Answer from Dr. Prior: The answer to the question you asked about whether or not she needed hormone therapy depends on whether she was still menstruating when she had the surgery, whether it was performed for a non-malignant reason, and whether she now has disturbing hot flushes or osteoporosis.

I’ve tried to summarize the good reasons for menopausal hormone therapy on the Centre for Menstrual Cycle and Ovulation Research website www.cemcor.ubc.ca . Briefly they are: menopause too early (doesn’t apply to your sister); severe hot flushes not helped by other therapies and osteoporosis with hot flushes. There is also an article called “Stopping Estrogen Therapy.”

Since the Women’s Health Initiative study (the estrogen arm was recently stopped because of increased strokes and no benefit for heart) we know that otherwise healthy menopausal women do not need hormone treatment. In fact those studies are quite clear about risks, especially that of blood clots with pill forms of estrogen. I never, any more, prescribe estrogen except as a patch, gel or cream.

Women who have their ovaries removed almost always lose bone rapidly following the surgery. That would be ok if their initial bone health was good. If your sister has no risk factors I would still urge her to look at the ABCs of Bone Health for Menopausal Women on the website. If she has risk factors she needs a bone density and if it is low the ABCs of Osteoporosis Treatment would be more appropriate.

One of the treatments that has been shown to treat hot flushes is progesterone cream in a dose of 20 mg twice a day. That would be useful if she has mild hot flushes/night sweats.

Otherwise, she may need to take no treatment at all! After all, menopause is not a disease!

Question: I am 46 years of age and I knew there would come a day when the “hot flushes” would start and I find it is now that I am in perimenopause (premenopause?). I just refuse to believe that I must suffer through my body’s inability to control its heating system.

I have been doing as much research as a layman possibly can regarding premenopause and menopause and interestingly, the name of Dr. Prior came up in my doctor’s office today. With much excitement I asked for a referral to Dr. Prior but did not know if she accepts patients. This is why I am emailing now. I am keenly interested in Progesterone treatment or any cutting edge information and tools for relief of these symptoms I am experiencing. I just don’t believe I have to wait it out. Can you please help?

Answer from Dr. Prior: Although I’m still following women I’ve ever seen, I am not taking new patients. However I would be happy to speak with your doctor about your situation.

In the meantime, I’d suggest you look at the material we have on the Centre for Menstrual Cycle and Ovulation Research website www.cemcor.ubc.ca. There are articles, in particular “Perimenopause–the Ovary’s Frustrating Grand Finale” and the Daily Perimenopause Diary and instructions so that you can track what you are experiencing.

We know a lot about treatment of hot flushes in menopause. Currently no randomized trial has tested perimenopausal women and identified an effective treatment of hot flushes. However, our clinical experience suggests that cyclic natural progesterone (Prometrium) is both effective and a safe therapy in women with hot flushes and periods. There is a handout about Cyclic Progesterone Therapy also on the website.

Question: I would like advice on assembling a team for diagnosing and treating my perimenopausal symptoms and other conditions, as well as providing me with support and access to services.

At the moment I am feeling pretty well. Since I have not had a period for many months I may be approaching menopause, which may partly explain the reduction of my symptoms. Certainly I have used (extreme) lifestyle modifications to assist myself in coping. I have suffered symptoms which have been debilitating to me, which have caused me to live in a condition of disordered thought for several years and significant pain for the better part of one year. This has disrupted my life and nearly bankrupted me.

I have not been diagnosed as perimenopausal. I have been variously diagnosed as having Post Traumatic Stress Disorder (which is probably also true), having anxiety starting several years ago, and as having had anemia and gastrointestinal bleeding within the last year. I also believe I had symptoms of Mild Traumatic Brain Injury (from a motor vehicle accident several years ago ), and may have had health effects from removing around 12 mercury amalgams from my mouth about five years ago.

I would like to provide some information, but hope my letter doesn’t sound bleak. I am feeling better and therefore am writing this letter. I would like to be tested, to know what is going on with my body and mind as a basis for treatment. Some questions which I have follow: What pertinent tests (including endocrinological) are available in BC, in Canada, or elsewhere, to examine me? What practitioners or clinics could help me? What insurance plans could help or could have helped me to afford alternative medical treatments, counseling, and to provide money to support me during an extended (though temporary) illness?

Answer from Dr. Prior: First of all it sounds like you are very close to ‘graduation!’ That’s what I consider menopause–you will reach that when you have been a year without flow. Menopause is a normal part of every woman’s life and doesn’t need any treatment. However, if it came before the age of 40, or if you know you have osteoporosis (especially if you also have hot flushes) or if you have persistent, disturbing hot flushes then and only then does menopause need treatment. We have learned from the Women’s Health Initiative Estrogen plus Progestin trial results that hormone therapy is not healthy for menopausal women who don’t have one of those three situations mentioned above. We now know the same about estrogen therapy.

This is the time of perimenopause when you are more likely to experience hot flushes and night sweats. But often if they only start now they are mild and go away quickly. You may also notice some vaginal dryness. That usually only needs some water soluble (over the counter) lubricant.

I trust you have looked at the BCERF website (www.bcendocrineresearch.com) which has the article ‘Perimenopause The Ovary’s Frustrating Grand Finale’. That will help you understand perimenopause which it sounds like you have almost completed. There is also information on our Centre for Menstrual Cycle and Ovulation Research website (www.cemcor.ubc.ca).

Now’s a good time to think positive and look ahead to many healthy years. You don’t need a specialist. You can deal with your family doctor for any problems. If you live in BC and have a perimenopause problem you and your family doctor can’t solve, you can ask your family doctor to phone me.

Perimenopause can be quite rough, and it sounds like you’ve had a difficult time of it. You can rejoice when it is over!

Question: I need your help. I had a total hysterectomy five weeks ago. Since then, I am literally falling apart, and cannot get the doctors here to either listen to me, or else I cannot get an appointment at all. I guess they don’t consider endocrinology an emergency. I am basically treating myself because the doctors aren’t listening to me.

I switched from Premarin to Menest because I thought the Premarin made me feel mentally foggy. I discovered that Premarin does contain androgens (they don’t tell you that) because it was making my skin break out. I am now taking a .625 Menest and a .3 Menest every day because on the .625 alone I was still having night sweats. It seems, however, that I am still not getting as much estrogen as on the Premarin because my skin is still dry, and I don’t know if Menest has as much or any androgens in it as Premarin.

Now for the worst part, the part I need immediate help with. Since the hysterectomy, I have arthritis symptoms almost overnight. I can’t get an appointment with an endocrinologist here. I’ve been trying to get an appointment with an endocrinologist who can write prescriptions for compounds because I think my DHEA, which used to be high, and other hormones are all messed up.

The doctors, my OB/GYN group, pooh-poohs me when I try to talk to them about it. They won’t order blood work yet, but I am extremely chemically sensitive, and drugs affect me immediately.

I don’t know what to do. I am at my wit’s end about all of this. I need to get the right treatment so I can go on with my life.

Thank you very much.

Answer from Dr. Prior: It sounds like life is pretty rough right now. I will do my best to provide you with some ideas and support. However, I can’t really know what is going on without having seen you and taken a history as well as done a physical exam.

It is not uncommon to feel badly after having a sudden removal of your ovaries. The natural menopause or perimenopause transition is a more gradual process with spikes and dips over about 10 years.

The first and most important thing is that you get a prescription for oral micronized progesterone (Prometrium) 100 mg and take 3 capsules at bedtime (as long as you aren’t allergic to peanuts–the medicine is in peanut oil). This will help your sleep (improves deep sleep by 15%), help the estrogen to control night sweats and may also help your joint symptoms.

I strongly suggest that you use a kind of estrogen that is a patch or a gel rather than a pill. We now know that important risks for blood clots (increased by 211% over placebo) occur in menopausal women on estrogen pills. Estrogen delivered through the skin is less likely to cause clots.

Other things that will help with the hot flushes/night sweats are some regular exercise and some relaxation (such as yoga). I’d also recommend 400 IU of vitamin E, 1200 mg of calcium/day (with 500 mg at bedtime) and at least one multiple vitamin to provide 400 IU of vitamin D. Calcium has been shown to decrease PMS-like symptoms in a randomized double blind trial.

I don’t know anything about you and what you do and what supports you have. But I would urge you to be with people you trust, to talk with close friends or family and to start thinking about what you are good at and that you want to do with the rest of your life. It is really easy, when life/hormones/health are disrupted as yours have been, to focus on illness and lose perspective.

Please also go to the Centre for Menstrual Cycle and Ovulation Research website at: www.cemcor.ubc.ca. You will also find the Daily Menopause Diary that you can use to track changes you are experiencing. Knowing changes helps you to better understand and deal with them.

I know that you will soon start to feel better.

Jerilynn Prior is a Professor of Endocrinology at the University of British Columbia and an internationally know expert on women’s health.

The post Question and Answer – with Dr. Jerilynn Prior appeared first on BC Diabetes Foundation.

First, we need to talk concepts and language. Women are obviously different from men ? our normal life cycle of hormones includes low estrogen and progesterone levels after menopause. However, for about six decades, medicine has taught us that having low menopausal estrogen was abnormal. Why? Because men’s high testosterone levels continue into old age (with a bit of a decline). Therefore, the idea that menopausal women were deprived of estrogen or ‘estrogen deficient’ became common. And ‘HRT’ was invented to fix women’s supposed problem.

But it wasn’t enough to say women were deficient’, this deficiency must cause disease. One early, important study, The Framingham Study, a decade-spanning observational study (meaning that the scientists observed what occurred over time) showed that when women reached menopause they started to have heart attacks. The authors noted that menopausal women have low estrogen levels. Therefore estrogen ‘deficiency’ must be the cause for heart disease! Of course, on average menopausal women were older, less active and heavier, too, but those facts were ignored.

The Framingham Study was followed by the huge Nurses’ Health Study that was another observational one. It showed that the women who took estrogen compared with the women who didn’t, had fewer heart attacks. However, women who took estrogen were slimmer, more active, less likely to smoke, less likely to have high blood pressure, abnormal blood cholesterol levels or diabetes. These characteristics, in addition to a family history, represent a woman’s main risks factors for heart attack. All of the observational studies, we now know, were biased’the women who took estrogen were healthier to start out with. Other similarly biased studies multiplied showing that women on estrogen had better sex, were less likely to get Alzheimer’s, grow wrinkles or fracture hips. ‘HRT’ became the wonder drug for women.

I don’t know quite why but I have never believed the estrogen deficiency idea of menopause. And I knew of the blood clots, strokes, high blood pressure and weight gain (for some) that estrogen therapy could cause. I also remembered a study of men who took estrogen or a placebo (sugar pill). The men taking estrogen had increased clots and heart attacks and the study was stopped early because of harm. This was in 1972. (Somehow the heart disease experts had forgotten that study). However, enough experts questioned the validity of the observational studies, that a very large multi-part, randomized, controlled trial called the Women’s Health Initiative was conducted. Results of the Women’s Health Initiative combined with several other controlled studies showed that one of every 250 women ages 50-59, and one of every 150 women over 60 taking estrogen treatment for five years will develop blood clots, stroke, heart attack or breast cancer.

But knowing this, what do we do now? First of all, accepting that low levels of estrogen after menopause are normal, means we don’t have to fear we’re missing out on some magic preventive. Instead we can concentrate on exercising, stopping smoking, getting to and keeping a normal weight, and (if needed) getting effective treatment for high blood sugar, blood pressure or cholesterol. There are now fracture-preventing non-hormonal treatments for osteoporosis such as etidronate (Didrocal), alendronate (Fosamax) and risedronate (Actonel). We can use very low dose vaginal estrogen or a compounded, safer kind of estrogen called estriol for vaginal dryness if over-the-counter lubricants don’t help.

And what about hot flushes? Relaxation, yoga, deep breathing and meditation decrease them significantly. Some of the newer anti-depressants and soy foods may also be effective. For severe hot flushes, relaxation combined with a synthetic progestin medroxyprogesterone (Provera) mean most women become virtually free of hot flushes. However, the pill form of natural progesterone that is the same as your ovaries made (bio-identical), Prometrium, is an effective option if you are worried that medroxyprogesterone might cause harm (because a low dose was used with full dose estrogen in one arm of the Women’s Health Initiative). The Centre for Menstrual Cycle and Ovulation Research (CeMCOR) at UBC and Vancouver Hospital is doing the first trial of Prometrium as treatment for hot flushes in a four-month placebo-controlled study in menopausal women. Because we are also studying blood vessel effects we are looking for women a year past their final period who have moderate or severe hot flushes and no risks for heart disease (for further information call 604 875-5917, email chris.hitchcock@ubc.ca or go to the website www.cemcor.ubc.ca).

What if you’ve re-started estrogen despite the bad news from the Women’s Health Initiative because you just couldn’t stand the hot flushes? As explained in ‘Stopping Estrogen Therapy’ on the CeMCOR website, the key is to take full dose progesterone to treat the symptoms while you very gradually taper and eventually stop your estrogen. Hot flushes are caused by the reaction of a brain that has become used to high estrogen levels. Therefore the process of effective withdrawal must be a slow one. Prometrium helps in the estrogen withdrawal process because it improves deep sleep (although this has only been proven in men!) and also treats hot flushes.

However, there are specific instances where menopausal women will need to take estrogen with progesterone therapy. These include women with early menopause (before age 40 for sure and probably before 45), women with both osteoporosis and hot flushes, and those with severe hot flushes not effectively treated by non-hormonal therapies. There are bio-identical choices for getting estrogen through the skin as a patch or gel (Estragel, Estradot and Climera, to name a few). These are less likely to cause clots than pill estrogen. Bio-identical progesterone is available as oral Prometrium (in peanut oil) or it can be compounded in oil by local pharmacies. Women with early menopause can safely continue estrogen and progesterone until they are 52 years old (the average age at menopause). Women with osteoporosis and hot flushes can count on combined hormones to treat hot flushes and prevent fractures. After five years estrogen should be replaced with a non-hormonal bone medicine (as described earlier). Women with severe hot flushes can use progesterone alone and (I believe) safely continue for as long as needed. Family doctors and women with questions will find more information on the CeMCOR website.

We are in a new and healthier world for women in 2004. We no longer need to rely on an old and wrong idea that menopausal women are estrogen deficient and need treatment. I think it is a good news story!

Jerilynn Prior is a Professor of Endocrinology at the University of British Columbia and an internationally know expert on women’s health.

The post Menopausal Women’s Hard Decisions appeared first on BC Diabetes Foundation.

I have received several requests for information regarding genetically modified organisms (GMOs). Given the previous issue’s Evolution of Diet article it seemed appropriate to follow with a brief comment on GMOs since these impact our food choices, food quality and the health and future of our children and the planet.

For this discussion a genetically modified organism (GMO) is a plant food that has been artificially created by splicing genes from one species into the DNA of another. I say artificial to distinguish from the natural process of pollination. What GMO’s typically represent is a combination of genetic material that would never ever have come together under any natural pollination process. In other words fish genes would never ever have combined with corn genes.

While this makes them a bit strange perhaps is it really cause for alarm? The answer to that is a resounding YES. The European Union ban on GMOs is certainly an indicator that someone is concerned about the impact of these plants on our health and on the environment. There is not room for a complete discussion here but a recently published book called ‘Seeds of Deception’ written by Jeffery M. Smith provides an excellent starting point and some valuable insight. The book has numerous references, websites and even suggestions for action if this is an issue that you find you would like to pursue.

One of the major problems with the theory behind the GMO concept is that it is based on an outdated concept of one gene regulating the production of one protein. This is now known to be false as demonstrated in the human genome project where the expected 100,000 genes for an equivalent number of proteins turned out to be only 30,000 genes. We now know that genes can code for numerous proteins, the record being held by a fruit fly gene which has been shown to generate 38,016 different proteins. Based on this new information it is clear that attempts to insert a gene with a single desired trait is going to also include numerous additional proteins with completely unknown effects. And they really are unknown because at this point in time there is no adequate safety testing of these foods. That is only the tip of the iceberg lettuce, as you’ll find out if you read Jeffrey Smith’s book. Numerous other genetic problems arise which further compromise the safety of the resulting food product. And this only refers to the human safety issues.

Another major issue is the environment and the fact that pollen travels in the wind and this cannot be controlled. This means that there is documented extensive contamination of adjacent crops and the potential for genes to move across plant species. This is not finely controlled laboratory science. This is happening right now in fields throughout North America and now that these genes are in the gene pool they can never be recalled. This is happening without our consent and our governments are not looking out for our best interests but rather the interests of the biotech industry.

The testing is in fact being done on us, the general population who consume these products without knowing it. There is no way of knowing since there is no labeling required to inform us which products contain genetically modified plant material. As mentioned by Arran Stephans in the Preface to Jeffrey Smith’s book, ‘we are now in the middle of the largest feeding experiment in history and we human beings are the guinea pigs’.

On May 1, 2003, a new organization, the Independent Science Panel was formed with a commitment to the Promotion of Science for the Public Good. The founding members consist of 24 scientists in a variety of disciplines from all over the world. They released a 136 page document on the GMO issue and at the end they recount the major problems with GMO’s. The excerpt below summarizes many of the concerns we should all share. For their comments they use GM when referring to the GMO issue.

Eric Norman is a research scientist investigating heart disease in post-menopausal women and in individuals with type II diabetes.

Reading

• Seeds of Deception, Jeffrey M Smith., 2003. Publisher YES1 Books, Fairfield, Iowa, US.
• The Case for A GM-Free Sustainable World, Independent Science Panel, May 10th, 2003.
• www.indsp.org

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