Bioidentical Hormones, the Confusion and Balance

Good day dear Readers

The issue of Bioidentical Hormone Replacement had come up again and again. Here in South Florida it is touted as a feel good, safe option and antiaging, youth enhancing, and general good for you regimen.

There is a webinar called "The Buzz on Bioidenticals" that is a good but somewhat biased resource. It presents the facts regarding bioidentical hormone replacement, and why practitoners like transdermal preparations. It was developed by a group called "the Red Hot Mamas" and Dr.Elizabeth Lee Vliet.
I found the discussion informative but biased against compounding pharamacies. 

The truth is of course, always somewhere in the middle.

Both FDA approved and compounding pharmacies dispense bioidentical hormone replacement. Until I arrived in South Florida, the need to prescribe compounded products was almost negligible. It seems to be local custom to get creams and gels from the compounder instead of the pharmacy. Not a problem for me, but buyer beware. The compounding pharmacist uses the same precursor ingredients as the phamaceutical industry, and is regulated by your individual State Board of Pharmacy. They are not compounding roots and berries. These products are essentially all from plant source originally.Any preparation that is compounded does not get you the FDA required information regarding side effects, risks and benefits. Many women interpret this as it must be "natural and safe". No, it is a drug and has the same risks and benefits as FDA monitored medication.

Depending upon your global location, you will have estradiol( E2), and progesterone available to you. Estrone (E1)is a weak estrogen that is not usually secreted until after menopause, it is biologically mostly inactive. Estriol ( E3)  is another estrogen made by the placenta during pregnancy. Neither of these is necessary as a postmenopausal hormone. They are often combined with estradiol in compounds, but are unnecessary.
Estradiol is the predominant estrogen prior to menopause.It is secreted by the ovarian follicles (eggs) every day.

Progesterone is secreted by the ovary after ovulation and during pregnancy. It stabalizes the uterine lining.It stops being secreted if you are not pregnant and a period ensues.Progesterone is not necessary after hysterectomy. It only serves to increase side effects and risk.

Testosterone is used rarely for short intervals for those women who need more control of hot flashes or increase in sexual thought. It has lots of side effects including hair growth, acne, adverse effects on lipids and cardiac risk. Like most anabolic steriods, it give people a feel good effect, but underneath is treacherous.

Methods and forms of administration vary from oral to topical cream, gel, lotion, patch and transvaginal gel and rings. In some localities there are subdermal pellets and implants. I try to stick with the cheap and easy to administer transdermals. Research shows these pose the least risk and are easy to manage.Remember that the sooner you start the most benefit and least risk is derived from HRT.

Good resources are:www.menopause.org,www.acog.org; http://www.thebuzzonbios.com/

I believe in evidence based medicine. We know what works, what the issues are with the problem/solutions and what to expect. Unfortunately that doesn't occur with each and every problem, issue or solution. I try to stick as close to that as possible to protect my patients. Sometimes I need to draw outside the lines and go to compounding, but rarely. If you are wondering about what to do, stick with the tried and true first. Most people respond just fine and the costs tend to be much lower. If you are having difficulties with your HRT talk to your provider and work them her/him to get to your happy place. I have worked with thousands of women in menopause and have yet to find one that didn't find her happy place. Sometimes it just takes a bit of doing.

Patience

I have a lovely patient whose issues with her sexuality I understand. She has always been very sexually responsive, and this waned recently. For  her, it was most distressing. We tried a few things, and found the right balance to get things back on track. For this she is most appreciative. She gave me a bottle of
 KY Intense for Christmas. What a woman!


What I really like about this lady, is that she did not give up with the first try. She allowed me to work with her to get to her happy place. That is most unusual as we have been led to believe that answers, solutions, and cures are almost instantaneous with coming to a doctor's office. Testing sometimes is done in real time with immediate read outs of imaging and results of tests. Online access to results fast tracks communication.


Medical problems are usually not acute, and develop over time. Diagnosis and treatement sometimes takes time, as well as healing. Just some thoughts next time you go to the Doctor. Discuss time. Be explicit about your expectations for the visit, and make sure you and the doc communicate on the importance of your problems to you. We can then address the issues with you on a level that speaks to you clearly.


Hope this helps.


until next time..........................

The Unhappy Vagina or Something's Wrong Down There

OK, I have become an ambulatory gynecologist. What does that exactly mean? After doing annual womens' health screening, my number two most seen problem is the UNHAPPY VAGINA.

I just returned from a meeting of the American Society of Colposcopy and Cervical Patholgy. Otherwise known, as cervix , vagina and vulvar specialists. We wreaked havoc on the psychological health of the media guy who ran the slide shows. We were fascinated by all the varying lumps and bumps on the vulva, new and terrific diagnoses of "Unhappy Vagina Syndrome".

Many women come in to see the gyn with a "something's wrong down there" problem. It's up to me to figure it out and fix it. AND FAST. This is usually a problem that occurs on Friday and needs to be fixed by Friday night. Monday, hmmm somthing may not be quite right. Tuesday, OK maybe I should get something. Wednesday is a trip to the drugstore. Thursday, it's not gone, and getting worse. Friday gets a call to the gyn. GET ME IN NOW!

Most of what women self diagnose as yeast infections are not. They are a myriad of other problems, some infectious, and many are from irritants and allergens.

About one third are correctly self diagnosed and treated at home with over the counter medications. Of those that need the doctor, we never see anything uncomplicated. It can be from a week to years in the making. From normal cervical mucus, to a mixture of problems that envies an onion. After upteen years I have gotten pretty good at figuring this stuff out.

I have a secret weapon, Ladies Magic Cream. I have sent the secret formula to Clevland Clinic to see if it is worth commercializing. We'll see. In the mean time, it is always worth a trip to the gyn to figure out if it is an infection, what type, mixed or single. Irritant, allergen, hormonal, or normal.

Yeast grows in especially hot and humid conditions. For heaven's sake, lose the underwear at bedtime.
Cool and dry makes a happy vagina.

Bacterial Vaginosis is the newer name for nonspecific vaginitis, gardenerella, etc. This is an upset in the normal bacterial ecology. Someone other than the lactobacilli grow, and a stinky discharge with burning is the winner. This is treated with antibiotics. Over the counter stuff rarely works.

Irritants come in all types. The changes in your detergents, soaps, clothing, shampoo, pads, etc will make you red and on fire. The tip is to lose the irritant and soothe the unhappy vagina. It ususally takes a trip in to see the extent of the damage to Rx something to relieve inflammation and institute a regimen of healing.
The bathtub is your friend. No soap, just water.

Allergens are rare, and have a delayed reaction. That is the key difference between them and irritants. Again, discovery and avoidance is how it is managed.

All in all, my experience validated me as a major geek interested something that would get you in prison in several countries.

Until next time...........

Discombobulated!

Hello all
The Holidays are upon us, and cyber week was a grand success! I was minding my own business when...I browsed through Amazon.com to find a movie one of my sons's wanted. In the featured cyber week ads were TVs.

Hmmm I thought, wonder if one would like to find its way to my bedroom? Or maybe the spirit of Xmas will fill me and I will see if my Mom would like one to replace her ancient tube. Well I am on the Amazon page, and call Mom. No she says, her tiny kitchen TV is just right for her and that 32 inch flat screen won't fit. OK then, now I am still thinking about the bedroom, when the mouse wanders over to the upper right hand of the screen, and I click to close out the page.

At least that's what I thought I did. No, I find out on Tuesday next. I look up the " Where's My Stuff" part of Amazon to find the movie I purchased for sonny boy. It asks if I want to track my ORDERS, emphasis on the S.
Just what have I done? Well looks like that 32 inch flat screen is on a truck headed for Grandma's house. I have ONE CLICKED MY MOTHER A TV.



This is at 8:30 am. My Mother is a night owl and rarely wakes prior to 9am. I call her. Ma, Ma listen, I need your help. I accidently ordered a TV and it is headed to you NOW. It is on the truck for delivery. I have her attention.

She bolts out of her fog, and starts up with " I can't wait all day for UPS, I have a hair appointment" and I have to go to the doctor. My ride is going to pick me up at such and so. I am now begging her to help me out of my embarassing mess. I frantically look up the returns part of Amazon. Seems simple enough. Reason for return... hmmmm. stupidity is not listed. OK, not wanted anymore ( or ever, actually ). I click, the instructions say, not to worry, the UPS driver will come get this TV tomorrow with a return label. My cost can go up to a total of $18.86. Chump change for idiocy. I am so happy free shipping goes both ways. I am hoping that this will not be a disaster.

By now my mother has all her feathers ruffled, going on and on about the UPS driver, needing to be home, and having to go to her appointments. I am pleading, just let him push it in the door and wait for another nice man to come take it away......Please Please...... She is near hysterical thinking they will leave it in her hallway in a NYC apartment building. God no I hope, gone in 60 seconds flashes through my mind.

Now I am guilty thinking I am going to give some poor guy a hernia dragging the TV to her apartment just to have her tell them what a moron her daughter has been, then the next guy the same rant when he comes to pick it up. I am sunk.

OK Mom, its not going to be a little box. It's a 32 inch flat screen TV. Big Box. Ok, ok, hopefully they won't show up until 7pm when you are back from the doctor. Ok she says. I cross my fingers.
Give me the tracking number she asks. Ok, I whimper.

I am terrified to call her in the evening to see how things have gone. She has called UPS to track the package. On the truck, out for delivery they say. They advise her to refuse delivery. Return to sender.
The driver eventually drags the TV to her apartment. Its a woman. Worse than I feared. She pleads with my mother to keep the TV. Lady, its a 32 inch flat screen TV someone wants to GIVE YOU for Xmas!!

No, Mom insists, her little tube is just fine. TAKE IT BACK. Ok, the driver says and drags the thing back to the truck. Now my mother lives on the 19th floor of a high rise. This has not been a good day for the UPS lady. I am doubly guilty again hearing the tale.

Well, its back on the truck. I hope.


Hope your HOLIDAYS are filled with the joys of the season. I know mine are.

Until next time ................

Endometriosis

This is not a disease. This is a curse, like diabetes. It robs people of their lives. Starts young and goes forever. Most cancers get better and more effective treatment. Most of you know that endometriosis is a benign gyn condition where uterine lining is found outside of the uterus. Lots of theories abound how this is possible. The most common theory is that menstrual lining refluxes through the tubes back into the abdomen and becomes like seeds on the sidewalk. A few take hold in the cracks and grow.

Another more recent theory is that of genetic predisposition and metaplasia of otherwise normal tissue turning into endometrium.

At any rate, either way, it is a bitch.

With each menstruation the uterine lining finds itself bleeding, which in the places where it shouldn't be, means pain. The fluid/tissue is irritating and causes moderate to severe pain on a monthly basis. Eventually it causes pain every day which can become debilitating. It sometimes leads to infertility as well.

Diagnosis is only by direct vision of the stuff in your abdomen by the doctor and sometimes a biopsy. No xray or blood test is helpful, however the story of painful menses leading to pain during more times in the cycle, painful intercourse is suggestive of endometriosis.

Treatment has centered around hormonal therapies simulating times when a woman is normal but not menstruating such as pregnancy, breastfeeding or postmenopause. These are commonly known as treatment with birth control pills, progestin only contraception such as Depo Provera, and GNRH analogs such as Lupron and now aromatase inhibitors such as Femara. They all work to some degree, but are temporary fixes.Conservative surgery has been the hallmark of diagnosis and treatment for some time, with hysterectomy being the final assault on the problem.

Conservative surgery includes laparoscopy with ablation/ cautery or excision of endometriosis lesions. The excision is the best therapy, however it can be tricky and sometimes technically impossible. There is always more, so hormonal therapy follow up is what I recommend.

When I was a medical student a million years ago, the professor taught us that young women with difficult periods needed to marry young and have their children early. Still good advice. A life plan is a critical part of this problem. Those words from the professor still ring true. For women with endometriosis, the sooner they complete their families the better. New and improved medical and surgical approaches are coming, but not soon enough for many women.

Until next time.........

 

Second Childhoods

I am not sure that the Baby Boomer generation will be having a second childhood.
At least to me, I didn't leave the first one behind. Fun, excitement, living in the moment, and pleasure have been our trademarks. I see us beginning to "retire" but I don't see us stopping. Now one thing is for certain, we worked hard. There were lots of us, and competetion was stiff for just about everything from parking space to college entry. And, then of course, we came of age during the first oil crisis in the 70's, where there were no jobs and the economy went south. Then we picked ourselves up and enjoyed the prosperity of the 80's and 90's. Those of us who did well may still have a nest egg. The rest of us will continue to work, for a while at least.

Now I remeber hearing about old folks who had second childhoods. They stopped being stern and grumpy and started to enjoy the simple things all over again. They laughed, played and felt at home with themselves. I don't think the Baby Boomers, a la Dennis Hopper's Amex commercial, have left that behind. Just look at any highway on a Sunday. Grey haired bikers, convertible couples, and fun seekers with arthritis are all over the place. Of course, I am in Florida, but just the same.................

I just came back from a trip to Epcot this weekend. It was terrific! Sun, fun, grazing at the Food and Wine Festival, thrill rides, whew! Then plopping myself in the Lazy River in a tube for a few hours and hot tubbing with my Margarita.. Now that's my childhood........................................

I looked at the 30 somethings with the twins in the strollers, saddled with their overstuffed diaper bags, and backpacks. No thank you, been there and done that. If I ever have a grandchild, there will be no stopping us. Remember Auntie Mame? That woman is ME. Just one adventure after another tasting the delights life has to offer. So I say no to a second childhood.

My advice - don't give up the first one.

Behind Closed Doors

Indiana University recently published  The National Survey of Sexual Health and Behavior.
Interesting reading for us gyn geeks. It seems that casual sex is bimodal, for those under 25 and those over 50. It's just riskier with a 50+ man. They only use condoms 25% of the time, while 18-19 year olds use condoms 80% of the time. Makes one wonder if the cougars know something.

This is not an unusual conversation I have with my over 50 patients. How to have that "how do we deal with std" conversation. See my earlier blog entries regarding herpes for some details.
It is now a fact, and will be a focus of public health efforts, that you should get the AIDS education along with your AARP card. Us old folks have been around the block. That means more time to accumulate little gifts that keep on giving. Again, see earlier blogs for the herpes virus heartbreak.

Now it seems that most of the sex is happening between ages 20-40. No big surprise. There is a progressive decline in reported sexual behavior with a partner after age 40 for women and men. The varieties of sexual behavior that was surveyed included solo and partnered masturbation, oral sex given and received by same and opposite sex partners, anal sex given and received , vaginal intercourse,  and condom use. It seems that most everyone has tried oral sex, but less than half anal intercourse.
Vaginal intercourse is still the mainstay of experience, however partnered masturbation was a surprise, at least to me. Non coital sex is an important part of the national repetoire.

The purpose of the study was to shed light on contemporary sex practices to focus on the future needs of public health campaigns. This surveys a  comprehensive statistically valid sample of Americans. The last such survey was about 1990. The survey was published in a supplement to the Journal of Sexual Medicine.

Until next time,