Index   --   WPGYN Newsletter  --  Volume 10, Issue 3,  July 2013

My Favorite Supplements — now available at WPMG

Many women ask us about which supplements we recommend, and we have had several requests that we make them available through the office.  We hope this will add to your convenience.  We support the use of those below and I'd like to tell you why.

The first is Vitamin D.  I have encouraged many of you to use this supplement as many women show insufficient levels of Vitamin D in their blood if they don't use supplements.  The clearest need for Vitamin D is in the area of bone health where a blood level above 32 has been associated with a decreased rate of fractures.  Studies are still being done in the area of heart disease, but a recent meta-analysis by Wang out of Harvard showed the risk of heart disease decreased as the Vitamin D levels increased from a level of 20 to 60 with a 52% decrease in all cardiovascular disease and a 42% decrease for cardiovascular mortality.  There is also preliminary research suggesting Vitamin D deficiency may significantly increase the risk of breast cancer and possibly other cancers as well.  We are carrying Vit D in liquid form with 1 drop is equal to 1000 IU.  You can take 1 drop a day, 10 per week, or whatever dose brings you to a sufficient Vitamin D level.  With 273,000 servings in a bottle, it is very cost-effective.

The second product is called Estrovera and is a non-estrogen treatment for the symptoms of menopause made from rhubarb root by Metagenics.  This phytonutrient has been shown in randomized controlled clinical studies to significantly reduce hot flashes and night sweats, as well as having beneficial effects on sleep, mood, fatigue, and sexual function.  Most women see some improvement in 4 weeks though maximum benefit may take up to 3 months.  In studies up to 24 months, there were no safety concerns.   In this newsletter, you will find more detailed discussion of menopause management using hormone replacement, but many women cannot take hormone replacement due to breast cancer, heart disease, coagulation abnormalities, or stroke risks, so Estrovera can be useful as an alternative.

The third product is EPA-DHA, a highly concentrated source of health-promoting omega-3 essential fatty acids from cold-water fish in Norway.  This supplement has been shown to improve triglycerides and cardiovascular health, as well as improve mood, and decrease inflammation.  This formulation by Metagenics has been refined to remove heavy metals and other environmental pollutants. The purified form does not result in a “fishy” taste or odor. 

The best source of vitamins and minerals is always natural food products in a healthy diet that includes lots of fruit and vegetables, fish, chicken, and milk products. Not everyone needs supplements.  But, in answer to your questions, Yes, I do take the above supplements. 

Menopause

Summer is here with a record heat wave for Northern California.  This time of year can be challenging for some women in perimenopause/ menopause who may have peeled off all possible layers and still feel like an internal furnace is burning.  I haven’t tackled this topic in a newsletter before because the opinions and guidelines have been controversial ever since the Women’s Health Initiative (WHI) report came out in 2002.  Recently, we are starting to see more consensus among experts as to rational management of menopausal symptoms.  Thank goodness!

What happens at menopause?

Menopause is a time when the ovaries stop producing the estrogen and progesterone hormones that lead to menstrual cycling.  The average age when periods stop is 51, but with a broad range anywhere from 45 to 55.  Some women are barely aware that their periods have stopped, but 75% of women will experience symptoms and some feel like they’ve “fallen off a cliff” with dramatic changes in their quality of life.  Hot flashes, night sweats, sleep disturbances, moodiness, fatigue, weight gain and decrease in sex drive may significantly affect a woman’s normal ability to function.  Symptoms may last from 3 months to 5 years, and in some women will never resolve without treatment.

What treatments work in menopause?

 The most effective treatment for the symptoms of menopause are estrogen (for women without a uterus) or estrogen and progesterone (for women who still have their uterus in place).  These result in significant relief >90% of the time compared to placebo effectiveness about 40% of the time.   There are many different forms of hormones including pills, patches, gels, creams, and sprays.

Just last month, in a controversial move, the FDA approved the first non-hormonal treatment for hot flashes called Brisdelle (generic name paroxetine).  This is an SSRI (selective serotonin reuptake inhibitor) commonly known as Paxil.  Other similar antidepressants, such as Effexor XR, have been used to treat hot flashes for many years even though the use was “off-label” since it was not FDA approved.  Unfortunately, SSRIs generally work only 55 – 60% of the time, not a dramatic improvement over placebo.  Over the counter products, such as soy, black cohash and Estrovera, have also been used and can be useful for some women.

What do studies on hormone treatments show?

 It helps to step back in time to understand the changing recommendations on hormones.  In the 1990s most women were offered hormone therapy as they entered menopause to help with their symptoms.  Furthermore, a large observational study, the Nurse’s Health study, which was begun in 1976 and reported in 2000, showed many health benefits including a 40% reduction in heart disease, significant decrease in osteoporosis, and an overall decrease in mortality.  Animal studies showed clear benefits in reduction of heart disease with hormone treatment.  It was quite a surprise in 2002 when the estrogen and progesterone arm of the WHI was discontinued early due to an increase in mortality related to heart disease and breast cancer.  The WHI was the gold standard for studies since it was a randomized placebo controlled trial.  Newspaper articles warned women of the evils of hormone replacement and almost overnight, women were stopping their treatments even if it meant suffering through the symptoms of menopause.

The design of the WHI study is now felt to be instrumental in its conclusions.  The average age of women in the study was 62 and they had to be off hormones before joining the study.  As a consequence, many women were elderly, many years away from the onset of menopause, without any symptoms, and without hormone treatments for many years.  Although randomized controlled trials are considered the best possible evidence, they are only applicable to the population studied.  A reanalysis of the WHI data in 2008 showed no increase in heart disease for women who began hormones between the ages of 50 and 59 and there appeared to be a decrease in heart disease for those without a uterus who were treated with estrogen alone.

Similar conclusions were reached by a Danish study in October 2012 of 1000 women entering menopause (average age 50) who were randomized to hormone treatment or placebo.  At the end of treatment, the primary outcome — a composite of death, MI, or heart failure — was less common among women on hormones; this significant benefit persisted through 16 years' total follow-up.  Risks for thrombosis, stroke, and cancer did not differ between the groups.

Further reassurance is coming from the Kronos Early Estrogen Prevention Study (KEEPS), a randomized trial of 700 women who took hormones or placebo within 3 years after menopause followed for 4 years' of treatment.  Preliminary results in 2012 showed  improvements in cognition, mood, menopausal symptoms, and sexual function in younger women, and a trend toward cardio-protective effects.

What are current recommendations?

 
Recently 4 important menopausal groups have published guidelines on the management of hormone replacement.  These are the International Menopause Society in 2011, the North American Menopause Society in 2012, the British Menopause Society in 2013,  and the brief concise Global Consensus Guideline published in 2013.   The Global Consensus has been endorsed by The American Society for Reproductive Medicine, The Asia Pacific Menopause Federation, The Endocrine Society, The European Menopause and Andropause Society, The International Menopause Society, The International Osteoporosis Foundation and The North American Menopause Society.  The first three of these guidelines included reviews all of the health issues that can be impacted by hormone use with data and references on benefits and risks related to each health issue.  The final one is a bullet point summary.

 
I concur with these guidelines.  Briefly, I would summarize them as follows:

· In symptomatic women who are going through the transition of menopause in their 50s, hormone therapy has a favorable benefit/risk profile.

· The decision of whether or not to use hormone therapy should be individualized, taking into account each individual woman’s risk and benefits.

· The dosage, regimen, and duration should be individualized, with annual evaluation of pros and cons.

· Lower doses and transdermal routes have the best safety profile.

· The IMS and BMS and the Global Consensus do not recommend arbitrary limits on the duration of use, whereas NAMS recommends using combined estrogen and progesterone for 3 to 5 years only, but with more flexibility in length of use for women taking estrogen only.

 If you would like to discuss menopause hormone management in more depth, please make a consultation appointment with a menopause expert, Dr. Katherine Sutherland, at 650-988-7550.

Wellness Updates

Screening for Cognitive Function

For those of you 65 and above, don't be surprised or offended if you are asked some extra questions during your routine wellness exam. We are now screening patients with a short questionnaire to test for early signs of cognitive loss as recommended by the Alzheimer's Association. Your score gives us an objective way to determine if there is a need for referral. One study found that these types of questionnaires detect more than 80% of patients who later converted to mild cognitive impairment or dementia during follow-up, compared with only 59% detection by physician observation alone.

Early detection and diagnosis can mean more favorable outcomes for patients with Alzheimer's and their families. With earlier detection, patients can access currently available treatments and patient services, as well as make any necessary financial and care plans.

Testing for Hepatitis C 

You may see a request for a new blood test added to your routine sceening labs this year, as recommended by the CDC and the USPTF (U.S. Preventive Services Task Force Recommendation Statement) . One in 30 baby boomers – the generation born from 1945 through 1965 – has been infected with hepatitis C, and most don’t know it. Hepatitis C causes serious liver diseases including liver cancer, a rising cause of cancer-related deaths, and the leading cause of liver transplants in the United States.

The good news is that early detection can largely prevent the consequences of this disease, especially in light of newly available therapies that can cure up to 75 percent of infections. “With increasingly effective treatments now available, we can prevent tens of thousands of deaths from hepatitis C,” said CDC Director Thomas R. Frieden, M.D., M.P.H.

There is currently no vaccine for Hepatitis C.  If you would like to be vaccinated against Hepatitis A or B, we have those vaccines available at Women Physicians.

New Medicines Available for Weight Loss

Last month  a new medicine called Belviq (generic locaserin) was launched.  This can be used along with a calorie-controlled diet and increased physical activity in adults with a body mass index (BMI) of >30 kg/m² or those with a BMI >27 kg/m² and at least one weight-related medical condition, such as type 2 diabetes or high blood pressure.  It works by reducing hunger and creating a sense of fullness.  Unfortunately, it is not without risks and has been classified as a Schedule IV medicine due to potential for abuse.  Furthermore, the European Union has not approved it due to potential risks for tumors based on animal studies. 

The other weight loss drug which became available in September is Qsymia (combination of the generic medicines phentermine & topiramate).  It is also indicated in adults on a weight loss program with a body mass index (BMI) of >30 kg/m² or those with a BMI >27 kg/m² and at least one weight-related medical condition.  The doses in the combination pill are lower than usual prescribed doses of phentermine and topiramate and the side effects of the 2 medicines tend to cancel each other out.  

If you think one of these medications is appropriate for you, please make an appointment with Barbara Dehn RNP or Katherine Sutherland MD.  We will use these medicines when appropriate as part of our weight management program at Women Physicians Gyn, but they are not magic bullets. 

Fortunately, most women don’t need medications and can avoid risks and side effects by concentrating on their lifestyle.   Our dietitian, Joanne Donovan RD, along with our nurse practitioner, Barbara Dehn, have created a very successful weight management  program.  Some women in the program have lost over 50 pounds!  Call 650-988-7550 for more information.

Have a great summer!

Information on this website is for educational and reference purposes only and should not be interpreted as specific medical advice.

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Women Physicians Gyn Medical Group

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