Theres a menopause revolution afoot and the three letters on everyones lips from Davina McCall to Sajid Javid are H, R, T. But one group missing from many of these discussions is cancer patients and, for many of them, hormone replacement therapy isnt a straightforward option. If this powerful patient movement is to be truly revolutionary, it must also find a way to include those going through the menopause alongside cancer.

Amy Meadows, a 48-year-old campaigns manager, tells me she feels completely excluded by the focus on HRT within the mainstream menopause discussion. A year ago, she was diagnosed with breast cancer after finding a lump. After undergoing surgery, chemotherapy and radiotherapy, Amy is now having hormone therapy a treatment that induces a chemical menopause, suppressing the bodys natural hormones to prevent oestrogen sensitive cancers like hers from spreading or recurring.

As Amys oncologist warned her, this type of medical menopause can be a more brutal experience than going through perimenopause naturally, because of the sudden drop in oestrogen levels. The nature of Amys cancer also means that HRT isnt an option to ease her menopausal symptoms of hot flushes, night sweats and insomnia. I do really welcome the extra profile being given to menopause, but I feel excluded from the fast-growing club of vocal HRT advocates, she says.

Almost all my friends are on some form of HRT and reporting the positive impacts, both in terms of short-term symptom relief but also the longer-term protective impact against dementia, diabetes, osteoporosis and cardiovascular disease. Some of these potential risks are the same very ones that I am now at greater risk of because of my cancer treatment, so I also worry that Im missing out on those benefits, Amy adds.

Menopause after cancer treatment doesnt just affect those with breast and gynaecological cancers. It can be brought on by the disease itself, or as a result of surgical removal of the ovaries, hormone therapy, chemo or radiotherapy. For example, radiotherapy to treat cancers in the pelvic area like bowel cancer can cause either temporary or permanent damage to the ovaries, inducing a medical menopause. HRT usually isnt recommended for anyone with a hormone-related cancer, most notably oestrogen receptor (ER) positive breast cancers, although topical oestrogen can be used to treat symptoms like vaginal dryness.

Even for those cancer patients who can take HRT, theres a much bigger conversation that needs to take place. Charity Trekstock, which supports young adults with cancer across the UK, runs a six-week Navigating Menopause programme and have found that 44 per cent of participants hadnt been told about early menopause by their oncology teams. 42 per cent of those who took part in the programme said they didnt get support when they sought help with their symptoms, and 88 per cent found their last doctors appointment on the subject unhelpful.

For young cancer patients, who may be going through menopause a decade or two earlier than they would have done naturally, its also a seriously isolating experience. Eighty per cent of people told us theyd never met another young person whod been through cancer and the menopause, so our programme isnt just about giving people the information and leaving them to it, its about sharing stories, empowering one another, and creating communities so people feel less alone, says Trekstocks Health Programmes and Engagement Lead Jemima Reynolds, who used her background in healthcare to co-create the programme alongside 43-year-old yoga teacher, menopause guide and patient advocate Dani Binnington.

A quality standard published by the National Institute of Health and Care Excellence (NICE) states that patients who are likely to go through menopause as a result of medical or surgical treatment should be made aware of this long-term after effect and its symptoms. In reality though, Jemima adds: Were finding time and time again that people arent told and, [even if they are told at their initial diagnosis] it isnt revisited.

Dani went through a temporary menopause during treatment for breast cancer in her 30s but at the time had no idea thats what it was. My periods stopped for a while when I was going through chemo, but I just thought all my symptoms were cancer or treatment related. I was poorly educated in terms of my biology and it wasnt until three years ago that I realised Id been in the menopause, she explains.

When Dani later found out she was a carrier of the BRCA gene mutation which increases the risk of both breast and ovarian cancers she made the decision to have a double mastectomy and an oophorectomy (surgery to remove her ovaries), with the latter putting her into an immediate surgical menopause.

This time, though, she was more clued up. I actually cancelled my oophorectomy twice because my appointment with the menopause specialist hadnt come through yet, and I knew I needed to speak to them before anyone touched my ovaries. This was six years after my cancer diagnosis and Id learned so much that I was a really good advocate for myself; I knew about my choices and what my options were, she explains.

Dani did opt for HRT, based on the fact she was more than five years on from her diagnosis, had already had a double mastectomy and had a type of breast cancer that wasnt hormonally driven. But she and Jemima are clear that cancer patients, regardless of their individual risks and treatment choices, need a far more nuanced conversation about the impact of cancer and the menopause on their lives. Theyre coping with the emotional trauma of going through cancer, with cancer-related fatigue, with body image changes, with all these costs to their mental and physical health, which are compounded by menopause. The onus shouldnt be on them to do the research and find out whats going on like Dani did. We need to equip them with the tools to not just survive cancer but thrive, Jemima says.

For this group that conversation must move beyond HRT and focus on overall health and wellbeing. We need some recognition that HRT is not the silver bullet everyone thinks it is. There are medical and non-medical alternatives to tackle menopausal symptoms, and these all need to be coupled with lifestyle factors like nutrition and exercise, Jemima says.

Weight-bearing exercise, she adds, is hugely important for post-menopausal bone health, as well as improving mood and cancer-related fatigue, both of which are often made worse by the menopause. Similarly, antidepressants which arent generally considered a first-line treatment for menopausal symptoms can be a great alternative to HRT when it comes to tackling not only mood changes but also physical symptoms like hot flushes.

Essentially, Dani adds, we need an acknowledgement that mainstream menopause advice doesnt necessarily apply to everyone. Much of this change will come from greater training and awareness for healthcare professionals within oncology and, in this sense, she says, its not too dissimilar to the mainstream menopause conversation. Theres a campaign for more GPs to go on specialist menopause courses; we also need more training for cancer nurses and oncologists. Its just an extension of the wider conversation thats going on anyway.

For patients too, there needs to be a much broader, more nuanced conversation about how menopause affects different people young and old, with and without cancer, on and off HRT. Menopause can be an isolating enough journey without being made to feel like an outsider, and this revolution must leave no one behind.

Read more here:
If the menopause movement is to be truly revolutionary, it needs to include women with cancer - iNews

This article was originally published on PracticalCardiology.com.

Although it has long been known that thyroid hormone levels are linked to cardiovascular (CV) regulation and that hyper- and hypo-thyroid states are detrimental to CV health, less is known about how the intensity of thyroid hormone therapy affects CV risk and mortality.

In a recent study, investigators sought to evaluate the association between thyroid replacement intensity and cardiovascular mortality by examining a large pool of data from the Veterans Health Administration database.

Josh Evron, MD, and colleagues looked at 705,307 adults who received thyroid replacement therapy.3 They found that 10.8% of those patients died of cardiovascular causes.3 Thyrotropin and Free T4 levels were gathered for all patients in the study to determine if therapy led to exogenous hypo-, euthyroid, or hyperthyroid conditions. The authors used regression modeling to produce survival analyses with cardiovascular mortality from myocardial infarction, heart failure, or stroke representing the primary outcomes studied.

The results clearly showed that patients with exogenous hyperthyroidism (thyrotropin levels <0.1 mIU/L) and those with exogenous hypothyroidism (thyrotropin levels >-20mIU/L) had increased risk of cardiovascular mortality when compared to patients who remained euthyroid.3 The association between exogenous hypo- and hyper-thyroid states and mortality increase with higher or lower thyrotropin levels in the hypo- and hyper-thyroid ranges.3

This study provides a unique perspective looking at cardiovascular risk based on a very common treatment, thyroid replacement therapy. When prescribing a replacement therapy, the goal of treatment is to achieve a normal level in vivo of whatever hormone you are replacing. This is not as easy as it seems.

Arriving at the appropriate dose takes time and requires frequent measurements of thyrotropin and free thyroxine levels. Even during stable therapy patient factors may change the response, absorption, and metabolism of thyroid hormone. Thus, the intensity of treatment the authors are talking about is a constantly moving target.

The results of this study highlight the importance of regular testing and a willingness among clinicians to put in the work. The authors found that allowing thyroid replacement therapy to fall short or overshoot has real consequences in the form of increased cardiovascular mortality.3

This means lives are at stake. This is the essence of a modifiable risk factor. Only, in this case, the modification is not a behavior the patient exhibits but one the clinician is responsible for. The authors state that variability in free T4 levels and thyroid hormone dosage adjustment are inevitable and thus agree with my assertion that regular monitoring and small targeted adjustments are essential parts of not only good thyroid care but also cardiovascular risk mitigation.3

These results and conclusions are underscored by the fact that cardiovascular disease is the leading cause of death in the United States. Even though this was an observational study, the results are robust.

An important feature of these results was the linear relationship up and down between the extent of hypo- or hyperthyroid intensity and CV risk. This gives clinicians some room to work while at the same time placing guard rails and warning signs on the limits of acceptability where over and undertreating are concerned.

More work is needed. While the authors have identified an area where we as clinicians can improve, they have also brought up a few new questions. It needs to be determined if there are sex differences in this effect. Further, the degree to which comorbidities were managed was not examined in this study. It is clear however, that tighter observation, monitoring, and intervention are in order with regards to thyroid replacement therapy.

References:

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Finding the "Sweet Spot": Thyroid Hormone Treatment and Cardiovascular Disease - Endocrinology Network

Dr Yasmin Tan is a Sydney gynaecologist, laparoscopic surgeon and womens ultrasound specialist. She works at the Womens Health and Research Institute of Australia (WHRIA) and at the Royal Hospital for Women. She is a Clinical Lecturer with The Universityof Sydney Northern Clinical School, Discipline of Obstetrics, Gynaecology & Neonatology.

In this session, we learn what exactly HRT is, whether it is safe and if it could help you.

Here's what we learned from Dr Yasmin Tan's session:

Hormone Replacement Therapy (HRT) is steeped in misinformation.

And that's a problem, because it's also one of the most effective methods for coping with many of the debilitating symptoms of perimenopause.

"HRT is any medication with female hormone in it, so it contains estrogen. That's the main hormone which we are trying to give back to the body because it's decided to make less of it, and as time goes by no estrogen," Dr Yasmin says.

"The second hormone we give usually with HRT is progesterone. And we need that for women who still have a uterus. The uterus is really an important organ that we have to protect with HRT because the lining of the uterus can thicken up if you just giveit estrogen alone."

HRT is used to relieve uncomfortable symptoms of perimenopause like hot flushes, mood swings, concentration issues, sleep problems and vaginal dryness.

There is a misconception that HRT is linked to breast cancer due to a study conducted over 20 years ago as Dr Yasmin explains.

"I think what this really stems from a big study that happened over 20 years ago called the Women's Health Initiative study.

"There are a lot of flaws with this study and we recognise this now. They were using very out of date, synthetic hormones, which we don't use anymore.

"The estrogen they were using was made from pregnant bears urine. So we don't use that anymore.

"And they also tried it in women of all age groups so the women were average ages around 65. That's not really our target age range for treatment.

"So they found that there was an increased risk of breast cancer and they touted this to the media and it was sold in a very catastrophic way.

Read this article:
The Very Peri Summit Resource Centre: Hormone Replacement Therapy with Dr Yasmin Tan. - Mamamia

In one section of Connor Lee OKeefes short documentary Imagine a Body, a film in which transmasculine people discuss their varied experiences of taking testosterone in order to medically transition, we see the construction of a birdhouse: there are closeups of a nail being hammered, a sharp edge sanded down, a screw twisted into wood. In a voice-over, one of the interviewees hints at the relationship between the imagery and the films subject matter. Theres this idea in sculpting where you take a chunk of wood, and you carve away whats not supposed to be there to reveal what should have been there the whole time, he says. He compares that idea to the feelings he had when he started on testosterone: Suddenly, its, like, Oh, theres the person that was supposed to be there this whole time.

OKeefe was inspired to make the film when, after taking testosterone for many years, he increased his dosage. Experiencing a new set of changes, he began to conceive of transition as a nonlinear process, an evolution rather than a clear-cut before and after. He decided that he wanted to create something that was exploratory in its approach, guided by subjects with a diverse array of notions about their own genders. He completed interviews with seven people, each one at least two hours long, and then sifted through the hours of recordings for the most interesting moments. A noticeable pattern that emerged was the way hormone-replacement therapy had defied expectations. Everyone came in with one idea of what gender was and what their relationship to it was, and kind of grew into a different place, he told me.

How can we talk about transition in a less medicalized way? OKeefe wondered. The film does not attempt to show the concrete effects of transition, and dispenses with the talking-head format that is customary for interview-driven documentaries; it favors, instead, an abstract approach. Imagine a Body takes a physical experience and, rather than render it in clinical terms, suggests its complex affective landscape. Interview responses are paired with images, a combination of picturesque landscapes, dynamic rotoscope illustrations, and scenes that subtly convey the changes caused by transition: shaving, or setting off on a run among the trees. With its surprising turns from one voice-over to the next, the film presents a swirling, evocative variety of insights. Once I started passing just by speaking, it completely changed my world, one subject says. Moments later, another says, I hated my voice as a child. And I cant say I ever stopped hating my voice. Like, I still do. In delving into the intricacies of trans experiences, Imagine a Body does not reduce the evolution of identity to a simple journey from problem to solution. The objective is not merely the treatment of a condition but the capacity to experience a more rich, full spectrum of life.

Originally posted here:
Rethinking Identity and Testosterone in Imagine a Body - The New Yorker

The term postmenopausal implies that the rest of life after what our grandmothers called the change is nothing but an afterthought. Clinical psychologist Louann Brizendine, MD, founder of UCSFs Womens Mood and Hormone Clinic and author of the bestsellers The Female Brain and The Male Brain begs to differ.

To hear her tell it, that stagewhich can be a full half of a womans lifeis more like aprs-ski: the luxurious reward after all the drama of hurtling down hormonal peaks and valleys. In her new book, The Upgrade: How the Female Brain Gets Stronger and Better in Midlife and Beyond, she renames and reclaims the M word, which she calls the Transition and recasts the years after as the Upgrade that gives the book its title.

Rest assured that the good doctor is not just advising women to look on the bright side and think positively about acquiring the wisdom and experience that come with age. (Although shes all for that.) She also explains the science behind the Upgrade, how after the Transition, were equipped with our Brain 2.0, which is less foggy, calmer, steadier, and primed to be more focused, creative, and happy than ever before. Then she tells readers how to make the most of that new functionality. We interrupted her Upgrade to ask her a few questions.

Why dont you use the terms menopause and postmenopause?

Perimenopause, menopause, postmenopause are a medical diagnosis, pharmaceutical words. Its a very narrow shaping of whats happening to us in our lives. I call it a below-the-waist-view of the uterus, the bleeding, but its not about whats going on in the brain. The idea that its a transition and an upgrade is multifaceted, more of what I call the whole-woman approach to the stage of life that were in. And the fact that you have a whole new breath of life for this second half of life, thats the concept I want to get across.

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You write that, post-Transition, our brains are primed for an Upgrade. Why is that, neurologically speaking?

When youre menstruating, estrogen going up in those first two weeks of your cycle starts to make all of these connections in the area of the brain called the hippocampus. And then when the progesterone starts to come in after ovulation, weeks three and four, it tears down all of those connections. That cycle goes on month after month after month, and it has all kinds of pushes and pulls for our behavior. We know from behavioral studies that three or four days before ovulation, we become more talkative, and toward the end of the cycle, we become more emotionalI call it the crying-over-dog-food-commercials stage. Whats going on in our brain is the building up of the circuitry and tearing it down and building it up and tearing it down. That stops after the Transition. Thats why I call it the Upgrade, because it gives you this incredible stability.

What if you take hormone replacement therapy?

If you do, youre getting a steady amount of hormones; theyre not coming in waves. As the waves of the hormones stop and get calmer, whether you take HRT or you dont, your hormones are going to be steady. That remakes the circuitry in your brain in a more stable, calm fashion.

You also talk in the book about how neurohormones, pre-Transition and during the Transition, can push us to be self-critical, and to feel the need to please people or win their approval.

The whole fertility phase of our lives as women is a very deep, deep hormonal push to cause behavior to make us try to be more attractive, so were able to procreate better. Its not something thats right in the front of your mind; its a kind of subconscious drive to procreate in the back of our brains.

Thats not happening so much after the Transition. So were not pushing ourselves to be complete people pleasers. We still dont want to be kicked out of our family or excluded from our community by becoming a total be-atch. Thats not what I recommend. But, subconsciously, because of the neuro changes in our brain, were able to speak our minds more without the fear that we once had, now that the subconscious pressure to procreate isnt going on.

In the book, you explain how if we know whats going on in our brain, we can use that knowledge to our advantage.

We just keep learning more about the brain. For example, we always called the cerebellum, the two little bumps in the back of your brain, the sports brain because it helps with your balance. But in 2018, studies showed that it also sends all of this feedback to the rest of the brain, and it helps to assess emotions and thinking. We do that in the front part of our brain, but if we get a little bit off, our cerebellum helps us with our emotional balance. It helps us with our thinking balance. Itll help slightly correct if you get too far off center. And if you choose an activity, like yoga or barre class, that helps with your balance, it will stimulate that area of the brain.

You offer a lot of actionable tips in the book for making the most of the Upgrade by using science-backed practices. What are some of your favorites?

When I wake up in the morning, I wiggle my toes and I smile. Wiggling your toes activates the sciatic, the longest nerve in your body, and stimulates all the way up into your brain, your cerebellum, your whole motor strip. And studies show that when you smile, the smiling muscles actually feed back into your brain to tell you that youre happy, so you could increase your feeling of happiness just by smiling at yourself.

I also do butt squeezes throughout the day, because in a study where they tested cognition in 80-year-old women, those women with the best cognition also had the strongest leg strength. When your muscles are strong or when youre moving your muscles, its feeding back into your brain all the way from your cerebellum to the rest of your motor area, telling you that youre alive and that youre okay. And one of the biggest muscles in our body is the glutes, our butt muscles. So if you want to improve some of your cognition, just keep doing butt squeezes during the day when you sit down or as you brush your teeth.

In another cool study, done 2010 at Harvard, they would text people and say, What are you doing now? And then theyd have to do a happiness scale. Those people that were just daydreaming, who had a wandering mind, reported that they were not happy, but the same person, when they were engaged in what they were doing when they got the text, said they were happy. If you let your mind wander, it can run into the hamster wheel of worry or other bad places. So you want to take the steering wheel of your mind and steer it toward engagement.

So, when the chatter of all the hormonal waves dies down in your brain, you get to choose what to fill it with, and you want to choose wisely?

Yes. Thats why I wrote this book, for women to just grab the steering wheel of their life, to move forward in a way that makes them happier, with more joy and serenity. As women go through this stage, its important to know that this is coming, so then you can seize that stability in the brain, and feel empowered by this idea that you have an upgrade, a chance to do something new. You have to feel delighted about your life in this next stage, because its really great. Theres a technical term, the positivity effect, thats been studied for the last 40 years at Stanford and other places that shows that with each decade of your life, you get happier. That goes along with the Upgradepeople just get happier each decade of their life. I think thats a really important message.

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Postmenopausal Years Are Creative and Satisfying for Women - Oprah Mag