Menopause and the Menopause transition

Along with various personal life challenges and changes (more frequent career dissatisfaction or job change/loss, kids leaving home for the first time, partner unhappiness that reaches new heights, caretaking of illness-affected parents …) come unfamiliar personal physical experiences. The average age of full menopause is 51.5 worldwide and 85% of women suffer moderate to severe early symptoms like hot flashes, sleep difficulties (insomnia), lower moods, joint stiffness and pain (feels like arthritis has set in).  Yet the majority of women who are not on systemic contraceptive hormones are unprepared for these changes and therefore can’t anticipate and deal with them successfully. Very few women arrive at this time of hormonal chaos with good information and reliable resources that would help them recognize and address such problems as they “quietly” appear. Lives are busy, most women don’t bother with a detailed daily journaling of symptoms and put off consulting a doctor until they’re miserable or unable to function normally.  To make matters worse, ample fear-producing confusion surrounds topics like HRT, bioidentical hormones, natural progesterone vs synthetic progestins, and potential risks versus benefits of hormonal support short and long term. Even after seeing a doctor, many women receive unsympathetic responses and encounter lack of provider awareness of the details of hormonal changes and how to optimally manage them. Dr. Pollycove has the head, heart and hands for the many factors that contribute to these complex issues. Her scientific rigor, empathic nature, many years of experience and passion for effective communication combined provide women with the most reliable and individualized approach to solving the complexities of the menopause transition and beyond.

During the transition from the reproductive years through menopause and beyond, a woman experiences many physical and emotional symptoms. Younger women, of reproductive age, experience hormone changes on a monthly cyclic basis. After menopause, estrogen production by our ovaries ceases, usually “bottoms out” and prolonged very low estrogen often creates an ever-increasing series of negative symptoms. Every woman journeys through this transition in her own unique way, some with profound life disruptions and others with few or minimal symptoms. Dr. Pollycove treats each patient as an individual, identifying strategies for optimal wellbeing, reviewing benefits and risks throughout the life span. The menopausal transition can be optimized with healthy dietary and life style changes as well as bio-identical or bio-similar hormone support in most cases. As estrogen levels continue to decline naturally in menopause, replacing estrogen is the natural treatment to return women to being 99% symptom free.  With many years of clinical research, active involvement in the Menopause and Breast Cancer Societies and her clinical practice, Dr. Pollycove helps women safely the road ahead and be prepared for the complex issues that may arise.

Clinical Care: Menopause Transition and Beyond

Once estrogen-deficiency symptoms occur (often before menses finally cease) the transition through full menopause can take months to years. A good working relationship with your gynecologist can be a huge benefit while navigating this previously untraveled road. Dr. Pollycove and her staff are intimately familiar with the range of experiences and are dedicated to helping make your individual experience maximally comfortable and confident in a consistent and unified wisdom underlying your choices. Fully post-menopausal women can actually achieve continuity of feeling good and virtually “never think about hormones” once the proper balance is obtained. Ongoing adjustments to customized treatment according to evolving needs and health experiences are discussed in detail.  Dr. Pollycove authored the Pocket Guide to Bio-Identical Hormone Replacement Therapy to help make menopause treatments understandable to and safe for millions of women (E-book on Amazon).

Dr. Pollycove strives to work in collaboration with each patient to find a balance with personalized lifestyle modifications to prevent disease and the full spectrum of integrated medical and non-Western therapeutics. Physical therapy/exercise, nutrition, emotional well-being, personal mindfulness practice and relevant elements that help each of us enjoy optimal health are typically addressed in our office. Sometimes menopause can unravel a woman’s identity. So the task becomes figuring out how to put yourself back together in fine form. Your symptoms are important clues in solving the problems that have developed in menopause. Think of yourself as a private investigator. Working closely with Dr. Pollycove should help you begin to resolve these issues. The broader goal is to support your ability to function well and enable you to live life to the fullest.

Right Hormone Product and the Best Way to Take it

Depending on symptoms, introduction of hormone therapies vary. In addition there are differences in the types of estrogen hormones: bioidentical estradiol or conjugated bio-similar estrogens.  And in women with a uterus, natural progesterone or similar laboratory-synthesized pure progestins are usually necessary to keep the uterine lining thin and healthy. Whether the estrogen is taken by mouth (oral) or applied to the skin- estradiol-patch, gel or spray, vaginal ring (transdermal route) are all relevant and important details of HRT, or hormone therapy. Choices are made through a careful process of assessment of past medical history, personal preference and complexity of symptoms.  Vast medical research is continuously published and read with interest by Dr. Pollycove. She participates actively on national advisory boards for menopausal medicine. Dr. Pollycove’s keen interest in the sub-specialties of cardiology and metabolism, make heart disease and diabetes risk reduction strategies at the forefront of your health care. Healthy longevity for women is achieved with a trustful partnership between well informed and motivated patients and passionate, well informed, up to date doctors.

Anxiety, Menopause and Evidence-based Medical Science

Media has done a dis-service to millions of women by fanning the flames of fear regarding breast cancer and estrogen since the original publication of the Women’s Health Initiative (WHI) was blazoned across the front page of American newspapers in 2002. The doctors interviewed as well as the Media didn’t put the actual data in perspective, which is very important. That study continues to be erroneously applied to younger symptomatic women entering menopause. In fact the WHI studies much older women (average age 63.5 years, 12 years after menopause) and only those who mostly had no hot flashes (because if they did they’d have known right away whether or not they were on estrogen or placebo).  The average woman today who is experiencing negative effects from hormone deficiency is in her mid to late 40’s or early 50’s; a full 15 to 20 years than those in the 2002 study.  15 to 20 years of estrogen deficiency has many adverse physiologic consequences, especially when estrogen is given by mouth (as compared to through the skin). What is most evident from the WHI, in fact, is that “timing” is very important to observed outcomes. Not surprisingly, the earlier the better when it comes to preventing heart disease and bone loss (which leads to osteoporosis).

Dr. Pollycove’s perspective is rooted in the biology and resultant physiology of evolutionary hormone patterns that are built in to our bodies and operate as they have for hundreds of thousands of years. With these scientific patterns “set in our genetic code” it is clear that optimal health, long term disease risk reduction for all disorders that increasingly burden older women, depend upon estrogen support, not 12-to-20 years of estrogen-deficiency. Bone loss is virtually universal when estrogen is severely deficient, no matter how active the life style or good ones’ nutrition may be. Inflammation in blood vessels of the heart also increases with estrogen loss as high cholesterol becomes a bigger issue in estrogen deficiency. Contrary to popular myth, fat accumulates more rapidly, especially in the belly, in estrogen-deficient women as compared to those on HRT, bio-identical or bio-similar estrogen regimens.

Delight (not devil) in the Details

Many observational scientific research studies before and after 2002 have consistently shown early use of HRT, HT, bioidentical hormones, all result in less heart disease, less diabetes, and fewer heart attacks. How could we get it so wrong as a culture?  And why is it that so few doctors offer symptomatic women appropriate hormone therapy in menopause? These are “fake news” kinds of problems in health care today.  They extend from non-medical consumer’s exposure to “news and information” to the sound bite reductions of medical education for most doctors outside of the rare menopause specialist.  Possibly a result of medical scientific information overload and media outpouring to allow sifting and sorting of reliable information. “Good news is not news,” if “It bleeds it leads” are ugly truths of the news industry, and our fear-paralysis engendering media universe has led millions of providers and consumers astray.

In fact the women on Estrogen in the WHI published in 2005, had 22% breast cancer as compared to women on no hormones (WHI, 10.7 years, analysis published JAMA 2011, LaCroix first author).  And more recent WHI data, the 18 year follow up comparing estrogen-users to non-users, showed a 45% rate of death from breast cancer. Dr. Pollycove engaged in breast cancer research (immunology of breast cancer at UC Berkeley Cancer Research Genetics Lab) before attending medical school at UCSF and has carried her depth of interest in the fundamentals of cancer cell biology and host defenses into her entire career. She takes exquisite care to assess individual risks and create ongoing adjustments to hormone therapy prescriptions according to age, individual needs and health issues that can arise over time.

The curious fact of breast cancer cells being less aggressive overall in estrogen users has been observed and documented for decades. And the decreased rate of breast cancer cell growth (cell division, called Ki67 in pathology reports) mirrors the data from the WHI estrogen-only users. It is the progestin, Medroxyprogesterone acetate, a non-bioidentical progestin that was added to Premarin ®to prevent uterine cancer, that caused the slight increase in breast cancers seen in PremPro users of WHI (8 excess cases in 10,000 women years of use, now adjudicated to 2 cases/10,000 women years of use).  Sadly the specifics and their clinical importance are mostly unknown by consumers and doctors alike. Millions of women continue to suffer hot flashes, foggy brain, insomnia, impaired memory, lowered mood, vaginal dryness and painful intercourse due to scientifically unfounded fears of breast cancer being caused by estrogen. In fact, the opposite is the biologic truth.  It is also true that we don’t have a way to insure no one will ever get breast cancer. Estrogen support in menopause actual risk for breast cancer yielding significantly better survival, while also relieving symptoms and preventing metabolic diseases of heart, bones and diabetes. Abnormal changes in cells occur and are repaired every day. At present, the best we can do is to engage actively in the known cancer risk reduction strategies, live our lives confidently, knowing that with appropriate screening (see the Breast section) and optimal self-care we are very likely to not have our life shortened by breast cancer, heart attacks or diabetes.

Menopause and Sex

For some women, when the fear of accidental pregnancy no longer exists, report the best sex life ever in menopause. But for many their experience with sexuality becomes a negative one. Attention to the nature of our intimacy in our relationship is an important factor as is hormone evaluation. Assessing estrogen and testosterone sufficiency, making sure that vaginal tissues are not too dry or too tight to allow normal pain-free sex and lubrication, are important considerations as women age. Women are encouraged to bring up all topics of concern in the course of an office visit, sexuality included. There are many positive health outcomes associated with good sexual experiences with aging. Physically and emotionally these areas of intimate health can contribute good feelings or negative ones. Including sexuality in routine women’s health care, throughout the life cycle, and post-menopausal, supports the whole person view of life and personal health care.