A discussion of hormones that affect women and how to stay balanced and optimize women's health through the stages of menopause. Treatment options including nutrition, lifestyle modification, hormone replacement therapy, herbal and botanical options, and bioidentical hormones discussed.

1. Parker Adventist Hospital | Women’s Wellness Expo
optimawomenshealthcare.com
drjerath.com

2. General Information

3. University of Denver | Women’s Wellness Expo | September 7, 2013
Vandna Jerath, MD, FACOG
FACOG - Board-Certified
Private practice - 15 years
Optima Women’s Healthcare
Located at Parker Adventist Hospital
Full-scope obstetrics & gynecology
Enjoy education and community outreach
Disclosure – no affiliations
Healthcare social media pioneer & expert locally
Educate, engage, and empower women
Website /Blog

4. University of Denver | Women’s Wellness Expo | September 7, 2013
Learning Objectives
General overview of hormones related to women’s
health
Review menstrual cycle
Learn about menopause condition and treatment
Review of current healthcare guidelines for women
with latest updates regarding Hormone Replacement
Therapy (HRT) and alternative therapy
Learn the latest research, news, and updates related to
hormones and women’s health issues

5. University of Denver | Women’s Wellness Expo | September 7, 2013
Global Women’s Health & Rights
1. The right to be full and responsible citizens of their countries, with equal property, economic,
voting and freedom of movement rights.
2. The right to equal education.
3. The right to work and earn a living with equal pay for equal work.
4. The right to be free of all forms of gender based violence such as domestic violence, sexual assault,
incest, female infanticide, honor killings, female genital cutting and self-immolation at a
husband’s death.
5. The right to the best available, scientifically based healthcare, including health and sexuality
education.
6. The right to autonomous decision-making, informed consent, privacy and confidentiality
regarding their own health care.
7. The right to participate equally in ethically conducted clinical and other research.
8. The right to decide when and if to have sex, including choosing one’s partner, and freedom from
coerced marriage and sex trafficking.
9. The right to decide whether to have children, the number and spacing of their children, and to
have the information, education and access to health services to make these choices.
10. The right to safe childbearing, with resources available to reduce maternal and infant morbidity
and mortality.
ACOG Statement of Policy, July 2012 (endorses FIGO resolutions)

6. Basic Overview

7. University of Denver | Women’s Wellness Expo | September 7, 2013
Hormones Overview What are hormones?
 Substances that control how organs work
 Made by certain glands/organs
 Ovaries
 Estrogen
 Progesterone
 Testosterone
 Androgens
 Hypothalamus
 Thyrotropin Releasing Hormone (TRH)
 Prolactin Releasing Hormone (PRH)
 Corticoptropin Releasing Hormone
(CRH)
 Gonadotropin Releasing Hormone
(GnRH)
 Dopamine
 Growth Hormone
 Somatostatin
 Oxytocin
 Vassopressin
 Pituitary
 Follicle Stimulating Hormone (FSH)
 Luteinizing Hormone (LH)
 Prolactin (Prl)
 Thyroid Stimulating Hormone (TSH)
 AdrenocorticotropicHormone (ACTH)
 Growth Hormone (GH)
 Thyroid
 Thyroid Hormones (T3 and T4)
 Adrenal
 Aldosterone
 Cortisol
 Catecholamines – epinephrine
 Androgens
 DHEAS
 17OH Progesterone
 Testosterone

8. University of Denver | Women’s Wellness Expo | September 7, 2013
Menstrual Cycle
Source: menstrupedia.com

9. University of Denver | Women’s Wellness Expo | September 7, 2013
Menstrual Cycle

10. University of Denver | Women’s Wellness Expo | September 7, 2013
Clinical Conditions
Menarche
Fertility-Infertility
Family Planning/Contraception
Polycystic Ovaries (PCOS)
Premenstrual Syndrome (PMS)
Pregnancy
Urinary Incontinence
Osteoporosis
Lifestyle
Obesity
Menopause

11. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause

12. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause
Pre, Peri, and Post-Menopause
No period for 1 year
Average age in U.S. is 51; range age 45-55
Increased FSH > 30
Increased Risk
CV Disease
Osteoporosis
Urinary Incontinence
Metabolic Syndrome
Risk CVD & diabetes
Natural aging vs medical disorder

13. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause – Symptoms
Symptoms
 Hot flashes – 75%
 Night Sweats
 Vaginal dryness
 Painful intercourse
 Mood swings
 Decreased libido
 Decreased concentration
 Memory Loss
 Insomnia
 Hair loss
 Menstrual disorders
 Weight gain

14. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause - Symptoms
Symptom What you can do
Hot Flashes/Night Sweats Dress in layers
Keep Thermostat down
Avoid hot drinks
Use a cold, wet washcloth against neck
Use a fan
Quit smoking, if you smoke
Vaginal Dryness Use lubricants before sex
Use a vaginal moisturizer
Do your kegel exercises
Sleep Problems Keep a circadian rhythm
Avoid naps
Avoid caffeine
Avoid alcohol
Relaxation
Try sleep aid
Depression Exercise and stay active
Seek social support
Talk about it

15. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause - Treatment
Hormone Replacement Therapy (HRT)
Types
 Estrogen
 Estrogen/Progestin
 Pills, patches, creams, vaginal suppositories, rings, shots, pellets,
intranasally (in Europe), progestin IUD
 Bioidentical hormones
 Cyclic or daily
Benefits
 Reduction and improvement of symptoms
 Protect bones
 May reduce risk of colon cancer
NAMS: Menopause.org

16. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause - Treatment
 Risks
 Side Effects – bleeding, breast tenderness, bloating, abnormal uterine bleeding (AUB)
 Anxiety
 Stroke
 Heart attack
 Blood clot
 Breast cancer
 Women’s Health Initiative (WHI) results
 Contraindications
 Breast Cancer
 Blood clots – PE, DVT
 CV disease
 Liver disease
 History of stroke or heart attack
NAMS: Menopause.org

17. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause - HRT
No longer recommended as primary prevention or treatment
of disease
Acceptable and safe option for the relatively young (up to age
59 or within 10 years of menopause)
Reduce total mortality by 30% when initiated in women
younger than 60 years
Lowest dose for shortest duration that is effective
Currently fewer than 1 in 3 women take
Breast cancer risk increases with use beyond 3 to 5 years
Many FDA approved HRT products are in fact bioidentical
NAMS Statement 2012

18. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause – Other Treatment
Low Dose Oral Contraceptive Pills
Antidepressants
 SSRI or SNRI – Venlafaxine (Effexor), Citalopram (Celexa),
Escitalopram (Lexapro), Paroxetine (Paxil)
 FDA approved Brisdelle
Gabapentin
Phytoestrogens/Botanicals
Bioidentical Hormones
Vaginal Moisturizers and Lubricants
Quality of life issue
Duration of Treatment
NAMS: Menopause.org

19. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause – Alternative Therapy
HRT used by less than 1 in 3 women
HRT often discontinued within 1 year
Holistic or natural approach – not an assurance of safety or
efficacy
Alternative therapy used by more than 30% of women
Not FDA approved
Significant costs
Multibillion dollar business
ACOG Committee Opinion – Compounded Bioidentical Menopause HRT, No. 532, August 2012
ACOG Practice Bulletin – Use of Botanicals for Management of Menopausal Symptoms, No 28, June
2001
Cleveland Clinic Journal of Medicine – Bioidentical HRT: Clarifying Misconceptions, Vol 78, No 12,
December 2011

20. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause – Bioidentical Hormones
 Bioidentical Hormones
 Identical in molecular structure to endogenous hormones
 Types of Hormones
 17-beta estradiol (E2)
 Estrone (E1)
 Estriol (E3)
 Progesterone
 Testosterone
 Compounded
 Tri-estrogen (tri-est)
 80% estriol, 10% estrone, 10% estradiol
 Bi-estrogen (bi-est)
 Estriol and estradiol in a ratio of 8:1 or 9:1
 Synthesized chemically by extracting diosgenin from plants
 Not FDA approved
 Compounding variance – no assurance of purity, safety, or efficacy
 Salivary testing not accurate or precise, not recommended
 May receive higher doses of hormones and have higher risks
 Reversal of aging process are unsubstantiated
 Transdermal progesterone creams do not protect the endometrium
 Some standard FDA approved HRT is bioidentical too
ACOG Committee Opinion – Compounded Bioidentical Menopause HRT, No. 532, August 2012
ACOG Practice Bulletin – Use of Botanicals for Management of Menopausal Symptoms, No 28, June 2001
Cleveland Clinic Journal of Medicine – Bioidentical HRT: Clarifying Misconceptions, Vol 78, No 12, December 2011

21. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause – Alternative Therapy
 Herbal/Botanical
 Not FDA approved
 High degree of variation
 Some studies show positive effects, but more research needed
 Hot flashes – soy, black cohosh, evening primrose, dong quai
 Mood disturbances – St. John’s wort, valerian root
 Sexual dysfunction – chasteberry, ginseng
 Menstrual Disorders – wild yam
 Sleep Disorders – Black Cohosh
 Overall wellness - Ginseng
 Phytoestrogens
 Isoflavones - soy, garbanzo beans, legumes
 60mg of active form
 45% reduction in vasomotor symptoms
 Avoid in Breast CA?
 Lignins – flaxseed
 Coumestans – red clover, sunflower seeds, bena sprouts
 Acupuncture
 Lifestyle modification
 Nutrition
 Exercise
 Yoga
ACOG Committee Opinion – Compounded Bioidentical Menopause HRT, No. 532, August 2012
ACOG Practice Bulletin – Use of Botanicals for Management of Menopausal Symptoms, No 28, June 2001
Cleveland Clinic Journal of Medicine – Bioidentical HRT: Clarifying Misconceptions, Vol 78, No 12, December 2011

22. University of Denver | Women’s Wellness Expo | September 7, 2013
FDA Approved Bioidentical Hormones
Cleveland Clinic Journal of Medicine – Bioidentical HRT: Clarifying Misconceptions, Vol 78, No 12, December 2011

23. University of Denver | Women’s Wellness Expo | September 7, 2013
Bioidentical Hormones –
prescription vs customized
Cleveland Clinic Journal of Medicine – Bioidentical HRT: Clarifying Misconceptions, Vol 78, No 12, December 2011

24. University of Denver | Women’s Wellness Expo | September 7, 2013
Vaginal Atrophy - Treatment May lead to dyspareunia and sexual dysfunction
 Moisturizers and lubricants
 Replens, Me Again, Vagisil Feminine, Feminease, K-Y Silk-E
 Water soluble - Astroglide, Slippery Stuff, K-Y Jelly
 Silicone based - Pjur Eros, ID Millennium
 Oil based - Elegance Women’s Lubricant
 Mechanical Measures
 Sexual activity
 Vaginal dilators
 Vaginal Estrogen Therapy
 Cream – Premarin, Estrace
 Ring – Femring, Estring
 Tablet – Vagifem
 Selective Estrogen Receptor Modulators (SERM)
 Oral tablet – Ospemifene (Osphena)
 Other
 Smoking cessation
 Oral Vit D
 Vaginal Vitamin E
 ?Testosterone – may help libido, but not vaginal atrophy

25. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause – WHI
Women’s Health Initiative
Launched in 1991, 15+ year study
Clinical trials and an observational study,
161,808 generally healthy postmenopausal women
Age 50-79
Test the effects of postmenopausal hormone therapy, diet
modification, calcium and vitamin D supplements on
heart disease, fractures, and breast and colorectal cancer.
Some follow-up studies ongoing
nhlbi.nih.gov/whi/

26. University of Denver | Women’s Wellness Expo | September 7, 2013
Menopause – WHI Data
 Compared with the placebo,
estrogen plus progestin resulted
in:
 Increased risk of heart attack
 Increased risk of stroke
 Increased risk of blood clots
 Increased risk of breast cancer
 Reduced risk of colorectal cancer
 Fewer fractures
 Increased risk of dementia (study
included only women 65 and older)
 Stopped 2002
 30/10,000
 Compared with the placebo,
estrogen alone resulted in:
 No difference in risk for heart attack
 Increased risk of stroke
 Increased risk of blood clots
 Uncertain effect for breast cancer
 No difference in risk for colorectal
cancer
 Reduced risk of fracture
 Stopped 2004
 8-10/10,000
NAMS 2012 Statement on HRT, Menopause, Vol 19, No 3, 257-271

27. Summary

28. University of Denver | Women’s Wellness Expo | September 7, 2013
Important Points
Hormones affect many clinical conditions
HRT improves menopausal symptoms
HRT is not used to prevent or treat disease
Must use progesterone if you have a uterus to prevent
endometrial cancer
Inform your doctor if you have postmenopausal bleeding
HRT is considered acceptable, safe, and appropriate
Use HRT in smallest dose for shortest duration
Some conventional FDA approved HRT is bioidentical
Bioidentical does not mean safe, effective, proven, or accurate
Herbal Alternatives are available, but still need more research

29. University of Denver | Women’s Wellness Expo | September 7, 2013
Tips
Maintain healthy lifestyle
Talk to your doctor
Do your own research and share it with your doctor
Be flexible , patient, and willing to experiment with
treatment options
Try conservative measures and lifestyle modification
first
Consider HRT or alternative therapy
Understand the risks, but do not live in fear
Remember your quality of life is important

30. Resources

31. University of Denver | Women’s Wellness Expo | September 7, 2013
Helpful Links
 General Women’s Health
 Acog.org
 Contraception
 Plannedparenthood.org
 Essure.com
 Nexplanon-USA.com
 Paraguard.com
 Mirena-us.com
 Skyla-us.com
 Infertility
 Resolve.org
 ASRM.org
 Sexually Transmitted Infections/Diseases
 cdc.gov/std
 Heavy Periods
 Novasure.com
 Pelvichealthsolutions.com
 Menopause
 Menopause.org
 Knowmenopause.com
 nhlbi.nih.gov/whi/
 Pause.acog.org
 Incontinence
 AUGS.com
 Mypelvichealth.com
 NAFC.org
 Osteoporosis
 NOF.org
 WHO.int/en
 shef.ac.uk/FRAX/tool.jsp
 Heart Disease
 Goredforwomen.org
 Cancer
 Foundationforwomenscancer.org
 Cancer.org

32. Contact Information

33. Contact Information
Optima Women’s Healthcare
Vandna Jerath, MD,FACOG
Sierra Medical Office Building
Parker Adventist Hospital Campus
9399 Crown Crest Blvd, Suite 450
Parker, CO 80138
303.805.1807 P | 303.595.5390 F
optimawomenshealthcare.com
drjerath.com
staff@optimawomenshealthcare.com