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What You Need To Know About Hormone Replacement Therapy

February 12, 2023 By Deborah

More than 1 million women in the United States experience menopause each year. Yet we are still in the dark about what to do about the troublesome symptoms that embrace this phase of life. Those symptoms can vary for each woman but primarily consist of intrusive hot flushes and night sweats with many hours of lost sleep. Low energy and mood changes that can disrupt work and relationships. Brain fog and difficulty grasping words which cause anxiety around the question of whether you are entering the beginning stages of Alzheimer’s disease. Then there’s the weight gain (especially in the mid-section) along with hair loss, dry skin, dry nails and eyes. The worst part is the fact that these symptoms begin 6 months to 12 years leading up to a woman’s last period, known as peri-menopause. This starts when women reach their late 40’s due to hormonal spikes and dips of estrogen and progesterone as the last eggs of the ovaries start to plummet in number. Irregular menstrual bleeding can also accompany these other symptoms making this time in a women’s life unpredictable. This presents confusion about where to turn for answers and options to get their lives back. Here is what you need to know about hormone replacement therapy (HRT).

Hormone replacement therapy has been around for many years (since 1942) until it took a dramatic turn. The prescriptions for hormone therapy, which was once the most commonly prescribed treatment in the United States suddenly dropped due to a 2002 poorly designed study finding links between hormone therapy and elevated health risks for women of all ages. This single study did women a disservice in how it generalized the use of HRT as opposed to what the study really was about- the unsafe and one-size-fits-all synthetic oral hormone, Prempro. The reasonable thing to do for women who were taking Prempro was to contact their gynecologist and yes, stop that form of HRT but to then discuss other hormone options. But instead, women flushed their pills down the toilet and never looked back. The message was “Hormones are Dangerous”.

It has been a disgrace to see women not even offered the option of HRT when symptoms were quite significant and after they had suffered years of unnecessary discomfort.

Hormone therapy can carry risks as do many other medications that people take to relieve serious symptoms. But dozens of studies since 2002 have provided reassurance for healthy women under the age of 60 or within 10 years of the onset of menopause who are free of contraindications. And the message is that the use of hormone therapy is safe and appropriate. The treatment’s reputation, however has never fully recovered and the consequences have been wide-reaching. It has been a disgrace to see women not even offered the option of HRT when symptoms were quite significant and after they had suffered years of unnecessary discomfort. Instead women are offered a pill for their insomnia, a pill for their depression, a pill for their newly diagnosed osteoporosis, a pill or injection for their diabetes, a pill for their high blood pressure, a pill for achy joints, a pill for their high cholesterol and plaque (caused by endothelial damage). Is it possible that there is a treatment for all these symptoms but has been overlooked by doctors? Yup! And it’s hormone replacement therapy. I am not saying that women would be immune to these conditions if they were on HRT, but it would be significantly less, if at all. This is just another example that reflects the medical culture’s challenges in keeping up with science as well as a representation of a lost opportunity to improve women’s lives.

Rebecca Thurston, a professor of psychiatry at the University of Pittsburgh who studies menopause, believes menopausal women have been underserved- an oversight that she considers one of the great blind spots of medicine. She states “it suggests that we have a high cultural tolerance for women’s suffering. It’s not regarded as important”.

So what does this mean now? Guidelines on hormone therapy from The North American Menopause Society has recently updated their 2022 position statement from 2017. It states that treatment should be individualized using the best available evidence to maximize benefits and minimize risks. Timing is important and the type of hormones are important. The risks of hormone therapy differ depending on type, dose, duration of use, route of administration, timing of initiation and whether a progestogen is used. The benefit-risk ratio appears favorable in lowering the risk of coronary heart disease, stroke, venous thromboembolism osteoporosis, depression and dementia for those that initiate treatment younger than 60 years or who are within 10 years of menopause and have no contraindications. Most women start HRT due to bothersome vasomotor symptoms (hot flushes) and genitourinary symptoms. Longer durations of therapy beyond the age of 65 are for persistent symptoms and women should be a part of the decision-making as periodic evaluation continues.

I still have patients tell me that their doctors insist they go off their HRT because they have been “on it for too long”. Do we say the same thing about a man’s testosterone or Viagra prescriptions?! Both women and their providers became very fearful after the 2002 WHI study. It is time to clarify and reassure women that hormone therapy can be given safely and effectively to relieve women’s symptoms and improve their quality of life as long as they are being monitored and the benefits continue to outweigh the risks. We also know that these hormones can delay or prevent many long-term degenerative diseases that are caused by aging. If women are expected to live on average another 30 years after menopause, let’s at least offer them the best quality of life for the years ahead.

We have come a long way…but we’re still not there. Let’s open up the discussion and allow women to voice their concerns and complaints without shame or guilt on whether their discomforts are “significant” enough. They deserve to ask questions and get reliable answers based on current studies with sound guidelines that we currently have, and not a study that was over 20 years old! More research is always needed to help navigate this topic not only for menopausal women now but for our younger generation of women moving forward.

References: Faubion, S, et al. NAMS Position Statement: The 2022 hormone therapy position statement of The North American Menopause Society. Menopause: The Journal of the North American Menopause Society, Vol 29. N0. 7, pp 767-794.

Dominus, S. Women have been misled about menopause. The New York Times magazine. February 1 2023. pp 1-19.

Kaunitz, A. Guidelines on HT have been updated by The North American Menopause Society. OBG Management. June 2017, Vol. 29, N0. 6. pp 18-23.

https://www.nia.nih.gov. Research explores the impact of menopause on women’s health and aging. May 6, 2022.

4 New Advanced Heart Disease Tools

January 22, 2023 By Deborah

There are some new advanced heart disease tools…and boy do we need them! There are some heart-health trends that are concerning cardiologists. There is a crisis in terms of a lowered life expectancy for the first time in decades according to cardiologist Sadiya Khan, M.D., assistant professor of medicine and of preventative medicine at the Northwestern University Feinberg School of Medicine in Chicago. The lowered life expectancy is due to several reasons: 1) midlife and younger adults are dying of heart diseases more often- death rates rose 8.5% for adults aged 45-64 between 2010-2020. 2) Fatalities due to heart disease for those over the age of 65 also rose significantly with our older population growing. 3) The COVID pandemic fueled the heart disease resurgence. The side effects of the pandemic’s long-term legacy of weight gain, inactivity and stress raised heart attack deaths by 21% for those 45-64 and 17.9% for people over age 65. The virus itself also plays a direct role in how lingering heart risks have been found a year after COVID infection. COVID could emerge as the #1 risk factor for future heart disease. We know a lot about how our lifestyle habits- diet and exercise-can prevent or increase cardiovascular risk. There are 4 new advanced heart disease tools to know and ask your doctor about.

Cleerly- an FDA approved system created by James Min, M.D. for evaluating heart plaque in CCTA (coronary computed tomography angiography) images. The plaque is assigned to a risk stage determining if it is hard stable plaque (good) or soft unstable plaque (not good). Patients can actually view the pictures and see what’s going on inside their own heart. This motivates people to stick with their medications and healthy habits. Cleerly health
Intravascular Lithotripsy is a new technique approved by the FDA in 2021 that uses shock waves to break up hard plaque deposits in vessels (similar to what they use to break up kidney stones). Patients can receive a stent after this procedure that are stronger, safer and more flexible. Biodegradable stents are on the horizon.
Advanced heart drugs: Sodium glucose transporter 2 (SGLT-2) inhibitors have been on the market to treat diabetes. But they really reduce episodes of heart failure in patients with or without diabetes. Studies have shown it can be used to cut the risk of hospitalization or death from heart failure by 33%. The other drug is PCSK9 for those who cannot tolerate or have not seen enough of a therapeutic effect with statins. It is given by injection q 3 or 6 months and lowers LDL cholesterol by 50-60% and also reduces the odds of a heart attack by 20% more than statins alone.
Transcatheter aortic valve replacement (TAVR). Instead of requiring open heart surgery which is deemed too risky for the elderly population (that need it most), the aortic valve can be repaired by implanting a new valve using a catheter that is threaded through the femoral artery. Patients are usually discharged after 1 overnight stay in the hospital.

According to a 2021 report from the American Heart Association, 77.5% of men and 75.4% of women ages 60-79 have some form of cardiovascular disease. Among those of us 80 and older, 90% have it. And by the time women reach their 70’s or 80’s, their risk of heart disease exceeds that of men. I know these statistics sound daunting….but the more we are aware of our own risk factors and have tools to measure our own heart disease, the more we can be proactive in prevention and early treatment.

References: Cleerlyhealth.com

Harrar, S. America’s war against heart disease. AARP Bulletin. Jan/Feb 2023. P 8-16.

6 Steps in Preventing Age-related Macular Degeneration

January 14, 2023 By Deborah

Healthy eye sight is dependent upon our overall well-being, which is dependent upon our genetic make-up, the foods we eat, our activity level, work environment and exposure to airborne toxins. Aging macular degeneration (AMD) is one of many eye diseases that can be slowed down. Although we can’t avoid aging or genetics which are the main causes of AMD, we can control other risk factors and delay or slow the progression of the disease.

AMD occurs when there is damage to the part of the retina known as the macula- which is the part of the eye that controls sharp central vision. When the macula deteriorates, it causes blurred vision. It may affect the ability to drive, to see faces and to read smaller print, but it rarely causes blindness. AMD

Specific habits have been identified in studies to be damaging to eye health. The main risk factors besides age and genetics is smoking, high blood pressure and a diet high in saturated fats and refined processed foods. So how can we prevent vision loss and keep our eyes and bodies strong? Here are 6 steps in preventing age-related macular degeneration:

1. Stop Smoking! Studies have shown that smokers have a 2-3 times higher risk in the development of AMD than non-smokers. A 2015 study found damage and inflammation to several layers of the macula in smokers. Smoking causes high blood pressure which raises pressure in the blood vessels and raises oxidative stress and free radicals.

2. Eat more leafy greens which are rich in carotenoids that your eyes need, especially lutein and zeaxanthin. These particular carotenoids have been shown to be low in people with macular degeneration. Collards, kale and spinach can be added to soups, salads, or pureeing them in smoothies. These nutrients in foods or supplements have been found to prevent and even improve AMD in many cases. Vitamin C can enhance the absorption of lutein.

3. Weight loss (if needed) helps digestion and lowers inflammation which allows for a healthier microbiome. Avoid the typical Western Diet which is high in saturated fats and high fructose corn syrups, sugars and processed foods.

4. Choose healthy fats such as omega-3 fatty acids. Omega-3’s have the ability to regulate formation of extraneous blood vessels that distort vision. Eating fish is a great way to increase omega-3 in your diet. Some people need supplementation and 2 grams daily with food is a good starting place. Vegetarians can choose algae, hemp or krill as good sources.

5. Zinc is necessary for a healthy macula and is found abundant in meats and seafood. It is also in nuts, grains and legumes but is not in a readily absorbable form. Zinc supplementation may be needed for vegetarians and vegans. A RBC Zinc level can determine deficiencies.

6. Vitamin D3 is easy to measure in a blood test. Low levels are associated with increases in macular degeneration symptoms. Vitamin D has anti-inflammatory and anti-angiogenic benefits, especially where genetic risk is greatest. D3 has an important role in the immune system and aging process of AMD and all diseases.

Choose a positive, healthy lifestyle that includes exercise, daily meditations or walks in nature and a healthy diet. It may prevent or slow down the diseases of aging and improve the quality of your life.

References: Grossman, M. Eye disease, integrative vision care, and nutrition. Townsend Letter. April 2022, issue #465, p 42-43.

Age-related Macular Degeneration. https://www.hopkinsmedicine.org/health/conditions-and-diseases/agerelated-macular-degeneration-amd.

Top 10 Health Breakthroughs in 2022

December 30, 2022 By Deborah

Here’s to a year of hope. We have slowly come out of this pandemic a little dazed and confused but for most of us all the better and knowledgeable about how precious life is. There were astounding new technologies and medical breakthroughs in 2022. Here is Wellcast’s top 10 Health Breakthroughs:

10. “Smart stethoscopes” are stethoscopes that identify heart murmurs before they can be heard. It can detect the slightest of murmurs which is important since 5-10% of people have one form of valvular heart disease or atrial fibrillation.

9. Hearing Aids: Over-the-counter (OTC) versions have arrived. Close to 90% of people with hearing loss have mild to moderate losses which these OTC versions would help. It is best to get a hearing test first. Learn more at aarp.org/hearing.

8. Eye Implants: For those who have age-related macular degeneration (AMD), the leading cause of severe vision loss in those over age 50, you can now opt for an eye implant device instead of monthly eye injections. This is primarily for the more severe type (“wet AMD”). The implant releases a steady dose of a drug, ranibizumab, to control blood vessel growth.

7. Ceramic teeth: Titanium implants have been the gold standard for dental implants. Ceramic options are worth mentioning because it is an option that is good for people with metal hypersensitivities and it is healthier for your gums. It also doesn’t show gray metal through the gum tissue.

6. Focused Ultrasound for Parkinson’s Patients: Like a magnifying glass concentrating sunlight… focused ultrasound beams of sound waves pinpoints an area deep in the brain, heating up and destroying cells associated with the movement problems of both Parkinson’s disease and essential tremor. This FDA-approved procedure has helped calm shaking, stiffness and other movement problems that are due to these nervous system disorders.

5. Blood Test that detects early cancers called the Galleri, multi-cancer early detection (MCED) from the health company Grail screens for more than 50 different cancers. It searches a blood sample for tiny scraps of DNA released by cancer cells. There are some questions about false positive test results which could lead to expensive, invasive and anxiety-provoking procedures and treatments. But then, the earlier a cancer is found the better the outcome. Follow-up studies are currently being done.

4. A new drug to treat Lp (a): Lipoprotein (a) is an independent risk factor for atherosclerotic heart disease. A new drug, Olpasiran is a small RNA molecule that interferes with the synthesis of Lp(a) in the liver. This is a major breakthrough because it is so difficult to treat Lp(a) outside of using oral Niacin (which commonly causes flushing so many people cannot tolerate it) and injectable drugs known as PCSK9 inhibitors (ie Repatha) given every 2 weeks. Olpasiran is a subcutaneous injection given every 12 or 24 weeks. More studies are being done before it comes out to market.

3. Inhaler Sensors that monitor your meds are now available. Nearly 1/3 of older adults miss doses on their inhaler schedule, and 74% use their inhalers improperly. Propeller Health’s FDA-approved sensors use a smartphone app linked to the senses to keep track of your inhaled medications. For more information go to inhaler sensors

2. Next generation of mRNA vaccinology: An effective COVID-19 vaccine was developed, produced, approved and delivered in less than a year!! New mRNA vaccines are being developed to prevent cancers, Zika virus and others. The world needed a new vaccine technology and what better way than a pandemic to get things started.

1. Paxlovid (nirmatrelvir-ritonavir): an oral pill for the treatment of mild-moderate COVID-19. Prior treatments were intravenous medications at hospitals and certain service centers. This pill that could be easily prescribed reduced hospitalization from 50-80%. A real deal breaker in getting people better and avoiding severe complications and disease progression.

Wishing you a very healthy, peaceful and hopeful New Year!

References: Harrar, S. Medical breakthroughs that are changing lives now. AARP. Oct/Nov 2022, p. 51-59.

Reale-Cooney, A. Cleveland clinic unveils top 10 medical innovations for 2022. Cleveland Clinic Newsroom. Feb 16, 2022.

Lin, P. Paxlovid use is associated with decreased hospitalization rates among adults with COVID-19. Practice Update, The New England Journal of Medicine, Dec 20, 2022.

Ostrominski, J. Efficacy and safety of Olpasiran for Lp(a0 level reduction. Practice Update, The New England Journal of Medicine, Dec 18, 2022.

6 Ways to Prevent Recurring Urinary Tract Infections

December 4, 2022 By Deborah

Urinary tract infections (UTI) are among the most prevalent bacterial infections in both inpatient and outpatient facilities. They affect about 150 million people annually. About 1 in 7 women suffers at least one infection per year. About a third of those women develop another UTI 6-12 months after the first infection. There are many ways to prevent recurring urinary tract infections. The prevalence of bacteriuria (a common feature in UTI) for those over the age of 60 is significantly higher in women than men. Nearly 20-30% of women with an infection experience recurrence. High risk populations for UTI include pregnancy, elderly, children, people with an indwelling catheter and those with a neurogenic bladder. Frequent sexual intercourse increases recurrence rate of UTI’s. Abstinence when having an infection will improve recovery and urinating immediately after coitus is recommended along with the higher intake of water.

A recurrent UTI is classified as having 2 symptomatic episodes within the last 6 months or if 3 episodes have occurred within the last 12 months. There are many approaches to reducing the recurrence rate of urinary tract infections. Non-antibiotic choices are best because they are easily managed but also because it prevents the development of resistance and the corresponding adverse reactions of antibiotics. Here are 6 ways to prevent urinary tract infections:

Drink sufficient fluids: The rule of thumb is to drink 1/2 your body weight in ounces. So if you weight 140 pounds, then you should drink about 70 ounces of water per day. Of course certain diuretics such as caffeine and alcohol, require adjustment of those numbers as well as exercise so that may mean close to 85 ounces/day. If you are prone to re-infection, caffeine and alcohol should be limited since they can irritate the bladder wall and cause dehydration.
Cranberries (Vaccinium macrocarpon): originated in New Zealand and is loaded with phytochemical compounds such as proanthocyanidins (PACs), anthocyanin, benzoic acid and ursolic acid. Escherichia coli (E.coli is a primary pathogen in UTI’s) is prevented from adhering from the uroepithelial cells by PACs contained in cranberries in the urinary tract. Even though studies on long-term prevention using cranberry products have been inconsistent, I still recommend them since they are safe (especially in children), easy to use in an extract capsule form or drink, and clinically effective in many of my patients.
D-mannose: This is a simple sugar, or monosaccharide found in many fruits. Small clinical studies suggest that oral D-mannose may reduce UTI recurrence, when used alone or when in combination with other ingredients (cranberry extract, tara gum and probiotic bacteria 1-2.5 billion live cells of L. planetarum, L paracasei and Strep thermophilus). It also inhibits E. Coli bacteria from binding to the bladder wall. In one study, the intake of 2 gms of D-mannose dissolved in a glass of water every day showed a significant drop of urinary tract infections compared with placebo.
Uro-Vaxom is an immune-stumulant agent with bacterial cell wall components from the strains of E.Coli. Uro-Vaxom caps. In 2 meta studies, the recurrence rate was reduced by 39% compared to placebo. There was a significant reduction from treatment time to breakthrough infections. Uro-Vaxom trial
Estradiol or Estriol vaginal cream for postmenopausal women. This treatment serves as therapy for vaginal atrophy and reduces both colonization with uropathogens and also balances the vaginal PH to reduce risk of vaginal bacterial infections.
Antibiotic therapy should only be used when all other options have failed. When choosing an antibiotic, make sure a urine culture has been done to choose the right antibiotic and avoid resistance. Single dose postcoital antibiotic prevention is a good prevention especially for women in whom a correlation between recurrent UTI’s and sexual intercourse has been suspected.

References: Hertlein, A. Recurrent Urinary Tract Infections: What’s Good Prophylaxis? Medscape, Oct 31, 2022.

Magasi, P, et al. Uro-Vaxom and the management of recurrent urinary tract infection in adults: a randomized multi center double-blind trial. Euro Urol, pubmed.ncbi.nim.nih.gov. 1994

Hisano, M, Bruschini, H et al. Cranberries and lower urinary tract infection prevention. Sao paulo clinic. 2012 Jun 67 (6): 661-667