Search for tag: "hormones"

Hot flashes, they are hard to describe and women experience them differently, and it's been a really long, hot summer. But what if that summer lasted 15 years?

All women who live long enough and it really isn't all that long, just to about 51, will have their ovaries stop working. When that happens, estrogen levels fall. And about 85 percent of women who make that transition from ovaries on to ovaries off will experience hot flashes.

The baby boomers, formerly the largest generation in the U.S., now replaced by the millennials, are aging and 6,000 women in the U.S. enter menopause each day. By the year 2020, coming right up, about 50 million women in the U.S. will be post-menopausal, one-third of all women in the U.S.

The two signature symptoms of estrogen withdrawl are hot flashes and vaginal dryness, and both are treated pretty well by estrogen. Many women are not distressed by these symptoms and good for them.

But AARP, formerly the American Association of Retired Persons—but as not all members are retired, they are just AARP—anyway, AARP did a menopause survey of their female members between 60 and 69, and 72 percent said that menopausal symptoms interfered with their lives and eight percent said it interfered a great deal.

Now, these women were actually about 10 years from their menopause. And when their ovaries stopped working 10 years ago and they're still having symptoms, 20 percent said that they had vaginal dryness, 24 percent had hot flashes, and 23 percent night sweats. Of course, some had all three symptoms and some had none.

Women with severe hot flashes typically experience them for seven to 15 years, and 15 percent of women with severe hot flashes experience them for more than 15 years. Now, what in the brain makes this hot flash happen? Do only women get them?

Recently, some very cool research on hot flashes was done in mice, and they found that the KISS1 neurons, kiss isn't that cool, KISS1 neurons that are part of the brain that make up the ovaries and testes work, so these KISS1 neurons make the ovaries and testes work, actually have their feet on the ground in the part of the brain that controls temperature.

These KISS1 neurons in mice work the same way that those neurons work in humans. Activating KISS1 neurons initiated a fast rise in the mouse's skin temperature followed by a drop in core body temperature. The same symptoms occurred in male and female mice. Removing the female mouse's ovaries made this temperature swing worse. We know that men that had their testes removed or who take medication for prostate cancer that makes the testes stop working can have hot flashes.

Now, we don't know if the mice who experienced these changes in their body temperature experienced distress, but some other studies suggest that they seek out cooler places in their cages. We don't know if they have spikes in anxiety or irritability, or if they're having hot flashes and they're getting angry, but that would be an interesting experiment to do.

Hot flashes at menopause may have more complex neuron functions than just KISS1, and about 15 percent of normal women never have hot flashes with menopause. So it's complicated. But understanding some of the brain's mechanisms might help us to think about new therapies.

Now, back to that survey from AARP, 46% of the women surveyed said that they had never discussed menopause with a health care provider, and only 1 in 12 had been referred to a menopause specialist. So what's the takeaway from all these numbers?

One, most women who experience menopause will have hot flashes.

Two, most women who experience hot flashes will tolerate them.

Three, most women with hot flashes will find that their flashes decrease in a couple of years. That sounds like a long time to me in a long, hot summer with hot nights.

Four, about one in eight women will have significant distress from their hot flashes and they'll go on for a long time. For 50 million women who will be post-menopausal in 2020, one in eight of 50 million is a lot of women.

Five, women who bring to their experience of menopause all the physical, social, cultural, environmental, emotional, financial, and spiritual experiences. In other words, hot flashes can be wrapped up in all of the seven domains of women's health.

Six, there are quite a few options other than estrogen, which works best, for managing hot flashes, and most clinicians don't know about all of the options.

Seven, if you are suffering from hot flashes that seem to go on and on and on, the longest summer ever, talk to your clinician. Ask them what is their training in menopause and ask what they know about different options. If you try some of the options they offer and you're not getting better, or if you don't like the side effects of the options, you should seek out a menopause specialist.

Eight and last, many specialists called reproductive endocrinologists have training in menopause. And some physicians, primary care providers and OB/GYN's have a special interest in understanding menopause and caring for women who are having difficulties. Some clinicians have made it their special interest in their practice. It could be a search, but your doctor probably knows where you can get help.

At University of Utah Health, you can use our app for finding a doctor who has an interest in treating menopause symptoms. That will get you started. The most important thing is that we're learning more and developing and understanding new options. So no big sweat, and thanks for joining us on The Scope.

updated: November 12, 2020
originally published: September 6, 2018

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: 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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Dr. Kirtly Parker Jones: Period. The punctuation at the end of a sentence that the Australians call the full stop. An amount of time in a high school day. Third period. Lots of other meanings. But to women, it means their menstrual period, and it assumes some periodicity, regularity. But what if it isn't regular? Is that normal? Or is there a problem? This is Dr. Kirtly Jones from the Department of Obstetrics and Gynecology at University of Utah Health Care, and this is The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Kirtly Parker Jones: My mother's generation called it my friend or falling off the roof. I remember the first time that I was in clinic in Boston and a patient's chief complaint was that her friend didn't come. My question to her was "Was there a problem with her travel plans? Was the train cancelled?" The young woman looked at me as if I were really clueless, and I was. What she meant was that her period was late. So is this a problem? What should you do about it?

Menstrual periods are called regular when the time between them is between 24 to 35 days. Women who have a 26-day cycle one month and a 31-day cycle the next are still called regular. Early in our evolution as humans, women were either pregnant, breastfeeding, or starving, all of which made periods absent or irregular. Today's idea that periods should be regular has only been part of our biology since we were well fed and life wasn't so calorically risky. Before several hundred years ago, most women on the planet were often at the lower limits of caloric intake, and periods were usually irregular.

All women are irregular at the beginning and the end of reproductive life. At the beginning, about 11 to 13, it takes about six months to get the system going, and irregular is the norm. If a woman hasn't achieved some kind of regularity in three years, there may be a problem. At the end of reproductive life, the perimenopause, 92% of women are irregular as the system grinds to a halt-menopause. But in between, women who were regular and then become irregular might want to see their clinician after the pregnancy test is negative. If it's positive, they should certainly see their clinician.

Common life changes can change a menstrual cycle. Weight gain or loss of as little as 15 pounds can disrupt the system. If the weight gain or loss isn't extreme or end up with women at the extremes of thinness or fatness, periods often settle themselves out again if a woman was regular before. Emotional or physical stress can disrupt a menstrual cycle for a month or two. Of course, if the illness is severe and ongoing, the disruption may continue.

Some women choose to limit the number of periods they have by their contraceptive method they use. Some contraceptive methods are associated with no periods or very light periods, and this is fine as long as this is a contraceptive effect. Some women manipulate the use of their contraceptive pill or patch or ring so they can take them continuously without a period break of one week each month, and these women choose to have their period every three months or six months or not at all.

So if you were regular and now you're not and none of the previous things apply, what could be going on? All of your brain hormones, thyroid hormones, and ovarian hormones have to be in sync to have a regular period. So women who become irregular should have a medical history and physical exam and have a couple hormones checked, their thyroid hormone and another hormone from the pituitary called prolactin. If these hormones are abnormal, things are pretty easily fixed. Of course, there are less common hormone problems, but your clinician can evaluate you for these if there are some clues from the medical history or the physical.

Some women run out of eggs early-premature menopause-either because they have an underlying condition that we understand to cause this or for no good reason. If periods become very irregular in a woman's thirties for no good reason, stress, weight gain or loss, pregnancy, etcetera, all that stuff we've talked about before, then the doctor might check a hormone called FSH, follicle-stimulating hormone, and see if it's high, suggesting there might not be so many eggs to grow and create the menstrual cycle.

So your friend didn't come and your pregnancy test is negative. Give it a month or so. But if she still didn't come, give your doctor's office a call, and we'll check it out. This is Dr. Kirtly Jones, and thanks for joining us on The Scope.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.

Dr. Kirtly Parker Jones: Taking estrogen after menopause. Does it solve all the problems of postmenopausal women? Or does it poison you and give you cancer? For the past 60 years women have been hearing both of these points of view. So what do we know today? I'm Dr. Kirtly Parker Jones, professor of OB/GYN at University of Utah Health Care, and this is The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Kirtly Parker Jones: In the 1950s and '60s, women were told that postmenopausal estrogen would make them feminine forever. In the '70s they were told it would give them uterine cancer. In the '80s and '90s we were told that it would keep our hearts healthy, our bones strong and help our hot flashes and sex lives. But we needed to add another hormone, progestin, if we had a uterus, to protect us against uterine cancer. In 2000 we were told that it would increase the risk of heart disease, breast cancer, blood clots and strokes, so we shouldn't take it, or at least for just a short time.
This pill is good, this pill is bad, this pill is just right; Goldilocks does menopause. Put on your thinking cap and get ready to do the numbers.
One, since 1976 almost 250,000, that's a big number, a quarter of a million, nurses have been recruited into the nurses health study, to follow women as they age and see what contributes to health and what to illness. Hormone replacement was associated with a healthier heart, better bones, less colon cancer, more blood clots and more breast cancer. Women starting hormones by choice were in their early 50s. In the women who elected to take estrogen there was 1 fewer heart attacks per 1000 women per year, 1 fewer bone fractures, 1 fewer colon cancers, there was 1 more breast cancer per 1000 women per year and 1 more blood clot per 1000 women per year.
In the mid '90s about 10,000 women, a big number, who were mostly healthy and on average 62 years of age, were randomized taking estrogen and progestins every day and they didn't know what they were taking, nor did their doctors, or placebo. They were followed for about 5 years. The results were the same except there was 1 more heart disease per 1000 per year in the hormone group, instead of 1 less. But the women were older. And there were no extra deaths in women who took estrogen or who didn't.
So what is Goldilocks to do? If Goldilocks is having trouble with some hot flashes, night sweats or vaginal dryness and she doesn't have a contraindication to estrogens, like breast cancer or blood clots, she should do what makes her feel better. Estrogens and progestins to protect the uterus is associated with 3 to 4 more bad things per 1000 women per year, and 3 to 4 more good things per 1000 women per year, so it comes out about equal. And for women with estrogen related symptoms, their quality of life is a lot better. But estrogens after menopause will not make Goldilocks thinner, or fatter, or more likely to look like Suzanne Somers, who's had a lot of help, will not solve global warming or congressional bad behavior, but she will feel better and be able to sleep well and think more clearly about these problems.
This is Dr. Kirtly Jones and thanks for joining us on The Scope.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.