The menopause may be
Natural or induced
Natural menopause - the permanent cessation of menstruation for 12 months caused by failure of ovarian function with elevated gonadotropins (FSH, LH).
Average is 51 years
Dr. Ann Steiner, Clinical Professor of OBGYN at Penn Medicine, discusses the changes that happen as a woman's body goes through menopause, as well as treating symptoms that result from these hormonal changes.
The menopause may be
Natural or induced
Natural menopause - the permanent cessation of menstruation for 12 months caused by failure of ovarian function with elevated gonadotropins (FSH, LH).
Average is 51 years
Dr. Ann Steiner, Clinical Professor of OBGYN at Penn Medicine, discusses the changes that happen as a woman's body goes through menopause, as well as treating symptoms that result from these hormonal changes.
Our patient accounts staff answers to frequently asked billing questions at Summit Medical Group. Topics include bringing your insurance card to all medical visits, the ABC's of co-pays, deductibles and co-insurance, and the difference between in-network and out-of-network services.
WELCOME to Big Idea Guru. This is the place and platform where ideas are allowed to flow,to excrete your brain juices and even display your ideas.
of course let's start with ours first :) we have a whole range of tote bags, shoulder sling bags, cartoon character bags and many more!
what's more is we have our specially designed bookmarks. All handmade uniquely designed by me, so you can't find anywhere else! you are able to find some of my works at novena square too :) enjoy..
Ronna Sherman, MD, has expertise in weight management, women's health, and internal medicine. She is located in the 233 Millburn Avenue office of the Summit Medical Group, in Millburn, New Jersey. In this presentation, first given on our Berkeley Heights campus, Doctor Sherman discusses menopause
Everything You Ever Wanted To Know About Your Child's NutritionSummit Health
New and experienced parents are invited to join us and learn about good nutrition and healthy dietary habits that can help children achieve and maintain a healthy weight for life!
BEATING THE BLUES: PRACTICAL SOLUTIONS FOR A COMMON HEALTH PROBLEMSummit Health
Lecture on depression, including information about causes, symptoms, and treatment. Learn to distinguish depression from feeling down. Find out how practical techniques can help improve short-term and long-term blue moods, sadness, and depression.
What Women Need to Know About Heart DiseaseSummit Health
Do you know your risk for cardiac disease? Take a closer look at guidelines, tools, and techniques that can assess your own risk and learn the latest on preventing cardiovascular disease. This community lecture at Summit Medical Group offers information regarding cardiac screenings such as cholesterol testing, calcium scoring, stress testing and echocardiograms .
Susan L. Simandl, MD, FACC http://www.summitmedicalgroup.com/doctor/ssimandl/
Suzanne Shugg, BSN, MSN, RN, ACNP, DNP http://www.summitmedicalgroup.com/doctor/sshugg/
Are you age 40 years or older and finding it difficult to lose weight? Learn how your age, menopause and hormones can affect weight loss. Find out about strategies that can help you maintain a healthy weight.
Women are as unique as their fingerprints, inside and outside. It is this fundamental premise that prompted Marla Ahlgrimm R. Ph. nearly 30 years ago to develop her revolutionary approach to helping women balance their unique hormone fingerprint, bioidentically, one woman at a time, with The Restore® Program. Learn why and how in this presentation.
Global Medical Cures™ | Womens Health- HORMONES & MENOPAUSE
DISCLAIMER-
Global Medical Cures™ does not offer any medical advice, diagnosis, treatment or recommendations. Only your healthcare provider/physician can offer you information and recommendations for you to decide about your healthcare choices.
A slight description on contraception, its types along with a brief explanation on Oral Contraceptives. Types of oral contraceptives, it's types, mechanism of action, contraindications, dosing, advantages, disadvantages, risk, benefit amd recent research trends.
A discussion of hormones that affect women and how to stay balanced and optimize women's health through the stages of menopause. Treatment options including nutrition, lifestyle modification, hormone replacement therapy, herbal and botanical options, and bioidentical hormones discussed.
Birth control pills (oral contraceptives) are prescription medications that prevent pregnancy.
Birth control (contraceptive) medications contain hormones (estrogen and progesterone, or progesterone alone).
Pediatric Talk: Managing Arthritis During the Holidays - Dr. Marla Guzman - ...Summit Health
While holiday celebrations and activities are great fun, it’s also a disruptor to the daily routine. Our expert will share tips to help you navigate holiday season stressors to minimize your child’s risk of a potential flare-up. This virtual event is hosted by the Arthritis Foundation.
Safety and Success in a Post-Pandemic Society - Daniela Accurso, MD, MPH - 7...Summit Health
The Covid-19 Pandemic has been a health crises that we have been fighting for the last year and a half. Dr. Accurso’s presentation is focused on reviewing how far we have come as a society and to address the questions, health concerns, and important precautions we need to take as we integrate ourselves back into a healthy community.
Melanoma: Prevention, Detection and Treatment - Stephanie Badalamenti, MD - L...Summit Health
Sun safety needs to start at an early age, and continue throughout life, in order to reduce the risk for skin cancer. Learn about prevention and ways to reduce your risk, screening for skin cancer and innovations in treatments.
Melanoma: Prevention, Detection and Treatment - Stephanie Badalamenti, MD - L...Summit Health
Sun safety needs to start at an early age, and continue throughout life, in order to reduce the risk for skin cancer. Learn about prevention and ways to reduce your risk, screening for skin cancer and innovations in treatments.
Shoulder Pain Relief: Common Rotator Cuff Injuries & Treatment Options - And...Summit Health
If you are experiencing shoulder pain, a rotator cuff tear could be the issue. Learn about how, and why, rotator cuff tears happen, how the condition and severity is diagnosed, and the non-surgical and surgical treatment options available.
My Knee Hurts! A Look at Joint Pain in Children - Marla Guzman, MD - 1.12.2021Summit Health
Is your child complaining of joint pain? Learn about concerning symptoms and when to seek medical advice. Our expert discusses the various causes of joint pains in children, how a pediatric rheumatologist evaluates musculoskeletal complaints, and available treatment options.
Mildred “Mitch” Bentler, MA, RD, CSP, CDE, presented a virtual lecture at on diabetes prevention. According to Ms. Bentler,
“A combination of small changes can really make an impact on lowering your blood sugar. Increasing physical activity and adopting healthier eating habits can go a long way to reducing your diabetes risk.”
Why Does My Stomach Ache? - Dennis Han, MD, Gastroenterologist - Morristown &...Summit Health
Do you have stomach issues which are bothering you and you can't figure out why? Learn about conditions that could be causing abdominal pain or discomfort at this virtual program. Our expert will discuss different conditions such as: Irritable Bowel Syndrome; Inflammatory Bowel Disease; Celiac Disease and other conditions that require a gluten-free diet; and GERD (Reflux). He will explain the differences between these various conditions, how they are diagnosed, and treatment options available. Hosted by Morristown & Morris Township Public Library.
Know Your Numbers and What They Mean for Your Overall Health - Madison Public...Summit Health
What does your blood pressure, BMI, cholesterol, blood sugar and vitamin levels tell you about your health? Our expert will discuss how these numbers tell a story, and why it’s important to understand what that story means to your overall health. Dr. Im-Imamura will also share tips for helping you get these numbers where they should be, and how increasing physical activity and improving nutrition are key factors that can impact those numbers in a good way.
Presented as part of the Madison Public Library Virtual Seminar Series.
Understanding Knee Arthritis and Cartilage Disorders - Maurice M. Pine Free P...Summit Health
Many people suffer from pain, swelling, stiffness, and loss of knee function as a result of knee arthritis. Our expert will discuss the causes, symptoms, and nonsurgical and surgical treatment options available. Hosted by Maurice M. Pine Free Public Library.
Pulmonologist, Jenny Kim, MD, FCCP of our Sleep Disorders Center partnered with the Livingston Health Department to present, Can’t Sleep? The ABCs of Your ZZZs to the community. During the session, Dr. Kim discussed tips for improving sleep and treatment options for common sleep disorders.
Christina Lavner, RDN, Nutrition Services, presented Healthy Eating for Cancer Survivorship, as the second session of our Now What? A Cancer Survivorship Speaker Series for patients wanting to learn more about nutrition that will benefit them during and after treatment. Be sure to check out upcoming presenters in this series and pass the word on to any patients you think would be interested in the information. The next presentation in this series is November 16, Coping with Treatment Side Effects, presented by Constance Gore, RN-APN
Guide to Eating an Anti-Inflammatory Diet Virtual Lecture - Christina Lavner,...Summit Health
An anti-inflammatory diet, along with exercise, can yield many health benefits, such as improved symptoms of many chronic conditions, reduced cancer risk, and a lower risk of obesity, heart disease, and diabetes. Learn more about this healthy way of eating and how to get started.
While most common in teens, the onset of acne can be troubling at any age. Depending on its severity, acne can cause emotional distress and scar the skin. The earlier you start treatment, the lower your risk of such problems. Learn about the causes of acne and effective treatment options for adolescents and adults.
Living a Heart Healthy Life - Liliana Cohen - West Orange Public Library - 2....Summit Health
Learn how to make healthy choices that impact heart health, the typical mistakes to avoid, and how to recognize the signs and symptoms of a heart attack.
Heart of the Matter - Ali Ahmad, MD, FACC - Livingston Library - 1.6.2020Summit Health
Heart disease is the leading killer of adults nationwide and it carries a significant morbidity for the population at risk. Learn about traditional and non-traditional risk factors associated with coronary artery disease, and how to modify your risk and prevent heart disease. Also, learn about how heart disease affects different ethnic backgrounds, particularly the high-risk groups, such as South Asians.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
2. Vasomotor Symptoms=Hot Flushes
• Estrogen alone or combined with
Progesterone, 75% reduction in flashes
• Orally or transdermally, in patches, gels and
sprays
• Low dose also effective; Ultra low dose not
effective, and not FDA approved
• Risks are thromboembolic disease and breast
cancer
3. Women’s Health Initiative Study, 1999
•
•
•
•
Primary focus was heart disease prevention
Average age of study participants was 63
Women had no menopausal symptoms
Women hadsignificant other medical
problems
• Maybe estrogen was triggering events in
patients who already had atherosclerosis?
• Study ended prematurely
4.
5. • Synthetic products
• Binds to many receptors giving side effects (fluid
retention, acne, weight gain, sugar intolerance)
• Can cause anxiety/irritability in central nervous
system
• Blunts estrogen’s favorable impact on lipids
• Stimulates breast cells
• Constricts blood vessel, increases heart disease
6. • Post WHI 2002:
• 50% decline in conventional hormone therapy
prescriptions in first 6 months
• Many patients turned to compounded therapy
• Many chose alternative therapies
• Discontinuation of HT-50% have recurrent
symptoms.
• No guidelines on discontinuing abruptly or
tapering
7. FDA Clearly States
“Other doses of estrogens and
progestins and other combinations
were not studied in the WHI trials,
in absence of data these risks
should be assumed to be similar”
8. Kronos Early Estrogen
Prevention Study (KEEPS) @ 2007
• Purpose: to evaluate progression of
atherosclerosis which causes heart disease
• Four year trial in women aged 42-58 with a
uterus, started on estrogen within 3 years of
menopause
• Received one of three treatments with
progesterone:
Oral estrogen, Transdermal, or Placebo
Brain Research 2013;1514:12-17
9.
10. North American Menopause Society
2012 Position Statement
• Individualization is of key importance in the decision to
use HT and should incorporate the woman’s health and
quality of life….as well as her personal risk factors.
• The recommendation for duration of therapy differs
for EPT and ET. For EPT, duration is limited by the
increased risk of breast cancer associated with 3-5
years of use; for ET a more favorable risk profile during
a mean of 7 years of use, allows more flexibility in the
duration of use
•
Menopause 2012;19(3):257-271
11. Global Consensus Statement on HRT (2013)
• Key Conclusions
• Benefits outweigh risks for women under 60 or
within 10 years of menopause
• HRT is effective for symptoms related to
menopause such as hot flashes, sleep, bone
health.
• Taking HRT should be individualized and made
in consultation with a qualified physician.
•
Maturitas 2013;74:391-92.
12. •
Bioidentical (native) Some are FDA approved
• “Natural”- found in nature, derived from pregnant mares urine
(thus the name Premarin)
Estrone sulfate (human bioidentical)
Equilin sulfate (native to horses)
• Synthetic- made in a laboratory, broken down in stomach to be
estradiol
13. What does it mean to be a bioidentical hormone?
– Derived from plants
– Claimed to be similar to human hormones, i.e. acts
like estrogen and progesterone
– Sometimes used to treat menopause symptoms
– Not from an animal, not synthetic (man-made)
14. FDA-approved Hormones for Menopausal Symptoms
Type/source
Estrogens
Brand name(s)
Form
Bioidentical?
Pill
No
Vaginal cream
No
Conjugated equine estrogens
(CEE)/pregnant mares’ urine
Premarin
Synthetic conjugated estrogens/plants
Cenestin, Enjuvia
Pill
No
Esterified estrogens/plants
Menest
Pill
No
Estrace, others
Pill
Yes*
Alora, Climara, Esclim,
Estraderm, Vivelle,
others
Patch
Yes
Estrogel
Transdermal gel
Yes
Estrasorb
Topical cream
Yes
Estrace
Vaginal cream**
Yes
Estring
Vaginal ring**
Yes
Ortho-Est, Ogen, others
Pill
No
Ogen
Vaginal cream**
No
Estradiol acetate
Femring
Vaginal ring
Yes
Estradiol hemihydrate
Ethinyl estradiol
Vagifem
Estinyl
Vaginal tablet**
Pill
Yes
No
17 beta-estradiol/plants ++Micronized
(Particles are made smaller for better
absorption)++
Estropipate (modified estrone)/plants
15. Progestins, micronized progesterone
Medroxyprogesterone acetate (MPA)
Brand Name
Form
Bioidentical
Amen, Cycrin, Provera
Pill
No
Prometrium
Pill
Yes
Prochieve 4%
Vaginal gel
Yes
Norgestrel
Ovrette
Pill
No
Norethindrone
Micronor, Nor-QD, others
Pill
No
Norethindrone acetate
Aygestin, others
Pill
No
CEE and MPA
Premphase, Prempro
Pill
No
Ethinyl estradiol and norethindrone acetate
Femhrt
Pill
No
Activella
Pill
No
Combipatch
Patch
No~
17 beta-estradiol and norgestimate
Prefest
Pill
No~
17 beta-estradiol and levonorgestrel
Climara Pro
Patch
No~
Micronized progesterone USP
Combined hormones
17 beta-estradiol and norethindrone acetate
16. – Compounded* bioidentical hormones NOT FDA
approved
• Considered a dietary supplement
• No rigorous testing required
– As a dietary supplement, the burden for the FDA is
to prove it is unsafe rather than effective
*Compounded hormone = mixed by pharmacists as prescribed by practitioners
18. • Estriol not available as single agent tablet in
USA, required to have “new drug” application
for FDA approval
• No safety studies for Biest or Triest
• No studies showing native hormones prevent
bone loss
19. Popular prescription method
• Variable dose over 28 day cycle
• Topical Application
Background on Wiley
• Author but not a physician
• No supporting scientific data
20. • “Ultrafiltrate” of blood; should be able to
measure free hormone available
• Measures deficiencies in order to customize
PROBLEMS
• No agreement between blood and saliva levels
• Saliva levels vary with diet and time of day
(need to measure 5x/day)
21. Dosing according to symptom response, NOT
blood levels. End points:
• Control of vasomotor symptoms (hot
flushes)
• Reversal of vaginal atrophy (dryness)
• insomnia improvement
FDA has not approved any bioidentical
combination product
23. COMPOUNDED PROGESTERONE
for menopausal symptoms
May not protect uterine lining
Doesn’t prevent osteoporosis,
Doesn’t eradicate symptoms,
so why would we use it by itself?
24. TESTOSTERONE
• Patch used for Hypoactive Sexual Desire
Disorder
• Increase in number of satisfying sexual
episodes from .5 (placebo) to 2.1(testosterone
patch)
• May change lipid profile unfavorably
Blood tests inaccurate in women
Again, not FDA approved
25. In patient’s with uterus in place, means taking two products,
and therefore, more cost
FDA products more likely to be covered by insurance
Compounded products more expensive overall
Conflict if doctor also selling product
More likely to be offered to economically more advantaged
Women seek it out to restore sexual well-being; may be
psychologically more vulnerable
26. •
•
•
•
•
Other Useful Agents-not estrogens
Progesterone alone may help hot flashes when used
alone, but safety unclear
Testosterone alone not FDA approved, shows no benefit
and has male hormone side effects. When used with HT,
improved sexual function scores
Clonidine- medication to lower BP, not FDA approved
for menopause symptoms
Gabapentin (Neurontin) anti-seizure, 45% effective in
studies, not FDA approved
SSRIs-anti depressants-Paroxetine (Paxil) is ONLY nonhormonal therapy that is FDA APPROVED
27. •Anti-depressant, not a hormone
•Hot flashes decreased by 55% in Lexapro group, 35% in
placebo group
•Women felt that 1.4 fewer hot flushes/day was a meaningful
improvement
•Similar result to other drugs in this category-area of exploration
•Strong placebo effect which means non-medical factors were
Important
JAMA.2011;305(3):267-274. doi:10.1001/jama.2010.
28. Selective Estrogen Receptor Modulators (SERMs)
Definition:
Synthetic compounds that selectively stimulate or inhibit the estrogen
receptors of different target tissues
Estrogen receptors in different target tissues vary in chemical structure
Example: Tamoxifen: inhibits breast tissue, but stimulates uterus
Evista: inhibits breast tissue, stimulates bone,
neutral on the uterus
New Product Bazedoxifene
Negative on the uterus, stimulates bone
29. Brand New: HT/SERM combination product known as a
Tissue Selective Estrogen Complex (TSEC)
Ideally, this combination would have the positive
attributes of both drug categories with fewer
undesirable side effects.
Alleviates hot flushes (estrogen)
Treat vaginal dryness (estrogen)
Protect against bone loss (both)
Would not stimulate the uterus (serm)
Does not require Progesterone (serm)
31. Alternative Therapies for
Menopausal Hot Flushes
• Phytoestrogens-plants substances with estrogenic biologic
activity-no benefit, not detrimental, not studied well
• Vitamins-limited data; Vitamin E (800 IU) effect was one less
hot flush/day
• Acupuncture-no benefit over placebo
• Reflexology-no benefit over foot massage
• Exercise-no significant improvement in hot flushes, but sense
of well-being
• Decrease alcohol and caffeine-slight benefit
• Placebo alone can have significant impact on flushes
32. • Good Manufacturing Practices (GMPs)-companies
must comply
• US Pharmocopeia (USP)
• National Sanitation Foundation (NSF)
• ConsumerLab-manufacturer can pay to have
product tested and listed on website
(Consumerlab.com)
• Although there is some supervision of this industry,
not sufficient data to support use for menopause
symptoms
35. Hormonal Treatment of Vaginal Dryness
and Painful Intercourse
• Local therapy in form of creams, rings, and vaginal
tablets (Estring, Estrace, Vagifem…)
• Local therapy does not require progesterone to
protect uterine lining
• May actually help urinary symptoms
• Patients with previous history of breast cancer often
eligible for vaginal estrogen after consultation with
oncologist
36. Vaginal Lubricants
• Lubricants reduce friction and pain related to
dryness during sex
• Moisturizers trap moisture and provide long
term relief- may reduce irritation, improve
acid-base balance
37. Ospemifene (Osphena) for
Vaginal Dryness
•
•
•
•
Oral product, SERM category of drug
Estrogen receptor stimulant on vaginal tissue
Does not stimulate the uterine lining
FDA approved for treatment of moderate-to-severe
dryness causing painful sex
• Side Effects: hot flushes, vaginal discharge, excessive
sweating
• Benefit: easy to take tablet
39. Sleep Hygiene
Sleep only as much as you need to feel refreshed the next day
•Maintain a regular sleep and wake pattern 7 days a week.
•Avoid napping during the day; it can disturb the normal pattern of
sleep and wakefulness
•Avoid stimulants, such as caffeine, nicotine and alcohol, too close to
bedtime.
•Exercise can promote good sleep. Vigorous exercise should be taken
in the morning or late afternoon. A relaxing exercise, like yoga, can be
done before bed to help initiate a restful night’s sleep.
•Food can be disruptive right before sleep; stay away from large meals
close to bed time.
40. More Sleep Hygiene
•
Associate your bed with sleep and sex only. It is not a good idea to use your bed
to watch television, listen to the radio or read.
• Make sure that the sleep environment is pleasant and relaxing. The bed should
be comfortable and the room should not be too hot, too cold or too bright.
• Establish a relaxing bed time routine. Try to avoid emotionally upsetting
conversations and activities before trying to go to sleep.
• Do not take your problems to bed. If necessary, plan some time earlier in the
evening for working on your problems.
• If you are unable to sleep, do not try harder and harder to fall asleep. Instead,
turn on the light, leave the bedroom and do something different, like reading a
boring book. Do not engage in stimulating or productive activity. Return to bed
only when you are sleepy. Get up at your regular time the next day no matter
how little you slept.
• Do not look at clock, turn it away
Source; Modified from the Thoray M Sleep hygiene; a new era CPAP therapy.
Arlington (VA): National Sleep Foundation; 2003.
41.
42. • More specific binding to JUST progesterone
receptors
• Mild diuretic
• Mild sedative effects (helps sleep)
• No effect on lipids
• Does not stimulate breast
• Relaxes blood vessels, decreases plaque
formation
Ended prematurely b/c breast cancer, chd, stroke and PE. Hysterectomy arm stopped b/c no cv benefit
Patients with the uterus in place must take both products so that estrogen doesn’t overstimulate the lining of the uterus. Note the difference when the progesterone is added, let’s look at some of the side effects of progesterone
Hard to know if these characteristics have any impact on the outcome of the WHI study
Suggests that we need to extrapolate from the WHI study and apply the same concerns to other forms of estrogen
There was a need for another study. Measured by carotid intima media thickness and coronary arterial calcification
Focus needs to be on the last bullet point, trial is still ongoing. Transdermal is associated with slightly lower risk of clot
So let’s review various types of ERT, bioidentical doesn’t mean better, it is just an attractive attribute. All birth control pills are synthetic to put it into perspective
But these levels don’t matter because prescribing guidelines have been set
You need to know what you are getting.
And finally some other reasons not to take compounded products
Was progesterone the culprit in the combined therapy of WHI
Gabapentin side effects dizziness, somnolence, swelling
This study was in the Journal of the American Medical Association. It is possible that many anti-depressants in this category would be effective
Brings us to a new category of products. Serms can act differently in different areas of the body. Biochemists design the product to attach to a particular location on the tissue in a very specific way to achieve the desired result.
Here are many organizations regulating the herbal industry
Even though 40% of men have erectile dysfunction at some point, vaginal dryness is a major concern because there are many products like Viagra that overcome this issue for male partners
I think to take this systemically without it having nay impact on hot flushes is slightly excessive when the local vaginal agents work well and it can get to the point where they only need to be used once weekly.
Many pts complain of waking during the night and first it has to be determined what wakes them. Sometimes it is to urinate, sometimes a hot flush, but if there is no apparent reason these steps can be helpful.
Consider sleep study to eliminate sleep apnea diagnosis. New apparatus is much better, more cosmetic and acceptable to patients