Are hormones the only best tools to drive women into a healthy geronarche ? by Manuel Neves-e-Castro,M.D. Neves-e-Castro,M.D Clinica de Feminologia Holistica Lisboa/Portugal Lisboa/Portuga E-mail: firstname.lastname@example.org Website: http://neves-e-castro.pt The 5th International Symposium of the Portuguese Menopause Society Porto, October 2011
Hormonal Treatments are very good for symptom relief to improve quality of lifefor the prevention of some diseases
For some in menopause, hormones may be the only option“There is no alternative treatment that worksvery well, whether it’s a drug or over-the-counter herbal preparation.” Dr. Deborah Grady
But… Hormonal Treatments are far from being enough… enough• To maintain a climacteric woman in good health• To add more years to her life• To add more life to her coming years
The “stay-in-good-health” issue Good counselling techniques by Manuel Neves-e-Castro,M.D. Neves-e-Castro,M.D The 6th Amsterdam Menopause Symposium September 2010
A good counselling techniqueis to demonstrate and persuade women that• lifestyle modifications are independent of the use of drugs, and may• diminish the need to use drugs to prevent diseases and preserve Health
I shall talk about...• Life Style Medicine• Aging• Genetics• Psychosomatics• Hormonal and non-Hormonal treatments
“Our main goal, as attending physiciansof postmenopausal women, is themaintenance of their health and theprimary and secondary prevention of thediseases, which are more prevalent afterage 50”.Neves-e-Castro M. When hormone replacement therapy is notpossible. The Management of the Menopause. The MillenniumReview, Parthenon 2000:91-102.
What is a menopausal woman? woman she is an individual with a name she is a woman in distress caused by symptoms and psycho-sociocultural influences she is a woman who is growing in age she is a woman who became hypo estrogenic MNC
menarche menopause postmenopause Puberty reproductive years Climacteric gerontarche geronarche Fertilarche Fertilpause Infants adolescents adults aged oldquality of life compressionmorbidity Chronobiology The Time Table of a Woman’s Life Span M.Neves-e-Castro,2008
“ The Compression of Morbidity “ Fries JF et al. 1981
Physical activity, the compression of morbidity, and the health of the elderly Fries JF. Journal of the Royal Society of Medicine 1996;89:64-68
Physical activity, the compression of morbidity, and the health of the elderly Fries JF. Journal of the Royal Society of Medicine 1996;89:64-68
As a mid-aged woman:She will suffer from the process ofnatural aging, both from a biological and aginga psychological perspective. MNC
If she is a 50 year old lady… and still has this car, made in 1960, the same year of her birth !
What would she do with it to increase its longevity?
What is Wellness?Wellness is more than simply the absence ofillnessIt is instead a state of optimal health including allaspects of our Being : Body, Mind and Soul. http://www.integrative-medicine.com.au
Lifestyle Medicineis defined as the “evidence-based practice ofassisting individuals and families to adoptand sustain healthy behaviors that canimprove health and quality of life.” Lianov L and Johnson M. JAMA 2010;304(2):202-3
The principles of Lifestyle Medicine are foundational to health promotion, disease prevention andchronic disease management. management Lianov L and Johnson M. JAMA 2010;304(2):202-3
Lifestyle MedicineThe practice of lifestyle medicine coversprimary prevention (preventing a disease from developing),secondary prevention (modifying risk factors to avert the disease) andtertiary prevention (rehabilitation from a disease state and prevention of recurrence).
Lifestyle Medicine requires the patientto change their high risk health behaviorsto adopt a lifestyle that includes health behaviors that will help to reverse the pathology and or reduce the likelihood of disease progression.
Lifestyle modifications included alowfat (10% of calories from fat),whole foods,plant-based diet high in fruits,vegetables,unrefined grains,legumes, andlow in refined carbohydrates;moderate aerobic exercise (walking 30 min/day, 6 days/week);stress management (gentle yoga-based stretching, breathing, meditation, imagery, and progressive relaxation techniques 60 min/day, 6 days/week), and a 1-h group support session once per week.
PHYSICIAN COMPETENCIES FOR PRESCRIBING LIFESTYLE MEDICINE Physicians cannot abdicate their responsibility for effecting behavior change in their patients and for leading change within their practices. Lianov L and Johnson M. JAMA 2010;304(2):202-3
‘Lifestyle Medicine’Exercise and nutrition are the ‘penicillin’ ofLifestyle Medicine;psychology is the ‘syringe’through which these are delivered. Egger G, Binns A and Rossner S. Med J Aust. 2009 Feb 2;190(3):143-5.
Minimum amount of physical activity for reduced mortality and extended life expectancy 15 min a day or 90 min a week of moderate-intensity exercise might be of benefit Wen CP et al –The Lancet ,2011(1 Oct) 378(9798):1244-1253
PHYSICIAN COMPETENCIES FOR PRESCRIBING LIFESTYLE MEDICINE the majority of physicians are not following these guidelines, citing lack of knowledge, skill, or confidence in counselling patients about lifestyle interventions. Lianov L and Johnson M. JAMA 2010;304(2):202-3
Lifestyle Medicinecan prevent risk factors• We are today using only medicines to modify risk factors but we are not looking at what causes risk factors.• Women’s health must be primarily the medicine of lifestyles
Differences between conventionaland “Lifestyle Medicine” approaches Egger G, Binns A and Rossner S. Med J Aust. 2009 Feb 2;190(3):143-5.
Effect of Intensive Lifestyle Changes on Endothelial Function andon Inflammatory Markers of Atherosclerosis Intensive lifestyle changes have been shown to regress atherosclerosis, improve cardiovascular risk profiles, and decrease angina pectoris and cardiac events. events Dod HS et al. Am J Cardiol 2010;105:362–367
Combined impact of lifestyle factors on mortality: prospective cohort study in US women even modest differences in lifestyle can have a substantial impact on reducing mortality. Van Dam RM, Li T, Spiegelman D et al.BMJ 2008;337:a1440
The recent INTERHEART study of 30.000 patients from 52 countriesfound that almost 95% of coronary heart disease could be prevented by changing diet and lifestyle.And the only side effects are beneficial ones. Ornish D et al. The Journal of Urology 2005;174:1065-1070
Brown CH, Baidas SM, Hajdenberg JJ, et al. Lifestyle interventions in the prevention andtreatment of cancer. American Journal of Lifestyle Medicine. 2009;3(5):337-348
Is aging a disease ?The fact that genes explain only part of individual varibility in aging means that aging75% must be accounted for by other factors: - life style variables (nutrition, exercise) - powerful effects of environment (effects on older age)
Restricting caloric intake Is the most proven method to extend life Avoid high caloric foods Try short term fastingUndereating is anti-aging !
Lifestyle and nutrition, caloric restriction, mitochondrial health and hormones: Scientific interventions for anti-aging Vitetta L and Anton B; Clinical Interventions in Aging 2007:2(4) 537–543
Vitetta L and Anton B; Clinical Interventions in Aging 2007:2(4) 537–543
Mediterranean Diet, Lifestyle Factors, and 10-Year Mortality in Elderly European Men and Women Among individuals aged 70 to 90 years, adherence to a mediterranean diet lifestyle is associated with a more than 50% lower rate of all-causes and cause-specific mortality. Knoops K et al. JAMA 2004;292:1433-9
Okinawa Island: Island A model of “healthy” agingThe exceptional longevity of the Okinawapopulation may result from a combination offavorable factors and not only geneticdeterminants. Nguyen C. NPG Neurologie-Psychiatrie-Geriatrie 2008 ;8(43):35-41.
Okinawa Island: Island A model of “healthy” agingThe association of a protect environment with a wayof life which combines specific food habits, low energy intake, physical activities, stress reduction, good familial support and rich social relationscould explain this exception despite the low incomein this population. Nguyen C. NPG Neurologie-Psychiatrie-Geriatrie 2008;8(43):35-41 .
Anti-Aging ?Anti-senescence ?Is to preventBiological ageto be greater thanChronological age
There are two forms of age :chronological age i.e. how old you are inyearsand biological age whereby the cells of someindividuals are older (or younger) thansuggested by their actual age. Issued on 07 February 2010 by University of Leicester at http://www2.le.ac.uk
The best characterized function of thetelomeric complex is to protect thechromosome ends from degradationWerner C, Hanhoun M, Widmann T, et al. J Am Coll Cardiol 2008;52:470–82
Telomers• The little tips of chromosomes get shorter every time a cell divides,and this shortening is a mark of cellular aging.• If they get short enough,the cell dies or stops dividing• Exercise correlates with longer telomers,as does levels of omega-3 fatty acids in the blood Elizabeth Blackburn Nobel Laureate 2009
Genes reveal biological agingFrom birth, every time a cell divides, thetelomeres get shorter and there is someevidence that people with shorter telomeres,may be at higher risk from age-related illness. illness Feb.2010 at http://crabsalloverhealth.blogspot.com/
• Telomerase repairs and lengthens telomeres, which cap and protect the ends of chromosomes housing DNA.• As people age, telomeres shorten and cells become dying. dying Published on 16th Sept.2008 at http://crabsalloverhealth.blogspot.com
TelomersThese cellular clocks,known as telomers,mayact as barometers of wether a person willremain healthy or not Elizabeth Blackburn Nobel Laureate 2009
Clean living slows “cell aging”It is the damage and death of cells that causesaging and disease in people.Several factors such as smoking, obesity anda sedentary lifestyle are associated withshorter-than-average telomeres. Published on 16th Sept.2008 at http://crabsalloverhealth.blogspot.com
Sedentary life speeds up agingLeading a sedentary lifestyle may make usgenetically old before our time, a study suggests:A study of twins found those who were physicallyactive during their leisure time appeared biologicallyyounger than their sedentary peers. Story from BBC NEWS: http://news.bbc.co.uk/go/pr/fr/-/2/hi/health/7212698.stm Published: 2008/01/29
Leukocyte telomere length is preserved with aging inendurance exercise-trained adults and related to maximal aerobic capacity • LTL is preserved in healthy older adults who perform vigorous aerobic exercise and is positively related to maximal aerobic exercise capacity. • This may represent a novel molecular mechanism underlying the "anti-aging" effects of maintaining high aerobic fitness. Larocca TJ, Seals DR, Pierce GL. Mech Ageing Dev. 2010;131(2):165-7
Increased telomerase activity and comprehensive lifestyle changes: a pilot study Ornish D et al. Lancet Oncol 2008; 9: 1048–57
Telomerase activity in peripheral-blood mononuclear cells Ornish D et al. Lancet Oncol 2008; 9: 1048–57
Lifestyle medicine stimulates telomerase thus avoiding DNA damage and maintaining chromossomal integrity.the incorporation of new lifestyles may lead to a better compliance and better outcomes in terms of health and longevity
Vitamin Dfor Cancer Prevention: Global Perspective Garland CF, et alAnn Epidemiol 2009;19:468–483.
Vitamin D for Cancer Prevention: Global Perspective Raising the minimum year-around serum 25(OH)D level to 40 to 60 ng/mL (100–150 nmol/L) would prevent• 58,000 new cases of breast cancer and• 49,000 new cases of colorectal cancer each year, and• ¾ of deaths from these diseases in the USA and Canada. There are no unreasonable risks from intake of 2000 IU per day of vitamin D3 Garland CF et al. Ann Epidemiol 2009:19(7);468-483
Relative risk of breast cancer mortality Garland CF et al. Ann Epidemiol 2009:19(7);468-483
Colon Cancer-free survival Garland CF et al. Ann Epidemiol 2009:19(7);468-483
Relative risk of colon cancer mortality Garland CF et al. Ann Epidemiol 2009:19(7);468-483
Exactly how psychological and social factors,personal beliefs, and stress affect thedevelopment of disease continues to bestudied.It is known, however, that the mind andbody communicate constantly.what the mind thinks, perceives, andexperiences is sent from our brain to the restof the body.
Depression and CancerDepression also affects components ofimmune function that may affectcancer surveillance. Spiegel D. Biol Psychiatry 2003; Vol 54(3):269-82
Effect of a psychosocial treatment on survival of patients with metastatic breast cancer Survival from time of randomisation and onset of intervention was:- a mean 36.6 (SD 37.6) months in the intervention group- compared with 18.9 (10.8) months in the control group. Spiegel D. Lancet 1989; 2(8668):888-91
A stress response pathway regulates DNA damage… through β(2)-adrenoreceptors and β-arrestin-1The human mind and body respond to stress… by activating the sympathetic nervous system and secreting the catecholamines adrenaline and noradrenaline in the fight-or-flight response. Hara Mr et al. Nature 2011 Aug 21.
A stress response pathway regulates DNA damage… through β(2)-adrenoreceptors and β-arrestin-1When chronic… epidemiological studiesstrongly indicate that chronic stress leads toDNA damage. Hara Mr et al. Nature 2011 Aug 21.
A stress response pathway regulates DNA damage… through β(2)-adrenoreceptors and β-arrestin-1This stress-induced DNA damage may promote : ageing, tumorigenesis, neuropsychiatric conditions Hara Mr et al. Nature 2011 Aug 21.
A stress response pathway regulates DNA damage… through β(2)-adrenoreceptors and β-arrestin-1“Our results … reveal how DNA damage mayaccumulate in response to chronic stress”. Hara Mr et al. Nature 2011 Aug 21.
Chronic stress - reduces telomere lenght maintenance A SOBERING THOUGHT ... “Every stress leaves an indelible scar and the organism pays for its survival after a stressful situation by becoming a litle older”. (Hans Selye)
Psychosomatics Benson Institute for Mind Body MedicineThe Relaxation Response
the relaxation response is a physical state of deep rest that changes the physical and emotional responses to stress (e.g., decreases in heart rate, blood pressure, rate of breathing, and muscle tension).When eliciting the relaxation response:• Your metabolism decreases• Your heart beats slower and your muscles relax• Your breathing becomes slower• Your blood pressure decreases• Your levels of nitric oxide are increased
Why so much interest in HRT? • To improve quality of life? • To prevent diseases?
Interventions investigated… Only “hormonereplacement therapy”!... therapy
• Too much concerns and interest about HRT• Too little attention to the life styles that prevent risks, diseases and increase longevity
Updated IMS recommendations onpostmenopausal hormone therapy andpreventive strategies for midlife health D. W. Sturdee and A. Pines on behalf of the International Menopause Society Writing Group CLIMACTERIC 2011;14:302–320
Symptomatic changes in postmenopause with different methods of hormonal therapyHT should be initiated for relief of symptomsthrough suitable selection of the route ofadministration and drug that has the greatesteffect on the predominant symptoms of eachpatient, for which medical evaluation wassought.Hernandez-Valencia M et al. Open Journal of Preventive Medicine 2011Vol.1, No.2, 20-24
Individualizing Hormone Therapy to Minimize Risk Estrogen is a medication that can decreasemortality, decrease cardiovascular disease,decrease osteoporosis fracture, urogenitalatrophy and dementia. Strategies to minimize riskinclude initiation of therapy within 10 years ofmenopause or under 60 years of age, using low-dose estrogen, adding a low-dose progestin inwomen with a uterus, and use of transdermaltherapy in women with risk factors forcardiovascular disease. Donna Shoupe. Womens Health. 2011;7(4):475-485.
Timing of hormone therapy, type of menopause, andcoronary disease in women Shufelt CL et al. Menopause 2011;18(9):943-950
HRT and breast cancer risk: a realistic perspectiveIt should be remembered that women using CEE aloneshowed a significant decrease in breast cancer risk inthe WHI trial and follow-up. Even if combinedestrogen-progestogen HRT did cause an increase inbreast cancer risk, and this is not proven, themagnitude of that risk is small, and less than that riskseen with many lifestyle factors. factors HRT is a benefit, not a risk, for those women requiring it. Stevenson JC, Hodis HN, Pickar JH, Lobo RA; Climacteric (Aug 2011)
Thus,Studies based ONLY on the use of hormonesdo not reflect good clinical practice!... MNC
Menopausal hormonal treatments are very goodbut ... Treatments without hormones may also be very good for a woman’s health MNC/02
Please remember: Our main target isMature Woman’s Health and Disease Prevention by all means, drug and non-drug related. MNC
The gynecologist is becomingthe woman’s family doctor. MNC
To knowthe disease that a woman hasis as important asto knowthe woman who has the disease William Osler
Let us not medicalize the Menopause..instead… Let us holistically approach the Climacteric and aging women. women MNC
Holistic ModelThe aim of the therapy is not only toproduce a physical cure but alsoto cure whole person.Ruiz R, et al. La incorporacion de um nuevo modelo en medicina:consequencias teórico-práticas. Aten Primaria 1992;10:629-34
I am not a Menopauselogist… instead my Speciality (?!...) isWomen’s Holistic Health
The Take Home Messages1. Promote changes in Life Style : they avoid risk factors that cause Diseases.2. See if you can make the Biological Age to be younger than the Chronological Age.3. Promote Mental Health,proper Nutrition and frequent Health Exercice ,based on what one knows about the Telomers.4. Give Vitamin D to everybody5. Remember that Estrogens are the best treatment for Vasomotor Symptoms and to improve Quality of Life.6. Hormonal Treatments have more benefits than risks if started early in the postmenopause7. The Wellness of a Woman is the TARGET !
And...as I told you before,The best Anti-Aging (?)(Anti-Senescence !) Treatment isThe practice of GOOD MEDICINE
therefore...we must learn… how to practice a GOOD MEDICINE
Because…there is NOMenopausalMedicine ! M.Neves-e-Castro,2011