads, this type of antidepressant (as well as most others) has warnings about monitoring patients for suicidal thoughts and behaviors and the directive to discontinue treatment if there’s worsening depression or suicidality. The new medication, called Brisdelle contains a much much lower dose of Paroxetine, only 7.5 mg. It is a very mild selective serotonin reuptake inhibitor that causes a mild increase in that “feel good brain hormone”, serotonin.

The history of the FDA approval is interesting and was the subject of the article. The approval ran counter to the recommendation of the FDA reproductive health drugs advisory committee which had concluded, by a vote of 10 to 4 , that the overall benefit-risk profile of Brisdelle did not support approval. The FDA always carefully considers the advice from its advisory committees but it is not required to follow their recommendations… Here is what the committee considered: Among a total 1184 menopausal women who had a median of 10 moderate-to-severe hot flashes per day, Brisdelle was shown to provide modest relief in comparison to placebo. At week 12 (in one of the studies) there was a median reduction from baseline of 5.9 moderate-to-severe hot flashes per day with Brisdelle as compared with the median reduction of 5.0 per day with placebo. At week 12 (In a second study), there was a median reduction from baseline of 5.6 moderate-to-severe hot flashes per day with Brisdelle as compared with the median reduction of 3.9 per day with placebo. But even though this was a very modest effect, Brisdelle remained efficacious at six months, the latest time point assessed. Because of Brisdelle’s very modest efficacy and concerns about suicidal ideation the advisory committee’s 10 to 4 vote against approval occurred. But recognizing that no hormone-free drug product has been approved to treat vasomotor symptoms, the FDA concluded that Brisdelle still offers a clinically meaningful benefit for some menopausal women.

So yes, we have a new FDA approved medication for hot flashes and in many cases insurance will pay for it. I applaud the fact that we have this alternative; I’m not sure that it will work for every woman but for those of my patients who cannot take hormones and who have quality-of life-affecting symptoms, it’s worth a try.

We know that hot flashes and night sweats are vasomotor symptoms (VMS) that affect up to 80% of women during the menopausal transition and may continue for years. They can be disruptive and unfairly compromise the quality of life. So when a study was published in the April issue of the Journal Menopause (the one with the red cover) that investigated the potential efficacy of omega-3 for menopause symptom control, I read it with interest. Should this be one of the supplements I suggest for my symptomatic menopausal patients?

The study was carried out in 355 women who were 40 to 60 years old and were in the menopausal transition or post menopause (and not on hormone therapy). Half were assigned to take omega-3s and the other half to take an identical looking placebo. They were then asked to provide diary data on week 6 or week 12 in which they recorded hot flashes, sleep quality, insomnia symptoms, depressive symptoms or anxiety symptoms. Those on the omega-3 were given 1.8 g per day of high quality omega-3′s (three pills per day each containing 425 mg of EPA, 100 milligrams of DHA and 90 mg of other omega-3′s).

The results were disappointing, at least for the manufacturers of omega-3s. The mean baseline hot flash frequency was 7.6 per day. The omega-3 group had a mean hot flash frequency on week 12 that decreased to 5.2 VMS per day corresponding to a 32% decrease or a mean of 2.5 fewer VMS per day compared with baseline. Based on this result one would perhaps surmise the omega-3′s were effective. However, a similar change occurred in the women taking the placebo; they experienced a decrease to 4.9 VMS per day on week 12, a 36% decrease or a mean of 2.7 fewer VMS per day. In other words and numbers, there was no difference in VMS reduction between the two groups… The placebo worked as well as the supplement! Also compared with the placebo the omega-3 intervention did not significantly improve any other menopausal symptoms such as sleep quality, insomnia symptoms, depressive symptoms, or anxiety symptoms.

Many women seek alternative treatments to hormonal agents and this is one of them. A recent report from the National Center for Complimentary and Alternative Medicine indicated that more than 40% of the adult population in the United States used at least one complementary and alternative medicine treatment during the previous year, with women being more likely than men to use complementary and alternative medicine.

Omega-3 supplements may help with cardiovascular disease, rheumatoid arthritis and perhaps depression. But you probably get the benefits of the supplement with ingestion of three portions of fish a week. That’s what I’ll continue to do… When it comes to vasomotor symptoms, estrogen still has the best track record but as we all know there are significant pros and cons that have to be considered. Why couldn’t this be easier? But before I end this with a down note let me remind you that women in the developed world have the opportunity to outlive our ovaries by more than a third of our lives. What a privilege to have those years!

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!

Philippine Typhoon Haiyan Response: every small donation counts: Give online: www.savechildren.org

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.

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!

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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.

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