Everything Your Doc Wants You To Know

Exploring Menopause

Today Dr. Jean Marie McGowan joins us to talk about menopause. Jean Marie McGowan, MD NCMP FACP is an Internal Medicine physician with a special interest in Women’s Health. She attended the American University of the Caribbean for medical school and completed Internal Medicine residency, serving as chief resident, at the University of North Dakota in Fargo. Dr. McGowan started working for Sanford Health in the summer of 2016 and focused on improving women’s healthcare. She became a certified provider for menopause management by the North American Menopause Society and became Fellow of the American College of Physicians. She is director of the Pelvic Floor Clinic and co-director of the Preconception Clinic. In addition to seeing consults for menopause, polycystic ovarian syndrome and post-breast cancer treatment, she is a primary care physician. Dr. McGowan is associate faculty for the UND School of Medicine and clinical director for the Women’s Health rotation for medical students, residents, and fellows. She’s dedicated to educating the future generations of healthcare providers as well as the community to improve care for women. Dr. McGowan is also involved in research and won the inaugural Faculty Research Mentor of the Year in 2019 from UND Internal Medicine residents. Dr. McGowan grew up in Brooklyn, NY and currently lives in Fargo, North Dakota. Outside of work, she enjoys singing, running, and playing with her maltipoo, Minnie.

Definitions:

Menopause - occurs after the last menstrual period; a women has formally been through menopause when she has been free of periods for 12 months. Average age is 51.

Perimenopause - the time preceding menopause, lasting about 2-4 years.

Postmenopause - time following menopause.

Surgical menopause - menopause that occurs after surgical intervention (removal of both ovaries). May have more severe symptoms.

Premature ovarian insufficiency - when menopause occurs prior to age 40.

Symptoms - can vary among women, starting 2-4 years prior to last menstrual period and often lasting 2-4 years after menopause (can be up to 10 years or longer)

Perimenopausal: most common are vasomotor symptoms - hot flashes/flushes. Mood can also be impacted by progesterone and estrogen. This tends to be transient during the menopausal time frame.

Decreased estrogen can cause changes in sleep, memory, vision, hearing, skin; vaginal dryness, urinary tract issues.

Postmenopausal: vaginal dryness and urinary tract issues tend to continue. Avoid hot baths, certain wipes, irritating pads.

Decreased estrogen also affects bone health, cholesterol, heart disease risk. These effects tend to be seen 10-15 years after menopause. Exercise, diet, smoking cessation, limiting alcohol consumption can help mitigate these.

Diagnosis of menopause - hormone testing is not needed in most cases and is made based on cessation of periods, age. If considering premature ovarian insufficiency, hormone testing is indicated.

Patients often note decreased sexual desire in the perimenopausal period. This is not related to age or menopause itself.

Treatment:

Vaginal dryness

Vaginal moisturizers & lubricants can help with painful intercourse. Good Clean Love & UberLube are some well balanced options.

The only treatment is estrogen.

Pelvic floor therapy can be effective for pelvic weakness, painful intercourse, and urinary symptoms. Beyond Kegels is a helpful book for pelvic weakness.

Hormone replacement therapy (HRT) is indicated for severe hot flashes and genitourinary syndrome of menopause (vaginal dryness / urinary symptoms). Start within 5-10 years of last menstrual period. Can benefit cholesterol, heart health, ovarian cancer risk. Should be avoided in women who have had a stroke, blood clot, or pulmonary embolism. Evaluate carefully in women who already have heart disease.

Combination therapy: estrogen + progesterone, used for women who still have a uterus.

Estrogen only therapy - lower risk of breast cancer than combination therapy.

Come in pill, patch, vaginal ring, or combination of estrogen pill/patch and progesterone IUD. Estrogen dose is lower than what is found in oral contraceptives.

Vasomotor symptoms: black cohash helps 30% of women who have tried it; it can affect the liver so caution should be taken.

Bio-identical hormones: not regulated by the FDA, not proven to be effective. Not recommended and potentially dangerous.

“Menopause” supplements - not proven to be effective.

Paroxetine (Paxil) - FDA approved medication for hot flashes. Commonly prescribed for depression and anxiety. Side effect is weight gain. Desvenlafaxine (Pristiq) can also help with hot flashes, as can venlafaxine (Effexor). Gabapentin, clonidine are other options.

Weight gain, changes in body shape occur around menopause. Exercise (especially strengthening) and healthy diet will help. Many other menopause symptoms improve with exercise, healthy diet, and good sleep.

The good news: not all women have all symptoms associated with menopause. The positives include no more periods to worry about, migraines may improve, autoimmune diseases may improve.

References & Products:

Good Clean Love Moisturizer

UberLube Lubricant

Beyond Kegels by Janet Hulme

North American Menopause Society website: www.menopause.org

Correction: premenstrual dysphoric disorder is the syndrome of low mood or irritability prior to menstrual periods

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The THYROID episode

Thyroid gland sits low in the neck. Secretes two forms of thyroid hormone - T3 and T4

Symptoms: affects the heart rate, weight, hair, mood, reflexes, bowels, energy

TSH (thyroid stimulating hormone) is measured in the blood to monitor thyroid levels

High TSH means low thyroid

Low TSH means high thyroid

Goiter is enlargement of thyroid tissue. Can be active and secrete thyroid hormone or inactive.

Thyroid cancer: most common is papillary thyroid cancer - highly treatable. Medullary thyroid cancer is rare.

Graves disease: autoimmune disease that causes hyperthyroidism, goiters, and eye disease

Hyperthyroidism is TOO MUCH thyroid hormone. Treated with radioactive iodine ablation or thyroid resection. Often end up needing thyroid replacement.

Hashimoto’s thyroiditis: most common cause of hypothyroidism or LOW thyroid

Levothyroxine is used for thyroid replacement. Dose is weight-based and then monitored with TSH.

Replacement levothyroxine must be taken first thing in the morning at least 30 minutes apart from other medications and foods to absorb.

Health Pearl: Toenail fungus (thick, yellow nails) is a common problem. It can be treated with applying Vicks VapoRub to the nails at night.

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Medications and Deprescribing

Today we discuss medications, polypharmacy, and deprescribing.

We are joined by clinical pharmacist Dr. Douglas Gugel-Bryant, PharmD, BCPS for this week’s conversation. Doug received his bachelor’s degree in chemistry and biochemistry from Capital University in Bexley, OH. He received his Doctorate of Pharmacy in 2017 from the Northeast Ohio Medical University. He went on to do a post-graduate residency program with the Cleveland Clinic Akron General in Pharmacotherapy. Doug moved to Fargo after finishing residency and has been a part of our clinic for over one year. His current role is Medical Home Pharmacist for the Sanford Internal Medicine Clinic. A majority of his work is on diabetes patient management and transitions of care. He is also a pharmacy resource for the clinic. Outside of work, Doug plays tennis and solo-acoustic fingerstyle guitar.

We discuss the following:

What is polypharmacy and why does it need to be evaluated?

What is deprescribing? Why is it important?

How do clinicians balance the benefits of medication versus potential interactions and side effects?

How do age and health impact the benefits of medications?

Which medications should be evaluated for deprescribing? What potential side effects do these medications have as individuals age?

What is the process of deprescribing? Can medications be stopped abruptly?

What are barriers to stopping medication?

Resources:

www.deprescribing.org

https://www.healthinaging.org/medications-older-adults

Health pearl:

Schedule an appointment with your clinician to discuss your medications, goals, and deprescribing.

Doug Gugel-Bryant - Guitar (YouTube)

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Understanding Your Lab Results

In this episode, Drs. Lindsey and Kirsten provide an overview of the routine labs. We answer the following questions:

- When are routine labs being ordered?

- What does the lab result mean?

- What are some causes of high or low results?

- Which labs, when mildly abnormal, are not worrisome?

Lab tests included are the chemistry panel, the complete blood count, thyroid tests, hemoglobin A1c, and cholesterol.

Health Pearl: diastole is a phase in the heart cycle during which the heart relaxes and fills up. People need to spend time in diastole, too, in order to refresh and renew! It’s important to take your vacation time, or find ways to incorporate rest and relaxation into your life.

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Bone Health

Osteoporosis diagnosis: DEXA scan T score of <-2.5 or diagnosed clinically - a fall from standing height resulting in fracture or evidence of spinal compression fractures

Risk factors: age, female sex, previous fracture, family history of osteoporosis, medication like prednisone, smoking, excess alcohol intake, small frame...

There are no symptoms of osteoporosis- can see loss of height or forward hunched posture “kyphosis”

People with osteoporosis break their hip and that is what generally causes the fall- not the fall that causes the fracture

Prevention: weight bearing exercise, getting adequate calcium and vitamin D

Treatment: Bisphosphonates, RANKL inhibitors or parathyroid hormone analogs

Health Pearl:

Alton Brown’s Chocolate Chia Breakfast Pudding

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Episode 16: Depression & Prevention of Suicide

Emily Gard, LICSW, joins us to talk about depression and suicide. Emily is a Licensed Individual Clinical Social Worker and nationally certified mental health first aid trainer with over ten years of experience in the field of social work. Emily earned her undergraduate degree from Concordia College and a master’s degree in Social Work from the University of North Dakota. She initially worked as a chemical dependency social worker before pursuing graduate education. Currently Emily is employed by Sanford Health as an Integrated Health Therapist. She was named Sanford Health Employee of the Year in 2017. When Emily is not working, she enjoys spending time at the lake with her husband and five children.

Depression - feeling down, depressed, hopeless, helpless. May come out of nowhere or be triggered by stressors. Symptoms include tearfulness, loss of interest, appetite and sleep changes, irritability, stomach aches, headaches. Symptoms can be physical - fatigue, diarrhea, upset stomach. Isolation, irritability, frustration, and slowed thinking can be seen in the older population. Sadness and bereavement generally do not last for more than a few months. Depression tends to be persistent and pervasive.

Suicide is a side effect of depression. Warning signs include thoughts of being better off dead or not wanting to wake up. Talking to people who are depressed about suicide does not make them more likely to commit suicide. Many people experience ambivalence about suicide and want to be asked about how they are doing.

Warning signs of suicide:

- talking about death

- statements like “people would be better off without me”

- feeling like they’re a burden

- feeling isolated

- feeling disconnected

- preparatory behaviors - giving away things, purchasing firearms, making sure will and/or insurance are in order

The next step for friends/family/clinicians:

- Ask how the affected person is doing

- Make observations to the person

- Using the word “suicide” is ok

People with depression need support just like people struggling with physical illness.

Local support groups

National Suicide Prevention Lifeline

American Foundation for Suicide Prevention

Columbia suicide severity rating scale - helps assess risk

Protective factors

- Valued relationships (pets, children, parents, close friends)

- Futuristic thinking

- Employment

As a friend, you can highlight protective factors and help them focus on these things. Do this without creating guilt by asking “what’s one thing that you’re living for?”

Terminology - language is changing. In the past we would say “committed suicide” but just as people die of cancer, they die of/by suicide. This is more accurate and helps decrease stigma.

The Columbia scale helps identify level of concern when someone is alluding to suicide. Preparatory behavior, plan for suicide, and suicidal intent predict suicide attempts.

People can recover! Every emotion is temporary. Recovery is possible. If someone has had suicidal thoughts in their life, they don’t typically experience them again. People generally get better and are able to experience joy and quality of life again. People should know that they aren’t alone. Depression and anxiety are common and treatable.

Treatment of depression:

Non-medical includes therapy, behavioral activation: exercise, healthy eating, connecting with others.

Medications include SSRI’s, SNRI’s, other antidepressants, sometimes antipsychotics

- These increase hormones in our brain that create positive feelings and emotion.

- Sometimes they have to be tried to find the right one. It can take a 4-6 weeks for these to reach their full effect.

- Medications don’t necessarily have to be life-long.

- Side effects: feeling emotionally “flat,” fatigue, nausea, weight changes, appetite changes, sexual side effects.

- Avoid heavy alcohol consumption while taking antidepressants.

Inpatient stays and partial hospitalization (PHP) can help individuals with suicidal intent. They help stabilize and facilitate mediation adjustments in addition to learning coping skills.

Exercise can be equivalent to taking a medication to help elevate mood. This shouldn’t be done in isolation but can be a helpful part of a treatment program. Being outside, being mindful of different sensations can elevate mood as well.

Cognitive behavioral therapy is a frontline approach for depression. Thoughts and behaviors are interconnected. Mindfulness, or the intention to pay attention, can be helpful in managing depression. Deep breathing can help regulate emotions.

Headspace, Calm, and Breathe are good apps. Or search “Guided meditation” on Youtube.

Health pearl of the week: Unplug! Technology can be enriching and helpful, but can also intrude into our lives. Think about having an hour of “unplugged” time per day (or even a day per week!).

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Congestive Heart Failure

2 types:

Systolic heart failure: pump weakens, ejection fraction (EF) less than 55%

Causes: heart attack, valvular heart disease, obstructive sleep apnea, viral, high blood pressure, excessive alcohol use

Symptoms: shortness of breath with activity, difficulty breathing when lying flat at night, swelling in the legs and fluid retention

Evaluation: clinical exam, stress test, echocardiogram, blood tests, chest xray

Treatment: medications include ACEi/ARB’s, beta-blockers, diuretics

Lifestyle changes: exercise, low salt diet, daily weights

Heart failure with preserved ejection fraction or diastolic dysfunction (poor relaxation):

Causes: age, hypertension, obstructive sleep apnea

Symptoms: swelling in legs, shortness of breath

Treatment: similar to above with focus on diuretics

Health Pearl: Colorful Stir Fry, adapted from Run Fast, Cook Fast, Eat Slow

Ingredients:

Two 8 or 12 oz packs of Extra Firm Tofu

2 Tbs Soy Sauce

1 Tbs Lime Juice

1 Tbs Honey

1 Tbs Minced Garlic

2 Tbs Sesame Oil

3 Cups chopped carrots, celery, broccoli

2 Cups sliced bell pepper, mushrooms, snow peas

1. Marinate sliced, dried tofu with soy sauce, lime juice, honey, and garlic in ziploc bag.

2. Saute carrots, celery, broccoli in sesame oil on high heat, stirring frequently, for about 5 minutes

3. Reduce heat to medium-high. Add pepper, mushrooms, snow peas. Saute 2 minutes

4. Add tofu with marinade. Saute, stirring occasionally. About 5 minutes

5. Serve over brown rice or quinoa.

Serves 4-6.

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What to expect when you’re… aging!

Consider yourself warned! We talk about normal aging and how to minimize the impact of age on the body.

From head to toe:

Hair thinning - occurs in women as well as men. Additionally, patterns of hair growth change with age.

Vision changes - decreased visual acuity, cataracts, and reading glasses are common

Dental - false teeth, dentures. Oral hygiene becomes more difficult due to decreased dexterity of the hands.

Hearing - hearing loss. Treatment is important due to potential for decreased cognition, changes in relationships due to hearing loss.

General physical appearance - change in distribution and appearance of fat distribution, decreased muscle mass. Metabolism slows, making it more difficult to lose weight. More protein is required to maintain and build muscle.

Cognition - some changes in thinking are normal, such as forgetting why you entered a room, forgetting names of people you haven’t seen in a long time.

Bowels - constipation can be a problem for many, looser stools occurs occasionally. Activity level, diet, and water intake can contribute to this.

Menopause and hormonal changes in men - both genders experience this. Can affect mood, libido, sexuality. Vaginal atrophy and dryness are common in women. Erectile dysfunction is common in men. Intimacy may need to change to accommodate both partners.

Urinary symptoms - lower urinary tract symptoms are common in men; urgency, frequency, incontinence can occur in both genders. Bladder becomes less elastic with age. Spasm can also occur related to triggers such as caffeine, citrus, and other irritants. Symptoms can be reduced with physical therapy, medical treatment.

Arthritis - osteoarthritis occurs in routine aging. Affects many joints depending on use, injuries, etc. A trainer or physical therapist can help remain active.

Balance - affected by vision, nerves, medications.

“Use it or lose it” for most components of normal aging. Healthy diet, physical activity, and adequate sleep help slow the impact of aging. Find out from your friends what has worked for them! Sharing your experiences and successes can help others.

Health pearl - Healthy Oatmeal, Chocolate Chip, Pecan and Orange Cookies
Adapted by Addie from SmittenKitchen.com

Makes about 3 dozen cookies

8 tablespoons unsalted butter, at room temperature
3/4 cup sugar
3/4 cup light brown sugar, firmly packed
1 teaspoon salt
1 teaspoon vanilla extract
2 large eggs
1 1/2 cups flour
1 teaspoon baking soda
1/2 teaspoon ground cinnamon
1/4 teaspoon ground nutmeg
1/8 teaspoon ground clove
1 ½ cup quick-cooking oats
2 cups chopped pecans
2 teaspoons freshly grated orange zest
12 ounces bittersweet chocolate chips (NOT semisweet)

Preheat oven to 350°F. Line a large cookie sheet with paper. Using an electric mixer, beat the butter in a bowl until light and fluffy. Add both sugars, salt, and vanilla, and beat until well mixed, about three minutes. Stir in eggs, one at a time. Sift together the flour, baking soda, cinnamon, nutmeg, and clove in a separate bowl. Add half of the flour mixture to the butter with the mixer on low speed. Once the flour has been incorporated, add the second half. Stir in the oats, pecans, orange zest, and chocolate chips. Drop approximately one tablespoon of dough onto the cookie sheet and bake for 10 to 12 minutes or until golden. Remove from the oven and cool the cookies on a rack.

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Episode 13 - Aging Well

Aging - the sum of all changes that occur with the passage of time that lead to functional impairment and eventually death

Factors affecting age: genetics, environment (stressors, habits such as smoking, alcohol consumption, diet)

It’s important to thing about death in order to help decide what living and aging well means for you. Take time to have conversations with your loved ones about what matters to you (quality of life versus quantity of life, what activities are important to you).

Answer the following: “How long do you think you’ll live?” and “How long would you like to live if given a fountain of youth?”

“What three things do you do to promote longevity?” “How well do you do at each of those (rate 1-5)?”

We all want to function as well as possible until death. Most of us will require help with at least one activity of daily living (dressing, bathing, toileting, food preparation) for the last 4 years of our lives.

Only 25% of longevity is due to genetics. The other 75% comes from environmental factors.

Life expectancy: 78.7 years for all comers, 81 for females, 76 for males

Blue Zones: National Geographic studied places in the world where people live the longest. People in these areas do the following: move naturally (walk, farm), have a sense of purpose, practice relaxation, in Okinawa - stop eating when 80% full; follow a plant-based diet; consume moderate alcohol; attend faith-based services 4 times per month; focus on loved ones coming first; surround themselves with the “right tribe” (family/friends with healthy habits).

Exercise can add years of independence to the end of life.

Diet: Mediterranean diet with plant-based protein, vegetables, olive oil, nuts and legumes adds health benefits to the heart, brain, and may contribute to longevity.

Control health conditions. Taking medication when needed will help prevent complications in the long-term.

Do supplements help with aging? Studies show more benefit from getting nutrients through a well balanced diet. If deficient in vitamin B12, vitamin D, supplements may be beneficial. Other supplements such as calcium, omega 3/fish oil haven’t proven to be as helpful. Ginko biloba hasn’t proven to be beneficial. Supplements are not well regulated.

Adequate sleep can contribute to longevity. Sleep related conditions such as sleep apnea should be treated.

Attitude appears to have an impact on longevity. Lindsey’s 104 year old grandmother choses to be happy, laughs daily, stays socially engaged (is on Facebook, church circle), has a sense of purpose, and has a sense of adventure.

Share your stories and life experience! The next generations need them.

Health pearl: Get outside! “Nature deficit disorder” is a loose term for symptoms related to inadequate time outside. Spending time in nature has a lot of positive health value, including reduced stress, better mood, better sleep, and lower blood pressure, among other things.

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The Waterworks for Men

Guest: Dr. Darin Lang, Internist and Geriatrician at Sanford Health. Trained at Virginia Mason in Seattle and Emory University for Geriatrics in Atlanta. Darin was born and raised in North Dakota. He’s been in his current practice at Sanford Health for 15 years working in outpatient Internal Medicine, nursing home care, and as a hospitalist. He is also the Internal Medicine Department Chair and an associate professor of medicine at the University of North Dakota School of Medicine and Geriatrics program. Dr. Lang is married and has 3 sons.

BPH = Benign Prostatic Hyperplasia. Affects older males and is an increase in the number of cells of the prostate, resulting in an enlarged prostate

Symptoms are urinary frequency, urgency, nocturia (waking at night to urinate), hesitancy, straining, slowed stream force, dribbling or obstruction

Alcohol, caffeine, and some over the counter medications can worsen symptoms (especially cold medicines)

Treatment:

Lifestyle changes include avoiding alcohol, caffeine and limiting fluids after evening meal

Medications: alpha blockers such as doxazosin and tamsulosin work quickly. Add on therapy - 5alpha reductase inhibitors (take months to work by shrinking the prostate)

Specialty physicians called Urologists are involved for procedures and more invasive evaluation

Health Pearl: Value of play

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