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Menopause and cognitive complaints: are ovarian hormones linked with subjective cognitive decline?
Subjective cognitive decline (SCD) and the loss of ovarian hormones after menopause have been independently linked to later-life Alzheimer’s disease (AD). The objective of this review was to determine whether menopause and the loss of ovarian hormones contribute to cognitive complaints and SCD in women. This would suggest that SCD at the menopausal transition might be an important marker of eventual cognitive decline and AD. We conducted a literature search using PubMed, PsycINFO and Web of Science in July 2020. All English-language studies assessing SCD and cognitive complaints with respect to menopause and ovarian hormones were included. A total of 19 studies were included. Studies found that cognitive complaints increased across the menopause transition and were associated with reductions in attention, verbal and working memory, and medial temporal lobe volume. Women taking estrogen-decreasing treatments also had increased cognitive complaints and reduced working memory and executive function. The current literature provides impetus for further research on whether menopause and the loss of ovarian hormones are associated with cognitive complaints and SCD. Clinicians may take particular note of cognitive complaints after menopause or ovarian hormone loss, as they might presage future cognitive decline.
Are chemicals shrinking your penis and depleting your sperm? Here’s what the evidence really says
May 4, 2021 6.08am AEST
- Tim Moss Adjunct Associate Professor, Department of Obstetrics and Gynaecology, Monash University
Tim Moss is Health Content Manager at Healthy Male (formerly Andrology Australia). He is the current President of The Perinatal Society of Australia and New Zealand.
Monash University provides funding as a founding partner of The Conversation AU.
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A doomsday scenario of an end to human sperm production has been back in the news recently, now with the added threat of shrinking penises.
Professor Shanna Swan, a US epidemiologist who studies environmental influences on human development, recently published a new book called Countdown.
In it, she suggests sperm counts could reach zero by 2045, largely owing to the impact of a range of environmental pollutants used in manufacturing everyday products: phthalates and bisphosphenol A (BPA) from plastics, and per- and poly-fluoroalkyl substances (PFAS) used, for example, in waterproofing. Under this scenario, she says, most couples wanting to conceive would need to rely on assisted reproductive technologies.
She has also warned these chemicals are shrinking penis size.
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Such extraordinary claims require extraordinary evidence. I would argue the evidence is not strong enough.
Correlation doesn’t equal causation
Epidemiologists find associations between disease and potential contributing factors, like lung cancer and smoking. But their work can’t identify the causes of disease — just because two things are associated doesn’t mean one is causing, or caused by, the other.
An article written by environmental activist Erin Brockovich in The Guardian in March leads by referring to “hormone-disrupting chemicals that are decimating fertility”. But causation is far from established.
It’s reasonable to expect chemicals that affect hormone function in our bodies, like BPA and PFAS, could affect reproduction in males and females, given available evidence. But we don’t have irrefutable proof.
In 2017, Swan and several colleagues published an exhaustive review study showing an apparent drop in men’s sperm counts of 59.3% between 1973 and 2011. This research informs the arguments Swan makes in Countdown and those we’ve seen in the media.
What’s not often mentioned is the fact the researchers only observed a decline in sperm count in groups of men from North America, Europe, Australia, and New Zealand, but not in groups of men from South America, Asia or Africa.
When Swan and her colleagues combined the data from all countries, they saw a decline because the studies of “Western” men outweigh those of men elsewhere (in the number of studies and participants).
Swan and her colleagues worked hard to avoid bias when conducting their study. But selection bias (related to how study participants are chosen), publication bias (resulting from researchers’ tendency to report only observations they think will be of interest) and other limitations of the original work used as the basis for their investigation could be influencing the results of the larger study.
Many studies from different parts of the world show declining sperm counts, which is concerning, but we don’t fully understand the reasons for the apparent decline. Blaming chemicals in the environment overlooks other important factors such as chronic disease, diet, and obesity, which people can act on to improve their fertility.
The problem with extrapolation
Swan’s 2017 study boils down to a straight descending line drawn between sperm counts of groups of men studied at different times between 1973 and 2011.
Just because a straight line can be drawn through the data, this doesn’t justify extrapolation of that line beyond its earliest and latest data points. It’s unscientific to assume trends in data exist outside the range of observations.
We know sperm counts of men in the early 1940s were around 113 million sperm per ml of semen, not the roughly 140 million/ml you get from extrapolating backwards from Swan’s research. Concluding sperm counts will reach zero in 2045, based on extrapolating forward from the available data, is just as likely to be incorrect.
When Swan told news website Axios “If you look at the curve on sperm count and project it forward” she was encouraging unjustifiable and unscientific interpretation of her data — even though she acknowledged it was “risky” to extrapolate in this way. Unfortunately this caution is too often unmentioned.
For example, Brockovich writes: “That would mean no babies. No reproduction. No more humans.” That’s hyperbole. It’s just not science.
Relax, your penis isn’t shrinking
Claims of shrinking penises are obvious clickbait. But only a single study, of 383 young men from the Veneto region in northeastern Italy, links men’s penis size to the types of chemicals Swan attributes to declining sperm counts.
Within Veneto there are geographic zones with varied levels of PFAS contamination. A group of 212 men who live in areas with high or intermediate PFAS exposure and have high levels of these chemicals in their bodies, had an average penis length of 8.6cm, about 10% lower than the average of a group of 171 men from an area without exposure (9.7cm).
But a few features of this study affect the reliability of the observations and whether we can generalise them to other populations.
- men were grouped according to where they lived, not where they were born. Since genital size is determined before birth, the environment during their mothers’ pregnancies is more relevant to penis size than where the men lived at the time of the study. Some men will likely have relocated from their place of birth but how many, and where they may have moved to and from, we don’t know
- the levels of PFAS exposure for men living in the contaminated regions of Veneto are extreme, because of decades of industrial pollution. How the potential effect of such large exposures relates to smaller and more common exposures to pollutants, like from plastic food wrap, we don’t know
- the study is missing details about its subjects and the conditions under which measurements were made. It’s usual to exclude people with conditions that might affect study outcomes, such as congenital abnormalities, but it’s not clear whether this happened in the study. Variables that influence penile measurements (such as room temperature, posture, and whether the penis is held straight or hanging) are not mentioned.
And from a semantic perspective, for penises to be “shrinking” they must be getting shorter over time, on either an individual or population basis. I cannot find any reports of men’s penises shortening as a consequence of environmental pollution. Available data don’t suggest a decline in penis size over the past few decades.
While environmental pollution is a pressing concern, the evidence suggests the catastrophic collapse of human reproduction and accompanying penis shrinkage is thankfully a pretty unlikely prospect.
SINK COVID-19 study: Can common drugs offer 2-step approach to combat deadly virus?
Researchers at Beaumont Hospital, Royal Oak have begun enrolling patients in a new clinical study aimed at treating COVID-19 patients with two common drugs – naltrexone and ketamine. It’s called SINK COVID-19, or the Study of Immunomodulation using Naltrexone and Ketamine for COVID-19.
Medicine specialist talks treatments for lingering COVID-19 symptoms
Functional medicine specialist Dr. Aaron Hartman says the solution to potentially treating Long-COVID isn’t new. He’s been following evidence that suggests that using a low dose of a drug called naltrexone, which is typically used for a drug overdose, could improve the condition.
Got Inflammation? How LDN can help in the times of Covid-19.
20 May 2020
There is something you can do to help lower the inflammation in your cells, organs and body. It is a prescribed drug called LDN. LDN, or low dose naltrexone, is used to relieve people from chronic, non-responsive pain that results from inflammation. LDN works by staying in the body for a very short time, supporting the body’s ability to produce endorphins and to kick start the immune system into gear. (High dose naltrexone does not work in the body the same way.) Of course, a healthy diet of low inflammatory, nutrient dense foods, lotsa rest, supplementation and mindfulness also rounds out the picture of optimal wellness.
Phase 2 Trial to Evaluate Safety and Efficacy of CYTO-205 in Mild COVID-19
13 January 2021
The aim of the study is to assess the safety and clinical efficacy of low-dose naltrexone (CYTO-205; Cytocom, Inc) in reducing the proportion of higher risk patients who progress from mild COVID-19 to a more severe disease category.
Low-Dose Naltrexone for Fibromyalgia and ME/CFS
04 November 2020
A series of Stanford University studies have shown as much as a 30% decline fibromyalgia symptoms compared to placebo. Researchers say results are best in people with higher sedimentation rates, which indicates an inflammatory response. Results also indicate that the drug is well tolerated. However, these studies have all been small and more work needs to be done before we know how safe and effective LDN is for this condition.
. 2012 Jun;15(3):213-6. doi: 10.3109/13697137.2012.655923.
Quality of life and the role of menopausal hormone therapy
- PMID: 22612606
- DOI: 10.3109/13697137.2012.655923
The quality of life of countless menopausal women world-wide has been significantly diminished following the sensationalist reporting of the Women’s Health Initiative (WHI) and the resulting 50% or more decline in the use of hormone replacement therapy (HRT) over the subsequent 10 years. Quality of life is difficult to measure as there are so many contributing factors and a large number of different instruments, some of which assess general health and only a few which specifically include symptoms related to menopause. HRT improves quality of life of symptomatic menopausal women and some studies of the effects of HRT provide reliable evidence on quality of life other than reduction in vasomotor symptoms. Until there is a better understanding of the minimal risks of HRT for the majority of women, too many will continue to suffer a reduced quality of life unnecessarily.
It’s time to teach the whole story about ovulation and its place in the menstrual cycle
May 26, 2021 5.39am AEST
- Felicity Roux Researcher, Curtin University
Felicity Roux currently receives a scholarship through the Australian government’s Research Training Program. In 2020, the project received awards from the Western Australian Institute for Educational Research and Fogarty Foundation, Curtin Medical School and Curtin Business School. She serves on the Board of Directors for the Australasian Institute for Restorative Reproductive Medicine, and she volunteers on the 2021 committees of the Gynaecological Awareness Information Network, Positive Education Schools Association and the Western Australian Institute for Educational Research.
Curtin University provides funding as a member of The Conversation AU.
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Republish our articles for free, online or in print, under Creative Commons licence.
Health education frequently fails to teach the menstrual cycle in its full entirety, focusing mostly on the bleeding part of the story and glossing over the ovulation chapter. In other words, many girls* often only get half the story about how their bodies work.
That’s a shame because knowledge of your own reproductive function is useful for monitoring and making decisions about personal health. Focusing on the period part of the cycle is like skipping to the last chapter of a book. In reality, ovulation is the protagonist of the menstrual story rather than a minor character to skim over.
For those who want to get pregnant, understanding ovulation is clearly crucial but research shows few can accurately identify their fertile window.
Beyond that, however, understanding ovulation can help you understand more about your health in general.
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What exactly is ovulation?
Ovulation occurs when an ovary releases an egg (sometimes more than one). A typical teaching describes a 28-day cycle with Day 1 as the start of period bleeding and ovulation around Day 14 or 15.
But this textbook 28-day cycle is not meant to be a one-size-fits-all and is not everyone’s experience. There are healthy ranges across the different stages of life (such as adolescence, adulthood and in the later years).
The simple skills for recognising ovulation have been around for over 40 years. Once taught what to look out for, most women find it easy to tell if they are likely ovulating. One tell-tale sign is changes in cervical mucus which a woman can recognise from different sensations at her vulva.
If cycle difficulties such as painful periods or pre-menstrual tension emerge, knowing the fixed days between ovulation and the next period gives a fair heads-up to put self-care strategies in place.
A practical example is the preventative use of non-steroidal anti-inflammatory drugs such as ibuprofen for primary period pain; in other words, taking painkillers before the pain arrives, because you know when it is coming.
If cycle difficulties become more complex, understanding the cycle helps a woman work with doctors to get the care she needs.
A role for educators and teachers
When it comes to teaching cycles in schools, the period dominates the story; probably because it is bleeding obvious and you have to manage it.
Educating boys about the cycle needs more research. At this stage, it is task enough to give girls the knowledge and confidence they need.
A recent review found school programs tended to focus on menstrual problems.
While these are important topics, it would also help to frame the cycle in a positive light, explain it fully and talk about the connection between biology, psychology, and socio-environmental factors (what researchers call the “biopsychosocial” aspects).
It is a wise teacher who is vigilant about both misinformation and pedagogically appropriate information. But professional development support is often limited for teachers and the curriculum is overcrowded.
This may explain the tendency for schools to parachute in external facilitators for sexuality education teaching.
The problems with this approach are a lack of available specialist expertise, potential loss of capacity-building within the school and the infrequent learning opportunities for students. External facilitators are there to reinforce what is already taught rather than be a substitute for it.
A role for parents
One role for parents is to encourage their adolescent children to start taking responsibility for their own health. This includes adopting healthy lifestyle choices (such as nutritious eating, keeping fit and getting enough sleep).
These choices can impact the menstrual cycle. Parents can support their daughters’ discipline in tracking their cycles and understanding their unique patterns.
Knowing this information can also help young women advocate for themselves and make informed health-care choices if cycle difficulties arise.
A research team at Curtin University has worked on developing a program called My Vital Cycles, which is currently being trialled in Western Australia. This school-based ovulatory-menstrual health literacy program aims to give teachers, parents and teenagers the tools they need to understand the whole cycle, including ovulation’s place in it.
Given the span of years from menarche (a girl’s first bleed) to menopause, ovulatory-menstrual cycle knowledge and skills are useful over a lifetime. They are what women ought always to have had, and it is time for the whole story to be told.
The information in this article is for general information purposes only and is not intended to be a substitute for professional medical advice, diagnosis or treatment. The terms *girls, women, and daughters are used in relation to a person’s sex, namely their biological characteristics or reproductive organs. This may differ from gender identity. The author believes anyone who menstruates should have the knowledge and skills necessary to understand and manage their cycle.
Female sexual problems doctors should be aware of
The following article is the first in a two-part series on sexual dysfunction. This article focuses on sexual dysfunction in women, while the second will cover sexual dysfunction in men.
It’s not all bliss in the bedroom. According to the Cleveland Clinic, about 43% of women and 31% of men say they experience some degree of sexual dysfunction—and along with it, stigma.
Female sexual dysfunction causes major distress for women, but research and treatment options have not kept pace with advances made for male sexual dysfunction.
Is female pleasure sidelined?
Despite the fact that sexual dysfunction is more common in women, male sexual dysfunction has received the lion’s share of attention in society, including more research and treatment options. In 1998, the FDA approved sildenafil (Viagra) for erectile dysfunction, and since then—thanks to an endless marketing blitz from pharmaceutical companies and new medicines—the topic of male sexual dysfunction has moved into the mainstream.
The same can’t be said for women, however. Treatment options for sexual dysfunction in women have been much slower to arrive on the market, although some progress has been made. In 2013, the FDA approved ospemifene (Osphena) for moderate to severe painful intercourse in women. In 2015, the FDA green-lighted flibanserin (Addyi) for low sexual desire in premenopausal women. Most recently, the FDA approved bremelanotide (Vyleesi ) in 2019, also for premenopausal women with low sexual desire.
Moreover, social stigma around female sexuality remains strong in Western culture, and as a result, women often avoid or are embarrassed to discuss their sexual health with their health care professionals (HCPs), according to the authors of an article in the Journal of Women’s Health.
“Based on cultural norms and biases, conversations about sex are sometimes thought of as taboo in American society and in many other cultures worldwide. This is especially true for women, and particularly when sex is for pleasure rather than reproductive purposes,” the authors wrote.
In addition, women in midlife are often unaware or have misconceptions about conditions that may adversely impact their sexual life, such as genitourinary syndrome of menopause and hypoactive sexual desire disorder. “Lack of training, tools, time, and limited treatment options impede HCPs from providing women with necessary sexual health support,” they added.
Any physician treating sexual dysfunction navigates a complex condition that’s emotionally charged and multi-layered. Let’s have a look at female sexual dysfunction.
Female sexual dysfunction
Sexual dysfunction in women typically presents as loss of desire, sexual pain, decreased arousal, and/or inability to reach orgasm—and these frequently overlap, according to the Journal of Women’s Health article. While sexual dysfunction can occur at any age, women in the menopausal transition and beyond tend to experience sexual health-related conditions or concerns more often.
Sexual dysfunction in women is less recognized than its counterpart in males, but the subject is attracting more research, according to the authors of a review published in the Canadian Urological Association Journal (CUAJ).
“Fortunately,” wrote the authors, “over the past decade there has been an increase in the clinical and academic interest in female sexual function. The times appear to be changing.”
Today, there are published guidelines and position papers that reinforce the practical aspects of female sexual dysfunction evaluation and management, an increase in research on the impact of cancer and its treatment on female sexual function, along with the new FDA-approved therapies for low desire and sexual pain, they added.
Here’s a closer look at the four common categories of female sexual dysfunction.
Low sexual desire
Loss of sexual desire in women can be distressing and is the most common of the sexual disorders in women, according to the Mayo Clinic.
Various etiologies for low sexual desire exist, including medical conditions (eg, cancer, kidney failure, multiple sclerosis; heart disease, or bladder problems; hormonal changes due to menopause or childbirth/breastfeeding; medications (eg, certain antidepressants, antipsychotics, opioids); hormonal contraception; and psychosocial factors like untreated anxiety and depression, or a history of sexual abuse.
Treatment often entails a multidisciplinary approach, and can include sex education and counseling; medications like the above-mentioned FDA-approved flibanserin and bremelanotide for premenopausal women; hormone therapy such as estrogen, testosterone (or ospemifene, if sexual pain is related to low desire); a vaginal insert called prasterone (Intrarosa); and lifestyle remedies, such as exercise, stress reduction, taking time for sexual intimacy, and more.
Sexual pain refers to pain associated with sexual stimulation or vaginal contact. Sexual pain is common among women of all ages and includes vulvar pain (eg, vulvodynia); deep pain with penetration (dyspareunia); or tightening of the pelvic musculature
Many conditions can cause sexual pain, including insufficient lubrication, vulvar skin lesions such as lichen sclerosus and lichen planus, pelvic floor muscle abnormalities leading to deeper pelvic pain, and endocrine abnormalities such as low testosterone or changes induced by oral contraception.
Depending on the cause, treatment can include vulvar physiotherapy, switching forms of contraception, and topical anesthetics. The above-mentioned treatment ospemifene is indicated for moderate to severe painful intercourse in women, and prasterone (Intrarosa) vaginal capsules are also designed to relieve dyspareunia.
Emerging research is also investigating local hormone treatment with intravaginal testosterone and estradiol-releasing vaginal rings, according to the CUAJ article. Vaginal laser therapy is also being explored, the authors wrote, and resection of vestibular tissues with posterior vaginal advancement flap (ie, vestibulectomy) can also be considered for refractory and severe cases of vulvodynia.
Low arousal—difficulty or inability to become or stay physically aroused or excited during sexual activity—can present as a decrease in vaginal lubrication or genital warmth due to decreased blood flow. A full medical and sexual history and physical examination should be conducted.
Low arousal states can be due to hypertension, hyperlipidemia, or diabetes, and should be treated. Also, low arousal may be related to hormonal changes following menopause. A decrease in estrogen leads to decreased blood flow to the pelvic region, which can result in less genital sensation, as well as needing more time to build arousal and reach orgasm, according to the Mayo Clinic.
In some, but not all, women with low arousal, PDE5 inhibitors (eg, sildenafil) have shown some efficacy, according to the CUAJ article. Cognitive behavioral therapy may also be helpful
Why Is Perimenopause Still Such a Mystery?
Over 1 billion women around the world will have experienced perimenopause by 2025. But a culture that has spent years dismissing the process might explain why we don’t know more about it.
By Jessica GroseApril 29, 2021
Angie McKaig calls it “peri brain” out loud, in meetings. That’s when the 49-year-old has moments of perimenopause-related brain fog so intense that she will forget the point she is trying to make in the middle of a sentence. Sometimes it will happen when she’s presenting to her colleagues in digital marketing at Canada’s largest bank in Toronto. But it can happen anywhere — she has forgotten her own address. Twice.
Ms. McKaig’s symptoms were a rude surprise when she first started experiencing them in 2018, right around when her mother died. She had an irregular period, hot flashes, insomnia and massive hair loss along with memory issues she describes as “like somebody had taken my brain and done the Etch A Sketch thing,” which is to say, shaken it until it was blank.
She thought she might have early-onset Alzheimer’s, or that these changes were a physical response to her grief, until her therapist told her that her symptoms were typical signs of perimenopause, which is defined as the final years of a woman’s reproductive life leading up to the cessation of her period, or menopause. It usually begins in a woman’s 40s, and is marked by fluctuating hormones and a raft of mental and physical symptoms that are “sufficiently bothersome” to send almost 90 percent of women to their doctors for advice about how to cope.
Ms. McKaig is aggressively transparent about her “peri brain” at work, because she “realized how few people actually talk about this, and how little information we are given. So I have tried to normalize it,” she said.
An oft-cited statistic from the North American Menopause Society is that by 2025, more than 1 billion women around the world will be post-menopausal. The scientific study of perimenopause has been going on for decades, and the cultural discussion of this mind and body shift has reached something of a new fever pitch, with several books on the subject coming out this spring and a gaggle of “femtech” companies vowing to disrupt perimenopause.
If the experience of perimenopause is this universal, why did almost every single layperson interviewed for this article say something along the lines of: No one told me it would be like this?
“You’re hearing what I’m hearing, ‘Nobody ever told me this, my mother never told me this,’ and I had the same experiences many years ago with my mother,” said Dr. Lila Nachtigall, a professor of obstetrics and gynecology at N.Y.U. Grossman School of Medicine who has been treating perimenopausal women for 50 years, and is an adviser to Elektra Health, a telemedicine start-up.
Dr. Nachtigall said her mother had the worst hot flashes, and even though they were living in the same house when her mother was experiencing perimenopausal symptoms, they never discussed it. “That was part of the taboo. You were supposed to suffer in silence.”
The shroud of secrecy around women’s intimate bodily functions is among the many reasons experts cite for the lack of public knowledge about women’s health in midlife. But looking at the medical and cultural understanding of perimenopause through history reveals how this rite of passage, sometimes compared to a second puberty, has been overlooked and under discussed.Sign up for the Well Newsletter: Get the best of Well, with the latest on health, fitness and nutrition.
From ‘Women’s Hell’ to ‘Age of Renewal’
Though the ancient Greeks and Romans knew a woman’s fertility ended in midlife, there are few references to menopause in their texts, according to Susan Mattern, a professor of history at the University of Georgia, in her book “The Slow Moon Climbs: The Science, History, and Meaning of Menopause.”
The term “menopause” wasn’t used until around 1820, when it was coined by Charles de Gardanne, a French physician. Before then, it was colloquially referred to as “women’s hell,” “green old age” and “death of sex,” Dr. Mattern notes. Dr. de Gardanne cited 50 menopause-related conditions that sound somewhat absurd to modern ears, including “epilepsy, nymphomania, gout, hysterical fits and cancer.”
Physicians in the 19th century believed that receiving bad news could cause early menopause, and that women who worked in “unwomanly” occupations, like fishwives, were most at risk, according to “The Curse: A Cultural History of Menstruation,” by Emily Toth, Janice Delaney and Mary Lupton. These Victorian doctors also believed that menopausal women grew scales on their breasts and experienced a “loss of feminine grace.”
Things did not get much better for women in perimenopause during the latter half of the 19th century. “A woman consulting the American gynecologist Andrew Currier in the 1890s would have been told that leeches were still an effective remedy for congested genitals,” more commonly known as pelvic pain, according to “The Curse.” Other physicians of the era thought that perimenopausal women were more susceptible to mental illnesses, “among them ‘morbid irrationality,’ ‘minor forms of hysteria’, melancholia and the impulses to drink spirits, to steal, and perchance, to murder.”
In the first half of the 20th century, the hormone estrogen was discovered and its role in menopause was clarified somewhat — after a woman’s period ceases, her estrogen levels are lower than they were during her fertile years. Even though doctors no longer thought menopausal women were murderous lizard people, cultural ideas about them did not improve.
It wasn’t until the 1980s that longitudinal studies — which followed the same cohort of women for years — deepened public knowledge about the role of hormones during menopause. Before that, doctors thought perimenopause was a slow draining of estrogen levels until you hit the end of your period. “But what we’ve learned is it is more of a turbulent process — hormones are bouncing around,” said Dr. Stephanie Faubion, the medical director of the North American Menopause Society.
Even now, perimenopause is described in medical research as an “ill-defined time period” primarily marked when the ovarian reserve is depleted and by irregular periods (but if one has a history of irregular periods, as 14 percent to 25 percent of women do, it may be tougher to tell when the transition has begun). This time period is still often referred to as menopause in common parlance, but the medical definition of menopause is just one day — the last day of your final period — though it is only diagnosed when a whole year has gone by without menstruation.
Because hormones fluctuate wildly during perimenopause, it can be difficult to test for. The average age of the beginning of perimenopause is 47, and the average age of menopause is 51, but again, the length of the transitional period may be much longer, and the onset of symptoms can happen earlier or later.
There are four symptoms of perimenopause that are most common: hot flashes, sleep disruption, depression and vaginal dryness, known as “the core four” among menopause experts. But the full panoply of symptoms related to the perimenopause transition “is not yet known with any great degree of certainty,” said Dr. Nanette Santoro, the chair of obstetrics and gynecology at the University of Colorado School of Medicine. At this point, the perimenopausal period is associated with as many as 34 different maladies ranging from hair loss to “burning mouth syndrome,” which is a tingling or numb feeling in your lips, gums and tongue.
There’s also what Dr. Faubion refers to as “the menopause management vacuum.” As she explained to Lisa Selin Davis, a Times contributor, no one medical specialty really “owns” treatment of perimenopausal and menopausal women, because the symptoms affect so many different systems and parts of the body. Furthermore, less than 7 percent of medical residents surveyed said they felt “adequately prepared” to manage women going through menopause.
Though images of midlife women have definitely improved — a popular meme compares Jennifer Lopez, who at 50 was pole dancing at the Super Bowl, to Rue McClanahan, who at 51 in 1985 was on “Golden Girls” drinking coffee on the lanai — there is still much progress to be made. It was only this year that an online Arabic dictionary changed the description of menopause from “age of despair” to “age of renewal.”
With so much negative cultural baggage, so much still unknown around symptoms and timing, and so few doctors confident in the treatment of midlife women, “no wonder people are confused,” Dr. Nachtigall said. And it helps explain why so many companies and writers are jumping into the morass.
Having a Moment
What Angie McKaig is trying to do on a micro level by freely sharing her perimenopause travails with colleagues, health care start-ups, beauty companies and writers are trying to do on a macro level: raising awareness about the experience of this period of a woman’s life (and sometimes selling them products and services along the way).
“Femtech” companies such as the telemedicine providers Elektra Health and Gennev are moving into the perimenopause market; Stacy London, the stylist and reality TV star, just started a skin care company called The State of Menopause; and celebrities like Michelle Obama and Gwyneth Paltrow have spoken honestly about their perimenopause symptoms (though Ms. Paltrow did it in the service of promoting a supplement called “Madame Ovary” that she sells on her website, Goop).
Books on the topic from Heather Corinna, a sexual health expert, and Dr. Jen Gunter, a Times contributor and OB/GYN, will be published this spring; newsletters and online communities like TueNight and The Black Girl’s Guide to Surviving Menopause are gaining traction with tens of thousands of readers.
One community aimed at connecting women during their perimenopausal transition is called The Woolfer — named for the writer Virginia Woolf. The website and social platform started as a Facebook group called What Would Virginia Woolf Do? The name was meant to be a “dark joke,” said Nina Lorez Collins, 51, the founder and chief executive of The Woolfer — as in, “Should we just throw in the towel and wander into a river,” as Woolf did?
The answer, of course, is a resounding no. Ms. Collins said her group has helped women normalize the more shocking symptoms of the menopause transition. (More than one woman interviewed for this piece used the phrase “crime scene periods.”) And they have also reframed the journey into menopause as one of triumph, not irrelevance.
Shifting the Narrative and Getting Help
Though perimenopause presents as so many different symptoms, there are treatments available, however there “is not one single solution,” Dr. Faubion said. The treatment is symptom dependent: If heavy or irregular bleeding is the issue, an intrauterine device, or a birth control pill could help. A low-dose birth control pill may also relieve hot flashes. “Birth control pills are made up of so many different permutations and combinations of hormones,” it’s important to discuss which one is right based on your medical history and individual needs, Dr. Nachtigall said. If mood issues are the biggest complaint, an antidepressant might be appropriate. (Hormone therapy may be an option for some women to help ease symptoms, but it is more frequently prescribed after menopause).
Ongoing longitudinal studies are finding associations between women with intense perimenopause symptoms in midlife, and risks of heart disease and osteoporosis in later years. Currently, there is not evidence to support the use of vitamins or supplements like black cohosh or magnesium, contrary to claims that these products help with hot flashes.
Despite expanded and continuing research, finding a knowledgeable physician who won’t dismiss your symptoms or tell you there’s nothing they can do to help is a struggle for many women. Ms. McKaig said that though her therapist diagnosed her as perimenopausal, her family doctor keeps telling her that her symptoms can’t be perimenopause because she’s still having her period sometimes. She said she’s “given up trying to educate her.”
For Black women, there is an added layer of difficulty in finding a sympathetic doctor, with ample research showing racial bias in physicians’ consideration of symptoms. As The Washington Post noted earlier this year, Black women “have a higher risk of experiencing hot flashes but are less likely to be offered effective hormone replacement therapy.” Jennifer White, 46, a journalist who recently relocated to the Washington, D.C., area, has been experiencing perimenopause-related insomnia and painful, irregular periods for a year. “Finding the right clinician to take seriously my concerns as a Black woman, and not tell me to walk it off, is top of mind,” she said.
The North American Menopause Society’s website lists qualified physicians throughout the country and abroad, but if you live outside major metropolitan areas, the pickings may be slim (for example, there are only two NAMS-certified menopause practitioners listed for the entire state of Wyoming). Telemedicine is aiming to fill the void, but even in the Covid era, there are limitations and complications to practicing medicine across state lines.
Though finding a qualified and sympathetic doctor may be a challenge, shifting the cultural narrative may be just as vital.
“I actually think it’s extraordinarily important to change the conversation. Because so much of what you hear about perimenopause is spoken about in an anti-feminist and ageist way,” said Dr. Lucy Hutner, a reproductive psychiatrist in New York. Dr. Hutner said that many of her patients who are navigating these midlife shifts find them deeply empowering. They feel more resilient, and are following their “inner compass.”
While part of it is just the wisdom that comes with age, many women feel that once they are through the menopause transition, they don’t have to make themselves appealing to the world. As Dr. Hutner put it: “I feel liberated because I’m not trying to take care of everyone else or correspond to anyone’s societal view. I have been able to shake off the shackles.”
Do You Really Need That Statin? This Expert Says No
Statins are medications that lower cholesterol by inhibiting an enzyme involved in its production by the liver and other organs. First approved by the FDA in 1987, statins are arguably the most widely-prescribed medicine in the industrialized world today.By Martha Rosenberg, Contributorreporter and author08/28/2012 11:50am EDT | Updated October 28, 2012This post was published on the now-closed HuffPost Contributor platform. Contributors control their own work and posted freely to our site. If you need to flag this entry as abusive, send us an email.
This is an interview with Barbara H. Roberts, M.D., author of The Truth About Statins: Risks and Alternatives to Cholesterol-Lowering Drugs.
Statins are medications that lower cholesterol by inhibiting an enzyme involved in its production by the liver and other organs. First approved by the FDA in 1987, statins are arguably the most widely-prescribed medicine in the industrialized world today — and the most profitable, representing billions a year in profits to the drug industry. In fact, Lipitor was the world’s best-selling drug until its patent expired recently. Yet most trials that prove statins’ effectiveness in preventing cardiac events and death have been funded by companies and principle investigators who stand to benefit from their wide use. In February, the FDA warned that statins can increase users’ risk of Type 2 diabetes and memory loss, confusion and other cognition problems.
Barbara H. Roberts, M.D., is director of the Women’s Cardiac Center at the Miriam Hospital in Providence, R.I. and associate clinical professor of medicine at the Alpert Medical School of Brown University. She spent two years at the National Heart, Lung and Blood Institute of the National Institutes of Health (NIH), where she was involved in the first clinical trial that demonstrated a beneficial effect of lowering cholesterol on the incidence of heart disease. In addition to The Truth About Statins: Risks and Alternatives to Cholesterol-Lowering Drugs, she is also author of How to Keep From Breaking Your Heart: What Every Woman Needs to Know About Cardiovascular Disease.An essential daily guide to achieving the good lifeSubscribe to our lifestyle email.Successfully Subscribed!Realness delivered to your inbox
Martha Rosenberg: Statins have become so popular with adults middle-aged and older in industrialized countries, they are almost a pharmaceutical rite of passage. Yet you write in your new book there is little evidence they are effective in many groups and no evidence they are effective in one group: women without heart disease. Worse, you provide evidence, including stories from your own patients, that they are doing serious harm.
Barbara Roberts: Yes. Every week in my practice I see patients with serious side effects to statins, and many did not need to be treated with statins in the first place. These side effects range from debilitating muscle and joint pain to transient global amnesia, neuropathy, cognitive dysfunction, fatigue and muscle weakness. Most of these symptoms subside or improve when they are taken off statins. There is even growing evidence of a statin link to Lou Gehrig’s disease.
Martha Rosenberg: One patient you write about caused a fire in her home by forgetting that the stove was on. Another was a professor who experienced such memory loss on a statin he could no longer teach; others ended up in wheelchairs. The only thing more shocking than the side effects you write about is the apparent blindness of the medical establishment to them. Until half a year ago, there were practically no warnings at all.
Barbara Roberts: There is no question that many doctors have swallowed the Kool-Aid. Big Pharma has consistently exaggerated the benefits of statins and some physicians used scare tactics so that patients are afraid that if they go off the statins, they will have a heart attack immediately. Yet high cholesterol, which the statins address, is a relatively weak risk factor for developing atherosclerosis. For example, diabetes and smoking are far more potent when it comes to increasing risk.
Martha Rosenberg: One group you say should not be given statins at all because there is no benefit and significant risk is women who have no heart disease.
Barbara Roberts: In three major studies [1-3] of women without diagnosed heart disease, but who were at high risk (in one of these studies, each participant had to have high blood pressure and three other risk factors), 40 women out of 4,904 on statins had either a heart attack or cardiac death, compared to 44 women out of 4,836 on placebo. That is not a statistically significant difference. Since the likelihood of experiencing a statin side effect is about 20 to 25 percent, the risk of putting a healthy woman on a statin far outweighs the benefit. Still, statins are routinely given to this group because the guidelines are shaped by Big Pharma. The guidelines are not supported by the evidence, and in the case of healthy women I don’t follow them.
Martha Rosenberg: You give a story in your book about your 92-year-old patient who had a total cholesterol of 266, triglycerides of 169, HDL cholesterol of 66, and LDL cholesterol of 165. Her primary care doctor wanted her to take a statin, but you did not feel she needed to because she had no evidence of heart disease, had never smoked, did not have high blood pressure and was not diabetic.
Barbara Roberts: Yes and today she is 103.5 — and doing fine, never having taken a statin.
Martha Rosenberg: In The Truth About Statins you explain pretty clearly how studies have made statins look more effective and safer than they are. How has this been done?
Barbara Roberts: First of all, the studies are of short duration, and some of them even have a “run in” phase during which people are given the drug to see if they tolerate it. If not, they are not enrolled in the study. Secondly, study subjects are cherry-picked to exclude the very elderly, people with liver or kidney disease or those with any chronic illness that might “muddy” the results —
Martha Rosenberg: In other words, the very people who will be taking them?
Barbara Roberts: Yes, and of course patients will also be staying on the drugs for life unlike trial subjects. Then, the data from the studies are usually given in terms of relative rather than absolute risk. The absolute risk of a cardiac event is only reduced by a few percentage points by statins and in some patients, like the women without heart disease we just talked about, the reduction is not even statistically significant. In some studies surrogate endpoints like inflammation or artery thickness are used but a favorable change in surrogate markers does not always translate into clinical benefit. In addition, many studies use composite end points, which include not only “hard” end points like heart attack or death (which are pretty hard to misdiagnose) but also “softer” end points like the “need” for revascularization or the occurrence of acute coronary syndromes. For example, studies may be performed in many countries with very different rates of revascularization procedures, making use of this as an end point very problematic.
Martha Rosenberg: This brings to mind the JUPITER trial, which enrolled people without heart disease, with normal levels (less than 130) of LDL or bad cholesterol, but evidence of increased inflammation as measured by the hsCRP test and treated them with placebo or rosuvastatin. JUPITER stood for “Justification for the Use of Statins in Prevention,” and both the study and its principle investigator were funded by AstraZeneca, who makes the statin Crestor. The principal investigator also holds the patent for the hsCRP blood test. Why was JUPITER regarded as medical science and not marketing?
Barbara Roberts: Actually, the JUPITER study was criticized to some extent. But you have to remember that medical journals depend upon Big Pharma for their ads and reprint orders just as medical centers and medical professionals rely on Big Pharma for funding. It is a round robin situation that probably won’t change until the patients, doctors and the public demand change. As for CRP, it can also rise if a patient has a cold, bronchitis or is taking post-menopausal hormones.
Martha Rosenberg: You are very outspoken about the problem of industry shaping and influencing medical practice, yet you also admit that you accepted Big Pharma money yourself.
Barbara Roberts: In 2004, Pfizer asked me to become a speaker, specifically on Lipitor. I told the drug rep who invited me to be a speaker that I would be interested in giving talks on gender-specific aspects of cardiac disease, but not in just talking about their statin, and I gave lectures in restaurants and hospitals. Despite the fact that Pfizer was sponsoring my talks, I never failed to point out that there was no evidence that Lipitor — or any statin — prevented cardiac events in women who did not have established cardiovascular disease. They tolerated this until one day a regional manager came to one of my talks, and then I was disinvited. I was on the speaker’s bureau for another company, Abbott, but when they began to insist that I use their slides rather than my own, I gave up being on any Big Pharma speaker’s bureaus. I write in my book that even though my interactions with drug and device companies complied with ethical guidelines it does not mean I was not influenced.
Martha Rosenberg: In journalism, when a reporter takes money from someone she is writing about, she is regarded as no longer a reporter but a publicist. Yet doctors who consult to Pharma are not judged as harshly and most contend they are not influenced by industry money…
Barbara Roberts: They are wrong. An article in the American Journal of Bioethics in 2003 found that gifts bestow a sense of indebtedness and influence behavior whether or not the recipient is directly conscious of it. More recently, research presented at a symposium at Houston’s Baylor College of Medicine called the Scientific Basis of Influence and Reciprocity mapped actual changes in the brain when gifts are received.
Martha Rosenberg: I was surprised to find recipes in your book and even more surprised by some of your dietary recommendations, such as avoiding a low-fat diet and eating a lot of olive oil. A lot of experts have recommended a low-fat diet.
Barbara Roberts: The first thing I prescribe to my patients who have low levels of the “good” or HDL cholesterol is two to three tablespoons of olive oil a day, and in every case the HDL increases. Olive oil is rich in polyphenols, which have anti-inflammatory and antioxidant effects. Several studies [4-5] have shown that the Mediterranean diet reduces total mortality and especially death from cardiovascular disease, yet it gets little media attention. The Mediterranean diet is a plant-based diet that includes colorful vegetables, fruits, whole grains, beans, cheese, nuts, olive oil, seafood, red wine with meals, and very little meat.
Martha Rosenberg: You indict professional medical associations like the American Heat Association (AHA) for profiteering at the public’s expense by calling harmful foods healthful in exchange for corporate money.
Barbara Roberts: For years, the AHA preached the gospel of the low-fat diet, calling it the “cornerstone” of its dietary recommendations though there was, and is, no evidence of its benefit. The AHA rakes in millions from food corporations for the use of its “heart-check mark.” Some of the so-called heart-healthy foods it has endorsed include Boar’s Head All Natural Ham, which contains 340 milligrams of sodium in a two-ounce serving, and Boar’s Head EverRoast Oven Roasted Chicken Breast, which contains 440 milligrams of sodium in a two-ounce serving. High sodium intake raises blood pressure, which increases the risk of cardiovascular disease. In addition, studies have shown that eating processed meat increases the risk of diabetes and atherosclerosis.
Martha Rosenberg: You are not afraid to express strong opinions. You say that the AHA has “sold its soul,” that medical centers conducting drug trials for Big Pharma have become “hired hands” and that one university medical center is Big Pharma’s “lapdog.” Are you afraid of retaliation from Big Pharma, medical centers or the colleagues you work with?
Barbara Roberts: I haven’t received any communiqués from Big Pharma. A few colleagues have expressed dismay, but I am thick-skinned and hard-headed and don’t care what they say. My main concern is the health and safety of my patients.
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‘Devastated and sad’ after 36 years of research — early detection of ovarian cancer doesn’t save lives
May 19, 2021 6.11am AEST
- Ian Jacobs President and Vice-Chancellor, UNSW
Ian Jacobs is a President and Vice-Chancellor of UNSW Sydney and a Board member of Ovarian Cancer Australia. He is a director and shareholder of Abcodia Ltd which holds a licence from Massuchusetts General Hospital for the Risk of Ovarian Cancer Algorithm and as a Co-Inventor of the Algorithm he has a potential royalty stream. He received funding awards for UKCTOCS from the Medical Research Council, Cancer Research UK, the National Institute of Health Research and the Eve Appeal.
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My colleagues’ and my efforts to develop a screening test for the early detection of ovarian cancer capable of saving lives arrived at a sad moment last week. The final trial results of the research I’ve focused on for 36 years, published in The Lancet, found early ovarian cancer detection doesn’t save lives.
The advances we have seen in science and technology over the past three decades have been nothing short of phenomenal. Each smartphone has more computational power than NASA had at its disposal during the moon landings. In medicine, researchers have sequenced the human genome, created life-saving treatment for HIV and rapidly developed vaccines for COVID-19.
There have been significant improvements in ovarian cancer treatment involving surgery and chemotherapy, but the sad and frustrating truth is of the four women diagnosed with ovarian cancer in Australia each day, three will eventually die from the disease.
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The diagnosis of ovarian cancer is dependent on women reporting symptoms to their doctor. However, few develop symptoms until they have advanced stage cancer, by which time the outlook is poor. Of all women’s cancers, ovarian cancer has the lowest survival rate, with just 46% of patients in Australia surviving five years. For breast cancer, it’s now 91%.
Back in the 80s
I was motivated to improve the outcome for women with ovarian cancer by my experience as a junior doctor in London in 1985. I was training with a brilliant surgeon who undertook operations for many women with ovarian cancer. In spite of the exhaustive surgery and the chemotherapy that followed, we saw far too many women suffer and die from ovarian cancer.
That experience inspired me to initiate a program of research designed to find a screening test to detect this cancer early. Women with the earliest stage of ovarian cancer had survival rates of 70%, but less than 20% of women with ovarian cancer were diagnosed that early.
My hypothesis was that if we could detect more cancers at an early stage it would save lives.
Based on evidence from other cancers, there was reason to be hopeful and two potential tests were available – a blood test called CA 125 and the use of ultrasound scanning which was then widely used in obstetrics.
Over the next 15 years, working with colleagues in the United Kingdom and United States, I developed and refined the screening tests and had great hope for what we called “multimodal screening”. This involved a “risk of ovarian cancer algorithm” for interpreting the change in blood levels of CA 125 over time to identify women who had a rising pattern, indicating an elevated risk of ovarian cancer. Women with an elevated risk could then have a secondary test involving ultrasound scanning.
During those 15 years, we published convincing evidence in studies involving over 50,000 women that this approach to screening was safe, acceptable to women, could detect over 85% of the cancers early and would probably be cost effective if sufficient lives were saved.
Promising early results
Before advocating screening of the general population, a massive trial would be needed to determine whether the screening would actually save lives.
The trial needed to involve screening and follow up of approximately 200,000 women for around 20 years. This would eventually include 2,000 women with ovarian cancer – enough to determine whether or not screening saved lives.
Work got underway in the United Kingdom in 2000 and optimism grew as initial results confirmed the ability of multimodal screening to detect cancer early in over 85% of cases.
By 2015, the preliminary mortality data were available and were tantalising. The curves hinted at a 20% or more reduction in deaths from ovarian cancer, but the findings did not quite reach statistical significance. So another five years of painstaking follow up was needed.
Disappointing final results
The final results of the UK Collaborative Trial of Ovarian Cancer Screening showed the multimodal screening approach could detect cancers early and increase the number of early-stage ovarian cancers by almost 50%.
But to our surprise and despair, that did not reduce the number of deaths from ovarian cancer. All it seemed to do was to bring forward the time of diagnosis of the cancers in these women, without improving their survival.
This is deeply disappointing. Disappointing of course for those who like myself have dedicated much of their professional lives to this effort, but much more importantly for the women across the world who we had hoped would have access to an effective screening test able to save lives.
The hope had been to deploy ovarian cancer screening for women in the general population alongside breast and cervical cancer screening, but that will not happen – for a while at least.
Why didn’t early detection save lives?
To answer that, we need to further analyse samples and data from the trial. Our suspicion is that the women whose cancers were detected early by screening had more aggressive cancers than those (the 10%) whose cancers were detected early without screening, on the basis of symptoms.
So even with early detection, their cancers progressed relentlessly despite them receiving the best available surgery and chemotherapy.
If that is the case, we are likely to require screening tests which can detect ovarian cancer even earlier than our algorithm, which we estimate picks up ovarian cancer 18 to 24 months early. Saving lives may require a test capable of picking up the cancers five or more years early.
Fortunately, there are exciting avenues of research involving advances in protein and DNA technologies which researchers in Australia and around the world are exploring. So there is hope.
But realistically, given the five-plus years needed to develop better screening tests and the ten to 15-plus years needed to have enough cases to conduct another large randomised trial, the solution is likely to be more than 20 years away.
Still, we’ve learnt a lot
This massive commitment of expertise, time, energy and funding has most definitely not been wasted. Much has been achieved along the way in this 36-year journey in developing ways to assess risk, diagnose cancer and prevent ovarian cancer which are now used in clinical practice.
New generations of researchers have been trained. The data and the blood bank collected is available to all researchers seeking new and better screening tests and is a unique resource. And the ability to detect ovarian cancer early may be invaluable in assessing new treatments.
I feel privileged to have led this effort and will always be grateful to the collaborators, researchers, health professionals, funding agencies and above all the 200,000 women who took part in the trial.
I feel a deep sadness that lives will not yet be saved by ovarian cancer screening, but I’m confident the next generation of researchers will build on our work and find approaches to screening and treatment of ovarian cancer which dramatically reduce the loss and suffering caused by this insidious disease