Category Archives: News

Mayo Clinic Controversies in Women’s Health, June 2013

A third of this conference involved menopause issues; appropriate, as women spend one-third of their lives in menopause. Except for Dr. Sanjay Asthana of the University of Wisconsin, all of the presenting doctors noted below were from the Mayo Clinic.

Dr. Lynne Schuster is a specialist in internal medicine; she is in charge of the Women’s Health Clinic at the Mayo Clinic. Her talk was on the effects of hormones on moods. Women have a 21% lifetime risk of developing depression, with the highest risk in perimenopause. Women are at higher risk of depression if they previously experienced post-partum depression or PMDD (premenstrual dysphoric disorder, a severe variant of PMS). This risk is affected by genetic factors, psychological factors, social factors, physical health and one’s environment; absolute levels of estrogen and progesterone have not been linked to depression. There are many difficulties in assessing associations between hormones and mental health. These include the wide fluctuations of hormone levels that affect women daily, appreciating the time lag between hormonal changes and mood symptoms, and inaccuracies in the scales used to assess moods, and in using the menstrual cycle the indicator of hormone levels. Checking hormone levels is not helpful in determining if hormones are the cause of mood problems. It is known that estrogen acts as a neuromodulator and it shares common pathways with neurotransmitters in the brain. Research has shown that estrogen increases norepinephrine and serotonin levels, serotonin receptor activity, and endorphin levels, among other actions. All of these chemicals affect our moods. Women are at greater risk of depression than men from decreased serotonin levels. Thus while hormones affect mood, mood disorders are not due to a deficiency of hormones. Lifestyle changes with healthy diet, increased exercise and social engagement are the most important ways of treating perimenopausal depression.

Drs. Walter Rocca and Sanjay Asthana spoke on the effects of estrogen on cognition. Summarizing all of the research in the past decade on this topic has led to “The timing hypothesis for dementia”. In summary, this hypothesis states that estrogen may be strongly protective before the age of natural menopause around 50 yr; moderately protective in early postmenopause (age 50 to 59 yr); and deleterious if started in later post-menopause (over the age of 60 yr).

Dr Virginia Miller spoke about the KEEPS study. KEEPS stands for Kronos Early Estrogen Prevention Study. This study randomized 727 women to low dose estrogen, either 0.45 mg oral conjugated equine estrogen or 0.5 mcg transdermal estradiol patch, plus cyclic micronized progesterone for 12 days per month or placebo instead of any hormone. The average age of women in the KEEPS study was 52.7 yrs, and all the women were within 6 to 36 months of their final menstrual period. The initial results came out in 2012, and showed an overall favorable benefit-to-risk ratio of the hormone therapy. Positive effects were seen on bone, VMS and sexual function, while there were neutral effects on cardiovascular disease, stroke and blood clots.

Dr. Sharon Mulvagh spoke about prevention of cardiovascular disease in women. Six to ten times more women die of heart disease than breast cancer; one in three women’s deaths in the US are caused by heart disease. She reviewed the estrogen effects on the blood vessels, most of which are protective pre-menopausally. Women with chronic persistent angina who do not have obstructive coronary artery disease have a worse prognosis than women with no angina. More women die following CABG (coronary bypass) than men. A large number of women have microvascular coronary disease (MCD), which is also called female-pattern ischemic heart disease. The good news is that more than 80% of heart attacks can be prevented with lifestyle changes. Every woman should know her body mass index, waist circumference, blood pressure, fasting glucose and cholesterol. The recommendations were mindful eating with heart-healthy food choices and regular activity of 30 to 60 minutes increased heart rate daily with weight training twice a week.

Dr. Richard Sood reviewed the controversies in menopausal hormone therapy. He reviewed recommendations for HT before the WHI, when it was offered to women between ages 40 and 60, and was sometimes prescribed for prevention of CVD and osteoporosis as well as to treat menopausal symptoms. He spoke to the controversies of the WHI including overgeneralization of results and the use of relative risks instead of absolute risks to provide risk estimates. Now, 11 years after the WHI, HT is not controversial for use in a healthy, young menopausal woman (

Physiatrist Dr. Edward Laskowski presented on exercise in older adults. Muscle mass declines 30% between ages 30 and 70. Basal metabolic rate declines 2 to 5 % per decade after 30. Lean muscle decreases and body fat increases to result in a gain of 10 lbs fat per decade. There is a decrease in elasticity and compliance of connective tissue with age. Regular exercise can mitigate these changes. Weak muscles contribute to falls and trouble with stairs and walking. Exercise decreases blood pressure and insulin resistance, helps prevent osteoporosis, decreases pain in osteoarthritis, has beneficial effects on mood, depression and anxiety, and helps to maintain cognitive status. Recommended to get at least 150 minutes of moderate cardiovascular exercise per week along with 2 strength training sessions and regular stretching to maintain flexibility.

Dr. Donald Hensrud spoke on the optimal diet for weight management. He stated there is no one best diet for weight loss and that diet recommendations should be individualized. Writing down everything we eat is helpful, as we tend to underestimate our caloric intake. To lose one pound in a week requires a calorie deficit of 500 Cal per day. Very low calorie diets work, but people regain the weight once they eat normally again. The Nurses Health Study found that women with the largest increase in intake of fruits and vegetables had a 24% decreased risk of becoming obese. We should emphasize eating healthy foods. Several of the many available diet programs available by book, club or online apps were reviewed. The importance of eating breakfast was noted, as were the facts eating one meal per day lowers metabolic rate and that it is best to eat small frequent meals throughout the day. The Mayo Clinic Diet was highly recommended (Dr. Hensrud is the medical editor-in-chief of the book). Further information on this may be found at www.mayoclinic.com .

0

SIGMA Canadian Menopause Society 1st Annual Conference, May 2013

This conference was the first one held by SIGMA (Special Interest Group in Menopause and Aging) Canadian Menopause Society.  Many renowned experts from NAMS (North American Menopause Society), IMS (International Menopause Society) and Canada spoke on a variety of topics.  Summaries of several of these talks follow.

Osteoporosis as a topic is always included in menopause conferences as women experience a period of rapid decrease in their bone mineral density at the time of the menopause transition.  Osteoporosis is one of the major risk factors of sustaining a bone fracture.  Fractures are often regarded in the categories of vertebral and non-vertebral fractures; studies of treatments look at the incidence of both categories of fractures.

 

Talks about osteoporosis were by Dr.John Stevenson of London, UK, Dr. Robert Josse of the University of Toronto, and David Kendler of the University of British Columbia.  Drs. Stevenson and Josse reviewed current treatments and prevention of osteoporosis.  After discussing the use of bisphosphonates (alendronate, risedronate, zoledronic acid), calcitonin, raloxifene, tibolone, teriperitide, denosumab, Dr. Stevenson concluded that for most women, excluding the elderly with severe osteoporosis, hormone therapy appears to be the best management.  He also felt that hormone therapy should be the first choice for prevention of osteoporosis in women without contraindications.  Hormone therapy has been shown to increase bone mass, decrease bone turnover and decrease the incidence of osteoporotic fractures.  Dr. Stevenson also noted that the bisphosphonates appear no safer than hormones in terms of unwanted effects, and other unexpected adverse effects could still arise in future.  Dr. Josse reviewed existing treatments and new agents being developed.  Dr. Kendler spoke on the importance of prevention of the first fracture; a woman is at increased risk of more fractures once she has had one.

 

Dr. Cynthia Stuenkel of the University of California at San Diego reviewed women’s risk factors for cardiovascular disease (see Heart Disease unders Topics of Interest).  She discussed a few new trends emerging from current research.  Women who experience a preterm birth, deliver a SGA (small for gestational age) baby or preeclampsia have been shown to have endothelial (lining of blood vessels) dysfunction, which is likely related to cardiovascular disease.  Dr. Stuenkel also quoted studies that have suggested increased cardiovascular risk in women with early menopause, excessive stress and PCOS.  Her discussion of risk management emphasized the need for women to make lifestyle changes at all risk levels.  These lifestyle changes include, but are not limited to, stopping smoking, eating a heart-healthy diet, managing weight, and regular physical activity.

 

Many women will not have heard of the “Window of Opportunity” as it pertains to hormone therapy.  Research on perimenopausal and early postmenopausal women have shown that those on hormones often are at lower risk of heart disease.  Dr. Stevenson discussed this in detail, quoting many studies that appear to support the idea, including one from Denmark that followed 1008 women for 16 years.  The women in this study were randomized to start either hormones or a placebo within a year of their last menstrual period, and continue the treatment for 10 years.  The women on hormones had decreased numbers with coronary heart disease with no increase in stroke, blood clots or breast cancer.  He noted that although hormone therapy may be beneficial for prevention of heart disease, this is not yet an indication for women to take it.

 

Dr. Robert Reid of Queens University discussed Breast Cancer and hormone therapy, how to interpret the risk.  He described in some detail the breast cancer awareness pink ribbon campaigns, and noted “the #3 killer of women raised 15 times more money for research that the #1 killer.”  He attempted to put into perspective the media preoccupation with purported risks of breast cancer of menopausal hormone therapy compared to the risks of other significant diseases that affect mid-life and older women, and further noted the risks of overdiagnosis and treatment of DCIS (ductal carcinoma in situ).

 

Dr. Claudio Soares is a psychiatrist and professor at McMaster University.  He presented a talk on Depression and the Mature Woman.  While noting that depression in mid-life is complex and influenced by many factors, research in neurochemistry has shown, simply put, that decreased estrogen levels lead to decreased serotonin levels in the brain.  Most women will transition into their postmenopausal years with no psychiatric or psychological difficulties, but there are some who have an increased risk of recurrent depression.  Women who have experienced previous post-partum depression, severe PMS, and prior trauma and/or abuse are all at higher risk of depression in menopause.  The presence of hot flashes and night sweats have been associated with increased occurrence of depression, but this may be due to or worsened by the related sleep disturbances and life stressors, as well as concurrent medical conditions.  Many women experience increased anxiety in the menopause transition.  In research on this, anxiety was found to peak in perimenopause, with symptoms declining afterwards.

 

Dr. Jan Shifren of Harvard University spoke about sexuality in mid-life and the continued controversy about testosterone therapy.  It is estimated that 40% of women in the US suffer from low libido (called hypoactive sexual desire disorder, or HSDD, in medical circles).  The possible causes of this in mid-life women are innumerable, and may include depression or anxiety, relationship problems, illness or medications, stress, fatigue, among others.  Treatment is complex, but obviously must deal with identifiable problems.  Many women and couples may benefit from consultations with a sex therapist.  There are no approved testosterone products available for women in Canada or the US.  There was a testosterone patch available in Europe, but it is no longer available.  If a woman chooses to try a compounded product or one formulated for men, blood levels should be monitored, as should lipid levels and liver function.  Results from studies of the effects of testosterone therapy on women’s sexual desire, activity and pleasure have not consistently shown benefit.

 

 

0