1. Are hormones the only best tools to
drive women into
a healthy geronarche ?
by
Manuel Neves-e-Castro,M.D.
Neves-e-Castro,M.D
Clinica de Feminologia Holistica
Lisboa/Portugal
Lisboa/Portuga
E-mail: manuel@neves-e-castro.org
Website: http://neves-e-castro.pt
The 5th International Symposium of the
Portuguese Menopause Society
Porto, October 2011

2. Hormonal Treatments
are very good
for symptom relief
to improve quality of life
for the prevention of some diseases

3. For some in menopause,
hormones may be the only option
“There is no alternative treatment that works
very well, whether it’s a drug or over-the-
counter herbal preparation.”
Dr. Deborah Grady

4. But…
Hormonal Treatments
are far from being enough…
enough
• To maintain a climacteric woman in good
health
• To add more years to her life
• To add more life to her coming years

5. The “stay-in-good-health” issue
Good counselling techniques
by
Manuel Neves-e-Castro,M.D.
Neves-e-Castro,M.D
The 6th Amsterdam Menopause Symposium
September 2010

6. A good counselling technique
is to demonstrate and persuade women that
• lifestyle modifications are independent of the
use of drugs, and may
• diminish the need to use drugs to prevent
diseases and preserve Health

7. I shall talk about...
• Life Style Medicine
• Aging
• Genetics
• Psychosomatics
• Hormonal and non-Hormonal treatments

8. before...
showing you...
the
Take-Home Messages

9. “Our main goal, as attending physicians
of postmenopausal women, is the
maintenance of their health and the
primary and secondary prevention of the
diseases, which are more prevalent after
age 50”.
Neves-e-Castro M. When hormone replacement therapy is not
possible. The Management of the Menopause. The Millennium
Review, Parthenon 2000:91-102.

10. What is a menopausal woman?
woman
 she is an individual with a name
 she is a woman in distress caused by
symptoms and psycho-sociocultural
influences
 she is a woman who is growing in age
 she is a woman who became hypo estrogenic
MNC

11. menarche menopause
postmenopause
Puberty reproductive years Climacteric
gerontarche
geronarche
Fertilarche Fertilpause
Infants adolescents adults aged old
quality of life
compression
morbidity
Chronobiology
The Time Table of a Woman’s Life Span
M.Neves-e-Castro,2008

12. “ The Compression of Morbidity “
Fries JF et al. 1981

14. Physical activity, the compression of morbidity,
and the health of the elderly
Fries JF. Journal of the Royal Society of Medicine 1996;89:64-68

15. Physical activity, the compression of morbidity,
and the health of the elderly
Fries JF. Journal of the Royal Society of Medicine 1996;89:64-68

16. As a mid-aged woman:
She will suffer from the process of
natural aging, both from a biological and
aging
a psychological perspective.
MNC

17. If she is a 50 year old lady…
and still has this car,
made in 1960,
the same year of her
birth !

18. What would she do with it
to increase its longevity?

19. Maintenance
strategies !
Regenerative
attitudes !

20. This means that…
she must follow
Life Style Medicine
Regenerative Medicine

21. LIFESTYLE MEDICINE:
MEDICINE
TREATING THE
CAUSES OF DISEASE
Mark A. Hyman, MD; Dean Ornish, MD;
Michael Roizen, MD
ALTERNATIVE THERAPIES, NOV/DEC 2009, VOL. 15, NO. 6;12-14

24. 90% of people die
due to errors in life style

25. Wellness?

26. What is Wellness?
Wellness is more than simply the absence of
illness
It is instead a state of optimal health including all
aspects of our Being :
Body,
Mind and
Soul.
http://www.integrative-medicine.com.au

27. Lifestyle Medicine
is defined as the “evidence-based practice of
assisting individuals and families to adopt
and sustain healthy behaviors that can
improve health and quality of life.”
Lianov L and Johnson M. JAMA 2010;304(2):202-3

28. The principles of
Lifestyle Medicine
are foundational to
health promotion,
disease prevention and
chronic disease management.
management
Lianov L and Johnson M. JAMA 2010;304(2):202-3

29. Lifestyle Medicine
The practice of lifestyle medicine covers
primary prevention (preventing a disease
from developing),
secondary prevention (modifying risk factors
to avert the disease) and
tertiary prevention (rehabilitation from a
disease state and prevention of
recurrence).

30. Lifestyle Medicine
requires the patient
to change their high risk health behaviors
to adopt a lifestyle that includes health
behaviors that will help to reverse the
pathology and or reduce the likelihood of
disease progression.

31. Lifestyle modifications included a
lowfat (10% of calories from fat),
whole foods,
plant-based diet high in fruits,
vegetables,
unrefined grains,
legumes, and
low in refined carbohydrates;
moderate aerobic exercise (walking 30 min/day, 6
days/week);
stress management (gentle yoga-based
stretching, breathing, meditation, imagery, and
progressive relaxation techniques 60 min/day, 6
days/week), and a 1-h group support session
once per week.

32. PHYSICIAN COMPETENCIES FOR PRESCRIBING
LIFESTYLE MEDICINE
Physicians cannot abdicate their responsibility
for effecting behavior change in their patients
and for leading change within their practices.
Lianov L and Johnson M. JAMA 2010;304(2):202-3

33. ‘Lifestyle Medicine’
Exercise and nutrition are the ‘penicillin’ of
Lifestyle Medicine;
psychology is the ‘syringe’
through which these are delivered.
Egger G, Binns A and Rossner S. Med J Aust. 2009 Feb 2;190(3):143-5.

34. Minimum amount of physical activity for
reduced mortality and
extended life expectancy
15 min a day or 90 min a week
of moderate-intensity exercise
might be of benefit
Wen CP et al –The Lancet ,2011(1 Oct) 378(9798):1244-1253

35. PHYSICIAN COMPETENCIES FOR PRESCRIBING
LIFESTYLE MEDICINE
the majority of physicians are not following
these guidelines, citing lack of knowledge,
skill, or confidence in counselling patients
about lifestyle interventions.
Lianov L and Johnson M. JAMA 2010;304(2):202-3

37. Lifestyle Medicine
can prevent risk factors
• We are today using only medicines to
modify risk factors but we are not looking
at what causes risk factors.
• Women’s health must be primarily the
medicine of lifestyles

38. Differences between conventional
and “Lifestyle Medicine” approaches
Egger G, Binns A and Rossner S. Med J Aust. 2009 Feb 2;190(3):143-5.

39. Effect of Intensive Lifestyle Changes on
Endothelial Function and
on Inflammatory Markers of Atherosclerosis
Intensive lifestyle changes have been
shown to
regress atherosclerosis,
improve cardiovascular risk profiles, and
decrease angina pectoris and cardiac
events.
events
Dod HS et al. Am J Cardiol 2010;105:362–367

40. Combined impact of lifestyle factors on mortality:
prospective cohort study in US women
even modest differences in lifestyle
can have a
substantial impact on reducing
mortality.
Van Dam RM, Li T, Spiegelman D et al.BMJ 2008;337:a1440

41. The recent INTERHEART study of
30.000 patients from 52 countries
found that
almost 95% of coronary heart disease
could be prevented by changing diet and
lifestyle.
And the only side effects are beneficial ones.
Ornish D et al. The Journal of Urology 2005;174:1065-1070

42. Brown CH, Baidas SM, Hajdenberg JJ, et al. Lifestyle interventions in the prevention and
treatment of cancer. American Journal of Lifestyle Medicine. 2009;3(5):337-348

43. AGING …

44. Is aging a disease ?
The fact that genes explain only part of individual
varibility in aging means that aging
75% must be accounted for by other factors:
- life style variables
(nutrition, exercise)
- powerful effects of environment
(effects on older age)

45. Anti-Aging ?
One cannot stop aging ...
One cannot stop growing older ...
but
One can prevent
senescence !

46. Restricting caloric intake
Is the most proven method to
extend life
Avoid high caloric foods
Try short term fasting
Undereating is anti-aging !

47. Lifestyle and nutrition, caloric restriction,
mitochondrial health and hormones:
Scientific interventions for anti-aging
Vitetta L and Anton B;
Clinical Interventions in Aging 2007:2(4) 537–543

48. Vitetta L and Anton B; Clinical Interventions in Aging 2007:2(4) 537–543

49. Mediterranean Diet, Lifestyle Factors, and
10-Year Mortality in Elderly European
Men and Women
Among individuals aged 70 to 90 years, adherence to a
mediterranean diet lifestyle is associated with a more
than 50% lower rate of all-causes and cause-specific
mortality.
Knoops K et al. JAMA 2004;292:1433-9

50. Okinawa Island:
Island
A model of “healthy” aging
The exceptional longevity of the Okinawa
population may result from a combination of
favorable factors and not only genetic
determinants.
Nguyen C. NPG Neurologie-Psychiatrie-Geriatrie 2008 ;8(43):35-41.

51. Okinawa Island:
Island
A model of “healthy” aging
The association of a protect environment with a way
of life which combines specific
food habits,
low energy intake,
physical activities,
stress reduction,
good familial support and
rich social relations
could explain this exception despite the low income
in this population.
Nguyen C. NPG Neurologie-Psychiatrie-Geriatrie 2008;8(43):35-41 .

52. Anti-Aging ?
Anti-senescence ?
Is to prevent
Biological age
to be greater than
Chronological age

53. There are two forms of age :
chronological age i.e. how old you are in
years
and
biological age whereby the cells of some
individuals are older (or younger) than
suggested by their actual age.
Issued on 07 February 2010 by University of Leicester at
http://www2.le.ac.uk

54. Dr. E. Blackburn,
Nobel Laureate 2009

57. The best characterized function of the
telomeric complex is to protect the
chromosome ends from degradation
Werner C, Hanhoun M, Widmann T, et al. J Am Coll Cardiol 2008;52:470–82

59. Telomers
• The little tips of chromosomes get shorter
every time a cell divides,and this shortening is
a mark of cellular aging.
• If they get short enough,the cell dies or stops
dividing
• Exercise correlates with longer telomers,as
does levels of omega-3 fatty acids in the blood
Elizabeth Blackburn
Nobel Laureate 2009

64. Genes reveal 'biological aging'
From birth, every time a cell divides, the
telomeres get shorter and there is some
evidence that people with shorter telomeres,
may be at higher risk from age-related illness.
illness
Feb.2010 at http://crabsalloverhealth.blogspot.com/

65. • Telomerase repairs and lengthens telomeres,
which cap and protect the ends of
chromosomes housing DNA.
• As people age, telomeres shorten and cells
become dying.
dying
Published on 16th Sept.2008 at http://crabsalloverhealth.blogspot.com

66. Telomers
These cellular clocks,known as telomers,may
act as barometers of wether a person will
remain healthy or not
Elizabeth Blackburn
Nobel Laureate 2009

67. Clean living slows “cell aging”
It is the damage and death of cells that causes
aging and disease in people.
Several factors such as smoking, obesity and
a sedentary lifestyle are associated with
shorter-than-average telomeres.
Published on 16th Sept.2008 at http://crabsalloverhealth.blogspot.com

68. Sedentary life 'speeds up aging'
Leading a sedentary lifestyle may make us
genetically old before our time, a study suggests:
A study of twins found those who were physically
active during their leisure time appeared biologically
younger than their sedentary peers.
Story from BBC NEWS:
http://news.bbc.co.uk/go/pr/fr/-/2/hi/health/7212698.stm
Published: 2008/01/29

69. Leukocyte telomere length is preserved with aging in
endurance exercise-trained adults and related to maximal
aerobic capacity
• LTL is preserved in healthy older adults who
perform vigorous aerobic exercise and is positively
related to maximal aerobic exercise capacity.
• This may represent a novel molecular mechanism
underlying the "anti-aging" effects of maintaining
high aerobic fitness.
Larocca TJ, Seals DR, Pierce GL. Mech Ageing Dev. 2010;131(2):165-7

70. Increased telomerase activity and
comprehensive lifestyle
changes: a pilot study
Ornish D et al. Lancet Oncol 2008; 9: 1048–57

71. Telomerase activity in peripheral-blood
mononuclear cells
Ornish D et al. Lancet Oncol 2008; 9: 1048–57

72. Lifestyle medicine stimulates telomerase
thus avoiding DNA damage and
maintaining chromossomal integrity.
the incorporation of new lifestyles may lead
to a better compliance and better
outcomes in terms of health and longevity

73. What else ?

74. Vitamin D
for Cancer Prevention:
Global Perspective
Garland CF, et al
Ann Epidemiol 2009;19:468–483.

75. Vitamin D for Cancer Prevention: Global
Perspective
Raising the minimum year-around serum 25(OH)D
level to 40 to 60 ng/mL (100–150 nmol/L) would
prevent
• 58,000 new cases of breast cancer and
• 49,000 new cases of colorectal cancer each year,
and
• ¾ of deaths from these diseases in the USA and
Canada.
There are no unreasonable risks from intake of
2000 IU per day of vitamin D3
Garland CF et al. Ann Epidemiol 2009:19(7);468-483

76. Relative risk of breast cancer mortality
Garland CF et al. Ann Epidemiol 2009:19(7);468-483

77. Colon Cancer-free survival
Garland CF et al. Ann Epidemiol 2009:19(7);468-483

78. Relative risk of colon cancer mortality
Garland CF et al. Ann Epidemiol 2009:19(7);468-483

79. and don’t overlook…
The MIND !

80. A woman
environmen
t
psycho
environmen
t
soma

81. Exactly how psychological and social factors,
personal beliefs, and stress affect the
development of disease continues to be
studied.
It is known, however, that the mind and
body communicate constantly.
what the mind thinks, perceives, and
experiences is sent from our brain to the rest
of the body.

82. Depression and Cancer
Depression also affects components of
immune function that may affect
cancer surveillance.
Spiegel D. Biol Psychiatry 2003; Vol 54(3):269-82

83. Effect of a psychosocial treatment on survival
of patients with metastatic breast cancer
Survival from time of randomisation and
onset of intervention was:
- a mean 36.6 (SD 37.6) months in the
intervention group
- compared with 18.9 (10.8) months in the
control group.
Spiegel D. Lancet 1989; 2(8668):888-91

85. A stress response pathway
regulates DNA damage…
through β(2)-adrenoreceptors and β-arrestin-1
The human mind and body respond to stress… by
activating the sympathetic nervous system and
secreting the catecholamines adrenaline and
noradrenaline in the 'fight-or-flight' response.
Hara Mr et al. Nature 2011 Aug 21.

86. A stress response pathway
regulates DNA damage…
through β(2)-adrenoreceptors and β-arrestin-1
When chronic… epidemiological studies
strongly indicate that chronic stress leads to
DNA damage.
Hara Mr et al. Nature 2011 Aug 21.

87. A stress response pathway
regulates DNA damage…
through β(2)-adrenoreceptors and β-arrestin-1
This stress-induced DNA damage may promote :
ageing,
tumorigenesis,
neuropsychiatric conditions
Hara Mr et al. Nature 2011 Aug 21.

88. A stress response pathway
regulates DNA damage…
through β(2)-adrenoreceptors and β-arrestin-1
“Our results … reveal how DNA damage may
accumulate in response to chronic stress”.
Hara Mr et al. Nature 2011 Aug 21.

93. Chronic stress - reduces telomere lenght maintenance
A SOBERING THOUGHT ...
“Every stress leaves an
indelible scar and the
organism pays for its
survival after a stressful
situation by becoming a
litle older”. (Hans Selye)

95. Psychosomatics
Benson Institute for
Mind Body Medicine
The Relaxation Response

96. the relaxation response is a physical state of deep
rest that changes the physical and emotional
responses to stress (e.g., decreases in heart rate,
blood pressure, rate of breathing, and muscle
tension).
When eliciting the relaxation response:
• Your metabolism decreases
• Your heart beats slower and your muscles relax
• Your breathing becomes slower
• Your blood pressure decreases
• Your levels of nitric oxide are increased

97. Hormones…
are not forgoten !

98. Why so much interest in HRT?
• To improve quality of life?
• To prevent diseases?

99. Interventions investigated…
Only “hormone
replacement therapy”!...
therapy

100. • Too much concerns and interest about HRT
• Too little attention to the life styles that
prevent risks, diseases and increase longevity

101. Updated IMS recommendations on
postmenopausal hormone therapy and
preventive strategies for midlife health
D. W. Sturdee and A. Pines on behalf of the
International Menopause Society Writing Group
CLIMACTERIC 2011;14:302–320

102. Symptomatic changes in postmenopause
with different methods of hormonal
therapy
HT should be initiated for relief of symptoms
through suitable selection of the route of
administration and drug that has the greatest
effect on the predominant symptoms of each
patient, for which medical evaluation was
sought.
Hernandez-Valencia M et al. Open Journal of Preventive Medicine 2011
Vol.1, No.2, 20-24

103. Individualizing Hormone Therapy to
Minimize Risk
Estrogen is a medication that can decrease
mortality, decrease cardiovascular disease,
decrease osteoporosis fracture, urogenital
atrophy and dementia. Strategies to minimize risk
include initiation of therapy within 10 years of
menopause or under 60 years of age, using low-
dose estrogen, adding a low-dose progestin in
women with a uterus, and use of transdermal
therapy in women with risk factors for
cardiovascular disease.
Donna Shoupe. Women's Health. 2011;7(4):475-485.

104. Timing of hormone therapy,
type of menopause, and
coronary disease in women
Shufelt CL et al. Menopause 2011;18(9):943-950

106. HRT and breast cancer risk:
a realistic perspective
It should be remembered that women using CEE alone
showed a significant decrease in breast cancer risk in
the WHI trial and follow-up. Even if combined
estrogen-progestogen HRT did cause an increase in
breast cancer risk, and this is not proven, the
magnitude of that risk is small, and less than that risk
seen with many lifestyle factors.
factors
HRT is a benefit, not a risk,
for those women requiring it.
Stevenson JC, Hodis HN, Pickar JH, Lobo RA; Climacteric (Aug 2011)

107. Thus,
Studies based ONLY on the use of hormones
do not reflect good clinical practice!...
MNC

108. Menopausal hormonal treatments
are very good
but ...
Treatments without hormones
may also be very good for a
woman’s health
MNC/02

109. Therefore…
and in
conclusion…

110. Please remember:
Our main target is
Mature Woman’s Health and
Disease Prevention
by all means,
drug and non-drug related.
MNC

111. The gynecologist is becoming
the woman’s family doctor.
MNC

112. To know
the disease that a woman has
is as important as
to know
the woman who has the disease
William Osler

113. Let us not medicalize the Menopause..
instead…
Let us holistically approach the
Climacteric and aging women.
women
MNC

114. Holistic Model
The aim of the therapy is not only to
produce a physical cure but also
to cure whole person.
Ruiz R, et al. La incorporacion de um nuevo modelo en medicina:
consequencias teórico-práticas. Aten Primaria 1992;10:629-34

115. I am not a
Menopauselogist…
instead
my Speciality (?!...) is
Women’s Holistic Health

117. The Take Home
Messages
1. Promote changes in Life Style : they avoid risk factors that
cause Diseases.
2. See if you can make the Biological Age to be younger than
the Chronological Age.
3. Promote Mental Health,proper Nutrition and frequent
Health
Exercice ,based on what one knows about the Telomers.
4. Give Vitamin D to everybody
5. Remember that Estrogens are the best treatment for
Vasomotor Symptoms and to improve Quality of Life.
6. Hormonal Treatments have more benefits than risks if
started early in the postmenopause
7. The Wellness of a Woman is the TARGET !

118. And...as I told you before,
The best Anti-Aging (?)
(Anti-Senescence !) Treatment
is
The practice of GOOD MEDICINE

119. therefore...we must learn…
how to practice a
GOOD MEDICINE

120. Because…there is
NO
Menopausal
Medicine !
M.Neves-e-Castro,2011

121. and now...

122. and now...
as Sir Winston Churchill said in
a speech, at the end of a War...

124. I also say,
at the end of the
Menopause War...

125. This is not the end...
nor even the begining of
the end.
But it is, perhaps,
the end of the begining !

126. Professor He was
Robert B. the Beginer
Greenblatt

127. A Woman
in the autumn of her life
deserves an indian summer
rather than a winter of a
discontent ...
Robert B Greenblatt
OH9900

128. Thank you
for your attention
read me in
http://neves-e-castro.pt