Although the debate over the safety of hormone replacement still rages in the press, it appears some semblance of common sense is beginning to be heard. Yes, we need more confirming studies, but today’s women - myself included - cannot be put on hold and forced to wait another 10 to 20 years until all of the definitive studies have been completed. As with so many other issues in medicine, physicians have to use their best clinical judgment based on the information available now. Each woman needs to make these decisions with input from her own physician.

After all my years of practice, I still believe we should try to mimic the normal human physiology whenever possible. That’s why I use topical over oral hormones, cyclic over continuous progesterone, natural over synthetic hormones whenever possible and blood serum measurement of estrogen and progesterone to get the optimal therapeutic dosage for each individual woman. My goal with any patient is to give the lowest dose of hormone that corrects her symptoms and still gives her therapeutic levels of her natural hormones. However, no prescription drug, including hormones, is without side effects or totally free of risks. That’s why it requires a prescription: so your physician can safely develop a hormone program that is monitored and takes into account all your medical concerns. Because the Endocrinologist is the definitive hormone specialist, it’s ideal to have bioidentical HRT prescribed and monitored by an Endocrinologist. However, there is a shortage of Endocrinologists who treat menopause. For that reason it is important to seek out a gynecologist, internist or family practitioner who has acquired expertise in treating menopause with bioidentical hormone therapy and to take responsibility for educating yourself about menopause and its related conditions.

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. Dr. Johnson was a medical writer and pharmacist before medical school and utilized these skills to research 450 medical journal articles to develop her book. She has no financial conflicts of interest or ties to any pharmaceutical company. Her only objective is determining the most effective, safest therapy for patients.

I often have women tell me - “I wish I’d never had my ovaries removed because all my problems started after I had that surgery.” Women with benign disease are sometimes told, “You’ve had all your children. You might as well take everything out so you can’t get ovarian cancer.”

I recall Gina, a 48-year-old patient who saw me after having undergone a total hysterectomy with removal of the ovaries at age 44. She had been a very accomplished businesswoman. She had enjoyed excellent health all her life and had normal regular periods “like clockwork” each month. She had a great metabolism, ate what she wanted and had always weighed around 110 pounds. In her early forties, she started having heavy bleeding and was diagnosed with fibroids. She sought out an ob-gyn who was an expert in fibroids and a professor at a major medical school far away from Gina’s home. The specialist told her she didn’t need a hysterectomy and recommended an endometrial ablation at a facility closer to home.

Gina followed up at a facility near her hometown and the physician there insisted she undergo a complete hysterectomy. She was told she needed to remove her ovaries because her mother had breast cancer in her seventies (after many years of Prempro). She reluctantly agreed to the surgery but now states it was the worst decision she ever made. She was started on oral HRT after the surgery but developed a litany of health problems.

In the first year after surgery, she gained 50 pounds that led to high cholesterol and high blood pressure. She developed poor sleep, fatigue, and problems with mental focus and concentration. She eventually sold her business because she couldn’t function well at work. Her life was totally changed, and she was very remorseful about her decision to remove her ovaries.

I don’t want to frighten women who truly need to have their ovaries removed for medical reasons like cancer. It all goes back to carefully considering the benefit-risk ratio. Undergoing a hysterectomy is major surgery and when you have cancer, severe uterine prolapse or any serious condition that has failed medical therapy, it is warranted. However, if you have a benign condition and medical therapy has not been exhausted, please get a second opinion. Do your homework to study all the available options and the potential consequences of each, so you can intelligently discuss your case with your physician.

With surgical removal of the ovaries and uterus, menopause occurs very suddenly. One day a woman is having menstrual cycles and then the day after surgery, she is in menopause. This can be a shock to the system, especially since she must also recover from major surgery. She has to heal and adjust to what has happened both physically and mentally. For some women who have never had children and even those who have, it is a poignant realization that they won’t be able to bear children ever again. Other women see it as a loss of their femininity. I think it’s important for the patient to know in advance that she is likely to experience these issues after surgery.

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. 

To obtain a copy of "Outliving Your Ovaries" click here

Where Do We Go From Here?

Key Points About Breast Cancer & Other Hormone Related Cancers

1. More deaths occur from heart disease than the next 16 causes of death combined including diabetes, all cancers, AIDS and accidents


2. A first pregnancy before age 25 protects against breast cancer


3. Dense breasts on mammography increase risk of breast cancer


4. Small breast cancers less than 2.1 cm (2.5 cm = 1 inch) have a lower mortality than large breast cancers


5. Positive family history occurs in only 15-20% of women with breast cancer but is an indication for closer monitoring and possible genetic testing


6. Bad estrogen” byproducts increase risk of breast cancer, ovarian cancer and uterine cancer


7. Good estrogen” byproducts lower risk of breast cancer, ovarian cancer, and uterine cancer and lower the risk of heart disease

You Can Lower Your Risk of Breast Cancer With the Following Actions

1. Lifestyle which includes exercise, not smoking and little or no alcohol


2. Diet which includes intake of cruciferous vegetables (broccoli, cauliflower, etc.) and low intake of saturated animal fats


3. Twenty to thirty minutes of midday sun exposure or vitamin D3 supplementation to maintain adequate 25-hydroxy vitamin D blood levels


4. Maintain a normal body weight


5. Sleep 7 to 8 hours nightly


6. Breast-feed your babies


7. Monthly self breast examinations after proper training from your physician


8. Monitor for "bad estrogen" and "good estrogen" by products under the guidance of your physician

In medical school, I acquired important clinical skills but it’s from my patients that I learned about life. I learned that one’s perception of life’s challenges can motivate you or paralyze you. As I listen to my patients’ stories, I am in awe of the power of the human spirit and its capacity to overcome adversity. This internal life force makes an individual struggle to get healthy instead of passively becoming a victim. The patients I see who do the best are those who are “fighters.” 

Marina Johnson, M.D., F.A.C.E.
Medical Director

RECAP CONSIDERING BREAST CANCER -REDUCING YOUR RISK BLOG SERIES

The content of this blog series is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. This blog series may discuss nutritional products and protocols that have not been evaluated by the U.S. Food and Drug Administration. These products or the information contained on this website is not intended to diagnose, treat, cure or prevent any disease. All website content is © Copyright 2012 by Marina Johnson MD - All Rights Reserved

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD.
Dr. Johnson has no financial conflicts of interest or ties to any pharmaceutical company.
Her only objective is determining the most effective, safest therapy for patients.

Screening: The Importance of Early Detection

Tumor size greatly affects mortality. The smaller the tumor, the more likely it is to be confined to the breast and therefore more responsive to treatment. In a study of 83,686 cases of women with primary breast cancer with tumor sizes ranging from 0.3 cm to 5 cm, and no lymph node involvement, the smallest tumors were associated with a mortality of 10% while the larger tumors were associated with a mortality of 25%. In women with tumor sizes ranging from 0.3 cm to 5 cm and positive lymph nodes, those with the smallest tumors had a 20% mortality and those with the larger tumors had a 40% mortality. Studies show improved mortality when breast cancer is detected as a small lesion, especially if it’s less than 2 cm.

Mammography

In November 2009, the US Preventive Services Task Force (USPSTF) issued new guidelines for screening mammograms for women with no signs or symptoms of breast cancer. They recommend screening every two years in women ages 50 to 74. In women 75 years or older insufficient evidence exists to recommend routine screening. USPSTF recommends against routine screening of women aged 40 to 49 years because the risks of mammograms outweigh the benefits. These recommendations do not apply to women 40 years or older who are at increased risk or breast cancer by virtue of a known underlying genetic mutation or a history of chest radiation. USPTSF recommends against routine clinical breast examination (CBE) unless the physician is committed to performing a more structured, standardized examination.

Various organizations are not in agreement with the USPSTF recommendations to not screen women ages 40 to 49. This contention has been further strengthened by a 2010 breast cancer screening study of 600,000 Swedish women that found annual mammography screening of women in their 40s reduces breast cancer death rate in these women by nearly 30%.

The American Cancer Society (ACS) in 2003 recommended annual mammography and clinical breast examination beginning at age 40. In 2003, The American College of Obstetrics and Gynecology (ACOG) recommended mammography every 1 to 2 years for women 40 to 49 and annually after the age of 50. ACOG recommends CBE and breast self-examination (BSE) for all women.

Breast tissue in younger women less than 40 tends to be both firmer and denser, making it more opaque to X-rays so that tumors are less likely to be detected. High risk women, especially those with BRCA1 or BRCA2 gene mutations or with a family history of breast cancer are advised against undergoing mammograms before the age of 20. Research presented in 2009 showed that women who underwent five or more annual mammograms starting at age 20, had a 2.5 times higher risk of breast cancer than those women not exposed to the mammography radiation.

It’s also important to emphasize that mammography can sometimes fail to detect tumors which can be felt on physical exam by the patient or the physician especially in women with dense breasts. Other imaging techniques include magnetic resonance imaging (MRI), ultrasound, and thermography. However, mammography remains the standard procedure for detecting breast cancer.

Breast Examination

Physicians perform the clinical breast examination (CBE) as part of the routine physical and ACOG and ACS recommend yearly examinations for women age 40 and older. Periodic breast exams every three years are advised in women ages 20 to 40 especially if they have firm/dense breasts or a strong family history of breast cancer. While not an official recommendation, ACS suggests that women begin practicing breast self-examination (BSE) beginning at age 20 and they should have their exam technique reviewed by their physician or provider. Women practicing BSE should perform their exams after their menstrual period when breasts are less congested.

A study of breast cancer patients sorted by the frequency of BSE found those who practiced monthly BSE presented with a lump averaging 2.1 cm, infrequent BSE averaged 2.5 cm and no BSE averaged 3.6 cm. The group who did monthly BSE also had fewer axillary nodes affected by cancer.

Between 80 and 95% of all breast cancers are discovered by the patient, then confirmed by the physician and mammography. It’s been reasoned that if blind people can be taught to read Braille with their fingers, an individual has the capacity to be trained to detect small breast lumps. Because mortality is decreased with early detection, it’s incumbent on both physicians and women to improve their skills in performing breast examinations.

There are a number of methods for practicing breast examination and studies have shown considerable variation in effectiveness at detecting lesions. Two scientists from the University of Florida, Dr. Henry S. Pennypacker and Dr. Mark Kane Goldstein initiated a research program to improve the accuracy of the clinical breast examination. They developed life-like silicone breast models imbedded with varying sizes of simulated tumors. They found that with training and practice, human fingers can reliably detect a 0.3 cm imbedded lump approximately 80% of the time. They incorporated varying levels of pressure and a more systematic process to ensure a more comprehensive exam.

This methodology has been incorporated into a teaching method called MammaCare that is being incorporated in various women’s centers around the country. I became certified as a MammaCare clinical breast examiner to improve care to my patients and to teach them this technique so that they can do more accurate breast self-examinations.

COMING TOMORROW: WHERE DO WE GO FROM HERE?- CLICK HERE

RECAP CONSIDERING BREAST CANCER -REDUCING YOUR RISK BLOG SERIES

The content of this blog series is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. This blog series may discuss nutritional products and protocols that have not been evaluated by the U.S. Food and Drug Administration. These products or the information contained on this website is not intended to diagnose, treat, cure or prevent any disease. All website content is © Copyright 2012 by Marina Johnson MD - All Rights Reserved

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD.
Dr. Johnson has no financial conflicts of interest or ties to any pharmaceutical company.
Her only objective is determining the most effective, safest therapy for patients.

Risk Factors You Can Modify To Decrease Your Risk of Breast Cancer

Obesity

Obesity and weight gain during adult life increases risk of postmenopausal (but not premenopausal) breast cancer because fat tissue increases estrogen levels. The adverse effect of obesity on breast cancer is strongest in women who do not use HRT. In the Nurses’ Health study, women gaining 22 pounds or more after menopause increased their risk by 18% while losing at least 22 pounds lowered their breast cancer risk by 57%.

Alcohol Intake

A meta-analysis of over 40 epidemiologic studies showed that drinking 2 drinks a day may increase the risk of breast cancer by 21%. The Million Women study published in 2009 showed than drinking even 1 drink a day increases the risk of breast cancer. Each additional alcoholic drink regularly consumed per day was associated with 11 additional breast cancers per 1000 women. Even though alcohol has been previously associated with cardiac benefits, Michael Lauer MD of the US National Heart, Lung and Blood Institute editorialized that the excess cancer risk seen in this study may outweigh the benefits.

Exercise

Several studies show that exercising 45 to 60 minutes daily for 5 or more days per week reduces the risk of breast cancer in postmenopausal women. One study showed regular physical activity, regardless of intensity, may reduce the risk of breast cancer in postmenopausal women.

Breast Feeding

Breast feeding has consistently been shown to lower the risk of breast cancer. A study of 47 epidemiological studies in 50,302 women with breast cancer and 96,973 women without breast cancer showed that the incidence of breast cancer was reduced by 4.3% for every 12 months of breast feeding. The protective effect is thought to be related to the delay in resumption of ovulatory cycles from breast-feeding.

Fibrocystic Breast Disease

Women diagnosed with fibrocystic breast disease (FBD) and a family history of breast cancer are at increased risk for breast cancer if a breast biopsy shows certain proliferative changes even though the pathology was benign for cancer. Symptoms of FBD may sometimes be improved with therapies including evening primrose oil, vitamin E, iodine, and diindolemethane, and avoiding caffeine.

Vitamin D Deficiency

Two 2010 meta-analysis studies showed that maintaining sufficient levels of serum vitamin D protects against breast cancer. One study showed a 41% reduction in breast cancer risk in case-control studies. The other study showed among those with the highest intake of vitamin D, the risk of breast cancer was reduced by 45% compared to those with the lowest intake of vitamin D.

Laboratory studies also support this protective action against breast cancer through several mechanisms. A 2010 review article reported that a vitamin D byproduct promotes apoptosis (programmed self-destruction) of breast cancer cells, decreases excess estrogen production and has anti- inflammatory actions.

Vitamin D is the “sunshine vitamin” and you can often get adequate levels of vitamin D by regularly receiving mid- day sun exposure in the late spring, summer, and early fall, exposing as much of the skin as possible for 20-30 minutes but being careful not to burn. Individuals with dark skin may need up to six times longer exposure time because of less ab- sorption. In winter, it’s often more challenging to get adequate levels from sun exposure alone.

For those who cannot get adequate sun exposure, vitamin D supplementation is recommended. The Canadian Cancer Society recommends a minimum of 1000 IU of vitamin D3 but much higher levels are often needed. Dr. John Cannell, Director of the Vitamin D Council suggests adults often need around 5000 IU of vitamin D3. He suggests monitoring blood 25-hydroxy Vitamin D to ensure adequate levels. Dr. Cannell also emphasizes the importance of other nutrients such as magnesium, zinc, vitamin K2, boron and a small amount of vitamin A, which improve the utilization of vita- min D.

Abnormal Estrogen Metabolism

This section may seem a little technical but do not gloss over it because it’s it is important for you to understand. Or at least come back to review it later. Anything taken into your body such as medicines or hormones produced by the body, has to be processed by the liver which is responsible for their orderly disposition. The liver is an important organ that has to break down any hormone, food, medicine or chemical you take into your body. Toxic materials are broken down into byproducts that can be easily removed from the body. The breakdown of these substances sometimes produces substances more beneficial to the body. For example, whether you’re still making estradiol or taking it, effects of estradiol occur from the estradiol itself and other effects occur through chemical reactions in the liver that produce byproducts from the processing of estradiol. The medical term for these byproducts is “downstream metabolites.”

Estradiol is broken down in the liver to various byproducts called 4-hydroxyestrone (4-byproducts) and 16-hy- droxyestrone (16-byproducts.) Excess levels are associated with a higher risk of breast cancer, ovarian cancer, and uterine cancer so we call these the “bad” estrogens. Estradiol is also converted to 2-hydroxyestrones (2-byproducts) that carry a lower risk of cancer and these are called the “good” estrogens. A small amount of the 16-byproducts is necessary to maintain strong bones. The goal is a healthy balance between these three estrogen byproducts. The 4-byproducts are the most harmful so the liver has a chemical process called methylation to neutralize these bad estrogens.

In 2006, a review article in the New England Journal of Medicine gave an extensive review of the literature supporting the role of estrogen metabolites as cancer initiators. While this may not be the only cause of these cancers, it is a risk factor that can often be modified with healthy lifestyle and supplements. There are not yet extensive randomized controlled trials showing benefit from these therapies. However, if the therapy is low-risk and possibly beneficial, why would we NOT want to consider this therapy to reduce cancer-promoting byproducts to improve the safety of estrogen therapy?

The relative amounts of “bad” estrogens can be improved with lifestyle intervention such as exercise, flaxseed, improved nutrition and the intake of cruciferous vegetables. Cruciferous vegetables include broccoli, cauliflower, cabbage, kale, and brussel sprouts. For women who may not consume adequate amounts of these vegetables, nonprescription supplements called diindolemethane (DIM) and indole-3-carbinol (I3C) contain the active protective ingredients of these vegetables.

In addition, recent studies in the cardiology literature show that when the 2-byproduct undergoes methylation, it is converted to 2-methoxyestradiol which protects against heart disease and has an anti-cancer effect. (Studies in the oncology literature are underway to study the potential use of this byproduct as an anti-cancer drug) When deficient, this beneficial byproduct can often be increased by use of supplements. Why would we NOT want to increase production of this beneficial byproduct to maximize the full benefit of estradiol therapy?

Methylation can be improved with nonprescription supplements including vitamin B12, folic acid, zinc, resveratrol, N-acetylcysteine, trimethylglycine, and S-adenosyl methionine (SAM-e). I would advise against any of the dietary supplements unless you are working with a knowledgeable professional who can monitor your levels and advise you on appropriate doses of these products. The estradiol byproducts can be measured in the urine. The test requires collecting the first morning urine made over the previous 8 hours, sending a sample of urine from that total volume and indicating the total volume. After therapy to improve estrogen metabolism has been initiated, follow-up testing is repeated in three months to assess whether there has been improvement. Thereafter testing is done on a yearly basis. With correction of estrogen metabolism, women often report reduction in breast tenderness, PMS and other menstrual related complaints. It also gives us another parameter to monitor to improve safety and enhance the full benefit of estradiol.

COMING TOMORROW: SCREENING: THE IMPORTANCE OF EARLY DETECTION- CLICK HERE

RECAP CONSIDERING BREAST CANCER -REDUCING YOUR RISK BLOG SERIES

The content of this blog series is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. This blog series may discuss nutritional products and protocols that have not been evaluated by the U.S. Food and Drug Administration. These products or the information contained on this website is not intended to diagnose, treat, cure or prevent any disease. All website content is © Copyright 2012 by Marina Johnson MD - All Rights Reserved

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD.
Dr. Johnson has no financial conflicts of interest or ties to any pharmaceutical company.
Her only objective is determining the most effective, safest therapy for patients.

DEDICATION

Breast cancer is the most feared health problem for women.  In a previous blog, I’ve pointed out that women experience more deaths each year from heart disease and strokes than breast cancer. I’ve given you specific data on the absolute risk of breast cancer.

For more information read my post on Relative Risks of Breast Cancer

In this series I want to give you information on ways to prevent breast cancer. My philosophy toward optimal health embraces the concept of engaging patients in their own health because it encourages patient responsibility and accountability. 

In medical school, I acquired important clinical skills but it’s from my patients that I learned about life. I learned that one’s perception of life’s challenges can motivate you or paralyze you. As I listen to my patients’ stories, I am in awe of the power of the human spirit and its capacity to overcome adversity. This internal life force makes an individual struggle to get healthy instead of passively becoming a victim. The patients I see who do the best are those who are “fighters.” 

Kathy and Les Kerr are personal friends. Kathy, a dancer, gymnast and exercise enthusiast, passed away from breast cancer on July 7th, 2010 but only after a five and one-half year fight during which she inspired her family and friends with her positive, courageous attitude. Kathy’s friends created Kathy’s Divas to provide their support. Les designed a symbol that depicts Kathy’s strength and determination as she faced her disease.  I challenge you to adopt this same proactive attitude toward practicing self-care preventive measures. With the right support, your body has an amazing capacity for self-healing. Les has graciously offered the Kathy’s Divas symbol to represent this concept.  To inspire and empower women everywhere, I want to dedicate this series as a tribute to Kathy’s fighting spirit.

Marina Johnson, M.D., F.A.C.E.
Medical Director

Considering Breast Cancer: Risk Factors (Mostly) Not Under Your Control

With regard to breast cancer risks, there are factors that are not within your control and those which are modifiable. The latter are the areas where you can have the most impact.  Besides being female, the most important risk factor for breast cancer is increasing age. This is understandable because as your immune system ages, it becomes less effective at protecting you against cancer. The widely touted figure of one in eight women having a “lifetime” risk of developing breast cancer does not apply until a woman reaches the age of 85. On the other hand, the chance of never having breast cancer by 85 is seven in eight.

The life-long cumulative exposure of the breasts to estrogen caused by early onset of periods and later menopause is a factor that increases the risk of breast cancer. Having a first pregnancy by age 25 confers a protective effect on the breast and lowers a woman’s risk of breast cancer by 10 percent. However, the general trend is for American women to marry later, and early pregnancy is often not an option. A 2007 study found the relative risk of developing breast cancer in post- menopausal women with dense breasts was 400% higher than in women with fatty, non-dense breast tissue. It used to be thought that the risk of dense breasts was simply a reflection of higher levels of circulating estrogen. However, this study showed that women with dense breasts who also had higher levels of circulating estrogen or testosterone had a 200% further increase in risk of breast cancer suggesting these are two independent factors.

Family History & BRCA

A positive family history of breast cancer is seen in only 15 to 20% of women with breast cancer. The risk is increased if there are multiple first-degree female relatives with breast cancer or if the relative’s cancer occurred before age 40. BRCA are breast cancer genes which pose no risk to a woman when they function normally. If however, the genes transform to BRCA-1 or -2 mutations, cancer risk increases. Although less than 10% of all breast cancers are linked to these genetic mutations, women with these mutations are at very high risk for breast cancer.

According to 2005 guidelines issued by the US Preventive Services Task Force, the following family history patterns are associated with an increased risk of BRCA-1 or -2 mutations: For non-Ashkenazi Jewish women, these patterns include 2 first-degree relatives with breast cancer, 1 of whom received the diagnosis at age 50 years or younger; a combination of 3 or more first- or second-degree relatives with breast cancer regardless of age at diagnosis; a combination of both breast and ovarian cancer among first- and second-degree relatives; a first-degree relative with bilateral breast cancer; a combination of 2 or more first or second-degree relatives with ovarian cancer regardless of age at diagnosis; a first or second-degree relative with both breast and ovarian cancer at any age; and a history of breast cancer in a male relative. For women of Ashkenazi Jewish heritage, an increased-risk family history includes any first-degree relative     (or 2 second-degree relatives on the same side of the family) with breast or ovarian cancer.

BRCA Testing

A blood test to detect BRCA genetic mutations is available but the US Preventive Services Task Force recommends referral for genetic counseling before BRCA testing.

Women with positive BRCA genetic mutations are advised to have clinical breast exams every six months and yearly mammograms. Surveillance for ovarian cancer includes yearly transvaginal ultrasounds and measuring cancer antigen (CA)- 125 blood levels.

Preventive mastectomy (removal of healthy breast tissue) - reduces breast cancer risk by 90% and removal of ovaries reduces ovarian cancer risk by 90%.

While these risks are generally not modifiable, knowing them may enter into your decision about whether to take HRT. It also will make you more diligent about addressing the factors that you can change and monitoring for early detection.

COMING TOMORROW: RISK FACTORS YOU CAN MODIFY TO DECREASE YOUR RISK- CLICK HERE

RECAP CONSIDERING BREAST CANCER -REDUCING YOUR RISK BLOG SERIES

The content of this blog series is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. This blog series may discuss nutritional products and protocols that have not been evaluated by the U.S. Food and Drug Administration. These products or the information contained on this website is not intended to diagnose, treat, cure or prevent any disease. All website content is © Copyright 2012 by Marina Johnson MD - All Rights Reserved

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD.
Dr. Johnson has no financial conflicts of interest or ties to any pharmaceutical company.
Her only objective is determining the most effective, safest therapy for patients.

Topical Estrogen Gives Better Protection Against Heart Disease - A compelling recent study in the European Heart Journal, September 2008 was designed to answer the question: Does estrogen cause heart attacks? A group of 698,098 healthy Danish postmenopausal women were followed for six years. The women were divided into groups by the TYPE of HT they were taking and compared to those women on no HT. The women on oral estrogen plus progestin had a 35% HIGHER occurrence of heart attacks as compared to women on no HT. The women on topical estrogen (patches, gels, NOT COMPOUNDED) had a 38% LOWER occurrence of heart attacks compared to women on no HT. So in essence, oral estrogen causes heart attacks while topical estrogen protects against heart attacks! 

After menopause without the use of estrogen, a woman can lose up to 20% of her bone mass. This increases her risk for osteoporosis leading to loss of height, hip fractures, chronic pain, and disability. Of women who suffer hip fractures, 24 percent die of complications within a year of the injury. Osteoporosis of the spine leads to the familiar “dowager’s hump.” A dowager’s hump is a prominence on the back resulting from collapse of the spine from spontaneous vertebral fractures. When it’s severe, the woman is totally bent over and cannot stand up straight. It is tragic to see a woman suffering from something that could have been prevented.

A recent British study estimated the lifetime risk for any fracture to be 53.2% at age 50 among women not taking estrogen. In comparison, the estimated lifetime risk for endometrial carcinoma for a 50-year-old woman is 2.6%, for breast cancer 10%, for coronary artery disease 46%, and for stroke 20%.

Prevention of osteoporosis was the first FDA-approved indication for estrogen therapy. In the Million Women Study, a prospective, cohort study of over one million women, all taking different formulations of estrogen, including oral and transdermal, were associated with a lower risk of hip and vertebral fractures. While not FDA-approved for this indication, estrogen is also effective for treatment of osteoporosis. In a study of 75 women treated with either topical estradiol or placebo for one year, the estrogen group had an increased bone density in hip and spine and 50% fewer fractures.

Estrogen is even effective at protecting bones when started after age 75. One study in 67 elderly women over 75 years old treated with estrogen for nine months showed improvement in bone density in the hip and spine compared to placebo. Improvements in bone density are seen even with ultra low doses of estrogen, like 0.25 mg of oral estradiol or a 0.014 mg estradiol patch. At such low doses there appears to be no stimulation to the uterine lining.

How does estrogen work to prevent osteoporosis? When people think of bones, they may have a visual image of the skeleton that you studied in biology class. They see the skeleton as inanimate, solid scaffolding that simply holds up the rest of the body. Nothing could be further from the truth. Bones are active living tissues maintained by a continuous balance between two types of bone cells, osteoclasts and osteoblasts that work upon an internal collagen framework. Osteoclasts break down bone (resorption) while osteoblasts build bone onto the collagen framework. When bones are injured, osteoclasts rush in to remove the damaged bone and osteoblasts deposit new bone to repair it.

Most women are very familiar with collagen because it is an important support structure which plumps up the skin preventing wrinkles. However, few are aware that collagen is also present in fingernails, hair, tendons and importantly, in bone. Since collagen normally declines with aging, reduction in the collagen framework can further weaken the bone leading to “brittle bones” commonly seen in elderly individuals. In animal studies, loss of estrogen increases immune cells that produce a protein called tumor necrosis factor (TNF) that increases the formation of osteoclasts. With an increase in osteoclasts over osteoblasts, the net result is bone resorption or bone loss leading to osteoporosis. Estrogen decreases this accelerated bone resorption and also plays a role in improving calcium absorption in the intestine.

Lifestyle measures which will further increase bone density include weight-bearing exercise, taking in adequate dietary calcium, taking adequate vitamin D, and treating inflammatory conditions that cause increased bone loss.

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. Dr. Johnson has no financial conflicts of interest or ties to any pharmaceutical company. Her only objective is determining the most effective, safest therapy for patients.

To obtain a copy of "Outliving Your Ovaries" click here

When a woman goes through menopause and her ovaries stop producing estrogen and progesterone, the pituitary responds by increasing FSH, a hormone from the pituitary gland that has regulated these hormones throughout her reproductive life. However, when all the eggs have been depleted, no further estrogen or progesterone can be produced. Nonetheless, the pituitary, which is “hard-wired” to respond to low estrogen, continues to make increasingly higher levels of FSH.

An elevated FSH is a diagnostic marker indicating menopause has occurred. Testosterone production occurs not from the eggs, but from different cells in the ovary, which continue to function in the postmenopausal ovary. Such increases in FSH leads to increased testosterone production. Testosterone can also be produced in fat cells and in the adrenal gland.

A postmenopausal woman with even normal testosterone in the presence of deficient estrogen often develops facial hair and acne. This explains why older women without HRT often develop facial hair and a deepening of their voice. Care should be taken to restore therapeutic levels of estradiol and progesterone before giving testosterone. Restoring therapeutic estrogen and progesterone lowers FSH resulting in a decline in testosterone production. However, FSH levels never return to levels seen in premenopausal women. Testosterone replacement is especially important in younger women who undergo surgical menopause. They will often have marked decline in libido and sexual dysfunction and may also develop urinary frequency and incontinence. Some studies suggest testosterone in the presence of estrogen and progesterone has a protective effect on the breast and may decrease breast cancer risk.

On the other hand, studies in premenopausal and postmenopausal women (on no HRT) who had naturally occurring elevated testosterone showed that testosterone is associated with an increased risk of breast cancer. In the Study of Women’s Health Across the Nation (SWAN), a longitudinal 9-year-study of 949 menopausal women on no HRT reported that testosterone predominance increases the incidence of metabolic syndrome. Metabolic syndrome is a name for a group of risk factors that increases your risk of heart disease and diabetes. Typically, people have elevations in blood pressure and fasting blood sugar, increased obesity around their waist and/or low HDL. In another study of 344 menopausal women ages 65-98, those with the highest levels of testosterone were three times more likely to have heart disease and metabolic syndrome than those women with lower testosterone levels.

Such studies point out the importance of respecting the normal physiology of the body. Testosterone is best prescribed after the woman is on adequate estrogen. Since testosterone can be produced by menopausal ovaries and the adrenal glands, deficient levels should be confirmed with an accurate laboratory blood assay that measures free testosterone levels before prescribing testosterone. Excessive testosterone replacement can cause facial hair, acne and loss of scalp hair and such symptoms are easily avoided by subsequent monitoring of blood levels.

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD.
Dr. Johnson has no financial conflicts of interest or ties to any pharmaceutical company.
Her only objective is determining the most effective, safest therapy for patients.

Bonnie has always been able to enjoy good sleep in the past. No matter how stressed she might be, she could count on laying her head on her pillow, falling fast asleep and waking up the next morning refreshed and rejuvenated. However, when she reached her mid 40’s, her periods started changing and she began experiencing sleep problems. First, she would just have insomnia the night before starting her period. As her periods became more irregular, she started waking up in the middle of the night around 2 or 3 am and would find herself wide awake and unable to go back to sleep. With so little sleep, she would be exhausted the next morning. Over-the-counter sleep aids would make her feel sluggish the following day. By the afternoon and early evening, she would be crashing. She came to see me on maximal doses of prescription sleep medicine and still was sleeping poorly.

Bonnie suffers from a very common sleep disorder that occurs with declining levels of estrogen and/or progesterone that accompany perimenopause and/or menopause. It is characterized by wakefulness in the middle of the night and can be very debilitating when it continues long-term. The typical patient with this type of insomnia often becomes addicted to prescription sleeping pills. Bonnie’s insomnia totally resolved after her estrogen and progesterone levels were normalized.

While menopause occurs in all women, insomnia does not uniformly affect all women and therefore, women may not recognize that this is a low estrogen symptom. Furthermore, if the insomnia has gone on for many years, other secondary conditions such as depression, anxiety, chronic fatigue, fibromyalgia, sleep apnea and obesity may develop.

It’s important to emphasize that insomnia can result from endocrine problems in both men and women. Disorders of thyroid hormone, testosterone, cortisol, and growth hormone can all cause sleep disorders. Detecting a subtle endocrine imbalance may sometimes be difficult requiring the expertise of an endocrinologist.

Sleep is a mysterious bodily process that is absolutely essential to good health. We should not have to rely on a drug to make us sleep! We do not have to be taught how to sleep. Every member of the animal kingdom has an obligatory need for sleep. If humans go much more than 18 hours without sleep, they start experiencing microsleep where they zone out from a few seconds to minutes. In fact many accidents occur when people are sleep-deprived such as the infamous Exxon Valdez disaster and the Chernobyl nuclear accident. Falling asleep while driving is responsible for at least 100,000 crashes, 40,000 injuries, and 1550 deaths per year.

People can also develop insomnia from poor lifestyle choices. Overzealous Americans intent on squeezing more work, more fun, more family time and more sheer activity into their lives often short-change their sleep. What are ways to promote a good night sleep? Try going to bed at the same time each night and getting up at the same time. The body likes a regular schedule. Sleep in a cool, dark room use nightshades, white noise or a sleep mask if necessary. Avoid spicy food or caffeine-containing foods in the evening. Finish eating at least 3 hours before bedtime. Many individuals find that heavy intake of sugar or alcohol at dinner leads to restless sleep. Start winding down in the evening. Do not engage in heavy exercise late at night. Don’t watch the 10 o’clock news or read grisly books which cause mental over-stimulation. Individuals who can’t function without a large dose of coffee in the morning are usually sleep-deprived.

Just how much sleep is enough sleep?Individuals who consistently get less than seven or eight hours of sleep per night are often sleep-deprived. Interestingly, people who need MORE than eight hours of sleep may also have a sleep disorder. They need more than eight hours of sleep because the sleep they are getting is poor quality sleep. People do not have less need for sleep with aging. It’s just that sleep disorders are so common in older people. Most sleeping pills will knock you out but do not tend to promote normal sleep architecture. There are now new sleep agents that promote the deep sleep, which tends to be more restorative.

If you are experiencing persistent insomnia, consider seeing an Endocrinologist, a physician who specializes in hormone disorders. Establishing hormone balance can lead to normal, refreshing sleep which is the body’s own way of healing a myriad of health problems.

Dr. Marina Johnson is a UCLA / USC trained physician who has been in private practice for 29 years.  While at UCLA medical school she was selected to be the Sam Goldwyn scholar. She is Board-Certified in Endocrinology & Metabolism and Internal Medicine. Dr. Marina Johnson  was an invited speaker at the Cleveland HeartLab Annual Symposium in September 2011. She has been a featured guest on Lifetime's The Balancing Act, Daystar's Joni Table Talk, FOX News, The Doctor's, and the nationally syndicated morning radio show DayBreak USA heard on over 1500 stations from coast to coast. To obtain a copy of her new book 'Outliving Your Ovaries' click here

I am often asked whether breast cancer survivors can ever safely initiate HRT. In addition, they are often taking estrogen blocker drugs, like tamoxifen, especially if their breast cancer was positive for estrogen receptors. These women frequently suffer severe symptoms of estrogen deficiency.

According to the 2010 Position Statement of the North American Menopause Society, controversy still exists regarding the safety of initiating HRT in breast cancer survivors. Two concurrent, randomized controlled trials, (the most reliable type of clinical studies) reported conflicting results. One study reported no harm and the other showed a statistically significant 2.4 fold increase in new breast cancer events.

In some women in remission for five years, who are severely symptomatic, their oncologists or breast surgeons permit them to start using low dose HRT. However, I must emphasize this practice is done on a case-by-case basis between a woman and her oncologist when a woman’s quality of life is so poor she is willing to accept a possible increased risk of cancer recurrence. HRT should never be given to a breast cancer survivor without the express consent and ongoing surveillance by her oncologist or breast surgeon.

Marina Johnson, M.D., F.A.C.E.
Medical Director

Click Here For Study

I am frequently asked the question, “How long can I safely stay on my hormone therapy? and I usually ask the woman, How long do you want to continue to feel well?” In all seriousness, there are no long-term studies that enable me to answer this question. Taking hormones less than five years seems to carry very little risk. However, the longer you take hormones the higher your risk.

The North American Menopause Society and the Endocrine Society have addressed this issue. They recommend that all women be informed of potential risks and benefits and given the lowest effective dose consistent with treatment goals. If a woman wishes to continue HRT for an extended period of time, this is acceptable if she and her physician believe that the benefits of continuing HRT outweigh the risks.

A woman’s decision to initiate or continue HRT must be based on her own unique circumstances and risks. Many of the available studies have not attempted to evaluate the differences in risks among the different HRT regiments. However, new studies are beginning to appear that help sort out the risks for the different types of HRT. In a sense, the Baby Boomers are the “test generation” that started HRT in larger numbers. We will be the first to see the consequences, positive and negative, of being on HRT for 20, 30, and 40 years.

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. Dr. Johnson has no financial conflicts of interest or ties to any pharmaceutical company. Her only objective is determining the most effective, safest therapy for patients.

To obtain a copy of "Outliving Your Ovaries" click here

All the adverse effects from the oral route of administration of estrogen as previously outlined in Outliving Your Ovaries can also occur from oral Prempro. However, the addition of the progestin seems to confer additional cardiac risk. Perhaps giving progestins daily instead of in cycles of 14 days each calendar month may be a factor in this increased risk. Earlier observational studies, like the Nurses’ Health Study, predominantly used oral cyclic progestins and did not show an increased risk of heart disease.

While estrogen increases the beneficial HDL cholesterol, adding a continuous synthetic oral progestin lowers HDL by 8 to 18%. Addition of oral, micronized progesterone causes little or no adverse effects on HDL. An animal study showed that adding MPA to estradiol blocks the conversion of estradiol to an important beneficial byproduct made in the liver called 2-methoxyestradiol.

In the Women’s Health Initiative, a randomized, placebo-controlled trial showed no change in the incidence of heart disease in women starting Prempro within 10 years of menopause when compared with placebo. Women starting Prempro 10 years after menopause had an increased risk of heart disease which increased the more time had elapsed since menopause.

The 2009 Danish Study, an observational study of 698,098 women, found those who took continuous combined oral HRT had a 35% increased risk of heart attacks compared to women who did not take hormones. In the women taking topical estradiol plus cyclic progesterone or cyclic progestin, there were 38% fewer heart attacks.

I had an acquaintance, Janet, who became newly menopausal and was exhibiting the typical symptoms. Her physician promptly started her on a daily combination pill containing synthetic estrogen and progestin. Within days of starting that therapy, she developed new onset chest pain sending her to the emergency room (ER). At the ER, Janet was evaluated and sent home and referred to a cardiologist who did stress testing and told her everything was normal. When she continued to have intermittent chest pain, her physician changed her to a combined topical estradiol/synthetic progestin patch. The pain lessened but she still had occasional chest pain. Not until she was finally put on topical estradiol with cyclic oral progesterone did she finally have resolution of her chest discomfort. Imagine the cost savings and the angst that would have been avoided if she had just been put on topical estradiol and cyclic progesterone from the beginning!

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. Dr. Johnson has no financial conflicts of interest or ties to any pharmaceutical company. Her only objective is determining the most effective, safest therapy for patients.

To obtain a copy of "Outliving Your Ovaries" click here

In the first five to seven years after the first menstrual period and the last ten years before menopause there can be variability in the cycles. Between the ages of 20 and 40 most women’s menstrual cycles fall into a familiar pattern of 28-day cycles. A pattern of very short (less than 21 days) or very long (greater than 35 days) time between menstrual periods or skipped periods indicates the woman is not ovulating. Extremely painful or heavy menstrual periods lasting longer than 7 days are also a cause for evaluation.

Sometimes young women with irregular cycles are incorrectly told “Well, that’s just normal for you!” It is very unfair to trivialize or dismiss these complaints in such patients. Signs and symptoms are your body’s way of telling you there’s a problem. It’s better to find the underlying cause of the menstrual disorder instead of masking it with birth control pills. In many instances birth control pills are prescribed without the woman ever undergoing a diagnostic evaluation. There are consequences to a young woman not having ovulatory cycles. These include bone loss, premenstrual syndrome (PMS), mood disorders, headaches, facial hair, acne, infertility, and a myriad of other symptoms. These symptoms can occur in polycystic ovaries syndrome, hypothyroidism, hyperprolactinemia, all of which are treatable endocrine conditions.

Secondary amenorrhea is the medical term that is used when a woman who was previously having regular or irregular periods, stops having them. When a woman younger than 40 stops having her periods, it is important to know that this condition is not likely to be menopause. Young women sometimes like the convenience of not having periods and may not seek medical attention. Women with elevations in prolactin and various other coexisting medical problems can have temporary cessation of periods. Women going through severe stress, marked weight loss or extreme exercise may stop having periods. If periods stop for three months or longer, be sure that you undergo a diagnostic evaluation and are not just started on birth control pills or oral contraceptives (OCs) which cause menstrual periods to resume in most women. Such treatment may give women a false sense of security that they are now “normal.” Nothing could be further from the truth. OCs in this instance let you know that you have a functioning uterus but nothing about the state of your ovaries. Proper diagnosis and treatment is especially important in younger women concerned about their future fertility.

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. Dr. Johnson has no financial conflicts of interest or ties to any pharmaceutical company. Her only objective is determining the most effective, safest therapy for patients.

To obtain a copy of "Outliving Your Ovaries" click here

A very few lucky women sail through menopause with minimal symptoms. They have usually been very healthy prior to menopause. However, they are the exception. Most women will have at least some symptoms. These can range from a mild sensation of feeling warm, to a beet red face and drenching sweats that leave the sufferer with wet hair and clothes soaked in sweat. As you can imagine, this can be especially disconcerting to a woman who’s in the middle of a business meeting.

A woman may have trouble falling asleep or she may awaken at 3 a.m. unable to get back to sleep. Sometimes she has both! Sleep is the body’s time for rejuvenation when new tissues are made or repaired. When this vital restorative time is short- changed, symptoms like chronic fatigue, weight gain, irritability, palpitations, headaches, and migraines can develop.

Dizziness is another symptom that occurs in menopause. Episodes are usually mild and short-lived lasting only a few seconds. Occasionally dizziness may be debilitating. Alice was a 54-year-old woman who came for menopause management. She had been a confident businesswoman and she told me, “My life is falling apart and I feel like a cripple!” She was suffering off/on unpredictable bouts of dizziness of such severity that she would have to hold on to the wall to keep from falling. The dizziness had been going on for months, and she’d undergone a very extensive evaluation from a neurologist, a neurosurgeon and a cardiologist. Because all their testing showed NO cause for her dizziness, she was pronounced NORMAL and sent on her way! She had not actually sought me out for the dizziness but rather had resigned herself to her plight. However, after I started her on topical HRT, she never had another bout of dizziness. She was ecstatic to finally be rid of that debilitating symptom! I’ve never seen another menopausal woman with such severe dizziness but her case taught me to recognize the possibility that it may be related to low estrogen.

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. Dr. Johnson has no financial conflicts of interest or ties to any pharmaceutical company. Her only objective is determining the most effective, safest therapy for patients.

To obtain a copy of "Outliving Your Ovaries" click here

To make the proper choice regarding hormone replacement, it’s important to understand the basic function of the endocrine system, that complex and elegant chemical enterprise within the body that controls and coordinates such functions as reproduction, metabolism, behavior, growth and development. Replenishing and rebalancing of this system are the goals of hormone replacement and the focus of Endocrinology.

Within the endocrine system, 10 or more major endocrine glands and a number of minor ones secrete hormones, or chemical messengers, that mediate communication between cells. The body seeks to establish a state called homeostasis - a perfect balance. It is an elaborate bodily harmony not unlike that created by the instruments of a symphony orchestra. One player out of tune diminishes the performance of the entire orchestra. Like the symphony, the harmonic interplay of the endocrine glands and the hormones they produce creates the beauty and power of the concert.

Hormones are molecules that act as signals from one type of cell to another. Most hormones reach their target cells via the bloodstream. The word itself is from the Greek word “horman” meaning “to set in motion” or “to excite.” Resuming the analogy of the symphony orchestra, the body has a number of section leaders controlling and regulating the woodwinds, brass, percussion and strings - these are the hormones and hormone-like substances of the endocrine system. The conductor of these control centers is the pituitary, often called the “king of glands.” The pituitary is the size and shape of a pea, and it has an intimate connection with the hypothalamus, which is actually part of the brain. More specifically, the hypothalamus is the interface between the brain and the endocrine system. Each gland has a corresponding hormone in the pituitary that regulates the function of that gland. In this manner, all the glands of the endocrine system are ultimately under the control of the brain.

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. Dr. Johnson was a medical writer and pharmacist before medical school and utilized these skills to research 450 medical journal articles to develop her book. She has no financial conflicts of interest or ties to any pharmaceutical company. Her only objective is determining the most effective, safest therapy for patients.

Understanding the biology and physiology of estradiol, progesterone, and testosterone gives us insight on how critical they are to the optimal function of the body. When they are deficient, as in menopause, it’s preferable, whenever possible, to utilize pharmaceutical bioidentical hormones to restore the very same hormones which have been in your body since you went through puberty. Cholesterol, which some people regard as something “bad”, is actually the basic building block for all the hormones made by the ovaries and the adrenal glands. Care should be taken to not aggressively lower cholesterol to extremely low levels with cholesterol lowering drugs because it can cause marked disruption in production of these vital hormones.

Jerry, a 58-year-old successful businessman, came to see me because of fatigue and sexual dysfunction. Because of his fatigue he was considering selling his business and taking early retirement. He had always enjoyed a healthy sex drive and lots of energy but now he was considering “calling it quits” and taking early retirement.

I diagnosed him with profoundly low testosterone but I also noted that his total cholesterol was only 105! I learned he had been started on a cholesterol-lowering drug the previous year that corresponded to the time frame when he developed his sexual dysfunction and fatigue. I made a modest reduction in his cholesterol medication and his testosterone level normalized without the need for testosterone replacement. Cholesterol lowering drugs can be life-saving but all these possible effects need to be considered. All this is further evidence that everything in our body is there for a reason. When you introduce drugs that cause drastic changes, adverse consequences can occur.

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. Dr. Johnson was a medical writer and pharmacist before medical school and utilized these skills to research 450 medical journal articles to develop her book. She has no financial conflicts of interest or ties to any pharmaceutical company. Her only objective is determining the most effective, safest therapy for patients.

When I was first starting my medical practice, menopausal problems were not taken very seriously. Hot flashes and premenstrual syndrome (PMS) were the source of a lot of jokes. Well, it isn’t funny when you feel awful and your life is falling apart. I can’t tell you how many times I’ve had women apologize for “wasting my time” with their complaints or tell me, “Thank you for listening to me.” I would always assure them that hearing their symptoms is essential for my finding the correct solution for their problem.

There are a few patients seared into my memory bank who forever changed my attitude about menopause. I once was called to do an endocrine consultation on Joan, a patient in the psychiatric ICU with “hirsutism” or excess facial hair. When I went to see Joan, she indeed had a moderate degree of facial hair. However, after reviewing her chart, I was astonished to learn that she’d been a banker with no prior psychiatric history. She’d undergone a total hysterectomy with removal of her ovaries for a benign condition the summer before and I was horrified to learn that she’d never been given hormone replacement.

After the surgery, her mental condition deteriorated to the point where she’d lost her job. She was put on various psychotropic medications but continued to do poorly. She’d become suicidal and ultimately was admitted to the psychiatric intensive care unit. It had not occurred to anyone that perhaps she needed hormones. When I started her on HRT, I saw firsthand how restoring deficient hormones can produce a total transformation in a person’s life. This woman eventually went off all her psychotropic medicines and was able to go back to her normal life. It still brings tears to my eyes as I think about how she was made to suffer needlessly. At the same time, it is incredibly gratifying when you can use your training and experience to help a person become whole again. That’s what drives most physicians - the desire to relieve suffering and help people.

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. Dr. Johnson was a medical writer and pharmacist before medical school and utilized these skills to research 450 medical journal articles to develop her book. She has no financial conflicts of interest or ties to any pharmaceutical company. Her only objective is determining the most effective, safest therapy for patients.

At the time of menopause, each woman has a window of opportunity during which she needs to make the important decision of whether to take hormones. As the estrogen levels fall, her body begins to go through degenerative changes that accelerate her risk of heart disease along with the other changes we have previously described. The sooner a woman starts HRT after menopause, the fewer degenerative changes she will experience. If a woman waits 10 years to start HRT, the heart protection from estrogen is greatly diminished. The same applies brain protection; once brain cells have been lost, it becomes difficult to retrieve normal function. However, for protecting bones, estrogen is effective even when started after age 75.

However, I would like to stress that each woman is an individual and if there are no contraindications to trying hormones, consider trying topical estradiol for a year to see if you experience any improvements. I recall Cora, an 82 year-old woman who was brought to me by her daughter June. Cora had never taken hormones after menopause.

June said, “Mom has always been so vibrant, energetic and happy and she loved to do gardening. However, for the past six months she just sits in a rocker and stares at the wall. I’ve taken her to several doctors and they have all told me that everything’s normal but this is not normal for my mother! Is there anything you can do to help her?” I examined her mother and the only abnormal lab result was her lack of estrogen. I told June, “I’m not sure how much benefit we can expect to see but let’s try her on estrogen and see how she responds.” A mere three months later, now with therapeutic estrogen levels, June told me with excitement, “I have my mother back! She’s smiling and happy and back to her old self.” Cora taught me to never give up on a patient just because they are older. Everyone deserves a chance to be better. People deserve to be treated as individuals not as statistics on a bell-shaped curve. I challenge my patients to become the outliers who defy the odds and do better than expected!

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. Dr. Johnson was a medical writer and pharmacist before medical school and utilized these skills to research 450 medical journal articles to develop her book. She has no financial conflicts of interest or ties to any pharmaceutical company. Her only objective is determining the most effective, safest therapy for patients.

3. YOU CAN’T JUST GO BY “HOW YOU FEEL!”

I strongly endorse monitoring estradiol and testosterone blood levels to ensure appropriate dosage and effectiveness of hormone therapy. Monitoring estradiol levels in thousands of women since 1986 has led me to develop more precise hormone regimens producing blood levels comparable to a low physiologic range. As noted earlier, monitoring blood levels is especially important with topical therapy. Most post- menopausal women who see me initially have NEVER had their estrogen level checked!

Early heart disease and osteoporosis are both consequences of low estrogen and have no symptoms in many women. Hot flashes eventually go away in many women even without taking estrogen. Dosing hormones simply by “how you feel” is an archaic notion and other hormones like thyroid hormone and growth hormone are never dosed that way! It is time for menopause management to come into the 21st century and not be treated like a stepchild among other hormone deficiencies. A few lucky women go through menopause and never have hot flashes but this can be a mixed blessing. If you don’t have symptoms, you’re less likely to seek help. However, even without symptoms, you may still be at risk for the degenerative consequences of low estrogen.

For insidious problems like osteoporosis or heart disease, there are usually no symptoms until the woman has a fracture or heart attack. If estrogen dosage for such women is determined simply by “how they feel” we may be giving them an inadequate dose and putting them at increased risk. Objective measurement of blood estradiol ensures adequacy of dosage. Studies have shown a protective effect on bones from fairly low doses of estrogen. In one study of postmenopausal women treated with estrogen alone, those with higher estradiol levels had less progression of subclinical atherosclerosis on CIMT than those with lower estradiol. Recall that CIMT is an ultrasound measurement of the thickness of the two inner layers (the intima and media) of the carotid arteries that the American Heart Association recommends as the best way to screen for early risk of heart disease or stroke. I routinely rely on CIMT to assist me in assessing these risks in my patients.

In general, creams and gels produce lower blood estradiol levels ranging from 9.8 to 30 pg/ml that are similar to the lower doses of estradiol patches. The highest estradiol blood levels are achieved with the 0.1 mg estradiol patches and are typically in the range of 80 pg/ml.

More studies need to be done to determine the optimal level that protects us from the consequences of low estrogen while avoiding the adverse effects that may occur with the higher doses of estrogen. For the time being, a reasonable approach is to give the lowest estrogen dose that relieves symptoms and still falls within the lower physiologic range for a premenopausal woman.

4. IMPORTANCE OF ACCURATE BLOOD ASSAYS

When measuring estradiol levels it is very important that an assay be utilized which has the ability to detect the very low levels present in post-menopausal women. The estradiol assay used in fertility practices for women undergoing ovulation induction or in vitro fertilization is not appropriate. An assay with sensitivity at the low end of the scale is required to monitor estradiol therapy in menopausal women. The assay should be capable of measuring less than 1.5 ng/dL of estradiol or less than 1.0 pg/ml of free estradiol. Similarly for free testosterone, assays that utilize equilibrium dialysis are the most accurate at detecting the lower levels of testosterone seen in women.

When I first see a female patient, I may check estradiol blood levels several times in the first few months while adjusting their dosage. Once the levels are stable, I check them once a year unless symptoms develop or there is another dosage change. Since postmenopausal ovaries often continue to product testosterone, it is important to document low testosterone levels before prescribing testosterone.

For a woman with an intact uterus, withdrawal periods on cyclic progesterone and a normal yearly TVS, there is less need to monitor progesterone. “Withdrawal periods” is the medical term given to the monthly menstrual flow occurring in postmenopausal women prescribed estrogen with cyclic progesterone. When a woman is perimenopausal and still having periods, progesterone levels on day 21 of her menstrual cycle are a useful indication of her endogenous progesterone. If low, adding progesterone therapy may improve symptoms of heavy bleeding, PMS or insomnia.

5. SALIVARY HORMONE TESTING IS NOT RELIABLE

Many women ask me about salivary hormone tests. While dependent on the accuracy of the testing laboratory, you can measure hormone levels of estradiol, progesterone and testosterone in saliva. However, an important reason for measuring hormones is to be able to determine the optimal dose of the hormone preparation. Salivary hormone tests are notoriously unreliable for this purpose. Numerous studies have shown inconsistent and skewed results with the use of salivary hormone testing in women on HRT. That’s why I utilize blood hormone testing.

RECAP WHY IS IT IMPORTANT TO MEASURE ESTRADIOL BLOOD LEVELS? BLOG SERIES

WHY IS IT IMPORTANT TO MEASURE ESTRADIOL BLOOD LEVELS? PART 1

The content of this blog series is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. This blog series may discuss nutritional products and protocols that have not been evaluated by the U.S. Food and Drug Administration. These products or the information contained on this website is not intended to diagnose, treat, cure or prevent any disease. All website content is © Copyright 2012 by Marina Johnson MD - All Rights Reserved

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. Dr. Johnson was a medical writer and pharmacist before medical school and utilized these skills to research 450 medical journal articles to develop her book. She has no financial conflicts of interest or ties to any pharmaceutical company. Her only objective is determining the most effective, safest therapy for patients.

To obtain a copy of "Outliving Your Ovaries" click here

Many women who initially see me for menopause have never had their estradiol level checked. Their previous physician may have diagnosed menopause with an elevated FSH, but usually no further tests are done. I’d like to go through various reasons why I believe it is important to monitor estradiol levels.

1. ESTROGEN IS A TWO-EDGED SWORD

I describe estrogen as a two-edged sword because it can be both protective and harmful depending on how your body uses it and on the amounts and duration of estrogen exposure. Endogenous estrogen refers to the levels of estradiol that a woman’s own body produces before menopause. Early in the book I outlined how estrogen is essential to many cellular functions throughout the body. In Chapter 22 - Risks of NOT Taking Estrogen, I listed the many symptoms and degenerative consequences that can result from a low estrogen state.

On the other hand, estrogen excess throughout a woman’s life is associated with increased risks of cancer. An increased risk of breast cancer is associated with longer exposure to endogenous estrogen, i.e. early menarche (starting your periods at an early age) and later menopause. Higher estrogen states seen with obesity increase the risk of breast cancer even more. Studies show women with a body mass index (BMI) over 35 have a twenty-fold increased risk of endometrial cancer.

Estrogen, estrone and testosterone can be produced from fat cells in obese postmenopausal women. These obese women also have lower production of a substance in the blood called sex hormone binding globulin (SHBG). SHBG serves as a carrier protein for storing estrogen in the blood. Lower levels of SHBG results in higher levels of available estrogen that thereby increases their estrogen exposure. In the Nurses’ Health Study of a subset of women on no HRT, an increased risk of breast cancer was seen in women with the highest endogenous estradiol compared to those with the lowest estradiol. A similar increased risk was seen in women on no HRT with the highest endogenous level of testosterone. However, in women on HRT with low testosterone, studies show that adding testosterone can be beneficial in lessening the risk of breast cancer.

These potentially protective and harmful effects of estrogen go back to the basic tenet of any hormone - adverse symptoms can occur with deficiency or excess while optimal function develops with the right level. I see this as an affirmation of the need to respect the balance among the different sex hormones. Monitoring estradiol and testosterone blood levels enables us to prevent a deficient state while guarding against excess levels. This is a standard practice when physicians prescribe thyroid hormone. Why should it be any different for estrogen and testosterone?

2. VARIABILITY OF TOPICAL ABSORPTION

While levels are consistent within a given individual, tremendous variability in the efficiency of absorption can be found from one woman to another and this constitutes another reason to measure blood levels. In a study of women given identical doses of topical estradiol there was considerable variation in blood levels with estradiol increases above baseline differing as much as 90 pg/ml from one woman to another. Studies have even shown differences in absorption when changing women from one patch to a different brand of the same dose. Despite such variations, absorption of topical estradiol is more stable and consistent than oral estradiol which peaks at 4 to 5 hours and is non detectable by 8 to 10 hours.

This phenomenon of variable absorption with topical patches, gels and creams has been documented in numerous studies. Importantly, estradiol blood levels tend to be consistent within a given woman once appropriate levels are achieved and frequent dosage changes are not generally required. Annual monitoring of estradiol blood levels is generally adequate to ensure therapeutic levels. With increasing age of the woman, drug metabolism may be slower, requiring dose reduction to prevent excess estradiol levels.

Since I routinely monitor blood estradiol levels, I have seen such variation in topical absorption in the thousands of women I have managed. This may also explain why some women who first start topical estradiol sometimes give up saying “it doesn’t work” and they switch to pills. Since you have learned of the lower risks from topical estradiol, it is worthwhile to persist in finding a topical product that works for you. In my clinical experience of managing over 100,000 female patient visits, I’ve found very few women who could not be managed with topical estradiol.

In general, thin women require higher estradiol doses while obese women with endogenous stores of estrogen in fat generally can be managed with a lower dose. Higher climate temperature in summer months may increase the need for higher doses of topical estrogen especially in women who are outdoors a lot and are very physically active. Women who take long hot baths will likely reduce estrogen absorption from estradiol patches because the hot water leaches estradiol from the patch. Taking showers does not have this effect. If a woman insists on long, hot, baths, she is best managed with topical gels and creams.

When a pharmaceutical drug is developed, in order to receive FDA approval, the manufacturer must show proof that their product has effectiveness and achieves significant blood levels. The pharmacology term for this is the “drug-response curve.” Studies are done to establish the optimal dose that will achieve certain blood levels and the desired therapeutic effect with the least adverse side effects.

Tomorrow: Why You Can’t Just Go By ‘How You Feel!' - Read Part 2

The content of this blog series is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. This blog series may discuss nutritional products and protocols that have not been evaluated by the U.S. Food and Drug Administration. These products or the information contained on this website is not intended to diagnose, treat, cure or prevent any disease. All website content is © Copyright 2012 by Marina Johnson MD - All Rights Reserved

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. Dr. Johnson was a medical writer and pharmacist before medical school and utilized these skills to research 450 medical journal articles to develop her book. She has no financial conflicts of interest or ties to any pharmaceutical company. Her only objective is determining the most effective, safest therapy for patients.

To obtain a copy of "Outliving Your Ovaries" click here

A recent study in Lancet Oncology looking at data from the Women’s Health Initiative (WHI) reported that the use of estrogen (Premarin) alone was NOT associated with an increased risk of breast cancer and the use of estrogen-progestin (Prempro) increased the risk of breast cancer. 

At first glance this may seem contradictory since estrogen has been traditionally associated with increased breast cancer.  Here’s a possible explanation.  The Million Women Study in England and the French E3N cohort study have reported that the timing for when estrogen is first started after menopause is a critical factor in determining breast cancer risk.  Women who started estrogen in the first 3-5 years after menopause had a higher risk of breast cancer than those starting estrogen AFTER 5 years. So starting estrogen more than 5 years after onset of menopause is considered a long gap time while starting estrogen immediately after menopause is considered a short gap time.

This is a complex issue so let me first give you some background to make it easier to understand. Most invasive breast cancers are the end result of a decades long evolution of increasingly abnormal premalignant cells. Estrogen is thought to promote breast cancer NOT by causing new cancer cells but rather by accelerating the growth of small, premalignant cells so they become detectable on clinical exam or mammogram. When breast tissue is deprived of estrogen at menopause for many years, it causes shrinkage of these premalignant cells.

Correlating this to the WHI study, recall that the WHI participants who were started on Premarin had been menopausal on NO estrogen for an average of 8 years.  Some of them were 20 years post menopause and had NEVER taken estrogen!  So you would expect to see less breast cancer because after so many years of being without estrogen whatever premalignant cells they had would have died off.  So that’s exactly what was seen with women in WHI.

Now if we’re postulating the TIMING as an explanation, why would you see increased breast cancer risk with the combination hormone pill called Prempro?  By the way, this increased risk of breast cancer with combined synthetic estrogen/progestin is a consistent finding in many studies.  A possible mechanism could be the addition of a daily progestin like the Provera found in Prempro that turns off apoptosis, a protective mechanism of the body that destroys early cancer cells. Another study reported another harmful effect of a daily progestin:  increased productions of RANKL, a protein molecule that stimulates breast cells to multiply and not die when they should.

So what does a woman do who’s considering HRT? Does she have to suffer miserably from hot flashes for 5 years to decrease her risk of breast cancer and then start estrogen?  Does she have a hysterectomy so she doesn’t have to worry about taking a progestin??  ABSOLUTELY NOT!!  First of all by depriving yourself of estrogen for 5 years, not only are you likely to be having the typical low estrogen symptoms like hot flashes but you’re also subjecting yourself to an increased risk of heart disease, osteoporosis, Alzheimer’s, sexual dysfunction and a poor quality of life!

The French E3N study in 53,000 women reported that women who took estrogen + progesterone had NO increased risk of breast cancer when they started HRT within 3 years of menopause.  So the take-home message from these studies is to avoid synthetic progestins and opt for natural hormones like estradiol and progesterone.  You can avoid the increased heart attacks and strokes seen in WHI by choosing topical estrogen in the form of patches, gels, creams and mists that are available at any drug store. It’s important for women to know that these pharmaceutical natural hormones (also called bioidentical hormones) are superior to compounded bioidentical hormones because they are required to meet higher standards for quality control and efficacy. 

Women need to know there’s a window of opportunity of 10 years from menopause when they will get the most protection from estrogen against heart disease, osteoporosis and Alzheimer’s.

The majority of women who go through menopause, get the classic symptoms: hot flashes, night sweats, insomnia, anxiety, depression, sexual dysfunction, and brain fog. For those who still have their uterus, menopause is easier to recognize because their periods stop. When a young woman in her 30’s or 40’s has a hysterectomy and has her ovaries removed, she will likely have severe symptoms.  However, for those women who have had a hysterectomy and still have their ovaries, the loss of estrogen may occur so gradually they don’t notice it.  Some of the subtle signs associated with estrogen loss can be:  weight gain especially around the waistline, crying spells for no reason, not being able to multi-task, dry skin, PMS, acne and sexual dysfunction.  Women are often treated with antidepressants and other drugs.  These are all symptoms that often resolve with estrogen therapy so it’s important for women to recognize this so they can ask their physicians about considering HRT.

This information is all explained in detail in my book, “Outliving Your Ovaries.“ My book is based on my review of 450 medical journal articles and supported by 30 years of clinical experience.  I wrote the book to give women a guidebook to sort out the confusion about HRT so they can better participate with their physicians in selecting the best HRT for themselves.  

1. Anderson GL, Chlebowski RT, Aragaki AK et al, “Conjugated equine oestrogen and breast cancer incidence and mortality in postmenopausal women with hysterectomy: extended follow-up of the Women’s Health Initiative randomised placebo-controlled trial,” The Lancet Oncology, Early Online Publication, 7 March 2012, doi;10,1016/S1470-2045(12)70075-X

2. Fournier A, Mesrine A, Boutron-Ruault MC, et al, “Estrogen-Progestagen Menopausal Hormone Therapy and Breast Cancer: Does Delay From Menopause Onset to Treatment Initiation Influence Risks?” Journal of Clinical Oncology 27: 5138-5143.

3. Leslie Bernstein, “Combined Hormone Therapy at Menopause and Breast Cancer: A Warning—Short-Term Use Increases Risk,” Journal of Clinical Oncology 27: 5116-7

4. Fournier, A, Berrino, F, and Clavel-Chapelon, F, “Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study,” Breast Cancer Research and Treatment, vol 107, no. 1 (2008): pp 1033-1111.

5. Ory K, Lebeau L, Levalois C, et al, “Apoptosis inhibition mediated by medroxyprogesterone acetate treatment of breast cancer cancer,” Breast Cancer Research and Treatment, vol. 68 (2001): pp 187-198.

6. Schramek D, Leibbrandt A, Sigl V, et al, “Osteoclast differentiation factor RANK controls development of progestin driven mammary cancer,” Nature, published online 9/29/10doi:10.1038/nature09387.

7. Beral V, Reeves G , Bull D, and Green J for the Million Women Study Collaborators, “Breast Cancer Risk in Relation to the Interval Between Menopause and Starting Hormone Therapy,” Journal of the National Cancer Institute 2011;103:296–305

In her new book, "Outliving Your Ovaries," Endocrinologist Dr. Marina Johnson reveals compelling research that compares the risks and benefits of Hormone Replacement Therapy (HRT) to statins and other commonly used drugs.

Thirty randomized controlled trials of women taking pharmaceutical HRT ( have shown a 40% reduction in mortality yet statins have not been shown to reduce mortality in women. Dr. Johnson emphasizes the point is not to advocate or criticize the use of one drug or another but to use some common sense and put the risks and benefits in clinical perspective. The risks of breast cancer from statins or HRT are rare (less than 1 event per 1000 women) and should be considered in light of potential benefits.

Reference

These studies appeared in the Cleveland Clinic Journal of Medicine and the Journal of the North American Menopause Society.

Hodis, HN, "Assessing benefits and risks of hormone therapy in 2008: new evidence, especially with regard to the heart," Cleveland Clinic Journal of Medicine, vol 75(4) (2008): pp S3-S12.
Download the Hodis Study

This is but one example of the ground-breaking research Dr. Johnson has included in her new book, "Outliving Your Ovaries"

Credentials

The average age for menopause is 50 to 55. I’ve seen an occasional woman who has regular monthly periods and then one month has her last period and never has another. However, this is the exception rather than the rule. Typically, women begin with perimenopausal symptoms in their forties. As a woman approaches the end of perimenopause, the periods become lighter and start to become more infrequent. She may skip several months without a period, and then finally the periods stop completely. When the decline in hormones occurs very gradually, a woman may not experience severe symptoms because her body has had time to compensate for the decline in estrogen and progesterone. Often the age of menopause is genetically determined and it is helpful to ask when an older sister or mother went through menopause. A catastrophic, stressful life event can bring on menopause earlier than expected.

Some women are elated when their periods have stopped and experience few adverse symptoms. Other women respond to the loss of estrogen with severe symptoms and find it difficult to do their work. Because of such differences, women experiencing great difficulties are sometimes written off as “hysterical” or hypochondriacal, which is very unfair to these women. Overall, there can be tremendous variation in how menopause is experienced by different women. Every time I think I have seen every “variation on the theme,” I see yet another woman who is having a slightly different experience.

After menopause, the adrenal glands continue to produce androstenedione, a hormone that is converted in fat cells to another form of estrogen called estrone. This is a reason why obese women may have less severe hot flashes. It also explains why thin women often require higher doses of estrogen to control their low estrogen symptoms.

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD.
Dr. Johnson has no financial conflicts of interest or ties to any pharmaceutical company.
Her only objective is determining the most effective, safest therapy for patients.

"Outliving Your Ovaries is a book that should interest every member of the human race, including men. Most men have women in their lives (I have a wife, daughter, mother, sister, cousins, etc.) and most women have men in their lives who care about them. Women have a unique biology that I never understood before reading Dr. Johnson’s book.

Women need to understand that even making 'no decision' about replacing female hormones carries consequences! Dr. Johnson’s book bridges the huge knowledge gaps between the layperson and the pharmaceutical industry, between hype and the facts, between the layperson and medical researchers, between sound byte news reports and detailed medical analysis of studies and between patients and treating physicians. Her passion for patient care comes through on every page of the book and every word focuses on giving her menopausal patients and the physicians who treat them, the medical knowledge necessary to allow them to live long, productive, vigorous and healthy lives. Any woman approaching perimenopause or menopause and any man who cares for such a woman, should arm themselves with the knowledge provided by Dr. Johnson’s book. "

Mark W. Walker - Attorney

“I want to thank Mark Walker, a prominent business attorney and patient, who gave me very helpful comments and even did a survey of the women in his office asking their opinion about certain sections to improve clarity and relevance.” Acknowledgement Taken From ‘Outliving Your Ovaries’

As a new physician, I thought I knew it all. However, I quickly learned in those first few years that medical school simply gives you the tools with which to evaluate the thousands of different patients you’ll see in your career. Even with those great tools, you must pursue ongoing medical education or you quickly become outdated. It’s definitely a stressful life, but gratifying when you find answers and relieve suffering. When faced with a sick patient for whom standard treatments are not working, physicians feel compelled to look for other options to relieve that patient’s suffering.

I saw such a patient in the 1990’s who caused my practice to take a turn in the road. I had a very busy managed care practice at that time. I had acquired a reputation among my colleagues as someone who was a very good diagnostician. Jane was a very pleasant patient sent to me by her family doctor. She complained of generalized symptoms of severe fatigue, poor concentration, irritability and joint pains which were making it difficult to care for herself and her family. She had been given pain pills for the joint pains that only made her fatigue and poor concentration worse. She told me her doctor said, I don’t know what you have, but I want you to go see Dr. Johnson. If she can’t help you, then you’ll need to go see a shrink! I did an endocrine evaluation and her test results all came back normal. I felt very badly for her because I knew she wasn’t making up the symptoms but yet I had no idea what was going on with her or what to do to help her.

I could have referred her back to her doctor saying I didn’t see an endocrine problem. However, I knew that if I did that she would just be prescribed an array of psychotropic drugs. In no way am I disparaging the important role that psychiatrists play in managing psychiatric patients. It’s just that sometimes in a busy practice, when the medical physician doesn’t know what’s going on with a particular patient, there’s a tendency to write the patient off as being “crazy.” In my opinion, this patient had neither a psychiatric nor an endocrine problem but I didn’t know what to do for her or where to send her. I wanted so much to help her that I had to start thinking more creatively.

It turned out while Jane did not have an endocrine problem, she did have a very significant, digestive problem and was having frequent, loose bowel movements each day. She had previously seen a gastroenterologist who had done a colonoscopy and told her everything was normal. He diagnosed her with irritable bowel syndrome (IBS). IBS is a “catch all phrase given to patients after serious pathology has been excluded. Gastroenterologists tend to focus on treating seriously ill patients with colon cancer, bleeding ulcers and other digestive conditions that often require hospitalization. Since IBS is regarded as a chronic, benign condition, such patients are generally referred back to their general practitioner. Because patients are reassured by the benign colonoscopy, they may resign themselves and think these symptoms are normal for them. This often occurs, especially with digestive problems because many people are embarrassed to discuss their bowel habits with friends or family so they don’t know what constitutes normal bowel habits.

Since every endocrinologist is first trained in internal medicine, I did have training in digestive disorders in my residency program. However, it wasn’t until I studied integrative medicine and functional medicine that I became aware of the importance of the gastrointestinal (GI) tract to good health.

The GI tract contains 60% of your immune system and produces 90% of your serotonin, the feel-good neurotransmitter which contributes to energy, good sleep and a sense of well- being. I did diagnostic tests and determined she had an intestinal bacterial infection causing her IBS. Once her infection was treated with an antibiotic, she had resolution of her loose stools. The GI tract is essential for absorption of nutrients that serve as building blocks to repair cells and make new ones. After restoring normal GI function, all her symptoms resolved and both of us were delighted with her recovery!

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD.
Dr. Johnson has no financial conflicts of interest or ties to any pharmaceutical company.
Her only objective is determining the most effective, safest therapy for patients.

Giving patients hope is an important aspect of the doctor-patient relationship that contributes to good outcomes. Early on in my career as a new Endocrinologist, I saw Alice, a 35-year-old woman with Type 1 diabetes and mild diabetic kidney damage. I started her on a protein restricted diet and medication to slow the progression of diabetic kidney disease. Eager to not be missing any other new therapy that might be helpful, I referred her to a kidney specialist. Alice came back to see me two weeks later, and burst into tears as soon as I entered the exam room. Alarmed at her distress, I asked what had happened. Through her tears, she sobbed,

I went to the nephrologist and showed him all the lab results you had done and your recommendations which he advised me to continue. Then he showed me a graph outlining the progression of diabetic kidney disease. He told me, based on your lab values, this is where you are now and in 4.2 years, you will have end-stage kidney failure and need to start on dialysis!

That nephrologist was a fledgling physician, like myself, and he was probably trying to be very scientific in presenting Alice the most precise data. What I learned from that experience was that a physician’s words can be destructive or healing. Giving Alice such cold, hard facts implied her progression to kidney failure was inevitable. In any study, there are always “outliers”, who do better than the average participant. It is important to not give false hope, but patients should be encouraged to defy the odds because the patient’s mental state and perception have a powerful effect on self-healing.

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD.
Dr. Johnson has no financial conflicts of interest or ties to any pharmaceutical company.
Her only objective is determining the most effective, safest therapy for patients.

I want to stress that Dr. Johnson saved me! By that I mean, I knew something was wrong but no other doctor took the time to really talk to me and, more importantly, listen.  I believe that to be her strongest attribute; as women we often just want someone to listen with compassion and not label us as needing a pill.  Her in depth review revealed what I needed. 

I am so lucky that I can afford her services financially.  I have many, many girlfriends who cannot.  Some of them are suffering the very things I have, and some eventually will ( I now know this because of the care they are/are not receiving).  This book will empower them to speak with their current medical provider with some level of knowledge of their own needs.  That is the greatest thing about her writing this book - EMPOWERMENT.  It is horrible to feel that no one is listening and to feel you are reduced to taking whatever is thrown at you.  Her book provides fundamental, real, plain English information.  It is easy for us "non-professionals" to understand and navigate.

Health care being what it is today, we all have to take more responsibility for learning about our bodies and be willing to speak.  We can't just take a doctor's word for it anymore - they don't have or don't take the time to know us.  We women are such wonderfully complex beings and Dr. Johnson is taking us seriously.  I love her!

The staff in Dr. Johnson's office is amazing.  They are just so darling and ALWAYS make me feel important, cared for and safe.  I have never gone to a doctor's office where I just wanted to hang and have a cup of coffee.  These people are an integral part of the service she provides.  Some of us are really sick when we finally find Dr. Johnson.  Being greeted by compassionate and sweet staff is of the utmost importance.  You are putting your care in their hands because you talk to them more often than the Dr.!!! I am so proud of the whole staff at The Institute of Endocrinology and Preventive Medicine.  I am so thankful to have found them.

Warmest regards, 

Elizabeth

To obtain a copy of "Outliving Your Ovaries" click here

Why I Recommend Pharmaceutical Bioidentical HRT

Let me tell you why I recommend bioidentical HRT. It is a therapy I have utilized in the 100,000 female patient visits that I have managed over the past 29 years since pharmaceutical topical estradiol was first introduced in 1986. I have had ample opportunity to see what therapies achieve results and what women tolerate with the fewest side effects.

An important concept regarding hormone therapy is that unlike most other prescription medicines, hormones are part of our biological make-up and are essential to the intrinsic function of our bodies. We've learned in previous chapters of the myriad biological actions of estradiol, progesterone and testosterone in a woman’s body. We have also seen that many of these actions are mediated through downstream byproducts of estradiol. So doesn't it make more sense to restore what's deficient rather than cluttering this complex, intricate system with an imitation, "wannabe" hormone?

HRT Is Not Without Risk

Female hormones have been in our bodies since we went through puberty. It is part of our original design since the beginning of time. Yes, there are some safety concerns about estrogen. So logically, if you've made the decision to take HRT, it makes sense to choose what appears to be the safer option. I have tried to fairly represent that bioidentical HRT is not without risks but the risks appear to be less with topical estradiol and progesterone than with imitation HRT. Should we wait another 20 years until large definitive, double-blind, placebo-controlled randomized studies produce more data in support of these findings? While some of the data are not supported by such scientifically rigorous studies, as a prudent physician needing to care for my patients today, I feel compelled to act on what is currently known and act accordingly, making adjustments as additional new studies provide us with more information.

The Goal Of Endocrinology

To those naysayers who contend that pregnant horse urine is “natural,” I choose the very same hormones, estradiol, progesterone, and testosterone that are present in a human woman’s body, not hormones from animals. Furthermore, you can take any natural substance that exists in the body, give it in excess amounts, and cause disease or death. For instance, something as essential to life as oxygen and water, given in excess, can be fatal. It is all about balance and respecting the normal physiology of the body. That is the goal of Endocrinology, a specialty that deals with diagnosing and treating diseases caused by too much or too little hormone(s.)

Bioidentical HRT is Often Given a Negative Connotation

Women are often surprised to learn that the bioidentical hormones, estradiol and progesterone, are available from pharmaceutical companies. That’s because the term "bioidentical hormone replacement" is often given a negative connotation. It often becomes a clash between pharmaceutical companies and compounding pharmacists.

Most pharmacists dispense prescription medications that are manufactured by pharmaceutical companies. Compounding pharmacists are trained to make individual hormone products from bulk raw materials. The physician writes a prescription for a particular hormone preparation and the pharmacist mixes it to those specifications. Pharmaceutical companies correctly assert that they have to meet higher manufacturing standards for quality control than compounding pharmacists. Pharmaceutical companies complain compounded hormone products are often given to women without the attendant information that outlines risks.

I Will Not Prescribe Prempro; or Any Oral Estrogen

I have no bias against pharmaceutical companies. They provide us with lifesaving and innovative therapies. However, I won't prescribe the most commonly prescribed HRT - Prempro or any oral estrogen - because it is not as effective as topical therapy and is associated with more side effects. As an advocate for my patients, it is my ethical responsibility to prescribe the safer, more effective therapy, and that principle governs all my professional decisions. The appropriateness of my choices has been demonstrated in the medical literature, and I have personally observed it in the thousands of patients I have treated over my clinical career.

Given The Choice I Will Always Choose Pharmaceutical Bioidentical

Having been a pharmacist, I am very supportive of the important role of compounding pharmacists. However, if I have a choice of a compounded or pharmaceutical bioidentical hormone product, I will always choose the pharmaceutical product because they have to meet stricter standards of quality control, and I achieve more consistent results when I monitor blood levels.

Compounding pharmacists play an important role in providing products for patients with allergies and other special needs. They can also compound products that are not commercially available. Pharmaceutical companies sometimes withdraw drugs from the market not because of poor efficacy but because there may not be enough market demand for their product. If a physician chooses to prescribe compounded hormones, it is imperative that blood levels be monitored. These patients need to be monitored in the same manner as any other patient receiving HRT. Patients also need to be informed that compounded HRT carries the same risks as pharmaceutical bioidentical hormones.

Talking to Your Doctor

Informing yourself of the risks and benefits of bioidentical HRT is important but since these are all prescription medicines, you will ultimately require the cooperation and advice of your physician. Your own physician can advise you if you have particular health issues which constitute a relative contraindication to bioidentical HRT. If you are having many menopausal symptoms, he/she will be more likely to prescribe HRT. All physicians want the best for their patients and are usually willing to listen and consider reasonable requests. If your physician believes that hormones are in your best interest, pharmaceutical bioidentical HRT is a good choice. Make a list of all your questions ahead of time and tell the scheduling person that you want an appointment to discuss hormone therapy. If you found Outliving Your Ovaries helpful, take a copy to your physician. Do not hesitate to seek out additional medical opinions about your individual condition - caring physicians will assist you in doing so.

Outliving Your Ovaries can increase your awareness of how hormones contribute to optimal health. Healing starts with your belief that it is possible. Use my book as a guide to educate yourself about your treatment options so you can ask meaningful questions and become a better partner in working with your physician.

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD.

To obtain a copy of "Outliving Your Ovaries" click here

According to the American Diabetes Association, diabetes was the sixth leading cause of death in 2007. Ninety-five percent of diabetes is type-2 that develops in older people or at any age in overweight people. Diabetes dramatically increases the risk for heart disease and stroke.

Women who do not take HRT have up to a 30% increased risk of developing type-2 diabetes. Use of estrogen or estrogen plus a progestin/progesterone is associated with a decrease in the risk for type-2 diabetes.

Women in their forties or fifties often complain about a tendency to gain weight, especially when they don’t take hormones. I recall Greta, a 38 year-old menopausal woman with obesity, diabetes, high blood pressure, and sleep apnea. She was only five feet tall and weighed 200 pounds. She told me, “When I was growing up I was skinny and barely weighted 100 pounds soaking wet! I could eat as much as the football players and never gained a pound. In my late 20s, I started having heavy bleeding from fibroids and when I was 28 years old, everything was taken out. No one ever told me I needed estrogen. Within a year of my hysterectomy, I gained 100 pounds and developed severe depression. My husband left me soon after that. A doctor finally gave me oral estrogen when I was 32 and I felt better but couldn’t lose the weight. I was diagnosed with diabetes and high blood pressure when I was 35.” Changing Greta to topical HRT and correcting her sleep apnea started her recovery toward losing weight and improving control of her blood pressure and diabetes. However, it saddens me that she suffered needlessly for ten years before getting help.

Weight gain with a change in body composition favoring central or visceral obesity accompanies menopause. Women lament the fact they start having thickening around their midriff! With loss of estrogen comes an increase in fasting glucose and the development of insulin resistance leading to diabetes in genetically susceptible women. Insulin resistance is a condition where the body becomes “desensitized” to the actions of insulin. Because insulin is a vital hormone, the pancreas responds by making more insulin. This satisfies the need for insulin action but at the expense of higher circulating levels of insulin. High levels of insulin signal fat cells to conserve fat stores and to convert new food into more fat! This is not a signal you want going to your fat cells!

In individuals who are genetically predisposed to diabetes, this relentless drive for more and more insulin production eventually exhausts the pancreas leading to the onset of diabetes. Even if they never develop diabetes, the presence of ongoing insulin resistance is associated with continued weight gain and accelerates the risk of heart disease, cancer and strokes.

In a group of 505 normal weight non-diabetic women, menopause was the determining factor and not age that was associated with insulin resistance. Leptin, a hormone made in fat cells is responsible for regulating appetite and metabolism. Although leptin is a hormone that reduces appetite, obese people tend to have elevated leptin levels and also seem to develop resistance to the effects of leptin.

A prospective study of 44 healthy postmenopausal women randomized to receive either no treatment or topical estradiol 0.05 mg per day combined with a cyclic progestin were followed for one year. Untreated postmenopausal women had an increase in total and percent body fat and increased visceral body fat. Untreated postmenopausal women also showed corresponding increases in serum leptin levels. The women receiving topical estradiol had no increase in leptin and had no increase in body fat.

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. 

To obtain a copy of "Outliving Your Ovaries" click here

Studies show about eight of every 100 women of childbearing age - about 3.9 million women - go through natural menopause before the age of 40. Sometimes early menopause has a genetic basis and a 2006 study has attributed it to certain genes. In these families premature graying of the hair, sometimes as early as the 20s, is often seen. About 3.2 percent of women with premature ovarian failure also have Addison’s disease, an autoimmune disease of the adrenal glands. Addison’s disease is easily treated but it can be dangerous for women who don’t know they have it. If a genetic basis is suspected these women are well advised to consider having their families at an earlier age. If your periods stop and you suspect premature menopause, see an endocrinologist to confirm that it is truly menopause and not a temporary cessation from some other abnormality.

Most people are familiar with autoimmune diseases like hypothyroidism and diabetes, in which antibodies destroy the thyroid or pancreas. A similar process can result from antibodies that damage the ovaries. Certain environmental factors may contribute to premature menopause. If a woman has undergone chemotherapy or radiation for cancer, the treatments may permanently damage the ovaries.

The risk of menopause depends on the type and length of treatment (chemotherapy, radiation) and the age of the woman at the time of treatment. The physical symptoms for younger women are much as they would be at age 50, but the emotional impact is often greater. Women with premature menopause often struggle with depression. If they are still childless, they realize their dreams of giving birth are crushed because their reproductive years are over. They often feel somehow “less of a woman.” It’s like a one-two punch. The body is going through immense changes, and the psyche is being shattered. When menopause comes at such an early age, the woman is subject to a higher risk of heart disease, dementia, osteoporosis and other complications because she is subjected to more years of low estrogen. Because these women will likely receive a longer duration of HRT, it becomes even more important to select topical estrodial, a safer form of HRT.

In an open label, randomized, controlled crossover trial, women with premature ovarian failure were randomly assigned to either topical estradiol and vaginal progesterone or oral ethinyl estradiol and synthetic progestin. After 28 months, the women receiving topical estradiol and vaginal progesterone had lower blood pressure, better kidney function and less activation of the renin-angiotensin system compared to those receiving oral synthetic estrogens and progestins.

Such findings suggest important implications for the future cardiovascular health of women who undergo premature menopause. The North American Menopause Society and the Endocrine Society recommend that the findings from the Women’s Health Initiative (WHI) and the Heart and Estrogen/ progestin Replacement Study (HERS) should NOT be applied to women who experience premature menopause.

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. 

In Response To Recent Social Media Question: 

Recently I was asked if “all women go through menopause the moment that their period stops?”  this is true ONLY if they are truly menopausal.  When women's periods stop, that could also be caused by various endocrine disorders, that when treated may lead to resumption of normal periods.

Women in their forties or fifties are often in the “sandwich” generation with responsibilities for children and husbands while caring for aging parents. It’s further compounded if they work outside the home. They may have been previously adept at this type of multitasking but now find themselves “overwhelmed.” These are obvious symptoms that get your attention and affect your productivity and well-being.

Mary came in to see me on a myriad of prescription medications. She relayed to me how she’d gotten on all those medicines. In her 40s when her periods started changing, she developed insomnia and depression. She was started on sleeping pills and antidepressants and initially felt better. When her periods stopped, she was put on Prempro and she gained 30 pounds in the first year. (women without estrogen often gain weight around their middle but it can also be worsened by oral estrogen.) Because of the weight gain and oral estrogen, she was diagnosed with high blood pressure and started on blood pressure medications. From the oral estrogen and weight gain, she developed high cholesterol and had to be started on cholesterol medications. Her weight gain continued and she developed fluid retention often seen with oral estrogen. She was then started on “fluid pills” (diuretics), to deal with her swollen hands and feet. She later developed anxiety and worsening depression at all the changes occurring in her body. Her antidepressants were increased and she was started on the strong, anti-anxiety medication (Xanax) which made her feel like a zombie throughout the day. She became sluggish throughout the day but she couldn’t sleep at night with her sleeping pills and was up doing laundry. Because of her fatigue, she was then started on Adderall, which is a potent amphetamine to give her energy! Her weight gain had also caused her to develop reflux and so she’d been given a potent acid blocker, (Nexium), which relieved the reflux but gave her bloating and constipation and she was miserable. So in essence she had been put on seven prescription medications when she probably just needed to be treated with topical bioidentical HRT.

I wish I could tell you Mary’s story is atypical, but sadly it’s an oft-repeated scenario that occurs in all too many women when their symptoms are simply treated with a drug instead of correcting the underlying cause of the symptoms. Often drugs are given to treat the side effects of the initial drugs that were given! In pharmacy circles, this is often called “polypharmacy.” After restoring appropriate levels of topical bioidentical estrogen, progesterone and testosterone, many of these prescription medications can often be gradually tapered off.

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. 

To obtain a copy of "Outliving Your Ovaries" click here

When women learn I’m a physician specializing in menopause, they usually tell me their stories. Earlier this year, I sat next to Jane, a PhD researcher, who works for a prominent east coast research institution. She had been menopausal for 3 years and was terrified of taking hormones because she was fearful of breast cancer. Jane lamented, “Dr. Johnson, I can’t remember articles I’ve just read. I have to read and re-read them to make any sense of them. I keep incessant lists of everything to keep me on task. I’m afraid I’m going to lose my job!” I reassured her about the risk-benefit ratio for estrogen, told her about topical HRT and advised her to follow-up with a menopause specialist.

On another trip this month, I sat next to Jackie, a woman in her 60s who told me about her experience when she became menopausal 10 years ago. Jackie said,

“I was having awful hot flashes and could not think straight. I became paranoid and frightened, and I was afraid to be in any social situations. I asked my young doctor for help but he just told me that was something normal that would eventually pass. I relied on advice from an older woman friend, long menopausal. I coped by refusing to go out of my house for six months and staying in bed most of the that time. My husband was worried sick about me until finally I felt a little better.”

I submit to you in the 21st century, this is not an acceptable way to treat fifty percent of our population who will all eventually go through this life stage. In addition to the suffering of these women, think of the lost productivity. When you don’t have your mind, your quality of life is severely compromised.

When estrogen deficiency continues long-term, there is an increased risk for the development of Alzheimer’s disease. In June 2008, the Centers for Disease Control and Prevention reported that AD is now the sixth leading cause of death in the United States, surpassing diabetes. There are currently five million Americans with AD or dementia and more than half of them are women. This total figure is expected to increase to 10 million as the Baby Boomers age.

Estrogen has the following effects on the brain:

1. Modulation of synapses, the special junctions where nerve cells communicate with each other

2. Increase of cerebral blood flow

3. Mediation of important neurotransmitters and hormones

4. Protection against apoptosis (programmed cell death)

5. Increase in anti-inflammatory actions

6. Antioxidant effects

There are estradiol receptors throughout the brain especially in the basal forebrain located near the bottom of the front of the brain. This area includes the hippocampus that is important for memory and learning.

There is clearly an association between the length of time a woman maintains her own estrogen production and her ability to have normal mental focus and memory. When women undergo surgical menopause at an early age and do not take estrogen, they have a sharper decline in these mental functions than women who undergo natural menopause. A Mayo Clinic study of 3000 women followed for 30 years found that women who had one or both ovaries removed before menopause and did not take estrogen were more likely to develop dementia and Parkinson’s Disease.

Despite the biologic importance of estradiol in a woman’s mental function, studies in women receiving HRT have been less conclusive. The Nurses’ Health Study of 13,087 postmenopausal women followed for eight years showed no appreciable mental benefits in women who took oral estrogen or estrogen/ synthetic progestin as compared to those on no HRT. On the contrary, they showed an actual increased risk of mental decline in those women who started HRT at an older age. A possible mechanism for this is that oral estrogen increases C-reactive protein that has been associated with increased dementia. A few smaller studies have shown a modest benefit in improving cognitive function. The WHI Memory Study showed worsening of dementia in women taking Prempro; however, the dementia appears to be related to the use of continuous combined estrogen plus medroxyprogesterone acetate (MPA). MPA has been found to reduce mental performance in both animal and human studies. See previous chapter on Risks of Adding Oral Synthetic Progestins.

Achieving The Optimal Protective Effect of Estrogen

To achieve the optimal brain protective effect of estrogen, women are advised to start on topical estrogen soon after menopause. In light of the lack of protection seen in the WHI Memory Study, it seems prudent to initiate topical estradiol. In women with an intact uterus, cyclic progesterone should be used over a synthetic progestin. Women who start estrogen after age 60 have no reduction in their risk of AD probably because they have already developed degenerative brain loss.

The Cache Study on Memory Health and Aging: Estrogen Use Reduced Alzheimer's Risk by 50%

While estrogen has been shown to prevent the occurrence of Alzheimer’s disease, in studies specifically evaluating the effect of oral estrogen in women with established AD, no effect on progression of the disease was seen. A few small studies have shown topical estrogen positively influences postmenopausal memory and may offer some protective effect against the mental decline seen in AD.

Future research on treatment for AD should focus on such variables as the route of estrogen administration, the form of estrogen (conjugated estrogens versus estradiol), when estrogen is initiated following menopause, duration of estrogen treatment, and the effects of opposed versus unopposed estrogen to define which HRT regimens may have a benefit.

Excerpt from "Outliving Your Ovaries" © 2012 by Marina Johnson MD. 

To obtain a copy of "Outliving Your Ovaries" click here

Click Here For Study

Zandi PP, Carlson MC, Plassman BL, Welsh-Bohmer KA, et al, Cache County Memory Study Investigators., Hormone replacement therapy and incidence of Alzheimer disease in older women: the Cache County Study, JAMA (2002) 288(17):2123-9
Click Here For Study

“A copy of ‘Outliving Your Ovaries’ is a must-have for every woman you know and care about. It is that important! Women’s quality of life has suffered too long because of scarce, fragmented, incomplete bits of information that exist about our health. Dr. Johnson’s life-long mission has been to seek out, study, question, observe and connect the dots correctly in an accessible manner. Her work and ‘Outliving Your Ovaries’ changes things! And you will immediately understand how when you read the book. And I speak from personal experience!”

Kim Young
President
The Forest & The Trees

The Forest & Trees helps for-profit and for-impact organizations evolve connections and conversations into partnerships for growth and sustainability.

The beauty of living into older age comes when you achieve a level of maturity that enables you to see and feel your connection to the cycle of life. You come to see the wonders of the natural world with new eyes that are both knowing and childlike in their appreciation. It’s a poignant moment of awareness that gives you a glimpse of the intricate, orderly balance of nature and how you fit into the cycle of life.

Yes, we will all die of something eventually, but it’s my mission to help you see menopause as simply the next stage in the normal cycle of life. Today, informed women have many proactive things we can do to soften the impact of aging and increase our enjoyment of life. Pharmaceutical topical bioidentical hormone therapy, exercise, healthy eating, not smoking, plus other self-care measures all play a major role in decreasing the disability of aging I challenge you to get engaged in this fascinating journey instead of simply drifting along as a passive participant.

Dr. Marina Johnson

"I had a hysterectomy when I was 46 years old and was prescribed Premarin as a hormone replacement by my doctor. Because my mother died of breast cancer and I had read many articles relating to hormones and breast cancer, I opted not to take the Premarin. I lived the night sweats, adult acne and decreased libido/vaginal dryness - but thought that was better to endure than the chance of breast cancer, (My husband was not so convinced.) Heck, I was emotionally balanced, slept great, and had plenty of energy - so what could possibly be wrong.

It wasn't until my normally perfect (even on the low side) blood pressure was off the charts did I decide to take my friends advice and see Dr. Marina Johnson. I was so impressed at the time she took to know me and my physical-emotional-spiritual history. I will admit, I was a little surprised at the thoroughness of her testing.

The lab results showed I lacked not only hormones, but calcium and other nutrients. Dr. Johnson convinced me that my blood pressure problems were far more dangerous than the threat of breast cancer. She began a gradual building of a balanced hormone replacement for me.

During my visits to her office, I had the chance to read 'Outliving Your Ovaries' as it was a lengthy work in progress. In every chapter, I saw some of my symptoms and those of friends.

I highly recommend this book and a balanced hormone plan!"

Pam Minick, Television Personality and Co-Owner of Billy Bob's Texas in Fort Worth

Topical Estrogen Has a Lower Risk of Breast Cancer - WHI (2002) showed that Prempro caused increased risk of breast cancer in women. At that time it was theorized that perhaps it was safe to take hormones for five years to relieve symptoms. In compelling NEW data published in 2009, WHI researchers showed in a randomized study of 17,000 women and from an ongoing observational study of 100,000 women starting Premarin/Prempro less than five years after menopause that those women had a greater risk of invasive breast cancer than women who started HT after five years. So in essence, there’s no justification for prescribing Premarin and Prempro even for short-term use when there’s a safer alternative!

In a 2009 French study of 53, 310 postmenopausal women, they reported that women who initiated estrogen plus synthetic progestin HT within three years of menopause and took HT for two years, had a 54% higher risk of breast cancer compared to those who never took HT. Of note, however, they reported that this increased risk of breast cancer was not seen in women given natural hormones, estradiol (In the form of Pharmaceutical patches and gels; Not Compounded) and progesterone within three years of menopause. In summary, since 352,000 women die each year from heart disease, this important information must get out to the women of America. In comparison, only 42,000 women die each year from breast cancer, but women tend to fear breast cancer above all other risks. If a SAFER therapy exists that carries a lower risk of breast cancer, women need this critical information NOW.

The primary reason I can see that’s held back this critical distinction between oral and topical HT is that Premarin and Prempro are made by Pfizer, the largest pharmaceutical company in the world. These synthetic oral estrogen products dominate 85% of the HT market in the US which accounts for about $1.3 billion a year and they ruthlessly protect their market share. Pfizer has enormous buying power and political influence in Congress, the FDA and medical schools. Because of the increased heart attacks, strokes, breast cancer and dementia reported in WHI, there are currently 9000 lawsuits from women who’ve been harmed. Yet physicians continue to prescribe Premarin and Prempro over pharmaceutical HT! It’s a travesty as far as I’m concerned.

My mother was a simple woman who never worked outside of her home. However, she was fiercely independent and taught us important principles: honesty, integrity and always doing your best. Seeing how she died has inspired me to follow her lead.Before passing at age 84, she was living in her own home, caring for herself and her husband, taking daily walks, reading her favorite books and enjoying times with her friends. One day she suffered a massive stroke and three days later slipped away but only after each of her five children were at her bedside to see her go.If more people followed my mother’s example, the nursing homes wouldn’t be filled with people waiting to die and Medicare wouldn’t be running out of money.

I’ve been blessed with a wonderful education and a full life and I thank God for allowing me to participate in so many women’s lives to ease their journeys. I love what I do and I want to share my experiences with others. For me, living is about learning and developing your mind. Did you know using your brain more actually grows new brain cells?I want to continue unraveling the mysteries of the body to find new and better ways to improve health problems. There are so many common-sense lifestyle ways to improve health that each of us can do. I love working with women who want to take charge of their health.

Like several of you mentioned I want to maintain good quality times with my husband, daughter, friends and hopefully, grandchildren, some day. Those human connections are so healing and give our lives more richness and depth.Those are more important to me than amassing material things.

I also enjoy the satisfaction of knowing I’m following God’s purpose for my life and hope to do that till the end.I don’t want to become a burden to my family or to society. I want to live a full, productive life and then die fast like my mother.

Dr. Marina Johnson

A Prayer for the Women of the World

I quietly stand in awe as I realize the

presence of God in everything.

The longer that I am in medical

practice the more I see the miracle

of the human body.

It is both a work of art and perfection

in form and function. With the right

input of nutrients and care, the body

is programmed to self-sustain and heal.

I have observed that patients who heal

in a remarkable way have an inner

strength of the human spirit

and passion for life.

That pursuit of purpose reveals

to all of us what is most beautiful

in each of us,

the will to endure,

the capacity to fight the darkness

that would surround us,

the strength of spirit to pursue the light.

That is what I wish for each of you.

Dr. Marina Johnson

As a board-certified Endocrinologist and former pharmacist, Dr. Marina Johnson ONLY prescribes bioidential "PHARMACEUTICAL" hormones, not COMPOUNDED products. Dr. Marina Johnson is a UCLA/USC trained Endocrinologist who has been in private practice since 1986 and has always utilized transdermal pharmaceutical therapy products since the original research by Dr. Howard Judd at UCLA in the late 70's.

Compounded bioidentical hormones became more popular after 2002 when the Women’s Health Initiative (WHI) reported increased heart disease, strokes, dementia and breast cancer from the use of Prempro, the most commonly prescribed HRT which is taken by mouth. Because compounded products are not dispensed with FDA "black-box" warning labels like pharmaceutical bioidentical products (as patches, gels and creams), women naturally assume compounded creams are safer.

All HRT carries risks, but numerous clinical studies of pharmaceutical bioidentical HRT, show fewer risks and better benefits with topical bioidentical HRT compared to oral synthetic estrogens. No major medical studies have ever been published with "compounded" products, only with "phamaceutical" bioidentical products.

Dr. Johnson explains, As a matter of course, I always measure a woman’s estradiol blood level with a highly sensitive laboratory test. Some women receiving compounded hormones show NO detectable estrogen. For the most effective, safest product, I advise women to choose 'pharmaceutical' bioidentical HRT. I have no financial conflicts of interest or ties to any pharmaceutical company. My only objective is determining the most effective, safest therapy for my patients.

Compounded products play an important role for patients with allergies to pharmaceutical ingredients; to provide medications that are no longer commercially available; and to enable physicians to develop novel products.

WHAT IS BIOIDENTICAL HORMONE REPLACEMENT THERAPY?

Bioidentical hormone replacement therapy (HRT) is an approach, which provides the same hormones found in a human female.  Bioidentical HRT can be found in pharmaceutical products ( Vivelle, Climara, Alora, Estragel, Estrasorb, Divigel, Evamist, Estrace, Prometrium ) and in custom formulas made by a compounding pharmacist.

Bioidentical HRT can also be made by compounding pharmacists who mix up various oral and topical preparations in their stores using techniques they learned in pharmacy school. Having been a pharmacist before medical school I feel especially qualified to discuss this issue.  However, pharmaceutical companies must meet stricter standards for quality control and efficacy.  Therefore pharmaceutical bioidentical hormones should be the first therapy of choice over compounded ones. Compared to other progesterone preparations, topical compounded progesterone has the poorest absorption and should not be used. Progesterone reduces a woman’s risk of uterine cancer. Uterine cancer has been reported from inadequate dosing of topical progesterone in women receiving estrogen preparations.

Physicians need to measure estradiol blood levels to verify effectiveness of the products and to ensure adequacy of dosage. Transdermal hormone preparations is the medical term for products applied topically to the skin as patches, gels or creams.  Topical hormone products have fewer side effects than oral products because they do not cause the liver to produce harmful byproducts. 

ARE THERE STUDIES USING BIOIDENTICAL HRT? 

It’s important to emphasize that ALL published studies on bioidentical HRT utilized pharmaceutical and NOT compounded bioidentical HRT. An important 2008 observational study, published in the European Heart Journal showed that in 698,098 Danish women followed for five years, women on combined oral estrogen plus oral synthetic progestin had a 35% increased risk of heart attacks while women on topical pharmaceutical gel or patch estradiol, with or without progesterone, had a 38% decreased risk of heart attacks.  Women on oral estrogen alone had no increase or decrease risk showing NO benefit compared to women taking no HRT.

There is a French study in 3175 women using transdermal estradiol and oral progesterone for 8.9 years which found no increased incidence of breast cancer.  More such studies need to be done including studies of preparations made by compounded pharmacists. However, for the time being, it seems prudent to choose the natural hormones, estradiol and progesterone, over Prempro and Premarin. 

HORMONES THAT MIMIC MOTHER NATURE

This is a confusing time for women in relation to hormone replacement therapy. On the one hand they have the option of taking hormones to relieve the symptoms of menopause but, on the other hand, they are faced with conflicting data on the safety of taking hormone replacement (HRT).  It is important to stand back, look at the real facts and use a little common sense. All of us know that the mass media often tends to sensationalize the news to grab your attention and make it more interesting. The decision to take HRT is too important to be made on the basis of a few sound bytes. Rather it requires careful discussion with your physician, who can inform you on the pros and cons of estrogen replacement in your particular circumstances.  Knowledge is power. Use it to arm yourself with the data you need to make an informed decision.  Because safety is a paramount issue, the fallback position should be to provide hormones that mimic Mother Nature. 

“Outliving Your Ovaries” is written by Endocrinologist Dr. Marina Johnson, Medical Director of The Institute of Endocrinology and Preventive Medicine. Dr. Johnson, a pharmacist and a physician, describes a wide body of research showing that pharmaceutical topical bioidentical hormones are safer than the most commonly prescribed hormones.   Dr. Johnson was recently an invited speaker at the Cleveland HeartLab presenting the extensive research in her approach to treating menopause. To obtain a copy of this latest book with all of the technical "peer-reviewed" research and explanations - Click Here

The Johnson Menopause Method Solution!

"Dr. Marina Johnson's book 'Outliving Your Ovaries' is an absolute  must read for all adult females. It should also be read by all healthcare providers who administer wellness advice to females. The Johnson Menopause Method™ is evidence based and backed up by years of clinical experience. Her advice is anchored in science and  delivered in a personalized manner. She tackles a very controversial subject with logic that is easy to understand. This book delivers clarity to the menopausal hormone replacement therapy issue. It is a refreshing vision of a frequently misunderstood subject.

From a medical standpoint, her method contains excellent concepts which are all too often missing in current clinical medicine. Patient education is a cornerstone in her method. This is wonderful and essential for women to be an active participant in their hormonal management. Dr. Johnson's method emphasizes cardiovascular wellness and places that concern on a platform of testing looking for actual arterial disease with a painless inexpensive carotid procedure. Her book lays out easily understood and achievable lifestyle measures to enhance the hormonal therapy benefit in maintaining health. The language utilized in her book is comprehensible to the lay public. It is apparent that she is not biased toward any pharmaceutical company. It is refreshing to read a book that is obviously divorced from medical industry bias. Dr. Johnson delivers her opinions in very objective scientifically based manner. Her thoughts are laid out in a very logical and understandable manner for medical providers as well as the lay public. This book is an extremely generous offering by Dr. Johnson. Her willingness to share her wealth of knowledge is commendable. Her book arms women with essential information that will allow them to take responsibility for their own well being. Any adult female who reads this book will be much better prepared to deal with the hormonal changes of menopause. Dr. Johnson will enhance the lives of millions of women with her book. Healthcare providers who deliver hormone replacement therapy should be required to read this book."

Dr. Bradley F. Bale
Co-Founder of the Bale/Doneen Method
Assistant Clinical Professor
Texas Tech School of Medicine

Bale/Doneen Method Website

To Obtain A Copy Of Dr. Johnson's Book-Click Here

Statistics, the language of medical researchers, can be a source of great confusion for the average health consumer.  I encourage women to look beyond the sensationalist headlines and arm themselves with the real facts.  Knowledge that encourages you to be proactive and take responsibility for your health is empowering and will greatly enhance your overall state of health. Your physician is there to help you but it’s YOUR body and you need to be part of the team!

Let me give you some background for the chocolate headline that caught your attention. For example, let’s say that 3% of the people who eat chocolates develop cavities, and 2% of people who do not eat chocolates develop cavities. The difference between these populations is only 1%. In terms of absolute risk, that means that for every 100 people who eat chocolates, 1 extra person will develop cavities (in addition to the 2 who will develop cavities without eating a single truffle). This is not a particularly frightening risk if you enjoy chocolate because 97 out of 100 who eat chocolate will not get cavities! 

                          But suppose we report the identical conclusion as a relative risk, a statistical term that compares the risk of a certain disease in two different groups.  The group who doesn’t eat chocolate is given a risk of 1.00, while the group eating chocolate is given a risk of 1.50 because they get TWICE as many cavities.  When people hear the risk of cavities from eating chocolate is increased by 50%, they may mistakenly assume that 50 of 100 eating chocolate get cavities!  On the contrary, it’s a very acceptable risk when you know that the absolute risk is only one more person who will get cavities!

Let’s use your new understanding of statistics to explain women’s concerns about hormone replacement therapy (HRT) and breast cancer. Many of the studies of HRT and breast cancer, have produced statistically modest or borderline results that have been made to look more impressive than they actually are by reporting them as relative risks.

The following slide on “Relative Risks for Breast Cancer” lists the reported increases in relative risks associated not only with HRT and ERT (estrogen alone) but also with birth weight, fish intake, eating 1 additional serving of French fries per week during preschool years, eating grapefruit, working on a night shift, working as an airline fight attendant in 2 different airlines, suffering from severe caloric restriction during the 1944-1945 Dutch famine, taking antibiotics and the use of electric blankets by African-American women.  (Yes, there were actual studies reporting all these different findings!)

The relative risks in almost all cases are very low and the use of HRT is virtually the lowest, being less risky than eating fish or grapefruit, using antibiotics or being a flight attendant!  To put the relative risks in perspective, the relative risk for smoking and lung cancer is 26.07!  That's something people can relate to that is an irrefutable risk of which most people are aware.  

Marina Johnson, M.D., F.A.C.E.

"Dr. Marina Johnson has been my primary physician for well over ten years. As a business woman, a sharp mind is critical to being successful. And as a grandmother, being able to crawl through the tunnels of Chuck E. Cheese with my grandkids and play a mean game of softball with them is priceless. I can honestly thank Dr. Johnson for that.

Her approach to wellness and preventive care has kept me in top shape both mentally and physically. I have been privileged to review Outliving Your Ovaries. It is filled with such important information that when I finished reading it, I asked Dr. Johnson to save five copies. I want my daughters and daughters-in-laws to each have a copy. All are in their thirties and forties and need to read this extraordinary Book."

Barbara

Marina Johnson,M.D., F.A.C.E , Medical Director

For a copy of Dr. Johnson’s innovative and insightful new book Outliving Your Ovaries

visit our website for the best price on the internet.

Click here to find out other testimonials and reviews of this new book, Outliving Your Ovaries!

Do you want more information about how to become a patient of Dr. Marina Johnson?