This presentation is for the education and information of patients of The Thayer Group for Women‟s Care, P.C. All other uses are strictly forbidden. This is the sole property of the Thayer Group. The opinions herein expressed are those of Dr. Thayer and are subject to change. No permission is granted for any other use of any part of this presentation, in whole or in part, without express written permission of Dr. Thayer. No one should begin a medical regimen without the evaluation of their physician, and based on their own medical situation. If you are interested in an evaluation please contact our office at 303-443-2010. 1 Hormonal Havoc: Making Menopause Manageable Presented by: david o. thayer m.d. david o. thayer m.d. Lived in Boulder for 24+ years. Two grown children. ❖ ❖ Board Certified in Obstetrics and Gynecology. ❖ Fellow of the American College of Obstetrics and Gynecology. ❖ Private practice, GYNECOLOGY ONLY. Obstetrics until 12/00, 2000+ babies. ❖ Surgical privileges at Boulder and Foothills Hospitals, Longmont Surgery Center, Longmont United Hospital, and Medical Center of the Rockies. ❖ Involved with teaching of Medical Students, Interns/Residents, Nurse Practitioners, Physician Assistants, Nurses, Medical Assistants, and the Public. ❖ Donate time and/or patient care to People‟s Clinic; Mante, Mexico; Children‟s Hospital; BVWHC; and THAYER GROUP FOR WOMEN’S Rebuilding Seminars. CARE, P.C. Thayer Group for Women’s Care, P.C. Care Providers Tamara Lester, WHCNP Erin Livers, ICNT Traci Shahan, RN,WHNP-BC,ND Sat Tara Kaur Khalsa, MS LPC Specialize in Women‟s Health, Preventative Health, Gynecology, and Health Education - for all ages. Special interest in the evaluation/treatment of menopause, hormonal imbalances, bleeding issues, fibroid tumors, and reproductive/pelvic pain. Focus on Non-Surgical Treatment. Holistic care. Minimally Invasive Surgery if needed. First Robotic gyn surgery for a Boulder County patient. www.thayermd.com Please visit our website to learn more about our philosophy of caring for individuals. Stay up to date with our Education section. Presentation Goals • Present an OVERVIEW. – Explain the terminology of menopause & perimenopause – Highlight ways this may be affecting YOU. – Discuss reasons for intervention. – Options for treatment-(natural, alternative, hormonal). • Explain the CONTROVERSIES. • Explain BENEFITS vs. RISKS -- DECISION MAKING • Leave you with tips on how to manage YOUR own situation. • Briefly discuss the concept of „The 100 Year Plan‟. • Not show slides with hundreds of data points! What I probably won‟t accomplish. - I won‟t answer all of your questions - I may not erase every lingering doubt. - I won‟t be able to give you an individualized answer to your own situation. - I won‟t impact the media‟s negativity. My personal goal is to give you enough information to encourage you to seek out advice and not accept the status quo! 8 UNLEARNING • According to humorist Josh Billings, “ the trouble with most folks isn‟t so much their ignorance. It‟s know‟n so many things that ain‟t so.” 9 UNLEARNING • Please open your minds to what I am about to share. • Try to quiet the inner critic, those voices that say: – “Thats not true.” – “I read something different.” – “I know the answer.” – “Dr. Phil said something different.” – “Suzanne Somers said something else.” 10 MENOPAUSE • What is it? • -and why do we care? And WHY is there so much controversy? Menstrual cycles • In order to understand menopause we need to first understand “normal” menstrual cycles. • Your cycles are driven by a complex “ballet” of hormonal changes. • These hormones are produced in the ovaries. • Hormones are never static. They are constantly changing. Rising or falling. 12 Menstrual cycles • Hormonal changes constitute a natural progression in women‟s lives - from birth to death. • Menses and any accompanying symptoms are driven by these changing hormone levels. • There are monthly cyclic changes that create fertile reproductive cycles. • There are plateaus that lead to months or years of milder or stronger symptoms or suboptimal fertility. • And then the eventual low plateau of menopause. • Unpleasantly, there can be daily fluctuations. FSH & LH Normal menstrual cycle Estrogen and Progesterone Stages and Plateaus Fertile Years: Fairly Predictable Teen years: Perimenopause: +/- Rough Variable Menopause: Menses “Pause” Age 0 10 20 30 40 50 60 70 80 90 100 Menarche: The Beginning Menstrual Cycles – 6 “ideal” months Red is estrogen, green is progesterone, and dotted lines are FSH and LH “Ideal” monthly cycles: smooth hormonal balance d d d d d d d d d d d d Let this single line represent the previous graph with multiple lines. Smooth sailing MENOPAUSE • Menopause strictly means the end (pause) of menses. • Menopause is a hypo-estrogenic state. • Estrogen surges have caused growth of the endometrium. • Now no growth = no shedding = no period • ~ FSH over 40 • Average age 51-52. PERIMENOPAUSE • By definition means the time around menopause. • (Could mean anytime from birth to death. ) • Usually refers to the transitional years leading from regular menses to the end of menses and the symptomatic years. • Ages 35 to 60. • Low, unreliable Progesterone & Fluctuating Estrogen. Perimenopause – 6 months Hormones are out of balance. • This person does not feel well! • Her partner is hanging out with his/her friends a lot lately! • And she‟s thinking about selling her kids. 22 23 24 Stages and Plateaus Teen years: Perimenopause: +/- Rough Variable Menopause: Menses “Pause” Age 0 10 20 30 40 50 60 70 80 90 100 Why are Menopause and Perimenopause so important? • 30 to 50 years of your life. • Uncomfortable Symptoms. • Possibly disruptive • Possible increase PMS (unexplained moodiness, sadness, lack of concentration). • More abnormal bleeding, iron deficiency. • Decline in general health. • Huge impact on reproductive system. Life expectancy has increased. 200 years ago, fewer than 30% of women lived long enough to experience menopause. 100 years ago the average women‟s life expectancy just reached 50 years of age. NOW-Average life expectancy is 80 and most of you will far surpass that. Ready or not, you can already expect a better QUANTITY of life. So the question really becomes - “How can I maintain the best QUALITY of life?” 28 Impacts of Estrogen Decline Menopausal impacts can be divided into two categories - short term and long term Estrogen Withdrawal Symptoms-short term (Resolve with time) hot flashes night sweats sleeplessness fatigue mental lapses moodiness MOST DISAPPEAR WITH TIME. irritability Impacts of Estrogen Decline Menopausal Symptoms long term impacts- Estrogen Deficiency -- ( Worsen with time) Vaginal effects (dryness, atrophy) Brain (cognitive decline) Bone (loss of mineral density) Blood vessels (atherosclerosis) Skin (wrinkling) Mucus membranes (dryness) Genitalia (atrophy) THESE IMPACTS DO NOT FADE - THEY GET WORSE. Estrogen Deficiency: Lets assume that you agree that these symptoms are problematic. That the long term effects are undesirable. Questions to resolve: A. Could anything be done? <--- YES B. What would the options be? C. How safe are they? Options to Maintain Quality of Life 1. NATURAL - Live a Healthy Lifestyle • – Enhance and accept what nature has given you. 2. ALTERNATIVE – use supplements, vitamins, naturopathic and homeopathic remedies. 3. MEDICAL TREATMENTS – treat specific symptoms or problems with medications as they arise. 4. HORMONAL – replace the original substance that is missing - prevention. (Similar to treatment of low thyroid) Option 1 -Natural Menopause Women‟s bodies are genetically programmed to go through a fertile phase that ends with the onset of menopause. Natural phenomenon - “why not accept it gracefully, and work to improve life quality by diet, exercise, and natural supplements.” Much to be said for this lifestyle. Symptoms - not everyone has them, or they may be mild, and even if uncomfortable, will usually resolve < 5 years. Learn to “Live with it”. Natural Menopause Most of these issues will be accepted by women as natural aging, not realizing they could have been prevented. Estrogen deficiency will NOT resolve, and over time the damage will become apparent. At some point the damage is irreversible. Most women at this point will be switched to ”Option 3 - Medical Treatments.” because now they have genuine medical issues. Early death has been the NATURAL outcome for thousands of years. (Slide 28) Option 2 – Alternative Therapy Many options available. No Rx needed. OTC (Over-the Counter). May consist of herbal supplements, nutraceuticals, Homeopathic treatment, Chinese herbs and treatments, acupuncture, massage, Chiropractic manipulation, mental imaging, crystal treatments. “Non-Western” style. People may get symptomatic relief. A lot can be said for feeling better. Relief of symptoms rather than disease prevention or reduction. Some are better than others. Alternative Therapy Alternative tx‟s give people power to make their own choices. Especially when so many of us have become so skeptical of our health care system and the motives of people making decisions and recommendations. Draw criticism as unproven. Most are “unproven” in truly scientifically controlled studies, but thats not the point. Most likely they are safe. Most have extremely limited data on safety so remember it‟s-“Buyer beware”. No data regarding disease prevention. Option 3 – Medical Treatments Medical treatments begin after a problem develops. Traditionally, this is what most Americans choose. Western philosophy of medicine. We seem to assume that disease is inevitable. “Eventually we all will get something.” “No one gets out of here alive.” This refers to specific drug therapies to treat conditions or disease states as they arise. Medical Treatments Examples: Treating elevated cholesterol with Statins Diabetes with oral therapy or insulin. SSRI’s for depression. Bisphosphonates for osteoporosis. These are REAL medicines, with REAL side effects and known risks, (including death). Option 4 - Hormonal Supplements Over the Counter (non-prescription) “hormones” Phytoestrogens and phytoprogesterones. “Natural hormones” Bio-identicals (non-prescription)-these are NOT identical to a human female! Traditional Hormone Therapy Premarin Synthetics Prescription “Bio-identical” hormones. Phyto-chemicals: Plants make chemicals that are necessary for their own survival. It turns out that those chemicals can have effects on humans. Certain plants make chemicals that will weakly stimulate estrogen and progesterone receptors. Supplementing with these can frequently alleviate mild symptoms. Phytoestrogens/progestins: They are extremely weak compared to your own ovarian hormones. They cannot be measured in available hormonal assays. I cannot see biological effects at currently used doses. Little risk of harm known, but limited data. Phytoestrogens/progestins: Someone discovered that you can extract these substances and sell them. This is a billion dollar industry that has as much of a vested interest in promoting their own products as does any giant pharmaceutical company. This is not to say they don‟t work, just exercise caution when evaluating their claims. Traditional hormonal tx: Premarin - derived from purified urine of pregnant mares. Longest track record of any estrogen. Hundreds of studies have documented its effectiveness. Study drug from the Women‟s Health Initiative (that received such bad press in 2002). Most of those negative findings have been totally disproved. The negative image still lingers, but the medication is totally valid. Traditional hormonal tx: Synthetic hormones All are derived from plants. No animal sources. NOT IDENTICAL to the human hormone molecule. Changes were made to make it better absorbed, last longer in the body, be more potent. (And allow patents to be obtained.) Main ingredients in a birth control pill. Traditional hormonal tx: Synthetic hormones Tremendous track record. Very safe. Oral Contraceptives use hefty doses of these to provide the pregnancy preventing effects. Millions of women-years of experience. Safe to stay on for decades. Zero convincing evidence of a link to breast cancer. Menopausal doses require small fractions of OC doses. “Bio-Identical” Hormone Therapy Prescription only. If you can buy it without a prescription, its either not bio-identical to a human hormone, or it‟s illegal. They are IDENTICAL molecules to the ones that you and I make. They have to be made (SYNTHESIZED). They start with the fancy chemical that certain plants make, and change the structure until it is IDENTICAL to ours. “Bio-Identical” Hormone Therapy Not as much research has been done. Orphan drugs. Criticized because of less research. However, MUCH has been done and its very encouraging and compelling. “Mother Nature” designed these molecules and theoretically could have invented any molecule she wanted. Truly “NATURAL”. That alone does not make them „better‟. “Bio-Identical” Hormone Therapy Claims that these are safer are largely unsubstantiated. But on the other hand, claims that they are not as safe are also unsubstantiated. Battle going on between major pharmaceuticals ( they have patents on synthetics) and the private compounding pharmacies ( they make a living off of selling bio-identicals). Both are safe and effective, in my experience. Safety: This decision is important and affects your mental and physical well being for years to come. Lots of conflicting data, and even more conflicting OPINIONS. I wish this were an easy answer. THE ANSWER MAY ACTUALLY BE EASY, BUT YOUR PROCESS WON‟T BE!! Safety: Beware of people or companies that are selling something! Beware of pronouncements from organizations who are at risk for liability! Beware of people with big egos who want to be in the spotlight! The truth is they are BEYOND SAFE!! The reality is that we live in fear-fear that maybe its safer to do nothing than something! Safety: Unlearning ★ Most of us are “learning“ from the media. ★ The media thrives on FEAR. (When was the last good news in the press?) ★ The media has no obligation to educate. ★ “BAD” news gets air time, “GOOD “ news is buried. Fear Drives Our Decision Making Process. Statistics • “Like a bikini - You can cover up or reveal as much as you want.” Statistics As much as we may dislike statistics, we use them to make our decisions. We have come to a fork in the road. We need to make some decision. Remember no decision, IS a decision! If confused, remember the immortal words of Yogi Berra--”When you come to a fork in the road, take it!” TWO TIMES RARE IS STILL RARE! PUTTING RISK INTO PERSPECTIVE: HOW COMMON ARE RARE EVENTS? • trial of estrogen alone in women who • • JAMA - July 2002 have had a hysterectomy is being continued, and the planned end of this trial • is March 2005, by which time the average • follow-upwill be about 8.5 years. • The WHI clinical trials were designed • in 1991-1992 using the accumulated • evidence at that time. The primary • outcome for the trial of estrogen • plus progestin was designated as coronary • heart disease (CHD). Potential cardioprotection • was based on generally • Author Information and Financial Disclosures appear at the end of this article. • Context Despite decades of accumulated observational evidence, the balance of risks • and benefits for hormone use in healthy postmenopausal women remains uncertain. • Objective To assess the major health benefits and risks of the most commonly used • combined hormone preparation in the United States. •Gynecology and Reproductive Biology Charting a Course Through Changing Tides: •Harvard Medical School An Evidence-Based Examination of Hormone Therapy in Women’s Health •Boston, MA Susan Wysocki, •Howard N. Hodis, MD WHNP-BC, NP, FAANP President and CEO •Harry J. Bauer and Dorothy Bauer Rawlins National Association of Nurse Practitioners in Women’s Health (NPWH) •Professor of Cardiology Washington, DC •Professor of Medicine and Preventive Medicine •Professor of Molecular Pharmacology •and Toxicology •Director, Atherosclerosis Research Unit •Keck School of Medicine •University of Southern California •LosAngeles, CA • •James A. Simon, MD, The Twisted Tale: Current careful analysis confirms that essentially all of the negative data from the huge WHI study were misleading and in almost all instances can be disproved. Deja vu. Back where we started! 50 years of research had shown us that HRT was effective and safe, before the WHI study muddled the picture. Now we can prove how misleading it was. Hormone Replacement Therapy Risks versus Benefits Opinions of The Thayer Group for Women‟s Care, P.C. HRT – impact on “cosmetic changes” Improves vasomotor stability, reducing hot flashes. Helps maintain elasticity of skin and tissues. Improves sleep patterns, decreases fatigue. Increased „sense of well being‟. Better recall, memory, problem solving. HRT - Impact on major health issues Cardiovascular Risk Osteoporosis Colon cancer Endometrial cancer Dementia Macular degeneration Insomnia TIMING and MODE of delivery Timing of treatment - it‟s critical to get started early to get the full benefit. Many of the benefits persist if you continue therapy for longer periods of time. Mode of delivery refers to how you get a substance into your body. NON-ORAL offers slight safety advantages over oral. Treatment: How to do it. Let‟s assume for the moment that there are safe choices. Therapy depends on your particular situation. • “Where you are” in this transition process. • Depends on your goals, health conditions, budget, etc. 1. Evaluate your situation. Thorough exam to rule out other underlying medical conditions. Probably blood tests - same reason. Possibly HORMONAL TESTING. Not always needed. Very tricky to interpret! Menstrual Record charting of any bleeding and symptoms. Evaluate nutrition, lifestyle, activity level, stress, smoking, vitamins, libido, sleep issues, and more! Sit with your caregiver and begin to put the puzzle together. Begin to formulate a plan of action. Where are you in this process? If you are pre-menopause (perimenopause) , but having symptoms &/or abnormal bleeding: Rule out underlying medical disease. The goal of therapy would be to evaluate/correct the bleeding issue. Suppress the symptoms, necessary changes in nutrition/life. LOW DOSES of hormonal supplements if needed. Frequent monitoring and adjustments due to volatility. Where are you in this process? If you have had your last period over one year ago, or lab tests suggest you are in early menopause and you have symptoms: Low dose treatment would boost your low and erratic levels to a point where symptoms would melt away. This could safely be continued as long as it were needed. Adjustments would be required as your ovary continued to decline. Where are you in this process? RECENT MENOPAUSE, but NO symptoms. It‟s great not to have symptoms but you still face the decline in health associated with the loss of estrogen. You are in a group that‟s harder to convince! You don‟t have symptoms so you don‟t feel “bad”. You won‟t “feel” the slow loss of calcium in your bones until it‟s too late. You may want to consider HRT to prevent some of the long term effects of chronic estrogen deficiency. Where are you in this process? MENOPAUSE, longer than 10 years but less than 20. Data is less kind to you. Osteoporotic fractures are reduced. Colon cancer is decreased. No increase in cardiovascular disease. Many women will FEEL better. Where are you in this process? MENOPAUSE, longer than 20 years. Very slight increase in cardiovascular deaths. Still a decline in osteoporotic deaths, and colon cancer. The “WINDOW OF OPPORTUNITY” is probably closing. The EARLIER a person starts treatment, the better the benefit. 100 YEAR PLAN There is a fair probability that most of you will live to see your 100th birthday. The real question is “How can I insure good QUALITY of life”. Mickey Mantel famously said “If I knew I was going to live this long, I‟d have taken better care of myself.” You drastically increase your odds, by following a healthy lifestyle. You further increase your odds by screening for the more common problems so they can be found early. Based on our current understanding of HRT, most women will be much safer if they begin a regimen of treatment at the onset of menopause. Presentation Goals Explain the terminology of menopause. Significance of this transition. How it‟s affecting YOU. Reasons for intervention. Options and alternatives for treatment. Data on SAFETY. Why there should be fewer controversies. Leave you with tips on how to manage YOUR own situation. Making a decision. „The 100 Year Plan‟. Not show miserable, confusing slides with too many dots and bars and arrows!! Carefully consider your options. There is no single answer for ALL women. Each person must weigh the facts for themselves. New evidence must be considered, but don‟t throw out the older evidence too quickly! Don‟t be misguided by well meaning, but less informed “experts”. If you truly want the best and most up-to-date advice, consider seeing one of our caregivers. Let us evaluate YOUR personal best choices. Carefully consider your options. There is no single answer for all women. Each person must weigh the facts for themselves. New evidence must be considered, but don‟t throw out the older info too quickly. Make an appointment with an expert like Dr. Thayer or his partners to assess your personal best choices. Don‟t be misguided by well meaning, but less knowledgeable “experts”. Allow us to give you the up-to-the-minute news. Thank you!
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