WOMEN'S HEALTH
in the incidence of breast cancer, heart disease, thrombosis or
stroke. Many menopausal women suffer from dry, itchy, painful
vaginas, dyspareunia and urinary incontinence and irritation which
can be safely treated with vaginal estrogen. The FDA requires that
these products carry a black box warning on the package insert.
This warning does not apply to vaginal estrogen. In the Women’s
Health Initiative, women who were on vaginal estrogen had no
increase in cardiovascular disease, thrombosis or cancer. In fact,
some studies indicate that the use of vaginal estrogen in women is
associated with a lower incidence of heart disease and hip fracture
than in non-users.
Menopause is not a disease but has affected women for cen-
turies. Prior to 1910, the average life expectancy for women was
51. Therefore, menopause was not discussed or addressed until
the last 25-30 years. Menopause is a unique opportunity for the
obstetrician-gynecologist to discuss other health issues, hormone
treatments and non-hormone treatment of menopausal symptoms.
Non-hormone treatments include SSRIS, Clonidine, Gabapentin,
Oxybutynin, herbal therapies, lifestyle changes, acupuncture and
exercise.
Because of the frustration that women have experienced in
obtaining treatment for menopausal symptoms, for-profit hormone
clinics have proliferated. In our region, these clinics charge approx-
imately $3,000 a year for services that most obstetrician-gynecol-
ogists can provide. Most of the time they use non-FDA approved
compounded products at a variety of doses and do not manage side
effects such as abnormal vaginal bleeding. There is no evidence that
compounded hormone preparations are any safer or more effective
than FDA-approved commercially available products. Purity, po-
tency, and reproducibility of compounded preparations cannot be
guaranteed. Occasionally there is a role for compounded hormone
therapy when a patient is not tolerating traditional therapies, is
allergic to a component of a commercial therapy, cannot afford
traditional hormone therapy, or desires testosterone treatment.
Testosterone therapy is not indicated for vasomotor symptoms or
energy, but it has been shown to improve sexual function scores.
Testosterone therapy is currently not FDA-approved for use in
women. Therefore it can only be obtained from a compounding
pharmacy. In the state of Kentucky, it is considered a scheduled drug.
If testosterone doses are too high, there are detrimental effects on
lipid parameters, clitoromegaly, hirsutism, acne, vulvar boils and
thinning of scalp hair. The North American Menopause Society
and the American College of Obstetrics and Gynecology does not
recommend compounded bioidentical hormone therapy as first
choice therapy at this time.
are important concerns to the patient, I feel there is still value in
the yearly visit. During a moment of frustration, a fellow physician
once commented to me that any robot could probably do what we
do. This may be true for the technical/typing part of our visit but
does not apply to the individual treatment that we give each patient.
At the end of the day, I hope that I have made a difference in the
life of at least one patient that I have seen that day. I know that my
primary care physician and my gynecologist do that for me.
Dr. Newman is in private practice Gynecology and Women’s Health
with Janet Wygal, MD and Janet Honchell, MD.
References
1. US Cancer Screening Rates improved, but still below targets.
Medscape, July 26, 2018
2. ACOG Practice Bulletin number 141, January 2014, updated
March 2018. Management of Menopausal Symptoms.
3. Rossouw JE, Anderson GL, et al. Risks and benefits of estrogen
plus progestin in healthy postmenopausal women: principal
results from the Women’s Health Initiative randomized con-
trolled trial. JAMA 2002;288:321-33.
4. Manson JE, Allison MA, Rossouw JE, et al. Estrogen therapy
and coronary-artery calcification. WHI and WHI-CAS Inves-
tigators. N Engl J Med 2007;356:2591-602.
5. Manson JE, Chlebowski RT, Stefanick ML, et al. Menopausal
hormone therapy and health outcomes during the intervention
and extended poststopping phases of the Women’s Health Ini-
tiative randomized trials. JAMA 2013;310:1353-68.
6. ACOG Committee Opinion, Number 556, April 2013. Post-
menopausal Estrogen therapy: Route of Administration and
Risk of Venous thromboembolism
7. ACOG Committee Opinion, Number 534, August 2012. Well-
Woman Visit
8. Manson JE, Aragaki AK, Rossouw JE, et al. Menopause hor-
mone therapy and long-term all-cause and cause-specific mor-
tality. The Women’s Health Initiative Randomized Trials. JAMA
2017;318:927-938.
Dr. Newman practices gynecology and women’s health in private prac-
tice with Wygal & Newman.
In summary, when the patient asks me if it is still necessary to
see an OB/GYN, I address the issues noted in this article. If those
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