Hormone Therapy Informational Session


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Hormone Therapy Informational Session

  1. 1. Hormone Therapy Informational Session Ann Stanger, MD 2940 Chapel Valley Rd. Madison, WI 53711 (608)233-2378
  2. 2. Ann Stanger, MD <ul><li>Graduate of Indiana University School of Medicine </li></ul><ul><li>Came to Wisconsin for OB/GYN residency at the University of Wisconsin Hospitals/Clinics </li></ul><ul><li>Opened an independent private practice in 2001. </li></ul><ul><li>Has been testing for and prescribing human identical hormones since 2001 </li></ul><ul><li>Added Digital Infrared Thermal Imaging in 2008 </li></ul>
  3. 3. Topics of Discussion <ul><li>Symptoms of perimenopause and menopause </li></ul><ul><li>Women’s Health Initiative and what it means </li></ul><ul><li>Symptoms of imbalances of thyroid hormones, adrenal hormones and ovarian hormones </li></ul><ul><li>Testing for hormone imbalances </li></ul><ul><li>Hormone therapy options </li></ul><ul><li>Screening </li></ul>
  4. 4. Perimenopause <ul><li>The 5-10 year period prior to the complete cessation of menses when periods are changing. </li></ul><ul><li>Symptoms usually start around age of 35-40. </li></ul>
  5. 5. Perimenopausal Symptoms <ul><li>Changes in menstrual cycle timing and flow </li></ul><ul><li>Fluid retention </li></ul><ul><li>Glucose/insulin imbalances </li></ul><ul><li>Increased body fat, especially abdominal </li></ul><ul><li>Decreased energy/fatigue </li></ul><ul><li>Altered thyroid function </li></ul><ul><li>Decreased libido </li></ul>
  6. 6. Perimenopausal Symptoms, Continued <ul><li>Anxiety/depression/mood swings </li></ul><ul><li>Sleep disturbances </li></ul><ul><li>Hot flashes/night sweats </li></ul><ul><li>Forgetfulness, inability to concentrate </li></ul><ul><li>Dry or itching skin </li></ul><ul><li>Dry or thinning hair </li></ul>
  7. 7. Menopause <ul><li>The cessation of the menstrual period. </li></ul><ul><li>Considered to be menopausal after one year without a period. </li></ul>
  8. 8. Menopausal Symptoms <ul><li>Any/All of the perimenopausal symptoms </li></ul><ul><li>Amenorrhea/missed periods </li></ul><ul><li>Hot flashes/night sweats </li></ul><ul><li>Vaginal dryness, pain with intercourse </li></ul><ul><li>Joint and muscle pain </li></ul><ul><li>Insomnia </li></ul><ul><li>Frequent urination </li></ul><ul><li>Frequent urinary tract infections </li></ul>
  9. 9. Who needs hormone therapy? <ul><li>Severe symptoms-unable to function at work/home, increased pain, sleep deprivation </li></ul><ul><li>Increased health risks-bone loss, memory issues, cardiovascular disease </li></ul><ul><li>Desire for improved quality of life-improved energy, appearance, libido </li></ul>
  10. 10. What can you do now to decrease your need for hormone therapy later? <ul><li>Maximize adrenal health </li></ul><ul><li>The adrenal gland is the source of precursor hormones that can be converted to estrogens and testosterone by the body after menopause </li></ul><ul><li>The healthier the adrenal gland, the easier the menopausal transition </li></ul>
  11. 11. Lifestyle changes for improved adrenal health <ul><li>Regular bedtime prior to 10 pm </li></ul><ul><li>Good quality sleep </li></ul><ul><li>Regular daily exercise </li></ul><ul><li>Stress management </li></ul><ul><li>Avoid excessive caffeine, alcohol, sugar, white flour products </li></ul><ul><li>Healthy diet with many cruciferous vegetables </li></ul>
  12. 12. Why not take hormones? <ul><li>Hormone therapy is controversial because of concerns about cancer, heart disease, strokes and blood clots. </li></ul><ul><li>Hormones were routinely recommended after menopause until the results of the Women’s Health Initiative study were released. The WHI was stopped early because of an increase in adverse outcomes. </li></ul>
  13. 13. Women’s Health Initiative (WHI) <ul><li>NIH sponsored, Wyeth funded </li></ul><ul><li>Multi center study recruited 1993-1998 </li></ul><ul><li>Ages 50-79, mean 63.2 </li></ul><ul><li>Randomized, blinded, placebo controlled </li></ul><ul><li>Goal was to show that the hormones helped to prevent cardiovascular disease in the postmenopausal woman </li></ul><ul><li>Continuous conjugated estrogen plus progestin therapy arm (CCEPT) 16,608 women (with a uterus) </li></ul><ul><li>Estrogen therapy (ET) arm 10,739 women (had hysterectomy) </li></ul>
  14. 14. CCEPT Arm breakdown <ul><li>33.4% ages 50-59 </li></ul><ul><li>45.3% ages 60-69 </li></ul><ul><li>21.3% ages 70-79 </li></ul><ul><li>Not on hormones prior to the study </li></ul><ul><li>Same dose for all, 0.625 mg conjugated equine estrogen and 2.5 mg medroxyprogesterone acetate (MPA) or placebo </li></ul><ul><li>No perimenopausal or early menopausal women included </li></ul>
  15. 15. CCEPT Arm of WHI <ul><li>40% drop out of both the treated and untreated group </li></ul><ul><li>Halted early after mean of 5.2 years (planned duration 8.5) </li></ul><ul><li>Stopped because of increased adverse outcomes </li></ul><ul><li>More heart disease, strokes, DVT, breast cancer in the treatment group </li></ul>
  16. 16. ET Arm of WHI <ul><li>10,793 women without a uterus </li></ul><ul><li>All on 0.625 conjugated equine estrogen or placebo </li></ul><ul><li>Ended after 6.8 years average </li></ul><ul><li>Increased risk of stroke </li></ul><ul><li>Decreased risk of fracture </li></ul><ul><li>Neutral risk for heart disease </li></ul><ul><li>Neutral risk for breast cancer </li></ul>
  17. 17. The Other Side of the Story <ul><li>Same dose for all, no other hormone is dosed this way </li></ul><ul><li>No screening for pre-existing illness that would have predisposed to heart disease and stroke </li></ul><ul><li>Billed as a preventive trial for CAD, yet started at average age 63 </li></ul><ul><li>Used oral hormones which increase HS-CRP and clotting factors </li></ul>
  18. 18. Thomas, et al Progestins initiate adverse events of menopausal estrogen therapy <ul><li>Climacteric. 2003 Dec;6(4):293-301 </li></ul><ul><li>Synthetic progestins caused endothelial disruption, accumulation of monocytes in the vessel wall, platelet activation and clot formation. </li></ul><ul><li>The CCEPT arm used MPA, a synthetic progestin </li></ul><ul><li>Human identical progesterone does not have these side effects </li></ul>
  19. 19. Progesterone <ul><li>Human identical progesterone has a different affect on the body and breasts than does medroxyprogesterone acetate (MPA) </li></ul><ul><li>Progesterone was not used in WHI </li></ul><ul><li>Progesterone cannot be patented, therefore no incentive on the part of drug companies to fund studies using it </li></ul>
  20. 20. Progesterone studies <ul><li>Some small studies have been done regarding human identical progesterone therapy </li></ul><ul><li>1981 Cowan, Am J Epidemiology. 1000 women followed from 1945-78. Progesterone deficiency was associated with 5.4 times greater risk of breast cancer </li></ul>
  21. 21. Progesterone studies <ul><li>Foidart, Fertility and Sterility 1998 looked at the topical affects of estradiol and progesterone. </li></ul><ul><li>Estradiol increased the number of cycling epithelial cells in the human breast. </li></ul><ul><li>Progesterone reduced the estradiol induced proliferation of normal breast epithelial cells </li></ul>
  22. 22. Progesterone studies <ul><li>Fromby, Annals of Clinical Lab Science 1998 </li></ul><ul><li>Progesterone was found to inhibit growth and induce apoptosis in breast cancer cells in vitro. </li></ul>
  23. 23. Cardiovascular effects of Bio-identical hormone therapy <ul><li>Hypertension 2009, March 30, Langrish et. Al </li></ul><ul><li>Compared human identical (transdermal estradiol and vaginal progesterone) to standard hormone (oral ethinylestradiol and norethisterone) therapy in 4 week cycles for 12 months. </li></ul><ul><li>Monitored 24-hour ambulatory BP, arterial stiffness and renal factors. </li></ul><ul><li>Women on the human identical hormone therapy had lower BP, better renal function and less activation of the renin-angiotensin system. </li></ul>
  24. 24. The Bio-identical Hormone Debate <ul><li>Holtorf, K; Postgraduate Medicine , 2009, Jan;121(1) </li></ul><ul><li>“ The bioidentical hormone debate: are bioidentical hormones (estradiol, estriol and progesterone) safer or more efficacious than commonly used synthetic versions in hormone replacement therapy?” </li></ul><ul><li>Review of published papers and data </li></ul><ul><li>Data and clinical outcomes demonstrated that bioidentical hormones are associated with lower risks, including risk of breast cancer and CVD, and are more efficacious than the synthetic and animal derived counterparts. </li></ul>
  25. 25. What hormones are involved in the hormone therapy I recommend? <ul><li>Thyroid hormones (TSH, T3 and T4) </li></ul><ul><li>Adrenal hormones (cortisol, pregnenolone, DHEA-S) </li></ul><ul><li>Ovarian hormones for women (estradiol, estriol, testosterone) </li></ul><ul><li>Testicular hormones for men (testosterone) </li></ul>
  26. 26. Thyroid hormones <ul><li>Made by the thyroid gland </li></ul><ul><li>Iodine and iodide are required for adequate thyroid hormone production </li></ul><ul><li>Related to metabolism </li></ul><ul><li>Affect mood and energy </li></ul><ul><li>Autoimmune thyroid disorders are becoming more common </li></ul>
  27. 27. Symptoms of Thyroid Hormone Excess <ul><li>Weight loss </li></ul><ul><li>Anxiety </li></ul><ul><li>Insomnia </li></ul><ul><li>Diarrhea </li></ul><ul><li>Fast heart rate </li></ul><ul><li>Heat intolerance </li></ul>
  28. 28. Symptoms of Thyroid Hormone Deficiency <ul><li>Weight gain </li></ul><ul><li>Fatigue </li></ul><ul><li>Brain fog </li></ul><ul><li>Dry skin/eczema </li></ul><ul><li>Hair loss/eyebrow thinning </li></ul><ul><li>Menstrual irregularities </li></ul><ul><li>Heavy periods </li></ul><ul><li>Low body temperature </li></ul>
  29. 29. Adrenal Hormones <ul><li>Cortisol (also known as hydrocortisone) </li></ul><ul><li>DHEA which circulates mostly as DHEA-S </li></ul><ul><li>Pregnenolone </li></ul>
  30. 30. Cortisol/Hydrocortisone <ul><li>Primary hormone of chronic stress management </li></ul><ul><li>Can become depleted over time from chronic stress </li></ul><ul><li>Low cortisol production is an underappreciated cause of fatigue </li></ul><ul><li>When cortisol becomes depleted, the “fight or flight” hormones are used by the body to manage stress causing anxiety, irritability, insomnia, hot flashes. </li></ul>
  31. 31. Pregnenolone <ul><li>Decreases with age </li></ul><ul><li>Improves memory/brain fog </li></ul><ul><li>Improves mood </li></ul><ul><li>Considered the “mother hormone” because it is a precursor to the other hormones </li></ul>
  32. 32. DHEA-S <ul><li>Dehydroepiandrosterone sulfate </li></ul><ul><li>Decreases with age </li></ul><ul><li>Decreases with stress </li></ul><ul><li>The original “anti-aging” hormone </li></ul><ul><li>Improves mood and sense of well being </li></ul><ul><li>Improves immune function </li></ul>
  33. 33. Ovarian Hormones <ul><li>Progesterone </li></ul><ul><li>Estradiol </li></ul><ul><li>Estriol </li></ul><ul><li>Testosterone </li></ul>
  34. 34. Progesterone Deficiency Symptoms <ul><li>Premenstrual syndrome symptoms </li></ul><ul><li>Anxiety </li></ul><ul><li>Headache </li></ul><ul><li>Mood swings </li></ul><ul><li>Sleep disturbances </li></ul><ul><li>Irregular periods/spotting </li></ul>
  35. 35. Progesterone Excess Symptoms <ul><li>Fatigue/tiredness </li></ul><ul><li>Sleepiness </li></ul><ul><li>Depression </li></ul><ul><li>Bloating </li></ul><ul><li>Acne </li></ul>
  36. 36. Estrogen Deficiency Symptoms <ul><li>Hot flashes/night sweats </li></ul><ul><li>Sleep disturbances/insomnia </li></ul><ul><li>Memory loss/trouble with concentration </li></ul><ul><li>Depression </li></ul><ul><li>Lack of libido </li></ul><ul><li>Vaginal dryness </li></ul><ul><li>Dry skin </li></ul><ul><li>Hair loss </li></ul>
  37. 37. Estrogen Excess Symptoms <ul><li>Breast tenderness/fullness </li></ul><ul><li>Fluid retention/edema </li></ul><ul><li>Irritability </li></ul><ul><li>Nausea </li></ul><ul><li>Headaches </li></ul><ul><li>Dizziness </li></ul><ul><li>Weight gain </li></ul><ul><li>Sweet craving </li></ul>
  38. 38. Testosterone Deficiency Symptoms <ul><li>Decreased libido </li></ul><ul><li>Difficulty with orgasm </li></ul><ul><li>Diminished sense of well being </li></ul><ul><li>Lack of drive and focus </li></ul><ul><li>Loss of muscle mass </li></ul><ul><li>Depression </li></ul><ul><li>Fatigue </li></ul><ul><li>Decreased bone density </li></ul><ul><li>Decreased pubic/body hair </li></ul>
  39. 39. Testosterone Excess Symptoms <ul><li>Acne </li></ul><ul><li>Oily skin </li></ul><ul><li>Increased facial hair </li></ul><ul><li>Scalp hair loss </li></ul><ul><li>Deepening voice </li></ul><ul><li>Anger/irritability </li></ul>
  40. 40. Testing for Hormone Levels <ul><li>Testing can be done via blood, saliva or urine </li></ul><ul><li>Testing for estrogen and progesterone must be done at the proper time of the cycle to be helpful </li></ul><ul><li>For the woman who it still having menstrual cycles, that is during the luteal phase, about cycle day 18-23, or the week prior to the next period </li></ul><ul><li>Testing should be done in the morning for most hormones when the levels are at their peak </li></ul>
  41. 41. How I test hormones in my practice <ul><li>Estradiol, progesterone and free testosterone are drawn in the morning on cycle day 18-23 in the perimenopausal woman and any morning for the menopausal woman. </li></ul><ul><li>TSH, free T3 and free T4 are drawn at the same time. </li></ul><ul><li>Four part saliva collections are used for cortisol and DHEA testing </li></ul>
  42. 42. Routes of Administration <ul><li>Hormone therapy can be administered in many ways </li></ul><ul><li>Topical/transdermal gels, creams, patches </li></ul><ul><li>Vaginal creams, gels, suppositories </li></ul><ul><li>Oral/sublingual tablets, capsules, troches, drops </li></ul>
  43. 43. In my practice <ul><li>I usually recommend compounded estradiol and estriol (also known as BiEst or E2/E3) cream dosed twice daily. Patches of estradiol are another option. </li></ul><ul><li>Progesterone capsule at night </li></ul><ul><li>Testosterone cream in the morning either topically or vaginally </li></ul><ul><li>DHEA and Pregnenolone orally in the morning </li></ul><ul><li>Armour thyroid and iodine/iodide in the morning </li></ul><ul><li>The doses and uses of these hormones depend on symptoms and the levels on laboratory testing </li></ul>
  44. 44. Hormone therapy <ul><li>Human identical hormones may be safer than those studied in WHI </li></ul><ul><li>Progesterone must be used along with estrogen in a woman who has her uterus. Unopposed estrogen will cause uterine cancer over time. </li></ul><ul><li>Estrogen use is a risk for the breast and some sort of monitoring of the affect on the breast is necessary. </li></ul><ul><li>Dosed for the individual to relieve symptoms </li></ul><ul><li>Testing of hormone levels is necessary </li></ul><ul><li>Duration of therapy is an individual decision </li></ul>
  45. 45. Cancer Screening <ul><li>Annual physical with breast and pelvic exam </li></ul><ul><li>Colonoscopy after age 50 or sooner for family history. </li></ul><ul><li>Screening Pap smear every other year until age 65 </li></ul><ul><li>Mammography </li></ul><ul><li>Digital infrared thermal imaging (thermography) of the breasts </li></ul>
  46. 46. Thermography <ul><li>No radiation </li></ul><ul><li>No compression </li></ul><ul><li>Highly sensitive to early changes in breast tissue </li></ul><ul><li>May detect changes in the breasts years in advance of micro calcifications being detected with mammography </li></ul><ul><li>Allows more time for non-invasive interventions to improve outcomes </li></ul>
  47. 47. Questions?