The holidays are over and as we return to the routine of our daily lives we begin to remember that it is winter in northeast Ohio, the glow of sunshine is more difficult to find.  The days are shorter and sunshine is scarce. Most people retreat to the warmth of their homes, rarely venturing outside resulting in rare exposure to the sun. This deprivation of sunshine, besides affecting our mood, can cause vitamin D deficiency. Vitamin D plays a significant role in the normal functioning of all major organ systems and therefore its deficiency adversely affects our health.

The major source of vitamin D is through sunshine.  Dietary sources of vitamin D are through vegetables (vitamin D2) and animal source (vitamin D3).  Vitamin D3 is synthesized in the skin through exposure to ultraviolet-B (UVB) light.  The activated form of vitamin D3 binds to receptors in tissues throughout the body to influence their functioning and ability to repair itself. In modern society sunlight exposure is limited by design (fear of skin cancer) and necessity (most work now is done in doors). Studies on young professionals revealed that 32% are deficient in vitamin D.  Aging only worsens this problem. As we get older our skin has reduced ability to synthesize vitamin D; older adults require three-times the amount of sun exposure as younger adults to maintain normal vitamin D levels. Up to 90% of older adults are deficient in vitamin D. Why is this important?

Vitamin D has long been recognized as being important in skeletal health and prevention of osteoporosis. It helps with the absorption of calcium in the intestine and helps maintain steady blood levels of calcium. It has also been shown to have anti-proliferative effects on malignant cells meaning it prevents or slows the growth of cancer. This includes very common cancers such as cancer of the breast, prostate, colon, and leukemic cells. Many epidemiologic studies have shown reduced incidence and mortality from these cancers in areas with a sunny climate or in populations taking vitamin D supplements. Low vitamin D levels also have an adverse effect on the immune system. Inflammatory bowel disease and rheumatoid arthritis are examples of conditions of an abnormal immune system in which patients often have vitamin D deficiency. Vitamin D deficiency has an adverse effect on the cardiovascular system increasing risk for heart attacks and stroke. It also contributes to the development of diabetes by contributing to insulin resistance.  Vitamin D deficiency contributes to postmenopausal syndromes of osteoporosis, muscle weakness, falls, fractures, depression, cognitive impairment, and dementia.

Because vitamin D deficiency is associated with multiple significant health problems it is not unreasonable to measure its level once a year, especially in older individuals who live in a northern climate. A simple blood test for vitamin 25 (OH) D and parathyroid hormone (PTH) should be drawn. Normal levels for 25(OH) D is higher in older individuals than the young because resistance to its effect occurs as we age. This resistance is reflected by elevated levels of PTH. Achieving and maintaining normal levels of vitamin D may lower the risk for breast and colon cancer by as much as 80%. The daily requirement of total vitamin D is 3,000 to 5,000 units per day, most of which is obtained by the sun. As a generalization most adults should take 1,000 to 2,000 units (IU) of vitamin D3 daily. An individual’s exact amount of dietary supplement varies depending on age, sun exposure, and other health conditions. The required daily oral intake of vitamin D may range between 2,000 to 10,000 units per day. It is best to have testing done by your physician to help determine what is the correct amount for you.

Vitamin D is not the “magic” pill that will provide good health and prevent disease but it is an important part of the equation. As always a healthy lifestyle of a balanced diet, regular vigorous exercise, sufficient sleep, and avoidance of tobacco and excessive alcohol will give you the best chance of having a long and healthy life.  And here is hoping our mild winter lasts and the sun keeps shining!

Osteoporosis is a condition that needlessly robs many people later in life, mostly women, of their independence, diminishes their quality of life, and prematurely shortens their life. Osteoporosis had a devastating effect on my own family. It essentially stole the last fifteen years of my mother’s life. When younger she stood five feet seven inches tall, by the time she died she wasn’t even five feet tall. My father couldn’t hug her without breaking a rib; even minor falls resulted in serious fractures.  With early attention to bone health, osteoporosis can be prevented. With early diagnosis, osteoporosis’s devastating effects can be prevented or greatly diminished.

Women who are over fifty, or have gone through menopause, have a very high risk for osteoporosis. This condition causes one out of every two women over fifty years old to suffer a bone fracture at some point in their life. Vertebral compression fractures are often silent, causing progressive loss of height and significant back pain. Hip fractures lead to major surgical treatment and nursing home admissions from which many women never recover. Osteoporosis is the progressive loss of bone mass resulting in weakening of the bone strength and increased susceptibility to fracture. It is a silent disease in which women lose up to 20% of their bone mass in the first five years of menopause.

Healthy bones are in a constant state of renewal; old bone is removed and new bone is being formed. The cells that build bone are positively influenced by estrogen in women. With the withdrawal of estrogen after menopause these bone building cells, osteoblasts, slow down but the cells that remove old bone (osteoclasts) keep on working resulting in progressive loss of bone mass. Currently in the United States, 10 million women have osteoporosis and another 34 million have low bone mass or osteopenia. Unfortunately, there are no early physical warning signs that osteoporosis is developing. The first sign of the disease is often a low trauma resulting in a fracture of the hip, wrist, or spine.

Women who are at most risk for osteoporosis are those who are menopausal, have slight stature, smoke cigarettes, drink alcohol, have a family history of osteoporosis, on chronic corticosteroid medications, and cancer patients. As with other common health conditions, like heart disease and diabetes, it often can be prevented or reduced with a healthy active lifestyle. Eating a healthy balanced diet, exercising on a regular basis, having adequate calcium and vitamin D intake, avoid smoking and excessive alcohol will result in healthier bones and greater bone mass.

Diagnosis of osteoporosis is based on a DXA bone density test. This is a special x-ray evaluation of the bone, usually of the spine and left hip. This test is completely painless and usually can be completed within ten minutes. I typically will order this test in my patients shortly after menopause to have a baseline level and to determine if early bone loss is present so preventive measures can be initiated in hopes of avoiding the use of medication.

Fortunately many very good medications are available for the treatment of osteoporosis. Unfortunately, the only thing many women know about osteoporosis is the potential side effects of these medications.  The most commonly prescribed family of medications for osteoporosis is bisphosphonates (Boniva, Fosamax, Actonel, and Reclast.) These medications act by slowing down the activity of the cells that removes bone (osteoclasts.) People hear about drug side effects of acute jaw necrosis or atypical fractures of the thigh bone. Jaw necrosis is most often seen in cancer patients and is extremely rare. Atypical fracture of the femur (thigh bone) may occur after 5 years of use. This allows the safe use of the medication for five years while realizing its benefits. At five years, the medication can be stopped for a two-year drug holiday or switched to another medication such as raloxifene (Evista.)  Evista belongs to a different family of bone sparing medications that also has the advantage of lowering a woman’s risk for breast cancer.  On average bisphosphonates lower the risk of fracture by 30 to 50 percent. By comparison, the risk of these side effects is miniscule. In other words, the risk of not taking the medication is significantly greater than the risk of taking it.

In summary, healthy lifestyle for prevention of osteoporosis includes smoking avoidance, low alcohol consumption, regular exercise, and daily intake of calcium 1200 mg/day and vitamin D3 1,000-2,000 units daily. Treatment of osteoporosis includes all the items for prevention with the addition of one of the many safe and effective medications. For more information please visit www.naples-health.com/resources-on-menopause.

The concern most women have with a late pregnancy is related to birth defects and chromosomal abnormalities. Down syndrome is the most common chromosomal abnormality seen in later pregnancies. Children affected with this syndrome are affected by varying degrees of mental retardation and physical birth defects such as heart anomalies. Every pregnancy, no matter the age of the mother at conception, has a chance to result in a baby with Down syndrome or some other chromosomal anomaly. The risk steadily increases with age. At age 25 the risk is 1 in 1250, at age 30 it is 1 in 1000, at age 35 it increases to 1 in 400, and at age 40 it is 1 in a 100.  What is important to realize, however, is that the odds always favor the birth of a baby without Down syndrome or any other chromosomal anomaly. The reason is that most pregnancies with a chromosomal problem end in a miscarriage. First and second trimester screening tests are available that recalculate the risk levels noted above. Diagnostic tests in the first trimester (chorionic villus sampling) and second trimester (amniocentesis) are also available. The diagnostic tests have an associated risk of causing a miscarriage, in a normal pregnancy, in the range of 1 in 100 to 1 in 500. Many women who choose to do testing will do the screening test first to see if their risk is significantly lowered. If it is lower, many will forego the diagnostic test to avoid the possibility of causing a miscarriage.

Another risk of pregnancy later in life is the higher chance of miscarriages. Miscarriage in women age 35 to 45 occurs much more frequently, ranging from 20% to 35%, as compared to only 10% in women in their twenties. Other conditions with higher rates include gestational diabetes (twice as high in woman after 35,) high blood pressure and pre-eclampsia, premature delivery, low-birth weight babies, twins, and stillbirth. When risks like this are put in print, it exaggerates their likelihood. The fact is most pregnancies in women after forty proceed normally and safely. These complications, if they do occur, can most often be managed and controlled in a safe manner. Certainly a woman pregnant after forty can expect to be followed more closely during the pregnancy with serial ultrasounds to monitor the baby’s growth and well-being. The mother will also be closely monitored to identify any developing health problems.

Often, I have patients ask me if a late in life pregnancy is too risky or too dangerous. Risk tolerance is an individual decision. The role of your obstetrician is to clearly explain what the risks are and to explain what the likelihood is of those complications occurring. But it is also extremely important to consider all the positives associated with the pregnancy, the joy and happiness this child can offer to your life. Too often we focus on the negatives and not the positives. If the positives outweigh the negatives then the risk is worth it. There are no guarantees in life. Whether we think about it or not, as soon as our feet hit the floor in the morning we are exposed to risk. Some risks are just worth it.

*An easy in-office procedure

You have reached the point in your life that you are confident your family is complete.  You and your husband have 4 beautiful children; the youngest is now 5 years old.  Next year she will begin school and you wish to resume your career.  Since her birth you have used a birth control pill for contraception.  This worked nicely in preventing pregnancy but the pill however is not something that you feel comfortable continuing into your forties.  A permanent form of contraception is appealing but you really don’t want surgery.  So what choices do you have?

Essure is a permanent sterilization procedure performed in the office and can be completed within 10 minutes. No hormones, cutting, burning, or anesthesia is required.  A small scope is passed through the vagina and cervix into the uterus (honest this doesn’t hurt!) enabling the tubal openings to be visualized. 

Small, flexible micro-inserts or plugs are placed into the tubes. It takes about 3 months for these plugs to heal into place. At that time a simple x-ray test is performed to make sure the tubes are completely occluded.  It is recommended that the pill or some other form of contraception be used until this x-ray is completed.  This procedure has been FDA-approved since 2002.  It is 99.8% effective and is the only birth control method with zero pregnancies.

Read more about this procedure which was recently highlighted in The Cleveland Plain Dealer’s Health and Fitness section.

 http://www.cleveland.com/healthfit/index.ssf/2011/09/nonsurgical_option_for_sterili.html

The combination of these two words strikes fear in most women.  Breast cancer is the number one health concern for women after the age of forty.   It is not, however, the number one health issue that affects women.  Lung cancer is the number one cause of cancer deaths in women, heart disease is the number one cause of all deaths, and osteoporosis is the number one disease that afflicts women.   If breast cancer is not the primary cause of death or even the primary illness that affects women, why is it so prominent a health concern?   Breast cancer is a very personal disease; it can alter a woman’s self image, confidence, and causes her to confront her own mortality.  It often strikes at a younger age than any of the other conditions mentioned above.  Breast cancer is the second leading cause of cancer deaths among women; it is the most frequently diagnosed cancer in women except for skin cancer.  A women’s life time risk for developing breast cancer is 1 in 8; the risk increases with age. The 10 year risk at age 40 is I in 69, 1 in 42 for women at age 50, and 1 in 29 at age 60. Over 250,000 women are diagnosed with invasive or noninvasive breast cancer each year; more than 40,000 women die of breast cancer yearly.  These are certainly very unsettling statistics but there is good news. There has been steady improvement in breast cancer survival over the past 2 decades. This improved survival rate has resulted from earlier detection and improved treatments.

From the early 1990’s there has been increased awareness, detection, and survival of breast cancer due to programs like the “Susan B. Komen Race for the Cure” and “Breast Cancer Awareness Month.” Recommendations for women to begin monthly self breast exams at age 30, annual or biennial screening mammograms at age 40, and annual mammograms at age 50.  Recently the United States Preventive Services Task Force (USPSTF), which is a government supported organization, made drastic changes in these screening recommendations. The USPSTF recommended that women with no genetic predisposition to breast cancer no longer do self breast exams, that screening mammograms not begin until age 50, only be performed every 2 years until age 75, and then discontinued after age 75. Five percent of breast cancers occur in women before the age of 40 and 20% occur before the age of 50. Why make such drastic changes in the recommendations for screening when the previous recommendations have produced such good results? They felt that self breast exams led to excessive anxiety and too many unnecessary tests.  Earlier mammogram screening required testing too many women in order to diagnose one woman with breast cancer; basically screening at an earlier age is not cost effective. Unfortunately this is the kind of analysis that we are going to see much more of in the future with national health care reform. The cost of tests and treatment will play an out of proportioned role in health care decisions.  Fortunately the outcry from the public and medical professionals about these changes has caused them to be retracted for now.

Currently the recommendations, therefore, are the same. Women should continue to do monthly self breast examinations; for women who are still menstruating this should be done on the last day or 2 of the menses. During the examination the woman should concentrate on the normal appearance and constituency of her breast. Once familiarity is achieved changes would more easily be recognized and an evaluation by your doctor would be important. Things to be on the lookout for during the self exams are lumps, dimpling in the skin, other changes in the skin appearance, or spontaneous nipple discharge. Screening mammograms should begin every 1 to 2 years at age 40 and yearly at age 50.  It is important to realize that mammograms are not 100% accurate; there are limitations to every test. If a change in the breast examination is noted either by you or your doctor it should continue to be followed even if the mammogram is negative. This may require alternative type testing, biopsy, or simply repeat examination by your doctor in a few months.

Every woman is at risk for breast cancer simply for the reason that she has breasts. The fact that there is no family history of breast cancer does not free a woman from the possibility. In my own family I have 2 sisters who had breast cancer. These are the first occurrences on either side of the family. Testing for genetic predisposition with testing for BRCA1 or BRCA2 genetic mutations is important if there is a history of breast cancer in close family members on either side of the family. This is a simple blood test. The risk for breast cancer increases with age, in women who went through early puberty or late menopause, women who had no children or who delayed childbirth until after age 30, and in obese women.

Breast cancer is a fairly common and worrisome disease but women are not defenseless.  By following screening recommendations, doing monthly self breast exams, and having yearly examinations by your physician earlier detection of breast cancer is possible.  Earlier detection improves survival and limits the extent of surgery necessary. Often breast preservation is possible thereby limiting self image concerns, discomfort related to surgery, and enables a return to a normal life style sooner. The risk for breast cancer can be reduced by maintaining normal body weight, eating a healthy balanced diet, exercising regularly, and limiting alcohol consumption and smoking.

In last month’s article “In Defense of Estrogen” I tried to explain how estrogen therapy for treatment of menopausal symptoms is a good and safe therapy for the majority of women.  Estrogen is the only treatment proven to address the myriad symptoms associated with menopause and is the most effective treatment for hot flashes and night sweats.  Medications such as Effexor, Neurontin, and natural supplements with phytoestrogens found in soy, black cohash, etc. may diminish hot flashes but not to the same extent as estrogen nor do they treat other problems associated with menopause. During the perimenopausal transition, ovarian production of estrogen, progesterone, and testosterone firsts begins to fluctuate and eventually stops altogether. The initial and most obvious results of this are irregular bleeding, intermittent hot flashes and night sweats, concentration difficulties, sleep disturbance, and fatigue. The long term result from the lack of estrogen may result in an increased risk for heart disease, stroke, osteoporosis, colon cancer, macular degeneration, urinary urgency, vaginal dryness, redistribution of fatty tissue to the abdomen, diminished sex drive, changes in skin appearance, and insulin insensitivity with possible development of diabetes. Estrogen receptors are contained in tissue throughout the body, that is why there is such a widespread impact from menopause and reduced estrogen production.

The “Woman’s Health Initiative” (WHI) study first released in 2002 was looking at estrogen to see if it should be given to all menopausal women to lower their risk for heart disease which is the number one cause of death in women after menopause. This study determined that it was not safe to recommend it uniformly to all menopausal women. What was lost in the release of the results is that it is a safe and effective treatment for the majority of women for specific indications. In other words, the woman and her doctor need to consider the risks and benefits for that particular individual to see if the benefits outweigh the risks. In the vast majority of women the benefits do outweigh the risks.

What are the risks associated with estrogen use? The biggest fear that women have concerning estrogen is that it causes breast cancer. The WHI study showed an increased occurrence of breast cancer in women who used a combination of estrogen and progesterone (EPT) for 5 years; there was no increased occurrence of breast cancer in women who took only estrogen replacement. In those women on EPT it is more likely that the EPT unmasked already existing breast cancer and did not actually cause breast cancer. The increased occurrence also was not large. The baseline risk for a woman 51 years old of developing breast cancer in her lifetime is 2% or in other words she has a 98% chance of not developing breast cancer. The increased occurrence with EPT is 25% which means her new lifetime risk for developing breast cancer is 2.5% or she now has a 97.5% chance of not developing breast cancer in her lifetime. You can see that this possible increased risk of developing breast cancer on EPT is extremely small.  Even this level of risk is now being questioned. The other most common risk associated with estrogen use is the development of blood clots that may result in pulmonary embolism or stroke. This risk is of a similar magnitude as the risk of breast cancer, higher but not excessive. Another risk of estrogen therapy is uterine cancer in women who still have their uterus; the addition of progesterone prevents this risk. In women who have had a hysterectomy, there is no proven benefit of taking a progesterone hormone after menopause.

What are the benefits of estrogen therapy? The main benefit, and the only approved indication, of estrogen therapy is for the treatment of symptoms of the perimenopausal transition and early menopause. It should not be used to primarily prevent heart disease or dementia. It is highly effective in reducing hot flashes, night sweats, mood changes, sleep disturbance, and any other symptoms that result from diminished estrogen production.  Estrogen is also approved for the prevention of osteoporosis. Osteoporosis is the most common condition afflicting women after menopause. Women lose the highest percentage of their bone mass in the first 5 years of menopause. Estrogen therapy is effective in preventing this loss. Other benefits of estrogen therapy are the prevention of vaginal dryness that occurs after menopause which leads to discomfort with intercourse. It also reduces the occurrence of hyperactive or irritable bladder, lowers a woman’s risk for colon cancer, reduces the accumulation of fat tissue around the waist, helps maintain the health and vitality of the skin, and reduces macular degeneration.

Estrogen replacement, like everything else we do in life, has risks and benefits. What each woman needs to determine is do the benefits of taking estrogen outweigh the risks; it is a quality of life decision.  This is a decision that should be made with the assistance of her doctor. The lowest effective dose of estrogen should be used for the shortest time period necessary to help with the transition through menopause. Certainly some women will choose to remain on estrogen indefinitely because they feel better on it. This is acceptable as long as they are aware of the potential risks verses the benefits. Women who definitely should not use estrogen are those who have a history of previous breast cancer,  a genetic predisposition to breast cancer, uterine cancer, heart disease, stroke, blood clots, or a blood disorder that predisposes them to clots.

by Patrick J. Naples, M.D.

The perimenopausal transition and early menopause has a profound physical, emotional, and psychological effect on women. Menopause is defined clinically as an absence of menses for twelve months or complete and permanent cessation of ovarian estrogen production by the ovaries.  This can happen acutely with the removal of the ovaries at time of hysterectomy or may occur naturally during the perimenopausal transition. The perimenopause is the period of years, usually beginning in a woman’s late 40’s, where hormonal production fluctuates. The perimenopausal transition is characterized by wide fluctuations in hormone levels and therefore wide fluctuation in symptoms; irregular bleeding, hot flashes, night sweats, and mood changes may vary greatly.  Symptoms may be severe for a few weeks and then completely resolve only to return later. As a woman gets closer to menopause, the abnormal symptoms often become more frequent and severe. This roller coaster ride towards menopause may last months or, more frequently, years.

There are estrogen receptors in every organ of the body; therefore the absence of estrogen has widespread impact on bodily function, appearance, and ability to repair itself. This can be seen by the rising risks that women acquire after menopause for heart disease, stroke, osteoporosis, colon cancer, urinary urgency and incontinence, skin changes, mood disorders, sleep disturbance, macular degeneration, and vaginal dryness. The degree of the effect of low estrogen level varies from woman to woman; certainly some women experience a more profound effect that others. Prior to the release of the “Women’s Health Initiative” study in 2002 concerning the safety of hormone replacement therapy, estrogen replacement for menopausal symptoms and prevention of menopausal risks was widely encouraged. There were two parts to this study; one was monitoring the effects of estrogen/progesterone replacement on women and the second was concerning estrogen only replacement in women who had a prior hysterectomy. The estrogen/progesterone arm of the study was halted early because of the unexpected finding of an increase risk for heart disease, stroke, and breast cancer in this group of women. The estrogen only arm of the study did not reveal the increase breast cancer risk. This led to the widespread withdrawal of estrogen as treatment for menopause; use dropped by 80%.  The fear of breast cancer led many women to stop, or to never consider, estrogen use for treatment of menopausal symptoms. As could have been predicted, many women were left to face the myriad symptoms of menopause without any effective treatment. Quality of life was sacrificed for disease avoidance.

There were a couple of big problems with how the information from this study was presented which led to the unnecessary withdrawal of the only effective treatment for menopause. The design of this study was one of a public health strategy; i.e. should all women be placed on estrogen for the prevention of heart disease. Previous studies of estrogen suggested that women who took estrogen replacement had a lower risk for heart disease and death than those who didn’t; this is important because heart disease is the number one cause of death for women.  Other examples of public health strategies are vaccinations, iodinated salt, and fluorinated drinking water. The benefits to the general population far outweighed the risks to the few. The WHI estrogen study enrolled women in late menopause and not those going through the menopause transition.  This group of women already had a higher incidence of vascular disease and probably a higher incidence of unrecognized breast cancer. The addition of estrogen in these women unmasked an already existing condition.  Women in early menopause and the women in late menopause are two distinct groups; the results found in the older group cannot be applied to the younger group. Concerning heart disease and stroke, this difference is evident when women in early menopause on estrogen therapy were studied. This study revealed a 30-40% reduction in mortality and no increase risk, or a slight reduction, in heart attacks in this group of women. The breast cancer concerns also are not as dire as first presented.

The study stated that women who took estrogen and progesterone for 5 years, not women who took estrogen only, had a 26% increase risk of developing breast cancer. Reporting risk in this fashion suggested one out of four women on estrogen would develop breast cancer; this is patently wrong and was very misleading. Women have an underlying risk for breast cancer merely by having breasts. The base line risk is 30 out of 10,000 women develop breast cancer each year; a 26% increase changes that number to 38 out of 10,000. This means there is potentially 8 more cases of breast cancer in women who have been on estrogen for at least 5 years; the actual risk for breast cancer goes up by less than 1 in a 1000 each year. What most likely will be found in future studies is that estrogen does not actually cause breast cancer but merely unmasks previously existing breast cancer. This is suggested by the rapid drop in the reported incidence of breast cancer after the release of the WHI study and the 80% reduction of estrogen use that resulted. If estrogen actually “caused” breast cancer the drop in reported incidence would have taken at least 8 years to be evident instead of 2 to 4 years. This is true because any cancer caused by estrogen in 2002 would take about 8 years before it would have become clinically evident. This makes it more likely that estrogen unmasked an existing cancer and did not cause it. An analogy would be the dormant grass in the front yard during the heat of the summer. The grass either grows very slowly or does not grow at all; if, however, water is added the grass begins to grow more quickly. Withdraw the water and the growth will stop quickly. The water did not cause the grass but only stimulated its growth. This is most likely the same relationship between estrogen and breast cancer.

Estrogen for most women is a safe and effective treatment for the symtpoms of menopause. As discussed previously estrogen affects many body tissues and functions in a positive way. Like every decision in life there are risks and benefits. The question that women must answer during menopause is, do the benefits of estrogen replacement outweigh the risks. Quality of life is certainly important and for many women their quality of life is greatly enhanced by the use of estrogen to help with the short-term and long-term results of menopause. Estrogen replacement should not be used as a public health strategy but certainly has a use for the individual. This is something the menopausal woman and her doctor should discuss and consider together. Next month’s article will deal more specifically with estrogen’s benefits and its risks.

Do heavy menstrual periods interfere with your life? Do you have to plan family and work related activities around your menstrual cycle? Heavy menstrual bleeding is an extremely common and bothersome condition. As many as one in four women suffer from this problem. It can occur at any age and can be variable in its occurrence. Surprisingly many women think that this is “normal” or that it is to be expected as one gets older. Excessive menstrual bleeding remains one of the leading indications for a hysterectomy. Up to 250,000 U.S. women have a hysterectomy each year for this problem.

Menorrhagia is the medical term used to describe this condition. The definition includes extremely heavy bleeding, too frequent bleeding, or prolonged menstrual bleeding. There are a number of causes for this condition:  clotting disorder, hormonal imbalance, or anatomic abnormalities such as fibroids, adenomyosis, or endometrial polyps. Fibroids are extremely common benign tumors that arise from the muscle of the uterus. Many women have fibroids without them causing any symptoms. Not uncommonly however fibroids may enlarge when women enter their late thirties or forties. When they do so heavy menstrual bleeding or pelvic pain may result requiring treatment. Adenomyosis is a very common condition that results from the growth of the endometrium (uterine lining) into the muscle of the uterus. This condition is benign and results from pregnancy. Endometrial polyps results from the over growth of the endometrial lining in a grape-like manner that also can result in excessive menstrual bleeding; rarely are polyps associated with precancerous or cancerous changes.

The age of the woman suffering from this problem determines the timing and extent of the evaluation prior to beginning treatment. Blood testing for a bleeding disorder or hormonal imbalance may be necessary. For anatomic problems or potential cancerous problems, pelvic ultrasound and a small uterine biopsy is typically all that is necessary. Most often this evaluation can easily be completed in the office; rarely is any hospital-based surgery required. In adolescent or early reproductive age women, treatment can be initiated with minimal evaluation. More extensive evaluation would follow only if treatment did not resolve the problem.

Treatment options are many depending on circumstances in which the symptoms are occurring.  They range from drug therapy to minimally invasive office procedures to hysterectomy. In women who have not completed their family, hormonal therapy is the mainstay of treatment if no anatomic problems exist. A common treatment is birth control pills to reset the menstrual cycle. Other drug therapies would include anti-inflammatory medication, cyclic progesterone use, or the diabetic medication Metformin if Polycystic Ovarian Syndrome (PCO) is the cause of the abnormal bleeding.

Surgical options include the correction of any anatomic abnormality such as fibroids or uterine polyps. This typically is done with an outpatient surgical procedure known as hysteroscopy. Hysteroscopy entails placing a small scope into the uterus through the cervix. This allows the visualization of the uterine cavity and removal of polyps and any accessible fibroids. As stated previously, hysterectomy remains a common surgical option for treatment of heavy menstrual bleeding in women who have completed their family. When treating a benign noncancerous condition the hysterectomy should be done in a minimally invasive manner, i.e. vaginally or laparoscopically. If done so, most patients can go home the same day and resume normal light activity within a week. There is almost no justification for a woman to have a hysterectomy performed through a large abdominal incision. Uteri of very large size can be removed through a laparoscope. Currently robotic surgery is being touted in many hospital and surgeon advertisements as the best approach for performing a hysterectomy in a minimally invasive manner. These advertisements state that women no longer need a large incision to perform a hysterectomy if a robot is used. The robot is an amazing piece of technology but is not necessary for 99% of hysterectomies. I have been performing minimally invasive laparoscopic hysterectomies since 1992 without the aid of a robot. Hysterectomies performed in this manner can be accomplished through 1 to 3 tiny incisions. Robotic surgery is beneficial when treating extensive cancer or endometriosis but greatly inflates the cost without providing additional benefit when used in the majority of circumstances.

A nice intermediate treatment between medications and hysterectomy is an endometrial ablation. This is a procedure that prevents the endometrial lining of the uterus from re-growing each month thereby reducing or eliminating menstrual flow. It does not cause any changes in hormonal secretion and therefore does not induce early menopause. Women are able to immediately resume normal activity. This procedure uses either a burning technology or cryotherapy (freezing) to cause destruction of the uterine lining. When cryotherapy is used, the procedure can easily and painlessly be performed in an office setting. Endometrial ablation is the treatment that I believe is ideal for most women with heavy menstrual bleeding that have completed their family and does not want to, or is unable, to take hormones. In most cases hysterectomy should be reserved for situations where the ablation is unsuccessful or is not the appropriate treatment for the patient’s particular situation. I have performed over 250 cryoablations in my office with a high degree of patient satisfaction. The in-office cryoablation procedure has greatly reduced menstrual flow along with risk, cost, and downtime for these women as compared to a hysterectomy. Heavy menstrual bleeding is a common problem but not one with which women need to live. Treatments are many and often can be accomplished without causing significant disruption in their life.

The pregnancy test is positive. For most women this realization is followed by shock, disbelief, and finally an overwhelming sense of joy.  It is a sense that something that was missing is found; she is now whole and complete. Very quickly in her mind she experiences the joy of delivery and holding her baby for the first time.  She experiences her child’s first smile, first word, first steps, and first birthday.  She is able to watch her child grow, go to school, graduate, begin a job, marry, and start his or her own family.  This is all very real; the joy and satisfaction of this experience is beyond anything that she has ever previously known.  This is why a miscarriage is such a devastating event. What was very real has been lost.  A very common reaction by a woman who has suffered a miscarriage is trying to understand why it happened. Was it something that she had done?  Was there something that she could have done to prevent it? Unfortunately many women often blame themselves.  The most important message that a woman who has suffered a miscarriage should be given is that there is nothing that she could have done to cause it nor is there anything that could (or should) have done to prevent it.

The birth of a healthy newborn baby is truly a miracle.  We should be much more amazed at the birth of a healthy baby than we are surprised by a miscarriage.  The development of a baby from conception, resulting from the joining of two cells, and culminating in the birth nine months later is the most complicated process in nature.  The egg and sperm have to join to form a new cell, that new cell must replicate billions of times and form all the different tissues and organs of the body. The differentiation of these cells must occur at a precise time during development; if something goes wrong early in this complicated process then everything after that is abnormal.  The enormity and complexity of this process is something that is not seen anywhere else in nature.  Not when you consider the result of this union is a completely unique human being; one who has never before and never will again be replicated, one who at birth has almost unlimited potential.

Miscarriage, or early pregnancy loss, is the most common complication of human gestation; it occurs in 75% of all pregnancies.  Fortunately, most of these losses are unrecognized and occur before the next missed menses. Of those recognized pregnancies, the miscarriage rate is 15% to 20%.  As a woman enters her late 30’s and 40’s the miscarriage rate is even higher. There are multiple causes of miscarriages. These causes may be due to genetic abnormalities of the fetus or the parents, anatomic anomaly in the mother, environmental or infectious cause, maternal illness, autoimmune or hematologic disorders in the mother, and as of yet unidentified causes.

Most spontaneous miscarriages are due to a genetic abnormality in the early cells after conception; one or more of these cells fail to multiply and divide in the proper manner. The body soon recognizes that this is not a normal development and a miscarriage results.  This type of occurrence is a random event and does not have a predictable reoccurrence; it is just bad luck. Another genetic cause that does have a predictable reoccurrence would be abnormal genetic material passed from the parents to any offspring. In the event of recurrent losses, genetic evaluation of the parents may detect certain abnormalities in one or both of them that may prevent normal development of their baby. The risk of this can be predicted for each pregnancy. Maternal uterine anomalies can be easily detected with an x-ray test known as hysterosalpingogram (HSG) or an ultrasound. Blood tests for autoimmune disorders or clotting disorders can also be done.  It is important that any maternal health conditions, such as diabetes or thyroid disease, be under optimal control prior to conception. Smoking, excessive alcohol intake, and illicit drug use increases the risk for pregnancy loss. Evaluation for miscarriages historically has not been recommended until a woman has experienced 3 consecutive pregnancy losses. It is hard, however, to deny a woman who has had 2 losses an evaluation if she so desires.

A miscarriage is a heart-wrenching experience for most women and is most often something that is not preventable.  It is important however that a couple does everything they can prior to conception to enhance the possibility of a successful outcome. A healthy life-style is at the top of this strategy. Medical conditions should be well controlled, exercise on a regular basis, try to obtain ideal body weight, immunizations should be up to date, avoid smoking, excessive alcohol, and drugs. Women should be on multivitamins with folic acid prior to conception; vitamin D3 and omega 3 fatty acids are also recommended. Doing these things does not guarantee a  successful pregnancy but it certainly helps and can also alleviate any guilt a woman may feel if she knows that she has done everything possible prior to conception. Fortunately most woman who have had a miscarriage go on to have successful pregnancies  in the future and are able to recapture the joy they previously experienced prior to a miscarriage.

Polycystic Ovarian Syndrome (PCO), as discussed in last month’s article, is a very common condition that affects adolescent girls and young women.  Women suffering from this problem very often are obese, have acne, excessive hair growth, and have infrequent periods. This is a condition that adversely affects a woman’s self image and causes considerable frustration. The frustration results because the hormonal and metabolic imbalances that cause PCO also make dieting ineffective; no matter how hard one tries dieting very often results in very little weight loss. PCO also can cause infertility due to infrequent ovulation. Long term effect of PCO is increased risk for diabetes, high blood pressure, heart disease, stroke, and cancer. Because of the short-term and long-term consequences of PCO, early diagnosis and treatment is very important; a woman’s quality of life will be greatly enhanced if this condition is reversed at the earliest possible time.

Diagnosis of PCO is first suspected by the patient’s appearance. Eighty percent of women with PCO are obese. Skin changes that are most frequently seen are acne and acanthosis nigrans. Acanthosis nigrans is a velvety mossy hyper pigmentation of the skin located on the neck, axilla, vulva, or underneath the breasts. Abnormal hair growth is also noted. This is most frequently seen on the upper lip and chin, neck, breasts, and lower abdomen. Blood tests are frequently ordered to confirm the diagnosis and to rule out other potential causes of the patient’s symptoms. The male hormone testosterone is frequently elevated. This is the main cause of acne and abnormal hair growth; it also greatly contributes to the patient becoming obese. The origin of the testosterone is mainly from the ovary; it also prevents regular ovulation. Ultrasound also reveals the ovary to have multiple small cysts, thus the name polycystic ovaries. Very often women with PCO will have elevated fasting blood sugar or an abnormal glucose tolerance test. This results from their insensitivity to insulin which controls blood sugar levels. This insensitivity results in women with PCO producing higher levels of insulin to keep their blood sugar levels normal. Higher insulin levels cause anovulation leading to increased testosterone production and reduced sex-hormone binding protein which also increases testosterone effect. In addition, insulin encourages the storage of fat contributing to obesity. It is mainly the elevated testosterone and insulin that a woman is fighting when trying to lose weight. Because of these elevated hormones, it is a fight that is often lost.

Treatment is centered on reducing testosterone and insulin levels. By doing so, a woman’s ability to lose weight will be greatly enhanced. It is weight loss, achieving appropriate BMI, which is the ultimate treatment. Medications are used to create the appropriate hormonal and metabolic environment so that a diet and exercise program can be effective. Medications alone will not achieve reversal of PCO. In the adolescent girl or young woman who does not wish to become pregnant, three medications are typically used. These medications include birth control pills, metformin, and spironolactone. The birth control pill effectively put the ovaries into a state of hibernation and stimulates an increase production of sex hormone binding proteins. This results in lower production of testosterone and reduces the circulation of active testosterone. The birth control pill also regulates the menstrual cycle, reduces bleeding and cramping, and lowers the woman’s risk for uterine cancer. The metformin is a diabetic medication. It mainly works by increasing a woman’s response to insulin. By increasing the patient’s sensitivity to insulin, less is required to control her blood sugar. The lower insulin level also results in diminished testosterone production, increased sex-hormone binding protein production, and less fat storage. The spironolactone is a mild diuretic and blocks testosterone receptors. It keeps testosterone from binding to receptors in tissue. If it can’t bind to receptors then it can’t induce an effect on the tissue such as acne or increase hair growth.  Patients with PCO who wish to become pregnant generally require ovulation-inducing medication such as clomiphene citrate; metformin sometimes is used in this situation also.

The changes that are associated with Polycystic Ovarian Syndrome are the result of the inappropriate excess production of testosterone and insulin. Reducing the production of these hormones creates an environment where acne treatment will be more effective, growth of inappropriate hair follicles will be inhibited, and weight reduction can be achieved. The long term benefit of controlling of PCO is to significantly reduce one’s risk for hypertension, heart disease, stroke, and cancer. Again, it cannot be stressed enough that diet and exercise is the most important treatment for reversal and control of PCO. Medications are an aid not a cure. For woman with PCO this is a life long struggle; discipline and determination is what will result in success.