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E. Conrad Hicks Jr.,
MD, FACOG
Menopause
management, particularly during the transitional peri-menopausal
(PMP) period has become one of the most rewarding aspects
of my gynecologic practice. It is my experience and belief
that our approach to patients during this often-turbulent
period needs to be modified. The conventional, simplistic,
cookie cutter approach to menopause or PMP will simply not
work to keep our patients happy over the long term.
Let’s
start with the term “transition”. This is appropriately
descriptive of the dynamic nature of hormone changes in the
blood occurring during this time of a woman’s life.
This period can last up to 10-15 years in some patients. Analogous
to the biological complexity and individuality in each of
us, every woman’s pathway will differ. During this period
our patients can present with a whole host of symptoms –
all related to the increasingly unstable blood levels of estrogen
(E), progesterone (P) and testosterone (T). This list includes
hot flushes, associated sleep disturbances, irregular, heavier
or lighter menstrual flow, depression, worsening of PMS symptoms,
decreased energy, decreased sex drive and ability to enjoy
a sexual relationship, and finally in some patients a decreased
“overall sense of well being”. This last issue
may be described in different ways by different patients,
but I find when I ask the question, those who feel this way
will jump at the opportunity to describe it for me.
Hormone
fluxes during this PMP period are secondary to a programmed
breakdown in synchronicity and communication between the hypothalamus
in the brain, the pituitary gland at the base of the
brain, and the ovaries that manufacture E, P and T
(aka the H-P-O axis). Commensurate with this period then, we see a decrease in regularity
of ovulatory cycles and a wider range of serum concentrations
of ovarian sex steroids. In other words, blood levels of,
let’s say E, will be both abnormally high and abnormally
low at different times during this period as compared to a
younger woman with an intact, synchronized H-P-O axis. This
explains the patient who presents with complaints of both
MORE menstrual flow but hot flashes at the same time…what
is going on here?!
Again,
this programmed period of transition will be different in
different patients. Some can begin this journey as early as
age 35, and the PMP transition can go on for 10-15 years in
some women. Though a lucky few will experience this transition
with few or no complaints, more often patients at this time
will present to the office to seek help in experiencing their
transition and maximizing their quality of life. Don’t
fail to ask these questions pointedly and in a safe environment
so that our patients will feel comfortable sharing with us
their experience.
Following
from the above is the realization that most women who present
to us for help with PMP issues actually have adequate estrogen
levels in their circulation! The amplitude of the highs
and lows of these hormone concentrations are just greater
during this period. This is an important concept to grasp
in understanding what is really going on in our patients at
this time and in crafting a sensible management program for
them. As a physicians, our first instinct is to, guess what,
give more estrogen in one form or other! In some patients
this certainly is a useful way to handle the situation. But
is it the only way?
Menopause
management has truly become an art in as much as we now have
so many options to present to our patients. The art comes
in crafting the right program, or blend of nutrients, herbal/natural
agents, and/or standard pharmaceutical preparations to maximize
both our patients’ health risk profile and quality of
life. As a physician I certainly believe there is a place
for all these options in certain patients at certain times.
As a group, physicians need to be more comfortable thinking
“out of the box” in managing these patients. This
means considering with our patients treatments other than
simply estrogen, with or without progesterone.
Through
conventional medical training we are certainly familiar with
the many options the pharmaceutical industry has given us
to administer E, P, and T. As physicians also we are aware
of the other pharmacological agents (bisphosphonates, SSRI
group anti depressants, certain anti hypertensives), which
can very effectively manage some aspects of the PMP for some
of our patients.
What
conventional medical training has not given us is a full appreciation
for the utility of a natural herbal approach to many maladies,
particularly the menopausal transition. I will say that a
significant number of my patients will ask about this option,
and I heretofore could give them only a blank look and no
useful information. The medical community has tended to frown
on this approach in general as an uninvestigated, un-standardized,
shot in the dark form of treatment and little more. I have
realized that it is time for me – and us as a medical
community – to begin to embrace some aspects of natural
approaches to what ails us as it may pertain to our specific
clinical areas. I don’t mean become naturopaths and
abandon all the good medicine we have learned to practice,
but certainly to begin to learn about and incorporate natural
remedies into our practices in a blended, complementary way.
For myself,
I have much to learn about herbal or natural approaches, but
feel I need to become comfortable with some basic herbal therapy
that may help my PMP patients. Something that has a sound
scientific basis, and which I can use time and again to get
a comfort level with patient responses, much as I do with
various ERT and HRT regimens.
An option
I feel comfortable using is one that I was introduced to at
the North American Menopause Society (NAMS) meeting in October.
Valerie Otto and the staff at Becoming Inc. have developed
a product called Oöna that contains black cohosh and
chaste tree berry – two agents with a wealth of experimental
data to support their usefulness with many PMP symptoms. Although
I was a bit hesitant and perhaps skeptical, what appealed
to me as a physician, is the time and expense Becoming Inc.
has elected to put into seeking not only THE best raw material
from which to make this product but also standardization and
purity testing for each batch.
This ensures the dosage will always be the same whether
the product is purchased in New York or Albuquerque.
Standardization
and reliable reproducibility of a products effect has heretofore
been an Achilles heel of the natural products genre. Oöna,
however, breaks this mold and indeed makes sense as a first
line therapy in controlling PMP symptoms. Physicians can have
this available particularly for their patients who request
– no, insist – on attempts at a natural approach.
Describing
Oöna’s effects in the simplest way means investigating
exactly how these agents affect the HPO axis and peripheral
tissues as well. On looking at this combination together it
is clear that the two constituents work together through several
mechanisms that essentially serve to dampen the wide amplitude
swings of blood hormone concentrations occurring during the
PMP. This serves to simply bring the patient back to smoother,
more stable serum hormone levels. The peaks and valleys are
eliminated. To the extent that most or all the symptoms our
patients present with are likely secondary to these changes,
this product makes perfect sense as a first line therapy to
offer our patients. Clearly this is not a panacea, but it
certainly deserves a place at the table with what we offer
our patients. Toxicity and medicine interaction with this
preparation is virtually non-existent, and of course any accompanying
fears about breast, uterine or ovarian cancer will be addressed
if this option is used and works.
Let’s
face it; ANY PMP or menopausal treatment vehicle that gets
a 60-80% response rate deserves a second look! This is the
kind of response I have seen in my practice in patients that
were selected as good candidates. In addition, I curry my
patients’ favor by being willing to at least try a natural
treatment approach. This opens the door to receptiveness when
an herbal does not work; they are more willing to try more
conventional methods. This is a win-win situation on all sides.
Clearly
our patients’ needs will change as they go through the
transition and reach a “steady-state” hormonal
situation with static decreased levels of E, P and T. PMP
by definition is a dynamic time of constant changes in hormonal
levels. When these changes occur, we must be ready to re-evaluate
each patient’s situation, assessing whether or if a
new program is warranted to improve her health risk profile
and quality of life.
I am
thrilled to have a product like Oöna available as a first
line treatment to use in transitional patients with PMP complaints.
It will take it’s place alongside the many other agents
that I known can and are helping my patients negotiate this
exciting time in their lives.
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