Search for tag: "hormones"

When the father of an iconic female pop star went public with the diagnosis of his breast cancer, it was clear that we don't think about our boys and men and this disease very often.

This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is "The Seven Domains of Women's Health" and a little bit of men's health on The Scope.

All humans have breast tissue as a developing fetus. Baby boys and especially baby girls often have breast tissue that can be felt under the nipple shortly after they are born that has been stimulated by the hormones of pregnancy. Boys in early adolescents may grow more breast tissue as their early hormones from the testes stimulate the breast cells until testosterone rises enough to suppress the effect of estrogen. And then we mostly forget about it.

Breast cancer in men is the same type of breast cancer as in women, cancer of the breast ducts called ductal cancer and cancer of the breast lobules is called lobular cancer. Breast cancer in men is uncommon and makes up only about 1% of all breast cancers. Men who do develop breast cancer do so at a later stage in life than women, with an average age of about 72. The rate of breast cancer in the U.S. is about 1.9 white men out of 100,000, and in African-American men it's about 2.7 in 100,000. And the lifetime risk of a man getting breast cancer is about 1 in 800.

So it's not so common, but the incidence of breast cancer in men has been slowly rising over the past 40 years. At least in one study of breast cancer of men in Britain, the exact reason for the rise isn't known, but the risk factors for men include anything that increases estrogen, obesity, liver disease, heavy alcohol use, and diseases where men make less testosterone. Of course, family history and genetics play a role. About one in five men with breast cancer have a close family member with breast cancer. Usually that's a woman.

Now, when a woman develops breast cancer, we think about her family history, the other women who are close to her genetically, mothers and sisters and daughters, and then grandmothers and maternal aunts. If there seems to be a family pattern, we often suggest genetic testing for women. If the woman with breast cancer is positive for one of the gene mutations associated with breast cancer, like BRCA1 and 2 mutations, we offer counseling to the family and suggest that the close women relatives be tested.

But we should be talking about whether the men should be tested as well. If a man develops breast cancer, we should offer him testing. If a man has a mutation in the BRCA1 gene, the chance of getting breast cancer is 6 in 100. And if he has a BRCA2 mutation, it's 1 in 100.

The signs of breast cancer in men are the same as in women -- a lump near the nipple, dimpling of the skin near the nipple, or nipple discharge or blood from the nipple. So families with genetic risk for breast cancer should consider testing and counseling the men in the family. There are no recommended screening tests for asymptomatic men, men without any signs or symptoms. And mostly, it is important for men who notice changes in their nipple or the tissue around the nipple, they should bring it to the attention of their clinician. Early detection is just as important for treatment in men as it is in women because who cares about men's health? We do.

And thanks for joining us on "The Seven Domains of Women's Health" because we love our men.

This is your brain on hormones. This is your brain off hormones. This is your brain just right. Sounds like Goldilocks? There's a new treatment for postpartum depression that aims to make this better.

About one in seven women will suffer from postpartum depression. This isn't just a couple of days of feeling overwhelmed with the baby blues, something most of us felt in the weeks after a baby is born. This is overwhelming depression and inability to care for oneself and one's newborn. Neuroscientists have always been interested by the effect of sex steroids on the brain, estrogens, progestin, and testosterone. Those of us who practice reproductive endocrinology like me have a particular interest in progesterone and its metabolites, the molecules that the brain makes out of progesterone.

Progesterone and its brain metabolite allopregnanolone seem to make the brain less irritable. And falling progesterone at the end of the menstrual period may have a role in PMS in some vulnerable women. Progesterone is the most abundant hormone in pregnancy and some think that dramatic drop in progesterone after birth may have a role in postpartum depression.

For most women with postpartum depression, it seems to go away in weeks to months, but some women benefit from talk therapy or the usual antidepressants. But that can take weeks for a measurable difference. Until now, the therapies focused on postpartum depression have been based on the same principles and medication as depression that happens to men and women who haven't been recently pregnant. However, looking at the link of falling progesterone and its brain metabolite allopregnanolone, some researchers have wondered if administering allopregnanolone to women with severe postpartum depression who aren't benefiting from regular therapy might be an approach.

A pharmaceutical company has created allopregnanolone in the lab and call it Brexanolone. The research focused on women with severe postpartum depression who are randomized to a 60-hour infusion of Brexanolone or placebo. The women were within six months of giving birth and had experienced depression within a month after delivery. These women were very depressed. Starting out with an average score of 28 out of 30 on a standard depression scale, that's really depressed.

After the infusion, right after the infusion, not weeks later, women who received the Brexanolone had an average score of nine to 10. And women who received placebo had an average score 14. That meant that placebo works which we know from all studies of antidepressants but the Brexanolone worked better. Twice as many women who received the study drug had scores similar to non-depressed women than women who received placebo. The effect lasted for up to 30 days and maybe longer. And this might be enough for other therapies to take hold.

It has some drawbacks. One is that the infusion has to be done in a hospital setting as one in eight women had dizziness and several women temporarily lost consciousness, passed out. The drug itself has an average cost of $34,000 but there may be some ways that insurance or rebates from the drug company might help. And there is the cost of the infusion in the hospital-based monitoring.

The pharmaceutical company is currently studying an oral form of this hormone though they don't call it a hormone. It looks and acts like a naturally occurring hormone allopregnanolone and that's made in the brain, so I call it a hormone.

The most important aspect of those women who had this treatment is that it worked so quickly. We're all concerned that women with postpartum depression get diagnosed, get into treatment, get family support, and get the best therapy. The consequences for the new baby and for the family of a mom who's withdrawn and possibly suicidal is very significant.

So, this therapy isn't necessarily for all women with postpartum depression but for women for whom regular treatment isn't working and who are struggling to care for themselves or their baby. It's an innovative approach and it's good news for the women, their babies, and their families who are struggling at a pivotal time of their lives. So, take care of yourself and your baby. Get help if you need it. There's new stuff on the way. And thanks for joining us on The Scope.

Dr. Jones: There's a problem that is very common in women after menopause. It can cause significant discomfort, it's very easy to treat with a medication that's widely available and low-tech, and it's really, really expensive. What's going on? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is about vaginal health on The Scope.

Announcer: Covering all aspects of women's health. This is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: Estrogen, my favorite hormone, is the primary hormone that keeps the vaginal skin healthy and elastic. The tissues in the vagina and the lower part of the urethra, the tube that comes out of the bladder are very sensitive to low doses of estrogens made naturally in women of reproductive years. Having these tissues be healthy and elastic is important for comfort during sexual intercourse, is important for the normal microbiome of the vagina, and helps women from getting too many urinary tract infections.

After menopause, women who don't take hormonal therapy with estrogen, and that's the majority of women actually, often find they have a sense of dryness or burning in the vaginal area. They may have painful intercourse. They may have more urinary tract infections. And the good news is the treatment is easy. Estrogen applied in very small doses to the vagina with the cream, a little pill, a suppository, or even a ring placed in the vagina that slowly releases small amounts of estrogens locally.

A big study that followed 50,000 women over 10 years, looked at these women who used local natural estrogen after menopause and compared their health outcomes to women who didn't use any estrogens. There was no increase in the risk of breast cancer, heart disease, or blood clots, diseases that can be slightly associated with postmenopausal estrogens taken in larger doses for hot flashes.

So what's the problem? It's a common problem, and it's a low-tech, easy fix. Now, if I wanted to take estradiol, my natural hormone, by pill for hot flashes, I could go to Walmart and get a 90-day supply for $10. If I wanted to use the same hormone vaginally, prepared to be absorbed by the vagina and this isn't rocket science, drug technology, it will cost $520 depending on how the estradiol is delivered. Now, $520 is the upper end, $300 is the lower end.

So what is the reason that the pharmaceutical industry puts such high prices on vaginal estradiol? It's because they can. Even women who might have a drug plan with their insurance might have to pay a lot for these drugs, much more than they would for oral contraceptives or birth control pills or oral estrogen. Drugs to treat sexual health for women like the estradiol products are frequently placed on a higher formulary tier, meaning you're going to have to pay a large percent of the list price. Although it may be covered by the insurance company, the amount that they might pay would be little.

The problem caused by vaginal atrophy, thinning of the vagina and the urethra are not only sexual. Women can have discomfort with some sports like bike riding, and they might have more urinary tract infections. Not only are the prices high, but they're going up, even doubling over the past five years, and the technology is not new.

The company that made the little vagina estrogen pill dropped the dose in half because the lower dose did a good job, but the price wasn't lower and it still keeps going up.

A new product just approved by the FDA with the rather odd, but sort of cute name called Imvexxy, it'll be available in July of 2018 and provides estradiol at a very low dose, the lowest of any product and could have made a big hit on the market if they'd priced it at a level that most postmenopausal women could afford. This drug is being priced about the same high cost as the other products. There is another product the FDA approved for vaginal atrophy, which isn't an estrogen, but is another naturally occurring hormone, DHEA comes in a vaginal suppository, and it's really expensive too.

So some women are turning to Europe or Canada to get these medications at a more reasonable price, even though it won't be covered by insurance, and it may not be strictly legal to import it. Also, many pharmacies that compound hormones with creams are selling the products at lower cost, but they aren't under the same control with respect to quality and consistency that the FDA approves manufacturers are.

So what is a woman to do? First of all, if you're a postmenopausal woman and having trouble with painful intercourse or symptoms of dryness or burning in the vaginal area or frequent urinary tract infections, you should talk to your clinician. They can easily check and make sure the problem is vaginal atrophy associated with low estrogen and not something else that might be treated in another way.

Speak up. If enough women complain to their insurance companies, maybe the word will get back to manufacturers. If your local compounding pharmacy can make vaginal estrogen at the correct low dose, that's an option. And this is the only situation where I actually recommend this particular option. There are some companies that are making these products generic, which will bring the price down a little bit, but not as low as the technology would suggest. They can keep the price up because they can.

Talk to your clinician about other options that might be available for your symptoms if you cannot afford vaginal estrogens or choose not to take them. Don't suffer, there are choices. Speak up, be heard. And thanks for joining us on The Scope.

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Dr. Jones: New news and old news about the risk of breast cancer and hormonal birth control. Get ready for some really very big and very small numbers. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University Health and this is The Scope.

Announcer: Covering all aspects of women's health. This is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Today we're going to talk about hormonal birth control and the risk of breast cancer. Primarily, we'll talk about birth control pills, but we'll also talk about hormonal patches, shots, implants, and IUDs. There are now 50 years of data on the topic of hormonal birth control pills and the risk of breast cancer. Largely, the studies have suggested that there's no significant increased risk of breast cancer in birth control pill users except maybe in women who used pills starting early in their teens, used them for a long time, and use them into their 40s. Recently, a study from Denmark looked at 1.8 million women between the ages of 15 to 49 who had used hormonal contraception between 1995 and 2012. They were using contraceptive methods that are commonly prescribed today. Because Denmark has a health system that can follow everyone and link diagnosis with prescriptions and health outcomes, they can really do big studies.

So what did they find? First, the extra risk of breast cancer in women of this age group who took hormonal birth control of any type during this time period was 13 extra breast cancers per 100,000 women per year. That's a very small number, 13, out of a pretty big number, 100,000. That is, for every 100,000 women using hormonal birth control, there are 68 cases of breast cancer annually compared to 55 cases a year among non-users. Another way to crunch these numbers is to say there was one extra breast cancer for every 7,690 women using hormonal contraception.

Of course, the details are a little more interesting. For the users of hormonal patches, the extra breast cancers were 5 per 100,000, but it ranged from 1 fewer and 11 more, and essentially it wasn't different from women not using hormonal birth control. Maybe there are just weren't as many women taking it. It's not clear, because the hormonal patch is kind of like the hormonal pill.

For women using vaginal rings, there were two fewer breast cancers. But the statistical range was 32 fewer to 28 more. So there wasn't any increased risk in this group.

The same kinds of numbers were seen for women using contraceptive implants or injections. There were about 5 to 10 fewer breast cancers, but the ranges were so large that there really wasn't an increase or a decrease.

Hormonal IUD users had about the same increase as pill users with about 16 extra breast cancers per 100,000 women. Importantly, and listen to this, the risk for women under 35 years of age was 2 extra breast cancers per 100,000 women per year, a really small number. Young women had a lower risk of breast cancer on hormonal contraception than older women. And women who had used hormonal contraception for a long time, meaning 10 years or more, had a slightly larger absolute risk than women who only used it a short time.

So what do we do with these numbers? First, don't panic. Every time there's bad news about contraception, even if it's barely bad, women stop their contraception and the unplanned pregnancy rate and abortion rate goes up. Now there, you're really taking some risks. It is really hard to know how to counsel women about a risk that is one extra per 7,960 women. Those are numbers that people don't really understand very well. Also, people really don't like numbers like 7,960. They like 10 or 1,000.

So I consider a significant risk is 1 extra in 10. A low risk is 1 extra in 100. A very low risk is 1 extra in 1,000, and an extremely low risk is 1 extra per 10,000, and that's really what we're talking about. The authors of this study admit that they didn't control for age of first period in these ladies, alcohol consumption, breastfeeding, and physical activity. All of these activities increase or decrease the risk of breast cancer by a little. Breastfeeding decreases the risk of breast cancer, and certainly women who breastfeed are less likely to use hormonal birth control. So that could be part of why there was a slight increase in hormonal birth control users.

Now, there's something called biological plausibility. In population studies, they'd find a correlation of one thing with another. Let's pick alcohol. People who drink alcohol moderately live longer. People who drink alcohol a lot don't live so long. Now, is it the alcohol that makes you live longer? Or is it the people who drink alcohol have more fun, have more friends, and having friends makes you live longer? So this is a biological plausibility issue.

Is there a biological reason that hormonal contraception might very slightly increase the risk of breast cancer? Over the past 20 years, researchers have been more interested in the progestin component of the hormonal contraception and menopausal hormone replacement therapy. We always thought that the risk for breast cancer was all about estrogen, but progestin, that other hormone in hormone replacement or in hormonal birth control, seems to add a little risk as well. So there's a possible biological reason for this very small increase in breast cancer in hormonal contraception users.

The authors of this study also suggest that women don't panic, but they didn't exactly say that. They mentioned that hormonal birth control pills have substantial health benefits. Birth control pills substantially decrease the risk of uterine and ovarian cancer and possibly colon cancer. In fact, women who have the BRCA gene for breast and ovarian cancer have been suggested to take birth control pills because even if the risk of breast cancer is slightly greater, the risk of ovarian cancer, a cancer that's hard to detect and hard to treat, is so much less on birth control pills.

So what should you do? We all know that hormonal contraception comes with risks and benefits. For the vast majority of us, the ability to control when and how often we have children is a fundamental factor in our ability to manage our lives. Many women use hormonal birth control, such as hormonal IUDs, to manage flooding periods and pain that debilitates them every month.

If these recent findings are a major concern for you, talk to your clinician about the risks and benefits for you personally. Not you in 100,000 women. Put things in your own personal perspective. There are options for us, probably more than you know, and thank you for joining us on The Scope.

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Dr. Jones: Uh-oh, now you have a family planning emergency. How much time do you have? This is Dr. Kirtly Jones from obstetrics and gynecology at the University of Utah Health, and this is The Scope.

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Today in The Scope studio, we're talking with family planning expert in emergency contraception. And what are the options and how do they work? Dr. Jennifer Kaiser is an OB/GYN at University of Utah Health and is currently in the family planning fellowship here. Welcome, and thanks for joining us and helping us out with this emergency on The Scope, Dr. Kaiser.

Dr. Kaiser: Thank you so much.

Dr. Jones: Well, when I was a young woman in the last century, we thought that a douche with Coca-Cola would work for emergency contraception. And douching with various chemicals after intercourse has been used for hundreds of years. Any truth to this ancient medical practice?

Dr. Kaiser: So there might be. I actually think one fascinating aspect of contraceptive care, both prophylactic, so using before intercourse or emergency using after, is how women have attempted to control their fertility for so long, for like you said . . .

Dr. Jones: Of thousands of years.

Dr. Kaiser: Of thousands of years. And in our modern era, though, we have plenty of options for birth control. And on the whole, women have really heard about all of these different options. In the past, this wasn't the case. Prior to the creation of the birth control pill in the 1960s, there really weren't any tried and true methods that were widely known. Women and their partners tried using home remedies that were passed on by word of mouth or methods they had read about in magazines. And douching, like you mentioned, was actually extremely popular as a means of preventing pregnancy following intercourse.

So in the 1800s, women could actually purchase special made syringes to douche with. They would use a wide variety of liquids for this, anywhere from cold water to tepid water, to hot water, boric acid, baking soda, and all sorts of astringents. And so we all know how acidic Coca-Cola is as we've seen people's YouTube videos of it dissolving all sorts of things. And it seems that douching with an acidic or basic compound is probably more effective than just water. So there is likely some truth to this, douching with either Coca-Cola or an astringent kind of liquid.

Sperm are very temperamental, and so they don't do well in a pH that's outside of the seven to eight range. So it may be very likely that the sperm were being killed with these kinds of treatments in the vagina or even the lower cervix. But that doesn't really cover the uterus or the fallopian tube where the sperm can get to in as little as 15 minutes. So if you're not right on top of it, it's really unlikely to work.

Dr. Jones: Oh, well, but let's move on to something that we know works a little bit better. So why do they call it emergency contraception? Why do we use that word?

Dr. Kaiser: Yeah. So in general, emergency contraception is so called because it describes the use of a contraceptive method in an emergent setting to prevent pregnancy. So that can be after unprotected intercourse, a rape, or after method failure. So somebody who was using a condom that broke or maybe they had some pills that they missed. This term has also dramatically changed over the past several centuries. In the 1800s, most contraceptive methods practiced were after intercourse with the notable exception of withdrawal or condoms. And so really, in the past, everything was emergency contraception.

The term post-coital contraception was used by scientists and physicians in the 1960s once the pill was created. And the popular media coined the term the "morning after pill" shortly after, which I'm sure is a familiar term to many listeners. But since the 1990s, the term emergency contraception was adopted to really emphasize that this shouldn't be an ongoing birth control method.

Dr. Jones: Right.

Dr. Kaiser: That it's for emergency use and then it also was used to correct misconceptions about when to take emergency contraception, the fact that it's not just limited to the morning after.

Dr. Jones: Right. But it is kind of urgent, and it's not likely to be available in an emergency room unless you're seeking health care in the ER. That's not the place you go for this unless you're already going there for, perhaps a rape or something violent, unfortunately, right? So what's available?

Dr. Kaiser: Yeah. So right now on the market, there are three current available forms of emergency contraception. There is Plan B, which is a synthetic progestin called levonorgestrel.

Dr. Jones: And it comes in other names too. There are a couple brands of this, yeah.

Dr. Kaiser: There's also Ella which is ulipristal, which is another progestin acting medication. And then there's also the copper IUD or para guard.

Dr. Jones: Okay. So let's pick Plan B or drugs like that. How does it work, and when is it too late for Plan B to work?

Dr. Kaiser: Yeah, those are great questions. So Plan B is an oral synthetic progestin called levonorgestrel. By taking this pill, the progestin in it blocks your body's ability to produce a surge of the hormone called LH or lutenizing hormone. By blocking the surge, ovulation is prevented so no egg is released, and thus fertilization and pregnancy are also prevented.

If it has been more than 72 hours from unprotected intercourse, there is less of a chance that Plan B will work. So in other words, it's best to take it within 72 hours, but it can be taken up to 120 hours from unprotected intercourse. But if you've already ovulated before taking Plan B, it's not going to work to prevent pregnancy.

Dr. Jones: Right. Okay. Well, can anybody take Plan B?

Dr. Kaiser: So the great news is that Plan B is now available over the counter at many pharmacies. There is no age limit as far as who can take or purchase Plan B over the counter at these pharmacies. And really, there's no reason why a woman can't take Plan B. The thought is that it's that there are no medical conditions that outweigh the benefits of taking and using emergency contraception.

Dr. Jones: Right.

Dr. Kaiser: The only aside to that is that there may be a little less efficacy if you weigh over 165 pounds.

Dr. Jones: Okay. Well, then let's talk about ulipristal or Ella.

Dr. Kaiser: Yeah. So ulipristal or Ella, also very similar to plan B in that this pill also interferes with the LH surge and prevents ovulation. But it also does this in a slightly different manner. So ulipristal actually blocks the progesterone receptor in the body which is associated with the LH surge and ovulation. So it mainly works through blocking the LH surge, but it may also postpone the release of the egg from the ovary.

So even if your body has already undergone the LH surge, it might be that Ella helps prevent the egg from being released from the ovary. And because of this and how it works in your body, Ella is actually effective for up to 120 hours from unprotected intercourse. The only downside to this one is that you need a prescription from a physician.

Dr. Jones: Now, neither of these, you know, once you take it, it isn't protecting you for days and days after. So you can say, "Well, I've taken it now and maybe it'll help me out. I just will have unprotected sex for the next week." It really doesn't work that way. In fact, that's often why people think it fails is because they kept having unprotected sex.

Dr. Kaiser: Exactly. So you know, like I mentioned, if you have taken it within the 72 hours for Plan B or the 120 hours for Ella, and your body has not ovulated yet, you are going to be protected from that one episode of unprotected sex. If you continue to have unprotected sex, like you said, Dr. Jones, for the remainder of the week, it's not going to work, you're going to need birth control for that.

Dr. Jones: Yeah. Because eventually you're probably going to ovulate, right?

Dr. Kaiser: Correct.

Dr. Jones: Okay. Well, what about the copper IUD? How does that work? And when is it too late?

Dr. Kaiser: Yeah. The copper IUD is actually a really exciting recent development in emergency contraception. So it combines the best of both worlds, like we're just talking about Plan B and Ella aren't going to protect you going forward. It's just for that one episode of unprotected intercourse. The great thing about the copper IUD is that it can give you really effective emergency contraception, and it gives women a long acting, highly effective method of birth control going forward. So this kind of method, once you get it, you can keep having all the unprotected intercourse that you want.

Dr. Jones: But it won't be unprotected anymore.

Dr. Kaiser: Right. Exactly, exactly. Now you have a great method. So we don't actually really know entirely how this works so well as emergency contraception, but we suspect it has to do with creating an inhospitable environment for sperm to prevent fertilization. But copper IUD may also impair implantation of a fertilized egg in the uterus. But again, we're not really entirely sure just how it works.

The great thing about the copper IUD as well is that it can be used for up to seven days following unprotected intercourse. So if a woman finds herself in need of emergency contraception and isn't interested in a pregnancy in the near future, the copper IUD is really a fantastic option.

Dr. Jones: Right. But it's not something you can get over the counter, and it's not something you can use yourself.

Dr. Kaiser: Correct.

Dr. Jones: You need to see someone who's good at putting in copper IUDs.

Dr. Kaiser: Right. So you would need to see a physician who would be able to place this IUD.

Dr. Jones: Or a nurse practitioner.

Dr. Kaiser: Or a nurse practitioner or a PA, whoever is available that has training, who can place one for you.

Dr. Jones: Right. Well, we don't want any woman to have a family planning emergency. We want everyone who isn't planning a pregnancy protected before they have sex. But you know, if stuff happens and now there are some options and some you can get online, check out our Scope podcast on emergency contraception over the internet. And thanks, Dr. Kaiser, for joining us. And thanks, everyone, for joining us on The Scope.

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Dr. Jones: We read in a newspaper that a famous man is taking an anti-hormone to help his hair grow. Now, what's an anti-hormone anyway, and would it make my hair grow? This is Dr. Kirtly Jones from University of Utah Health, and this is The Scope.

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: So guys who have male-patterned hair loss, loss of hair on the temples and the forehead can take an anti-hormone, or a hormone blocker to help slow their hair loss. What's this about? Well, male-patterned baldness is partly genetic, and partly related to testosterone. An anti-hormone drug, in this case Finasteride, blocks the conversion of testosterone to the most active form of testosterone in tissue, 5-dihydrotestosterone.

Finasteride blocks that conversion. Incidentally, it was invented to help shrink the prostate in guys with prostrate problems, testosterone makes the prostate gland grow in men, of course only in men, because women don't have one, but it also works for hair.

Well, what about women? Some women's hair loss is related to the same hormone, 5 DHT in the skin of the scalp. Maybe it would help women. Firstly, the FDA specifically says that women shouldn't even go near the lid of a bottle of Finasteride, the lid with a little drug powder in it. This is because 5 DHT is very important in developing boy babies, boy-baby parts in the uterus. And women who are pregnant who are exposed to Finasteride can have boy-baby part birth defects.

What happens if a woman is beyond her child-bearing years and cannot get pregnant, and wants to use Finasteride? Well, it still isn't approved for women, and it doesn't work for hair loss in many women, but there are some studies that it works for some women.

Can a doctor prescribe an FDA-approved drug that isn't approved for women? Legally, she can, but she would have to be really careful about who she prescribes it for and who might take it.

But let's get back to anti-hormones, specifically anti-androgens and anti-estrogens. Anti-hormones, or hormone antagonists, can work either by blocking the production of a hormone or blocking the receptor of the hormone. One of the progestins, called drospirenone in a commonly prescribed birth control, has mild anti-androgen activity because it mildly blocks the testosterone receptor. So it's good for women with acne, but I wouldn't recommend it for men to help their hair grow.

Anti-estrogens are used in a number of conditions for women. Women with breast cancer are often prescribed a drug that blocks the conversion of testosterone to estrogen. Yep, ladies, we make our estrogen out of male hormones. One of these medications is called Letrozole. It turns out that in young women who have ovaries with eggs, but who aren't ovulating, if they take an anti-estrogen, their brain thinks their ovary isn't working and it yells at the ovary to make eggs and estrogen. So this drug is also used for ovulation induction, even though it isn't approved for that use.

Clomiphene is an anti-estrogen because it blocks the estrogen receptor so estrogens can't do their work. It works differently that Letrozole, but they both are anti-estrogens, and they're both used for fertility therapy.

Tamoxifen is commonly used by women with breast cancer, and to decrease the risk of breast cancer in women who are a high risk. It is sort of an anti-estrogen. It blocks the estrogen receptor so estrogen cannot do its work, but it's sort of a weak anti-estrogen. It works differently in different tissues. In the breast and the brain, it acts like an anti-estrogen, so breast cancers don't grow, and women have hot flashes. In the bones in the uterus, it sort of acts like an estrogen, so it keeps women's bones strong. It's complicated.

So why do you need to know about anti-hormones, except to understand famous men's hair issues? These types of drugs are commonly used for women, for infertility, for some types of contraception, for some menopausal therapy, and for some cancer therapy. They all have some side effects. A smart Scope listener should explore how their medications work, and what kind of side effects they have.

Ask your physician. They probably can give you handouts or websites that can explain more, and health researchers actively looking at new anti-hormones, that might help women and men in health and disease. Thanks for joining us in this little lesson on hormones on The Scope.

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Dr. Jones: What's new in the treatment for menopausal symptoms? This is Dr. Kirtly Jones from obstetrics and gynecology at University of Utah Health Care, and this is The Scope.

Announcer: Covering all aspects of Women's Health, this is the seven domains of women's health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Before the 1960's there wasn't much for the treatment of menopausal symptoms. In the 1970's we found out that women who took just estrogen, had a greater risk of uterine cancer and women and physicians were hesitant to prescribe. In the 1980's and 90's we learned about all the benefits of estrogen and added progestin to protect the uterus, and lots of women took hormones for menopausal symptoms. In 2000, the results of the women's health initiative suggested that women over 60 who took hormones had a higher risk of breast cancer and heart disease. You should be asking yourself what does "higher" mean? For Scope listeners, and prescriptions dropped off.

The North American Menopause Society's older guidelines suggested that the lowest dose of hormones for the shortest period of time, should be offered. And many clinicians only offered for hormonal therapy for five years, but now we have new guidelines informed by research from the past ten years. So what is new now?

What's new isn't really new to those of us who've practiced menopausal medicine. What's new is that the decision to take hormonal therapy for menopausal symptoms or non-hormonal therapy for menopausal symptoms is a conversation that takes more than just a few minutes in your clinicians office. The clinician must be informed about the real numbers involving risks and benefits of hormone therapy and they must have the time to talk to the patient about her symptoms, her options in therapy, her benefits and her risks. And because menopause symptoms change over time, the conversation should happen every year. Most women can safely use hormones if they want and hormones shouldn't be discontinued just because of a women's age. It's an individual risk/benefit analysis.

So this is what often happens. "My period stopped and I'm having terrible hot flashes". The clinician says, "Just wait, they'll go away soon." Well, that's not necessarily true, hot flashes persist for an average of 7.4 years. Some women will feel better in several months but the majority of women with troublesome hot flashes will have them for years.

Another, "I'm only 55 and my bone density shows that I have thin bones. What should I do?" Well here's a prescription for a medicine that will block bone thinning. No, it isn't hormone." Well, drugs like bisphosphonates do decrease bone thinning but they have their own risks and benefits and for young women, meaning within ten years of menopause, estrogen might be a good choice. And estrogens are FDA approved for the prevention of bone thinning. Estrogens have the benefits of protecting bones, treating hot flashes and vaginal thinning that causes pain with intercourse.

For the two main symptoms of menopause, hot flashes and vaginal dryness, estrogen is the best therapy. The new "North American Menopause Society's Guidelines" outline the importance of individualizing therapy for each woman. Looking at the options, discussing the symptoms and the patient's own biology. There are few if any absolute contraindications to hormonal therapy. It's all risk/benefit discussion. If the risks are small and the benefits for the woman is great, than the options should be open. The first ten years after menopause, the last period, are the years when the benefits are the greatest and women who had early menopause for whatever reason might have significant benefits of taking hormones for longer.

Dr. Joanne Pinkerton, who's the executive director of the North American Menopause Society and is the lead author of the new guidelines said, in an interview, "We want to remove the fear of using menopausal hormone therapy for healthy women under 60 and within ten years of menopause and make sure the benefits and the risks are discussed with women in an appropriate way."

What should you do if you're significantly troubled by menopausal symptoms? For those of you who are just getting started, if you're babies about menopause, there is a lot of not very scientific information out there on the web. Be careful and if you need menopause basics go to menopause.org/forwomen. For those Scope listeners who are data driven, you can go the website for the North American Menopause Society which is menopause.org and look at their treatment guidelines and clinical care recommendations. They are free for non-members, and there are guidelines on menopause therapy, treatment of vaginal thinning and non-hormonal treatments for menopause that actually work and which ones don't work.

If your clinician isn't a specialist in menopause, these guidelines are available to them too. Be prepared for your visit for with your doctor. What are your symptoms? How much do they bother you? What is your medical history? And what are your fears and concerns and hopes? Clinician time can be limited, but if your questions aren't answered or you need more time, make another visit. But coming prepared will help you and your clinician focus on your needs. For the many main symptoms of menopause, there are lots of options, and there is something that will work for everyone. You can feel better, and being informed is a really great start.

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Dr. Jones: All of us who've had menstrual periods know that we feel a little different in our bodies in the days around the start of our periods. We have what is called catamenial symptoms, symptoms around the period, but sometimes something big happens. This is Dr. Kirtly Jones from of obstetrics and gynecology at University Health Care and we're talking about catamenial catastrophes today on The Scope.

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women Health, with Dr. Kirtly Jones, on The Scope.

Dr. Jones: The hormonal events at the start of the period are a big deal. Estrogen and progesterone levels made by the cyst that created the egg for that month were high the week before the period. If no pregnancy happens, these hormones drop rather quickly and that signals the uterus to make prostaglandins, a chemical that causes the uterus and the blood vessels in the uterus to contract and that starts the period.

These are normal and natural events, but they may cause cramping and occasionally nausea and vomiting and diarrhea, sometimes even fainting. But for some women with other medical problems, the drop in hormones and the rise in prostaglandins can exacerbate other conditions. Asthma and seasonal allergies can get worse. Some skin conditions, including eczema and hives can get worse around the pre-menstrual time.

But I use the word catamenial catastrophe and I made up that term, for things that can really go wrong and here are a few. Catamenial migraine, now this is really pretty common. About 15% of women have migraine and many of those women have predictable migraine with their periods. Catamenial migraine may be triggered by the change in hormones, or it may be the prostaglandins. For some women, it's the only time they have migraine. Migraine is one of those headache conditions that tendsto get better after menopause. No more periods, but for migrainers, that's the name of someone with a migraine, the monthly migraine can be very disruptive.

Catamenial epilepsy, seizures that occur just before or on the first day of the period. This happens to women who usually already have a seizure disorder, but they predictively have seizures about the time of their period. There are some women whose seizures start in adolescence when their period started, and some people have all of their seizures controlled with medications, but just not the ones that happen when they have their period.

Catamenial pneumothorax, this is a biggie. A pneumothorax is when there's a hole in the surface lining of the lung that lets air out underneath the ribs. With each breath, the air is trapped, making the lung get squished smaller and smaller. We're not exactly sure why this happens, but it can be associated with endometriosis on the surface of the lung that bleeds when the period starts and makes a hole for the air to leak out. Compared to the first two catastrophes, this one is rare and it can really be a catastrophe, requiring medical intervention to get the air or blood that's compressing the lung. Rare means about one in 100,000 women per year and that's really pretty rare.

Catamenial anaphylaxis, now, anaphylaxis is an acute reaction that is usually allergic that can cause hives, itching, swollen airways and difficulty breathing, low blood pressure and fainting. Catamenial anaphylaxis is really rare and it isn't probably an allergic reaction, but it is a reaction to the prostaglandins made by the uterus, which is also made in the ordinary kind of anaphylaxis. This is so rare, it hasn't been studied much.

If you think you have a big problem associated with your periods, who should you see? Your doctor who's helping you with your migraine, seizures, pneumothorax or anaphylaxis should consult with an OBGYN, preferably a reproductive endocrinologist, omeone who specializes in women's hormones. Together, they can figure out if it's really consistently related to the periods. Often, women say, "Oh yes, it happens before my periods and during my periods and after my periods."

For women with a 28-day cycle, that means it happens all the time so that's not really period-related. In some cases, it's appropriate to stop the periods and there are several hormonal ways of doing this. The good news is that once the connection is made between the period and the catastrophe, there are a number of options available. It makes cramps and crabbiness seem not so bad, huh? It makes the menopause sound better and better every day.

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Interviewer: Puberty's over, but you still have acne. Is this normal? We'll find out next on The Scope.

Announcer: Questions every woman wonders about her health, body, and mind. This is, Am I Normal? On, The Scope.

Interviewer: I'm here today with Dr. Kirtly Parker Jones, she's the expert on all things woman. Dr. Jones, I have one question that's on my mind. I feel like it's on the mind of a lot of other women. My teenage years are over, I'm supposed to be done with acne, but I still have them. First of all, why is acne happening, and is it a normal thing?

Dr. Jones: It's important for the listener to understand, I'm not a dermatologist. I am a reproductive endocrinologist, so I am a ladies hormone doctor. Acne is related to hormones. So what happens is that your skin makes oils, and the little hair follicles that you have on your face make oils. But when you go through puberty, both men and women start making more male hormones which actually start to make more oils in the skin. Female hormones are also made at the same time, but the oils of the skin then can get infected a little or build up, and that's how you get acne.

So when you're young, and a young male or a young female, your hormones are high, right? Every mother knows that, every teen knows that. And not everyone gets acne, but people who are predisposed to this who have certain kinds of genes, or who have certain kinds of bacteria in their skin, can get acne. Acne's very common in adolescence. So you say, okay fine, your hormones are kind of wacky the first couple years of your periods, but then they settle down and you think "Why do I still have acne?"

Well certainly there are some people who have acne all their life, and those people should see a dermatologist if it's severe acne with big bumps that are very painful and get infected, because there's medication that can calm down your skin. Many young women know, that when they go on the pill for contraception and actually can go on the pill just for their skin, that many of the new pills can calm down the male hormones, and it can significantly improve their skin.

However for women to continue to have significant acne after the first rocking and rolling years of adolescence, they may actually have a hormone problem. Particularly women who also have irregular periods. So there is a condition called polycystic ovary syndrome, about 1 in 20 women have this. It's associated with irregular periods. Eggs that kind of get stuck in development in the ovaries and so they don't grow and ovulate, so their periods are irregular, and these little eggs, these little follicles that make the eggs make male hormones. So women with this condition often have irregular periods and persistent acne. So this may carry on, and it's worthwhile talking to your clinician about it, because in fact, there are things that can make your face better. So that's the good news.

Interviewer: If it's related to hormones, do I have to see a dermatologist then?

Dr. Jones: I think if it's something which isn't the most severe kind of what we call cystic acne, that's going to take a medication that only dermatologists prescribe. It's not uncommon, particularly during the early teenage years, when women have acne and they have irregular periods. For their moms to bring them in maybe for their very first visit to the gynecologist and say, "You know gosh she's got acne, and she has irregular periods and I had that when I was a teen and I went on pills and my face just cleared up beautifully." I say "Great. If it's the right thing for your daughter, we can do that now." So that's an appropriate choice.

Interviewer: So what I'm hearing is, your hormones are kind of out of whack during your teenage years and that's the main reason why young girls and guys get acne. But then what happens when you grow older say in your 20s or 30s, even into your 40s and 50s and you still have acne, is it still because of your hormones?

Dr. Jones: Well it's still hormones in the sense that it's still hormones that are active in your face. However, everybody makes hormones during the reproductive years and men continue to make hormones all their life. So the question is, if you have continued to may have acne after adolescence, then it's worth seeing a dermatologist or and a gynecologist, who can sometimes work together to come up with the right hormone package for you, and the right anti-acne package for you. So here's, here's the other thing. So just as hormones are a little bit wacky at the beginning of reproductive life, they get that way at the end too. And about 10% of women going through menopause get acne again.

Interviewer: Wait you get acne during menopause, is this a Dr. Kirtly Jones problem, or is this still a dermatologist problem?

Dr. Jones: So if you get acne after, when you're going through menopause, it's probably both, in a sense that for certainly menopause women are at the age when they want the dermatologist to look at their skin so they can get a skin check. But a skin check by dermatologists is often just an excuse for someone to say, "Oh I have acne, my skin's not great, but can you look at these wrinkles right here, what can I do about that?" '

In fact, the transition into the perimenopause can cause acne again, because women's hormones are a little disrupted. Again, women may actually stop making as many ovulations, they may make a little bit more male hormones. The other important thing is the dermatologist can separate what is acne from what's rosacea.

Interviewer: Okay.

Dr. Jones: So there's another condition of the skin common in women of menopausal years that can look like acne in that it's red and it's bumpy.

Interviewer: It's not.

Dr. Jones: But it's not. You don't treat it the same way. Now, for women who are going through menopause who get acne, the good news is, as they get older, the ovaries stop working entirely and in general it gets better. The other news is that some women who go on hormone replacement therapy, estrogen and progesterone or estrogen alone if they don't have a uterus, they often notice that their skin gets a little bit better because they're balancing things out a little bit.

So, A, your dermatologist can help differentiate what's acne from what's rosacea, a bumpy condition where your skin gets quite red, and it gets a lot redder when you have hot flashes. That's no fun. And they can make that difference and they can help guide you in terms of what might be the best therapy. And ladies, I've never seen a 70-year-old with acne so good news from that.

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