NEWS FROM MENOPAUSE SOCIEY ANNUAL CONFERENCE
Greetings from Arcadia Women’s Wellness
NEWS YOU CAN USE - September 2024
September in Chicago
I returned less than 24h ago from the annual Menopause Society (brand new updated website with lots of great info for perimenopausal women) meeting. To say I learned some things is a gross understatement, including a few that will change my practice moving forward. What follows is a recap of the most important take-homes I gleaned. And please feel free to forward this to anyone you think might benefit from the info.
This is a long one, but I do think there is a lot of good info, please contact me with questions, but there may be a delay due to travel.
And some reading for the chilly fall days to come:
International Menopause Society White Paper addressing the key controversies re: menopause & MHT
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OUT OF CLINIC:
September 18-October 14 will be on vacation with limited availability
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PLEASE READ…please:
Texts: unless urgent/canceling appt, limit texting to between 9am-5pm, do not expect immediate replies, please sign name.
I am not a PCP: if you are having a general medical issue please proceed to urgent care of you PCP, if you need one look here.
Appointments: online scheduler; if cannot find time, let me know, currently scheduling ~4 weeks out.
Refills: contact pharmacy & try to plan ahead.
Emails: like you, I am inundated. Limit to quick questions, updates, etc, otherwise, schedule using online scheduler
Lab results: sign up with Sonora Quest/Labcorp; if want to discuss results/follow up after, schedule appointment
Thank you in advance for your understanding & assistance.
Hormones & Disease Prevention
This might be different from what you have been led to believe, but estrogen is NOT indicated for the prevention of cardiovascular, disease diabetes, or dementia.
Estrogen can help decrease cholesterol levels, decrease cardiac inflammation, and stabilize blood sugar levels, BUT this is not the same as preventing cardiovascular events & deaths. For example, I have shared that I had very high LDL (>200), HDL (>170, at this level this is not a good thing) and total cholesterol (>365), if I were to simply use MHT, I may be able to drop LDL 15 pts, but that is not enough to prevent me from having an event. What will is a statin, and that is what I take. Same with blood sugar, levels may drop several points on estrogen, but for someone with frank diabetes, it won’t be enough alone.
We have a lot of good data supporting what estrogen CAN do, and decreasing hot flashes & night sweats are more important than you might expect. Having moderate to severe hot flashes increases the risk for cardiovascular disease & white matter lesions in the brain which contribute to dementia, the mechanism is unknown, but if we use estrogen to treat hot flashes, this does appear to have a protective effect.
Bottom line: Using estrogen for the prevention of cardiovascular disease, diabetes, and dementia in non-symptomatic people is not recommended, BUT if hot flashes are significant, treating them with estrogen may offer some protection. This reaffirms the Menopause Society’s guidelines that estrogen should not be used in women without symptoms. The non-hormonal treatment for hot flashes fezolinetant (Veozah) can also provide this protection. The ONLY condition that has the indication for the use of estrogen for prevention is osteoporosis.
For dementia, the current evidence suggests a POSSIBLE increase in risk if used past 10y in women who have ceased having hot flashes.
This is an ever-evolving field and these recommendations may change in the future, but this is where we are now.
For now, if you haven’t done so, check out this new cardiovascular disease risk calculator , with a copy of your most recent labs on hand, you should have all info needed to get a good idea where you stand at least in terms of heart health (will also be putting this on website).
Radiographic Health Screenings
There were a lot of updates in expert beast and bone density screening opinions in the face of what have turned out to be very controversial recommendations by the government (USPFTS). You might be asking why the experts disagree with the USPFTS and that’s a good question. These experts work at some of the finest hospitals in the world: Cleveland & Mayo Clinics and have. decades worth of specialty training & experience in breast cancer & osteoporosis respectively.
First, and likely the most straightforward, is osteoporosis. We build peak bone mass by our mid-twenties- thirty, then, we struggle to maintain it through weight-bearing exercise & nutrition, until estrogen levels start to drop. Perimenopause marks the start of falling estrogen levels and can begin to impact our bone health silently, most significantly in the years preceding the final menstrual period. Estradiol loss is the most important mechanism of bone loss in women.
Unfortunately, way before perimenopause, many things could interfere with reaching adequate peak bone mass: use of corticosteroids, disordered eating, low body fat/weight, calcium deficiency, depo-provera, lactation, genetics, (para)thyroid disease, smoking, alcohol, etc. The problem is, none of us know the peak bone mass we, as individuals, reach or when our estrogen levels will start to decline.
The USPFTS suggests starting bone density screening at 65, unless one or more risk factors are known or there is a fracture. BUT, the experts say we are likely missing a window of opportunity even in those without concrete risk factors and that it makes more sense to do a baseline DEXA scan around the time of the final menstrual period, and earlier in case of surgical removal of the ovaries or premature menopause. The experts also recommend initiating treatment with estrogen in otherwise good candidates for Dexa scores that are borderline instead of waiting for osteoporosis. And please remember that all the calcium, D, K, and weight-bearing exercise dose not build bones anything like estrogen…there are reasons to still do those things, but they do not take the place of estrogen for those with or at risk for low bone density.
If you are barely menstruating or have stopped and haven’t had a baseline or it has been over 2y since your last, let’s get a bone density scan now.
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Breast cancer screening has also been the subject of controversy. The USPFTS came out this summer with new recs for mammograms starting at 40, every 2y until 74. The experts say this will miss very early and/or fast-growing cancers that could be treated more easily & with less interventions. They have elected to recommend in line with the American College of Radiology: start at 40 annually through 79, possibly longer in healthy women. It is estimated that the increase from every two years to annually could decrease breast cancer-related DEATHS by an additional 15%. That seems significant to me.
Please be aware there is no substitute for mammography, you cannot replace with thermography or ultrasound alone. And for those that have been told they have “dense breasts” the decision to do further imaging or MRI is up to the radiologist, so be sure to ask them if it is mentioned. Also, it is NOT a guarantee that insurance will cover MRI, so be sure to have the imaging center check
Another important fact: 22% of BRCA1 and 36% of BRCA2 carriers DO NOT have any family history of breast cancer. And the same can be said, though with different stats, for other genetic risk factors. If you are interested in getting FREE genetic testing, including polymorphisms, for breast cancer risk and all related follow-up, you can enroll for the WISDOM study. Personally, I did this immediately after hearing the lecture. This is way more accurate than anything you have likely heard of being able to get unless you have had a family member with genetically linked breast cancer. Even if your test is completely normal, it doesn’t mean you can skip that annual mammogram, but it will allow you to determine in some cases if there are preventive measures you can take now.
Not interested in a study? You learn more about your breast cancer risk you can also use this online calculator (will also be putting this on website).
And Some Other Tidbits…
Recommendations for treatment of insomnia has significantly moved away from meds like Lunesta/Ambien. If you are on these meds, or using advil (etc) PM, benedryl, alcohol, or cannabis, please consider other options and contact me. Also, if haven’t seen asleep specialist, it may be time, sleep apnea increases in perimenopause
Free CBT apps are available as well: From the VA
There is an increased risk of breast cancer when use estradiol + progesterone, it is a small increase of BC, about the same as being obese and/or drinking alcohol, but still underscores why you might choose to stop MHT when your symptoms stop. Standard recommendations include taking “hormone holiday” every few years to see if you still have menopausal symptoms…some will continue even until the 90’s, but most will stop within a few years after final menstrual period, and there is no mandatory stop age.
Hot flashes/night sweats (VMI) seem to be causative (though mechanism unknown) for at least part of this increased risk of dementia/alzheimers and cardiovascular disease, events, deaths. Using MHT to treat these VMI may help protect against this increased risk.
Remember to contact me with any changes in bleeding in the perimenopause, especially after the final menstrual period.
If premature ovarian insufficiency or ovarian removal, need to consider MHT ASAP.
You have a 50% chance of shingles if you live to 80y, have you received your vaccination? It never had chicken poix, get the varicella vaccine, if uncertain, get the shingles vaccine.
Learned a lot of new tips in management of hair loss in midlihfe, hint supplements are not the answer, but as many of you know because you are already taking, oral minoxidil is effective and safe.
Intermittent fasting has not been shown as superior to general calorie restriction for weight loss.
Testosterone should not be used via pellets, injection, or compounded if you can use FDA approved instead, please contact me if on compounded and want to discuss change.
Similarly, I have been prescribing naltrexone for both weight loss and alcohol over use, this was further supported at conference.
Last but not least, due to evidence presented at the conference, I am re-evaluating my use of semaglutide/tirzepitide. Later this year I will start prescribing and/or continuing these medications for my perimenopausal patients that meet clinical criteria (more in future newsletter) and will be intended for longterm use. I will not be prescribing it to everyone who asks for it, or those who do not meet criteria, and I will not start people on compounded GLP1s. If you have specific questions about this and want to be considered for this type of treatments, please make an appointment using the on-line scheduler.
AND LASTLY, A RECIPE
Well, not really a recipe, but an idea. Because of the heat I have not been cooking much. I have been making charcuterie-style plates for midday and assembled one to take on plane to Chicago (yes, it made it through TSA no problemo). A great way to emphasize veg, legumes (hummus), calcium (herbed feta), sometimes slices of prosciutto for extra protein and whole grain crackers for extra fiber.
Quick, easy, healthy, and keeps me from eating other quick, easy, non-healthy options.
Eat & drink well!
Follow me on instagram for more on all things menopause, recipes, and Pepe!