MENOPAUSE AND ESTROGEN DEPRIVATION

 

 Menopause Specialist in NYC Dr Steven R. Goldstein is a past President of the International Menopause Society, past President of the North American Menopause Society, a Certified Menopause Practitioner and co-author of the books “Could it be….Perimenopause?” and “The Estrogen Alternative”.  

 

There are very real medical issues that accompany estrogen deprivation after there is no more ovarian function (the medical definition of menopause). Other higher order primates live a very short time after they stop reproducing. My patients will spend more than 40% of their lives in a post reproductive state. There are very real consequences medically of the lack of estrogen production that menopause brings.

 

Loss of bone mass occurs quite rapidly, and osteoporotic fractures are a significant medical issue as the population ages more and more. A 50-year-old woman who does not already have cancer or heart disease has a life expectancy of 91. If a woman suffers a hip fracture her chances of being dead within the next year are 20–30% and she has a 25% chance of never living independently again.

 

There are also serious changes in the vagina as a result of a lack of estrogen. A change in the normal bacteria causes diminished production of lactic acid and thus the pH will change dramatically, as does the cell count. This leads to dryness and lack of normal lubrication which, in patients who are sexually active, can result in severe discomfort.

Almost all of you are aware of the symptoms of hot flashes and night sweats, the most common of the menopausal transition. Fortunately, for the majority of women, these will ameliorate by 4–5 years, although some women will have these indefinitely. In addition, lack of estrogen can result in joint pains.

 

After the Women’s Health Initiative published its findings in 2002 showing that estrogen plus progesterone therapy caused an increase in breast cancer and heart disease, 50% of women stopped their hormones immediately but 25% went back on. The most common reason for resuming was hot flashes and night sweats as you would think. The second most common reason was joint pains. Furthermore, menopause, with its lack of estrogen, on average causes an increase of 15 -20% in total cholesterol and LDL cholesterol (the bad cholesterol). In addition, estrogen helps promote lean body mass and after menopause women tend to accumulate more fat centrally (that old “midriff bulge”).

 

I am not trying to medicalize menopause. However, we cannot ignore the effects of estrogen deprivation on a variety of organ systems especially as women are living longer and longer. There are new approaches to replacing estrogen without the use of progesterone. As evidenced by the Women’s Health Initiative, it is the addition of progesterone in order to protect the uterus that seems to be the culprit in causing most of the negative findings. These new approaches are, in my opinion, much safer than what we’ve done for the past half century. They involve combining the estrogen Premarin with a different category of drug than progesterone. That category is SERM (selective estrogen receptor modulator). There are a number of SERMs already on the market for breast cancer prevention and prevention and treatment of osteoporosis. 

 

In summary, yes menopause can and should be a time of healthy aging and continued productivity and personal satisfaction indefinitely. The pros and cons of replacing estrogen need to be individualized and discussed on a case by case basis. 

 

If you are a woman going through Menopause or approaching Menopause, then a consultation with Dr Goldstein, a hormone specialist in NYC, may be in order

 

HOW OFTEN SHOULD YOU HAVE A PAP SMEAR?

 

 

Dr Steven R. Goldstein, a leading Gynecologist in NYC highly recommends that women have a Pap Smear as part of their gynecological exam. Dr Goldstein says that the pap smear is one of the single biggest success stories of modern medicine (barely behind the discovery of polio vaccine). 

 

The number of cases of invasive cervical cancer in this country has fallen dramatically over the last 60 years mainly because of the pap smear.  Currently, 50% of new cases of cervical cancer today are in women who have never had a pap smear and another 10% in women whose pap smear is abnormal, but have never bothered to follow-up!  In Dr Goldstein’s 25 plus years of practice he has had two cases of invasive cervical cancer and both of those women walked into his office with the disease already.  No one who has been under his care has developed invasive cancer.

 

Dr Goldstein, a NYC Gyn, writes: Several years ago, the USPSTF (United States Preventative Services Task Force) made the recommendation for less screening in women. That decision to reduce pap smear frequency is strictly a financial one, called a cost-benefit ratio.  They did this in England years ago.  They knew that there would be more cases of cervical cancer, but it was felt that it was cheaper to treat the small incremental increase in the number of cases of cancer than it would be to screen every woman annually.   I suppose if I were the Secretary of HHS (Health and Human Services) I too might be looking at the population as a whole, but as your physician I’m only concerned with you.  Let me explain:

 

If a woman has a hysterectomy for an advanced pre-cancer then the system considers that a victory because she never developed invasive cervical cancer.  If one of my patients were to have such an advanced premalignant lesion that she required a hysteroscopy, I would feel that I had failed her miserably.  My goal is to pick up abnormalities at a stage where they can be treated much more simply than with surgery as radical as a hysteroscopy.  I guess it depends on whether you believe my job is to 1) put out forest fires, 2) put out brush fires, or 3) blow out matches.  I prefer to blow out matches.

 

Finally, my biggest concern is that if the message is "you do not need a pap smear," many women will assume that they do not need a visit to the gynecologist.  Many women have come equate the pap smear with the visit.   Thus, if there is no need for a pap, they would feel that there is no need for a visit.  Nothing is further from the truth.  A visit to me is important for a myriad of reasons including the breast exam, blood pressure check, concerns about bone health, vaginal health, contraception, menstrual function, and in my opinion, perhaps most importantly, a transvaginal ultrasound evaluation of your ovaries and uterus.

 

Dr Steven R. Goldstein, a Gynecologist in NYC, likes to see his patients every six months. If they develop HPV, he’d like to know as soon as possible so that the HPV can be monitored so it does not become cervical cancer.

 

THERE SHOULD BE NO BLEEDING AFTER MENOPAUSE

 

Dr Steven R. Goldstein MD, a leading gynecologist in NYC, is a Certified Menopause Practitioner, a past President of the North American Menopause Society (NAMS), and past President of the International Menopause Society. He is also a former Director of Gynecologic ultrasound at NYU Langone Medical Center, and a past President of the American Institute of Ultrasound in Medicine.

 

Dr Goldstein’s skill and knowledge of gynecologic ultrasound combined with his knowledge of menopause makes him unique in the field menopause practitioners

 

As a menopause specialist in NYC Dr Goldstein regularly has patient encounters with menopausal women who are bleeding. This should never be the case since their ovaries are no longer functioning and therefore not making any estrogen or progesterone. Any post menopause bleeding must be evaluated at once, and be considered “uterine cancer until proven otherwise”.

 

Dr Goldstein uses painless Transvaginal Ultrasounds and Sonohysterograms to rule out uterine cancer, hyperplasia and polyps. These simple, inexpensive transvaginal ultrasounds produce very clear, high resolution images and allows Dr Goldstein to see detail on the endometrial lining and make an accurate diagnosis as to whether it is the cause of the post menopausal bleeding. You do not need to have needless, painful diagnostic surgery in order to determine your condition.

 

Regular sonograms employ a transducer rubbed on the abdomen. With a transvaginal ultrasound, very high frequency probes are placed in the vagina and image pelvic structures such as the and ovaries with greater magnification. These transvaginal ultrasounds (also called vaginal sonograms) do not only tell about the anatomy of the uterus, ovaries and fallopian tubes, but also their physiology, that is, their function and whether hormonal function is normal.

 

Dr Goldstein, a menopause specialist in NYC points out that the original observational studies in postmenopausal women with bleeding consistently found that an endometrial echo on transvaginal ultrasound <5 mm was associated with lack of significant tissue. Multiple large, prospective trials, mainly out of Western Europe, caused the American College of Obstetrician and Gynecologists in 2009 to opine that “when present, a thin, distinct endometrial echo on transvaginal ultrasonography 4 mm or less has a risk of malignancy of 1 in 917 and, therefore, endometrial sampling is not required.”

 

With uterine cancer ruled out, the post menopausal bleeding can be caused by what is known as Endometrial atrophy, where the endometrial lining degenerates and becomes very thin in a post menopausal woman. This is because of a lack of estrogen.

 

If you are in menopause and experiencing bleeding, please schedule a consultation with Dr Steven R. Goldstein, a menopause specialist in NYC  immediately to determine whether your condition is because of a thin endometrial lining or something more serious. Bleeding in post menopausal women must be examined immediately and considered uterine cancer until determined otherwise.  

 

 

CONSIDER THIS BEFORE ANY INVASIVE GYNECOLOGICAL SURGERY

 

 Women with complaints of abnormal uterine bleeding, heavy menstrual bleeding, menorrhagia, ovarian cysts, thick endometrial lining, fibroids and so on who have been recommended for painful biopsies, exploratory surgeries or Dilation and Curettage (D&C) should opt for painless Transvaginal Ultrasounds or Sonohysterography says  Dr Steven R. Goldstein MD, an expert Gynecologist in NYC for a second opinion before any gynecologic surgery.

 

These procedures are painful, expensive, require anesthesia and recovery time and not guaranteed to properly diagnose the cause of bleeding or other conditions. Surgery should not be the first method of diagnosis.

 

Dr Goldstein prefers using non-invasive methods for diagnosis and treatment instead of blind endometrial biopsies or unnecessary and painful surgeries. In 1989 Dr Goldstein was the first to suggest that simple cysts in postmenopausal ovaries were benign and did not require surgery. This became the standard of care in 2009.

 

Since 1995 Dr Goldstein has argued against blind endometrial biopsies, instead recommending saline infusion hysterograms. This was finally endorsed by the American College of Obstetrics and Gynecology (ACOG) in 2012.

 

In 2004 Dr Goldstein was the first to warn against unnecessary biopsies in nonbleeding postmenopausal patients with an incidental finding of thick endometrial lining. This was affirmed by ACOG in its practice bulletin in 2009, and reaffirmed in 2015.

 

Instead of painful exploratory surgeries, Dr Goldstein, a top gynecologist in NYC uses non-invasive methods such as Transvaginal ultrasounds (water sonograms) and Sonohysterography to obtain clear images of the ovaries, fallopian tubes, uterus and endometrial lining. Dr Goldstein performs each of these procedures himself and does not delegate it to a technician.

 

For instance, with abnormal uterine bleeding, it may be caused by hormonal factors, which Dr Goldstein can easily detect using the 2 non-invasive methods.

 

Upon conclusion and review of the images from Transvaginal Ultrasounds or Sonohysterography, Dr Goldstein sits personally with each patient to discuss the findings for their condition and discuss possible treatment options.

 

Doctor Steven R. Goldstein MD is one of the nation’s top Obstetricians and Gynecologists and is well known internationally for ground breaking work in gynaecological ultrasound and imaging. He is regarded as one of the nation’s top doctors in Gynecology. He is a Professor of Obstetrics and Gynecology at New York School of Medicine, served as former Director of Gynecologic Ultrasound at New York University Medical Center and is a past President of the American Institute of Ultrasound in Medicine.

 

If you are suffering from abnormal bleeding, heavy periods, post menopausal bleeding etc. do not opt for painful exploratory procedures or surgeries. Instead you may contact Dr Goldstein, an expert NYC Gyn  at his New York office to schedule a consultation

 

IS THERE ANYTHING WOMEN CAN DO TO AVOID PERIMENOPAUSE?

 

Dr Steven R. Goldstein is a Perimenopause Specialist in NYC who has helped thousands of women navigate the difficult stage of life called Perimenopause (the decade or so before menopause). Some patients ask whether there is anything a woman can do to delay the onset of Perimenopause, perhaps because their mothers and old sisters went through menopause in their forties.

 

It is impossible to say how much of perimenopause / menopause is genetic. Certainly, when a woman says that her mother and both of her older sisters went through their “changes” in their early forties, it is understandable why she thinks she will as well.

 

Dr Goldstein usually tells his patients that genes are incredibly powerful. Although menopause is not like blue eyes (if your mother and father both have blue eyes, you will definitely have blue eyes), one should never underestimate its hereditary component. However, there is no question that most things have a genetic predisposition and then need environmental influences to cause their expression.

 Some of the other factors that seem to be good predictors that a woman will reach menopause slightly younger than her peers include:

  

 Smoking cigarettes, especially more than half a pack a day

·        Being more than ten pounds underweight
·        Having had surgery to remove all or part of an ovary
·        Having been treated for cancer with chemotherapy or abdominal-radiation therapy.

 

The median age of the onset of perimenopause is 47.5, though it can start earlier or later. As many as 70 percent of women in their forties experience a change in their menstrual cycles. About 35 percent of women experience their first episodes of depression during perimenopause. Twenty to forty percent complain of sleep problems. Up to fifty percent ultimately experience hot flashes as they get close to actual menopause. And yes, there are women who experience nothing at all. There are also women who do not attribute these symptoms to their changing patterns of ovulation and never seek medical intervention or even tell their medical doctors about what they’re experiencing psychologically.

 

All in all, there are many women who avoid the roller coaster of transition or whose symptoms are very mild.

 

Dr Steven R. Goldstein,  a Perimenopause Specialist in NYC, and past President of the International Menopause Society, past President of the North American Menopause Society, is a Certified Menopause Practitioner and co-author of the book “Could it be….Perimenopause?” If you are a woman in her late thirties or forties and going through this phase of subtle symptoms such as period irregularities, then a consultation with Dr Goldstein may be in order.