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

written by Deborah McBain, CNM MSN

Much confusion exists among consumers about the term “bioidentical hormones”.  Strictly used this term simply means hormones which are identical to those produced by the body.  As a marketing term it often refers to custom-compounded hormones.  These are drugs made by a compounding pharmacist from a individualized prescription.  What is the truth about bioidenticals?  Are they better or safer?  This is what you should know.

1.  Many well-tested brand name products containing bioidentical hormones are approved and available commercially.  Cost for these approved products are often covered by prescription insurance plans.

2. All hormonal drugs contain filler ingredients to hold drugs together such as for pellets suppositories or tablets or provide a vehicle to administer such as gel, cream or liquid.  Custom-compounded hormones can vary greatly and are not tested for batch standardization, purity, safety or efficacy.  Commercially approved formulations have been tested and  are subject to regulation.

3.  FDA investigations have found some compounding pharmacies have made false and misleading claims about the safety and effectiveness of individually compounded hormones.

4.  Salivary or hair testing used to adjust custom hormone levels is not justified on any scientific basis.  This may be recommended by practitioners who advocate custom-compounding.  Beware of this because these same practitioners may profit monetarily from selling the services and products they are advocating.  Many health care systems have worked very hard to eliminate the influence of drug companies on the practitioners who prescribe the drugs.  You want drugs prescribed for your benefit, not for the benefit of the practitioner.

5.   There is no evidence that bioidentical hormones or custom-compounded drugs are safer or work better than other hormones or commercial drugs.   It is presumed they carry at least the same risks as any other hormones.  Custom-compounding has the advantage of offering doses, ingredients or routes of administration not available commercially but carries the risk of being untested and at greater cost to the consumer.  Be smart about where you get your information,  who is writing your prescriptions and mixing your drugs and who is apt to benefit the most.

written by Deborah McBain, CNM MSN

I get a lot of questions about how menopause effects mood.  What do you think?  Have your responses to situations changed as you journey through menopause?  How have you coped?  What advice do you have for others?  Your comments are welcome.

On October 9th, the HFHS Neurology Department hosted the second lecture in a series of three focusing on neurological health for women.  Dr. Doree Ann Espiritu, service chief of Psychiatry at West Bloomfield Hospital spoke about mood disorders and women.  Below I share information about mood and menopause and my notes from the lecture.  The final lecture in this series is October 30.  The topic is Memory.  I suspect it will be very popular and space is limited .  Call 313-916-8088 if you are interested in attending.  If you can’t make it, stay tuned here.  I will report back.

It is a common belief that menopause makes you crazy.  In truth, there is no scientific evidence for this.   There is evidence, however, that mood is definitely tied to hormones.  Duh!  Women who have suffered from premenstrual dysphoric disorder or postpartum depression may indeed be at higher risk for mood problems during the hormonal roller coaster of perimenopause.    The good news is that once menopause is acheived (remember this is confirmed 12 months after the last menstrual period) the risk for mood disorders actually decreases.  Whew.

According to Dr. Espiritu’s statistics, a lifetime chance for a women to develop depression is 21%, social phobia,15.5%, drug and alcohol dependence 14%.  Although rates of depression are lower in men, rates of drug and alcohol dependence are higher.  Women are 6X more likely than men to have Seasonal Affective DIsorder (SAD).  We are 3X more likely than men to develop anxiety disorders.  Anxiety disorders include generalized anxiety, phobias, obsessive-compulsive disorders, panic disorder and post-traumatic stress disorder.

Hormones are by no means the only culprit for mood problems in women.  Women with mood disorders should be screened for other causes of their symptoms, according to Dr. Espiritu.  Medical problems, medications and assessment of past and recent traumatic events should be considered.  Some women having their first perimenopausal hot flashes with heat sensations and sweating that take their breath away may mistake them for panic attacks.

Medications and cognitive-behavioral therapies now provide very effective treatment and management of mood disorders.  Like any illness, treatment for a mood disorder is easier when recognized early.   Also, like most other diseases, life-style changes can help.  There is strong evidence that exercise and a healthy diet improves mood. November topic is stress management and I will discuss life style and mood more in the next few weeks.

In Christine Northrup’s book, The Wisdom of Menopause, irritability and menopause is attrubuted to the “lifting of the hormonal veil”.  By this she means that the stopping of the monthly cycle of reproductive hormones which keep us focused on caring for others allows us to consider our own needs more clearly.  You may have a darn good reason to feel irritated!   A surly boss, unhelpful kids or husband,  a higher number on the bathroom scale?   If you are in a bad mood, consider why.  It may be just the motivation you need to change your life in a new and better direction.

Irritability is one thing, clinical depression or other mood disorders are another. If you are stuggling to get out of bed or having difficulty coping day to day then get help.  Talk to your health care provider about your symptoms.   If you thought you had an infection you wouldn’t hesitate to get treatment and a mental illness should be no different.  If you would like more information about women’s hormones and relationship to mood a good book is Women’s Moods: What every Woman Must Know about Hormones, the Brain and Emotional Health by Deborah Sichel, MD, Jean Driscoll MS,RN,CS.  The National Institute of Mental Health web site is another good source for information- www.nimh.nih.gov

written by Deborah McBain, CNM MSN

Among the myriad of perimenopausal and menopausal symptoms, hot flashes seem to be among the most troublesome.  This post will address this burning issue (burning, get it?).  Ahem, yes, well what causes hot flashes?

What causes hot flashes is a question that even the experts continue to debate!  Although why hot flashes occur is not fully understood, it is generally agreed it is related to decreasing estrogen in the body.  There are hot flashes and then there are HOT FLASHES.  Some women have just a few and can live with them and some have frequent and severe flashes and are totally incapacitated by them.  Some women may not experience hot flashes at all.   Many women learn to recognize certain things which trigger hot flashes or make them more severe and frequent.  Stress, alcohol, spicy foods, hot foods, warm temperatures are common triggers to hot flashes.  Some medications or cancer treatments may cause hot flashes or make them worse.  Hot flashes may start years before the actual menopause (remember, that is 12 months after the last menstrual period)  and some women may continue having hot flashes ad infinitum!  Experts estimate an average of 6 years of hot flashes. (But I know someone who shall remain nameless who is going on 10 years)

Many women may be able to lessen hot flashes by avoiding triggers mentioned above.  Dressing in layers and keeping homes cooler is a common sense solution.  Slow, controlled deep rhythmic breathing, known as paced respiration, practiced twice a day can decrease hot flashes. Take a slow, deep breath, hold it for a few seconds, and exhale just as slowly. Paced respiration may also help relieve a hot flash when started as the hot flash begins.  Herbs have not been shown in studies to be particularly helpful and may have side effects.  Herbal supplements are not well regulated and some brands may not have very much of the herb in them at all.  Although Black Cohosh has been shown to help some women with hot flashes, long term effects are not known.  It has been associated with irregular uterine bleeding and is not recommended to be used longer than 6 months.

For those women whose hot flashes are disrupting their ability to function, estrogen therapy may be a saving grace.  HT has gotten a bad rap since the Women’s Health Intitiative (WHI) stopped a study of  women on estrogen and progestin therapy (EPT) in 2001 after they had a larger than expected number of cardiovascular complications.  The women in the study who had a history of hysterectomy and were on estrogen therapy (ET) alone, without progestin did not experience these side effects.  Women with a uterus and taking estrogen need progestin to prevent cancer from forming in the lining of the uterus.  Since that time there has been a better understanding about how EPT effects heart and blood vessels in women in different age groups.  There is evidence that women starting EPT in perimenopause or within 5-10 years of reaching menopause do not have the same risks on EPT as women starting at an older age.  It also appears that it is the progestin in combination with the estrogen which may contribute to a slight increase in breast cancer, but only after 5 years of use.  Clinicians and researchers are looking at different ways to give progestin to minimize this risk.  HT is considered by menopause experts to be reasonably safe for many women and can dramatically improve quality of life for those who suffer severe symptoms.  Some women are not good candidates for HT because of health conditions such as a history of blood clots, heart disease or breast cancer.  For those women, relief can sometimes be found in non-hormonal medications such as clonidine, gabipentin or effexor.  Beware of individually compounded bioidentical hormones.  There is no evidence that these are safer or more effective than FDA approved products.

written by Deborah McBain, CNM MSN