A discussion of hormones that affect women and how to stay balanced and optimize women's health through the stages of menopause. Treatment options including nutrition, lifestyle modification, hormone replacement therapy, herbal and botanical options, and bioidentical hormones discussed.
3. University of Denver | Women’s Wellness Expo | September 7, 2013
Vandna Jerath, MD, FACOG
FACOG - Board-Certified
Private practice - 15 years
Optima Women’s Healthcare
Located at Parker Adventist Hospital
Full-scope obstetrics & gynecology
Enjoy education and community outreach
Disclosure – no affiliations
Healthcare social media pioneer & expert locally
Educate, engage, and empower women
Website /Blog
4. University of Denver | Women’s Wellness Expo | September 7, 2013
Learning Objectives
General overview of hormones related to women’s
health
Review menstrual cycle
Learn about menopause condition and treatment
Review of current healthcare guidelines for women
with latest updates regarding Hormone Replacement
Therapy (HRT) and alternative therapy
Learn the latest research, news, and updates related to
hormones and women’s health issues
5. University of Denver | Women’s Wellness Expo | September 7, 2013
Global Women’s Health & Rights
1. The right to be full and responsible citizens of their countries, with equal property, economic,
voting and freedom of movement rights.
2. The right to equal education.
3. The right to work and earn a living with equal pay for equal work.
4. The right to be free of all forms of gender based violence such as domestic violence, sexual assault,
incest, female infanticide, honor killings, female genital cutting and self-immolation at a
husband’s death.
5. The right to the best available, scientifically based healthcare, including health and sexuality
education.
6. The right to autonomous decision-making, informed consent, privacy and confidentiality
regarding their own health care.
7. The right to participate equally in ethically conducted clinical and other research.
8. The right to decide when and if to have sex, including choosing one’s partner, and freedom from
coerced marriage and sex trafficking.
9. The right to decide whether to have children, the number and spacing of their children, and to
have the information, education and access to health services to make these choices.
10. The right to safe childbearing, with resources available to reduce maternal and infant morbidity
and mortality.
ACOG Statement of Policy, July 2012 (endorses FIGO resolutions)
12. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause
Pre, Peri, and Post-Menopause
No period for 1 year
Average age in U.S. is 51; range age 45-55
Increased FSH > 30
Increased Risk
CV Disease
Osteoporosis
Urinary Incontinence
Metabolic Syndrome
Risk CVD & diabetes
Natural aging vs medical disorder
13. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause – Symptoms
Symptoms
Hot flashes – 75%
Night Sweats
Vaginal dryness
Painful intercourse
Mood swings
Decreased libido
Decreased concentration
Memory Loss
Insomnia
Hair loss
Menstrual disorders
Weight gain
14. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause - Symptoms
Symptom What you can do
Hot Flashes/Night Sweats Dress in layers
Keep Thermostat down
Avoid hot drinks
Use a cold, wet washcloth against neck
Use a fan
Quit smoking, if you smoke
Vaginal Dryness Use lubricants before sex
Use a vaginal moisturizer
Do your kegel exercises
Sleep Problems Keep a circadian rhythm
Avoid naps
Avoid caffeine
Avoid alcohol
Relaxation
Try sleep aid
Depression Exercise and stay active
Seek social support
Talk about it
15. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause - Treatment
Hormone Replacement Therapy (HRT)
Types
Estrogen
Estrogen/Progestin
Pills, patches, creams, vaginal suppositories, rings, shots, pellets,
intranasally (in Europe), progestin IUD
Bioidentical hormones
Cyclic or daily
Benefits
Reduction and improvement of symptoms
Protect bones
May reduce risk of colon cancer
NAMS: Menopause.org
16. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause - Treatment
Risks
Side Effects – bleeding, breast tenderness, bloating, abnormal uterine bleeding (AUB)
Anxiety
Stroke
Heart attack
Blood clot
Breast cancer
Women’s Health Initiative (WHI) results
Contraindications
Breast Cancer
Blood clots – PE, DVT
CV disease
Liver disease
History of stroke or heart attack
NAMS: Menopause.org
17. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause - HRT
No longer recommended as primary prevention or treatment
of disease
Acceptable and safe option for the relatively young (up to age
59 or within 10 years of menopause)
Reduce total mortality by 30% when initiated in women
younger than 60 years
Lowest dose for shortest duration that is effective
Currently fewer than 1 in 3 women take
Breast cancer risk increases with use beyond 3 to 5 years
Many FDA approved HRT products are in fact bioidentical
NAMS Statement 2012
18. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause – Other Treatment
Low Dose Oral Contraceptive Pills
Antidepressants
SSRI or SNRI – Venlafaxine (Effexor), Citalopram (Celexa),
Escitalopram (Lexapro), Paroxetine (Paxil)
FDA approved Brisdelle
Gabapentin
Phytoestrogens/Botanicals
Bioidentical Hormones
Vaginal Moisturizers and Lubricants
Quality of life issue
Duration of Treatment
NAMS: Menopause.org
19. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause – Alternative Therapy
HRT used by less than 1 in 3 women
HRT often discontinued within 1 year
Holistic or natural approach – not an assurance of safety or
efficacy
Alternative therapy used by more than 30% of women
Not FDA approved
Significant costs
Multibillion dollar business
ACOG Committee Opinion – Compounded Bioidentical Menopause HRT, No. 532, August 2012
ACOG Practice Bulletin – Use of Botanicals for Management of Menopausal Symptoms, No 28, June
2001
Cleveland Clinic Journal of Medicine – Bioidentical HRT: Clarifying Misconceptions, Vol 78, No 12,
December 2011
20. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause – Bioidentical Hormones
Bioidentical Hormones
Identical in molecular structure to endogenous hormones
Types of Hormones
17-beta estradiol (E2)
Estrone (E1)
Estriol (E3)
Progesterone
Testosterone
Compounded
Tri-estrogen (tri-est)
80% estriol, 10% estrone, 10% estradiol
Bi-estrogen (bi-est)
Estriol and estradiol in a ratio of 8:1 or 9:1
Synthesized chemically by extracting diosgenin from plants
Not FDA approved
Compounding variance – no assurance of purity, safety, or efficacy
Salivary testing not accurate or precise, not recommended
May receive higher doses of hormones and have higher risks
Reversal of aging process are unsubstantiated
Transdermal progesterone creams do not protect the endometrium
Some standard FDA approved HRT is bioidentical too
ACOG Committee Opinion – Compounded Bioidentical Menopause HRT, No. 532, August 2012
ACOG Practice Bulletin – Use of Botanicals for Management of Menopausal Symptoms, No 28, June 2001
Cleveland Clinic Journal of Medicine – Bioidentical HRT: Clarifying Misconceptions, Vol 78, No 12, December 2011
21. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause – Alternative Therapy
Herbal/Botanical
Not FDA approved
High degree of variation
Some studies show positive effects, but more research needed
Hot flashes – soy, black cohosh, evening primrose, dong quai
Mood disturbances – St. John’s wort, valerian root
Sexual dysfunction – chasteberry, ginseng
Menstrual Disorders – wild yam
Sleep Disorders – Black Cohosh
Overall wellness - Ginseng
Phytoestrogens
Isoflavones - soy, garbanzo beans, legumes
60mg of active form
45% reduction in vasomotor symptoms
Avoid in Breast CA?
Lignins – flaxseed
Coumestans – red clover, sunflower seeds, bena sprouts
Acupuncture
Lifestyle modification
Nutrition
Exercise
Yoga
ACOG Committee Opinion – Compounded Bioidentical Menopause HRT, No. 532, August 2012
ACOG Practice Bulletin – Use of Botanicals for Management of Menopausal Symptoms, No 28, June 2001
Cleveland Clinic Journal of Medicine – Bioidentical HRT: Clarifying Misconceptions, Vol 78, No 12, December 2011
22. University of Denver | Women’s Wellness Expo | September 7, 2013
FDA Approved Bioidentical Hormones
Cleveland Clinic Journal of Medicine – Bioidentical HRT: Clarifying Misconceptions, Vol 78, No 12, December 2011
23. University of Denver | Women’s Wellness Expo | September 7, 2013
Bioidentical Hormones –
prescription vs customized
Cleveland Clinic Journal of Medicine – Bioidentical HRT: Clarifying Misconceptions, Vol 78, No 12, December 2011
24. University of Denver | Women’s Wellness Expo | September 7, 2013
Vaginal Atrophy - Treatment May lead to dyspareunia and sexual dysfunction
Moisturizers and lubricants
Replens, Me Again, Vagisil Feminine, Feminease, K-Y Silk-E
Water soluble - Astroglide, Slippery Stuff, K-Y Jelly
Silicone based - Pjur Eros, ID Millennium
Oil based - Elegance Women’s Lubricant
Mechanical Measures
Sexual activity
Vaginal dilators
Vaginal Estrogen Therapy
Cream – Premarin, Estrace
Ring – Femring, Estring
Tablet – Vagifem
Selective Estrogen Receptor Modulators (SERM)
Oral tablet – Ospemifene (Osphena)
Other
Smoking cessation
Oral Vit D
Vaginal Vitamin E
?Testosterone – may help libido, but not vaginal atrophy
25. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause – WHI
Women’s Health Initiative
Launched in 1991, 15+ year study
Clinical trials and an observational study,
161,808 generally healthy postmenopausal women
Age 50-79
Test the effects of postmenopausal hormone therapy, diet
modification, calcium and vitamin D supplements on
heart disease, fractures, and breast and colorectal cancer.
Some follow-up studies ongoing
nhlbi.nih.gov/whi/
26. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause – WHI Data
Compared with the placebo,
estrogen plus progestin resulted
in:
Increased risk of heart attack
Increased risk of stroke
Increased risk of blood clots
Increased risk of breast cancer
Reduced risk of colorectal cancer
Fewer fractures
Increased risk of dementia (study
included only women 65 and older)
Stopped 2002
30/10,000
Compared with the placebo,
estrogen alone resulted in:
No difference in risk for heart attack
Increased risk of stroke
Increased risk of blood clots
Uncertain effect for breast cancer
No difference in risk for colorectal
cancer
Reduced risk of fracture
Stopped 2004
8-10/10,000
NAMS 2012 Statement on HRT, Menopause, Vol 19, No 3, 257-271
28. University of Denver | Women’s Wellness Expo | September 7, 2013
Important Points
Hormones affect many clinical conditions
HRT improves menopausal symptoms
HRT is not used to prevent or treat disease
Must use progesterone if you have a uterus to prevent
endometrial cancer
Inform your doctor if you have postmenopausal bleeding
HRT is considered acceptable, safe, and appropriate
Use HRT in smallest dose for shortest duration
Some conventional FDA approved HRT is bioidentical
Bioidentical does not mean safe, effective, proven, or accurate
Herbal Alternatives are available, but still need more research
29. University of Denver | Women’s Wellness Expo | September 7, 2013
Tips
Maintain healthy lifestyle
Talk to your doctor
Do your own research and share it with your doctor
Be flexible , patient, and willing to experiment with
treatment options
Try conservative measures and lifestyle modification
first
Consider HRT or alternative therapy
Understand the risks, but do not live in fear
Remember your quality of life is important
33. Contact Information
Optima Women’s Healthcare
Vandna Jerath, MD,FACOG
Sierra Medical Office Building
Parker Adventist Hospital Campus
9399 Crown Crest Blvd, Suite 450
Parker, CO 80138
303.805.1807 P | 303.595.5390 F
optimawomenshealthcare.com
drjerath.com
staff@optimawomenshealthcare.com