We’ve all been hearing more and more about HPV infections; that they cause cervical cancer, vaginal cancer, anal cancer, throat cancer, mouth cancer and venereal warts. I’ve written several articles about the need to immunize girls and boys with the HPV vaccine. The most common vaccine, Gardasil is given in 3 doses, it is a quadravalent vaccine, which means it gives immunity to 4 types of HPV (6,11,16 and 18). These are the ones that cause 70% of cervical cancers, many of the other above mentioned cancers as well as venereal warts. But alas, despite the multiple direct to consumer ads in the media, recommendations by most doctors and the studies in peer-reviewed journals, only one third of adolescents are currently being immunized.

We would certainly expect the prevalence of these infections to be significantly diminished in those whose parents had the clinical acumen to have their children immunized. But they represent just 30% of their peers. So it was pleasantly surprising to find that a study published online in the Journal of Infectious Diseases reported that the prevalence of infections with the human papilloma virus types included in the Gardasil vaccine dropped by almost 60% among females aged 14 to 19 years during the four-year period after the vaccine became available and was recommended. Dr. Thomas Frieden, the CDC director, said during a press conference held to announce the results of the study, that increasing the vaccination rate to 80% would prevent about 50,000 cases of cervical cancer among girls alive today. “We owe it to the next generation- our sisters, our daughters, our nieces and to protect them against cervical cancer.”

Just to remind you, a three dose series of the quarivalent HPV vaccine was recommended in 2006 by the CDC as a routine vaccination for females age 11 to 12 years and for females aged 13 to 26 years who had not been previously vaccinated. In 2011, the recommendation for the vaccine was expanded to include boys aged 11 and 12 years and for non vaccinated males up to 26 years. No data is yet available on the proportion of males who have been vaccinated and/or the impact of vaccination on their infection rates.

The nearly 60% drop in HPV infection is greater than expected but can be due to “herd immunity” from vaccination (nothing to do with animals, it means that those who got the vaccination were unable to infect those who did not).

Remember, HPV is the most common STD in United States. The estimate is that 14 million people becoming infected with HPV every year. According to the CDC, 79 million of the those who have become infected with HPV are in their late teens and early 20s. Every year, about 19,000 cancers in women are caused by HPV; most are cervical cancer. And of 8,000 cancers caused by HPV that occur in men in the United States, most of them are oropharyngeal (mouth and throat).

Wow, this vaccine can make a huge difference. It may be too late for many of us who are over the age of 26 but we certainly can make sure that the younger (and youngest) generation are vaccinated… Not to do so is malparenting!

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!

I have obsessively discussed the positive health aspects of the various forms of contraception in my newsletters over the past few years. (Clearly a part of my Planned Parenthood background!) I have also proclaimed gender health success when the Affordable Care Act (ACA) stated that after August 1, 2012, preventive health services recommended by the Institute of Medicine and endorsed by the Department of Health and Human Services would be covered by insurance companies. These services are meant to promote the development of a health system that sustains health rather than merely treats illness. The services include all FDA approved forms of contraception, the morning after pill as well as sterilization procedures. And women will now be afforded health mandated services for cervical cancer screening, screening for sexually transmitted infections, mammograms and maternity care. But as we all know, some religious organizations and private employers have demanded exemptions from providing contraception stating that this violates their religious beliefs. Many of us have been outraged. Our umbrage was beautifully voiced in a “viewpoint” article published in the May 15th Journal of JAMA. Three physicians from the Northwestern University Feinberg School of Medicine in Chicago, Illinois contributed to the article and I would like to share their arguments with you.

I routinely ask my new patients: “How much, on average, do you drink each week?” In order to make this question slightly less accusatory, I also add “do you usually have wine with dinner or a cocktail before?” If the answer is “yes, one or two glasses”, I then feel obligated to discuss the pros and cons of women’s alcohol consumption. I was therefore delighted to find an article under the heading of “Clinical  Crossroads” in last week’s JAMA which dealt with the question of whether a person (in this case, a 42 year old man) should drink for his health. The authors were kind enough to also consider the health implications of drinking for women. Here are some of the facts that they presented:

The estimated ethanol (alcohol) content per serving of various alcoholic beverages is similar, although their caloric content may vary. Twelve ounces of beer have 14 grams of ethanol and 150 calories, light beer contains 11 grams of ethanol but about 50 calories less; 5 ounces of wine contain 15 grams of ethanol and 120 -125 calories and finally 1.5 ounces of “hard alcohol” or spirits have 14 to 15 grams of ethanol and 100 calories.

Because women have a smaller volume of distribution in which to dilute the alcohol, overall smaller body size, and a different first –pass metabolism (alcohol is not as quickly metabolized by the liver), we experience the toxic effects of alcohol at approximately half the daily dose of alcohol as do men. One glass of  wine, serving of beer or “a drink” for a woman is like two for a man….so ( and I don’t meant to insult your intelligence, but  want to write this for emphasis)….two drinks at dinner would be the equivalent of four for a man. And that’s a number that would cause concern to most of their female companions.

Alcoholism has been ranked the third most important preventable cause of death in the United States. The National Institute on Alcohol Abuse and Alcoholism has issued the following guidelines for safe drinking:

* Up to 2 drinks for men younger than 65
* Up to one drink per drinking day (I’m not sure what constitutes a drinking day, but it’s their wording) for non-pregnant women and older adults

No alcohol for

* Women who are pregnant or trying to become pregnant
* Persons with medical conditions that could be made worse by drinking
* Persons who plan to engage in activities that require alertness and skill (such as driving a car)
* Persons taking certain over-the-counter or prescription medications (think sleeping medications, ant anxiety meds, antihistamines or anything that effects brazen chemistry)
* Persons recovering from alcoholism
*  Persons younger than 21

In order not to sound like an abolitionist, let me also proffer the data that was cited on the “biochemical effects of light to moderate alcohol consumption in short term feeding studies”. (Actually they were drinking studies). Researchers looked at certain biomarkers for cardiac disease and the effect of ethanol on these markers. HDL or high density lipoprotein (the good cholesterol) was minimally increased, but a lot of alcohol was needed to do this (60 grams per day in men and 35 grams in women). Alcohol seemed to work best on HDL if the levels were low to begin with. (Before menopause most women have fairly high HDL levels, perhaps due to their production of estrogen.) Triglycerides were increased in men who drank moderately but may have decreased in women (although beer with more carbohydrates seems to erase this phenomenon). Fibrinogen which is involved in clot production was lowered. Adiponectin which increases insulin sensitivity (a good thing) did minimally increase and as such may have lowered the risk of diabetes.

Now here is the concern for women: Light to moderate drinking increases the bodies own sex steroid hormones by 5% to 20% and can increase risk of breast cancer! This translates to an approximate 1% increase in the relative risk for each one gram a day of alcohol.   It also has an adverse effect on other cancers in men and women. Malignancies of the mouth, larynx and esophagus are increased in all moderate drinkers. The relative risk of developing these cancers (compared to nondrinkers) is approximately 1.4 to 1.7 with “just” 2 drinks a day.

So should we drink for our hearts or abstain for our breasts? Studies dating back at least 25 years have shown that 10 grams of ethanol per day among women (and 25 grams for men) lowered risk of coronary heart disease by 20 to 30%. The authors calculated that this conferred a 1% lower absolute 10 year risk for a 50 year old man who was deemed “average”, but remember our 10 year average risk at 50 is usually less than that of men.

It sounds like that one drink is a draw…but the authors go on to state that the typically high HDL levels in premenopausal women would appear to make any clinical benefit for alcohol limited at best, “and since the risk of breast cancer is increased, it is unlikely that premenopausal women would profit from drinking”.

There is so much more that we can do to prevent heart disease…not smoking, exercising, maintaining a reasonable body weight and if necessary treating elevated lipids (LDL cholesterol and triglyceride).

Alcohol is not a medicine. If you love it and want to drink a glass of wine with dinner or have that drink before….limit it to one.  Your choice to imbibe is similar to your desire for desert, but without the “nose”….it tastes good, you enjoy it and it adds to your meal. The toast “l’haim” (to life) that accompanies that drink is a wish, not a medical certainty.

Recently, a mother brought her adolescent daughter to my office for advice about  menstrual migraine therapy. After I made my suggestions, I thought it might be timely to give a few “notes” (I sound like a producer) for the website regarding the causes of and treatments for this debilitating disorder. Migraine headaches are unfortunately very common; they affect nearly 28 million Americans including 18% of all women and 6 % of all men. A migraine is defined as a one sided, severe, pulsating headache aggravated by physical activity together with sensitivity to light (photophobia) and sound (photophonia). The true migraine usually manifests itself in 4 phases. (This is not a simple come and go headache).

The Premonitory Phase (Prodrome): This phase is due to neurochemical alterations in the brain and is most commonly associated with fatigue, difficulty concentrating, stiff neck and light sensitivity. It can also include mood swings, food cravings, yawning, change in vision, nausea and vomiting.

The Aura Phase: This occurs in 15% t 20% of migraine attacks. The ends of the 5th  facial nerve ( the trigeminal nerve) are activated causing symptoms that include scintillating lights, distorted vision and numbness and tingling in the hands or face. These sensations are usually followed within 60 minutes by the headache. Rarely an aura can occur and not be followed by pain; it’s then aptly called a migraine aura without headache. This may be a final neurological diagnosis (by exclusion) once a full work up for symptoms of stroke is negative.

The Headache Phase: The trigeminal nerve that gives us our sensory perception from our face also provides a pain pathway from the meninges (the capsule around our brain). Though a complex system called the trigeminovascular system, the nerve can become activated by many triggers. This trigeminal activation then instigates the transmission of impulses in the brainstem and causes a release of substances called vasoactive neuropeptides. They, in turn, cause dilation of blood vessels and inflammation in the meninges. The activated trigeminal nerve fibers become abnormally sensitive and any stimulus, such as light, sound or even gentle touch can increase pain. (This explains why most migraine sufferers want to be left alone in a dark room without human contact once the migraine occurs.)

The Post Headache Phase (Postdrome): Migraine symptoms can last for up to 2 days. This “post” seems to go on forever!

More than half of the women who suffer from migraines have them in association with their menstrual cycles; moreover, the migraines that occur with their periods are worse than all others. There are 2 kinds of cycle associated migraines… (Medicine is chock full of nomenclature.) Pure menstrual migraines occur without aura 2 to 3 days after the start of menstruation but do not occur at any other time during the menstrual cycle. Menstrual related migraines include menstrual migraines but attacks can also occur at other times in the menstrual cycle (often days before the onset of the period, or right after ovulation). It is thought that change in hormones, especially the decline of estrogen before and during the period, play a role. Also as an added insult, when we menstruate, pain stimulating substances called prostaglandins are released and can trigger headache, nausea, vomiting and diarrhea even in women who do not have true migraines!

OK, now that I have given you a synopsis of Migraine 101, let me get to therapies. First … those that are nonphamacologic: This is where we try to limit migraine triggers, use relaxation training and biofeedback. Although I can’t teach you how to do the latter two in this summary, I can at least acquaint you with triggers that you can avoid. They fall into 4 categories:

  • Diet: Alcohol, chocolate, aged cheese, monosodium glutamate artificial sweeteners, caffeine, nuts, nitrates and nitrites and citrus fruit. Not all these affect the same person and clearly there are other foods that can less frequently act as triggers.
  • Changes: weather, seasons (maybe we should all live in San Diego or Hawaii), travel, altitude, schedule changes, sleeping patterns, diet changes, skipping meals.
  • Sensory Stimuli: Strong lights, flickering lights, odors
  • Stress: Let-down periods, intense activity, loss (death, separation, divorce); relationship difficulties, job loss/change and anything that causes emotional or physical crisis.

The above includes much of what we do or experience in life! But I would be remiss if I didn’t give you this list. (In case you want to know my reference it’s from The New England Center for Headaches… it should also be applicable to those of us residing in the West Coast).

Now let’s get to pharmacologic therapy:

  • Nonsteroidal Anti-Inflammatory Drugs (NSAID’s): These interfere with those pain promulgating substances, the prostaglandins. They include ibuprophen, aspirin and naproxen. Some of these OTCs also include caffeine. If they don’t work after 4 to 6 hours or result in “bounce back” of the migraine once stopped and/or they need to be used continuously for several days, you are probably better off with a prescription medication.
  • Triptans: These are prescription medications that bind to and activate specific receptors called 5-HT which are expressed on the smooth muscle cells in the walls of blood vessels. They induce constriction of those dilated vessels in the meninges of the brain that caused the migraine in the first place. The good news is that they usually work within 20 to 30 minutes and don’t cause sedation so you can continue your normal activities. There are at least seven triptans. One type is combined with an NSAID. The best way to use them is at the very onset of the migraine.
  • Ergots: These have been used since the 1930’s. They constrict blood vessels and activate 5-HT. They are less “in vogue” for migraine therapy because of their potential side effects (such as an elevation of blood pressure).

Preventive Treatment: This requires daily use and includes medications that are used to treat hypertension (beta-blockers, calcium channel blockers), certain antidepressants that decrease the conduction of pain stimuli (tricyclics) as well as anticonvulsants. I would include hormonal therapy as a mode of migraine protection for many women. I frequently prescribe oral contraceptives to my younger patients who are migrainers in order to stop the ebb and flow of hormones during their cycle. (Remember that hormonal contraception signals the pituitary to NOT send signals to the ovaries to develop follicles and ovulate.)  I suggest using the active pills or a contraceptive vaginal ring continuously so that there in no break in the hormone level it provides. (No you don’t NEED to stop and get your period.) If there is a break in active contraceptive hormone use (some patients prefer to take it for  3 months at a time, or experience bleeding after a few months and “take a short break” from the Pill or ring), I prescribe an estrogen patch to “cover” the time off so that the decline of estrogen does not instigate a migraine.

At this point, I should add a warning: The occurrence of migraines without aura has been shown to increase the risk for stroke by a factor of 3, whereas if aura is present this increases to a factor of 6.  The use of oral contraceptives in women with stroke is considered an independent risk factor for stroke. So ACOG (the American College of Obstetricians and Gynecologists) discourages use of oral contraceptives in women who have migraines with aura.

Now, let’s consider migraines in menopausal women. They often improve. (Finally, something to look forward to as we age!) Once we stop the vacillations of our hormones in our reproductive years, the migraines may lessen. However (sorry, but there is often a “however” in medicine), some menopausal women begin to experience migraines once they no longer produce estrogen. If they want to reinstate their premenopausal estrogen status, I then prescribe transdermal estrogen….usually a patch so that they achieve a “steady state” of estrogen with no ups and downs.

This has been a longer website article than most. But since so many of my patients, friends, staff and relatives (my daughter) suffer from migraines; I felt I owed it to them to give a fairly complete summary. I hope it didn’t give you a headache!

As I sat down to write this newsletter, I felt that I did not have a favorite new article to use for an update. So rather than leave a blank newsletter this week, I thought I might re-issue one that I wrote for MSNBC several years ago. (There is nothing like quoting oneself!) It dealt with ways to cope with breakthrough bleeding while on birth control pills. Here it is (with just a few changes):

I often get calls from patients who have started taking birth control pills and have experienced bleeding at the wrong time. They wonder if this means they should change their particular pill or whether they should consider another mode of contraception.

Bleeding at the wrong time does not necessarily mean that a woman is a “pill failure”. Breakthrough bleeding is very common in the first few months after starting combined oral contraceptives. (“Combined” means the pill contain both an estrogen and a progestin… progestin- only pills are notorious for breakthrough bleeding and hence are less commonly prescribed.) The bleeding usually decreases within three months of pill use and should stop by the fourth month with correct and consistent use.
Before you decide if breakthrough bleeding is the pill’s fault or your own consider the following:

Are you taking the pill at the same time every day? Missing one pill or taking it late could affect the integrity of the uterine lining (built up by the daily, consistent levels of hormone achieved with on-time pill use). If the hormone level drops, even momentarily, “bits and pieces” of the lining can shed causing spotting or bleeding.

Are you taking any medications that could affect the absorption of the pill? These include antacids, antibiotics, some over-the-counter digestive medications and herbal remedies such as St John’s wort. Also, medications that induce a liver enzyme system called P450 can increase the metabolism of birth control pills. These include anticonvulsants, anti-tuberculosis and antifungal medication. Steroids in pill form (prednisone) or shots (even joint or epidural injections) can also have a hormone changing effect.

Do you smoke? If you take the pill and smoke, you increase your risk of heart attack and stroke, especially if you’re 35 or older. I’ve always said that the pill be should be available over the counter and smoking should be by prescription only. Smoking decreases the absorption and effectiveness of the hormones in the pill, possibly leading to more breakthrough bleeding. Smokers have a 30 percent increased risk of bleeding irregularities in their first cycle of pill use, and this rises to 86 percent by the sixth cycle. Smoking also has anti-estrogenic effects, and increases the metabolism and breakdown of estrogen in the liver. (This is important to know when we give hormones to menopausal women … but I digress in my anti-smoking tirade!)

Now let’s look at other potential pill issues that may require professional consultation… If you’re taking a very low-dose pill (20 micrograms of estrogen) and have consistent breakthrough bleeding switching to a higher (but still low-dose) pill containing 35 micrograms of estrogen might help prevent shedding of the uterine lining . Some progestins may be more potent than others and also help prevent “lining breakdown” and bleeding.  This is where pill changes (and your physician or health care provider’s understanding of what is contained in the multiple pill formulations currently on the market) may help. There are monophasic pills (the same dose of progestin and estrogen in each active pill), biphasic pills (the amount of estrogen and progestin changes once during the cycle) and triphasic (the amount of estrogen and progestin changes three times) formulations of the pill. If you routinely experience breakthrough bleeding during a change of the estrogen-progestin ratio with a biphasic or triphasic pill, you may want to switch to a monophasic pill where the estrogen and progestin levels remain the same throughout the cycle. Or if you consistently have bleeding late in the cycle, a pill that increases the amount of progestin in that second half may correct this form of breakthrough.

Finally, if you’re trying an extended cycle pill (one without the placebo) so you go without a period and attendant side effects for three months or even longer, you’re more likely to have breakthrough bleeding. It may be worth going back on a monthly pill, or — if you want to keep trying to extend the time between periods — at the time of the breakthrough bleeding, simply stop the active pill for five days (you’ll have your “period”) and then start over again. The bleeding should cease and you can keep going on the active pills until this happens again.

After four months and/ or changing your pills, you still continue to have breakthrough bleeding, your doctor may want to run some tests. These should include a blood count (to make sure you’re not anemic from all of the bleeding), a thyroid blood test, and if the breakthrough bleeding is severe, a blood test for clotting abnormalities.  I also suggest you get an ultrasound to check for internal polyps, fibroids or ovarian masses. And of course, your doctor should make sure your cervix shows no irritations, polyps or tumors.

Bottom Line: If you have breakthrough bleeding and you’ve just started the pill, make sure you’re taking the pill at the same time every day and that its absorption isn’t being affected by medications or smoking. If it’s not heavy, wait three to four months and the bleeding should subside. If not consult your physician.

A quick reminder (or as I like to put it, a 101 course on menstrual cycles):

Two ovarian hormones are responsible for your menstrual cycles; estrogen and progesterone. Each has some amazing effects on your tissues and may instigate  good days and bad days. Estrogen  begins to be synthesized from cholesterol  within the ovary on day one of your cycle (when your period starts). It’s production in the primitive eggs your born with (called follicles) is “commanded”  by the pituitary release of FSH (follicular stimulating hormone), which in turn is produced in response to the low levels of estrogen that occur just before the onset of your period. Levels of estrogen begin to exponentially rise about a week before ovulation and peak just a day before. This estrogen peak then sensitizes the pituitary and it responds with a surge of LH (luteinizing hormone). LH then causes the follicle to release an egg (ovulation). The “shell” of the follicle now becomes a corpus luteum which now concentrates on producing increasing amounts of progesterone.  Circulating progesterone can rise 10 fold during the week following ovulation. Estrogen production also rises about 6 or 7 days after ovulation. Both these hormones cause the glands in the lining of the uterus to become thick and lush so, if an embryo were to be deposited, it could implant, be nourished and grow. If there is no pregnancy to keep the corpus luteum going it succumbs and there is a decline (so sad) of both estrogen and progesterone. These fallen levels can no longer support the lining of the uterus….it sloughs and hence bleeding occurs. The now low level of estrogen stimulates the pituitary to begin to produce FSH and the entire process begins once more. (Just think of it as waves of rising and falling hormones each month.) Androgens (male hormones) are also produced in the ovaries.

The combination birth control pill basically supplies amounts of synthetic estrogen and progestin which shuts off the pituitary signals to the ovary and hence cyclical hormone production (and ovulation) cease. After menopause, when the follicles in the ovary are “used up” the levels of both estrogen and progesterone will drastically fall.  In an abortive effort to get the ovary to produce these hormones, FSH levels rise and continue to remain high for the rest of our postmenopausal lives.

How do the rise and fall of these hormones effect our skin:

  • The skin is the largest organ we “own”….There are hormone receptors in the skin and the blood vessels that supply it. Most of what we know regarding to the effects of estrogen on the skin come form studies of what happens to the skin in the absence of estrogen (during menopause).

Here is the estrogen good stuff: It increases skin thickness, decreases collagen breakdown, increases collagen production, increases water binding capacity, increases the ability of blood vessels to dilate, increases elasticity and improves wound healing. This hormone helps prevent sebum (lipid) production, which feeds bacteria and increases the development of pimples. Estrogen also effects fat accumulation under the skin (subcutaneous). Here’s an interesting stat: The thickness of subcutaneous fat has been measured during the menstrual cycle, using ultrasound and MRI. The maximum thickness of subcutaneous fat over the thighs and abdomen has been found to increase during the menstrual cycle (as much as 7.3% in the abdominal region and 4.1% in the thighs). This certainly appears to validate your frequently voiced concerns that you are “get fatter” during your period. Whether this is due to an increase in water retention or changes in the fat cells is not clear.
There is also estrogen bad stuff that can occur in the skin. It increases pigmentation (this is especially evident when combined with sun exposure and use of the estrogen containing birth control pills in sensitive women who then develop pigmentation on the cheeks (chloasma). It also has been associated with decreases cellular-immune response.
Here is what has been noted during the luteal (progesterone) phase of the cycle: There is more sebum production and an increase in skin microbial count….these 2 factors can make you more prone to acne a week before and during your period. The skin is also more sensitive to UVB rays between days 20 and 28 which mean an increase in sun sensitivity.
Effects on the Immune system:   This is complicated….estrogens suppress immune response in the cells as well as what we call natural killer activity. (There is a war going on between our bodies and the antigens to which we are exposed. )  Estrogen also increases certain immune proteins in the blood. Because of this increase in antibodies, estrogen may be the significant factor in our high ratio compared to men (20:1) of developing the autoimmune disorder systemic lupus erythematosis (SLE).  And if you remember that T cells help us fight infection….well progesterone seems to suppress their formation. (Note T cell numbers remain depressed throughout pregnancy when there is a huge amount of progesterone produced by the placenta….a possible reason for infection severity in pregnant women.)

Effects on Vaginal Discharge: Obviously in the beginning of the cycle there is menstrual blood flow. The average amount is 50 to 100 mL and lasts for 4 to 6 days. As estrogen levels rise the cervix produces more and more mucous and the discharge becomes clear and slippery …sort of like uncooked egg white. (Women as well as their doctors have been checking for this type of mucous to predict fertile days for decades….I even wrote a paper about it in medical school.) As progesterone levels rise after ovulation the mucous becomes stickier. There is a greater glycogen (a form of sugar) content and some women complain of an increase in yeast infections. On the other hand growth of bacteria that don’t like oxygen (bacterial vaginosis) is more likely to become worse during the first 2 week of the cycle.
Effects on overall health:  Disorders and distress seem to increase during the luteal phase of our cycles. The list is long: asthma, acne, epilepsy, migraines, myasthenia gravis (severe muscle weakness), certain tachycardias (fast heart beat), sleeping disorders, Reynaud syndrome (where hands and feet become blue from diminished circulation), schizophrenia, glaucoma, insulin resistance and viral diseases. Skin disorders that worsen include acne, rosacea, skin lupus, psoriasis, eczema, vulvar itching, lichen planus and uticaria.

When it comes to estrogen surges and cancer there seems to be an influence on melanoma, certain blood vessel cancers of the skin and of greatest impotence to so many of us, breast cancer. This is a subject for multiple entries and I still wouldn’t be able to give all the final conclusions….But estrogen does stimulate cell divisions in the breast. Many therapies for breast cancer are geared to stopping this estrogen stimulation….these include removal of the ovaries before menopause, inhibition of estrogen production with compounds termed LH agonists  and aromatase inhibitors as well as estrogen receptor blockers such as tamoxifen. But pregnancy with its high production of estrogen, especially in younger women is protective! And I have to add this….estrogen and progestin (now termed hormone therapy or HT) may not increase breast cancer for the first few years of use, moreover estrogen therapy given alone (in postmenopausal women who have had a hysterectomy) seems to have little impact on breast cancer risk.

This started out as a simple menstrual cycle primer….sorry that it (and the complexity if our hormonal responses) became more than that. I guess this is the reason that some of us intensely study the effects of female hormones during and after our reproductive years.

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