Women's Health Over 60: Interview with Dr. Judith Reichman
I recently interviewed Dr. Judith Reichman about her latest book, Relax, This Won't Hurt: Painless Answers to Women's Most Pressing Health Questions. Although, Dr. Reichman's book explores women's health during each decade from our twenties, to our seventies, and beyond, our conversation focused on an often, overlooked population of women&emdash;those who are over sixty.
Dr. Reichman is also the author of I'm Too Young To Get Old and I'm Not In The Mood; a regular contributor for the Today Show about various women's health issues including How to Get the Most Out of Your Doctor Visit; and a practicing gynecologist in California. We explored issues from hormone replacement therapy (including estrogen, natural vs. synthetic progesterone, and testosterone), hot flashes, to osteoporosis and exercise, and breast cancer risk, as well as what to do when symptoms occur.
Q: Should women over 60 continue taking estrogen if they have been taking it since menopause?
A: Basically, the issue of estrogen replacement once you are in your sixties&emdash;If you've been on it then you have given your bones a boost, and you have probably not lost 2 to 3 percent per year, in the first 7 to 10 years of menopause. But, the minute you stop taking the estrogen you fall back, literally fall back, to that same rapid loss of bone density. So that, if you've managed to stay on hormones since say your fifties, and you've now hit your sixties, and you stop your estrogen you will then restart the process of osteopenia or osteoporosis.
Q: Will a woman then return to the level she would have reached had she never taken estrogen?
A: It will within five years, probably be as if you did not take estrogen from the onset. And the other issue is that estrogen we feel protects you from coronary vascular disease. But, that protection is there as long as you take your estrogen.
Once you stop taking the estrogen then you again fall back to menopausal levels of HDL which falls and LDL which rises. And you also leave the protective effect of estrogen that occurs directly on your vessels, the lining of your vessels and plaque formation, and perhaps spasm of the vessels. So if we're giving estrogen for coronary vascular disease prevention or decreased risk once we stop it, we stop the protection.
Q: So, basically a woman would want to continue estrogen?
A: She would want to continue it, exactly. If she's benefiting then she will continue to benefit. As far as the benefits that have to do with memory loss there's more and more data showing that long term estrogen replacement may decrease Alzheimer's. In addition to the fact that there are many women who feel that once they lose their estrogen, their short-term memory diminishes. Now if we've managed to keep our short term memory with estrogen and then we stop it … we're going to go right back to a lot of the symptoms that might have started from the onset of menopause.
Q: Does that mean women who discontinue estrogen will return to hot flashes?
A: Yes they may definitely return to hot flashes. Vaginal dryness--we've protected with estrogen-- when we stop it we'll go back to vaginal dryness. What I'm saying is that when you take it in your fifties, when you stop it in your sixties you may go back to having symptoms.
Now some women won't. Some women will stop and they'll say, 'Oh, I'm not getting hot flashes. I feel OK, vaginal dryness is not an issue, I'm remembering pretty well, I have no family risk for Alzheimer's or coronary vascular disease, my cholesterol's are great and if I don't have symptoms, why should I take it?'
And if a woman is in that category-- she got the bone density and that looks OK, and she's doing everything right, she doesn't absolutely have to stay on the hormones. But, she should be monitored, her cholesterol's should be checked, her bones should be checked and she should see how she feels.
I mean there are no… What you learn in medicine are that there is no absolute black and white. The only absolute is that, unfortunately, at some point we all die.
Q: What about the woman who never took estrogen?
A: As far as a woman who's never taken estrogen, and she hits sixty or seventy and she says 'You know my doctor never told me about estrogen, and now I'm reading all this stuff about it, should I start it?'
And my answer would be, 'Let's look at your risk factors, see if you have risk factors for coronary vascular disease, it might be a very good idea, if you're developing osteoporosis or osteopenia and your bone density is low…hey this is one of the best things you can do for your bones.'
Q: Will taking estrogen help to rebuild bone loss?
A: Yes. What it does is all of the drugs that are currently out for treatment of osteoporosis help diminish bone resorption. And estrogen does it probably better than all the other drugs out there. When you stop making those little holes in the bones, then with time the holes that are there begin to fill up and that's why you can build back some degree of bone… what you're doing is filling up the holes that are there and not making new ones.
Q: My mother, who is 71, had a hysterectomy over 20 years ago. She never took estrogen. I believe she probably has osteoporosis, although she's never been diagnosed, because she's shorter and she walking is difficult for her. What would you advise a woman like my mother?
A: She should have a bone density and if indeed-- I'm sure she does have osteoporosis, then she has to talk to her doctor. She might be an excellent candidate for estrogen. If she really has very bad bones we are in some cases adding to the estrogen-- Fosamax&emdash;because in combination they work better than by themselves.
If for some reason she doesn't want to take estrogen or can't take estrogen then you've got some other excellent alternatives. In addition to the Fosamax, you can do fosamax, or she can consider the raloxifen (Evista®) which is shown to be very good as far preventing the resorption.
Miacalcin is a nasal spray that also diminishes resorption rates in women who are post menopausal at least five years. And then there's also the issue of having to make sure she takes enough calcium because none of these will work if you don't get enough 'cement' from which to build a support system and that cement is calcium.
In your mother's age group any woman who is either menopausal and not on estrogen, or over the age of 65 and even if she is on estrogen, needs 1500 mg of calcium a day. Very important to take it in divided doses because if you take it all at once you can't absorb that much.
And there are wonderful calciums out on the market. I know one of the new ones that I really like, and it's the only way I got my daughter to take calcium, is the Viactiv because it's this chocolate or cappuccino tasting chew like a tootsie roll. And then a lot of my patients I tell them to take calcium and they say 'I'm not going to swallow those horse pills, I'm not going to take Tums.' But then, I give them a sample of the Viactiv and they say 'Oh, this is good, I can do this.'
So your mom, in her age group, should take it 3 times a day. She should be sure she is getting Vitamin D. As you get older your skin doesn't convert Vitamin D from sunlight as well nor do your kidneys make it as well so you need more Vitamin D. So instead of what we tell the usual woman to take 400 mg, you need 800 mg.
And then weight-bearing exercise, even in elderly women just doing weight bearing fifteen minutes, five times a week, plus calcium, plus Vitamin D, has been shown to significantly reduce fracture rates, even women in nursing homes who already have significant osteoporosis.
Q: My mother walks very slowly…
A: She can go ahead and get light weights, and do maybe some light weight lifting. And what helps in the beginning is to have her work with a physical therapist, just to show her what she can do without hurting herself and let her continue at home. But, I would say for her to do the weights three times a week for fifteen minutes. Plus walking&emdash;she should be walking thirty minutes a day even if she doesn't walk fast. If she can get her heartbeat up that will not only help her fitness, but will help her bones.
Q: What is your opinion about natural progesterone vs. synthetic progestins?
A: I deal with it quite a bit in the book, but what I basically say is that the PEPI Study has shown that some of the benefits that estrogen gives women, as far as raising the HDL and lowering the LDL is somewhat diminished with the synthetic progestin. But, the natural progesterone doesn't have that same adverse effect.
Additionally, women who sometimes get PMS or headaches or breast tenderness on the synthetic progestin&emdash;feel better with the natural progesterone. One that is on the market, and FDA approved, is Prometrium.
Q: Is testosterone beneficial for women over 60?
A: First of all, if a woman has a complaint of low libido and she's on hormone replacement therapy; chances are that her testosterone is low. We check free testosterone because that's the testosterone that has the effect on libido.
We know that if they're on hormone replacement therapy, what happens is estrogen causes an increase in the protein that binds up male hormone. So, on the one hand you're giving estrogen and that makes the vagina more lubricated and sex more comfortable.
But, the estrogen is causing a decrease in the free testosterone. And that's why women will sometimes take HRT and say, 'Oh, this is great. Sex doesn't hurt anymore, but I don't feel like having it.' And those are women that would benefit probably by adding on very small amounts of testosterone. There is a product that combines estrogen with testosterone and that's called Estratest.
Now, if a woman is not on hormone replacement, but she's six years menopausal or more&emdash;with time, her ovaries make less and less testosterone. She too might benefit from testosterone. But, I hesitate to give it without estrogen because estrogen has a beneficial effect on our lipids&emdash;testosterone many have a slightly non-beneficial effect.
So, if I give them together I sort of feel like I am canceling it out. Also, if a woman is not on estrogen and she's menopausal, I question her as to whether there is vaginal dryness and some of her lowered libido is because she hurts when she has sex. If something hurts, you don't want to do it.
Now in some of my patients-- especially those who have had breast cancer-- what I may do is give them an estrogen ring (Estring). That builds up the vaginal mucousa, and then let them add on testosterone either as an ointment or lozenge under the tongue, and that has to be made by a compounding pharmacy.
Q: What is a good free testosterone level?
A: It depends on the lab. The doctor has to look at what the norms are for the lab. So I hate to give you a number because each lab has its own scale.
Q: Are monthly breast self-exams and mammograms still important over 60?
A: Monthly breast self exam, and annual mammogram should be done in women over sixty. Actually, the older we are the higher our risk of developing breast cancer.
Q: Is there anything else that you feel it's important for women over 60 to understand?
A: In my intro (to her book), I talked about the fact that we are often made to feel useless, and not powerful, and somehow in a lessened position when we turn 65. Maybe part of that is because we go on Medicare. But, our sixties are still viable, wonderful years&emdash;and so can our seventies be. And there is something called aging, in my book I talked about how you can eat with the ability to continue a significant part of what you have been doing with your life.
What I don't want women to think is any new symptom, any complaint, can be simply dismissed with the phrase, 'Well, you're getting older what do you expect.' I think that what we have to expect is that our symptoms will be taken seriously by our physicians, and that appropriate testing be performed if we do have symptoms to figure out what the underlying problem is, and what can be done, if anything, about it. I don't like the fact that we tend, in our society, to both reject and neglect women as they get older.
Want to know more about women's health over 60, as well as during each decade of a woman's life? Read Dr. Reichman's latest book, Relax This Won't Hurt: Painless Answers to Women's Most Pressing Health Questions.
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