THE LATEST ON HORMONE REPLACEMENT THERAPY

 

 

Dr Steven R. Goldstein MD is a past President of the International Menopause Society, a past President of The Menopause Society, and a Certified Menopause Practitioner. A Past Chairman of the American College of Obstetrics and Gynecology (ACOG), Dr Goldstein was the author of their practice guidelines on SERMs (Selective Estrogen Receptor Modulators), a form of hormone replacement therapy (HRT). In private practice for over 35 years as a Menopause Specialist in NYC, Dr Goldstein has helped thousands of patients combat the symptoms of Menopause by using SERMs.

Here is a summary of what these SERMs are in HRT and how they can be used by women to alleviate the symptoms of Menopause while protecting other organs.

A SERM (selective estrogen receptor modulator) is a molecule that combines to the estrogen receptor and produces estrogenic effects in some tissues like bone, vagina, sometimes uterus, while being an estrogen blocker in other tissues – breast, sometimes uterus. There are a number of SERMs, many of which you have heard of and some which you have not. 

 

TAMOXIFEN

The original SERM was tamoxifen. Most of you have heard of this as a breast cancer drug. It binds to estrogen receptors in the breast and acts as an anti-estrogen. It also acts as estrogen in bone metabolism; thus it is good for protection against breast cancer and helps maintain bone health.

Any bleeding whatsoever in a patient on tamoxifen has to be reported immediately and must be evaluated because a very small number of women will develop endometrial cancers and precancers while on it. More women will develop benign endometrial polyps.

 

RALOXIFENE

Originally marketed as Evista but now generic, is a cousin of tamoxifen without the baggage in the uterus. It acts as an anti-estrogen in breast and estrogenic in bone. In 1997, it was approved for prevention and treatment of osteoporosis. So, raloxifene, also known as Evista, is approved for prevention and treatment of osteoporosis and breast cancer prevention. What is also little known is that on average, it will lower cholesterol approximately 20%. It is neutral in the uterus unlike tamoxifen, but it does not improve vaginal dryness or atrophy which are often the causes of painful intercourse in menopause.

 

OSPEMIFENE

Still another SERM is called ospemifene and marketed under the name Osphena. This is estrogenic in the vagina and is approved by the FDA to treat dryness and atrophy of the vagina which results in painful intercourse and discomfort in menopausal women, which simply gets worse the further into menopause a patient gets. Osphena, may have some benefit in bone and breast but the magnitude of that benefit is unstudied. In addition, because it is unstudied, it is not carried in the label. Very, very few healthcare providers are aware that Osphena has any benefit in bone and breast.

 

BAZEDOXIFENE

Bazedoxifene is yet another SERM which gives the best protective effect in the uterus. Pfizer produces a hormone replacement product called Duavee which combines their estrogen Premarin with the SERM bazedoxifene. The bazedoxifene is given for uterine protection. Thus, this is hormone replacement which is progestogen-free.

Hormone Replacement Therapy (HRT) has come a long way. These SERMs are rigorously tested and FDA approved for use. As a leading  HRT Specialist in NYC, Dr Goldstein has worked with pharmaceutical companies in testing these drugs for uterine safety.

 If you are a woman in the Menopause stage of life or are post-menopausal and need help coping with Menopause, then perhaps SERMs may be a course of treatment for you. A consultation with Dr Steven R. Goldstein, a Menopause Specialist in NYC may be in order.

 

ENDOMETRIAL BIOPSY? NOT SO QUICK!

 

 

Dr Steven R. Goldstein is a highly regarded Gynecologist in NYC for abnormal uterine bleeding, Menopause, Perimenopause and more for women’s health. His research in the field of gynecological ultrasound has been ground breaking with much of it being adopted as the standard of care by the American College of Obstetricians and Gynecologists.

Many women who suffer from pelvic pain or irregular bleeding are told to have an “endometrial biopsy” as the first means of diagnosis. If you’ve been told to have an endometrial biopsy, then “not so quick.”

 Blind endometrial biopsies with these tiny plastic devices became very popular in the early 90’s. and became the standard of care after a report said they were 97.5% accurate. Before that, women had Dilatation and Curettage (D&C) or a scraping that was done under anesthesia. Both of these are painful, invasive, procedures that cause women a lot of discomfort and needless pain.

In 1995, a much better study of women with known cancer had a biopsy in the operating room before the hysterectomy. They missed 11 out of 65 of the cancer in those women, which meant that 16% of the time in these women with cancer who had a blind biopsy, the cancer was missed! In all of these cases, it was found that the cancer occupied less than half of the surface area of the uterine cavity. So, unless the cancer or precancer is detected by a blind biopsy, a gynecologist should not consider a blind endometrial biopsy as a stopping point for diagnosis.

Dr Goldstein, a NYC Gyn, says that a better option for diagnosis is a saline infusion sonohysterogram where some fluid is put into the uterus with a much thinner catheter tube. This enables the operator to see the uterine cavity better. The reason ultrasound is such a home run in obstetrics is because the baby is in a bag of water. This is why we get such beautiful images. So, by putting some fluid into the uterus, we can see better and get high resolution images of the entire uterine cavity instead of doing a blind biopsy and only sampling a small portion of the uterine lining for diagnosis.

A sonohysterogram has become the new standard of care in such situations. In the right hands, it is painless, takes a few minutes and is done right in your gynecologist’s office. The clear, high-resolution images produced show minute detail of the ovaries, fallopian tubes, uterus, endometrial lining etc. Such details cannot be obtained with painful, invasive endometrial biopsies that are unfortunately still performed by physicians who are not using up to date methods to diagnose patients.

Either that or, for some women, the use of disposable office hysteroscopes may be appropriate. With these, a physician can see inside the uterus in a matter of minutes painlessly, but the procedure requires more preparation and analgesia.

So, if you, a friend, relative or colleague are told to have an endometrial biopsy, ask first for a saline infusion sonohysterogram. As usual, Dr Goldstein, a leading Gynecologist in NYC is always available for a consultation.