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Holly Thacker, MD - Physician, Author Dr. Thacker is the author of the recently published book, Women’s Health: Your Body, Your Hormones, Your Choices - a Cleveland Clinic Guide.
Questions and Dr. Thacker's answsers were posted May 17, 2007. Regards, Lisa Turner Dr. Thacker: All decisions about hormone therapy (HT) need to be individualized. The new term is HT as opposed to HRT (hormone replacement therapy) as most naturally menopausal women have the option of therapy and not all women need ‘replacement’ as menopause is a normal and natural life event. However, women with early or premature menopause many times need HRT/replacement. Most women with menopausal symptoms who are recently menopausal are actually good candidates for hormone therapy (HT) particularly if they have symptoms that disrupt the quality of their life. Midlife is a great time to reassess your overall health. If you are considering HT, you need to undergo an individualized history, physical exam and risk-benefit assessment with your doctor. Therapy should be highly individualized and periodically assessed. In my recently published book "Women’s Health: Your Body, Your Hormones, Your Choices, a Cleveland Clinic Guide" I go into detail on how to find a women’s health doctor who will listen to you and offer you an individualized assessment . I discuss in great detail the pros and cons of various hormone regimens and other non-hormonal treatments for women. Many women are great candidates for HT and do well and feel well on HT. Other women breeze through menopause and do not need any HT but may have bone, vaginal and/or bladder issues that need to be assessed. Question: If a woman has a history of 'lumpy breasts' which sometimes cause concern after mammograms, is hormone replacement contraindicated if there is no personal or family history of breast cancer? Dr. Thacker: Hormone therapy is NOT contraindicated in women with fibrocystic breast disease. If women have breast tenderness and/or breast cysts we may use much lower doses and sometimes will recommend that hormone therapy be stopped 1-2 weeks in advance of the yearly mammogram if a women has very dense breasts. Most women with fibrocystic breasts can use hormone therapy if needed and in general we use the lowest effective dose. There are many newer lower dose options that allow a woman and her physician to individualize therapy.
Dr. Thacker: There is information published almost daily about menopausal hormone therapies. An excellent resource for unbiased information is the North American Menopause Society web site Question: What are some treatment options for vaginal dryness? Dr. Thacker: There are a number of over-the-counter water based lubricants-like KY Jelly, Astroglide, as well as non-hormonal vaginal moisturizers like Replens or Silk E. The two oils that can be used in the vaginal as a lubricant / moisturizer are vitamin D oil or olive oil. If there is severe thinning or dryness, the best treatment is local vaginal estrogen that comes in a variety of creams, a tablet and a vaginal ring (the latter which can be used in many breast cancer survivors.) Local vaginal estrogen will restore the integrity of the vaginal tissues and can reduce recurrent bladder infection. Question: What are some of the most successful ways to deal with hot flashes and mood swings? Dr. Thacker: In my recently published book "Women’s Health: Your Body, Your Hormones, Your Choices, a Cleveland Clinic Guide", I have a chapter on "Maintaining Mood at Midlife" that reviews the various mood stabilizing treatments and talks about which comes first, menopause or depression? Estrogen treats hot flashes and is a mild mood elevator but is not a standard stand alone treatment for depression. Whereas antidepressants like Effexor / venlafaxine in low doses treat menopausal hot flashes where in higher doses don’t help hot flashes so much but does treat depression and anxiety. Sometimes vitamins, nutritional supplements, exercise, omega 3 fatty acids, and lifestyle changes are enough to treat minor hot flashes and mood changes. Sometimes hormone therapy is needed, other times antidepressant therapy is needed and sometimes both treatments are needed! In my book, I detail how a doctor and an individual woman can go about dealing with vexing mood symptoms and perimenopausal symptoms which can collide at the same time! In the future, we are expecting the first FDA approved non-hormonal medication Pristiq / desvenlafaxine to treat hot flashes. Currently, only hormonal products are FDA approved to treat menopausal hot flashes. Question: Are any natural supplements available for hot flashes and vaginal dryness? Dr. Thacker: I’ve mentioned the use of either vitamin E oil or olive oil for the vagina. Black cohosh, in the form of remifemin, has been used to treat hot flashes/night sweats for up to 6 months. Some women who eat soy foods convert soy protein into equol, a weak estrogen, and this may blunt their flashes. However, we do NOT recommend taking high doses of soy pills/powders-only soy in the form of whole foods, as soy pill supplements have been linked to uterine stimulation. 3. Question: I am 44, am in great health and work-out 5 days a week. I have had problems with very heavy flow the last 3 to 4 years. I have done all the preliminary testing: Pap, uterine biopsy, ultrasound etc. and everything looks good. If you take the body's natural rhythm and function of having a period each month away, will the body and hormones figure out something is wrong and throw me into menopause early? Dr. Thacker: It sounds as if your doctor might have recommended taking ‘the pill’ or hormonal contraception (HC) in a continuous fashion to prevent menstrual periods and/or reduce the frequency or length of the periods. In general, this is a very acceptable option for many women (provided they don’t smoke, have blood clots or other medical conditions that preclude the use of HC/hormonal contraception.) Using treatments like long cycle pills or actually ANY birth control pill taken continuously (with the placebo/sugar dummy pills thrown away) is an option to reduce heavy flow and/or lengthen out periods. The Mirena IUS-inserted into the uterus is another option for women with heavy flow. Endometrial ablation, where the lining of the uterus is ablated/permanently removed / reduced is another option as long as the woman is not planning further pregnancies. In my book, "Women’s Health: Your Body, Your Hormones, Your Choices, a Cleveland Clinic Guide" I have a chapter on abnormal bleeding and what to do about it. Taking the ‘the pill’ will not throw you into an early menopause. The trend is to use HC for longer durations to reduce or even eliminate menstruation. I personally take long cycle HC and I’m the one to decide if and when it’s convenient for me "to have a period." I tell women if you are worried about not losing blood every month you can always visit the Red Cross to donate your blood! 4. Question: After a complete hysterectomy, how often should I visit my Gyn? Dr. Thacker: You are a woman so you need a women’s health exam every year. Without a uterus and cervix, you may no longer need a pap (a scrape of the cervix to collect cells) but you still need a vaginal/pelvic exam and a breast and genital exam. Women who have had a hysterectomy because of cancer and/or women whose mothers took DES when they were pregnant still need to have a vaginal pap. But many women post hysterectomy, including removal of the cervix, no longer have to worry about cervical cancer. 5. Question: With no family history of breast cancer, how often should I have a mammogram? Dr. Thacker: All women age 40 and older should have a yearly mammogram. It’s best to schedule your mammogram right after your period as the breasts are less tender. Don’t schedule your mammogram right before some big event or travel because up to 1 in 2 women get called back for extra views of the breast, a so called ‘diagnostic mammogram’ for extra views. For many women this causes anxiety. I think it best just to plan that you might have to go back in a week or so for extra views rather than to get anxious and fret. Do be sure to always schedule a YEARLY mammogram. Mammograms save lives through early detection. Do it for yourself, do it for your family. 6. Question: Is it possible that your cholesterol and blood pressure might rise when you stop taking hormones? Dr. Thacker: Yes it is possible. Some women will have an increase in the LDL-cholesterol - the so called ‘bad’ cholesterol - and a decrease in the so called ‘good’ cholesterol - HDL-cholesterol - when they stop estrogen. And some women have very slight decreases in mean blood pressure on HT so when they go off they may note rises. The good news is that healthy diet and exercise and weight control will control most of these minor changes. Using HT (hormone therapy) to treat cholesterol or blood pressure is not recommended. 7. Question: Is joint pain a symptom of hormone inadequacies? Dr. Thacker: Joint pain can be related to overuse, injury, degeneration, medical illness as well as simple vitamin D deficiency - something very common in adults and those persons living in northern climates. Question: Is joint pain tied to menopause? Dr. Thacker: Joint pain is NOT a classic menopausal symptom although there are estrogen receptors on the cartilage and some postmenopausal women do report less stiffness on HT. I recommend good nutrition, calcium, vitamin D (800 to 1,000 international units daily) and a sound exercise program after consulting with your doctor. Weight loss, physical therapy and selected use of medicines and even joint injections may be needed for some women. Glucosamine is a supplement that has been shown to decrease knee osteoarthritic symptoms in some postmenopausal women. 8. Question: What are your thoughts on hormone replacement therapy that uses patches versus the oral version? Dr. Thacker: There are pros and cons with each regimen. In my book, "Women’s Health: Your Body, Your Hormones, Your Choices, a Cleveland Clinic Guide" I have an entire chapter titled "Customizing Hormone Therapy: one size does not fit all." The use of patches and creams may be associated with a lower risk of clot and are many times preferred by women seeking ‘bioidentical hormone therapy’ as transdermal-via skin as well as via vagina mimics more closely how the ovary delivers estrogen to the body. Conversely, oral regimens may be better for some women with skin or hair problems as oral HT can reduce elevated testosterone levels that can cause hair thinning, acne and a deepening of the voice. If taking oral HT-taking it with food lessens the effect on the liver. Some vaginal rings have estrogen that affects only the vagina and bladder-like Estring and some estrogen rings have higher doses that affect more that just the vagina. 9. Question: What are your thoughts on progesterone cream? Dr. Thacker: Progesterone creams over-the-counter may or may not have progesterone in the container. Many only contain diosogen-the precursor to progesterone - which only plants, NOT humans, can convert to progesterone. Question: What is it used for? Dr. Thacker: It has been used for women with PMS and /or perimenopausal symptoms. Question: It is available without a doctor’s prescription and could it have any adverse effects? Dr. Thacker: Some progesterone creams have been found to reach blood levels like with prescription oral or vaginal progesterone so there can be definite hormonal effects. And even though they are purchased over-the-counter, patients who use them need to be monitored by a physician. Conversely, blood levels may not be high enough so progesterone cream can NOT be relied upon to protect the uterus in women who need progesterone therapy. 10. Question: Could you speak about the best and worst foods relative to high cholesterol and heart health and describe why they are good and bad? Dr. Thacker: A Mediterranean type diet overall seems to be the healthiest diet. It’s rich in fruits, legumes, vegetables, whole grains, fish and the use of olive oil. Trans-fats are ‘bad’ fats - anything with ‘partially hydrogenated’ oils should be avoided. The ‘good’ fats are the essential fats-omega 3 and omega 6 that our body doesn’t produce. Fish oil and flaxseed are examples of omega 3 while many foods, including dairy foods, contain omega 6. 11. Question: After menopause and the use of hormone replacement therapy, is it necessary for a woman to see a gynecologist or is it no longer necessary for a woman to consult a gynecologist? Dr. Thacker: All women should continue to have yearly breast / genital and pelvic exams. 12. Question: Do you recommend that women in their late 30s who want to have children should check fertility before trying to avoid spending time on ‘chance’ when alternatives might need to be used? Dr. Thacker: After age 35 and particularly age 37 fertility rates markedly decrease. Time is of the essence if you want to conceive. Question: How many months should we wait before seeking advice from a doctor? Dr. Thacker: If you are over age 30 and haven’t conceived in 6 months of unprotected intercourse I would recommend seeing a fertility specialist whereas if you are under age 30, 12 months of unprotected intercourse is recommended. Dr. Tommaso Falcone, Chair and Professor of OB-GYN at The Cleveland Clinic, wrote a book for women titled "Overcoming Infertility" a Cleveland Clinic Guide-Cleveland Clinic Press. 13. Question: Last year I had a complete hysterectomy and since then I have fungus in my finger nails and toes. Can you tell me why this has happend? Dr. Thacker: I’m not sure the hysterectomy is related to fungus infection. I’d recommend seeing a dermatologist for a nail fungus culture and treatment. Lack of estrogen after hysterectomy, though, can contribute to thin hair and thin nails. 14. Question: What is the latest news on Osteoporosis? Dr. Thacker: In "Women’s Health: Your Body, Your Hormones, Your Choices, a Cleveland Clinic Guide" I go into detail on ‘Boosting Bone health’. Question: I have osteopenia. Is the progression to osteoporosis inevitable? Dr. Thacker: Not necessarily. Question: I am 60 years old. Statistically, do medication and calcium supplements work? Dr. Thacker: Yes, but don’t forget the 1,000 international units of vitamin D3 daily. Question: In the past 6 years, I have not had any progression, only work out with weights, no medication. Dr. Thacker: Good, no loss of bone is great news! Question: Do you think it will progress without medication? Dr. Thacker: It’s hard to predict the future. You have to be serially monitored. Question: Do you think working out will continue to keep osteopoenia from progressing to osteoporosis? Dr. Thacker: Calcium, vitamin D, good nutrition and exercise are all necessary but not always sufficient for postmenopausal women to avoid developing osteopososis so it is important to keep monitoring. 15. Question: Would like to know all the benefits of taking the omega 3 fatty acids and how much we need to take per day? Dr. Thacker: Omega 3 fatty acids are important for brain, breast, and heart health. It is important to ingest at least 2 servings weekly (not daily). 16. Question: I've recently heard that the weight that is gained around the waist is very "active" and produces estrogen. Although I am in the process of losing weight, how does it factor into the doctor determining the correct amount of hormones one should take? Dr. Thacker: Too much body fat anywhere can be harmful. The weight around the belly is linked to a higher rate of diabetes and cancer and heart disease, while weight around the hips and thighs is less harmful. Too much body fat can increase hormone levels although not always. Women who are overweight have a higher risk of breast and uterine cancer. 17.Question: What causes an enlarged heart? Dr. Thacker: High blood pressure, heart attack and heart failure. Question: What are the implications? Dr. Thacker: When the heart is too large it doesn’t contract as efficiently and heart failure - shortness of breath, fluid around lungs, fluid in extremities - can ensue. 18. Question: Many women asked about ways to improve sleep. What steps should women take to enhance sleep? Dr. Thacker: 1. Go to sleep and wake up at the same time every day, even on holidays and weekends. 2. Use the bed for sleep and sexual activity only, not for reading, watching television, or working. 3. Avoid napping. 4. If sleep does not begin within 20 to 30 minutes leave the bed and return only when drowsy. 5. Keep the room quiet, cool, and dark. 6. Use ear plugs to decrease ambient noise. 7. Avoid caffeine within six hours of bedtime. 8. Avoid alcohol and smoking one to two hours before bedtime. 9. Establish relaxation pre-sleep rituals, such as a warm bath or reading. 10. Wear socks to bed (lowers core body temperature). 11. Exercise earlier in the day. 12. Use a 10 minute 'worry period' daily. 13. Read the chapter in my book titled "Midnight Madness: From Sweet Dreams to Nightmares" for additional information and tips. Question: What causes women to develop sleeping problems? Dr. Thacker: Pain, worry, depression, anxiety, poor sleep habits, restless legs, hormone fluctuations, weight gain which can result in disordered breathing and sleep apnea, are just some of the reasons women may not sleep well. 19. Question: What are fibroids and how are they formed? Dr. Thacker: They are benign muscle growths of the uterus and up to 1 in 2 women have them. They may or may not cause problems. Question: Do bleeding problems result if you have them even when not menstruating? Dr. Thacker: Usually fibroids shrink after menopause. If they cause pain or grow in size or press on the bladder, kidneys, or rectum they may have to be treated. There are surgical and less invasive non-surgical treatments available. 20. Question: What are bio-identical hormones? Dr. Thacker: Bio-identical hormones are simply hormones like estrogen, progesterone and testosterone that have the same chemical structure as the hormones that are produced in the body. Question: How do they work? Dr. Thacker: They work similar to any hormone and can have benefits and can have risks. There is much confusion and controversy about ‘bio-identical’ hormones as many women are being hoodwinked by persons promoting only compounding hormones. Any hormone has potential risks and potential benefits-even if completely identical to the body’s own hormones. It is important to work with a reputable physician when taking any type of hormone. Women are inundated with misleading messages, and teasing out the facts can be difficult. This was the main reason why I decided to write my book; because I saw so many women needless suffering and/or putting themselves at unnecessary risk because of the media hype over hormones and other women’s health conditions. This ‘hormone hysteria’ has caused panic, confusion. 21. Question: I am interested in trying one of the over-the-counter colon cleansing products. How do they work and what are the advantages? Dr. Thacker: Regular bowel function is important and women commonly have constipation. Prior to the use of any colonic agents, it is important to visit your health care provider. Question: Could adverse effects result from using one? Dr. Thacker: Some of the over-the-counter agents can actually damage the nerve enervation to the bowel. Some potent bowel cathartics can lead to electrolyte imbalance which can lead to serious heart rhythm problems. The first step I usually recommend to women who are prone to constipation (which can happen on calcium supplements and with iron supplements) is to use oral daily magnesium oxide 250-400 mg tablet providing no kidney problems. Question: I have to schedule my first colonoscopy within the next month. Do you recommend not using a colon cleansing product prior to such a procedure? Dr. Thacker: In general you should follow a clear liquid diet the day before a colonoscopy and then drink a colon cleansing product the night before as prescribed by the doctor who is performing the colonoscopy. It is important to cleanse the bowel of all stool prior to a colonoscopy. By age 50, all women (and men) should undergo colon cancer screening. I think it is great that Katie Couric had hers on national TV to encourage adults to have a colonoscopy. Nationally, men are screened at twice the rate as women and that is why at the Cleveland Clinic we have set up ‘women only’ colonoscopy suites staffed by women for women in a private atmosphere. I myself have had to have two colonoscopies and, other than getting a bit hungry on the clear liquid diet, I breezed through the procedure and was back seeing patients in my office later that day. 22. Question: What are the new remedies for polymyalgia? Dr. Thacker: PMR - polymyalgia rheumatica - tends to affect older persons and causes serious pain and can sometimes be associated with the more serious temporal arteritis. Corticosteroid medications as well as other immune modulators can be used. Question: Other than pain medication, what else can be done to relieve pain? Dr. Thacker: Seeing a rheumatologist who specializes in Physical Medicine and Rehabilitation is important. Question: Does the immune system have any relationship to this disease? Dr. Thacker: Yes, this is one of the suspected mechanisms. 23. Question: What causes spider veins to appear? Dr. Thacker: Genetics, aging, weight gain. Question: What are the choices in removing spider veins? Dr. Thacker: There are laser treatments as well as sclerotherapy which are salt water injections into the tiny veins. Question: Are any natural treatments available? Dr. Thacker: Salt water is ‘natural’ but has to be done by an experienced doctor. The simplest ‘treatment’ is to use some leg make-up or cover up camouflage. Question: How can I avoid getting them in the first place? Dr. Thacker: I recommend that women who are going to stand for long periods of time and/or during pregnancy to wear support hose. I’m wearing support hose right now! 24. Question: Why do some women experience thinning hair? Dr. Thacker: Up to 40% of us notice thinning hair with aging. There are hormonal conditions, vitamin deficiency (like iron and zinc) that can worsen the problem. Question: Can anything be done to enhance hair re-growth? Dr. Thacker: There are a number of treatments from vitamin supplements, to hormonal treatments, to topical treatments to prescription shampoos that can be prescribed. In the chapter in my book, "Look Good, Feel Good" I talk about some of the skin and hair treatments that are available to women. 25. Question: I’m 36 years old. My mother’s side of the family has a history of heart disease. Two of my family members recently died from sudden heart attacks. My mother and 2 uncles have had either heart attacks or by-pass surgery. What should I do? Dr. Thacker: With such a strong family history of heart disease, you may want to be evaluated in a preventive cardiology clinic. We have set one up for women at the Cleveland Clinic and many hospitals are focusing on prevention of heart disease. Question: Are there some tests I should get to determine my baseline? Dr. Thacker: Blood pressure, fasting blood sugar, fasting lipid profile. There are other special tests like homocysteine, lp(a), lipoproteins, fibrinogen and cardio-CRP that might be obtained. Everyone’s LDL-cholesterol (bad cholesterol) should be under 130 and having it under 100 is even better. Folks who have had heart attacks, women with diabetes, should have the LDL-cholesterol even lower. 26. Question: Please explain the saliva test for pre-menopause / menopause hormone levels? Dr. Thacker: The level of hormones in your blood or in your saliva is really not nearly as important as the level of hormones in your actual body tissues-bone, brain, vagina, breast, etc. In my book, Women’s Health: Your Body, Your Hormones, Your Choices" I describe how we assess a woman’s hormonal balance. 27. Question: If you are over weight by 40-50 lbs., is it possible to follow a strict nutrition plan so as not to gain wait during pregnancy? Dr. Thacker: Women who are overweight and expecting a baby still need to gain some weight. It is important to work with a women’s health nutritionist so that you gain 15-20 lbs as opposed to 30-35 lbs. a leaner women might gain. 28. Question: I have been diagnosed with endometriosis, and have been on the active birth control pill for three years, except when I get breakthrough bleeding, and then I allow my body to have a period by stopping the pill. Dr. Thacker: When you stop the pill, in general we’d only recommend stopping for 3-4 days then resuming Question: Please describe other recommendations for treating endometriosis other than the birth control pills. Dr. Thacker: Lupron can be used temporarily to induce a ‘medical menopause’ which will quiet down endometriosis in some women. There are surgical treatments and some exciting future treatments that are being studied now. Sometimes endometriosis will regress after a pregnancy. Some women find some relief with the progesterone IUD or Mirena IUS. Question: I also experience migraines that appear to be cyclic. I notice that if I forget to take a pill, a migraine will result. Dr. Thacker: Yes, this is common. The brain of migraineurs is very sensitive and can detect that drop in hormones. It is important to take your pill the same time every day and many times we have women with migraines and endometriosis take a pill every day-even if there is some break-through bleeding. Riboflavin and magnesium supplements seem to help reduce migraine headaches in women and in my book I have an appendix of information on managing migraines. Thank you, Dr. Thacker, for your insight. Speaking of Women's Health selects the most relevant questions for experts. Experts may decline to answer questions. 'Ask The Expert' does not offer medical advice. Please refer to our Disclaimer for futher information. |
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