September 11, 2007
Cleveland_Clinic_Host: Welcome Dr. Thacker and thank you for joining us today. Let's begin with one of the questions.
Speaker_-_Dr__Thacker: Thank you for having me.
Women’s Health – Frequently Asked Questions
meekkn: I feel I need a quality physical. I just feel that something isn't right. What do you tell the physician? Being thorough is not what I'm getting from my physician. I want a quality examination with blood testing and answers. How do I get a thorough exam without being offensive to the physician?
Speaker_-_Dr__Thacker: It is very important to feel comfortable with your physician and be able to get a comprehensive exam and testing that is appropriate for your age and gender. I start on discussing how to find the right doctor in my recently published book 'Your Body, Your Hormones, Your Choices- A Cleveland Clinic Guide' 2007 Cleveland Clinic Press.
emschick: I have recently had a hysterectomy- now I am having problems and my doctor says it's nothing. Do I need a second opinion?
Speaker_-_Dr__Thacker: Absolutely! You need at least a hormonal evaluation and possibly bone evaluation.
newtonm: If taking the depo shot for birth control/control of menstrual cycle, how long is it safe to take?
Speaker_-_Dr__Thacker: After two years of use of depo-provera for contraception, it is advisable to get a bone density test to make sure you are not losing bone.
gollygee: With no family history of breast cancer, how often should I have a mammogram?
Speaker_-_Dr__Thacker: All women age 40 and older should have a yearly mammogram. It is best to schedule your mammogram right after your period as the breasts are less tender. Do not schedule your mammogram right before some big event or travel because up to 1 in 2 women get called back for extra views of the breast, a so called 'diagnostic mammogram'. For many women, this causes anxiety. I think it best just to plan that you might have to go back in a week or so for extra views, rather than to get anxious and fret. Do be sure to always schedule a YEARLY mammogram. Mammograms save lives through early detection. Do it for yourself, do it for your family.
WQTTIGER: My sister has been diagnosed with the H-POXY infection in her stomach and a swollen liver,high blood pressure Stage II, back pain, blood in urine, she has had gastritis, and Hiatal Hernia, and skin cancer which she has had removed from inside mouth, dorsal hand tumor. What could be wrong with her?
Speaker_-_Dr__Thacker: I presume you mean h. pylori infection. I’d recommend evaluation starting first with a general internist. jennifer36: I have been diagnosed with a mitral valve and tricuspid valve insufficiency. To what grade I don't know until I go back to the cardiologist Sept 20 Do they have to stop your heart to fix the valves? If I am 36 years old, 350 pounds and an apple shape with most of my weight on the top and breasts, do you think I would even be a candidate for the minimal invasive or would I most likely have to have the chest opened? I would never have known this if my feet and ankles didn't swell out of nowhere and I had an Echo Cardiogram b/c of it and I have to wait for the actual results from the doctor.
Speaker_-_Dr__Thacker: There is a live chat tomorrow with the Heart Center and you might want to ask this question again then. You really should discuss these concerns with a cardiologist.
lwthu: Is it normal for premenopausal women to have a stinky smell? Several tests have been done but revealed no infection (GC, Chlamydia, Yeast, STD). Have experienced NO discharge. No amount of perfume is covering it. Is there any solution? Thank you so much- Will appreciate your input.
Speaker_-_Dr__Thacker: I recommend the use of over the counter repHresh vaginal gel-it lowers the pH of the vagina which helps keep odor causing bacteria out of the vagina.
maryb: If a woman has a history of lumpy breasts, which sometimes cause concern after mammograms, is hormone replacement contraindicated if there is no personal or family history of breast cancer?
Speaker_-_Dr__Thacker: Hormone therapy in NOT contraindicated in women with fibrocystic breast disease. If women have breast tenderness and/or breast cysts, we may use much lower doses and sometimes will recommend that hormone therapy be stopped 1-2 weeks in advance of the yearly mammogram especially if a woman has very dense breasts. Most women with fibrocystic breasts can use hormone therapy if needed and in general we use the lowest effective dose. There are many newer lower dose options that allow a woman and her physician to individualize therapy.
bonnielass: I am 44, am in great health and work out 5 days a week. I have had problems with very heavy flow the last 3-4 years. I have done all the preliminary testing (Pap, uterine biopsy, ultrasound, etc.) and everything looks good. If you take the body's natural rhythm and function of having a period each month away, will the body and hormones figure out something is wrong and throw me into menopause early?
Speaker_-_Dr__Thacker: It sounds as if your doctor might have recommended taking the pill or hormonal contraception (HC) in a continuous fashion to prevent menstrual periods and/or reduce the frequency or length of the periods. In general, this is a very acceptable option for many women (provided they do not smoke, have blood clots or other medical conditions that preclude the use of hormonal contraception). Using treatments like long cycle pills or actually ANY birth control pill taken continuously (with the placebo/sugar dummy pills thrown away) is an option to reduce heavy flow and/or lengthen out periods.
The Mirena IUS-inserted into the uterus is another option for women with heavy flow. Endometrial ablation, where the lining of the uterus is ablated/permanently remove/reduced is another option as long as the woman is not planning further pregnancies. In my book, "Women's Health: Your Body, Your Hormones, Your Choices, A Cleveland Clinic Guide," I have a chapter on abnormal bleeding and what to do about it. Taking the pill will not throw you into an early menopause. The trend is to use HC for longer durations to reduce or even eliminate menstruation. I personally take long cycle HC and I'm the one to decide if and when it is convenient for me ‘to have a period.’ I tell women if you are worried about not losing blood every month you can always visit the Red Cross to donate your blood!
Hormone Therapy: One Size Does Not Fit All
sallybgood: What is the latest health information on hormone replacement therapies?
Speaker_-_Dr__Thacker: There is information published almost daily about menopausal hormone therapies. An excellent resource for unbiased information is the North American Menopause Society web site www.menopause.org, an organization dedicated to women's health by educating both health care providers and the lay person about women's health though a better understanding of the study of menopause.
b3vfoley: What is the best way to test your hormone level?
Speaker_-_Dr__Thacker: It is NOT salivary levels. We can sometimes get blood hormone levels, but the most important assay is what is in the body tissues such as the bone and the vagina. I discuss how we do a menopausal hormone assessment in my book, 'Your Body, Your Hormones, Your Choices-a Cleveland Clinic Guide'. The book provides a lot of detail concerning this question.
newtonm: What guidelines are generally followed with respect to offering hormone replacement to a woman?
Speaker_-_Dr__Thacker: All decisions about hormone therapy (HT) need to be individualized. The new term is HT as opposed to HRT (hormone replacement therapy). Most naturally menopausal women have the option of therapy, and not all women need hormone replacement as menopause is a normal and natural life event. However, women with early or premature menopause many times need HT/replacement. Most women with menopausal symptoms who are recently menopausal are actually good candidates for hormone therapy (HT), particularly if they have symptoms that disrupt the quality of their life. Midlife is a great time to reassess your overall health. If you are considering HT, you need to undergo an individualized history, physical exam and risk-benefit assessment with your doctor. Therapy should be highly individualized and periodically assessed.
In my recently published book, ‘Women's Health: Your Body, Your Hormones, Your Choices, a Cleveland Clinic Guide,’ I go into detail on how to find a women's health doctor who will listen to you and offer you an individualized assessment. I discuss in great detail the pros and cons of various hormone regimens and other non-hormonal treatments for women. Many women are great candidates for HT, do well and feel well on HT. Other women breeze through menopause and do not need any HT but may have bone, vaginal and or bladder issues that need to be assessed.
newtonm: What are your thoughts on hormone replacement therapy that uses patches versus the oral version?
Speaker_-_Dr__Thacker: There are pros and cons with each regimen. In my book I have an entire chapter titled ‘Customizing Hormone Therapy: one size does not fit all.’ The use of patches and creams may be associated with a lower risk of clot and are many times preferred by women seeking 'bio-identical hormone therapy' as transdermal-via skin, as well as via vagina mimics more closely how the ovary delivers estrogen to the body. Conversely, oral regimens may be better for some women with skin or hair problems as oral HT can reduce elevated testosterone levels that can cause hair thinning, acne and a deepening of the voice. If taking oral HT - taking it with food lessens the effect on the liver. Some vaginal rings have estrogen that affects only the vagina and bladder - like Estring and some estrogen rings have higher doses that affect more than just the vagina.
crusher: Please discuss the pros/cons and myths of HRT? Do you recommend bio-identical hormones over other types?
Speaker_-_Dr__Thacker: Yes - the heart of my book is dedicated to these very important questions. Many people over-estimate the risk of hormone therapy. Hormone therapy needs to be individualized. Many women are hood-winked by compounding pharmacists that tell them that compounded hormone therapy is risk free and safer than prescription or conventional hormone therapy. I prescribe bio-identical hormones, bio-similar hormones as well as bio-antagonistic hormone therapy depending on the woman's individual medical history and concerns.
happyme: Is it possible that your cholesterol and blood pressure might rise when you stop taking hormones?
Speaker_-_Dr__Thacker: Yes, it is possible. Some women will have an increase in the LDL-cholesterol - the so called 'bad' cholesterol - and a decrease in the so called 'good' cholesterol - HDL-cholesterol - when they stop estrogen. Some women have very slight decreases in mean blood pressure on HT, so when they go off they may notice rises. The good news is that healthy diet and exercise and weight management will control most of these minor changes. Using HT (hormone therapy) to treat cholesterol or blood pressure is not recommended.
calico288: Hello Dr. Thacker, I am a 61-year old woman on hormone replacement (.625 mg. estrogen and 100 mg. progesterone daily) for 5 1/2 years and am getting spotting or bleeding much of the time now, usually just enough to be a real nuisance. I don't want to go off HRT because both my parents, my grandmother and my uncle had dementia for years before they died and I am getting osteoporosis. I am not at risk for breast cancer and am quite physically active and eat well. My doctor does not support me being on HRT and just says ‘go off it’ when I mention the spotting, but I have read much research supporting estrogen for preventing dementia. Can you suggest a way that I could stop the bleeding without going off the hormones?. Any help appreciated, and thank you.
Speaker_-_Dr__Thacker: If you take both estrogen and progesterone daily after 6 months there should not be bleeding or spotting. You need to have an evaluation of the endometrium/lining of the uterus with an outpatient endometrial sampling and/or a transvaginal ultrasound. Likely the doses of the hormone therapy (HT) need to be adjusted. We don’t use HT solely to prevent dementia. In older women HT does not treat or prevent dementia though in women taking HT for menopausal symptoms, the observational research suggests a reduction in the risk of dementia. Controlled blood pressure, cholesterol, weight and risks for heart disease also reduce the risk for stroke and memory loss. I’d suggest you see a North American Menopause Society (NAMS) credentialed menopause specialist for evaluation.
b3vfoley: Is estrogen, progestogen and testostrogen closely linked to the autoimmune system?
Speaker_-_Dr__Thacker: Yes, these hormones have effects on the immune system and the entire body. In general, women have a more 'active immune system' hence they recover from infections like viruses faster than men. However, they have a higher rate of autoimmune conditions such as Hashimoto's thyroid (female to male ratio is 50 to 1).
jbf: What is progesterone cream used for?
Speaker_-_Dr__Thacker: It has been used for women with PMS and/or perimenopausal symptoms.
kathyk: What do you think about progesterone cream?
Speaker_-_Dr__Thacker: Progesterone creams obtained over-the-counter may or may not contain progesterone. Many only have diosogen - the precursor to progesterone - which only plants, NOT humans, can convert to progesterone.
kathyk: Do you need a doctor's prescription to get progesterone cream and does it have any adverse effects?
Speaker_-_Dr__Thacker: Some progesterone creams have been found to reach blood levels like with prescription oral or vaginal progesterone, so there can be definite hormonal effects. Even though they are purchased over-the-counter, patients who use them need to be monitored by a physician. Conversely, blood levels may not be high enough so progesterone cream can NOT be relied upon to protect the uterus in women who need progesterone therapy.
jacksonp: After menopause and the use of hormone replacement therapy, is it necessary for a woman to see a gynecologist or is it no longer necessary?
Speaker_-_Dr__Thacker: All women should continue to have yearly breast/genital and pelvic exams.
Endometriosis and Fibroids
maddiegirl: Dr. Thacker - I had endometriosis and was treated about 20 yrs ago with Danazol. I had two IVF procedures and was hyperstimulated with the 2nd one. No pregnancies - we ended up adopting. Can endometriosis return later? I have abdominal discomfort and tenderness but I have always considered that to be normal. Will the endometriosis just disappear with menopause?
Speaker_-_Dr__Thacker: Usually, endometriosis, like fibroids regress during menopause. Based on your symptoms, you should see a physician for evaluation as opposed to just attributing them to endometriosis.
goldie: What are fibroids? How do you get them?
Speaker_-_Dr__Thacker: Fibroids are benign muscle growths of the uterus and up to 1 in 2 women have them. They may or may not cause problems.
toonces: If it is discovered you have 8 fibroids - would you suggest a complete hysterectomy?
Speaker_-_Dr__Thacker: No, not necessarily. It depends on the symptoms, size of the fibroids and the bleeding pattern. There are many non-hysterectomy alternatives that I detail in my book, The Book ‘Women’s Health: A Cleveland Clinic Guide’
Cleveland_Clinic_Host: Dr. Thacker, can you tell us a little bit more about your book? What topics do you cover? Is it a book that someone in her 40's would find useful or what about someone that is in her 60's?
Speaker_-_Dr__Thacker: My book covers a myriad of interesting Women's Health topics from menstrual disorders to migraines to menopause as well as bone health, sexual health. There are also important comments about nutrition, vitamin supplements and exercise. I think that women ages 30-80+ will find the book interesting and helpful.
Hot Flashes, Mood Swings and More
maddiegirl: Actually, I just finished reading your book and enjoyed the wealth of information. I am 50 yrs. old, probably Perimenopause although my symptoms are mild. But, when I sleepy legs and sometimes whole body will sweat despite a cool room, fan, cotton sheets and light PJ's. I'm not sure I consider this a hot-flash or the beginning of one. I have tried everything but sleeping with socks.. Does that really work? Or, am I approaching a time to start inquiring about Hormone Therapy?
Speaker_-_Dr__Thacker: It sounds like you are having hot flashes and night sweats. Yes, it would now be a good time to discuss options of hormone therapy and or other treatments.
jbf: What are some of the most successful ways to deal with hot flashes and mood swings?
Speaker_-_Dr__Thacker: In the book, there is a chapter on 'Maintaining Mood at Midlife,' that reviews the various mood stabilizing treatments and talks about which comes first, menopause or depression? Estrogen treats hot flashes and is a mild mood elevator, but is not a standard treatment for depression. Whereas antidepressants like Effexor/venlafazine in low doses treat menopausal hot flashes, in higher doses they don't help hot flashes too much. However, they do treat depression and anxiety. Sometimes vitamins, nutritional supplements, exercise, omega 3 fatty acids, and lifestyle changes are enough to treat minor hot flashes and mood changes. Sometimes hormone therapy is needed. Other times, antidepressant therapy is needed. Sometimes both treatments are needed! In my book, I detail how a doctor and an individual woman can go about dealing with vexing mood symptoms and perimenopausal symptoms which can collide at the same time! In the future, we are expecting the first FDA approved non-hormonal medication, Prestiz/Desvenlafaxine to treat hot flashes. Currently, only hormonal products are FDA approved to treat menopausal hot flashes.
gettingold: Are any natural supplements available for hot flashes and vaginal dryness?
Speaker_-_Dr__Thacker: I've mentioned the use of either vitamin E oil or olive oil for the vagina. Black cohosh, in the form of remifemin, has been used to treat hot flashes/night sweats for up to 6 months. Some women who eat soy foods convert soy protein into equol, a weak estrogen, and this may blunt their flashes. However, we do NOT recommend taking high doses of soy pills/powders, only soy in the form of whole foods, as soy pill supplements have been linked to uterine stimulation.
health1234: Menopausal vaginal dryness has been a significant problem for over two years; replense and other aids are no longer working. I have not used the E-ring replacement for fear of the estrogen risk. This continues to cause problems that my research has not found other answers to. I have not had breast or other cancers, but do have chronic low neutrophile counts. Are there any suggestions you may have? Thank you.
Speaker_-_Dr__Thacker: In general, there is NO reason why a woman can not use Estring as it ONLY affects the vagina-it does NOT increase estrogen levels in the blood stream. It is unfortunate that you are suffering with excess fear related to misinformation about estrogen. In the book, I discuss how we even use the Estring vaginal ring in breast cancer survivors. Vitamin E oil and olive oil are the only 2 oils that are fine to use as a 'natural' lubricant/moisturizer.
carlie: What causes a woman, as they age, to grow hair in places they never had hair before (i.e. chin and upper lip)? Does taking and/or stopping different forms of birth control cause this?
Speaker_-_Dr__Thacker: When women go into menopause, their estrogen levels begin to drop, but the testosterone levels may not. Therefore, they may develop chin whiskers, deepening of the voice and male-patterned hair thinning. In younger women, birth control pills actually reduce testosterone levels which may improve hair and skin problems.
survivor: What is your response on getting enough Vitamin D, especially in areas of the country with limited sunshine?
Speaker_-_Dr__Thacker: Most people need to take a Vitamin D supplement. Recent evidence has suggested that adequate levels of Vitamin D intake can reduce cancer incidence by 70% and increase longevity. Even areas in the country with more sunshine than Cleveland, OH up to 50% or more of the general population are Vitamin D insufficient. I recommend 1,000 IU of Vitamin D3 (cholecalciferol) daily. It is very easy for your doctor to check your Vitamin D level with a 25-OH Vitamin D level. Again.
crusher: Isn't there a screening test for ovarian cancer that can be done with the yearly exam similar to a man's PSA test for prostate cancer? If there is, then why aren't doctors performing it routinely? Is it an insurance issue? This would be a great tool as many ovarian cancers are not detected early enough!
Speaker_-_Dr__Thacker: Actually, the answer is NO. It is too bad that we do not yet have a simple blood test to screen for ovarian cancer. Cleveland Clinic researchers are working on this. Emails telling you to get your CA-125 test unfortunately are just a hoax. In normal women, this is NOT a screen for ovarian cancer. Many doctors will go ahead and order the test if you ask them rather than explain that a normal test does not exclude ovarian cancer AND an abnormal test does not diagnosis ovarian cancer. An abnormal test result could actually lead to having your normal ovaries surgically removed.
Dianne: I am 60 y/o recently dxd with dermoid cyst on the left ovary. CA-120 marker is not elevated. A total hysterectomy has been recommended. What are the advantages/disadvantages over just having a lap and having the cyst removed? If one is post-menopausal, is there any estrogen secretion going on in the ovaries? Are there studies in post-menopausal women regarding removal of ovaries/estrogen and dementia?
Speaker_-_Dr__Thacker: In general, we like to preserve the ovaries up to age 65 yrs. because there continues to be hormone secretion. However, if there is cancer it is best to have a complete hysterectomy. It is important to find a surgeon that you feel comfortable with and will offer you all of your choices. In young women, particularly under age 35, that have their ovaries removed without benefit of estrogen therapy, there is a higher risk of both heart disease and osteoporosis.
PeppermintPatty: I am 60 years old. Do medications and calcium supplements help prevent progression to osteoporosis?
Speaker_-_Dr__Thacker: Yes, but don't forget the 1,000 international units of Vitamin D3 daily.
sallybgood: Is joint pain tied to menopause?
Speaker_-_Dr__Thacker: Joint pain is NOT a classic menopausal symptom, although there are estrogen receptors on the cartilage and some postmenopausal women do report less stiffness on HT. I recommend good nutrition, calcium, vitamin D (800 to 1,000 international units daily) and a sound exercise program after consulting with your doctor. Weight loss, physical therapy and selected use of medicines and even joint injections may be needed for some women. Glucosamine is a supplement that has been shown to decrease knee osteoarthritis symptoms in some postmenopausal women.
PeppermintPatty: I have osteopenia. Is the progression to osteoporosis inevitable?
Speaker_-_Dr__Thacker: Not necessarily.
Diet and Exercise
crusher: Ever since I've slipped into the menopausal abyss, I've packed on 10-15 lbs that will not go away despite diet and exercise. Any suggestions? Once I get to the other side of menopause will the added weight come off? If I'm not having serious menopause symptoms I wouldn't want to start HT just for weight control.
Speaker_-_Dr__Thacker: Unfortunately, your metabolism takes a nose dive during menopause. You actually have to eat less and exercise more just to prevent weight gain! However, women on hormone therapy tend to be leaner than women not on hormone therapy BUT this is not a sole reason to take hormone therapy. I would recommend daily exercise for one hour a day with weight lifting exercises. You also may want to have your thyroid function tested.
newtonm: I've recently heard that weight that is gained around the waist is very ‘active’ and produces estrogen. Although I am in the process of losing weight, how does it factor into the doctor determining the correct amount of hormones one should take?
Speaker_-_Dr__Thacker: Too much body fat anywhere can by harmful. The weight around the belly is linked to a higher rate of diabetes, cancer and heart disease, while weight around the hips and thighs is less harmful. Too much body fat can increase hormone levels, although not always. Women who are overweight have a higher risk of breast and uterine cancer.
bjones: What are the benefits of taking the omega 3 fatty acids and how much we need to take per day?
Speaker_-_Dr__Thacker: Omega 3 fatty acids are important for brain, breast, and heart health. It is important to ingest at least 2 servings weekly (not daily).
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Thacker is over. Dr. Thacker, thank you again for taking the time to answer our questions today.
Speaker_-_Dr__Thacker: Thank you ladies, this has been an enjoyable chat. For more information, don't forget to look for my book!
Cleveland_Clinic_Host: If you would like more information regarding Women's Health, please visit the Cleveland Clinic Women’s Health web site at www.clevelandclinic.org/womenshealth. For general health information you may also wish to visit www.clevelandclinic.org/health.
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