These are the latest recommendations from  the National Endocrine Society:   The following was taken from a recent Medscape report.  The bottom line is that for certain groups of women, namely healthy women younger than 60, benefits of hormone therapy may very well outweigh the risks.   And so the pendulum begins to swing again…

June 29, 2010 — A new Endocrine Society scientific statement published in the July 2010 issue of the Journal of Clinical Endocrinology & Metabolism evaluates benefits and risks for postmenopausal hormone replacement therapy (HRT), now known as menopausal hormone therapy (MHT). The statement, entitled “Postmenopausal Hormone Therapy: An Endocrine Society Scientific Statement,” was also posted online ahead of print on June 21 and presented in San Diego, California, at ENDO 2010: The 92nd Annual Meeting & Expo.

Although MHT was in widespread use in the 1990s in hopes of lowering cardiovascular disease risk as well as to treat menopausal symptoms, the Women’s Health Initiative (WHI) Study showed that MHT was actually associated with an increased risk for heart disease, stroke, and breast cancer. However, recent evidence suggests that these risks may be affected by time after onset of menopause when MHT was started, a factor not considered in the WHI assessment of MHT safety and efficacy.

“Before the WHI, MHT was believed to prevent heart disease, fractures, memory loss and dementia in addition to relieving uncomfortable menopausal symptoms,” said task force chair Richard J. Santen, MD, professor of medicine at the University of Virginia in Charlottesville, in a news release. “Following the WHI reports of increased health risks associated with MHT, MHT use declined by 80%. New data however [show] that these health risks may not apply to all women using MHT, and that MHT may in fact be very beneficial to some women.”

Controversy regarding WHI’s applicability to women just entering menopause stems from the fact that the average age of participants was 63 years, and only 3.5% of the women were aged 50 to 54 years, which is the age range when women typically decide whether to start MHT. Furthermore, the WHI did not address menopausal symptom relief. Therefore, this scientific statement considered new data from later studies evaluating the effects of MHT in women aged 50 to 55 years.

Compared with women who begin MHT after age 60 years, those who begin MHT a short time after onset of menopause at ages 50 to 59 years appear to benefit. According to recent evidence, women in the short-time group using MHT for 5 years had a 30% to 40% reduction in mortality risk and no increased cardiovascular disease risk. In addition, they had a 90% decrease in hot flashes, overactive bladder, or other menopausal symptoms.

“Some women in the short-time group still developed breast cancer but only with the combination of estrogen plus a progestogen, not with estrogen alone,” Dr. Santen said. “This may be due to the stimulation and uncovering of very small, undiagnosed breast cancers, rather than causing these cancers de novo.”

Conclusions Reached

Evaluation of the new data along with WHI evidence led the task force to reach the following conclusions, with level of evidence A:

• “Standard-dose” estrogen used with or without a progestogen is associated with marked reduction in frequency and severity of hot flashes. For many women, lower doses of estrogen are also effective.
• For symptoms of vaginal atrophy, very low doses of vaginal estradiol are effective.
• Symptoms of overactive bladder may be reduced by estrogen given vaginally or systemically.
• Vaginal estrogen is associated with lower rates of recurrent urinary tract infections.
• For women in late postmenopause, estrogen given with or without a progestogen is as effective as bisphosphonate therapy for preventing early postmenopausal bone loss and increasing bone mass.
• Use of estrogen alone and estrogen plus a progestogen is associated with a lower incidence of hip and vertebral fractures.
• Treatment with the selective estrogen receptor modulator raloxifene is associated with increased bone mineral density and lower rates of vertebral, but not hip, fractures.
• Use of MHT containing estrogen plus a progestogen is linked to a lower risk for colon cancer.
• Raloxifene is associated with a lower risk for breast cancer.
• Mammographic density is increased in women taking estrogen alone or with a progestogen.
• Sexual function is improved by physiologic amounts of transdermal testosterone, but not by dehydroepiandrosterone.
• Risk for venothrombotic episodes is approximately doubled in women using MHT, and this risk is multiplicative with baseline risk factors such as age, increased body mass index, thrombophilias, surgery, and immobilization.
• Use of raloxifene is associated with an increased incidence of venothrombotic episodes.
• Raloxifene is not associated with any increase in stroke risk.
• In older women with preexisting vascular disease, hormone use does not reduce stroke incidence.
• Although continuous estrogen plus a progestogen does not cause endometrial cancer, estrogen alone without a progestogen is associated with an increased incidence in endometrial cancer. 
• Risk for gallbladder disease is increased in women using estrogen alone or with a progestogen.
• MHT started after age 60 years does not improve memory.

“It is important to remember that most women considering MHT are between the ages of 50 and 55 and in this group MHT may have many benefits,” Dr. Santen concluded. “Physicians and their patients need to re-think the use of [MHT] based on data pertinent to the 50-55 year old and therapy should be individualized based on symptoms and underlying risks of breast cancer and heart disease.”

written by Deborah McBain, CNM MSN

Keeping our bones strong is essential to our overall health and quality of life.  Throughout life we constantly lose old bone and form new bone, reaching our peak bone mass between the age of 25 and 35. But after age 35, women tend to lose bone, a loss that accelerates after menopause. Women can lose up to 20 percent of their bone density in the five  to seven years after menopause. Therefore, it is important to protect our bones and keep them healthy by maintaining a balanced diet rich in calcium and vitamin D.

Calcium is the building block for bones. Calcium is found in milk, leafy green vegetables, soybeans and foods fortified with calcium. Over the age of 50, the US RDA is 1200-1500 mg per day. Some great ways to meet these recommendations is eating a well balanced diet rich in calcium. One cup of skim milk=300 mg, one cup of plain yogurt=400 mg, one cup of broccoli=72 mg, one cup of spinach=150 mg and one cup vanilla frozen yogurt (soft serve)=205 mg. For more information on calcium rich foods, visit http://www.whfoods.com/genpage.php?tname=nutrient&dbid=45

Vitamin D is essential for the absorption of calcium. Most vitamin D comes from the sun. However for those of us who live above the Mason-Dixon line, we may not be getting enough sunlight, especially during the winter months. Thirty minutes of sun provides from 10,000-12,000 IU of vitamin D. Vitamin D is found naturally in a few foods such as salmon, mackerel, canned tuna,  sardines and eggs. Many foods are fortified with vitamin D, including milk and breakfast cereals.

Taking calcium with vitamin D can provide a nice supplement to your dietary intake. It is important to take the calcium and vitamin D with food to promote absorption, and if taking 1200 mg of calcium daily, it should be taken in two divided doses to maximize effectiveness.  Also important to remember, if you are taking thyroid medication, synthroid and calcium supplements should be seperated by four hours.

Strong bones support us, provide the framework for our muscles and allow us to move. Our bones are a storehouse for vital minerals, they protect our heart, lungs, brain and other vital organs. It is important to take care of our bones, so they can continue to take care of us.

written by Suzanne Mahoney, FNP-BC

As a nurse practitioner working in a Women’s Gyn office, I am continuously amazed at the strength and resilience of women. Although, I see women of all ages in our practice, I am particularly impressed by those adult women, age forty and beyond. This woman may be dealing with concerns related to children of all ages including grown children and possibly grandchildren, aging parents, financial stressors, and maybe some newly diagnosed health issues of her own.

She may be working full time and/or she may be taking classes to continue her education.  You know her.  She can bring home the bacon, fry it up in a pan, and all the while, she continues to make everything look absolutely perfect. She tells me that she is stressed, tired, and often times feels that she has way too much on her plate, and she does! Oh, did I mention she is also dealing with symptoms of menopause?

If you are able to recognize yourself in any or all of the above scenarios, I have a few tips that you may find helpful.Three concepts I try to reinforce with my patients; Strive for balance, Keep it simple, and most importantly, Be reasonable.

It is important to remember to look for balance in your life. Although work is important, you need to find time for fun, relaxation, and quiet time.

What ever you define as work, whether you are actually going to a place of business for 30, 40 or 50 hours a week or whether you are a homemaker, each individual needs to be able to strive for balance between what we define as “work” and what we do with the rest of our day. We all know that we need to be active, so try to find some fun ways to stay active. Walking is a great form of exercise and it may only cost you the price of a decent pair of walking shoes. Some helpful hints, now that the weather is nice, set a goal of walking at least 30 minutes a day, three to five days a week. It‘s a great place to start, and if you’re already there, increase it a little. Keep it simple, you do not have to join a gym, to walk. If the weather isn’t to your liking, walk the mall. If you get bored with a treadmill or walking around the neighborhood, grab a friend and visit any of our Michigan metro parks. A one-day pass is only $5.00 and an annual pass to all of the Michigan metro parks is $50.00. They have great walking and bike trails and they are open all year long. A winter walk can also be fun, just remember to wear a good pair of warm boots and layer your clothing in order to adjust to the temperature. Along with bike and walking trails, some of the metro parks also have cross-country ski trails, for those of you who are a little more daring. Another fun way to increase your walking is to wear a pedometer and challenge yourself to 10,000 steps a day; you might be surprised at how easy that can be. So lace up your sneakers, set goals, track your progress and put a star on your calendar when you have accomplished your goal. Be reasonable; exercise does not have to be expensive and setting reasonable goals will help you to be successful.

Rest and Relaxation is also important. Take time to do something that you enjoy. Perhaps it is reading a good book, watching a movie, taking a warm bath, or working on puzzles or projects. Get outside in the fresh air, take advantage of the great summer weekend art fairs, visit the zoo, reconnect with an old friend, or join a book club.  Whatever it is, make time for it, because you deserve it. Everyone needs a little down time.

Call it meditation, call it quiet time, call it prayer, what ever you call it, try to find some time to engage in it. Turn the TV, radio, blackberry, pager, cell phone off and just listen to the quiet. From the time our alarm clock goes off in the morning, until we go to bed again at night, our brains are bombarded by noise and distraction.  No wonder we feel so stressed. Give yourself a “time-out”. Make some quiet time every day to reflect and regroup. Experts agree that as little as 15 minutes per day can decrease stress, increase our energy and regenerate our spirit.

One of the simplest ways to keep ourselves healthy is by maintaining our weight. Many of my patients are being treated for hypertension, high cholesterol and diabetes. I often remind my patients that losing as little as 10% of their weight may be enough to reverse the effects of those chronic conditions. Again, set reasonable goals. With exercise and a healthy diet, you should see a slow and steady weight loss, which in the long run will be easier to maintain.

As we age, a decrease in blood estrogen prompts the body to store more fat, which results in a reduction in muscle tissue and in muscle strength. A reduction in muscle strength contributes to fractures. Therefore, lifestyle changes including increasing physical exercise, eating a healthy diet and smoking cessation cannot be overemphasized. Healthy lifestyle changes will increase circulation, strengthen bone and increase overall function. Optimal health and wellness will increase your ability to meet those challenges and stressors that we encounter every day. Remember to celebrate healthy lifestyle changes; you deserve to look and feel your very best.

written by Suzanne Mahoney, FNP-BC

 This month’s menopause support group hot topic was “Stressed and Depressed.’ And boy oh boy, is this a popular topic!  We  had one of our biggest responses for reservations  with an impressive waiting list.  Our speakers did a fantastic job of outlining the symptoms and causes of stress and depression as well as a useful discussion about management and treatment.  The most outstanding thing that I observed during the meeting at the Fairlane clinic on May 12 was the phenonmenal openness and support the participants were willing to give to each other.  Now understand, this is largely a group of strangers but with shared interests and experiences.   One woman openly described the physical symptoms of heart palpitations and pain which was eventually diagnosed as anxiety and stress as a result of being care taker for her sick mother.  I was particularly touched when another woman turned around and gave this woman a book she pulled from her bag  and explained, “  This book helped me immensely when I was going through a similar situation.  I knew I brought it for a reason. This is for you.”  The book is:  The 36 hour Day: A Family’s Guide to Caring for person’s with Alzheimer’s Disease by Nacy Mace and Peter Rabins. 

Although the issue of caretaking for parents is not a new one it is now getting much needed attention at the government level. The following was excerpted from a post on the White house web site.  It was written earlier this year by Terrell McSweeny who is Domestic Policy Advisor to the Vice President. 

“The Middle Class Task Force unveiled a series of initiatives in the President’s FY 11 budget that are aimed at helping families with soaring child care costs, balancing work with caring for elderly relatives or people with disabilities, paying for college, and saving for retirement. These are costs that – along with health care – have risen dramatically for families at a time when their incomes haven’t. Some people call this “squeeze” because of the pressure these costs put on family budgets. But for many families it just seems like it is impossible to get ahead. This is particularly true for the so-called “sandwich generation” – people who are caring for children (or grandchildren or adult children who are struggling financially) and their parents. The Vice President often speaks very personally about his experience caring for his parents and in-laws. And almost all of us know someone who has juggled caring for a parent or relative who can’t get along completely on their own. Millions of Americans provide unpaid care to aging relatives – including approximately 23 million caregivers with jobs and 12 million who are also caring for their own children. That’s why the Middle Class Task Force’s “squeeze” initiative includes help for family caregivers. These caregivers play a vital role in helping seniors stay in their communities or at home. But too often they don’t have the support they need to balance caregiving with work and family responsibilities.  Approximately 65 million Americans provide care to a loved one, giving more than $375 billion worth of unpaid care each year—often at their own financial and emotional expense.   The caregiver initiative won’t magically alleviate all the strain on caregivers and their families – but it is an important first step toward providing more support for families and caregivers and the vital services they are performing.”

The group meeting this month really helped me understand what an important issue this is for women who are also coping with the changes and personal health issues of menopause.  The planning team has already started to discuss how we can help meet your needs for information on this subject and likely will repeat the stress and depressed topic and caregiving  as a fall event.  Your imput is welcome either by comment or contact via email through this blog.  Thanks.

written by Deborah McBain, CNM MSN

This was recently reported by Laurie Barclay M.D. from Medscape Medical News.

Higher vitamin D levels are linked to a lower risk for female pelvic floor disorders, according to the results from the National Health and Nutrition Examination Survey (NHANES) reported in the April issue of Obstetrics & Gynecology.

“Because vitamin D receptors are present in human muscle tissue, a direct effect of vitamin D on muscle physiology is biologically plausible,” write Samuel S. Badalian, MD, PhD, and Paula F. Rosenbaum, PhD, from SUNY Upstate Medical University and St. Joseph’s Hospital Health Center in Syracuse, New York. “Thus, it is not surprising that vitamin D deficiency has long been clinically associated with impaired muscle strength and loss of muscle mass. Given that vitamin D insufficiency or deficiency is epidemic among adults, it is plausible that low vitamin D status contributes to the development of poor muscle strength and can lead to different pelvic floor disorders such as urinary/fecal incontinence and POP [pelvic organ prolapse].”

written by Deborah McBain, CNM MSN

In the most recent issue of Obstetrics & Gynecology, Jan Shifren and Isaac Schiff reviewed the literature about the use of hormone therapy (HT) in the menopause. The principle indication for hormone therapy remains the treatment of hot flushes and night sweats. Benefits generally outweigh the risks for healthy women with bothersome symptoms who elect to HT at the time of menopause. Although hormone therapy increases the risk of coronary heart disease, recent analyses confirm that this increased risk occurs primarily in older women and those a number of years beyond menopause. These findings do not support a role for HT in the prevention of heart disease but provide reassurance regarding the safety of use for hot flushes and night sweats in otherwise healthy women at this difficult time of life. An increased risk of breast cancer with extended use is another reason short-term  treatment is advised.

Hormone therapy prevents and treats osteoporosis but is rarely used solely for this indication. Estrogen is as effective as the other treatments for osteoporosis, so most women using HT for menopausal symptoms will not need additional treatment for their bones except for adequate calcium and vitamin D intake. If only vaginal symptoms are present, low-dose local estrogen therapy is preferred. There are creams, pills, and an estrogen ring which can be used to treat vaginal symptoms. They are all equally effective and which is used may be based on the woman’s preference. The risk profile for vaginal therapy is very different from systemic therapies, and there is no data that suggests a link between use of vaginal estrogen and the development of breast cancer or heart disease. There are safety studies up to 1 year showing no adverse endometrial effects, but studies of long-term effects of low-dose vaginal estrogen therapy are lacking. Therefore, women using vaginal estrogen therapy should report any vaginal bleeding and should undergo thorough evaluation.

Contraindications to HT use include breast or endometrial cancer, cardiovascular disease, history of blood clots, and active liver disease. Alternatives to HT is advised for women with or at increased risk for these conditions. The lowest effective estrogen dose should be used for the shortest duration necessary. Women should be informed of the potential benefits as well as the risks of all therapeutic options. Care should be individualized, based on a woman’s medical history, needs, and preferences.

written by Charla Blacker, MD

When a post menopausal woman comes in to my clinic complaining of vaginal dryness or pain with intercourse, I get excited.  No, I am not a sicko.  I am excited because I  know I can usually fix the problem and make a big difference in her quality of life.  That  is very satisfying.  Women are very grateful and I become their hero. So what is going on “down there”?  Well, I’ve got bad news and good news.

The bad news is that unless you are taking hormones, sooner or later it is going to happen.  It is called vaginal atrophy.  It means the skin and tissue in the vaginal area gets thinner and more fragile.  It is caused by the decrease in estrogen which occurs during menopause.   It can cause a feeling of dryness, itching and pain with sexual activity.  The good news is that there is help for this problem.

Even women who may not be appropriate candidates for systemic estrogen may be able to safely use local estrogen creams with good result.  There are many estrogen recepters in the vaginal area which means that a very little amount of estrogen is needed to get relief from symptoms.  Because the amount needed is small, the side effects and risks are small as well.  Often just a small pearl size amount of estrogen cream a couple times a week is all that is needed to maintain vaginal  tissue health.  Other factors which contribute to vaginal health are important to consider too. 

• It is important to check for and treat any vaginal infections like bacterial vaginosis, candida vaginitis (yeast) or even sexually transmitted diseases.  Treating these conditions may clear up symptoms.
•  Maintaining sexual activity of any kind helps  good blood flow and lubrication, keeping vaginal tissues healthy.  I call it the “ use it or lose it” factor.   Widows or divorced women who may enter a sexual relationship after many years of abstinence are often greatly dismayed with their discomfort and greatly relieved that there is effective help for their problem.
• Over- the- counter vaginal moisturizers and lubricants can offer a good starting point for help with dryness  or discomfort during intercourse.  There are many good products on the shelves of any drug store.  If after trying these, you still are not getting relief, see your physician or practitioner.  They may end up being your hero.

written by Deborah McBain, CNM MSN

  Julie has a BFA in dance from the University of Michigan and has been teaching creative movement and ballroom dancing since 1977.  She completed her yoga teacher training and began teaching in 2000.  She has taught a wide variety of classes in the community for all age groups and continues to teach classes at West Bloomfield Parks and Recreation.  In 2008, she completed training in a yoga therapeutic program, “Yoga of the Heart,” based on Dr. Dean Ornish’s study on reversing heart disease.   She feels proud and fortunate to be an employee at Henry Ford Vita Wellness Center, teaching yoga classes which focus on the health benefits of yoga. In addition to the daily yoga classes, she also teachs Zumba, Ballet Stretch and Tone and Dance Your Way to Fitness.  She recently answered my questions about how Yoga may benefit women during menopause and beyond.

 I know you teach a Yoga for Wellness class now and have offered a Yoga for Menopause class in the past.  What prompted your interest in yoga and specifically yoga for menopause?

When I began my first yoga classes in 1995, I truly had little understanding of yoga.  I was recovering from a dance injury and thought yoga would be a good way to stay in shape while I was recovering.  I quickly recognized that yoga was as much about the body as it was about the mind.  In short order I began to notice the many benefits from practicing yoga.  I was inspired from my earliest classes to become a yoga teacher, guiding others to discover the benefits. The overall benefits of yoga, which include stress reduction, improved focus, mood regulation, improved sleep as well as strength, balance and flexibility have served me well as I have made the transition through menopause.  

 Yoga is well known for its benefits in managing stress.  How is it specifically helpful for menopausal symptoms?

 What  are the other health benefits of Yoga for women as they age ?

Is Yoga safe for everyone?  Are there any precautions women need to be aware of?

How would you recommend someone get started with Yoga?  Do you have any good resources you can share?

written by Deborah McBain, CNM MSN

Most of us tend to think of immunizations as kind of a kid thing.  Most of us  were pretty good at getting our kids in for their “baby shots”.  I did have some friends who were pretty adamant at NOT getting their children immunized due to concerns about side effects, but most of us figured the benefits outweighed the risks.   And we were right.  Pediatric immunization programs have been very successful in reducing and even eliminating  many childhood diseases, saving countless lives with very little risk.  But despite the fact that there are many vaccine preventable adult diseases,  rates of adult immunizations are low.  Why is this, when immunizations so clearly are effective in reducing the occurance and severity of many serious and nasty adult diseases?   Experts believe that a lack of a cohesive national program promoting adult immunization strongly contributes to  a lack of information among both patients and care providers.   When you go see your doctor, does he/she talk to you about immunizations?  Do you  bring up the subject?  Most likely not.  So here is a primer on immunizations you should consider getting and when.    These are recommendations from the Centers for Disease Control & prevention (CDC).  Next time you go to the doctor, ask. 

Tetanus, Diptheria. Pertussis (Td/Tdap)  All adults age 19-64 should get a Tdap once and all adults should get Td booster every ten years. Pertussis, which is known as Whopping Cough caused a great deal of illness in death in children and infants in the 1940s.  For years it was nearly wiped out  due to immunizations but has recently reemerged.   Adults  have largely lost their immunity to the disease.  Getting the Tdap booster will prevent you from getting the disease and passing it on to any children you may come in contact with. ( think grandchildren). Obviously, parents, teachers and health care providers are also important adult groups to immunize.

Varicella-  (chicken pox).  2 doses recommended unless you have evidnece of immunity.

Zoster- (shingles).  One dose is recommended at age 60 or above.  Shingles can be very debilitating and the pain can last for months and months. Vaccines don’t always completely prevent infection but can greatly reduce symptoms and time for recovery.  The disease seems to get worse as we get older so it makes good sense to get this vaccine. 

Pneumococcal- (Pneumonia). One or two doses for people with medical conditions putting them at high risk and one dose if you are over 65.  Most people who die from the flu actually die of pneumonia so  this vaccine is often given along with the annual flu vaccine.

Influenza-   Get the flu vaccine yearly.  Flu shots are safe for most people and even if you do get the flu your symptoms will be milder.

Other vaccines that may be appropriate for you to get  include Measles- Mumps- Rubella (MMR),  Hepatitis A and or B and Meningococcal.  Check with your doctor to see if you are in a high risk group for these disesases and should be immunized. 

I wish you health.

written by Deborah McBain, CNM MSN

One of the most important and controversal questions regarding hormone therapy (HT) for postmenopausal women is “ Does Hormone Therapy reduce or increase risk for heart disease?”  An important study is underway that may help answer this question.     The Kronos Early Estrogen Prevention Study- KEEPS is designed to address  whether or not  risk depends on the age of the woman when beginning HT.  It will also seek to answer whether  patches are any safer than pills.  Observational studies have long suggested that HT can offer protection against heart disease in some women.    In 2002 another very large and important study- (WHI) Women’s Health Initiative  not only failed to show protection but was stopped when participants showed increased incidents of heart attack and stroke.  The average age of women in WHI was 63 and 12 years past menopause with 20% over the age of 70.  KEEPS will attempt to address whether it was the older age of the WHI participants that made the difference by studying a younger group of women who more recently entered menopause.   The age range for KEEPS participants is 42-58 and 6 -36 months from onset of menopause.  KEEPS will also use different types of hormones than were used in WHI including bio-identical formulas.    Women and those of us who advise them are anxious to see  if  KEEPS can offer guidance when making decisions about HT.  Keep a watch out for results from this study as it comes out in the media.  The only way we can know the truth about what is safe and effective is through studies like this.  If you want to know more about this study, go to their web site www.keepstudy.org 

The importance of heart disease prevention for women can hardly be overemphasized. Coronary heart disease is the single greatest killer of American women, extinguishing more lives (approximately one death per minute) than the next seven leading causes of female mortality.  In other words heart disease accounts for 45% of deaths in women.  Compare this to breast cancer which causes 4% of deaths in women or all cancers which accounts for about 21%.  This is in sharp contrast to the perceptions of most women who see cancer,  particularly breast cancer as the biggest threat.  Women should be aware that far more is known about risk factors for heart disease than for cancer and in general, heart disease risk factors are more susceptible to interventions.

written by Deborah McBain, CNM MSN