Year: 2001

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Estrogen Therapy

“One of the most complex and difficult health care decisions that women face is whether to use postmenopausal hormone-replacement therapy”, says an article in the New England Journal of Medicine (NEJM).

Couple of weeks ago we discussed hormone-replacement therapy (testosterone) for aging men. Benefits and risks of testosterone therapy in men are still being debated. And there aren’t millions of men on testosterone yet.

But hormone replacement therapy (HRT) – estrogen – for women has been prescribed for many years. On an average, women live 30 years after menopause. Currently, approximately 38 percent of postmenopausal women use HRT although there is dearth of conclusive evidence regarding the benefits and risks of this therapy.

What are the definite benefits of postmenopausal HRT in women?

About 50 to 80 percent of women suffer from menopausal related symptoms like: hot flashes, night sweats, vaginal dryness, insomnia, mood swings, and depression. There is strong evidence that estrogen therapy is highly effective. For genital and urinary symptoms, vaginal estrogen is as effective as oral or skin patch estrogen.

HRT reduces age-related bone loss (osteoporosis) and reduces the fracture of the spine by 50 percent and the risk of hip fracture by 30 percent. Increased physical activity and adequate intake of calcium and vitamin D may also help reduce the risk of osteoporosis-related fractures.

What are the definite risks of HRT?

Cancer of the uterus (endometrial cancer) and blood clot in the legs and lungs (venous thromboembolism) are definite risks related to HRT.

Besides these there are two probable areas where there is increased risk of HRT. These are breast cancer and gall bladder disease. There is no appreciable increase in the risk of breast cancer if the postmenopausal estrogen therapy is given for less than five years. In contrast, the risk of breast cancer was increased by 35 percent in women who used estrogen for five years or more. Combination therapy – estrogen and progesterone – is worse than estrogen therapy alone when it comes to breast cancer risk, says the NEJM article.

What are the areas of uncertainty?

Coronary artery disease
Colon and rectal cancer
Alzheimer’s disease
Ovarian cancer
Diabetes

What is the best approach to starting HRT for a postmenopausal woman?

Two most valid reasons for starting HRT are menopausal symptoms and prevention and treatment of osteoporosis. Patients with intact uterus should be warned that they might get vaginal bleeding if on estrogens therapy alone. They should be on combination therapy (estrogen-progesterone).

Short-term use (less than five years) is appropriate for relieving menopausal symptoms. But longer-term use (five years or more) of HRT is problematic due to increase risk of breast cancer. Some women with osteoporosis will require long-term therapy.

Your family physician or gynaecologist will carefully weigh the risks and benefits before prescribing HRT.

The central principle is that menopause does not always need to be treated with medication, says the NEJM article. Life style changes, such as quitting smoking, increasing physical activity, and maintaining a healthy diet, may be useful in controlling symptoms and preventing chronic disease.

Further research on this subject continues. Results of one large-scale study are expected to come out in 2005 and another one in 2012. Until then, postmenopausal women and their clinicians will have to make the best possible judgement regarding the use of HRT.

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Terrorism

On September 11th, nineteen misguided young men chose to take lives of thousands of people in New York and Washington. Within two hours they managed to terrorise the whole world.

They left thousands of children without one or two parents. They left thousands of individuals without a spouse. They left thousands of parents without sons and daughters. They left thousands of siblings without brothers and sisters. Basically, they damaged the whole fabric of trust and kindness.

Now there is anger and call for revenge.

Recent CNN poll shows that more than 90 percent of the Americans want revenge by military action. Afghanistan government has warned of “dire consequences” against any government that helps Americans to strike against Afghanistan.

International guerrilla warfare is waiting to start.

Guerrilla wars are not like conventional wars. There will be snipers and suicide bombers. There will be significant damage to life and property. The current killings in the Middle East, Northern Ireland, and other regional wars will then become small print. The value of life will further diminish.

The memories of mass murderers like Hitler, Mussolini, Bokassa, Idi Amin, Dr. Harold Shipman, the Oklahoma bombers and others will become a blur. And the fanatics who kill abortion doctors will never find a place in the newspapers and prime time TV.

Everybody will be angry. Somebody somewhere known to us is going to get hurt or killed. Then there will be political and religious leaders who will exploit the situation for their own narrow minded and selfish reasons.

Salama bin Laden was trained by the CIA to fight the communists in Afghanistan. Now CIA will have to train more bin Ladens to fight the guerrilla warfare for them. Is terrorism going to breed more terrorism? Is there going to be a winner in the end?

There are too many questions and many thoughtful people have suggested solutions. And there is a heavy price to pay for freedom and safety.

Judaism, Christianity, and Islam believe in the same God, the God of Abraham. All three religions essentially share the same code of morality and believe in preserving life.

I wonder if there was a meeting of Jesus, Mohammed and Moses, what sort of solution they would offer? What would Mahatma Gandhi, Martin Luther King Jr. and Mother Teresa would have to say? We can only guess.

But all reasonable people agree that no individual or group should be allowed to terrorise, maim, or murder people.

But the dilemma remains: How are we going to punish and prevent terrorist activities? Are we going to invest billions of dollars in the military might or spend that sort of money to uplift the self esteem of the poor people who need healthy food, clean water, clothes, shelter, education, freedom, justice etc.?

Would there be few millions to eradicate disease and sickness? For physical and mental health of our children round the world? And few millions to understand and treat the psychosocial causes of terrorism?

Anger and revenge are understandable immediate human reactions to the events of September 11th. President Bush should be congratulated for very thoughtful leadership so far. Our future depends on the political leaders we have elected. We can only wait and pray that they make decisions that will be in the best interest of our safety and security.

In the meantime, let us love our family, our friends and our neighbours! Let us teach our children and ourselves sense of tolerance and kindness. And let us hope and pray that they grow up to be responsible citizens who will make a difference for the better.

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Male Menopause (Andropause)

Dear Dr. B: My doctor recently told me that I have male menopause. Can you please tell me more about this? Yours: Mr. Menopause.

Dear Mr. Menopause: The correct name for this condition is “andropause”. “Andro” stands for androgen – a male sex hormone, such as testosterone or androsterone, that controls the development and maintenance of masculine characteristics.

Andropause is also known as ADAM (androgen decline in the aging male). The onset of andropause is unpredictable. Its clinical manifestations are subtle and variable.

The symptoms of andropause include fatigue, depression, hot flushes, sweats, decreased libido, erectile dysfunction, changes in cognition (like poor concentration and memory) and mood. Since these symptoms are more subjective than objective, some experts have trouble accepting andropause as a clinical condition.

Physical examination of an aging male patient with andropause may be quite normal. There may be presence of gynaecomastia (enlargement of male breast) and/or soft small testicles. Low testosterone level does not produce any specific organ changes. Another reason why some experts have trouble accepting andropause as a clinical condition.

Diagnosis of andropause is made by symptoms, physical signs and early morning non-fasting specimen of blood for testosterone level. Testosterone level is highest in early morning and can decrease by 35 percent in the midafternoon and evening.

Early morning testosterone level less that 7 nmol/l indicates that a man has poor gonadal function. This will warrant further investigation to find the reason for low testosterone level. Is it the normal aging process or some other pathology?

Testosterone level found to be critical for sexual function in men lies around 10.4 nmol/l. There can be some variation between individuals.

Normally men experience a continuous slow (an average of one to two percent a year) decline in serum testosterone level after about age 30 years. This is due to decrease in testosterone production. There are many other reasons why testicular function may fail – injury, infection, tumours, surgery, effect of other hormonal problems etc.

The goals of treatment for poor gonadal function are to improve erectile function, restore libido, and improve psychological well-being and mood. It is important to remember that in men over 50, cause for erectile dysfunction may be other than low testosterone level. So testosterone replacement therapy will improve libido and psychological well-being in this age group but may occasionally improve erectile dysfunction.

Testosterone replacement therapy improves bone mass, coronary artery disease, reduces total cholesterol and LDL (bad cholesterol) levels.

What are the contraindications?

Testosterone should not be given to individuals with prostate or breast cancer. Sleep apnea has been shown to contribute to low serum testosterone levels and testosterone therapy has been reported to make sleep apnea worse. Testosterone therapy may make blood thick (polycythemia), promote benign and malignant changes in the prostate, and can cause tenderness and enlargement of breasts.

Before starting an individual on testosterone therapy, the physician should screen the patient for sleep apnea, prostatic symptoms, and family history of prostate cancer. Do digital rectal examination, complete blood count, lipid profile and PSA. These tests should be repeated every six months.

Testosterone is available for clinical use in many forms: injectable, oral pill, skin patch, gel, and implantable formulations. Each one has advantages and disadvantages. Your physician will advice you the best formulation for you. The physician should monitor the treatment to check for any side-effects and for any long term complications like prostate cancer.

So, Mr. Menopause (or rather Mr. Andropause or Mr. ADAM), we haven’t heard the last word on this condition. Data on the benefits and risks of testosterone replacement therapy for older testosterone-deficient man are scanty, but new clinical information continues to be generated. So there is hope for aging men too!

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Hypertension

When was the last time you had your blood pressure checked?

High blood pressure (hypertension) is the leading reason why so many people see their doctor. And widespread treatment of hypertension is also the main reason why there is a decrease in the incidence of stroke, heart disease, and kidney failure in the last 30 years.

It is not enough to get your blood pressure checked and then do nothing about it. If the blood pressure is normal then adopt measures to keep it normal. As we get older, the arteries tend to harden and the blood pressure goes up. If the blood pressure is high then make sure you follow the advice of your doctor. And medication is not always the best answer. There is more you can do to control hypertension than just popping pills once or twice a day.

What is the normal blood pressure?

Normal blood pressure is defined as systolic blood pressure of less than 140 mm Hg (mercury) and diastolic blood pressure of less than 90 mm Hg. It is written as – systolic over diastolic (for example 120/80 mm Hg).

Why do people have hypertension?

Hypertension affects 22 percent of Canadians. The incidence of hypertension increases with age. Most elderly Canadians have high blood pressure. No cause is identified in 80 to 95 percent of people with hypertension. This is known as idiopathic or essential hypertension. Others have hypertension due primary disease of kidneys or due to certain hormonal disorders.

What is the effect of hypertension?

For close to 100 years, it is known that hypertension causes premature death. It negatively affects the heart, brain, kidneys, and retina. It causes heart disease, stroke, kidney failure and retinal damage – blindness.

What can you do to prevent and control hypertension?

Hypertension can be prevented and/or treated with lifestyle changes with or without medication. Life style modification requires significant amount of changes in what you do and what you eat. Here are some of the things you can change:

-Lose weight if you are overweight

-Don’t smoke

-Limit alcohol intake

-Eat a low salt diet

-Do regular exercise – three to five times a week

-Relax and learn to manage stress

Hypertension is a silent killer. You may have high blood pressure but have no symptoms.
It is estimated that 25 percent of the 42 million people with high blood pressure in the United States are unaware that they have high blood pressure and approximately three fourths of those with known hypertension have blood pressure that exceeds the recommended level! This is dangerous!

So, when was the last time you had your blood pressure checked?

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!