Dr. Brittain: Good afternoon. This is Dr. Brittain. I want to share with you a personal story here about a patient that I saw in my office today. This is a woman who comes in who is interested in hormone replacement therapy. As you might know, women tend to lose their hormone production as they go through menopause around the age of 50, or sooner if they are surgical and have had their uterus removed. There could be some gradual or rather abrupt changes that occur because of the decline in hormone production. In menopause, women lose about 90% of their estrogen production. Estrogen helps with hot flashes, night sweats, concentration, memory, mood, vaginal lubrication, skin texture, joint lubrication. Women also lose a large percentage of their testosterone production, which happens mostly in the ovaries. Testosterone helps with strength, endurance, muscle mass, mental clarity, sexual desire. Progesterone levels decline dramatically during menopause. Progesterone helps with mood and has a calming effect and really works along with estrogen to help women sleep a lot better.
This is really important because I don't know if you're aware of this, you can live 30 days without food, about seven days without water, but only five days without sleep, so in some respects sleep is more important than food and water, and we tend to neglect this as a health issue. I'm going to now present our patient, Mrs. Johnson, that's not her real name, and this is a real interview prior to examination in my office.
Dr. Brittain: Hi there, Mrs. Johnson. How you doing?
Mrs. Johnson: Just fine, thank you.
Dr. Brittain: Well, welcome to our practice. I'm Dr. Brittain. Erica here is going to take some notes for us. How can I help you today?
Mrs. Johnson: Well, I came in looking for some answers for hormone replacement I believe.
Dr. Brittain: Okay. Well, what are your questions?
Mrs. Johnson: The questions are you know, as you get older, the sex drive's not there and seeing what solutions is out there.
Dr. Brittain: Okay. Well, what have you done so far?
Mrs. Johnson: Not really anything.
Dr. Brittain: Uh-huh. So suffered in silence?
Mrs. Johnson: Yes, yes. Talked with my regular family physician and she referred me.
Dr. Brittain: Have you mentioned this along the way that you're having some problems, have you mentioned to any other doctors?
Mrs. Johnson: Basically I had talked to her about it for a few years. She just suggested maybe extra time and put forth a little bit more effort maybe.
Dr. Brittain: Yeah, you know, that's a pretty common thing that a lot of doctors do and it's not because they don't want to take care of you but they're not maybe tuned in to what our bodies need and the proper interpretation of the literature. And it's unfortunate because there's a lot of things that we can do. As you know at menopause all this crazy stuff happens. You have hot flashes, night sweats, problems with concentration, memory, mood, vaginal lubrication, strength, endurance, muscle mass, mental clarity, sexual disorder. All those things suffer for want of hormones that are pretty easy to replace actually. It has to be done properly and under some supervision but there's some pretty cool things that we can do medically.
But I'd like to educate you for just a moment if you don't mind, about what we know and maybe some things that you might think are going on or that you've been told that just aren't so.
Let's start with the Women's Health Initiative which was begun in 1997 and in 2002 there was this report, "Oh, my God, estrogen is killing women. It's causing breast cancer. Quit taking it." I don't know if you remember that or not?
Mrs. Johnson: Yeah.
Dr. Brittain: Okay. Well, what actually happened was that these researchers studied placebo and Premarin and Prempro three different groups of women, large groups, 9,000 women in each group, and they wanted to look at different outcomes. Placebo is a sugar pill. Premarin is the old fashioned conjugated estrogen and then Prempro is the conjugated with a synthetic progesterone. After five years of this study they noticed that the Prempro patients had a little more breast cancer so ethically they said we need to stop that part of the study.
But at the same time, the women who took only the estrogen had less breast cancer than the women who were taking nothing. Well, let's continue that part of the study. But the public media got a hold of this and all they could see was, "Well, there was estrogen in this pill. It must be bad. Everybody should quit taking it." Millions of women quit taking it. Thousands of doctors quit prescribing it without reading what the study actually said and meant. I read the study and I realized that this was a gold mine of information but the press was interpreting it incorrectly.
The average person and the average doctor didn't read the study. So these doctors went ahead and continued studying these women who were taking just Premarin compared to the women who were taking the placebo for another eight years. At the end of 13 years of study, the women taking Premarin had more than 20% reduction in breast cancer incidence than the women who took nothing. So in that part of the study, women taking Premarin actually had less breast cancer than the women who took nothing.
Mrs. Johnson: I have been advised by doctors that that would be my highest risk. If I would go on hormone replacement that it was a high risk of developing cancer.
Dr. Brittain: It's a misinterpretation of that study that is still prevalent today that is scaring women away from taking hormone replacement therapy. What do you suppose is the number one cause of death in menopause?
Mrs. Johnson: I don't know.
Dr. Brittain: Heart disease.
Mrs. Johnson: Heart disease. Okay.
Dr. Brittain: So heart disease kills more women in menopause than the next 16 causes of death combined. There is a pretty great study out of Denmark published just about 10 years ago, where they have this healthcare system where everybody is in an electric medical record catchment, if you will. So, they can follow everybody. They looked at all the women who were between the ages of 50 and 59 and followed them for seven years and looked at what they took or didn't take and who got heart attacks, 698,000 women. And guess what? The women using estrogen properly cut their risk of heart attack in half compared to the women who took nothing. But the women who took Prempro, like the Women's Health Initiative, they had a higher risk of heart attack than the women who took nothing. The women who took just estrogen had a markedly reduced risk.
So after years of studying and looking at this, the American College of Obstetricians/Gynecologists has said that in menopause women should take hormone replacement therapy unless there is some specific contraindication and that women who do, reduce their risk of death from preventable disease by as much as 50% compared to women who take nothing. So that's breast, heart, colon, less dementia, less osteoporosis. Oh, and you'll feel better.
Mrs. Johnson: Alright. That's great. Everybody's looking for that magic pill.
Dr. Brittain: Yeah, no kidding. Well, and if you think about it, you spent what, 40 years of your life making a lot of hormones? How did things work?
Mrs. Johnson: Pretty good.
Dr. Brittain: Yeah. So you had a life. Did you make babies?
Mrs. Johnson: Unfortunately no.
Dr. Brittain: Did you try?
Mrs. Johnson: I tried.
Dr. Brittain: Did that feel good?
Mrs. Johnson: Many years of fertility drugs though, yeah.
Dr. Brittain: But that felt good, right? Having the sexuality and expressing it with intercourse and all that. When you become menopausal around the age of 50, that hormone support disappears. What we know about this is if you can put those hormones back into you in a way that it makes your body think you're still making them, that's healthy and you can do it forever and you'll feel good.
Mrs. Johnson: Okay.
Dr. Brittain: Are you ready for that?
Mrs. Johnson: I am ready for that. I definitely am.
Dr. Brittain: Let me ask you a couple more questions. What seems to be bothering you? What prompted this visit?
Mrs. Johnson: I think the low sex drive which in turn causes marital issues.
Dr. Brittain: Yeah. I hear that a lot.
Mrs. Johnson: Yeah, yeah. You don't want to be traded in for a 20-year-old so ...
Dr. Brittain: Or a couple of them.
Mrs. Johnson: A couple of them, yeah.
Dr. Brittain: Are you having intercourse?
Mrs. Johnson: Yes.
Dr. Brittain: Is it painful?
Mrs. Johnson: At times, yes.
Dr. Brittain: Are you getting satisfied?
Mrs. Johnson: No, I mean my sex drive has been pretty low for a while.
Dr. Brittain: So you feel like just a passive recipient or just a ...?
Mrs. Johnson: Yes.
Dr. Brittain: So you're not getting anything out of it?
Mrs. Johnson: Exactly.
Dr. Brittain: But you did in the past?
Mrs. Johnson: Oh, definitely, yes.
Dr. Brittain: So you're not even able to have an orgasm now?
Mrs. Johnson: Not with normal intercourse.
Dr. Brittain: Yeah, yeah. But you wouldn't initiate that kind of thing now?
Mrs. Johnson: Well, I still do, yeah.
Dr. Brittain: Do you have to use a lubricant?
Mrs. Johnson: Yes.
Dr. Brittain: Do you get infections?
Mrs. Johnson: No, no, haven't had any issues with that.
Dr. Brittain: Good. Do you have any bladder irritation?
Mrs. Johnson: No.
Dr. Brittain: Do you get hot flashes, night sweats?
Mrs. Johnson: I don't. I went through menopause probably at about 43. Probably because of a lot of years of fertility pills.
Dr. Brittain: Oh, yeah, yeah, yeah.
Mrs. Johnson: Actually I've been one of the fortunate ones about ... Didn't really have many side effects from menopause.
Dr. Brittain: Okay. So not a lot of the hot flashes or night sweats you said, okay. Do you get irritable?
Mrs. Johnson: I don't think so.
Dr. Brittain: How's your sleep?
Mrs. Johnson: Good.
Dr. Brittain: Have you had a bone density scan?
Mrs. Johnson: Yes.
Dr. Brittain: How long ago was it?
Mrs. Johnson: Actually I just had one about a month ago.
Dr. Brittain: What did it show?
Mrs. Johnson: Not good but I've had some issues for about ... I guess my last one was probably six years ago and it showed not osteoporosis but ...
Dr. Brittain: The osteopenia.
Mrs. Johnson: Yes, yes.
Dr. Brittain: Where did you have that done?
Mrs. Johnson: IU Health.
Dr. Brittain: Okay. Well, we can actually reverse that trend and improve your bone density with proper hormone replacement therapy. Has anyone ever looked at your female hormone levels?
Mrs. Johnson: Yeah.
Dr. Brittain: Okay. That's a pretty important thing to follow and, of course, your symptoms and your physical exam. So we put all that together. We look at what's going on with you with the various symptoms, vaginal dryness or whatever it might be, or low libido. And then we look at your blood work and we look at a physical exam and that usually matches up. Then we come up with a plan if you're interested.
Mrs. Johnson: Um-hmm. (Affirmative)
Dr. Brittain: And then we do some surveillance.
Mrs. Johnson: Okay.
Dr. Brittain: So what I tell my patients is that I'm glad to follow you. I love to do this work and to me it's not even work. To me it's emotional enrichment. But we're going to be metaphorically joined at the hip because you want to get a good result. You want to feel better and I'd like you to also and so that is going to involve, at least initially for a little while, a periodic exam, a reassessment of what's going on with your symptoms and some labs.
Mrs. Johnson: Okay.
Dr. Brittain: I may have to do this two or three times to get the proper balance of what works for you, that makes you feel better. Does that sound like sort of a plan?
Mrs. Johnson: Sounds like a very good plan.
Dr. Brittain: What kinds of questions does that bring up for you so far?
Mrs. Johnson: Basically I guess just your guidance, what you recommend. Like I said, the doctors that I dealt with before was reluctant to put me on anything because I do have breast cancer in my family and they didn't want to do anything that might initiate on the cancer side of things.
Dr. Brittain: Right, right.
Mrs. Johnson: So I just came to you to see if there's better answers out there than what I've been given.
Dr. Brittain: Well, I think there are and I have a lot of patients who think the same way. Once they get going it's like, "Oh, man, I'm never going back to the way it was before." Well, I'm going to start an exam here in just a minute and I'm going to turn off the recorder. If you have some questions at the end we'll sure take care of that too.
Mrs. Johnson: Okay.
Dr. Brittain: Thank you very much.
Mrs. Johnson: Thank you.
We just concluded our interview, examination, and an exit interview on Mrs. Johnson here. And, we came up with a plan to begin some vaginal Estrogen, some oral Progesterone. And both of these are bioidentical. And keep in mind that women are not deficient in Conjugated Estrogen like Premarin. They're deficient in biologically identical Estrogen. And, there's no reason in the world to consider using other than bioidentical hormone therapy. Even though some of the medical societies and so forth say, "Well, there's really no qualitative difference."
Well, there is, and my wife is a family doctor. She and I attended the International Menopause Society's World Congress Meeting in Vancouver, Washington a few months ago and smart doctors from Africa, Asia, Europe, North and South America, Australia get together every couple years. And people who attend these meetings are experts in treating the menopausal woman. And to a doctor, they advocated the use of Estrogen, Estrogen, Estrogen and don't quit. And, they also say it matters what you take, what form of Estrogen you take, and how you take it.
And, the North American Menopause Society went a step further and issued a paper last fall. And put physicians on notice to remember that menopause is forever. If you have a 65-year-old woman, just because she's 65 doesn't mean she has to quit taking hormones. She can take them forever. Doctors in the past have frequently told their patients at about that age that, "Oh, you need to quit taking it." And that's not based on any evidence whatsoever. And one of the things that I pride myself on in my practice is to practice evidence-based medicine, and stuff that makes sense.
So, we started Mrs. Johnson on some vaginal Estrogen, which is bioidentical Estradiol and some oral Progesterone at bedtime. And, got a series of labs which are pending. And then we'll do a follow-up examination after a couple months of doing just that simple intervention. And reassess how she's feeling biologically and emotionally, and with her vaginal lubrication and so forth. And then we'll get some follow-up labs at that time, and probably do a little bit more vigorous therapy.
So this is kinda how I approach the menopausal woman. In this particular case there's variations of this, but this is a pretty basic look at the care of the menopausal woman. Now, if you have questions, I'd invite you to visit my website www.drbrittain.com Facepage that we have is Vibrant Life. That is the trade name of my private practice that I use for my hormone patients. And, you can call our office at 812-331-9160. Once again, that's www.drbrittain.com Vibrant Life on Facebook, and 812-331-9160. Hope to see you soon. Thank you.
