Posts Tagged 'menopause'

Tips on maintaining health through perimenopause and beyond

If you’d like an overview of hormonal changes that happen for women at mid-life, check out this presentation by Lisa Brent, ND. Dr. Brent is a naturopathic physician who is a specialist in women’s health. We were delighted to host Dr. Brent this summer at Koshland Pharm and to hear her presentation, “Mind Over Menopause: Maintaining Health Through Perimenopause and Beyond,” and to share it here in its recorded version.

-Krista Shaffer, Outreach Director at Koshland Pharm and Peter Koshland, PharmD




Getting to the Root Cause of Symptoms

tree-rootsWe are fortunate through our work to get to meet physicians across the Bay Area who are committed to the health and well-being of their patients. We recently had the opportunity to interview one of these doctors, Dr. Todd Maderis, for our Prescriptions for Health newsletter. Dr. Maderis talked with us about his passion for getting to the root cause of symptoms:

Practice Approach

In my practice at Marin Natural Medicine, I’m keen on communicating two concepts with my patients. The first is education. I find that if patients are aware of the reasons behind their condition, they have a better chance of getting better.

The second concept, and the premise of my practice, is getting to the root cause of a patient’s symptoms.  Sleep is a great example of this. If a patient comes in complaining of insomnia, she might say, “I’m taking all of these wonderful supplements like melatonin and kava, and I’m still not sleeping.” In response, I might say, “Melatonin and kava are nice, and I like them…but let’s figure out what’s going on with you. What has changed in your life that might cause the insomnia?” We look at age, and the way hormones might have shifted, to see if there is a connection. The patient may not necessarily have a melatonin deficiency; she may have a hormonal imbalance.

I often talk with patients about correcting menopausal symptoms such as insomnia with hormonal balancing. The goal is to mimic nature in how we administer hormones. When we get patients back to their normal physiological range of hormone production, they often feel better and move through the world with greater ease. Ultimately, if we can identify and treat the root cause of their symptoms, the results are more sustainable over time.

Compounding Success Story

There was a woman who had had open heart surgery a few years before coming to see me, and she had been feeling very fatigued ever since. She had a low-grade depression, and wasn’t doing the activities she liked to do, such as playing the piano or reading. It took everything she had to get up and out of the house each day. Because she was clinically presenting with low estrogen and progesterone, I prescribed a topical bi-est (80%estriol/20%estradiol) cream and progesterone capsules from Koshland Pharm. Two or three months into her prescription, she felt a bit better. I had her do a follow-up urine test, and it turned out that her testosterone was also very low. Once testosterone was added to her prescription, she went from feeling 70 percent better to feeling 100 percent better. She started playing the piano and reading again; she got her life back.

Current Inspirations

It is the stories of patients improving the quality of their lives that keeps me inspired. I am also inspired by learning from experts in different fields, and then bringing that knowledge back to my patients in Marin County.

For example, last year I did a physician training with Ray Stricker, M.D. and the International Lyme and Associated Disease Society. I became interested in Lyme because there was always a subset of patients I treated with symptoms of chronic fatigue syndrome who did not respond to typical therapies.

I find that the American health care system is being burdened today not by acute illnesses but by chronic, debilitating conditions such as chronic fatigue, chronic pain and depression. Oftentimes, people are put on multiple drugs to address their different symptoms, but the cause is never approached.

Most patients with chronic conditions didn’t get sick overnight, and they are definitely not going to get better in one day. It’s a process.  I recall a saying I heard from a mentor of mine: “In the same way we do not light a room by removing darkness, we do not achieve health by removing disease.” If I can help at least one patient every day to move further away from disease, and closer to good health, then I’m doing my job. That’s my passion.

For more information about Dr. Maderis and Marin Natural Medicine Clinic, see Marin Natural Medicine Clinic’s webpage.

As always, we welcome your comments and feedback.

~Krista Shaffer, Outreach Director at Koshland Pharm and Peter Koshland, PharmD

FDA approves Paxil for hot flashes? Come again?

Peter Koshland, Pharm.DOn June 28, 2013, the FDA approved the anti-depression drug paroxetine (Brisdelle, in a higher dosage form known as Paxil) as the first non-hormonal drug to treat hot flashes, which many women experience in menopause. This approval came despite the FDA’s own Advisory Committee’s 10 to 4 vote against approving paroxetine for this particular condition because its benefits did not outweigh its risks. (Paroxetine was only associated with on average one or two less hot flash/es per day than a placebo in two clinical studies, with the women in the studies starting out with an average of 10 hot flashes per day.) (“FDA Approves a Drug for Hot Flashes”, Andrew Pollack, The New York Times,  June 28, 2013)

As a pharmacist, I was shocked to see the FDA approve paroxetine—which the FDA’s own committee determined was only “minimally effective” for hot flashes—because it comes with many troublesome side effects. These include agitation, insomnia, sexual dysfunction and the life-threatening serotonin syndrome. Anti-depression medications can be very difficult to stop taking once on them as well; this is especially true for paroxetine. I’ve had several patients who have had severe withdrawal effects from this drug. Our pharmacy has had to make specially formulated 0.5mg doses so that these patients could titrate the dose very slowly and even then it was a rocky road.

Although the FDA did not explain in its announcement its reasons for going against its own committee’s recommendations, it seems as though there was pressure to approve a non-hormonal medication for hot flashes. The FDA stated in their June 28th press release: “There are a variety of FDA-approved treatments for hot flashes, but all contain either estrogen alone or estrogen plus a progestin.” This statement makes it sound as though estrogen and estrogen/progestin therapy are inherently bad.

This kind of statement is extremely frustrating to me as a pharmacist, because in fact, there is strong clinical evidence to support the use of bioidentical hormones to address menopausal symptoms both because of their efficacy and strong safety profile. (For a summary of some of the research on bioidentical hormones, see “The Bioidentical Hormone Debate” by Kent Holtorf.) In my experience as a pharmacist, I have also seen first-hand thousands of women benefit from these treatments.

A decision like this makes me believe there is still work to do when it comes to education around healthy aging for women in menopause and beyond. We can do better than giving women experiencing menopausal symptoms a drug that was designed for depression.

I welcome your thoughts and comments.

–Peter Koshland, PharmD

Recent Trial (KEEPS) Shows Benefits of Hormone Therapy in Newly Menopausal Women

The researchers who conducted the KEEPS trial (Kronos Early Estrogen Prevention Study) presented initial findings to the North American Menopause Society on October 3, 2012, summarized in the statement:

“Estrogen/progesterone treatment started soon after menopause appears safe and relieves many of the symptoms menopausal women face as well as improving mood and markers of cardiovascular risk.”  (KEEPS press release, “Hormone Therapy Has Many Favorable Effects in Newly Menopausal Women,”10-3-12)

This four year, randomized, double-blinded, placebo-controlled clinical trial (the gold standard in clinical trials) compared oral vs. transdermal estrogen in conjunction with cyclic progesterone.  The participants were healthy women aged 42-58 who started therapy within three years of the onset of menopause.  The oral estrogen used was conjugated equine estrogen (Premarin), and the transdermal estrogen was a bioidentical, estradiol patch (Climara).

The researchers are still analyzing the data, but have so far concluded that “The results provide reassurance for women who are recently menopausal and taking HT for short-term treatment of menopausal symptoms.  KEEPS also highlights the need for individualized decision making about hormone therapy, given that oral conjugated equine estrogen and transdermal estradiol  have different profiles of effects and different women have different symptom profiles and priorities for treatment”  (KEEPS press release, “Hormone Therapy Has Many Favorable Effects in Newly Menopausal Women,” 10-3-12).  The different profiles of effects include an association with the use of oral conjugated equine estrogen with an increase in HDL (“good”) cholesterol, a decrease in LDL (“bad”) cholesterol, and an increase in triglyceride levels (a lipid fraction that is of uncertain significance), and an association between the use of bioidentical transdermal estradiol with with improved insulin sensitivity (lower insulin resistance).  For more information, see:

These initial findings support our understanding of existing studies that estrogen therapy, started close towards the beginning of menopause, can be an effective treatment of menopausal symptoms without  posing a risk to cardiovascular health.


OB/Gyn organization gets it wrong about compounding pharmacies

PCAB Accredited SealThe American College of Obstetricians and Gynecologists (ACOG), one of the leading organizations of OB/Gyn’s in the country, recently came out with a position statement telling their members not to use compounded medications for their patients.  Their statement includes factual inaccuracies about the quality and validity of compounded medications.

Compounded (or customized) medications are an important part of the host of therapeutic options available for an individual patient, and unfortunately, the ACOG position limits doctors’ ability to treat their patients’ conditions by suggesting that they solely rely on medications provided by the pharmaceutical industry.

One of ACOG’s key criticisms of bioidentical hormones from compounding pharmacies is the lack of quality control when it comes to purity and potency of the finished medications.  They mention an often cited FDA survey from 2001 (mistakenly referenced as being from 2009 in the ACOG paper, p. 4), that found a 34% potency failure rate from compounded prescriptions obtained over the internet.

Importantly, this FDA study (2001) about the potency of compounded products predates the founding of the Pharmacy Compounding Accreditation Board (PCAB), which created in 2006 “a system of standards by which each compounding pharmacy can test its quality processes.”  PCAB is a not-for-profit organization founded and directed by eight leading national pharmacy organizations:  The American College of Apothecaries, the National Community Pharmacists Association, the American Pharmacists Association, the National Alliance of State Pharmacy Associations, the International Academy of Compounding  Pharmacists, the National Home Infusion Association, the National Association of State Boards of Pharmacy, and the United States Pharmacopeia.

The ACOG paper states, “the purity, potency and quality of compounded preparations are a concern” (pg. 3).  They are clearly unaware of the rigorous quality control measures required in PCAB accredited compounding pharmacies, including the testing of multiple finished products as a way of ensuring quality and validating the processes used to make the compounded medications.

Compounded medications may not be right for all patients in all situations, but they are an important therapeutic tool for situations where a manufactured pharmaceutical does not meet a patient’s needs.  ACOG’s position perpetuates factual inaccuracies about these customized medications at the expense of a patient’s ability to obtain the best possible treatment for her/his specific condition.

For patients and doctors who want to ensure that they are working with a pharmacy whose compounded products have reliable potency and purity, they can check to see if the pharmacy is accredited by PCAB.  In addition, both patients and doctors can ask to see a pharmacy’s certificates of analysis of the products that they routinely test.

For 6 concise questions to ask a compounding pharmacy to evaluate the quality of its compounded medications, see Koshland Pharm’s “How to Evaluate a Compounding Pharmacy” hand-out.

I welcome your comments and feedback.

Peter Koshland, Pharm.D

Lady Brain Interview

Interested in hearing a frank discussion about peri-menopause?  I was recently interviewed by Lauren Schiller and Stephanie Dominguez Walton on their March 26th, 2012 broadcast of “The Lady Brain Show.”  In minutes 10:50-24:20 of that broadcast, we discuss possible signs of hormone imbalance and what women can do about it.   Each week, Lauren and Steph address topics relevant to women with irreverance and humor.  Check out the Lady Brain Show at this link.  I welcome your feedback and questions!  ~Peter

Factors to Consider for Hormone Therapy

I was recently interviewed for a Huffington Post article (December 2011) about hormone replacement therapy.  The article discusses the recent history of hormone therapy for women in the U.S., and addresses the following questions:

  • Why were concerns raised about hormone therapy in the early 2000’s?
  • How are synthetic hormones different from bioidentical hormones?
  • Why does the dosage form of a hormone (for example, a capsule vs. a patch) make a difference?
  • Why is age an important factor to consider when prescribing or taking hormone therapy?

In the article, two California gynecologists, Dr. Susan Podolsky and Dr. Ricki Pollycove, also weigh in on the topic. I hope that you find it helpful!  ~Peter

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