Thursday, February 26, 2015

Cold Facts on Hot Flashes


Because of our icy weather and emergency conditions in Tennessee, I have been glued to the news, monitoring school closings and road conditions.  Headlines yesterday posted “news” that many of my patients could have shared long ago:  hot flashes last longer than the medical community had previously acknowledged!  Is this a news flash to anyone?

I am currently working with a patient who has been experiencing hot flashes for years without relief, and her experience has inspired this week’s post.  For those of you who have yet to experience a hot flash, just think of it as an internal volcano.  The eruption begins, and progresses to a full explosion of discomfort that finds little relief from an external source because it all happens inside the body.  No one in the immediate vicinity understands why the person beside them is suddenly panting for breath and pulling at clothing in a futile effort for relief.

Although we do not yet have a perfect solution, there is a scientific explanation.  Each person has a thermoneutral zone.  In simplest terms, this is the temperature tolerance range.  Go too far one way and shivering occurs.  Go too far the other way; sweating is the result.  In some postmenopausal women, this zone is greatly reduced, which means that a slight temperature variation can trigger flushing.  This slight temperature variation can also be tilted by stress because the chemicals that the body releases during stress can cause changes in the core body temperature and can be enough to initiate a hot flash.  Therefore, the postmenopausal woman can be supremely sensitive to physical and emotional changes in her surroundings that others will never feel.  Again, this is not news to my postmenopausal patients!

Having this information is useful because it helps us realize that there are environmental changes (like wearing lighter, looser clothing) that we can make to help hot flashes.  Although medications like gabapentin, clonidine and venlafaxine are being used for treatment, I would always suggest environmental changes first as any medication can have side effects.

Changes to make include stopping smoking!  We have already covered this, but it will always top the list.  Losing weight can help as the extra body fat works as insulation and can prolong the hot flash.  Wearing loose clothing and having a cool drink (water) at hand is useful.  Deep breathing and meditation exercises have been found to be helpful, so this is the time to begin yoga and to recall the Lamaze training.  Fans and air conditioning help, but initiating deep breathing at the onset of a hot flash has been shown to be the most effective at reducing symptoms.  The onset of a hot flash is like the beginning of a panic attack, so it is important to practice breathing exercises beforehand to be able to have any kind of good result.  Layered, loose clothing can help reduce the thermostat battle. 

The theme continues to be balanced diet, exercise, and stress reduction…..

Healthy for life with John Hollis Pharmacy!

Tuesday, February 10, 2015

Progesterone: The Flip Side of the Estrogen Coin

Women who have an intact uterus and are taking estrogen replacement therapy must also be on some form of progesterone. Estrogen, with all of its benefits, stimulates the tissues of the uterus and can set up the body for uterine cancer. The use of progesterone reduces this risk to that of a woman who is not on hormone replacement therapy. Progesterone can also minimize the impact of estrogen on any estrogen-dependent tumors; therefore, women on oral or topical estrogen therapy must be on progesterone also. This does not apply to women using vaginal estrogen cream or inserts, as the absorption seems to be minimal in the body.

Progesterone can be given as either medroxyprogesterone or micronized progesterone. Micronized progesterone is the bio-identical form of progesterone and is the preferred choice. It is manufactured from plants (Mexican wild yam and soy) and seems to have a lower side effect profile than medroxyprogesterone.

Besides the cancer protective benefit, progesterone can also:

-improve sleep

-decrease anxiety

-build and maintain bone density

-increase HDL, the "good" cholesterol component

Micronized progesterone helps to avoid the "first pass" effect that we discussed with estrogen; however, studies indicate that levels of micronized progesterone given orally return to baseline after approximately 8 hours. There is evidence that giving progesterone in a sublingual form allows levels to last for 24 hours when the sublingual tablets are compounded using cyclodextran, available by prescription through your compounding pharmacy. Progesterone cream is also an option and is also available through your compounding pharmacy.

There are recent reports of "dermal fatigue" with progesterone cream. In simple terms, this means that the tissue becomes oversaturated with progesterone that is stuck in a storage form, and a change to another dosage form of progesterone could be necessary. Symptoms may include breast tenderness and moodiness. Rotating the application sites with progesterone cream helps with this, and having a strong working relationship with your gynecologist is essential in gaining the maximum benefit..

Hormone levels fluctuate. I know….This is a "sky is blue; grass is green" statement! What is important about this is that your hormonal needs will change over time. This is why a great working relationship with your physician and pharmacist creates a healthier patient: keep those annual appointments!

As an additional note, situations can change and impact hormones also. I have been maintained on HRT, doing quite well with the generic oral micronized progesterone; however, our insurance changed resulting in a change of pharmacy. The new pharmacy carries a different generic brand. It has taken about two and a half weeks, but I am now having trouble sleeping through the night on the new form. I left my gynecologist’s office today with a prescription for sublingual micronized progesterone tablets. I will let you know how this works!

Healthy for life with John Hollis Pharmacy!

Wednesday, February 4, 2015

The Estrogen Dilemma

To replace or not to replace…that is the question. The answer is confusing. Most of the available information seems contradictory at best and frightening at the worst. To truly answer the question, we need to start with the definition of estrogen and the role it plays in the body. Estrogen is a term for a group of chemically similar hormones: estradiol and estrone, produced primarily by the ovaries, and estriol, primarily produced by the placenta during pregnancy.

Estradiol is the most potent form of estrogen in the body and estradiol is the form of estrogen that women lose at menopause. Estradiol is the bio-identical hormone replacement used in most patches or creams.

Estrone is the weakest of the naturally occurring estrogens and its only known function is to serve as a storage unit for functional estrogen. Estrone is produced in small amounts by fatty tissue and by the liver and adrenal glands and is increased by routine alcohol use. High levels of estrone can stimulate breast and uterine tissue, possibly increasing cancer risk. This could explain the increased cancer risk associated with excess alcohol use and high fat diets.

Estriol is interesting because it does not promote breast cancer. It also does not have the bone, heart, or brain protection of estradiol, but it can help lower cholesterol. Estriol has been used widely in Europe and Scandinavia. A combination of estriol and estradiol cream seems to maximize the relief of menopausal symptoms while minimizing cancer risk and this combination seems to hold the most promise for future research. There is no estriol /estradiol cream commercially available and this can only be obtained by prescription and through a compounding pharmacy.

Cancer risk is the dilemma with hormone replacement therapy. The initial studies with estrogen in women found that women taking estrogen only had an increased risk of uterine cancer. Women taking estrogen and progesterone did not have an increased risk, so the standard of practice is that a woman on estrogen replacement therapy must also use progesterone (next week’s topic) if she still has her uterus. Women using vaginal cream only generally do not need progesterone. Estrogen alone can increase the risk of estrogen dependent breast cancer; however, this risk is reduced by using topical estrogen and can be further reduced by using the estriol/estradiol combination.

Bottom line: Hormone replacement therapy has both risks and benefits associated. For myself, I had to evaluate the benefit of how much better I felt overall and the cariodprotective/bone-protective/neuroprotective benefits versus the risk. I had extensive discussions with my gynecologist to reach the decision that was right for me including a review of family history for cancer and cardiac risk and a commitment to a healthy lifestyle --more on that in future topics!

Making healthy choices for life at John Hollis Pharmacy!

Important note: estrogen levels are lower in smokers. Smokers often have more menopausal symptoms than non-smokers. Smokers have more wrinkles than non-smokers. There are nicotinic receptors in the bladder that lock on to the nicotine in cigarettes. This is why smokers also have to deal with incontinence at an earlier point in time. Bottom line: Don’t smoke! It wrecks your body!