1. The Doctor, the Patient and
QoL
by
Manuel Neves-e-Castro
Lisboa-Portugal

2. The Doctor, the Woman and
QoL

3. There are controversies about the
present management of the
climacterium which are due to:
• a lack of culture that prevents a correct
criticism of the published results
• a bad practice of medicine that ignores the
woman in her totality (holism)
• political lobbies from the NIH
• a lack of scientific honesty manifested by
many of the WHI writers
• lobbies from several pharmaceutical
industries through the activities of many well
known doctors that “offer” themselves to transmit
their “messages”

4. HOW TO DO IT ?
•The Objective QoL
•The Target the Woman
•The Agent (or Actor) the Doctor

5. Quality of Life
(QoL)

6. How to promote it ?

7. QoL = Health !
“A condition of physical, mental and
social well-being and not only the
absence of disease”
WHO
Therefore one must:
- prevent diseases
- promote health

8. The midaged Woman
• How does she feel? Confused? Insecure?
• What is she afraid of ? Hormones?
• What does she want from the Doctor? QoL !

9. Definition
A Climacteric woman
is a woman (gender based medicine)
is an ageing person (geriartrics)
is perimenopausal (hormone deficient)

10. Looking after a menopausal woman is a
most
fascinating,
gratifying and
complex
vivid experience in the life of a physician.
MNC/2005

11. man
woman

12. The Doctor : a Gynecologist?
If so
• What is in his/her mind? WHI? Million WS?
• What does he/she know about it?
• What is he/she afraid of? Cancer? TED?
• How does he/she practice Medicine?
• How should midaged women be taken care
of?

13. What has experience thought
me over the years about how
to give QoL after the
menopause:

14. Is there a Menopausal
Medicine?
There is only ONE Medicine (L. Speroff)
There are only TWO Medicines (M.N.C.):
a BAD Medicine and
a GOOD Medicine

15. Therefore,
what we must learn, is…
how to practice a
GOOD
MEDICINE!
mnc/05

16. “We are drowning in
information,
but starved for knowledge”
knowledge
John Naisbilt

17. then...
how is Medicine practiced
today?

18. There are two types of medical
practice:
– the Medicine for one individual, at a
time (Clinical Medicine)
– the Medicine for many individuals,
the population, at the same time,
(Social Medicine,Public Health
Medicine)
MNC/05

19. Who are the actors ?
• Is a clinician
The practitioner • Sees patients in the office
• Treats individuals
• Works in Hospitals
• Is not a clinician
The public health doctor
• Does not see patients in an
office
• Does not treat individuals
• Works in a Public Health
department

20. Concerns of the
Doctor of an individual •Absolute risk reduction
(practitioner)
•Absolute risk increase
•Benefit/risk analisys
The Public Health Doctor •Relative risk reduction
•Relative risk increase
•Cost/benefit analysis

21. But ... today ...
many • Act in their offices as if they
were public health doctors...
practitioners
and many
public health doctors • Act in their departments as if
they were clinicians ...
This is wrong!

22. WHI results calculated as:
NNT/1 year NNH/1 year
CHD 1428
Stroke 1250
VTE 588
Breast Cancer 1250
Colon Cancer 1667
Osteoporotic fractures 227
Neves-e-Castro M. Menopause in crisis post-Women´s health Initiative? A view
based on personal clinical experience. Human Reproduction 2003;18:2512-8

23. Public Health doctors are guided by
what epidemiologists suggest ...
but ...
most epidemiologists only establish
associations of events and seldom
determine cause/effect relationships
MNC/05

24. Practioners are guided:
• by the best available information that
can be extrapolated with validity to
their patients, and
• by their acumulated experience
MNC/05

25. thus ...
both,the practitioners who act as if they
were public health doctors,
and the public health doctors who act as if they
were clinicians,
should not overemphasize the
epidemiological associations of events that are
not necessarily cause/effect findings
MNC/05

26. We must manage our
Clinical Practice by objectives:
objectives
- Critical
Objectives (C.O.)
- Specific Objectives (S.O.)
- S.O. Targets (S.O.T.)
- S.O. Projects (S.O.P.)

27. Critical Objectives
a) The diagnosis of health
b) The identification of risk factors
c) The presence of symptoms
• gender related
• age related
• hormone related

28. Critical Objectives
d) The treatment of symptoms
e) The elimination of risk factors
f) The diagnosis of diseases
g) The treatment of diseases

29. Specific Objectives
(S.O.)
1. CVD and metabolic diseases
a) obesity
b) dislipidemias
c) hypertension
d) insulin resistance (metabolic syndr.)
etc

30. S.O.
2. CNS
a) vasomotor symptoms
b) mood, sleep
c) sexual disfunctions, libido,
etc

31. S.O.
3. Bone
a) osteoarticular,
etc

32. S.O.
4. Reproductive organs
- vaginal discharges
- atrophic vaginitis
- fibroids
- meno and metrorrhagia,
etc

33. S.O.
5. Breast
lumps and tenderness,
etc

34. S.O.
6. Bladder
incontinence
chronic cystitis,
etc

35. S.O.
7.Contraception

36. S.O. Targets
1. exercise
2. nutrition
3. mental health
4. sexual conseling
5. pharmacotherapy
a) hormonal
b) non-hormonal

37. S.O. Projects
(treatments)
P, E+P, E
Androgens
Ca + vit D
Bisfosfonates, Strontium
Statins
IACE
Diuretics
α and β Blockers
Aspirin
Serm’s
Tibolone
Gabapantin
Psychotherapy
etc
routes, schemes of administration

38. and now
think about the interelation of
CVD, Osteoporosis and Obesity...
since they seem to share common risk
factors...

39. The unified hypothesis of interactions among
the bone, adipose and vascular systems:
'osteo-lipo-vascular interactions'.
Epidemiological evidence has established
a link among hyperlipidemia, visceral
obesity, osteoporosis, and cardiovascular
diseases (CVD).
Koshiyama H et al. Med Hypotheses 2006;66:960-3

40. The unified hypothesis of interactions among
the bone, adipose and vascular systems:
'osteo-lipo-vascular interactions'.
The unified hypothesis of three organs,
which we call 'osteo-lipo-vascular
interactions', may be explained by the
common origin of the cells in each organ.
Koshiyama H et al. Med Hypotheses 2006;66:960-3

41. The unified hypothesis of interactions among
the bone, adipose and vascular systems:
'osteo-lipo-vascular interactions'.
The mesenchymal stem cells are capable
of differentiating into osteoblasts, vascular
smooth muscle cells, and adipocytes.
Koshiyama H et al. Med Hypotheses 2006;66:960-3

42. The unified hypothesis of interactions among
the bone, adipose and vascular systems:
'osteo-lipo-vascular interactions'.
Alternatively, macrophages may evolve
into osteoclasts or infiltrate both the
vascular and adipose tissues, thereby
leading to chronic inflammation.
Koshiyama H et al. Med Hypotheses 2006;66:960-3

43. Osteoporosis and cardiovascular disease:
brittle bones and boned arteries, is there a link?
Elevated LDL and low HDL cholesterol are
associated with LBMD; altered lipid
metabolism is associated with both bone
remodeling and the atherosclerotic
process, which might explain, in part, the
co-existence of osteoporosis and
atherosclerosis in patients with
dyslipidemia. Similarly, inflammation plays
a pivotal role in both atherosclerosis and
osteoporosis.
McFarlane SI et al. Encdocrine 2004;23:1-10

44. Osteoporosis and cardiovascular disease:
brittle bones and boned arteries, is there a link?
Elevated plasma homocysteine levels are
associated with both CVD and osteoporosis.
McFarlane SI et al. Encdocrine 2004;23:1-10

45. Osteoporosis and cardiovascular disease:
brittle bones and boned arteries, is there a link?
Nitric oxide (NO), in addition to its known
atheroprotective effects, appears to also play a
role in osteoblast function and bone turnover.
McFarlane SI et al. Encdocrine 2004;23:1-10

46. Osteoporosis and cardiovascular disease:
brittle bones and boned arteries, is there a link?
Statins, agents that reduce atherogenesis,
also stimulate bone formation
McFarlane SI et al. Encdocrine 2004;23:1-10

47. Osteoporosis and cardiovascular disease:
brittle bones and boned arteries, is there a link?
Bis- phosphonates, used in the treatment of
osteoporosis, have been shown to inhibit
atherogenesis. Intravenous bisphosphonate
therapy significantly decreases serum LDL and
increases HDL in postmenopausal women
McFarlane SI et al. Encdocrine 2004;23:1-10

48. anyway,and
in the light of the present evidence,
doctors and women should be
reassured that the suggested HT’s for
the relief of symptoms in the
menopause
are safe and very effective !

49. Many women taking hormones were
urged by their physicians to stop taking
these medications immediately or
decided to stop taking them on their own.
Petitti DB. JAMA. 2005;294:245-246.

50. Convictions are more
dangerous enemies of thruth
than lies
Friedrich Wilhelm Nietzsche

51. Based on the WHI study group,
implementation of the results
into clinical practice has little, if
any, scientific basis.
Adam Ostrzenski and Katarzyna M Ostrzenska. Am J Obst Gynecol
2005;193:1599-604

52. The applicability of the WHI
findings to women between age of
51.1 and 56.1 years and younger is
unknown...
Ostrzenski A and Ostrzenska KM.
Am J Obst Gynecol 2005;193:1599-604

53. The WHI Estrogen only arm

54. Effects of conjugated Equine Estrogen in Postmenopausal Women
with Hysterectomy.JAMA, 2004;291:1701-1712

57. Stroke
“In women 50-59 years not taking HT,
ischemic stroke is expected to occur in
3 out of 1000 women during 5 years.
Five years use of HT would yield 1
additional case of stroke/ 1000 women”
women
EMAS Statement; 2004.

60. Biased opinions
be they pro or con,
dishonor the profession
and
harm our patients.
Sacket DL. The arrogance of preventive medicine. Can Med Assoc J
2002;167:363-364

61. Then, why all this noise?...
noise
Mainly because the conclusions of
recent trials were severely misinterpreted
by the medical professionals, the media
professionals
and by the women, themselves
MNC/05

62. Causes of Death Among
Women*
Other Cancers
Heart Disease
15%
Breast Cancer 34%
Diabetes 4%
3%
Chronic Lower 6%
Respiratory
Disease
10%
28%
Other Cerebrovascular
Disease
*Percentage of total deaths in 1999
among women aged 65 years and older.
Anderson RN. Natl Vital Stat Rep. 2001;49:1-13.

63. Hormones and the Heart
1 in 3 women will die from coronary
heart disease (CHD) in the USA.
1 in 25 women will die from breast
cancer
Fitzpatrick LA. JCEM 2003;88(12):5609-10

64. “HRT is associated with a
35% reduction in mortality
for women who suffered
myocardial infarction”.
Shlipack MG, Angeja B, Go AS, et al Circulation 2001;104:2300-2304

65. Effect on the risk of CHD
WHI Significant increased risk
RR 1.29 (CI 1.02-1.63); 29 % increased risk
AR 0.37% vs 0.30% (ie, 37 vs 30 events
annually per 10.000 women)
HERS Nonsignificant decreased risk
RR 0,99 (CI 0.84-1.17); 1% decreased risk
AR 3.66% vs 3.68% (ie, 366 vs 368 events
annually per 10.000 women)

66. NNH / Year
(Number Needed to Harm)
(the reciprocal of the AR,or of the atributable AR)
Coronary Heart Disease
WHI (RR 1.29) 1428
HERS (RR 0.99) 5000
Breast Cancer
WHI (RR 1.26) 1250
HERS (RR 1.27) 833
MNC

67. “Not everything that can be
counted counts;
and not everything that
counts can be counted”
Albert Einstein

68. Hormone replacement therapy:
where to now?
Recent studies suggest HRT may inhibit
the process of atherosclerosis in
healthy arteries soon after menopause,
and observational studies (NHS, updated
2006) in younger women starting HRT
strongly suggest a potential
cardiovascular benefit
Mikkola TS, Clarkson TB. Cardiovasc Res 2002;53:605-19.

69. Lessons from the WHI
“…most articles and broadcast segments
tended to focus exclusively on either the
small absolute risks or the larger relative
risks, neglecting the more even-handed
risks
picture that presented both.
Since the sharply increased relative risks
got the most play, news coverage about the
play
trial’s findings had an alarming cast.”
Denzer S. Editorial. Ann Intern Med.2003;138:352-353

70. “WHI: Now that the dust has
settled…”
• To publish data that may or may
not be entirely true or certainly
premature is a disservice to the
medical profession and, most
important, to our patients.
• The majority of the data that were
published is not statistically
significant even at the nominal
level.
Creasman WT. et al. Am J Obst Gynecol 2003;189:621-626

71. Recent reports did not find, for
continuous combined treatments, any
increased risk of either CHD or breast
cancer.
The difference from WHI being that
women were younger, symptomatic
and with lower body weights
Heikkinen J. NAMS 2004, Abstract LB38
Lobo R. Arch Int Med 2004;164:482-484

72. “At the moment, I believe we can say with
relative certainty that hormone therapy in
younger postmenopausal women
results
in lower coronary heart disease events
and total mortality.”
Salpeter S. Climacteric 2005;8:307-310

73. An update of the WHI Study !
WHI investigators reported (Feb 2006) a
statistically significant (34%) lower risk for the
combined endpoint of myocardial infarction
(heart attack), coronary death, coronary
revascularization and confirmed angina among
women who were between the ages of 50 and
59 at the start of the study (RR 0.66; 95% CI
0.45-0.96).
Hsia J et al.Arch Intern Med 2006;166:357-363

74. Younger Women May Receive Heart Protection From
Estrogen Therapy
In women ages 50-59 who had undergone a
hysterectomy, a significant protective effect of
estrogen treatment, when both primary (heart
treatment
attacks and heart attack death) and secondary
(coronary artery bypass surgery, angioplasty,
confirmed angina pectoris) cardiac endpoints
were considered.
Dr. S. Mitchell Harman, director and president of Phoenix-based
Kronos Longevity Research Institute (KLRI) in Archives of Internal
Medicine 2006;106:357-363

75. Hsia J, Langer RD, Manson J et al. Conjugated equine estrogens and coronary heart
disease. Arch Int Med 2006;166:357-65

76. Hsia J, Langer RD, Manson J et al. Conjugated equine estrogens and coronary heart
disease. Arch Int Med 2006;166:357-65

77. Hsia J, Langer RD, Manson J et al. Conjugated equine estrogens and coronary heart
disease. Arch Int Med 2006;166:357-65

78. Press Statement IMS
In a subgroup of women demographically
similar to those in the WHI, there was no
significant relation between HT and CHD among
women who initiated therapy at least 10 years
after the menopause
(RR = 0.87, 95% CI 0.69–1.10 for estrogen alone;
RR = 0.90, 95% CI 0.62–1.29 for estrogen with progestogen).
Feb 2006

79. Press Statement IMS
The estrogen plus progestogen arm of the WHI
and the estrogen-alone arm actually showed that
HT does not
increase the risk of coronary heart disease in
the peri- and early menopause,
and may even carry beneficial effects.
effects
Feb 2006

80. Press Statement IMS
The WHI study was not designed, and
designed
therefore was not powered, to investigate the
consequences of hormone therapy (HT) in
women below 60 years of age. Therefore,
age
any attempt to present the results of the study
as indicating that HT may inflict damage to the
heart in general – a message that was accepted
by many medical societies and regulatory Authorities
is simply wrong and must be amended.
amended

81. Breast Cancer

82. Menopausal women and their
doctors are scared about the side
effects of HRT
mainly about breast cancer
MNC/05

83. It must be emphasized that we are
talking about an increased incidence of
the disease, which does not
automatically translate into an increase
in deaths from the disease.
Baum M. The Breast 2005;14:178-80

84. Extended use of estrogen for
10 years increases risks by 0,5%, and by
15 years increases risks by 0,9%
but..
upon cessation of HRT, the
relative risk quickly returns to 1.0 !
Coombs N J, Taylor R, Wilcken N. and Boyages J. BMJ 2005;331:347-349

85. Breast Cancer
• The diagnosis of a breast cancer after the
initiation of a HRT (with a duration of less than 5
years) is only a proof of its growth stimulatory
effect (not of its carcinogenic effect)
• Therefore, the reversal of the risk to 1 after the
cessation of HRT confirms again only its growth
promoting effect and denies a carcinogenic
effect.
Dietel M., Lewis MA. and Shapiro S. Human Reproduction 2005;20:2052-60

86. Breast Cancer
• The doubling time of an initial cancer
cell, up to the diagnosis of a resultant
cell
1cm tumor, is most likely greater than
10 years.
• This is why many dormant cancer cells
may exist in a “normal” breast !
MNC/05

87. Occult Breast Cancer
Clinically occult in situ
BC’s are frequent in
young and middle-aged
women.
Nielsen M et al-Br J Cancer 1987;56:814-9

88. Occult Breast Cancer
Breast malignancy was
found in 22 women
(20%)
Nielsen M et al-Br J Cancer 1987;56:814-9

89. Thus…
• Mammographies give more false
negative than false positive results !
• A “normal” mammography does not
exclude the presence of cancer cells
that may “explode” a few months later…
MNC/05

90. Estrogen replacement therapy in
patients with early breast cancer
The mortality rates from breast cancer for
the ERT users was 4.28% compared with
22.3% in the nonusers.
nonusers
Natrajan PK and Gambrell RD. Am J Obstet Gynecol 2002;187:289-95

91. “Recurrent breast cancer was
found in 9% of HRT users and
15% of nonuser”.
O’Meara ES et al.JNCI 2001;93:754-761

92. Mortality following development of
breast cancer while using
oestrogen or oestrogen plus progestin:
W Chen, DB Petitti and AM Geiger.
British Journal of Cancer 2005;93:392–398

93. This study explored survival after
exposure to oestrogen or oestrogen
plus progestin at or in the year prior to
breast cancer diagnosis
oestrogen plus progestin users
had lower all-cause mortality and
breast cancer mortality
Chen W, Petitti DB and Geiger AM. British Journal of Cancer 2005;
93:392-398

94. Breast cancer survival after hormone
exposure

95. Overall survival after hormone
exposure

96. A menopausal woman expects
from her attending physician
to be receptive to all of her complains,
to understand her psychic and physical
concerns,
to support her insecurity and
to help overcome her crisis.
crisis
MNC/05

97. Many Doctors fail to persuade
them to go on with HRT, in
despite of telling that the
benefits are far greater than
any potential risk
MNC/05

98. One may easily conclude that
without an adequate technique of
communication, using the proper
language,
there is no possible help
Thus,
physicians must acquire expertise in
the technique of communication
MNC/05

99. then...
let us talk about
Risks...
Risks

100. Are there risks?
It is crucial that information be given
about the difference between relative
risks and absolute risks, since the latter
risks
are the major cause of misinformation and
alarmism, being the favorites of the
media…
MNC/05

101. Example of Risks
• If you buy one lottery ticket you will
have a one in 1 million chance of
winning (“absolute risk”) 1x 10 6
• If you buy five lottery tickets your
chances are five fold higher or 5 in one
million (“absolute risk”) 5x 10 6
• Your chances of winning are increased
by five fold (“relative risk”) 5.0

102. Relative Risk
The risk of an event occuring
under certain circumstances
compared to the risk under
other circumstances

103. Attributable or Excess Risk
The difference between
underlying risk and risk when
receiving HT is called the
attributable or excess risk

104. Do not confuse…
Relative Risk
with
Absolute Risk!

105. Conclusion
• Relative risk is a confusing
word and is only important if
the absolute chances of an
event are high
• Attributable or excess risk is
the thing that one should be
most concerned about

106. Validity
Internal: the study measured what is set out to
measure
External: the results can be extrapolated to
one’s patients
Observational research (NHS) may have
poorer internal validity
better external validity
Randomized controlled trial (WHI)
better internal validity
poorer external validity
MNC/04

107. Confidence interval (C.I.)
A 95% C.I. signifies that there is a 95%
chance that the population “true value”
lies between the two limits.
If C.I. crosses the “line of no
difference” the point at which a benefit
becomes a harm (i.e.1) then one can
conclude that the results are not
statiscally significant
MNC/04

108. Risks of women medicated with E+P (5.2 years)
women

109. Risks of women medicated with E only (6.8 years)
women

110. Risks of Breast Cancer
according to different factors

111. “It appears that half of the
benefits in the prevention of
cardiovascular diseases are
not hormone related”!
Mosca L, Grundy SM, Judelson D, et al. Circulation 99;99:2480-4

112. Nurses’s Health Study
from 1980 to 1994 CHD ↓ 31%
↓ Smoking ↓ 13%
↑ Obesity ↑ 8%
↑ THS ↓ 9%
↑ Better nutrition ↓ 16%
Hu FB, Grodstein F et al. Trends in the Incidence of Coronary Heart
Disease and Changes in Diet and Lifestyle in Women. NEJM
2000;343:530-537.

113. Can side effects be minimized ?

114. What about the best treatments
during the climacterium and
beyond?
Little attention is paid to other
pharmacological interventions (non
hormonal) and strategies that have been
shown to be important for the
prevention of diseases and to maintain or
improve health.
MNC/05

115. Hippocrates promoted specific
diets to prevent and cure
diseases, such as illnesses of
the heart.
Lyons AS et al. In Medicine: an illustrated History. New York:Abradale
Press,1990:20719

116. The Polymeal
Franco O et al. BMJ 2004;329:1447-50

117. Doctors could retrain as
Polymeal chefs or wine advisers
The Polymeal—an evidence based menu that
includes, wine, fish, dark chocolate fruits,
vegetables, garlic, and almonds—promises to be an
almonds
effective, safe, cheap, and tasty solution to reducing
cardiovascular morbidity and increasing life
expectancy.
Polymeal could reduce cardiovascular disease by
more than 75%.
Franco O et al. BMJ 2004;329:1447-50

118. The Polypill
Wald N and Law M. BMJ 2003;326:1419-25

119. Wald N and Law M. BMJ 2003;326:1419-25

120. One third of people taking this pill from
age 55 would benefit, gaining on
average about 11 years of life free from
an IHD event or stroke.
Wald N and Law M. BMJ 2003;326:1419-25

121. Moderate exercise cuts breast
cancer biomarkers in
postmenopausal women
Increased physical activity significantly
reduces serum estrogens in
postmenopausal women and thus may
reduce the risk of breast cancer.
McTiernan A. Cancer Res 2004;364:2923-8

122. Aspirin could be used to prevent
cancer
Three recently published studies indicate
that aspirin, already enjoying a second
lease of life in the prevention of heart
disease, may soon become a first line of
defense against cancer.
London O. BMJ 2003;326:565

123. In conclusion …
and to make a long story
short…

124. There are no really “safe”
biological active drugs...
There are only “safe” physicians !
Kaminetzy HA 1993

125. “Each time we learn something new, the
astonishment comes from the recognition
that we were wrong before…
I truth, whe ne ve r we d is c o ve r a ne w fa c t, it
n
invo lve s the e lim ina tio n o f o ld o ne s . . .
thus, as it turns out,
WE ARE ALWAYS IN ERROR ! ”
Le wis Tho m a s Eng lis h Bio lo g is t (1 9 1 3 -1 9 9 3 )

126. My Message is:
.To prescribe postmenopausal hormonal
treatments when clinically indicated, if
not contraindicated
. No answers from ongoing clinical
trials are indispensable to practice
today a good Medicine
MNC/05

127. To know
the disease that a woman has
is as important as
to know
the woman who has the disease
William Osler

128. What are the best recommendations of
the climacteric woman’s doctor?
1. Understand what is happening to the body during
the climacteric and the postmenopause
2. Mental occupation
3. Physical exercise
4. Proper nutrition (moderate consumption of red
wine, and abundant fish, vegetables, fruits, soy,
milk, garlic, chocolate, etc)
5. Keep the body mass index (BMI) within normal
limits
6. Keep a normal girdle/hip ratio, waist circumference
7. Refrain from smoking
8. Keep a normal blood pressure
9. Keep the blood lipids within normal values
(statins?)
10. Examine the breasts (palpation, inspection,
mammography)

129. What about the best treatments
during the climacterium and
beyond?
There is a general tendency to consider
that sex steroid hormones are the only
instruments with which to treat women
when they enter in the climacteric phase
of their lives…
MNC/05

131. Which is the best treatment?
In general terms, is the one that is wisely
indicated, if not contraindicated, after
balancing benefits and risks, of all strategies
and interventions, hormonal or not.
It must be aimed at specific objectives and
targets that will be monitored at regular intervals
in order to determine its efficacy and to estimate
the occurrence of any side effects, a condition
that will determine its duration.
MNC/05

132. Which is the best treatment?
Patient needs and preferences are decisive, based on
decisive
the doctors’ advice. Let it not be forgotten that although
many treatments are available, they are nevertheless
not indispensable. Doctors have the duty to give their
indispensable
best unbiased information to their patients so that they
may make the right choices and then be compliant.
compliant
The woman is the decision maker, if the doctor
sees no contraindication.
thus,
the best treatment is what a well
informed woman has chosen.
MNC/05

133. I personally believe that for the healthy
early post menopausal woman the long term
HT’s, other than relieving vasomotor
symptoms, may play an important role in
improving QoL and in the prevention of
CVD, osteoporosis and Alzheimer, under
surveillance.
Systemic (parenteral) estrogens, added
estrogens
when needed to vaginal progesterone or
progestagen loaded IUD’s, may be very
IUD’s
beneficial, largely overpassing minimal
risks.
MNC/05

134. The conclusions of the WHI trial suggest that the
“safe “ woman (NNH between 600-1000 women)
to initiate HT is
- between 50-59 years of age
- with vasomotor symptoms
- less than 10 years after the menopause
- being treated with statins
- with a good lipid profile and
- with a Body Mass Index >25
Neves-e-Castro M. Human Reproduction 2003;18:2512-2518

135. This is precisely the profile of the great
majority of women who come for
consultation after their menopause.
Therefore it seems that what most
gynecologists are doing to their
predominant population of patients is not
unsafe and contributes not only to a
good quality of life but to prevention, as
well.
Neves-e-Castro M. Human Reproduction 2003;18:2512-2518

136. Postmenopausal hormone therapy: critical
reappraisal and unified hypothesis
83:558-66

137. Do others agree ?

138. “He who learns,
but does not think
is lost.
He who thinks, but
does not learn is
dangerous”.
dangerous
Confucius

139. If we both learn and think
we will
neither be lost
nor dangerous
to our postmenopausal women
patients”
Wenger NK. Am J Geriatr Cardiol 2000;9:204-9

140. NAMS position statement on
estrogen and progestagen use in
peri-and postmenopausal women
Revised breast cancer statements indicate
that the risk of breast cancer probably
increases with EPT use but not with ET
use.

141. NAMS position statement on
estrogen and progestagen use in
peri-and postmenopausal women
Place no limit on ET/EPT treatment
duration, provided it is consistent with
duration
treatment goals; if monitored regularly, no
stipulation is made regarding when to
reduce or stop therapy

142. If there are no incoming contraindications
we see no reason to establish a time limit
to the duration of therapy, mainly if there is
a recovery of symptoms after its
discontinuation
Cochrane B, NAMS 2004, P53
IMS www.imsociety.org
NAMS www.menopause.org

143. Evidence informed practice
• It is clearly time to change “evidence based
medicine” to “evidence informed practice”.
practice
• I suggest the era of evidence informed rather
than evidence based medicine has arrived
Glasziou P. Centre for Evidence-Based Medicine. University of
Medicine
Oxford OX3 7LF. BMJ 2005;330:92

145. What has been learned from the
major observational studies and
clinical trials?
the first lesson
systematically administered
progestagens may in part suppress
some of the beneficial effects of
estrogens and may also slightly increase
the risk of breast cancer after treatments
with duration greater than five years.

146. What has been learned from the
major observational studies and
clinical trials?
the second lesson
estrogens, when given alone to
histerectomized women, did not appear
to minimally affect the risk for breast
cancer when compared with controls
MNC/05

147. What has been learned from the
major observational studies and
clinical trials?
the third lesson
Metabolic effects of estrogens and
progestagens, as a whole, can differ
depending on the route of administration,
i.e. oral vs. parentheral, and on the
combination of both, in a sequential regimen or
in continuous combined administration.
MNC/05

148. What has been learned from the
major observational studies and
clinical trials?
the fourth lesson
Hormonal treatments are the first choice for
vasomotor symptom relief as long as they
are needed (on and off assessment). They
should not be used for the secondary
prevention of CVD, when atheroma plaques
CVD
are already present.
MNC/05

149. What has been learned from the
major observational studies and
clinical trials?
the fourth lesson (cont)
Conversely, they may protect from CVD
if started early during the transition
into the post menopause.
menopause
Hormonal treatments are preventive of
osteopenia and osteoporosis at any
stage in life
MNC/05

150. What has been learned from the
major observational studies and
clinical trials?
the fifth lesson
Estrogens may prevent degenerative
lesions of the CNS since, so far, they
seem to be the only available drugs with
nerve growth effects
MNC/05

151. Preventing a woman from the
benefits of a
sound postmenopausal
hormone therapy
because of the fear of rare
side effects
does not seem to be
satisfactory Medicine...
M.Neves-e-Castro, 2000

152. Primum non nocere :
neither by excess,
nor by deffect …
M.Neves-e-Castro

153. and now...
see the
differences...
in QoL :

154. like this one ?...

155. Secret for longevity !

156. Secret for longevity
A passerby noticed an old lady sitting on her front step:”I couldn’t help noticing
how happy you look! What is your secret for such a long, happy life?”

157. Secret for longevity
A passerby noticed an old lady sitting on her front step:”I couldn’t help noticing
how happy you look! What is your secret for such a long, happy life?!”
“I smoke 4 packs of cigarettes a day,”she said. “Before I go to bed, I smoke a nice
big joint. Apart from that, I drink a whole bottle of Jack Daniels every week, and
eat only junk food. On weekends I pop a huge number of pills and do no exercise
at all.”

158. Secret for longevity
A passerby noticed an old lady sitting on her front step:”I couldn’t help noticing
how happy you look! What is your secret for such a long, happy life?!”
“This is absolutely amazing at your age!!!!”, says the passerby. “How old are you?”

159. I’m 24
I’m 24
years
years
old...
old...

160. or like these?…

161. They are living after
“MATURE WOMEN’S
MEDICINE”!
(hormones, life style, nutrition, exercise, etc)

162. A WOMAN
in the autumn of her life
deserves an indian summer
rather than a winter of discontent ...
Robert B Greenblatt

163. and now...
this is not the end...
nor even the begining of the end.
It is perhaps,
the end of the begining !
Winston Churchill

164. This is what I have learned