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Perimenopause
The Guesswork of
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WOMAN FIRST
IN THIS ISSUE
HRT
Hormone Replacement Therapy........4
Why see a Midlevel Practioner?..........9
The Guesswork of
Perimenopause.................................12
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Welcome to
Women First
Women First is a medical practice specializing in obstetrics and gynecology. Our
practice was founded in 1989 with the goal of providing comprehensive medical
care to women in a comfortable, friendly, and efficient manner. In order to
achieve that goal we maintain a state-of-the-art facility, and provide the latest in
medical innovation and technologies in a setting that is tranquil, courteous, and
comfortable.
To meet your health care needs efficiently, we offer a broad range of services within our
office. These services include digital mammography, osteoporosis screening, OB/GYN
ultrasounds (3D/4D), high risk obstetrics, genetic/preconception counseling, urinary
incontinence testing/surgery, minimally invasive GYN surgery, in-office sterilization,
in-office treatment of abnormal bleeding disorders and lactation counseling.
Women First employs six midlevel practitioners and allows for same day appointments
for established patients. Additionally, our triage team is available by phone from 8
a.m. to 4 p.m. Monday through Friday to answer your medical questions and physician’s
office schedules are designed to minimize your waiting time.
Our practice consists of 10 board certified physicians. Dr. Rebecca Terry, Dr. Lori
Warren, Dr. Mollie Cartwright, and Dr. Rebecca Booth focus their practice on GYN
only. Dr. Leigh Price, Dr. Ann Grider, Dr. Michele Johnson, Dr. Kelli Miller, and
Dr. Stephanie Dutton provide both OB and GYN care. Dr. Ann Clark specializes
in High Risk Obstetrics.
We understand OB/GYN from a patient’s perspective and have a vested interest in
women’s health issues.
Call and make an appointment today... We’ll treat you the way you expect to be
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OUR M I DL EVEL P R A C T IT IO NER S:
(From left to right)
Cristen Singer, ARNP
Annette Davis, ARNP
Linda Ohlmann, ARNP
Shannon Bretz, ARNP
Peggy Wolf, ARNP
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WOMAN FIRST
3
HRT
(Hormone Replacement Therapy):
Rebecca Booth, MD
I do not think there is an area of medicine that generates more confusion than that
surrounding the issue of hormone replacement therapy in menopause. At the crux of
the issue is the fact that menopause is not a disease, but the changes associated with
it can be so difficult for some women that qualitity of life is severely compromised,
yet many other women find it extrememly liberating and do not suffer symptoms
at all. This small, but indisputable fact makes collecting information about
needs, wants, benefits, and risks surrounding HRT nearly impossible.
The arena of hormone replacement has traditionally meant
estrogen replacement, with or without progesterone. The practice
has blurred somewhat with the advent of anti-aging HRT, which
might also include replacment of testosterone in both men
and women, and replacement of non-sex hormones such as
DHEA, human growth hormone, and others, again for men
and women. Each substance has its own risk-benefit profile,
as does every combination of these hormones.. For practical
purposes in this article let us refer to HRT as estrogen and/
or progesterone replacement for women.
Why HRT in the First Place?
Part of 20th century disease prevention strategies inspired
the attempt of medical professionals to head off some
disease processes that are accelerated in menopause. One
of the focuses for preventive health care for women has
been diagnosis, treatment, and prevention of bone loss.
In the late 1980s and early 1990s, estrogen therapy was
strongly promoted as a way to prevent hip fractures, and
this and other suspected benefits resulted in a movement
of many physicians toward putting all eligible women
on HRT. Other previously touted benefits included
some evidence that HRT may reduce heart disease and
dementia. Many experts were calling for confirmatory
research in this area, as pharmaceutical companies were
making new formulations, seemingly daily, to meet
the demand.
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WOMAN FIRST
To Take or Not to Take,
That is the Question
The winds of change blew in 2002, when early results were released
from the very important Women’s Health Initiative (WHI). The
WHI was started in 1998 at forty American clinical centers to look
at HRT in postmenopausal women and how various disease states
were influenced by it over time. The HRT compound used in this
study for the women without hysterectomy was Prempro®, one
of the most common replacement formulations at that time. This
formulation includes a type of estrogen (Premarin®) combined with
a progestin (synthetic progesterone), Provera, in a daily dosing.
The planned duration of the study was 8.5 years. After five years,
this portion of the study (initially almost 17,000 women) was
stopped because the risk of breast cancer was seen to increase in the
Prempro group, and the risk-benefit calculations could not justify
continuing the study. The Prempro group was discontinued. Other
negative findings associated with Prempro included increased risk
of stroke, blood clot, and heart disease. However, benefits included
fewer hip fractures due to stronger bones and significantly less risk
of colon cancer.
Another part of the WHI, known as the “estrogen-alone study,”
involved 11,000 women who had had prior hysterectomy. This
group on Premarin alone demonstrated less overall risk, but
nonetheless was called off prematurely (after seven-plus years) due
to increased stroke risk (0.12 percent increase in stroke risk per
year of use). Interestingly, this group showed 23 percent less breast
cancer than the placebo group, a finding that is still raising a great
deal of speculation about the connection between progestins (such
as Prempro) and breast cancer.
The Premarin-only group also was found to have less artery
buildup (plaque), harkening to the long-held view that estrogen
offers some vascular protection despite the tendency to increase
clotting. The increase in clotting risk cause by estrogen has long
been thought to be a protection from hemorrhage risk associated
with menstruation, ovulation, and childbirth. As a woman ages her
tendancy to clot increases making HRT more risky with age with
regard to blood clots.
Generally HRT is only prescribed to a woman who is suffering
from the side effects associated with low estrogen levels mentioned
previously who understands and accepts the risks with the benefits.
Most women opt not to take HRT due to fears of the risks, and a
general inclination to “tough it out.” Our job as gynecologists is to
counsel and educate our patients about their options in order to
help them navigate the changes and challenges of menopause.
Reasons not to Take HRT
Several women should not take HRT under any circumstance.
For example, women who have had a blood clot in a deep vein,
those that have an inherited conditon that increases the chances
of clotting, those with a previous stroke or heart attack, those with
blockage of the coronary arteries, or those with a known active
estrogen or progesterone receptor positive cancer should not take
hormones. Women who smoke, or those who are overweight,
and/or diabetic should be very cautious about HRT as they are
already at increased risk for complications involving heart diease
and clotting.
Benefits of HRT Include:
Estrogen alone: lower risk of hip fracture, improved menopausal
symptoms in some women (i.e., hot flashes and insomnia), less
artery build-up (assumed to indicate protective effect on blood
vessels), improved vaginal lubrication, improved cholesterol profile,
and improved skin quality.
Progestins plus estrogen: All of the above, minus the protective effect
on cholesterol and artery build-up, but with the added benefit of
reduction in colon cancer risk. It is important to understand that
synthetic progesterone-like substances seem to take away some of
the cholesterol, hence artery build-up, benefits with estrogen alone,
as well as increase the risk of breast cancer. Progestins seem to have a
protective effect on colon cancer risk when added to estrogens. Some
have therorized that the negative effect of progestins on the breast and
cardiovascular system are the result of increased insulin resistance seen
with synthetic progesterone-like compounds (progestins).
WOMAN FIRST
5
Risks of HRT Include:
Estrogen alone: Increase in blood clot formation leading to increase
risk of stroke, clots to the lung (pulmonary embolus), possible slight
increase in ovarian cancer, and increases in gall-bladder disease.
Progestins plus estrogen: All of the above plus increase in breast cancer
after 5 years of use, increase in heart disease; especially the first year of
use.
While many women do chose to take HRT, mainly for symptom relief,
current accurate numbers of American women on HRT are hard to come
by. Some women are on compounded products through independent
sources or mail-order pharmacies. Some are “on them,” but only take
one daily dose a week in an attempt to lower the risks. Whatever the
case, the usage has been estimated to have dropped significantly due to
recent information about risks based on large studies.
The fact that estrogen in combination with progesterone or progestins
may add risk to the mix (i.e., increased heart disease and breast cancer
risk) presents a dilemma. Many procedures and medications are now
available to help women avoid hysterectomy, so most will have to take
progesterone if they choose to take HRT in order to prevent the uterine
lining from becoming cancerous. This fact has given those women who
have had hysterectomy a distinct advantage with regard to HRT at this
point in time as estrogen-alone therapy is associated with a better risk/
benefit ratio.
No Little Old Ladies, Please
Estrogen receptors are everywhere in the body and are known to
exist in joint material and may contribute to cartilage content as well
as bone collagen. Degenerative disc disease (herniating, bulging, or
flattening discs), a common problem causing much pain in the elderly,
is a result of arthritis in the spine, destroying the healthy nature of
the cushioning discs. This is a big contributor to height loss and is
not helped by the most common drugs for osteoporosis. While corestrengthening exercises are protective and restorative (to some degree),
studies have shown that estrogen may play a protective role with respect
to arthritis.
When is it too Late to Start HRT?
Dr. Alan Altman, a gynecologist and assistant professor at Harvard
Medical School, presents a compelling critical analysis of the WHI
results with much food for thought. He stresses that we doctors
rarely randomly start senior women on HRT (the average age in the
Prempro study to initiate therapy was about sixty-four). Rather, the
tendency is to begin replacement when women are most symptomatic,
around fifty, and continue for a varied amount of time depending
on the individual needs of the patient. His question is: “Is HRT a
preserver, or a repairer?”
The WHI study indicates that repairer may not be the answer,
but what about preservation? In other words, does HRT prevent
some of the decline associated with aging (i.e., bone loss, arthritis,
memory changes, skin changes, etc.) if it is initiated at the time of
menopausal
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WOMAN FIRST
transition, and if so how late is too late to reap the preserver role?
More and more experts are considering a window of time during
which HRT may be administered to diminish some of the decline
associated with the rapid hormone fall off after ovulation stops.
The preserver role is critical to understand, as the so-called window
of time after which one may lose the benefit of HRT has not been
defined. Some have suggested five years may be the upper limit of this
time window, but there is no general consensus at this time. Another
question: Can HRT help preserve verbal memory? An accompanying
study of the WHI, known as the WHIMS study, looked at HRT (both
Premarin alone and Prempro) and the possible benefit for prevention
of cognitive decline. The enrollees had to be sixty-five or older. Neither
compound showed benefit and in fact, the HRT group fared worse
from a dementia standpoint. This has led critics to surmise once again
that HRT is not a repairer, and may after a period of time cause much
more harm than good. It is felt that in older patients, the stroke risk
may trump any cognitive benefit, essentially worsening the scenario.
What about the woman who is transitioned through
menopause on low-dose HRT and later assessed for brain
functioning? Prospective studies are due out in the near
future, but some data in the past have been positive. One
very interesting observational study involving Swedish
twins (published by Rasgon et al. at Stanford University)
revealed in 6,700 women ages sixty-five to eight-four that
the use of HRT was associated with a “40 percent decline
in the risk of cognitive impairment, independent of type
and timing of treatment.” In other words, they concluded
that HRT was significantly protective of brain decline
when comparing twins.
In an elegant and comprehensive review of the role of HRT
concerning the aging brain, John H. Morrison et al. (Mount
Sinai School of Medicine, New York, NY) concluded that
we are facing an unprecedented incidence of Alzheimer’s
disease—and it is primarily affecting women—in our
country. The compelling data that estrogen, with or without
progesterone may have a preserving effect on cognitive
function despite the recent WHI data begs for more research
and perhaps the development of safer hormonal therapies.
Bioidentical HRT
Recent attention given to bioidentical hormones has raised
hope among many women that molecules identical to
human sex hormones, rather than synthetic or “derived”
hormones that are similar but not identical, are somehow
safer in the menopausal woman. While it does seem
appropriate to use molecules designed for humans when
replacing them, all women need to remember that our
own hormones pose risks to us, as much as they add
vitality, beauty, desire, and other positive qualities. They
are designed to facilitate reproduction, and there is a price.
The bioidentical estrogen is still estrogen, and there is no
significant evidence that it is any safer than the formulations
that have been extensively studied. Fortunately, much
more work is being done in this area, and more positive
information may emerge in the near future.
Topical or Transdermal HRT
HRT that is designed and formulated to be absorbed
through the skin, vagina, or other body orifice may have
some biologic benefit with regard to risk. Oral formulations
have been shown to stimulate more of the risk associated
with blood clotting due to what it called the “first pass
effect.” This is the passing of oral medication through the
liver by way of the intestinal track, allowing a larger dose to
hit the liver “all at one time” stimulating more blood clotting
factors (made in the liver). If a hormone is administered
through another route, the passing through the liver effect
is much more subtle, and creams, patches, suppositories and
the like may offer advantages due to this.
Strategies to Lower Risk
Women who opt to take HRT can minimize their health
risks by imploring a healthy, active life style and taking
supplements. Women on combination (estrogen and
progestin, or progesterone) therapy should be particularly
careful about breast cancer prevention.
WOMAN FIRST
7
A low carb diet and regular exercise can help lower insulin resistance
that is associated with progesterone. Low dose aspirin (81mg) daily
has been shown to lower stroke risk in senior women, and may be
a useful strategy to help offset the increase in clotting associates
with estrogen therapy. Omega 3 fatty acids (fish oils), are also
helpful as they help stabilize mood and metabolism and are also
good for the heart and brain health. Take 1000 mg a day, usually
a combination of two common omega-3s, EPA and DHA (not to
be confused with DHEA—a prohormone). Good brands include:
Eskimo 3 (Integrative Therapeutics, Inc.), GNC’s Fish Body Oils
(lemon flavored). A multivitamin daily is of importance to make
certain your body has the tools to keep its chemistry optimal.
One A Day Women’s ® is a good brand as is GNC’s Women’s
Ultramega Vitamin (it is a twice a day formula which makes it
easier on the stomach, but it is a large tablet). For those who have
trouble swallowing or who have stomach upset with a multi, try
a chewable vitamin such as Viactiv brand multivitamin (many
flavors), available in most pharmacies and Target.
Calcium is also of utmost importance as menopause marks the time
of a loss in bone density due to declining estrogen. I recommend
1500mg a day in divided doses as women cannot absorb more
than about 500 to 600 mg at any one time. Remember calcium
is a mineral, not a vitamin and there may not be much in the
multivitamin you are taking.
Vitamin D is also important in perimenopause as in other stages.
Studies show that most women do not get adequate Vitamin D,
which is imperative for bone health but also for cancer protection.
Many health experts feel the current US RDA (recommended
daily allowance) is too low at 400 IU. I recommend at least 1000
IU a day, and this is usually accomplished if you take a calcium
supplement with added vitamin D.
Exercise is a must to offset the increased clot risk associates with
estrogen therapy, and the insulin resistance that may be increased if
progesterone or progestins are added to the mix.
Prescription medications (non-hormone) may also help hot flashes
in many women. Some antidepressants, for example Effexor, have
a positive effect on hot flashes and night sweats. Some high blood
pressure medicines such as Clonidine can help ease the flushing.
There are risks and benefits to these as well, but they are well tolerated
by most.
The Consensus
The general medical world consensus since the WHI has been to
only recommend HRT in the face of specific estrogen-withdrawal
symptoms (e.g., hot flashes) at the lowest dose possible and for the
shortest amount of time. The facts are that most women suffer at
least some side effects of the loss of the higher levels of estrogen
and testosterone present during the cycling years. Helping a woman
navigate the decision about HRT is the challenge for her health care
provider and it is a welcome challenge for us at Women First.
Much of the information for this article has been taken from The Venus Week, by Dr.
Rebecca Booth, Da Capo Lifelong Books, 2008.
Garden Analogy for HRT
Say you have a garden full of beautiful plants. Many pests can
threaten the garden, such as infections, parasites, and even
predators. As the gardener, you set up many varied systems
of protection. Natural elements provide some sustenance (sun,
water, soil), but you may want to fertilize to encourage growth
and maintain the beauty and even the health of your plants.
Of course, using chemical fertilizers in your garden is not
without risk. You might overdo it and “burn” the plants. If you
don’t have the right mix of fertilizer, you might force the blooms
inappropriately, and if your timing is off, the plants may not
flower at all. You may very well stimulate the weeds that are
quietly hiding under the mulch, waiting to take advantage of
Even for women not taking HRT insulin resistance goes up
after menopause in part due to declining estrogen levels. Every
woman should get at least 150 minutes a week of some sort of
heart-pumping exercise. That’s just 22 minutes a day! A treadmill,
elliptical, or recumbent bike is a wise investment in a woman’s
health. A regular yoga practice helps keep the blood flowing
through veins and muscles easing clot risk as well as improving
flexibility and body confidence.
your favorite plants. Yet if you study your gardening guides and
Other options for symptoms
There are many non-hormonal treatments for the symptoms of
menopause. Several over the counter formulas are available, and
while evidence of more than a placebo effect has been scant, the
science behind plant derived estrogens as a healthful; choice for
menopause symptoms is mounting. Estroven® and Healthy Woman
Soy Supplement® are examples of over the counter supplements
made from plant estrogens that may relieve hot flashes in many
women. These are available in most drug stores.
you are trying to grow and maintain are your organs. Just as
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WOMAN FIRST
carefully follow the directions for using fertilizer, you will reduce
your risks, and if you weed the garden fastidiously, you may
prevent them from taking over. Ultimately, you can grow a garden
without fertilizer, and whether you use it or not, over time, some
plants will not thrive, and others will.
Now think of the garden as your body, and the beautiful plants
your garden may benefit from the right fertilizer carefully applied,
your body may benefit from HRT, but if you choose to take it you
must understand the known risks. This is not a perfect analogy,
and certainly if we could simply “weed out” cancer, we could all
get better sleep, but the idea of fertilizer as a comparison to HRT
helps communicate the fact that HRT is a mixed bag of benefits
and risks that each informed menopausal woman must sort out.
our practitionors
Meet our Women First Midlevel Team
Our midlevel team consists of five nurse practitioners and one physician assistant, all of whom play an integral role in our overall
patient care program here at Women First. Our midlevel’s will often be the provider caring for same day appointment patients, in
addition to partnering with our physicians to provide routine follow-up care for their respective patients. Additionally, our midlevel’s
see their own established patients for annual exams, follow-up and problem visits, with some specializing in providing lactation
consultation services as well as evaluation and treatment of recurrent vulvo-vaginal problems. Our midlevel’s provide an invaluable
service that helps us to achieve the full circle of care that is the foundation for our mission: Women First… in all we do.
Ann Grandon, PA-C
Cristen Singer, ARNP
Ann graduated Cum Laude from the Physician Assistant
Program at Alderson-Broaddus College in Philippi,West
Virginia in 1991 after receiving a bachelor’s degree
from West Virginia University. Prior to joining Women
First in 1996, Ann worked for five years as a Physician
Assistant in OB/GYN at Valley Health Systems in
Huntington, West Virginia. As our first Physician
Assistant to join the practice, Ann brings 18 years of
experience as a seasoned practitioner to her patients and other midlevel
colleagues in our practice.
Cristen received her Master’s Degree in Nursing
from the William Connell School of Nursing at
Boston College, where she was a Nursing Honor
Society member. She received her Women’s Health
Nurse Practitioner certification in 2007. Cristen’s
background includes working as a Registered Nurse
in Labor and Delivery at Norton Suburban Hospital
and as a Registered Nurse in the OB/GYN in-patient unit at Hennepin
County Medical Center in Minneapolis. She has also worked as a Nurse
Practitioner for Planned Parenthood of Kentucky. Cristen joined Women
First in 2009 and works in partnership with Dr. Lori Warren.
Shannon Bretz, ARNP
Peggy Wolf, ARNP
Peggy received her Master’s Degree in Nursing from
the University of Louisville and received her Nurse
Practitioner certification in 2000. After working for
a number of years as a Charge Nurse and Certified
Registered Nurse in Labor and Delivery at Baptist
Hospital, and as a Nurse Practitioner for an area OB/
GYN group practice here in Louisville, Peggy joined Women First in 2008.
Annette Davis, ARNP
Annette received her Bachelor of Science in Nursing
with Concentration in Obstetrical Nursing from
the University of Louisville and received her Nurse
Practitioner certification in 1994. Prior to joining
Women First in 1999, Annette worked as a Nurse
Scrub Technician at Humana Hospital University and
as a Labor and Delivery Nurse and Prenatal Childbirth
Educator at St. Anthony Medical Center. She has also
worked as a Nurse Practitioner for Planned Parenthood of Louisville and
Clark County Family Planning and Prenatal Clinic. Along with the wealth
of experience that Annette has brought to Women First, she specializes in
providing consults for patients referred by their physician’s for the evaluation and treatment of chronic and recurrent vulvo-vaginal problems.
Shannon received her Master’s Degree in Nursing from
the University of Louisville and received her Nurse
Practitioner certification in 2008 and her Lactation
Counselor Certification in 2009. She joined Women
First in 2008. Shannon’s background includes working
several years as a Labor and Delivery Nurse at Baptist
Hospital East. Shannon works in partnership with our
physician obstetric team and is Women First’s lactation counselor.
Linda Ohlmann, ARNP
Linda received her Diploma in Nursing from Norton
Memorial Infirmary School of Nursing, and received
her Nurse Practitioner certification in 1977. Prior
to joining Women First in 1996, Linda worked as a
Public Health Nurse for Family Planning of Louisville
and Jefferson County and as Clinic Director/Nurse
Practitioner for Planned Parenthood of Louisville. She
also worked as the Director of Nursing and OB/GYN
Nurse Practitioner for EMW Women’s Surgical Center, as well as a OB/
GYN Nurse Practitioner for an area private group practice. As our first
Nurse Practitioner to join the practice, Linda brings years of experience as
a seasoned healthcare provider to her patients and other midlevel colleagues
in our practice.
WOMAN FIRST
9
OUR PHYSI
OUR PHYSICIANS
Dr. Leigh Price
Dr. Leigh Price grew up in Louisville and
completed her undergraduate studies at
Western Kentucky University. She then
entered the University of Louisville for
her medical studies, receiving her medical
degree in 1989.
Her special interests include laparoscopic surgical procedures,
conservative management of uterine bleeding problems,
diagnosis and treatment of abnormal pap smears, osteoporosis
and gynecologic urology, management of menopause and
perimenopause, treatment and prevention of osteoporosis and
preventative health care services.
Her postgraduate training consisted of
an internship and residency at the University of Louisville in
the Department of Obstetrics & Gynecology, and her board
certification was completed in 1995 by the American Board
of Obstetrics & Gynecology. She is a fellow of the American
College of Obstetricians and Gynecologists and joined
Women First in 1993.
Dr. Mollie Cartwright
Dr. Mollie Cartwright, a native of Louisville,
completed her undergraduate degree and
medical training at the University of
Louisville. She received her internship and
residency training with the Department of
Obstetrics and Gynecology at the University
of Louisville School of Medicine and joined
Women First of Louisville in 1989.
Dr. Lori Warren
Dr. Lori Warren was born in Ithaca, NY.
She received both her Bachelors degree
and Medical degree at the University of
Kentucky, and completed her residency
training at Tufts University, becoming board
certified in Obstetrics and Gynecology in
1993.
Dr. Warren has professional society memberships in the
American College of Obstetricians and Gynecologists
(Fellow), the Kentucky Medical Association, and the Greater
Louisville Medical Society. She is also a member of the
American Association of Gynecologic Laparoscopic Surgeons
and is certified in Bone Desitometry. She joined Women
First in 1991. Dr. Warren has launched a broad-based
national platform informing women about hysterectomy
surgical options. Visit www.betterhysterectomy.com for more
information.
Dr. Rebecca Terry
A Kentucky native, Dr. Rebecca Terry
was born in Cadiz, KY, and grew up
in northern Indiana. She graduated
from Transylvania University in 1976
and then attended and graduated from
the University of Louisville School of
Medicine in 1980.
Her residency training was at the University
of Oregon in Portland, OR, which she completed in 1984.
Her board certification was in 1986 and re-certification was
done in 1996, 2004, 2005 and 2006.
Dr. Terry was one of the founding partners for Women First
of Louisville PLLC in 1988. Her current practice focuses
on gynecology. She is a Fellow of the American College
of Obstetricians and Gynecologists and a member of the
Kentucky Medical Association, Jefferson County Medical
Association, American Medical Association and the Louisville
OB/GYN Society. She is also certified in clinical Bone
Densitometry and has been named in Louisville Magazine as
one of Louisville’s “Top Docs”.
Dr. Cartwright is board certified in Obstetrics and Gynecology.
Her professional society memberships include Fellow of
the American College of Obstetricians and Gynecologists,
the American Medical Association, the Kentucky Medical
Association, and the Jefferson County Medical Association. She
has been named in Louisville Magazine as one of Louisville’s
“Top Docs.”
Dr. Ann Grider
Dr. Ann Grider grew up in Columbia, KY,
and completed her undergraduate degree at
Centre College. She received her medical
degree from the University of Louisville
School of Medicine and completed her
residency in Obstetrics & Gynecology at
the University of Cincinnati.
Dr. Grider is board certified in Obstetrics & Gynecology
and is a fellow in the American College of Obstetricians and
Gynecologists, a member of the American Medical Association,
Kentucky Medical Association, Society of Laparoendoscopic
Surgeons, Greater Louisville Medical Society, and the Louisville
Obstetrics & Gynecology Society.
Dr. Kelli Mudd Miller
A Louisville native, Dr. Miller completed
her undergraduate education at the
University of Louisville. She received her
Medical Degree as well as her training
in Obstetrics and Gynecology at the
University of Louisville.
Dr. Miller is board certified in Obstetrics
and Gynecology. She is a member of Alpha Omega Alpha Honor
Society, American College of Obstetricians and Gynecologists
(Fellow), American Medical Association, and the Louisville
Obstetrical Gynecological Society.
She is currently on the American College of Obstetrics and
Gynecology Committee for the Heathcare of Underserved
Women. Dr. Miller practices Obstetrics and Gynecology.
ICIANS
Dr. Rebecca Booth
Dr. Rebecca Booth was born in Columbia,
TN, and moved to Louisville as a child.
She completed undergraduate studies at
the University of Kentucky and studied
medicine at the University of Louisville
where she was inducted into the Alpha
Omega Alpha Honorary Society and
received her medical degree in 1985.
Her internship and residency were completed at the University
of Louisville Department of Obstetrics & Gynecology, and she
received her board certification in 1991.
Dr. Booth joined Women First in 1989 and her practice is
currently primarily gynecology. She is a fellow in the American
College of Obstetricians & Gynecologists, and a member of the
Kentucky Medical Association, the Jefferson County Medical
Association, the American Medical Association, the Louisville
Obstetrics & Gynecology Society, the International Society
for Clinical Densitometry, and the American Association of
Gynecologic Laparoscopists. She has been named in Louisville
Magazine as one of Louisville’s “Top Docs”. Dr. Booth is the
author of The Venus Week: Discover the Powerful Secret of Your
Cycle...At Any Age (Da Capo Lifelong Books, 2008).
Dr. Stephanie Dutton
Dr. Stephanie Dutton completed her
undergraduate studies at the University
of North Carolina and received her
medical degree from the University of
Louisville School of Medicine in 2000.
Her internship and residency training
were completed at Wake Forest University
School of Medicine and she joined Women
First of Louisville in 2004.
Dr. Dutton is board certified in Obstetrics and Gynecology
and has been inducted into Alpha Omega Alpha Medical
Honor Society, Phi Kappa Phi Medical Honor Society, and has
received the American Medical Women’s Association Scholastic
Achievement Citation.
Professional society membership includes Junior Fellow of the
American College of Obstetricians and Gynecologists, American
Medical Association, and the American Medical Women’s
Association.
Dr. Michele Johnson
Dr. Johnson was born in Dayton, Ohio.
She completed her undergraduate degree
at Xavier University and then attended
the University of Cincinnati College of
Medicine. She was inducted into the Alpha
Omega Alpha Honor Society and received
her medical degree in 1996.
She completed her residency at the University of Cincinnati in
June of 2000. She then joined Women First.
Dr. Johnson is board certified in Obstetrics and Gynecology
and is a fellow of the American College of Obstetricians &
Gynecology, a member of the Kentucky Medical Association
and the Greater Louisville Medical Society.
Dr. Ann Clark
Dr. Clark was born in Greensburg, KY, and
completed her undergraduate training at
Western Kentucky University. She received
her medical degree from the University
of Louisville School of Medicine in 1990
and her residency training in obstetrics
and gynecology was also completed at the
University of Louisville Department of
Obstetrics and Gynecology.
From 1994 to 1996 Dr. Clark conducted subspecialty training
in maternal fetal medicine at the University of Louisville. She
received board certification in general obstetrics and gynecology
in 1997 and was board certified in Maternal Fetal Medicine in
1999. Dr. Clark served as an Associate Professor in Obstetrics
and Gynecology at the University of Louisville, Department of
Obstetrics and Gynecology for 3 years and joined Women First
in 2000.
Professional society memberships include Fellow of the American
Board of Obstetricians and Gynecologist, Alpha Omega Alpha
Medical Honor Society, Fellow of the Society of Maternal Fetal
Medicine, member of the American and Kentucky Medical
Associations and the Greater Louisville Medical Society. She has
been named in Louisville Magazine as one of Louisville’s “Top
Docs”.
Dr. Clark primarily practices obstetrics with an emphasis on
preconceptional and genetic counseling, management of high risk
pregnancies, and ultrasound diagnosis of fetal abnormalities.
Dr. Holly Brown
Dr. Brown was born in Campbellsville,
Kentucky. She completed her undergraduate
degree at Centre College and attended the
University of Louisville School of Medicine
and received her medical degree in May of
1989.
She completed her residency at St. John’s
Mercy Medical Center in St. Louis, Missouri in June of 1993,
and has been in private practice in the Louisville area since July
of 1993. She’ll be joining Women First on July 1, 2009.
Dr. Brown is board certified in Obstetrics and Gynecology
and is a fellow of the American College of Obstetricians and
Gynecology and a member of the Kentucky Medical Association
and the Greater Louisville Medical Society.
The Guesswork of
Perimenopause
Rebecca Booth, MD
When women hit their late thirties or early forties, many
begin the rather drawn out process of perimenopause, a
highly variable period of time when the reproductive cycle
begins to shorten, eventually starts to skip (usually around age
forty-seven), and then finally comes to a halt with menopause
(average age fifty-one). The term perimenopause is more of a
description than it is a true developmental state. It is a time of
transition from full fertility into menopause.
The average age of perimenopausal onset is within a broad
range, between thirty-nine and fifty-one (but it can start
anywhere after age 25, the peak age of fertility) and is highly
unpredictable with respect to any individual woman. How
and when perimenopause appears is an inexact process; its
symptoms vary month-to-month and even day-to-day. Often
the earliest sign is the shortening of the monthly cycle. You
still will have your period, but you may notice that it comes
sooner, is more heavy and/or shorter. You may skip some
months. You may also notice physical changes reflecting
changing ratios of hormones.
These changes are the result of the aging and declining number
of remaining follicles, or eggs in the ovary. The ovaries are
somewhat like an hourglass of sand, with the follicles (eggs)
being represented as the grains of sand. The hourglass is
turned over even before you are born, and the follicles begin
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WOMAN FIRST
to slip away. As women age the “sand” begins to run out,
the volume left behind is less, affecting the end mix of the
hormones generated by the remaining follicles. This lessening
of hormonal influence becomes more evident usually in the
early to mid forties, but even earlier for some women.
When the remaining eggs cells can no longer generate the
response the brain demands for fertility, the hormones
generated by the follicles begin to change in duration of
maximum peak and in the ratio of one hormone to another.
This is what kicks in the symptoms of perimenopause. Some
of the symptoms of perimenopause include:
• Shorter cycles (shorter and earlier periods)
• Bleeding amounts changing: heavier or lighter, and more
dramatic
• Night sweats, especially before periods
• Decreasing vaginal lubrication
• Worsening PMS (more abrupt)
• Insomnia, worse premenstrually
• Adult acne
• Increasing facial hair
• Thinning head hair
• Symptoms of anxiety: racing thoughts, air hunger, feelings
of unexplained worry
• Palpitations
Handling some or all of these changes at once can be an
incredible challenge when many forty-somethings are in a
triple-decker sandwich between parenting demands, spousal
needs, aging parents, and professional expectations. What is
absolutely clear is that no two women have the same way of
experiencing perimenopause, or its symptoms. Many women
experience hot flashes, sleep disturbances, lessening of libido
(sex drive), and vaginal dryness (usually associated with
menopause), and some women experience no symptoms at all.
Others may experience a short period of hot flashes, but as soon
as they hit menopause (the actual cessation of menses), and
their hormones complete the transition, the symptoms stop.
The duration of symptoms also varies from woman to woman.
Occasionally, symptoms that begin in perimenopause, such
as hot flashes, may persist into the postmenopausal years
indefinitely. Sometimes women suffer typical PMS associated
with one cycle, only to have hot flashes and insomnia the next
month. Such is the roller coaster for many in perimenopause.
During perimenopause estrogen levels may remain normal in
your blood and saliva (or even slightly higher than average,
in response to the brain’s signal for more), and the peak of
estrogen that generally occurs right before ovulation (the
midcycle) may remain, but the duration of the estrogen
dominant days is lessened by the aging follicle(s), or eggs.
This can be confusing to patients who are told that their
hormone levels are normal when they feel so hormonally
“different.” As the ovary ages, blood levels of estrogen may
not reflect the health of your follicles until they (the eggs
themselves) have nearly disappeared.
Estrogen is associated with elevation of mood, communication,
romantic thought, and verbal memory. Progesterone (the
dominant hormone after ovulation in the middle of the cycle)
is associated with a calming influence, a more restful state.
Progesterone increases at a time in the cycle when women are
assumed to be pregnant (after ovulation in the middle of the
cycle, often around day 14).
dopamine and serotonin that hormones readily stimulate in
the peak fertility years. Certain foods such as plant protein
(hummus, soy, nuts, wheat germ) also elevate dopamine, the
“feel-good” brain chemical associated with estrogen. Omega
3 fatty acids in fish oils and flax seed also seem to elevate
dopamine. Such supplements can fill in the gaps the waning
hormones leave in the perimenopause.
Much has been theorized about the various causes of “ovarian
decline”; however, the truth is that it is not a disease, but a
natural occurrence. As human women, we are programmed
to stop reproducing long before our expected time of death,
so that we can be around for an extended time to raise our
youngest child. For some, ovarian decline begins somewhat
early, but it happens eventually for all women. Again, the ovary
is programmed to spend its follicles (beginning before birth),
but ovarian decline is not often obvious until about age fortythree, when a woman may develop clear symptoms (such as
those listed earlier).
Perimenopausal Irregular Menstrual Bleeding
Some physical consequences follow the change from regular
ovulation to a sporadic pattern. Ovulation must occur to
generate progesterone. In the mid to late forties ovulation
is interrupted more easily, and time may stretch between
ovulation occurrences, causing skipped periods. If significant
amounts of estrogen in your body tissues are present, the
absence of bleeding can lead to what is known as an unopposed
estrogen effect. Without progesterone and the coordinated
sloughing of the menstrual uterine lining, the lining can build
up, resulting in very heavy, unpredictable vaginal bleeding and
even increase the risk of uterine (endometrial) cancer. Uterine
The fact that blood levels of estrogen may remain normal or
even higher than in more fertile years makes perimenopause
even more of a mystery to those who recommend blood tests as
a way to direct treatment. Most women will be better served to
have a clinician focus on symptom relief, rather than on blood
hormone levels. Estrogen peaks and reserves are declining in the
perimenopause, as are the peaks and reserves of progesterone.
Both estrogen and progesterone support brain chemicals that
stabilize mood (dopamine for estrogen, and probably serotonin
for progesterone). As the peak and duration of these hormone
“highs” decline with the number of remaining ovarian follicles
(eggs) a woman often feels less prepared to deal with the ebb
and flow of her cycle, and “moodiness” results. Perimenopause
is an important time to maximize a healthy lifestyle to support
these changes. Diet and exercise as well as some supplements
can help fill in the gaps of lessening hormonal “highs.” For
example, exercise has been shown to elevate the brain chemicals
WOMAN FIRST
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cancer is very rare before menopause, but abnormal bleeding
is common in my forty-something patients. Often using cyclic
hormone therapy or even the low dose birth control pill can
help these problems. You may need an ultrasound to check for
other causes of bleeding and possibly a biopsy of the uterine
lining to rule out pre-cancer or cancer, although rare.
than one or two visits to the gynecologist. I recommend over
the counter phytoestrogens such as those found in soy, black
cohosh derivatives, and red clover supplements. Estroven ®
is such a product and may be taken daily to help stabilize
symptoms. I recommend “extra strength”, and it is available
at most pharmacies.
Unpredictable Emotions
The ebb and flow of emotions at this time can also be a source
of frustration. Some women in perimenopause feel so depressed
the week before their period that they are literally stymied
in their lives. Other women come into the office wanting to
reconnect with their husbands but are frustrated by their low
libidos. Still others are actually experiencing an increase in libido
due to the lessening of estrogen’s presence, which can free up
more testosterone (estrogen’s effect can suppress testosterone);
these women may also experience unpleasant symptoms of
testosterone dominance such as adult acne, negative cholesterol
changes, scalp hair thinning, and facial hair.
What About Weight Gain?
A woman’s metabolism also changes in perimenopause, and
she will become more likely to store fat after eating processed
carbohydrates (sugar, starch, etc). The tiny waistline that is
enhanced by full fertility levels of estrogen will often start to
broaden. Many women are not aware that estrogen enhances
metabolism by lowering resistance to insulin. Insulin resistance
is something that is getting a lot of attention these days. It
means that the body (or specifically, the pancreas gland) must
make more insulin to achieve the same amount of blood sugar
control. Resistance to insulin happens as we age, but is more
pronounced in women as a result of the decline in estrogen
with perimenopause and menopause. I recommend reading
Sugarbusters!, an excellent book about the dangers of “bad”
carbs to help explain the metabolic changes in perimenopause.
Most women need an individualized approach to their
perimenopause. There is no one-size-fits-all, and a careful
analysis of physical and emotional issues must be carried out
with each individual who has questions or problems. With
patience and a properly tailored approach to symptoms,
women can navigate through perimenopause successfully to
find the treasures of life after forty—but it may take more
14
WOMAN FIRST
Exercise is of utmost importance at this time: at least 150
minutes a week, (22 minutes a day). Exercise will help even out
the dramatic hormone fluctuations and stabilize mood (besides
the fact that it is good for your heart, brain, and sex-life).
Calcium is also of
Omega 3 fatty acids (fish oils), are also helpful as they help
stabilize mood and metabolism and are also good for the heart,
brain, and sex-life. I recommend about 1000 mg a day, usually
a combination of two common omega-3s, EPA and DHA (not
to be confused with DHEA—a prohormone). Good brands
include: Eskimo 3 (Integrative Therapeutics, Inc.)*, GNC’s
Fish Body Oils (lemon flavored).
A multivitamin daily is of primo importance to make certain
your body has the tools to keep its chemistry optimal. One
A Day Women’s® is a good brand as is GNC’s Women’s
Ultramega Vitamin (it is a twice a day formula which makes
it easier on the stomach, but it is a large tablet). For those
who have trouble swallowing or who have stomach upset
with a multi, try a chewable vitamin such as Viactiv brand
multivitamin (many flavors), available in most pharmacies
and Target.
Calcium is also of utmost importance as perimenopause marks
the time of a loss in bone density due to declining estrogen.
I recommend 1000 to 1200mg a day in divided doses as we
cannot absorb more than about 500 to 600 mg at any one time.
Remember calcium is a mineral, not a vitamin and there may
not be much in the multivitamin you are taking. Calcium has
been shown to help stabilize mood with PMS, so there are more
than enough reasons to focus on it in the perimenopause.
Vitamin D is also important in perimenopause as in other
stages. Studies show that most women do not get adequate
Vitamin D, which is imperative for bone health but also
for cancer protection. Many health experts feel the current
US RDA (recommended daily allowance) is too low at 400
IU. I recommend at least 1000 IU a day, and this is usually
accomplished if you take a calcium supplement with added
vitamin D.
Perimenopause happens to all women if we live long enough.
It can be a very challenging passage, but with understanding
women can more easily rise to the challenge. The key is in the
knowledge of what is happening, and a willingness to focus
on strategy to meet the changes. While Mother Nature is
taking back some of the rewards associated with full fertility,
the promise is one of more time for individualized priorities.
The next stage: full menopause, can be a relief from some of
the burdens of the fertile years. In the meantime your provider
at Women First is ready to help you navigate the changes of
perimenopause.
utmost importance as
perimenopause marks
the time of a loss in
bone density due to
declining estrogen.
Perimenopause
Supplements Summary:
Multivitamin (preferably women’s formula)
Examples: One A Day Women’s, GNC Women’s
Ultramega
Calcium, from your diet or supplements:
1000 to 1200 mg a day in divided doses (no more
than 500-600 mg at once). Keep in mind after
menopause 1500 a day is needed.
Examples: Viactiv® chews. Caltrate® chewables
Vitamin D:
1000 IU a day (you will need to do the “D” math,
as only 400 IU are typically in your vitamin, but you
may have more from your calcium supplement).
Omega 3 fatty acids (fish oils): 1000mg a day
Examples: Eskimo 3 brand*, GNC Fish Body Oils
(lemon flavored)
Tip: Keep your fish oils refrigerated for freshness and
to reduce “burp-back” of a fishy taste.
Phytoestrogens:
50 -70 mg of isoflavones a day to reduce night
sweats and stabilize declining estrogen levels
Examples: Estroven® extra strength, Healthy Woman
Soy menopause supplement
* Eskimo 3 brand omega 3 fatty acids as well as a host of other good
quality supplements are available at Simon’s Apothecary in Prospect,
KY, right off Hwy 42 (9217 US Hwy 42, Prospect KY 40059 502228-4161)
Much of the information in this article has been taken from The Venus
Week, by Dr. Rebecca Booth, Da Capo Lifelong Books, 2008.
WOMAN FIRST
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