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  • In contrast with the previous slide of perceived health concerns, this slide shows actual rates for cause of death. What is apparent is that a generalized fear of cancer, and breast cancer specifically, skews postmenopausal women’s understanding of their health risks. Such misinformation often represents a barrier when women make decisions about ET/HT. Although the results of the WHI trial have provided and will continue to provide valuable information on the effects of various preventive strategies on chronic disease in menopausal women, they are unlikely to change this misperception. Anderson RN. Deaths: leading causes for 1999. Natl Vital Stat Rep . 2001;49:1-13.

Emas curso Presentation Transcript

  • 1. The Doctor, the Patient and QoL by Manuel Neves-e-Castro Lisboa-Portugal
  • 2. The Doctor, the Woman and QoL
  • 3. There are controversies about thepresent management of theclimacterium which are due to:• a lack of culture that prevents a correct criticism of the published results• a bad practice of medicine that ignores the woman in her totality (holism)• political lobbies from the NIH• a lack of scientific honesty manifested by many of the WHI writers• lobbies from several pharmaceutical industries through the activities of many well known doctors that “offer” themselves to transmit their “messages”
  • 4. HOW TO DO IT ?•The Objective QoL •The Target the Woman •The Agent (or Actor) the Doctor
  • 5. Quality of Life (QoL)
  • 6. How to promote it ?
  • 7. QoL = Health !“A condition of physical, mental andsocial well-being and not only theabsence of disease” WHOTherefore one must: - prevent diseases - promote health
  • 8. The midaged Woman• How does she feel? Confused? Insecure?• What is she afraid of ? Hormones?• What does she want from the Doctor? QoL !
  • 9. DefinitionA Climacteric woman is a woman (gender based medicine) is an ageing person (geriartrics) is perimenopausal (hormone deficient)
  • 10. Looking after a menopausal woman is amost fascinating, gratifying and complex vivid experience in the life of a physician. MNC/2005
  • 11. manwoman
  • 12. The Doctor : a Gynecologist?If so• What is in his/her mind? WHI? Million WS?• What does he/she know about it?• What is he/she afraid of? Cancer? TED?• How does he/she practice Medicine?• How should midaged women be taken care of?
  • 13. What has experience thoughtme over the years about how to give QoL after the menopause:
  • 14. Is there a Menopausal Medicine?There is only ONE Medicine (L. Speroff)There are only TWO Medicines (M.N.C.): a BAD Medicine and a GOOD Medicine
  • 15. Therefore,what we must learn, is…how to practice a GOOD MEDICINE! mnc/05
  • 16. “We are drowning in information, but starved for knowledge” knowledge John Naisbilt
  • 17. then...how is Medicine practicedtoday?
  • 18. There are two types of medical practice:– the Medicine for one individual, at a time (Clinical Medicine)– the Medicine for many individuals, the population, at the same time, (Social Medicine,Public Health Medicine) MNC/05
  • 19. Who are the actors ? • Is a clinicianThe practitioner • Sees patients in the office • Treats individuals • Works in Hospitals • Is not a clinicianThe public health doctor • Does not see patients in an office • Does not treat individuals • Works in a Public Health department
  • 20. Concerns of theDoctor of an individual •Absolute risk reduction(practitioner) •Absolute risk increase •Benefit/risk analisysThe Public Health Doctor •Relative risk reduction •Relative risk increase •Cost/benefit analysis
  • 21. But ... today ...many • Act in their offices as if they were public health doctors...practitionersand manypublic health doctors • Act in their departments as if they were clinicians ... This is wrong!
  • 22. WHI results calculated as: NNT/1 year NNH/1 yearCHD 1428Stroke 1250VTE 588Breast Cancer 1250Colon Cancer 1667Osteoporotic fractures 227 Neves-e-Castro M. Menopause in crisis post-Women´s health Initiative? A view based on personal clinical experience. Human Reproduction 2003;18:2512-8
  • 23. Public Health doctors are guided bywhat epidemiologists suggest ...but ...most epidemiologists only establishassociations of events and seldomdetermine cause/effect relationships MNC/05
  • 24. Practioners are guided:• by the best available information that can be extrapolated with validity to their patients, and• by their acumulated experience MNC/05
  • 25. thus ... both,the practitioners who act as if theywere public health doctors, and the public health doctors who act as if theywere clinicians, should not overemphasize theepidemiological associations of events that arenot necessarily cause/effect findings MNC/05
  • 26. We must manage ourClinical Practice by objectives: objectives- Critical Objectives (C.O.)- Specific Objectives (S.O.)- S.O. Targets (S.O.T.)- S.O. Projects (S.O.P.)
  • 27. Critical Objectivesa) The diagnosis of healthb) The identification of risk factorsc) The presence of symptoms • gender related • age related • hormone related
  • 28. Critical Objectivesd) The treatment of symptomse) The elimination of risk factorsf) The diagnosis of diseasesg) The treatment of diseases
  • 29. Specific Objectives (S.O.)1. CVD and metabolic diseases a) obesity b) dislipidemias c) hypertension d) insulin resistance (metabolic syndr.) etc
  • 30. S.O.2. CNS a) vasomotor symptoms b) mood, sleep c) sexual disfunctions, libido, etc
  • 31. S.O.3. Bone a) osteoarticular, etc
  • 32. S.O.4. Reproductive organs - vaginal discharges - atrophic vaginitis - fibroids - meno and metrorrhagia, etc
  • 33. S.O.5. Breast lumps and tenderness, etc
  • 34. S.O.6. Bladder incontinence chronic cystitis, etc
  • 35. S.O.7.Contraception
  • 36. S.O. Targets1. exercise2. nutrition3. mental health4. sexual conseling5. pharmacotherapy a) hormonal b) non-hormonal
  • 37. S.O. Projects (treatments) P, E+P, E Androgens Ca + vit D Bisfosfonates, Strontium Statins IACE Diuretics α and β Blockers Aspirin Serm’s Tibolone Gabapantin Psychotherapy etcroutes, schemes of administration
  • 38. and nowthink about the interelation ofCVD, Osteoporosis and Obesity...since they seem to share common riskfactors...
  • 39. The unified hypothesis of interactions among the bone, adipose and vascular systems: osteo-lipo-vascular interactions. Epidemiological evidence has established a link among hyperlipidemia, visceral obesity, osteoporosis, and cardiovascular diseases (CVD). Koshiyama H et al. Med Hypotheses 2006;66:960-3
  • 40. The unified hypothesis of interactions among the bone, adipose and vascular systems: osteo-lipo-vascular interactions. The unified hypothesis of three organs, which we call osteo-lipo-vascular interactions, may be explained by the common origin of the cells in each organ. Koshiyama H et al. Med Hypotheses 2006;66:960-3
  • 41. The unified hypothesis of interactions among the bone, adipose and vascular systems: osteo-lipo-vascular interactions. The mesenchymal stem cells are capable of differentiating into osteoblasts, vascular smooth muscle cells, and adipocytes. Koshiyama H et al. Med Hypotheses 2006;66:960-3
  • 42. The unified hypothesis of interactions among the bone, adipose and vascular systems: osteo-lipo-vascular interactions. Alternatively, macrophages may evolve into osteoclasts or infiltrate both the vascular and adipose tissues, thereby leading to chronic inflammation. Koshiyama H et al. Med Hypotheses 2006;66:960-3
  • 43. Osteoporosis and cardiovascular disease:brittle bones and boned arteries, is there a link? Elevated LDL and low HDL cholesterol are associated with LBMD; altered lipid metabolism is associated with both bone remodeling and the atherosclerotic process, which might explain, in part, the co-existence of osteoporosis and atherosclerosis in patients with dyslipidemia. Similarly, inflammation plays a pivotal role in both atherosclerosis and osteoporosis. McFarlane SI et al. Encdocrine 2004;23:1-10
  • 44. Osteoporosis and cardiovascular disease:brittle bones and boned arteries, is there a link? Elevated plasma homocysteine levels are associated with both CVD and osteoporosis. McFarlane SI et al. Encdocrine 2004;23:1-10
  • 45. Osteoporosis and cardiovascular disease:brittle bones and boned arteries, is there a link? Nitric oxide (NO), in addition to its known atheroprotective effects, appears to also play a role in osteoblast function and bone turnover. McFarlane SI et al. Encdocrine 2004;23:1-10
  • 46. Osteoporosis and cardiovascular disease:brittle bones and boned arteries, is there a link? Statins, agents that reduce atherogenesis, also stimulate bone formation McFarlane SI et al. Encdocrine 2004;23:1-10
  • 47. Osteoporosis and cardiovascular disease:brittle bones and boned arteries, is there a link? Bis- phosphonates, used in the treatment of osteoporosis, have been shown to inhibit atherogenesis. Intravenous bisphosphonate therapy significantly decreases serum LDL and increases HDL in postmenopausal women McFarlane SI et al. Encdocrine 2004;23:1-10
  • 48. anyway,andin the light of the present evidence,doctors and women should bereassured that the suggested HT’s forthe relief of symptoms in themenopauseare safe and very effective !
  • 49. Many women taking hormones wereurged by their physicians to stop takingthese medications immediately ordecided to stop taking them on their own. Petitti DB. JAMA. 2005;294:245-246.
  • 50. Convictions are moredangerous enemies of thruththan lies Friedrich Wilhelm Nietzsche
  • 51. Based on the WHI study group,implementation of the resultsinto clinical practice has little, ifany, scientific basis.Adam Ostrzenski and Katarzyna M Ostrzenska. Am J Obst Gynecol2005;193:1599-604
  • 52. The applicability of the WHIfindings to women between age of51.1 and 56.1 years and younger isunknown... Ostrzenski A and Ostrzenska KM. Am J Obst Gynecol 2005;193:1599-604
  • 53. The WHI Estrogen only arm
  • 54. Effects of conjugated Equine Estrogen in Postmenopausal Womenwith Hysterectomy.JAMA, 2004;291:1701-1712
  • 55. Stroke“In women 50-59 years not taking HT,ischemic stroke is expected to occur in3 out of 1000 women during 5 years.Five years use of HT would yield 1additional case of stroke/ 1000 women” women EMAS Statement; 2004.
  • 56. Biased opinionsbe they pro or con,dishonor the professionandharm our patients.Sacket DL. The arrogance of preventive medicine. Can Med Assoc J2002;167:363-364
  • 57. Then, why all this noise?... noiseMainly because the conclusions ofrecent trials were severely misinterpretedby the medical professionals, the media professionalsand by the women, themselves MNC/05
  • 58. Causes of Death Among Women* Other Cancers Heart Disease 15%Breast Cancer 34% Diabetes 4% 3%Chronic Lower 6% Respiratory Disease 10% 28% Other Cerebrovascular Disease *Percentage of total deaths in 1999 among women aged 65 years and older. Anderson RN. Natl Vital Stat Rep. 2001;49:1-13.
  • 59. Hormones and the Heart1 in 3 women will die from coronaryheart disease (CHD) in the USA.1 in 25 women will die from breastcancer Fitzpatrick LA. JCEM 2003;88(12):5609-10
  • 60. “HRT is associated with a 35% reduction in mortality for women who suffered myocardial infarction”.Shlipack MG, Angeja B, Go AS, et al Circulation 2001;104:2300-2304
  • 61. Effect on the risk of CHDWHI Significant increased risk RR 1.29 (CI 1.02-1.63); 29 % increased risk AR 0.37% vs 0.30% (ie, 37 vs 30 events annually per 10.000 women)HERS Nonsignificant decreased risk RR 0,99 (CI 0.84-1.17); 1% decreased risk AR 3.66% vs 3.68% (ie, 366 vs 368 events annually per 10.000 women)
  • 62. NNH / Year (Number Needed to Harm) (the reciprocal of the AR,or of the atributable AR)Coronary Heart Disease WHI (RR 1.29) 1428 HERS (RR 0.99) 5000Breast Cancer WHI (RR 1.26) 1250 HERS (RR 1.27) 833 MNC
  • 63. “Not everything that can becounted counts;and not everything thatcounts can be counted” Albert Einstein
  • 64. Hormone replacement therapy: where to now?Recent studies suggest HRT may inhibitthe process of atherosclerosis inhealthy arteries soon after menopause,and observational studies (NHS, updated2006) in younger women starting HRTstrongly suggest a potentialcardiovascular benefit Mikkola TS, Clarkson TB. Cardiovasc Res 2002;53:605-19.
  • 65. Lessons from the WHI“…most articles and broadcast segmentstended to focus exclusively on either thesmall absolute risks or the larger relativerisks, neglecting the more even-handedriskspicture that presented both.Since the sharply increased relative risksgot the most play, news coverage about the playtrial’s findings had an alarming cast.” Denzer S. Editorial. Ann Intern Med.2003;138:352-353
  • 66. “WHI: Now that the dust has settled…”• To publish data that may or may not be entirely true or certainly premature is a disservice to the medical profession and, most important, to our patients.• The majority of the data that were published is not statistically significant even at the nominal level.Creasman WT. et al. Am J Obst Gynecol 2003;189:621-626
  • 67. Recent reports did not find, forcontinuous combined treatments, anyincreased risk of either CHD or breastcancer.The difference from WHI being thatwomen were younger, symptomaticand with lower body weightsHeikkinen J. NAMS 2004, Abstract LB38Lobo R. Arch Int Med 2004;164:482-484
  • 68. “At the moment, I believe we can say withrelative certainty that hormone therapy in younger postmenopausal women results in lower coronary heart disease events and total mortality.” Salpeter S. Climacteric 2005;8:307-310
  • 69. An update of the WHI Study !WHI investigators reported (Feb 2006) astatistically significant (34%) lower risk for thecombined endpoint of myocardial infarction(heart attack), coronary death, coronaryrevascularization and confirmed angina amongwomen who were between the ages of 50 and59 at the start of the study (RR 0.66; 95% CI0.45-0.96). Hsia J et al.Arch Intern Med 2006;166:357-363
  • 70. Younger Women May Receive Heart Protection From Estrogen Therapy In women ages 50-59 who had undergone a hysterectomy, a significant protective effect of estrogen treatment, when both primary (heart treatment attacks and heart attack death) and secondary (coronary artery bypass surgery, angioplasty, confirmed angina pectoris) cardiac endpoints were considered. Dr. S. Mitchell Harman, director and president of Phoenix-based Kronos Longevity Research Institute (KLRI) in Archives of Internal Medicine 2006;106:357-363
  • 71. Hsia J, Langer RD, Manson J et al. Conjugated equine estrogens and coronary heartdisease. Arch Int Med 2006;166:357-65
  • 72. Hsia J, Langer RD, Manson J et al. Conjugated equine estrogens and coronary heartdisease. Arch Int Med 2006;166:357-65
  • 73. Hsia J, Langer RD, Manson J et al. Conjugated equine estrogens and coronary heartdisease. Arch Int Med 2006;166:357-65
  • 74. Press Statement IMSIn a subgroup of women demographicallysimilar to those in the WHI, there was nosignificant relation between HT and CHD amongwomen who initiated therapy at least 10 yearsafter the menopause(RR = 0.87, 95% CI 0.69–1.10 for estrogen alone; RR = 0.90, 95% CI 0.62–1.29 for estrogen with progestogen). Feb 2006
  • 75. Press Statement IMSThe estrogen plus progestogen arm of the WHIand the estrogen-alone arm actually showed thatHT does notincrease the risk of coronary heart disease inthe peri- and early menopause,and may even carry beneficial effects. effects Feb 2006
  • 76. Press Statement IMSThe WHI study was not designed, and designedtherefore was not powered, to investigate theconsequences of hormone therapy (HT) inwomen below 60 years of age. Therefore, ageany attempt to present the results of the studyas indicating that HT may inflict damage to theheart in general – a message that was acceptedby many medical societies and regulatory Authoritiesis simply wrong and must be amended. amended
  • 77. Breast Cancer
  • 78. Menopausal women and theirdoctors are scared about the side effects of HRT mainly about breast cancer MNC/05
  • 79. It must be emphasized that we aretalking about an increased incidence ofthe disease, which does notautomatically translate into an increasein deaths from the disease. Baum M. The Breast 2005;14:178-80
  • 80. Extended use of estrogen for10 years increases risks by 0,5%, and by15 years increases risks by 0,9%but..upon cessation of HRT, therelative risk quickly returns to 1.0 ! Coombs N J, Taylor R, Wilcken N. and Boyages J. BMJ 2005;331:347-349
  • 81. Breast Cancer• The diagnosis of a breast cancer after the initiation of a HRT (with a duration of less than 5 years) is only a proof of its growth stimulatory effect (not of its carcinogenic effect)• Therefore, the reversal of the risk to 1 after the cessation of HRT confirms again only its growth promoting effect and denies a carcinogenic effect. Dietel M., Lewis MA. and Shapiro S. Human Reproduction 2005;20:2052-60
  • 82. Breast Cancer• The doubling time of an initial cancer cell, up to the diagnosis of a resultant cell 1cm tumor, is most likely greater than 10 years.• This is why many dormant cancer cells may exist in a “normal” breast ! MNC/05
  • 83. Occult Breast CancerClinically occult in situBC’s are frequent inyoung and middle-agedwomen. Nielsen M et al-Br J Cancer 1987;56:814-9
  • 84. Occult Breast CancerBreast malignancy wasfound in 22 women(20%) Nielsen M et al-Br J Cancer 1987;56:814-9
  • 85. Thus…• Mammographies give more false negative than false positive results !• A “normal” mammography does not exclude the presence of cancer cells that may “explode” a few months later… MNC/05
  • 86. Estrogen replacement therapy inpatients with early breast cancer The mortality rates from breast cancer for the ERT users was 4.28% compared with 22.3% in the nonusers. nonusers Natrajan PK and Gambrell RD. Am J Obstet Gynecol 2002;187:289-95
  • 87. “Recurrent breast cancer was found in 9% of HRT users and 15% of nonuser”. O’Meara ES et al.JNCI 2001;93:754-761
  • 88. Mortality following development of breast cancer while usingoestrogen or oestrogen plus progestin: W Chen, DB Petitti and AM Geiger. British Journal of Cancer 2005;93:392–398
  • 89. This study explored survival afterexposure to oestrogen or oestrogenplus progestin at or in the year prior tobreast cancer diagnosisoestrogen plus progestin usershad lower all-cause mortality andbreast cancer mortalityChen W, Petitti DB and Geiger AM. British Journal of Cancer 2005; 93:392-398
  • 90. Breast cancer survival after hormone exposure
  • 91. Overall survival after hormone exposure
  • 92. A menopausal woman expects from her attending physicianto be receptive to all of her complains,to understand her psychic and physical concerns,to support her insecurity andto help overcome her crisis. crisis MNC/05
  • 93. Many Doctors fail to persuade them to go on with HRT, in despite of telling that the benefits are far greater than any potential risk MNC/05
  • 94. One may easily conclude thatwithout an adequate technique ofcommunication, using the properlanguage,there is no possible helpThus,physicians must acquire expertise inthe technique of communication MNC/05
  • 95. then...let us talk about Risks... Risks
  • 96. Are there risks?It is crucial that information be givenabout the difference between relativerisks and absolute risks, since the latter risksare the major cause of misinformation andalarmism, being the favorites of themedia… MNC/05
  • 97. Example of Risks• If you buy one lottery ticket you will have a one in 1 million chance of winning (“absolute risk”) 1x 10 6• If you buy five lottery tickets your chances are five fold higher or 5 in one million (“absolute risk”) 5x 10 6• Your chances of winning are increased by five fold (“relative risk”) 5.0
  • 98. Relative RiskThe risk of an event occuringunder certain circumstancescompared to the risk underother circumstances
  • 99. Attributable or Excess RiskThe difference betweenunderlying risk and risk whenreceiving HT is called theattributable or excess risk
  • 100. Do not confuse… Relative Riskwith Absolute Risk!
  • 101. Conclusion• Relative risk is a confusing word and is only important if the absolute chances of an event are high• Attributable or excess risk is the thing that one should be most concerned about
  • 102. ValidityInternal: the study measured what is set out to measureExternal: the results can be extrapolated to one’s patients Observational research (NHS) may have poorer internal validity better external validity Randomized controlled trial (WHI) better internal validity poorer external validity MNC/04
  • 103. Confidence interval (C.I.)A 95% C.I. signifies that there is a 95%chance that the population “true value”lies between the two limits.If C.I. crosses the “line of nodifference” the point at which a benefitbecomes a harm (i.e.1) then one canconclude that the results are notstatiscally significant MNC/04
  • 104. Risks of women medicated with E+P (5.2 years) women
  • 105. Risks of women medicated with E only (6.8 years) women
  • 106. Risks of Breast Canceraccording to different factors
  • 107. “It appears that half of thebenefits in the prevention ofcardiovascular diseases arenot hormone related”! Mosca L, Grundy SM, Judelson D, et al. Circulation 99;99:2480-4
  • 108. Nurses’s Health Studyfrom 1980 to 1994 CHD ↓ 31% ↓ Smoking ↓ 13% ↑ Obesity ↑ 8% ↑ THS ↓ 9% ↑ Better nutrition ↓ 16%Hu FB, Grodstein F et al. Trends in the Incidence of Coronary HeartDisease and Changes in Diet and Lifestyle in Women. NEJM2000;343:530-537.
  • 109. Can side effects be minimized ?
  • 110. What about the best treatments during the climacterium and beyond?Little attention is paid to otherpharmacological interventions (nonhormonal) and strategies that have beenshown to be important for theprevention of diseases and to maintain orimprove health. MNC/05
  • 111. Hippocrates promoted specific diets to prevent and cure diseases, such as illnesses of the heart.Lyons AS et al. In Medicine: an illustrated History. New York:Abradale Press,1990:20719
  • 112. The PolymealFranco O et al. BMJ 2004;329:1447-50
  • 113. Doctors could retrain asPolymeal chefs or wine advisersThe Polymeal—an evidence based menu thatincludes, wine, fish, dark chocolate fruits,vegetables, garlic, and almonds—promises to be an almondseffective, safe, cheap, and tasty solution to reducingcardiovascular morbidity and increasing lifeexpectancy.Polymeal could reduce cardiovascular disease bymore than 75%. Franco O et al. BMJ 2004;329:1447-50
  • 114. The PolypillWald N and Law M. BMJ 2003;326:1419-25
  • 115. Wald N and Law M. BMJ 2003;326:1419-25
  • 116. One third of people taking this pill fromage 55 would benefit, gaining onaverage about 11 years of life free froman IHD event or stroke. Wald N and Law M. BMJ 2003;326:1419-25
  • 117. Moderate exercise cuts breast cancer biomarkers in postmenopausal women Increased physical activity significantly reduces serum estrogens in postmenopausal women and thus may reduce the risk of breast cancer. McTiernan A. Cancer Res 2004;364:2923-8
  • 118. Aspirin could be used to prevent cancerThree recently published studies indicatethat aspirin, already enjoying a secondlease of life in the prevention of heartdisease, may soon become a first line ofdefense against cancer. London O. BMJ 2003;326:565
  • 119. In conclusion …and to make a long story short…
  • 120. There are no really “safe” biological active drugs...There are only “safe” physicians ! Kaminetzy HA 1993
  • 121. “Each time we learn something new, theastonishment comes from the recognitionthat we were wrong before…I truth, whe ne ve r we d is c o ve r a ne w fa c t, it ninvo lve s the e lim ina tio n o f o ld o ne s . . .thus, as it turns out,WE ARE ALWAYS IN ERROR ! ” Le wis Tho m a s Eng lis h Bio lo g is t (1 9 1 3 -1 9 9 3 )
  • 122. My Message is:.To prescribe postmenopausal hormonal treatments when clinically indicated, if not contraindicated. No answers from ongoing clinical trials are indispensable to practice today a good Medicine MNC/05
  • 123. To know the disease that a woman hasis as important asto knowthe woman who has the disease William Osler
  • 124. What are the best recommendations of the climacteric woman’s doctor? 1. Understand what is happening to the body during the climacteric and the postmenopause 2. Mental occupation 3. Physical exercise 4. Proper nutrition (moderate consumption of red wine, and abundant fish, vegetables, fruits, soy, milk, garlic, chocolate, etc) 5. Keep the body mass index (BMI) within normal limits 6. Keep a normal girdle/hip ratio, waist circumference 7. Refrain from smoking 8. Keep a normal blood pressure 9. Keep the blood lipids within normal values (statins?) 10. Examine the breasts (palpation, inspection, mammography)
  • 125. What about the best treatments during the climacterium and beyond?There is a general tendency to considerthat sex steroid hormones are the onlyinstruments with which to treat womenwhen they enter in the climacteric phaseof their lives… MNC/05
  • 126. Which is the best treatment?In general terms, is the one that is wiselyindicated, if not contraindicated, afterbalancing benefits and risks, of all strategiesand interventions, hormonal or not.It must be aimed at specific objectives andtargets that will be monitored at regular intervalsin order to determine its efficacy and to estimatethe occurrence of any side effects, a conditionthat will determine its duration. MNC/05
  • 127. Which is the best treatment?Patient needs and preferences are decisive, based on decisivethe doctors’ advice. Let it not be forgotten that althoughmany treatments are available, they are neverthelessnot indispensable. Doctors have the duty to give their indispensablebest unbiased information to their patients so that theymay make the right choices and then be compliant. compliantThe woman is the decision maker, if the doctorsees no contraindication.thus,the best treatment is what a wellinformed woman has chosen. MNC/05
  • 128. I personally believe that for the healthyearly post menopausal woman the long termHT’s, other than relieving vasomotorsymptoms, may play an important role inimproving QoL and in the prevention ofCVD, osteoporosis and Alzheimer, undersurveillance.Systemic (parenteral) estrogens, added estrogenswhen needed to vaginal progesterone orprogestagen loaded IUD’s, may be very IUD’sbeneficial, largely overpassing minimalrisks. MNC/05
  • 129. The conclusions of the WHI trial suggest that the“safe “ woman (NNH between 600-1000 women) to initiate HT is - between 50-59 years of age - with vasomotor symptoms - less than 10 years after the menopause - being treated with statins - with a good lipid profile and - with a Body Mass Index >25 Neves-e-Castro M. Human Reproduction 2003;18:2512-2518
  • 130. This is precisely the profile of the greatmajority of women who come forconsultation after their menopause.Therefore it seems that what mostgynecologists are doing to theirpredominant population of patients is notunsafe and contributes not only to agood quality of life but to prevention, aswell. Neves-e-Castro M. Human Reproduction 2003;18:2512-2518
  • 131. Postmenopausal hormone therapy: critical reappraisal and unified hypothesis 83:558-66
  • 132. Do others agree ?
  • 133. “He who learns,but does not think is lost.He who thinks, but does not learn is dangerous”. dangerous Confucius
  • 134. If we both learn and think we will neither be lost nor dangerous to our postmenopausal women patients” Wenger NK. Am J Geriatr Cardiol 2000;9:204-9
  • 135. NAMS position statement onestrogen and progestagen use inperi-and postmenopausal women Revised breast cancer statements indicate that the risk of breast cancer probably increases with EPT use but not with ET use.
  • 136. NAMS position statement onestrogen and progestagen use inperi-and postmenopausal women Place no limit on ET/EPT treatment duration, provided it is consistent with duration treatment goals; if monitored regularly, no stipulation is made regarding when to reduce or stop therapy
  • 137. If there are no incoming contraindicationswe see no reason to establish a time limitto the duration of therapy, mainly if there isa recovery of symptoms after itsdiscontinuationCochrane B, NAMS 2004, P53IMS www.imsociety.orgNAMS www.menopause.org
  • 138. Evidence informed practice• It is clearly time to change “evidence based medicine” to “evidence informed practice”. practice• I suggest the era of evidence informed rather than evidence based medicine has arrived Glasziou P. Centre for Evidence-Based Medicine. University of Medicine Oxford OX3 7LF. BMJ 2005;330:92
  • 139. What has been learned from themajor observational studies and clinical trials? the first lesson systematically administered progestagens may in part suppress some of the beneficial effects of estrogens and may also slightly increase the risk of breast cancer after treatments with duration greater than five years.
  • 140. What has been learned from themajor observational studies and clinical trials? the second lesson estrogens, when given alone to histerectomized women, did not appear to minimally affect the risk for breast cancer when compared with controls MNC/05
  • 141. What has been learned from themajor observational studies and clinical trials? the third lesson Metabolic effects of estrogens and progestagens, as a whole, can differ depending on the route of administration, i.e. oral vs. parentheral, and on the combination of both, in a sequential regimen or in continuous combined administration. MNC/05
  • 142. What has been learned from themajor observational studies and clinical trials? the fourth lesson Hormonal treatments are the first choice for vasomotor symptom relief as long as they are needed (on and off assessment). They should not be used for the secondary prevention of CVD, when atheroma plaques CVD are already present. MNC/05
  • 143. What has been learned from themajor observational studies and clinical trials? the fourth lesson (cont) Conversely, they may protect from CVD if started early during the transition into the post menopause. menopause Hormonal treatments are preventive of osteopenia and osteoporosis at any stage in life MNC/05
  • 144. What has been learned from themajor observational studies and clinical trials? the fifth lesson Estrogens may prevent degenerative lesions of the CNS since, so far, they seem to be the only available drugs with nerve growth effects MNC/05
  • 145. Preventing a woman from thebenefits of a sound postmenopausal hormone therapy because of the fear of rare side effects does not seem to be satisfactory Medicine... M.Neves-e-Castro, 2000
  • 146. Primum non nocere : neither by excess, nor by deffect … M.Neves-e-Castro
  • 147. and now... see thedifferences... in QoL :
  • 148. like this one ?...
  • 149. Secret for longevity !
  • 150. Secret for longevityA passerby noticed an old lady sitting on her front step:”I couldn’t help noticinghow happy you look! What is your secret for such a long, happy life?”
  • 151. Secret for longevity A passerby noticed an old lady sitting on her front step:”I couldn’t help noticing how happy you look! What is your secret for such a long, happy life?!”“I smoke 4 packs of cigarettes a day,”she said. “Before I go to bed, I smoke a nicebig joint. Apart from that, I drink a whole bottle of Jack Daniels every week, andeat only junk food. On weekends I pop a huge number of pills and do no exerciseat all.”
  • 152. Secret for longevity A passerby noticed an old lady sitting on her front step:”I couldn’t help noticing how happy you look! What is your secret for such a long, happy life?!”“This is absolutely amazing at your age!!!!”, says the passerby. “How old are you?”
  • 153. I’m 24 I’m 24years years old... old...
  • 154. or like these?…
  • 155. They are living after “MATURE WOMEN’S MEDICINE”!(hormones, life style, nutrition, exercise, etc)
  • 156. A WOMAN in the autumn of her lifedeserves an indian summer rather than a winter of discontent ... Robert B Greenblatt
  • 157. and now...this is not the end...nor even the begining of the end.It is perhaps,the end of the begining ! Winston Churchill
  • 158. This is what I have learned