Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Perimenopause The Guesswork of Why See A Midlevel Practitioner? WOMAN FIRST B As one of the leading Women’s Centers in the Southeast Women’s Diagnostic Center in Louisville, Kentucky is committed to providing their patients state-of-the-art care with the most advanced equipment available. Women’s Diagnostic Center was developed in 1986, with a focus on breast cancer detection based on screening mammography.. The mission of the group and its physicians has been to provide the women of Louisville and the surrounding areas the highest level of care, respect and understanding. SE RV ICE S PROVIDED: A RT J. M CL AU GHLI N, MD R AY MONDA L . ST E VENS, MD AT EF E H G U PTA, MD Consultations Digital Mammography Breast Ultrasound Bone Density Study Ultrasound-guided Biopsies Stereotactic Biopsies 4004 D up ont Circle, S uite 230 • Louisville, KY 40207 • Phone l 502.893.1333 • Fax l 502.899.9576 A WOMAN FIRST IN THIS ISSUE HRT Hormone Replacement Therapy........4 Why see a Midlevel Practioner?..........9 The Guesswork of Perimenopause.................................12 be sure to read our upcoming issue Just What is HPV My Bladder is Leaking What Can I Do? Women First would like to thank the following advertisers who made this magazine possible: Cotton & Allen Farmers Bank/ Leasing One Corporation Julene B Samuels, MD Stites & Harbinson Van Zandt, Emrich & Cary Women’s Diagnostic Center 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 treated by a group who medically and personally understand your situation. 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 Women First magazine is published by Ink Publishing and Design Incorporated. To advertise in the next issue contact Yetta Blair at 502-271-1166 Ann Grandon, PA-C www.inkmagazines.com 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. 4 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 6 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 8 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 12 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 13 Debra Copeland, CPCU, CLU, CIC Business Insurance Bobby Neutz Employee Benefits VALUE, EXPERTISE, COMMITMENT Here’s what Rebecca Terry, MD, physician with Women First of Louisville, PLLC says: Jackie McClain, CIC Professional Liability “We’ve seen cut-rate insurance companies come and go, leaving doctors personally liable for claims. Lowest rates are not always the best value. Value is a quotient of quality over price. VanZandt, Emrich & Cary has always provided A-rated insurance companies at the best possible premiums. That’s value.” www.vzecins.com 502.456.2001 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 15