 Family practice  15 years of practice  Bellevue  Specializing in natural medicine : nutrition, herbs, bio-identicals, lifestyle, Acupuncture  My approach is Integrative: integrating the best of conventional and natural medicines and integrating care with your other physicians.  Covered by all insurance companies

 The symptoms of menopause can start as early as the late-30’s, with most significant symptoms in the late 40’s  Symptoms include: hot flashes, nightsweats, sleep disturbance, depression, anxiety, weight gain, arrhythmia, vaginal dryness, low libido, cognitive changes, changes in pelvic floor/urethral tissue, menstrual cycle changes, headaches/migraines, fatigue etc……

“Bio-identical” is a term that was coined to mean ‘biologically identical’. Prior to menopause, a woman produces 3 different estrogens: Estrone Estradiol Estriol

A woman also produces Progesterone

DHEA Testosterone

Examples of Estrogen : Ethinyl Estradiol Conjugated Equine Estrogens (Premarin) Estradiol Acetate “Progesterone” actually, should be called a Progestin: Medroxyprogesterone Norethindrone Drospirenone Levonorgestrel

Methyl-testosterone Although DHEA declines with age and can impact the symptoms of menopause, it is not usually treated by OBGyn’s

 Estrone  Estradiol  Estriol  Progesterone  Testosterone  DHEA  Ethinyl Estradiol  Conjugated Equine Estrogens  Esterified estrogens  Estradiol acetate  Medroxyprogesterone  Norethindrone  Drospirenone  Levonorgestrel  Methyltestosterone

 Postmenopausal Estrogen/Progestin Interventions Trial  Premarin + bio-identical progesterone, Premarin alone, Premarin +medroxyprogesterone  Increased HDL cholesterol was seen to the greatest benefit with the bio- identical progesterone group.

 Study of Premarin (conjugated equine estrogens) or Prempro (Premarin + medroxyprogesterone)  Over 16,000 women  Study was halted due to increased risk of breast cancer, stroke, and blood clots.

 Estradiol is assoc. with increased risk of breast cancer when used for >5 years, but not <5 years.  French E3N-EPIC study of over 54,000 women found greater risk of breast cancer with synthetic progestins  Natural Progesterone has an anti-proliferative effect on breast tissue  Prometrium when compared to Progestin did not adversely effect HDL  Preliminary research shows E2 +Prometrium protect against coronary vasospasm (contrary to Progestin)  Estriol –preliminary research suggests it may be protective to breast tissue

 Estrogen alone has a beneficial effect on bone density; estrogen + progesterone the results are mixed.  Progesterone has a calming effect on the nervous system, Progestins actually increased risk of dementia.

 Menopause is NOT a disease, it is a stage of life:  Treat based on Quality of Life symptoms  Genetics  Personal Philosophy  Treat with the lowest possible dose to alleviate side effects, for the shortest duration (usually 5 years)

 Salivary testing  Blood testing  Urine testing  Testing of estrogen & progesterone is not necessary, unless needed to monitor efficacy & safety of treatment  Testing of DHEA-S and testosterone can be helpful  Benefits of Blood testing

 Originally derived from soy or wild yam (dioscorea), chemically modified  Compounding pharmacies-benefits of individual dosing, different delivery systems, lack of additives/chemicals to formulations  “Bi-est” meaning two estrogens; estradiol and estriol (80/20)  Progesterone

 Creams (transdermal)  Sublingual drops  Pills  suppositories

 Bi-est  Progesterone  Testosterone  DHEA  Estradiol tablet (Estrace, Gynodiol)  -Vivelle, Climara, Estraderm, Menostar  Estring, Estrace, Vagifem  Prometrium  No testosterone or DHEA alternative from conventional pharmacies.

 Estrace: includes corn starch, lactose, blue 1, red 27, yellow 5 (tartrazine)  Estrace Cream: includes propylene glycol, sodium lauryl sulfate, methylparaben, EDTA (an organic pollutant), tertiary-butylhydroquinone (an organic phenol)  Prometrium : contains peanut oil, yellow 10 and red 40

 Suzanne Somers  What does “anti-aging” mean ?  Dose of hormones  Menstrual cycles  Continued use of hormones > 5 years  Long term safety is not known

 Herbal medicine:  Phytoestrogens: dang quai, black cohosh, soy, cimicifuga, Phytoprogesterones: dioscorea, vitex, glycyrrhiza  No plant-based DHEA or testosterone  Other libido-assisting herbs: maca, damiana leaf, black cohosh, dioscorea, ashwaghanda, muira puama, ginko biloba

 Herbal medicine can also help with sleep issues, depression, anxiety, cholesterol

 Nutritional Supplements: evening primrose oil, hesperidin, flax seed, ipriflavone  Vitamin D,calcium,magnesium strontium, boron, minerals  Acupuncture:  Lifestyle :  Diet –alcohol, sugar, sleep,  Decreasing processed foods  exercise

 Bloodwork: chemistry, CBC, TSH, lipid panel, 25-OH-vitamin D, CRP, homocysteine  Consider VAP testing  Bone Density: 1 year post-menopause  Colonscopy: age 50  Mammogram  Annual pap/physical  Consider advanced nutrition testing

 Hormone Replacement is an individual decision, based on quality of life issues, genetics and personal philosophy  Bio-identical hormones are “biologically identical”  Compounding pharmacies specialize in manufacturing natural products including hormones

 Research is limited  Safety is a balance  Testing is not necessary, unless to assess treatment efficacy & Safety  Anti-aging has not been studied long- term  Acupuncture, herbal medicine, lifestyle Trina Seligman

 Sign up for our newsletter  Facebook.com/EvergreenIntegrativeMedicine

 Natural Progesterone: The Multiple Roles of a Remarkable Hormone. Dr. John Lee  The Wisdom of Menopause. Christiane Northrup  What your doctor may not tell you about menopause. Dr. John Lee  Natural Hormone Replacement. Jonathan Wright  Smart Medicine for Menopause. Sandra Cabot  Screaming to be heard. Elizabeth Vliet  The Hormone of Desire. Susan Rako