As a practicing ob-gyn for the last 35 years, I have certainly seen the “hormone wars.” As is true in so many subjects in medicine, studies are presented that demonstrate a significant benefit of a drug or supplement, only to be challenged months or years later with the opposite findings, leading to confusion and angst, and concerns about the harm that this intervention might have had.
Most women remember the sensational presentation of the Women’s Health Initiative (WHI) findings in July, 2002. Hormone replacement therapy caused breast cancer, heart attacks, strokes, and blood clots. Many, many women stopped their hormones that day, and some were miserable. To this day, I find that the overall negativity of hormone replacement still persists, and I am told by many women that their physicians will not prescribe hormones for them despite incapacitating menopausal symptoms. I, after years of observation, was convinced of the benefits for so many of my patients who experienced hot flashes and night sweats, sleeplessness, depression, decreased cognitive function, painful intercourse, and many other symptoms that significantly affected their family and work lives.
I attended the meeting of the North American Menopause Society last fall to hear the latest data, for it has been 15 years since the WHI results were reported.
For context, the NIH began the WHI study in 1994 to assess the benefits of hormone therapy on the cardiovascular disease in women ages 50-79. There were many previous studies that demonstrated a benefit for the heart, and the NIH wanted to see if giving women hormones in their later years would prevent heart attacks and strokes. When they found more heart attacks and strokes in this age group, they were surprised and abruptly ended the study, which led to many women abruptly stopping therapy.
In the studies which followed, scientists looks at what is called “the timing hypothesis”. The theory is that it truly matters if hormones are begun soon after menopause or many years later. In reality, hormones are most often prescribed soon after the cessation of the last menstrual cycle, and this was found to be very safe. The data actually demonstrates that women who take hormones in their 50’s, within 10 years of the onset of menopause, have a decreased all-cause mortality of 30%. Women in their 60’s, within 20 years of menopause, had no increased or decreased mortality, and women in their 70’s had increased risks. Now, women must be chosen carefully, since those with cardiac risk factors, diabetics, and those with a history of blood clots should not take hormones at any age. But the reality is that most healthy women in their 50’s can truly benefit from hormones, and the risk is very low.
Here are some of the “pearls” learned from the conference. Hormone therapy reduces the risk of new onset diabetes, and one study demonstrated a reduction in congestive heart failure by showing a benefit in the small blood vessels of the heart. Studies did not show an increase in stroke in the first 10 years of hormone therapy. Hormones improved sexual function, and topical vaginal products for vaginal dryness and painful intercourse were very, very safe, even in breast cancer survivors, except those taking aromatase inhibitors. Women who experience early menopause, with an average age of menopause being 51 years old, especially with surgical menopause, should consider hormones because this group of women experience more osteoporosis, depression, and cardiac risks.
Estrogen alone, without progesterone, demonstrated a decreased risk of breast cancer and heart disease. Women have have a uterus are given progesterone along with estrogen to prevent uterine cancer. Using transdermal estrogen, a patch, gel or aerosol spray is safer than oral therapy. When hormones are taken orally, they pass through the digestive system and the liver, and clotting factors are increased. These increased clotting factors can increase the risk of heart attacks, strokes, blood clots, and pulmonary embolism Transdermal products are absorbed directly into the bloodstream, and do not increase the clotting factors. The latest data demonstrates that transdermal estrogen and bio-identical micronized progesterone are safer than the estrogen and progesterone which were used in the WHI.
Dr. James Simon, Past President of the North American Menopause Society, even ventured that if the WHI had used transdermal estrogen and bio-identical progesterone, that the results of the WHI would have been very, very different.
Once again, what goes around, comes around.
P.S. A decision about hormone therapy should be made by a knowledgeable physician, taking into account a patient’s past medical history, family history, and physical examination.
Dr. Marilyn Jerome
Foxhall Ob-Gyn Associates
5215 Loughboro Road, Suite 500
Washington, DC 20016
A post from Julie:
I'm reading Tom Friedman's latest book, "Thank you for being late" as I'm traveling in London and Dubai for the next few weeks. Such different cultures, such different societal norms. An interesting juxtaposition of just how the world is changing, and for women in particular but we all share one commonality: We're hearing the call to restart the machine.
He cites a perspective from a highly regarded leader in business: “When you press the pause button on a machine, it stops. But when you press the pause button on human beings they start,” posits Dov Seidman, CEO of LRN, which advises global businesses on ethics and leadership. “You start to reflect, you start to rethink your assumptions, you start to reimagine what is possible and, most importantly, you start to reconnect with your most deeply held beliefs. Once you’ve done that, you can begin to reimagine a better path.” But what matters most “is what you do in the pause,” he added. “Ralph Waldo Emerson said it best: ‘In each pause I hear the call.’”
This is what's happening with us as we pass through the menopause "pause" and into an environment where we can actually choose how, when, where, why and on whom we want to impact.
But where to start? Our older selves are more informed - thus, more cautious, than our younger selves that were all-consumed with our families, soccer, doctors' appointments, careers and spouses. Now, we're moving onto what Tom Friedman is calling the, "second half of the chessboard." Our chessboard moves will satisfy us when they're impactful and satisfying to our most strongly held beliefs.
So, what do we need to do to restart the machine and implement our next moves?
Several simple but crucial elements:
* Reflect and decide what it is that moves you now. Before you're done, what's the one most important thing you'd like to see changed in our world? As I talk with women in the UK and the UAE, the answers really arent' that much different: They want to chart that better path, create those opportunities that didn't exist when they were younger (and the world was not interconnected), and lead. We're not afraid to make mistakes anymore; we just don't want to waste any time.
* Reach out to your network and find out who is in a position to help you advance your cause, your passion. Whether it's LinkedIn or Facebook or just starting a conversation with a complete stranger in an airport (as I've been doing a lot recently), find out what they do, tell them about your passion. Elicit their advice and suggestions and establish any synergies or complementary skill sets. Moving the chess pieces gets a lot easier when they're moved in groups. You've just grown your knowledge base and your Rolodex.
* Make sure your technology skills are up to date; you gotta know how to maximize your time and value to move your chess piece. Take an IT class at a local college or earn a Certificate in your goal field. For me, that meant going back for a Masters in Public Health and partnering with an OB/GYN. (Truth be told, I wanted to go back to medical school and get the MD but that meant no dinner with the husband for the next decade or so...which didn't get his vote...). The Masters in Public Health with a focus on older women's issues gets me basically to the same place with Marilyn's help on the clinical side of life.
* Remember you have a lot of years to go on average. We're living well into our 80s and that's ample time to start it, grow it, and watch it succeed - whatever "it" is for you. For me, it was to better understand what to expect when we're NOT expecting anymore.
* Be brave. Don't be afraid to start. For me this was the biggest obstacle to starting Menopause Pro; I thought, "Who's going to care what I think?" What I found is that a LOT of people do - men and women. We're all seeking way to make an impactful difference in this world - regardless of where we're from - and we're all asking these same questions. Don't be afraid to admit you have no idea what you're doing, where it will end up or the ultimate goal. As in chess, strategy changes as environments change and, lord knows, today's environments surely look nothing like they will in 10 years but the problems won't really change unless and until we change them. Gotta start somewhere.'
Enough for now as I'm boarding for Dubai and maybe a little shopping in the souks - not a bad distraction. But even in Dubai, the souks are next to the biggest mall in the world with indoor skiing, no less!
So, reflect, rethink, reimagine and restart the machine. You'll hear your call.
Rarely does a week go by, that patients do not mention the symptom of bloating. If you are a woman of a certain age, you certainly know that bloating can be a symptom of ovarian cancer. Many of us know women who have been diagnosed with ovarian cancer, some with minimal symptoms. Of those symptoms, bloating is quite common, but bloating is also common in a number of other conditions, many involving the GI system.
Today, WebMD published a presentation on bloating. It was under their Digestive Diseases section. Let’s look at the various causes of bloating, and try to differentiate them from the symptoms of ovarian cancer.
Here are some highlights of the article:
Bloating is that sensation that your abdomen feels very full and may be protruding. Maybe you did eat too much, and maybe the foods you ate gave you some terrible gas. This can happen, but will usually resolve by the next day. GI conditions that can cause this are irritable bowel syndrome and gastric reflux. In IBS, the symptoms can be abdominal pain, gas, bloating, and diarrhea or constipation. In reflux, acid from the stomach enters the esophagus and causes pain. Sometimes, excessive salt and carbohydrates can lead to water retention and the sensation of bloating. The gas in soda, beer, champagne, and seltzer can also make you feel bloated. If you eat too fast, your stomach can fill with air, and make you will be distended. It takes about 20 minutes after eating for the signal to get to your brain that your stomach is full, so eating slowly makes sense, and helps to prevent overeating.
Then, there is constipation. Some people suffer from chronic constipation, and often feel very uncomfortable. Drinking more water, exercising, and a high fiber diet can help. Sometimes medications need to be prescribed. Some people develop lactose intolerance as they get older. If you develop lactose intolerance, taking dairy products such as milk and cheese can cause gas, abdominal pain, and bloating. Some dairy products are lactose-free.
It is not unusual to gain about five pounds with menopause. Many women know that the weight often goes to the abdominal area. Women who always had flat stomachs complain that their pants are too tight. No one is really certain why the weight seems to settle in the mid-section, but it is a very common complaint.
Fructose is a type of sugar that can be hard to digest, and fructose is found in corn syrup, dried fruits, honey, onions and garlic. Monitoring your reaction to these foods can help determine if they bother your GI tract. Excessive fat in the diet can make you feel bloated, because it takes longer to digest.
Hormones can play a role in feeling bloated. Many women notice bloating premenstrually, and will sometimes feel constipated. Soon after the period begins, these symptoms seem to abate. Many women who are in the peri-menopause will notice that they feel bloated for weeks at a time, and feel premenstrual, but the period is delayed. This is related to changes in hormones that occur during this time, and this is very difficult to treat.
Have you heard of anyone on a FODMAP diet? Doctors have found that foods that contain certain carbohydrates are difficult for some people to digest, so they are started on an elimination diet that includes restricting such foods onion, garlic, many vegetables and fruits, grains and dairy. The diet is very restrictive, but foods are added back until it is determined which are the most problematic. Many patients have found the FODMAP diet very helpful in eliminating their irritable bowel type symptoms. Many patients have found the FODMAP diet very helpful in eliminating their irritable bowel type symptoms.
If you have celiac disease, you GI tract has trouble digesting a protein in wheat, barley and rye. Celiac disease is autoimmune, and affects about 1% of the population. In celiac disease, the villi of the intestine that absorb nutrients are destroyed, this can lead to weight loss and osteoporosis. The symptoms of celiac disease can vary from none, to abdominal pain, diarrhea, gas, and loss of weight. Adhering to a gluten-free diet can correct some of the damage and eliminate symptoms. Tests can be done to diagnose celiac disease.
The symptoms of ovarian cancer can mimic some of these previously mentioned GI complaints. In early stage ovarian cancer symptoms are often absent. Many women notice mild symptoms of bloating, distention, feeling full more quickly when eating, or pressure on the bowel or bladder. Pain or discomfort is often mild. Moderate or severe pain is not typically present, but it can signal obstruction of the bowel. Sometimes the first symptom a women will notice is that her clothes feel tight or she cannot button her pants. Symptoms of ovarian cancer are often thought initially to be related to the stomach or bowels, and many women receive this diagnosis from a gastroenterologist who performs an evaluation for GI disease. An important distinction can be made when you look at the frequency of symptoms. GI problems often come and go, while symptoms of ovarian cancer will worsen over time.
My best advice would be this: if you develop a symptom such as bloating and it is persistent over several weeks, see your doctor. Taking a good history, performing an exam,and possibly ordering some tests can often determine the cause and rule out any serious disease.
Marilyn Jerome, M.D.
P.S. Additional information on ovarian cancer can be found under that title in Menopause 101