Barton Health Wellness Lecture: Managing Menopause

Barton Health Wellness Lecture: Managing Menopause


I work at Barton Women’s Health as well as I see patients at
the Community Health Center at the OB and GYN Clinic there as well. I have no financial disclosures. So one of the main questions
I get a lot of times from people is just what is menopause? Essentially menopause is that
last period that you have that’s then lead or confirmed by having 12 subsequent months
with no further periods. In the United States, the average age of menopause is about 51, and the majority of women
will go through menopause somewhere between 45 and 55. What is not menopause? Menopause is not a disease. It’s actually a normal natural event. It’s something that we will all, as women eventually go through. It’s marked by a reduced
functioning of the ovaries due to aging, and this leads to lower estrogen levels in our bodies. It also marks the end of fertility. Luckily for us we’re not like chickens, and we don’t always have
to see the number of eggs that are there or not. Perimenopause is this other term that kind of refers to this
gradual transition time. So in our lives that kind
of can define our lifespan as far as relating to our ovarian function into premenopause, which
is the time between your first period, so
menarche and menopause. So anything before that. Menopause which is that
cessation of period, so stopping your periods, and then post menopause. Perimenopause is this
kind of gradual transition between your reproductive
years and menopause, and for many women, this is a longer and a
more unpleasant transition than you may like. It can last for up to four to 10 years. What do you expect to see when you’re going through perimenopause? Many women may have shorter
menstrual intervals, meaning that the time from
the first day of one period to the time of the next
period is actually shorter. People who had maybe
28-day clockwork periods for years and years may
start to have periods every 24 days or every 23 or 21 days. You might start to skip a month. You have a period and then you go two to three months without one. Your periods may get lighter although some women do experience shorter but heavier periods during this time. Another really common
symptom is hot flashes or night sweats, and night sweats are essentially just hot flashes that occur during the night time. These can proceed at the time of menopause in those perimenopausal years as well. Some of these symptoms
can become so bothersome that they might interfere
with your quality of life, and for that reason some women
do seek medical intervention for some of these symptoms. So we’ve talked about
menopause and perimenopause. I’d like to talk a little
bit about induced menopause, and this really refers to women, whose periods stop due to
sort of artificial reasons. And that can be due to
either surgical removal of the ovaries and maybe
due to chemotherapy that they’ve received for
another type of cancer during their life. Radiation therapy,
particularly radiation therapy to the pelvis can be very
damaging to the ovaries and can put you into
menopause prematurely. And then there are
other medical conditions where you might be on a medicine that actually also stops your periods, and gives you an induced
form of menopause. Women who have induced menopause or early menopause also tend
to have more severe symptoms or the same symptoms that you get with regular menopause but
just a little bit more intense. I don’t know about that. Another question that I
get a lot at my office is what about a hysterectomy? I mean if you have a
hysterectomy where your uterus has been removed you’re
obviously not having periods, but does that mean that I’ve gone through menopause at that point? And really the kind of
the key to a hysterectomy is what happened to the ovaries? So even though menopause is
marked by this dissociation of your periods, it’s
really the ovarian function that’s driving the process. So if you’ve had a hysterectomy where, or you’ve removed just the uterus, and maybe the fallopian tubes, but the ovaries are
actually still remaining, that is not menopause. And your body will continue to go through those normal hormonal cycles and go through kind of natural
menopause at the same time. If you have a hysterectomy where you remove the
uterus, the fallopian tubes, and both of the ovaries
that would be functionally surgical menopause at that time. For some women, they may go
through this menopausal change a little bit earlier than others. Early or premature menopause
refers to these symptoms that are either natural or induced that happen at age 40 or earlier. This occurs naturally
in about 1% of women. And this can be due to genetic factors like Fragile X syndrome,
some metabolic changes, and some autoimmune diseases. As I mentioned earlier
if you do go through premature menopause,
oftentimes your symptoms are a little bit more
intense than they would be for women who are going
through it a little bit later, just because of the
relative difference in age. Additionally it’s important to note that if you have symptoms of early menopause, if you stopped having
periods for any reason, if you’re having hot flashes these are things that should
be thoroughly evaluated by a physician, because
it also can signify underlying medical conditions
that would be important to recognize and treat. With every premature menopause, you also have more years without the benefits of estrogen. So that puts you at risk for getting some of those estrogen related diseases like osteoporosis as
well as heart disease. And so that kind of plays
into our conversation if we’ve confirmed that as far as the role and benefit of it potentially being on hormone replacement
therapy to give your body that benefit up until the time when you would have more
naturally gone through it at a later age. Sorry. So we’ve talked a lot about
kind of different types of menopause and I’ve
mentioned the symptoms, but what are those
symptoms that we think of? I think the first one that
most everyone thinks of is the hot flashes and the night sweats, and honestly we don’t
really truly understand why night sweats happen or
what causes the hot flashes. We think that it might have to do with some increased sensitivity
in a part of our brain that’s basically like
our body’s thermostat. And that the hormonal
fluctuations make that thermostat just a lot more sensitive, so you kind of go from being
hot to cold very quickly. Other common symptoms
include vaginal dryness, difficulty sleeping. Many women experience mood disturbances of feeling more irritable, having less patience, feeling depressed. There can be changes in our skin and hair, decreased libido and weight
gain are also very common as well as a feeling of
kind of this brain fog or memory problems that comes
around that time as well. Not all of these are hormone related, and some of them like your hot flashes and the memory problems tend
to get a little bit better after menopause is completed. They also could be referred to as the Seven Dwarfs of Menopause. (all laughing) So we will start by
talking about hot flashes. Very, very common. About 70-80% of women will
experience hot flashes. Like I said often starting in that perimenopausal transition. Interestingly only
20-30% of women actually seek medical advice for these. So lots of people are
out there having them, and only a smaller percentage
of people are actually bothered enough or seek care for that. I think it’s also important to notice that they last for a long time. They can last for up
to seven to eight years with four to five years
of that potentially being after you’ve
completed that final period. So after menopause. A lot to look over to. I like this one. A lot of healthy suggestions. (all laughing) Vaginal dryness is also very common. Vaginal dryness is often something that we see a little bit later more in that postmenopausal period. Because of the decrease
in estrogen the lining of the vagina actually becomes more thin. It becomes drier. It loses some of its natural
elasticity or stretchiness and then you also have decreased
secretions and lubrication. Because of all of these
changes to that lining, you also change your natural
kind of acidic pH balance, so the acid-base balance of our body, and the vagina is supposed
to be very acidic. And because of the change in the mucosa, it actually can become
a little bit more basic, which puts you at higher risk of getting other infections like bacterial vaginosis or yeast infections,
which can be bothersome. There is a kind of group of symptoms that we refer to for these changes that are associated with
the decrease in estrogen on the vagina called the genitourinary symptoms of menopause. It’s basically kind of
vaginal and urinary symptoms, kind of all together. And this would be irritation,
feeling like you have to go to the bathroom more frequently, feeling of some pressure or urgency like you have to go right
away when you have to go. And sometimes a little
bit of pain or leaking. These symptoms are very well treated with local vaginal estrogens, which can be given in the
form of either a cream, a tablet or a ring. And they, the local estrogen does not have the same side effects or risk factors that we’ll talk about when we talk about systemic hormone replacement therapy. You may have heard about
some of these other kind of more alternative treatments for vaginal dryness like the Mona Lisa. Some places call it vaginal rejuvenation, which just sounds so lovely. But it’s really kind of
experimental at this point still. There were some very promising studies that this might be a
way to treat that area and give a long lasting effect. But some more recent
studies have shown concern for scarring and damage to the area and sometime increased pain. So as of this point I don’t
recommend that to my patients. I’d like to see a little
bit more data on the safety and efficacy of that before we
start using it more broadly. There are also over-the-counter things that you can purchase that can help with some of these symptoms. There’s vaginal moisturizers like Replens as well as things you
might find in your pantry like coconut oil. I feel like you can put
coconut oil basically anywhere and it will help, as well as olive oil. Vaginal lubricants are important, and then also this idea
of vaginal exercise. So having sexual activity, stretching and pelvic physical
therapy can help increase that elasticity as well
as increase the secretions by kind of using those muscles. Two other medications that I
won’t touch on quite as much are Osphena as well as Intrarosa. These are other prescription medications that also target this. You might feel young at heart, but our bodies do start
to notice these changes. Sleep problems are super
common in menopause, and they are some very multifactorial, meaning there’s a lot of reasons why you might start to
have difficulty sleeping as you get into this perimenopausal and menopausal transition. There are hormonal changes for sure that change the quality of our sleep. Women who are in menopause tend to have spend less time in the REM
or the restful sleep state. So even if we’re getting sleep it’s not as restorative to us. And then there’s kind
of this vicious cycle that can happen with sleep as well. You start to have difficulty sleeping. If you’re having hot flashes
that may be the trigger. And then that leads to feeling more tired, which then when you’re
more tired during the day, you start to feel like
you’re having difficulty concentrating, having a
hard time with your memory, makes you feel kind of
irritable when you’re at work, and you’re feeling those things, then you don’t work as efficiently, and that leads to more stress because you’re stressed
about what’s happening with all of these things at work and life. That can lead to decreased coping, and feeling more irritable. So when you get home, you then feel like you have less patience and then
we kind of beat ourselves up about all of these things, and then we’re not sleeping well again. So definitely kind of
a multifactorial cycle that can happen and so
we try to address it kind of looking at each
one of those issues. There are some lifestyle changes, things that we can do just
by changing our habits that might help with some of those things. There’s this concept of sleep hygiene. Basically where do we sleep, how do we sleep. So think quiet dark and
cool is the best environment to really have restful sleep. Having a white noise machine
or a fan by your bedside also can help to kind of keep you in that more restful sleep state. Different relaxation techniques
like guided imagery, yoga and meditation can also be very
helpful for sleep problems, and avoiding our screen time. And we all have our phones
and Kindles and televisions. Get the TV out of your bedroom Make sure you spend at
least an hour before bedtime where you’re not looking at a screen because that definitely
stimulates our brains in a way that makes it more
difficult to fall asleep and to stay asleep. Also avoiding stimulants. So things like caffeine,
other medications. If you’re on prescription medications it’s worthwhile to talk to your doctor and see if some of them
might be better taken in the morning time versus the night time. Some of those medications
for other diseases may have side effects of sleepiness, which you might want to
then take at nighttime, so that adds to your benefit. Also avoiding eating large
meals in the afternoon can also help. I don’t know how many of
you out there have husbands who snore, but our partner sleep habits also can make a big difference. Maybe their snoring all
throughout the night that’s waking you up. Maybe they’re watching
TV till late at night and coming in once you’ve
already gone to sleep. So kind of addressing
some of those sleep habits too can be helpful. And then exercising
daily also has been shown to help improve sleep. Besides our habits, which
are easy to talk about but hard to change, there are some medical
treatments that you can use. There’s over-the-counter medications like melatonin, valerian
root, and chamomile. Lavender and passionflower
have also been shown to be helpful. Over-the-counter medications
like Benadryl or Unisom which is basically a cousin
of Benadryl, can be helpful. Seeing a therapist and doing cognitive behavioral therapy can
help with sleep issues too and then there are
prescription medications, which I generally recommend
using with caution, because they can be a little habit-forming and can be difficult to come off of. And of course if you’re having
hot flashes and night sweats that are waking you up at night, treating those hot flashes
may be very helpful too. Weight gain is definitely
something people talk a lot about to me about as they kind of go into
their 40s and early 50s. Some of the weight gain
that happens in midlife is not related to menopause
per se, but just aging. As we age, there’s a change
in our body composition. We tend to have less lean mass. We deposit our fat in different locations and that can then lead to a
slowing of our metabolism. so it makes it a little bit harder. I think nobody likes to hear it but unfortunately there’s definitely this finding that as we age, we have to exercise more
and consume fewer calories to be able to maintain our weight. And so just kind of being
aware of that as we age, that’s a normal metabolic change. Hair loss also very common. A lot of women experience the sensation of thinning hair. This can kind of be in
two general patterns that we see associated with menopause. There’s diffuse shedding. So just kind of general
thinning and feeling like every time you comb your hair or would take a shower, there are just gobs of hair on your hands, kind of like the hair
loss you might experience after having a baby. That does luckily tend
to resolve on its own, and it usually gets better
after about six months. And then there’s female pattern hair loss, similar to kind of male pattern baldness. This generally presents
with kind of a widening of the center part and then loss of hair mainly at the crown or top of your head. It’s not very well understood but we think it might be related to the changes and the relative levels
of estrogen and androgens or the male type hormones
that we have in our bodies kind of leading to this hair loss. Having good nutrition and thyroid disease also can affect and cause your hair loss. So if you are experiencing hair loss, one of the first things we
might check is your thyroid to make sure that that is normal because thyroid disease
is also more common in women as we age. Some studies have shown
that having a healthy diet, low in red meat, low calories
and having a lot of zinc, iron, vitamin T and
biotin might help decrease some of the hair loss. And then there are
medications like minoxidil and anti dandruff shampoos that also can be helpful. Seeing a dermatologist
for these things can also, they may also have some
additional treatments. There’s lots of things
that target out there for our skin and hair as
we go through menopause. Libido also very, very common and again kind of multifactorial. A lot of the other symptoms
that were talked about with menopause like sleep issues, mood issues, can also then lead to
feeling a lower sexual desire and sexual drive. Same thing with vaginal dryness. If you’re having pain with intercourse if you’re having that
decreased lubrication it definitely makes it more challenging. And then the sleep disturbances. Additionally menopause
comes out of this time in our lives where a lot
of people are experiencing major life transitions. There may be children leaving the home. You may be going through retirement. You may have changes in your
relationship with your partner, and all of these factors can lead to just stresses on libido. A lot of times I’ll get asked like what’s the deal with testosterone. So when we think about
male and female hormones, estrogen is primarily
thought and progesterone are thought of as female
hormones and testosterone is the male hormone. The truth is even men and women we all have both in our bodies and it’s all kind of about this balance. Very low levels of testosterone may be related to low
libido and weaker orgasm in some women and for this reason, there are lots of studies
going on right now looking at this issue to
see if using testosterone might be helpful for low libido. Currently in the United States, there’s no FDA-approved
formulations of testosterone in Canada or the United States. There are some in Europe and
women in the Unites States will sometimes get
prescriptions for off-label use of testosterones
that are designed for men at a much lower dose. There’s this patch that
has been seen in Europe that’s very promising for this, but Canada and the United States have drug approval
regulation bodies, the FDA. They’re waiting for a little
bit more safety data before, long-term, before approving that here. If you are taking testosterone some of the common side effects that you might experience could be acne. You can have facial and body hair growth. Very rarely there might be
enlargement of the clitoris and then irreversible voice deepening. So I think it’s really
important to be aware of those side effects before
taking that medication. And then because we have
enzymes in our bodies that convert testosterone
in our peripheral fat to estrogen, taking
testosterone, you also have the same risks as when
you’re taking systemic estrogen therapy because it
gets converted to estrogen by our bodies. So you have kind of these increased risk of blood clot as well. So any hipster over
here will tell you that a beard is fashionable
and super in right now, but it might not be the
look that you’re going for as you go through this. DHEA, just to talk briefly, is a hormone that is converted to testosterone and estrogen by our bodies, and they’ve looked at
intravaginal use of this to help treat low libido and dryness. And so far, there’s been
some very promising studies seeing that it improved kind of all benefits of dryness,
desire, arousal, and orgasm, without significantly
elevating the blood levels of estrogen, DHEA, or testosterone above their normal postmenopausal levels. So definitely an area
to kind of keep watching but still a very new drug. I’m just going to take a sip here. So now that we’ve talked about all of these different symptoms, I’d like to move into
talking a little bit more about how we can treat and
manage some of the symptoms if they’re very bothersome. So particularly kind of
this slide talking more about hot flashes, so lifestyle modifications can be helpful again changing our habits,
dressing in layers. So if you get super flushed, you can take off your scarves, you can take off a layer or
a sweater can be helpful. Avoiding caffeine, alcohol, spicy foods all of the fun stuff as usual has also been shown to help. Doing yoga, meditation, and guided imagery can be helpful to kind of cope through those hot flashes. There are some non hormonal options like antidepressants, anti-epileptics, and a blood pressure
medication that we’ll touch on. And then hormone replacement therapy, which is estrogen and progesterone. So what is hormone replacement therapy and who do we use this for? We generally will use
hormone replacement therapy for women who have moderate
to severe hot flashes that are interfering with our daily life. And who do not have any
reasons to avoid using hormones and we’ll go over to those a little bit. By far hormone replacement therapy is the most common
treatment for hot flashes. It’s one of the most
effective and the goal is to improve and relieve
those menopausal symptoms. Most women who present for
hormone replacement therapy present some time in their 40s to 50s. The risks of, so why not put everybody on hormone replacement therapy? If we’re losing our estrogen and it’s naturally going away and it’s causing all
these bothersome symptoms, why wouldn’t we just
start everybody on it? There are some risks although
the risks are relatively low in young healthy and perimenopausal and postmenopausal women. Additional symptoms that might help might also respond to
hormone replacement therapy, includes some of the mood symptoms, the vaginal atrophy, sleep disturbances and then some of the just
joint aches and pains that people feel like I’ll often say that those get a little bit better
when you’re on hormones. I do want to point out again that if your symptoms are only dryness rather than using systemic
hormone replacement therapy it’s really better to use
local estrogen for that because it doesn’t have
the same risk factors. So when we start hormone
replacement therapy, we are starting this
to treat the symptoms. We’re starting this to treat hot flashes. We’re not using it to
help prevent disease. There are a variety of different types of FDA-approved estrogen
and progesterone treatments. And these come in the forms of pills. There’s patches, creams, a ring, gels, and the doses of these vary
based on their preparation. Who is a good candidate for this? In general we want to start
hormone therapy for women who are healthy, having symptoms and who are within 10 years of menopause or under 60, and who do not have any other contraindications. For women who have been on
hormone replacement therapy and are experiencing recurrent hot flashes after stopping it, we
generally try to think about considering some of those
non hormonal treatments because they tend to be
beyond that 10 year mark. Contraindications are
reasons to not people who should not have estrogen therapy include women who have past
or active breast cancer, women who have coronary heart disease, a previous blood clot like
a deep vein thrombosis or a pulmonary embolism, a stroke, active liver disease,
unexplained vaginal bleeding. If you have a uterine cancer or if you have very high triglycerides. So the different types of
hormone replacement therapy that we can use, generally the estrogen is what gives most of the benefits as far as treating the hot flashes, but if you have a uterus, if you have not had a hysterectomy, you need to have progesterone in addition to be able to help protect
that lining of the uterus. In addition to relieving the hot flashes, the estrogen also can stimulate
the lining of the uterus. And so progesterone helps protect
and counteract that effect so that you don’t have a
uterine cancer caused by what we call unopposed estrogen. Additionally the first
studies that were done looking at hormone replacement therapy were primarily with pills. And we found later on that using a patch or transdermal forms of estrogen actually has a lower risk of blood
clot than the oral pills do. That being said, the absolute
risk of blood clot and stroke is overall very low and so women prefer an oral tablet and are otherwise healthy, that also is very reasonable. The progesterone form can be given in a couple of ways as well. There’s two main types of progesterone. There’s Provera and
then there’s Prometrium, which is a micronized like more, a form of progesterone that’s very similar to the one that your body makes. There also could be the progesterone IUD. We can use Mirena to help locally protect the lining of the uterus. The Prometrium and Provera can be given either continuously where you
take it every day of the month or cyclically where you take
it 14 days out of the month. Some women choose to do it cyclically because they’re bothered by the
side effects of progesterone which can include some
feeling of bloating, also some sleepiness, but for many women, it’s easier just to take it everyday. If you do do cyclical progesterone, you may have some cyclical spotting even if you’re postmenopausal especially in those first
humans as you start that. For premenopausal women, so women who have not
yet had that final period if they’re having bothersome symptoms, we also can use very low
dose birth control pills to help with that and then transition them to hormone replacement
therapy around age 54 at the time of kind of average menopause. For women who have had a hysterectomy and no longer have that
lining of the uterus there, they do not need the progesterone. And so we typically will
choose to treat those women with estrogen only. So once you’re on it, if
you’ve chosen to do that, how long do we continue this for? The party line and kind of goal is to use the lowest dose for the
shortest period of time. In general their recommendations
are to not use it for more than five years if you’re using combined
estrogen and progesterone treatment or more than
seven years if you’re just using estrogen alone. But that being said, it’s
really important to know that the treatment can be individualized. We don’t discontinue it simply just based on your age alone. If you have talked with
your doctor and have come to an agreement that the
benefits of continued treatment outweigh the potential risks
in your given situation, continuing use is very reasonable as long as we kind of
continue to readdress, okay we’re going to try
this for another year. At what point are we going
to try coming off of it? Because of this and I
think that plays into a lot of the fact that up to 40% of women who are between 60 and 65 still have persistent hot flashes that impair their quality of life. So it’s definitely
reasonable for some women to continue it a little bit longer. So we’ve kind of talked
and alluded to the risks of hormone replacement therapy. And I think that this is
a really good example of again one of these pendulums of medicine that has swung back and forth
over the course of time. For a long time people were
very kind of supportive and used hormone replacement therapy a lot more liberally and then
there was a period of time where we were very restrictive of it. And a lot of that had to
do with this large study called the Women’s Health Initiative. It was a large randomized control trial which means it was a
placebo control trial. They gave women three different arms, a placebo group, an estrogen group, and an estrogen plus progesterone group. And the main goal of the
study wasn’t actually to treat hot flashes, it was
actually to see if by giving women hormone therapy, it reduced the risk of having coronary artery disease. The women who enrolled in the study were anywhere between age 50 to 77. The average age was actually in their 60s which I’d like to point out because it’s a lot older
in that study group than who we now recommend
hormone replacement therapy for. This study went on between 1990s to 2002, when it was actually stopped early, when they noticed that
there was a statistically significant increased risk
of breast cancer for women who are in the estrogen
progesterone only arm. The answer that they got from the study for their primary question
of heart disease was, no it doesn’t help to
prevent heart disease to be on hormones, but it
also doesn’t increase it. When they looked at these
kind of more refined analyses of the different complications
that we were seeing other diseases that they were
kind of seeing the effect on, the breast cancer was the big-ticket item that got everybody’s attention. There was this increased risk of women having breast cancer, who
had combined hormone therapy, but I’d like to point
out that while this was, because this was an enormous study, there were so many women in the study and they followed them very
thoroughly for a long time that even though this was a
significant increased risk, the actual risk of that was
nine additional breast cancers per 10,000 women over the course after five years of use. So for many women the actual, the clinical significance of that risk some women feel that
that’s acceptable to them. There are other people who feel like any increased risk of breast cancer is not acceptable to them. So I just like to point that
number out to my patients because the media
presentation of this study at the time made it seem like everyone who uses hormone
replacement therapy had this really high chance
of getting breast cancer. And it’s true, it did increase the risk, but overall it was this nine per 10,000 over five years. I also think it’s really interesting that in their study the estrogen only arm actually had a reduced
risk of breast cancer. There were seven fewer cancers in women who used estrogen only
compared to the placebo group. Some of the other complications that were seen in women using
hormone replacement therapy included blood clot. And this affected both the estrogen only and the estrogen progesterone arm. This was an additional
18 per 10,000 women, additional 18 blood clots. However when they sub analysis of the transdermal estrogen that increased risk was not seen, and so that’s why we do often recommend the patches over the pills. The medications that
they were using also in the Women’s Health Initiative were Provera and Permpearl. So it was the conjugated
equine estrogens and Provera. And those are available but not often are first line these days. There was also an increased risk of stroke in both groups about 10 additional kind of for both groups. So nine versus 11. There were some benefits seen I think that are also
important to point out. Overall the women who used hormones had an overall improved quality of life, and they were less likely
to die overall by anything. So there was a 30% decrease in mortality in women under 60. We also saw a decrease in
the estrogen related diseases like osteoporosis, less type II diabetes as well as a lowered risk of colon cancer and a reduced risk of cataracts. Besides kind of the risks and benefits, there’s also some
side-effects as with anything. The side effects of
hormone replacement therapy most commonly are breast tenderness. Some women do experience even an increase in kind of the density of their breast that you may even be able
to pick up on a mammogram. There can be vaginal bleeding
like we talked about, especially if you’re having, using cyclical progesterone. This feeling of bloating
and then mood symptoms. Mood symptoms are hard. They’re part of the problem. They may also be part of the solution. I’d like to shift gears a little bit now and talk about some of
the non hormonal options. So for women who have moderate
to severe hot flashes, but are not good candidates
for hormone replacement therapy or who choose not to use it, someone who has a breast cancer per se or other reasons or women who have stopped hormone replacement therapies,
but still have persistent hot flashes, we start to think about some of these non hormonal options like the antidepressants, anti-epileptics, clonidine and then some of the, we’ll talk about some
alternative therapies, some that are very promising, some that are more inconsistent and some that unfortunately
have been shown to be fairly ineffective. So antidepressants, when
we traditionally think of antidepressants, we
expect to see this kind of long buildup time of when
you start taking them to when your symptoms improve and the good news with using
antidepressants for hot flashes is that you tend to respond
a little bit more quickly than what we tend to see
for clinical depression. More in the matter of
days rather than weeks. They were shown to be equally effective in women with breast cancer, who have undergone through
surgical as well as natural menopause. So they’re good use for all women. The only FDA-approved
formulation of an antidepressant for the use for hot flashes is Brisdelle, which is essentially a super
low dose of Paxil or paroxetine and I’d like to point out that women who had breast cancer,
who are on tamoxifen, this medication should be avoided because of some interactions there. Other SSRIs and other antidepressants that have been shown to be
effective for hot flashes include Wellbutrin, Celexa,
Lexapro and Effexor. A lot of times I’ll
also use these medicines if someone’s having kind of
a combination of symptoms. It helps treat depression as
well as the hot flashes do or if someone’s already
on an antidepressant increasing their dose or
adjusting that may also help improve those symptoms. Some of these, particularly Wellbutrin may also help improve libido. We all can be a little moody. Hopefully our families
will watch out for us. Anti-epileptics, the main one that we think of is gabapentin. It has been shown to be
very effective for women, especially who are having night sweats or hot flashes at night. At high doses it can actually
be as effective as estrogens, but the side effects really
limit its use in that high dose. The side effects of dizziness, headache, this kind of brain fog and disorientation make it really difficult
to tolerate higher doses. So (audio cuts off) one kind
of downside for this one. They’ve also looked at
combining it with SSRIs and that wasn’t found
to be any more effective than using it on its own. So some of the alternative
therapies that have been found to be more promising if you want to avoid something,
like avoid medications. Cognitive behavioral
therapy has been shown to be very effective for menopause
associated insomnia or sleep disturbances, as well as hypnosis which can work for both
sleep and hot flashes. And then the mind-body based therapies, so guided imagery, meditation,
yoga, and deep breathing have been shown to be helpful. Some other things a little
bit more inconsistent include a lot of our plant based therapies that you might find in
the natural food stores and things like that. Isoflavone and some of
the herbal therapies have shown in some of
the literature to have no benefit over placebo, but some have shown that
they may have some benefit. These are typically what we
think of as phytoestrogens or estrogen type things
that are found in foods, like soy beans, lentils,
chickpeas, flaxseed, fruits and vegetables. There is some concern
that these phytoestrogens may contain some estrogenic,
meaning stimulation of estrogen receptors and anti estrogenic, doing the opposite properties. And for women who have breast cancer most experts feel that it’s
okay to consume some dietary soy but that we should avoid
supplementation with soy products until they’ve had a little
bit more safety data has been shown. Some of the more inconsistent ones too, black cohosh and some of
the Chinese medications like Dong Quai, have been
inconsistent in the data as well as paced respirations,
weight loss, and exercise. Acupuncture is something that
a lot of people ask me about and unfortunately there
was this big meta-analysis of six randomized control
trials for acupuncture. And it was found to have
no benefit over placebo. However, I think it’s
important to point out that there were several studies that looked at the combination of acupuncture
and some of the Chinese herbal remedies like Dong Quai that actually did show some benefit. So there may be some potential there. Evening primrose oil and flaxseed alone, those didn’t work out so well. We can always look for
our own ways of coping with our hot flashes as well. At this point, I kind of want
to just talk a little bit about this idea of bioidentical hormones. Just by a show of hands who here has heard about bioidentical hormones? Okay so bioidentical hormones technically it refers to hormones that have the same structure as what’s produced by the body. And I think it’s really
important to point out that there are many
FDA-approved formulations of estrogen and progesterone
that are derived from soy and plant-based extracts that are modified to be identical to our
body’s own hormones. There’s only a few of them that are still this conjugated equine estrogen, which is essentially
estrogens that are derived from pregnant horse’s urine. And I can understand why
people are may be a little averse to using that. Those ones are Premarin and Prempro. Those are the pills. However in popular culture,
bioidentical hormones has this totally other
kind of connotation. It’s used to refer to this
custom compounded regimens that can be as gels, creams,
suppositories or pellets. And a lot of times these
preparations are used and dosed based on serial blood testing or saliva testing. One of the difficulties with that is that there’s really no good reference range for what your estrogen
level or progesterone or testosterone for that matter should be. So there’s no data to guide
how these medications, if they’re looking at blood levels like how do you even interpret that. The goal of hormone replacement therapy is usually guided by dosing to improve symptoms
rather than a blood level, which is a little different
than when we think of other hormones like your thyroid. If you have hypothyroidism, we check your TSH and we adjust
the dose of the medication based on that. Unfortunately we just don’t know those reference ranges for hormones. Our hormones because they’re produced by pulsing from our brain, they can be quite fluctuant during the day depending on the time of day, the times that you’ve eaten, and some of the salivary testing that a lot of people will do has also been shown to number one, not correlate well with blood levels and also have a lot of
inconsistency throughout the day, and based on what you’ve eaten. Overall generally for most societies, the American College of Ob-Gyn and the North American
Menopause Society and the FDA don’t recommend bioidentical hormones because there can be
some problems with them. The contents of these
compounded medicines, the dose, the quality, the
sterility of these products it’s not subjected to any regulation. The FDA does not have any
oversight of the production of these and compounding pharmacies. Additionally, there’s no
good trials or studies that have shown that these are safe or that they work. When they have been tested,
a lot of times the potencies of these compounded
formulations as well as the absorption can vary quite a lot. And that not only leads to
fluctuation of your symptoms, your cream might be
right on track one month, and then the next time, it’s a little bit of a
different preparation, and so you have more symptoms. But also it puts you at risk of having an imbalance of the
estrogen and progesterone, particularly if you have a uterus. We see it everywhere. If you go on I feel like
any magazine or TV show, you’re going to hear and see celebrities who are out there promoting these things. Suzanne Somers is a big proponent. Cindy Crawford, even Oprah,
love Oprah but not for this. Talking a little bit more
about the fluctuation of the quality and the dose, there was a magazine, moral magazine that did an investigational study looking at bioidentical hormones. They essentially sent a
prescription for TriEst, which is one of the most commonly compounded creams that’s used. It’s a combination of three
different forms of estrogen, and they sent it to 12 different
compounding pharmacies, and then they tested what they got back. And what they found was that
of the three different types of estrogen, the majority of them ranged from anywhere between 20% to 260% over two and a half times the dose that was supposed to be contained
in that medication. And also to note that
the progesterone amount in those medications was
often subtherapeutic. So they found that they had
basically too much estrogen and not enough progesterone. I unfortunately in my own
practice have actually seen a handful of women who
have had I have diagnosed uterine cancers, who were
using bioidentical hormones that were probably stimulated
because of insufficient protection of the lining of
the uterus from progesterones. There have been several doctors that have had disciplinary actions from the Medical Board. Prudence Hall is actually Suzanne Somers’ key person who she likes to … she was put under
disciplinary action last year. It’s no longer able to
practice as an OBGYN because of negligence,
because of failing to diagnose uterine cancer. And the Rancho Mirage was a
big hit in the early 2000s and he also was forced to
surrender has medical license. So I think besides the safety and efficacy of bioidentical hormones,
one of my big problems with bioidentical hormones
is that they’re often promoted to women as kind
of this Fountain of Youth, which they aren’t and nor should they be. Aging is a natural part of our lives. It’s a natural process but the way society makes us
feel about our aging bodies often leads women looking
for ways to either maintain or get back the way it was. Jennifer Gunther is a notable
OBGYN out of San Francisco, and she notes that we
all fear getting older, lots of sexuality and the
way society makes women feel, women are more vulnerable to it. Bioidentical hormones is a
multimillion-dollar enterprise that takes advantage
of that vulnerability. I think in a culture that
really values fertile and young people, aging can make us feel unattractive and worthless. We beat ourselves up
over our changing faces and our unrecognizable bodies. Instead I feel like we should be embracing those changes, especially during times of transition, whether it’s adolescence,
motherhood, or menopause. We should embrace our changing
bodies and cherish them. We should empower people to
know that they’re beautiful in all of their forms. Even if it’s not what
society tells us to look like or we don’t feel the way they
tell us that we should feel. Nora Ephron, who was a fantastic writer and I love her book on this topic, I Feel Bad About My
Neck: And Other Thoughts on Being a Woman, she
tells us anything you think is wrong with your body at 35, you will be nostalgic for at 45. But she also asks us to be
the heroine of our lives and not the victim. We are going to be postmenopausal. We spend about a third of our lives in the post menopausal period, and I think that we need to
accept that and embrace it, and make steps to make positive change so that we can make the best of it. Things like eating healthy and exercising can make us feel better about our bodies. Shifting into a positive
thinking mode is hard, but it’s really important. Sometimes therapy can help but people who have a
positive outlook on life, radiate energy and are often perceived as being more beautiful. We should try to develop new interests, pick up old hobbies,
rekindle relationships and maintain them. Surround yourself with
women who are going through the same thing, who are
around your same age who get it by fostering
this community and support and embracing each other, we can help to change the status and the kind of image of that. We can create change that makes you feel good about yourself and
support and encourage others like yourself to do the same. Often men around the same time
are going through their own set of changes, and they
may also be reluctant to talk about it. Society is not much more kind to aging men than it is is to aging women. So I think it’s important
to keep that in mind. There are some great
resources that I really like. The North American
Menopause Society or NAMS. They have the great website. It’s very easy to remember,
it’s menopause.org. It’s easy to navigate. They have information for patients and frequently asked questions as well as the Meno Notes, of which I have provided some of those out at the back table on common symptoms and
some of the treatments that we talked about. It has really good
evidence-based information, and if you’re looking for
a little bit more in-depth, they have a book called
The Menopause Handbook, which you can purchase
through their website. There’s also a new app
that I haven’t quite checked out yet but
I’ve heard good things, it’s called the Rosy
Wellness app and it’s free. You can download it on your phone, and the goal of it is to provide
evidence-based information and resources for women,
who have questions about their sexual wellness. There’s also the American
College of Ob-Gyn. They have some good patient
information handouts as well. And then also you can
come talk to your doctor. We love to talk about this stuff and they’re hard conversations to have, but it’s definitely something important and to not feel alone. These are the references for my talk. And I didn’t have the picture of my kids, but I would be more than
happy to answer any questions.

One comment

  1. Thank you for your information. What impact does diet have and wouldn't a healthy diet be a better alternative than drugs? What about a keto way of eating? Thank you again.

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