gloved hands holding breast implants

A healthy body image leads to better sexual health, but are breast implants worth the confidence boost?

There are several options on the market for breast implants these days; silicone or saline, textured or smooth, even fat injections are an option. But which of these are the safest to use?

According to Michael S. Kluska, D.O., smooth, round silicone breast implants made of a highly cohesive gel are the safest and most popular option. He says textured implants and contoured implants (which are usually textured) could lead to a rare type of breast cancer called anaplastic large cell lymphoma, or ALCL. He also mentions that textured implants have a higher likelihood of getting “stuck” in place and healing, resulting in lop-sidedness.

Saline vs. silicone is another thing to consider for breast implants. Saline implants have a slightly higher risk of rupturing compared to silicone, and that they tend to ripple more than silicone implants. Saline implants are a three-part system, which Dr. Kluska cites as the reason for more frequent ruptures. “Usually, failures of saline implants occur at the port where we fill the implant,” says Dr. Kluska.

Breast augmentation using fat injections is also an option, but according to Dr. Kluska, fat can be unpredictable, and often requires several appointments where fat grafts are taken from the patient and transferred into their breasts to achieve the desired size. A woman who is young, healthy, non-smoking and not obese is an ideal candidate for fat grafting.

So, why take the risk of breast cancer, a ruptured implant, or go through the trouble of fat grafting? Well, self-image is an important part of overall health and well-being, and particularly for women who have had mastectomies, breast implants are an obvious solution to help them feel sexy and beautiful. And when getting breast implants, bigger isn’t always better. “We know now that bigger implants can potentiate bigger problems. Sizing the implant to make the patient have better anatomical proportions is always in the patient’s best interest,” says Dr. Kluska. Self-acceptance is still an important part of your well-being and your sexual health, and it will still be part of your journey if you choose to get breast implants.

The long and short of it is, breast augmentation can be a way to help you achieve greater self-confidence in your daily life, and in the bedroom. Always be sure to talk to a doctor you trust, and if you are in the Washington, DC area, we are always here to listen and talk you through what options are best for YOU. Call us at 202.293.1000 or e-mail info@dev.loebigink.com to make an appointment!

holding hands

Ever since we were infants, skin-to-skin contact meant closeness, calm and intimacy. So when disorders of the skin like Psoriasis interfere with such an important sexual organ (the skin, our largest by far), there are consequences. Psoriasis is more than a skin condition; it can affect everything from your self-esteem and your mood to your sexual health and well-being. According to a recent study, psoriasis is directly linked to sexual dysfunction and erectile dysfunction. But, it doesn’t have to be that way.

Psoriasis is an autoimmune disease, which means the body’s immune system attacks itself. With psoriasis this means the white blood cells known as T cells attack the skin cells, causing your body to over-produce skin cells and resulting in the red, scaly pile-up of skin cells, or plaque, that is associated with psoriasis. Psoriasis is genetic and non-contagious, but nearly one-third of people with psoriasis report that it has a negative effect on their sex lives.

Psoriasis flare-ups usually occur on a person’s hands, feet, face, neck, scalp, and in the joints, but have also been known to affect the genital area. Having psoriasis is sometimes embarrassing; if you are having a bad flare up it might make you want to stay covered up and avoid intimate situations with a partner, and having a flare-up on your genitals can make sex physically uncomfortable if not impossible.

Depression and anxiety are also more likely for people with psoriasis because the disease can be frustrating to treat and can affect one’s self-esteem. Stress can cause flare-ups, which can lead to more stress, and it might seem like you’re caught in a never-ending battle with your psoriasis. All this can make it difficult to seek out or be receptive to sexual intimacy with a partner.

Does this mean if you have psoriasis you can’t ever hope to have good sex again? Of course not!

woman, thoughtful

  New research published this month on the JAMA Network Open indicates that 7.0% of women and 10.3% of men have what is now classified as compulsive sexual behavior disorder (CSBD). CSBD is defined as “failing to control one’s sexual feelings and behaviors in a way that causes substantial distress and/or impairment in functioning.” There are a few things we can glean from this data, but it might tell us a whole lot more about our society than it does about human sexuality.

  First off, the results are self-reported and based on perceptions of one’s own behavior. Negative stigma about sexual urges or thoughts within certain cultures and sub-cultures in the United States could result in what researchers are now calling a disorder, but might actually be healthy urges interpreted through an unhealthy social lens. Psychologists have argued about what constitutes “healthy” sexual behavior since the dawn of the field, and the discussion is nowhere near a conclusion. Unfortunately, using a self-reporting survey does not allow researchers to be able to distinguish between participants feeling distressed about compulsive and intrusive sexual impulses, and participants feeling distressed about their sexual urges because of moralistic pressures within their sub-cultures.

  Secondly, the close percentage of men and women who are now diagnosed with CSBD could be telling, or it could not be. The long unspoken “rules” about male and female sexuality in the US could be at play here. Men have been told that their sexual urges cannot be repressed and that it is unhealthy to do so, while women have held the role as “sexual gatekeepers.” Those societal factors and gender roles may have led to fewer men and more women reporting distress due to their sexual urges and behaviors. On the other hand, it could be interpreted that men and women actually have similar sex drives and sexual habits. With interpretations of sexuality in America in such a complicated place, it is difficult to make a determination about this.

  The bottom line is this: if your sexual behaviors or urges are causing you distress or impairment in functioning, whatever that means to you, it is worth talking about! It is our goal to help you feel whole and healthy, and we believe sexual wellness is a huge factor in achieving that goal. Give us a call at 202.293.1000 or email info@dev.loebigink.com to make an appointment with one of our specialists today. We are here to help.

 

Women featured in the Observer

We at IntimMedicine are thrilled about the positive changes happening in our culture surrounding the discussion on female sexuality. In a recent article in The Guardian, Sharon Walker interviews five women who are on the forefront of a new sexual revolution: reclaiming women’s sexual pleasure. For far too long, today’s culture has downplayed female desire and the pleasure that women can get from sex, whether that sex is solo or with a partner. From a squeamish discomfort around female anatomy to a male-centric view on sex within modern society, women have not been given the language or even a place to speak about their own sexual desires or what actually feels good. It is time to destigmatize female sexual anatomy, desire, and pleasure!

The five women in the article have vastly different approaches to breaking down barriers to these discussions. A sex therapist, an installation artist, a computer scientist, an author, and a dominatrix all chime in with the various ways they are challenging the way our culture views female sexuality. Of particular interest to us at IntimMedicine was the work by Stephanie Theobold, Camilla Mason, and Kate Moyle.

Stephanie Theobold, author of the new memoir, “Sex Drive,” argues that the taboo on honest language about female sexuality is one of the last to fall. “I believe it’s positively dangerous not to talk about honest female sexuality. That old chestnut that corporations love to use, ‘female empowerment’, means nothing unless sex is in the mix, too,” Theobold told Walker in her interview. In her memoir, Theobold takes a road trip around the United States to meet the first wave of 1970s and 80s sex-positive feminists, including Betty Dodson and Joycelyn Elders. She says “the pleasure revolution is about women asserting their own power” in the face of the male-dominated discussion on sex and sexuality, and a positive response to the #MeToo movement, which focuses on “men imposing their pleasure on women.”

Betty Dodson, who Theobold meets in her book “Sex Drive,” says “we really need to start using the correct words for our genitals. We have a ‘vulva’ not a ‘vagina’; the vulva incorporates the clitoris, the inner lips, the outer lips, the urethra, and the vagina – which only has sensation in it because of nerves from the clitoris. If we say ‘vagina’, then we’re leaving out the primary female sex organ, which is the clitoris.” IntimMedicine’s own Dr. Rachel Rubin has addressed using the proper language for female sexual anatomy and helping women feel more comfortable discussing sex and sexual desire in her recent presentation, “Below the Belt.”

Closely related to this work on the language around female sexuality is the work of performance artist Camilla Mason. Mason is on a team that creates an installation of an interactive and anatomically correct representation of female genitalia at the annual Shambala music festival. Mason makes the point that sexual anatomy is rarely discussed in schools, with even more of a taboo on female genitalia, and her goal with last year’s art installation of the “vulva cave” was to help facilitate those conversations. Feedback was excellent, and according to Mason, the installation “brought up all these topics of conversation that revolve around female sexuality and genitalia and just femalehood in general, which was the main agenda for me.”

Kate Moyle, a psychosexual therapist, works hard to help normalize discussions about sex and sexuality, especially for women. She argues that women have been fed a sanitized, Hollywood version of their own sexuality, which has resulted in shame about their bodies and their sexual function. “It’s about understanding the difference between the realistic and unrealistic, because that’s where the gap is,” Moyle says in her interview. “The problem is that we’re playing catch-up in an environment where sex is everywhere you look … and the assumption is that everyone else is having great sex.” She also makes an encouraging observation that it’s “not only women who want to have better sex. Men want their women to have better sex, too – we’re all in this together.”

Moyle and Theobold both make the point that female sexual dysfunction is only now becoming part of the conversation even though it is quite common. Research on and treatments for female sexual dysfunction only attract a fraction of the attention of male sexual dysfunction research/therapy. We at IntimMedicine agree that this needs to change, and change now.

We applaud the work these women are doing to break down the barriers in discussing female sexuality and sexual function! The specialists at IntimMedicine are internationally renowned experts on sexual wellness with an emphasis on helping our patients find pleasure in sex again and eliminating unwanted pain during sex. We treat nearly all sexual dysfunction and conditions in women of all ages, including dyspareunia, vulvodynia, loss of desire, poor arousal and weak or absent orgasm, to name just a few. Please call us at 202.293.1000 or email us to make an appointment with someone on our compassionate care team to talk about what’s causing you pain, develop a tailor-made treatment plan for you and your body, and help you make your sex life great again!

Thanksgiving dinner

Ok, I am sure you know someone who has or has had sex on Thanksgiving. Maybe it was you. But, if the Masturbation Diet® hypothesis is correct (see the other blog posts in this series if you have no idea what I am talking about), then one should have very little sexual interest after filling up on turkey, stuffing, and pumpkin pie. If The Masturbation Diet® is correct, then “more food consumption, leads to less sexual consumption.” In other words: if your hunger is filled up with food, your residual hunger for sex will be lower, and it will be less likely that sexual activity will actually occur.

I also suspect that few people have sex on Halloween or Labor Day either. Halloween is largely a children’s holiday where hordes of children dressed up as Wonder Women or maybe a hand-me-down Little Mermaid or Spiderman extort candy from adults in the neighborhood. The Moms and Dads who accompany the smallest of kids are too exhausted from trailing after their children to have the interest or energy to engage in sexual relations or once they get their own kids down from their sugar highs to go to bed, it’s just too late to have sex. And further, the possibility of inadvertently creating another infant-Little Mermaid or toddler-Spiderman may be disincentive enough. Those with older or grown children who are at home, getting up from their easy chairs or their desks 50 or more times to hand out the sugar-laden delicacies are simply pooped. As for Labor Day, many women remember the labor day they went through to push out their last child or the pain of that C-section following a long labor, disincentives enough… Yikes, better avoid sex on Labor Day.

So my advice…eat less, and exercise more (The Horizontal Mambo with orgasm burns about 150 calories). But if your appetite for sex is low or absent, and not just on Thanksgiving when you are full up with turkey, stuffing, and pumpkin pie, come see us at IntimMedicine® Specialists (202-293-1000). We can treat your low libido and help reignite your intimacy flame.

smiling couple, embracing

Ladies, rejoice! If you are covered under Medicare Part D and you are experiencing Dyspareunia (painful sex) after menopause, you can now be prescribed drugs to treat this condition! As many as 1 in 3 postmenopausal women experience painful intercourse, caused by vulvar or vaginal atrophy (VVA). VVA happens because of a decrease in the levels of estrogen that happens during menopause, which means your vaginal tissue will change over time. If left untreated, Dyspareunia can get worse.

“Against the background of significantly better aging men’s sexual health coverage, compared to women’s, CMS [Centers for Medicare and Medicaid Services] has taken the scientific high road and mandated vastly improved Medicare coverage for aging women’s sexual health, beginning in 2019. Hurray!” said our very own Dr. James A. Simon when asked to comment on the news.

Email or call us at 202.293.1000 to make an appointment to talk with someone from our compassionate care team to discuss if taking a prescription drug might help you experience pain-free sex again.

Exploring the Relationship between Food and Sexual Desire, and Food and Sexual Satiety (Part 2)

By James A Simon, MD, CCD, NCMP, IF, FACOG

In part one of this blog series, I focused on the profound impact obesity has on health generally. Literally every organ system in the body is affected. This includes reproductive organ cancers (i.e. breast, uterus, cervix and prostate) which demonstrate a significant increase in the number of cases and their severity in overweight and obese individuals. The costs to society are extraordinary. For example, the total cost of diabetes alone in the US was $327 billion (not a typo) in 2017, a 26 percent increase over the previous five-years (http://www.diabetes.org/advocacy/news-events/cost-of-diabetes.html). In this blog post (The Masturbation Diet Blog (Part 2), I want to zoom in on the impact of overweight and obesity on reproductive processes.

Weight gain over the reproductive lifecycle in women is incredible. For example, the percentage of US women with a body mass index or BMI of =25 kg/m2 (the standard definition of overweight individuals) increases from 56% for women aged 20-40, to 66% in women aged 40-60, and further increases to 74% in women aged 60-80 years. Yes, 3 out of 4 women aged 60 years and older are overweight or obese. Yikes! Further, the increase in “midlife spread” is focused in that stubborn truckle fat or visceral fat which carries with it changes in metabolism known as the metabolic syndrome (see below) which can increase heart attacks and strokes. (Flegal KM et al. JAMA. 2012;307:491-497.). When overweight and obesity affects a pre-pregnancy women, it can reduce her fertility (even with in vitro fertilization/”the test tube baby procedure”), and cause sexual dysfunction. When that women is pregnant, overweight or obesity can result in a greater risk of early miscarriage, congenital abnormalities in the baby, high blood pressure during later pregnancy (pre-eclampsia), added risk of the baby’s shoulders getting stuck during vaginal delivery (shoulder dystocia), and even the risk of a required Cesarean delivery. And women who tend to have excessive weight gain during pregnancy seldom lose it all, adding even more weight with each subsequent pregnancy.

In no case is the imbalance between one’s sexual appetite (too little) and one’s appetite for food (too much) more disproportionately affected than in overweight and obese individuals. Overweight and obese men have a 30-90% increased risk of erectile dysfunction (ED) compared with normal weight men. Women with the metabolic syndrome due in part to overweight or obesity (see above) have an increased prevalence of sexual dysfunctions as compared with matched control women. Lifestyle changes aimed at reducing body weight and increasing physical activity can improve both erectile function in obese men and arousal (lubrication and genital tingling) in women. The Mediterranean-style diet might be effective in ameliorating sexual dysfunction in women with the metabolic syndrome. (Esposito K, Giugliano , Ciotola M, et al. Obesity and sexual dysfunction, male and female. Int J Impot Res. 2008 Jul-Aug;20(4):358-65.)

Most importantly, we can now change the balance, that is, increase the desire for sex while decreasing the desire for food. Really? Yes! Deep in the brain, the hypothalamus and surrounding neural networks are the control center between desire for sex and desire for food. Let’s think evolutionarily. When there is famine (there are no famines at the Safeway, Publix, or Kroger these days), and associated severe weight loss, or starvation etc., reproduction stops. No menstrual periods, no hormones to trigger sexual appetite, resulting in low libido and little or no sex. Similar processes occur when a women is breast feeding. She is living off her “baby fat,” and in the process losing calories as she breast feeds the baby. The balance in the hypothalamus is likewise turned against sex, it’s all about the baby, the hell with sex, as Mother Nature didn’t want another pregnancy too close to the last one. Further if there is sex, it’s usually very painful because the imbalance in hormones is also focused on the health of the baby, not healthy genital tissues…and if there is pain with sex, well that’ certainly a disincentive for more sex.

These natural phenomena: the impact of weight (too low or too high) on sexual reproductive/function in both men and women, extensive research into the mechanisms controlling one’s appetite either for sex or for food, informs us on how to modify the balance between these two natural desires. We call that The Masturbation Diet, a counseling program in the area of sexual activity, wellness, and nutrition where we can help get the balance corrected.

In The Masturbation Diet Blog (Part 3) we’ll talk specifically about these controls and how affect the balance.

Exploring the Relationship between Food and Sexual Desire and Satiety (Part 1)

By James A Simon, MD, CCD, NCMP, IF, FACOG

Over the next few blog posts, I will discuss our appetites for food and sex. It should be no surprise to anyone reading this post that there is an obesity problem in the US. 2016 data from the Centers for Disease Control (CDC) show that every state in the US had at least 20% of its citizens who were obese. Every single state! Three states and DC had a prevalence of obesity between 20% and 25%, and 22 states had a prevalence of obesity between 25% and 30%. There are actually 20 states (plus Puerto Rico, and the US Virgin Islands) that had a prevalence of obesity between 30% and 35%.  If that weren’t bad enough, there are actually five states (Alabama, Arkansas, Louisiana, Mississippi, and West Virginia) where 35% or more of the people living there are obese—quite a distinction! (http://www.cdc.gov/obesity/data/prevalence-maps.html)

While most people appreciate that there are significant health consequences to being overweight or obese (see below), few recognize the degree and severity of the bias and discrimination that overweight and obese individuals face every day. Such negative attitudes/stereotypes toward women with obesity (15%) are almost as common as gender bias (28%) and more common than racial bias (10%) (Puhl, Andreyeva, Brownell, 2008).

The medical complications of obesity are profound. They affect nearly every organ system in the human body. As it relates to general medical complications and disease, here is a short list of medical problems made worse by obesity:

Pulmonary disease

  • abnormal lung function
  • obstructive sleep apnea
  • hypoventilation syndrome

Nonalcoholic fatty liver disease

  • steatosis
  • steatohepatitis
  • cirrhosis

Gallbladder disease

Idiopathic intracranial hypertension

Stroke

Cataracts

Coronary heart disease

  •  diabetes
  • dyslipidemia
  • hypertension

Severe pancreatitis

Phlebitis

  • venous stasis
  • deep vein thrombosis

Osteoarthritis

Gout

Cancer

  • breast
  • uterus
  • cervix
  • colon
  • esophagus
  • pancreas
  • kidney
  • prostate

You’ll note that this list contains quite a few obesity consequences focusing on the reproductive organs (i.e. cancer of the breast, uterus, cervix, and prostate). Further, as we will discuss later, there are huge effects of excess weight on sexual desire, and reproduction, and this is not a coincidence. In The Masturbation Diet Blog part 2, I’ll discuss how women and their reproductive system are disproportionally affected by an imbalance between one’s sexual appetite (too little) and one’s appetite for food (too much). We now know these two appetites are inextricably linked. Most importantly, we can now change the balance, that is, increase the desire for sex while decreasing the desire for food. If that sounds interesting, maybe even too good to be true, stay tuned for part 2.

Personalized Care

Any medical treatment should be considered specific to the needs and hormone concentrations of each individual patient. This is why we share our full breadth of knowledge about endocrinology, medical safety, and treatment efficacy in addition to treating gynecologic function and overall wellness.

 

So we were dismayed to read that the U.S. Preventive Services Task Force (USPSTF) final recommendation statement on the use of menopausal hormone therapy in post-menopausal women, citing health risks such as breast cancer, heart attack, dementia, and stroke. The key words are post-menopausal. The USPSTF recommendations did not address the overwhelming evidence that hormone therapy (HT) greatly benefits women who are going through the menopausal transition (aka with menopausal symptoms) and who do not have additional health problems. The USPSTF again failed to highlight the population of women who need hormones the most and are most likely to benefit from taking them (see Part 1 of this two-part blog). We can agree with their statement that women who START on their hormone therapy when they are older than 60, or more than 10 years following their last menstrual period, shouldn’t use hormones for the prevention of most diseases. But it doesn’t apply for the women a decade younger; that is, the patient population most often experiencing the symptoms that need treatment (hot flashes, night sweats, vaginal dryness, painful intercourse, mood swings, etc.). The safest time to use HT is during the so-called “estrogen window,” which is the decade-long time-frame between the ages of 50 and 60, or 10 years from the time of menopause (where menopause is defined as the start of at least 12 consecutive months menstrual period-free.

 

Hormone Therapy (HT) Is Effective for Hot Flashes, Night Sweats, and More

The North American Menopause Society’s most recent position statement (2017) concludes that HT remains the most effective (italics are mine) treatment for hot flashes and night sweats and the genitourinary syndrome of menopause (vaginal atrophy, painful intercourse, recurrent urinary tract infections, etc.), and it has been shown to prevent bone loss and fractures (osteoporosis). The risks of HT differ depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen or progesterone is used. Treatment should be individualized to identify the most appropriate HT type, dose, formulation, route of administration, and duration of use, using the best available evidence to maximize benefits and minimize risks. Also, check-ups with each patient during this time to evaluate benefit should be ongoing.

 

Where the Women’s Health Initiative (WHI) Erred

The WHI hormone studies have increasingly come under fire for the way they were designed, most importantly for the inclusion of women up to age 79, and results reported as if all women are the same. The results of these studies have reverberated through the medical community, causing changes that may have been both too broadly applied and, in some cases, simply incorrect (see commentary by David. L. Katz, MD, MPH, FACPM, FACP on such overgeneralizations. The findings that hormone therapy was putting many women at risk for conditions like breast cancer and cardiovascular conditions caused many women to go off their hormone-replacement therapy “cold turkey” without knowing how to address the consequences and not fully understanding the risks versus rewards. For example, some of the patients in the WHI study were already at increased risk for cancer or cardiovascular disease because of lifelong smoking, being overweight and the age at which they started hormone therapy (> 60 years, and up to age 79). However, otherwise healthy women should be able to use these therapies to ward off the symptoms that affect sleep, mood, sexual health, pleasure, etc.

 

We’ve Done Our Homework

In wanting to help my patients find effective ways to treat their symptoms, I analyzed a database of 13 million patients to investigate whether two forms of estrogen therapy (oral versus transdermal) differed in how patients experienced negative effects, particularly focusing on heart attacks, strokes and deep vein thromboses (blood clots in the veins) (see: Simon JA, Laliberté F, Duh MS, Pilon D, Kahler KH, Nyirady J, Davis PJ, Lefebvre P. Venous thromboembolism and cardiovascular disease complications in menopausal women using transdermal versus oral estrogen therapy. Menopause. 2016 Jun; 23(6): 600-10). I concluded that patients who used transdermal estrogens had significantly fewer blood clots in their veins, pulmonary emboli, and heart attacks than those who took an oral estrogen (i.e., pills). Stroke risks were also slightly lower for transdermal estrogen users.

 

I used this information to hypothesize just how different the WHI results would have been had that study used transdermal estradiol and micronized progesterone (see: Simon JA. What if the Women’s Health Initiative had used transdermal estradiol and oral progesterone instead? Menopause. 2014 Jul; 21(7): 769-83.). Those investigations showed that HT type, dose, formulation, route of administration, and duration of use can be tailored to maximize benefits while reducing or eliminating risks. “One size doesn’t fit all,” as the USPSTF suggested.

 

Key Points

  • HT benefits in early menopausal women include reduced coronary heart disease and all-cause mortality.
  • Randomized trials in women initiating HT after age 60 have shown benefit primarily for osteoporosis and fracture but overall increased harm.
  • Reassessment of clinical trials in women initiating HT treatment close to the onset of menopause and newer studies and meta-analyses now show benefit and rare risks.
  • More studies show benefit with estrogen alone than with estrogen plus progestogen.
  • No available medication except HT has demonstrated prevention of osteoporotic fractures in women not previously identified as having osteoporosis.
  • The effects of reduced cardiovascular disease and mortality in women initiating therapy around menopause (the “estrogen window”), and the beneficial effects of HT on the skeleton at any age, together suggest a role for hormone-replacement therapy in disease prevention.

 

Stop Suffering, Start Living

Please contact our office at (202) 293-1000, and make an appointment to get your questions answered and determine the best course of HT treatment that is specifically tailored to you.

We unequivocally support the use of menopausal hormone therapy to mitigate menopause symptoms and prevent disease for a variety of patients. Let’s review the facts of the case. THIS IS NOT FAKE NEWS!

 

When our institutions fail us, it’s time to openly and directly say so. No, this is not a political rant. I’m talking about the United States Preventative Services Task Force (USPSTF), a well-meaning, highly educated group of 12 so-called experts (no endocrinologists, no reproductive endocrinologists, and no menopausal specialists), consisting of two pediatricians, a PhD specialist in health management and public policy, four internists, four family physicians, and our token Ob/Gyn (who isn’t a menopause or hormone therapy expert). Yes, this is the same group (some different players) who recommended every-other-year mammography — and you may remember the backlash and public outcry over that suggestion. (FYI, the major organizations in women’s healthcare didn’t accept that recommendation.)

 

Well, this group is at it again, this time over postmenopausal hormone therapy. Last month (December 2017), the group gave a “D” recommendation for the use of postmenopausal hormone replacement therapy for disease prevention in both naturally menopausal women and women who have had a hysterectomy. A “D” recommendation means: recommends against the use of combined estrogen and progestin (in women with a uterus) or estrogen alone (in women who had a hysterectomy) for the primary prevention of chronic conditions in postmenopausal women. You can read their recommendations for yourself.

 

So, what happened? First, let’s be clear. Experts looking at the same scientific information can disagree on its meaning. But that’s not what happened here. I know this because a real group of menopause and hormone therapy experts replied to the draft recommendations of the USPSTF, attempting to explain the errors of their draft recommendations (see: Langer RD, Simon JA, Pines A, Lobo RA, Hodis HN, Pickar JH, Archer DF, Sarrel PM, Utian WH. Menopausal hormone therapy for primary prevention: Why the USPSTF is wrong. Menopause. 2017 Oct; 24 (10):1101-1112. doi: 10.1097/GME.0000000000000983., Or Langer RD, Simon JA, Pines A, Lobo RA, Hodis HN, Pickar JH, Archer DF, Sarrel PM, Utian WH. Menopausal hormone therapy for primary prevention: Why the USPSTF is wrong. Climacteric. 2017 Oct; 20(5): 402-413. doi: 10.1080/13697137.2017.1362156. Epub 2017 Aug. 14.).

 

These two publications are essentially the same. One was meant for the U.S. audience of menopause and hormone therapy experts, the other for the international menopause and hormone therapy audience. These same recommendations were sent to and received by the USPSTF during their comment period. Nothing from our suggestions was incorporated into the USPSTF documents. One conclusion could be that the USPSTF didn’t care, they had their minds made up, and no amount of scientific information was going to change their opinion. That’s not what happened, in my opinion.

 

The USPSTF opted to do two things to support their forgone conclusions:

  1. They so severely limited the evidence they were willing to consider that they made their judgement based only on the evidence in support of their opinion
  2. They made simplified judgments to apply to every menopausal woman as if they were all the same.

 

This first tactic is prime territory for every lawyer. You define the evidence in such a limiting way as to exclude all evidence not in support of your client. The USPSTF, by excluding so much of the scientific information available, was left with only a few important studies … the usual suspects, the Women’s Health Initiative (WHI) being so large and all encompassing, that it overwhelmed any analysis of the other studies considered.

 

The second tactic, treating all menopausal women as if they were the same, fits well into tactic 1, since the WHI Investigators initially reported on their study “overall” (Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, Jackson RD, Beresford SA, Howard BV, Johnson KC, Kotchen JM, Ockene J; Writing Group for the Women’s Health Initiative Investigators. JAMA. 2002 Jul 17; 288(3): 321-33.), lumping together women aged 50 through 79 as if they were all the same. And that was 15 years ago (prehistoric in scientific years).

 

These two errors in judgment are elegantly summarized by David. L. Katz, MD, MPH, FACPM, FACP who published another paper showing that NOT taking estrogen therapy following a hysterectomy actually resulted in a minimum of 18,601 — and as many as 91,610 postmenopausal women — dying prematurely because of the avoidance of estrogen therapy (ET) over a 10-year span, starting in 2002. Prevention of death is what I would call the ultimate prevention of disease. (See: The mortality toll of estrogen avoidance: an analysis of excess deaths among hysterectomized women aged 50 to 59 years. Sarrel PM, Njike VY, Vinante V, Katz DL. Am J Public Health. 2013 Sep;103(9):1583-8. doi: 10.2105/AJPH.2013.301295. Epub 2013 Jul 18.)

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