Making 20Menopause 20Manageable by HC111111101345

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									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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