Frequently asked questions

    What are premenopause and menopause?

    Premenopause is due to decreased production of female hormones by the aging ovaries. During menopause, the decrease in production is such that there is a cessation of uterine bleeding during a period of 12 consecutive months.

    The average age of menopause in Quebec is 51 ½ years. Premenopause is the period of time typically ranging between 2 to 8 years before menopause.

    The two major ovarian hormones are 17 β-estradiol and progesterone. During premenopause, the first deficit in production is often a progesterone deficiency. Eventually, and more or less chaotically, a deficit of progesterone and 17 β-estradiol will occur.

    The main signs and symptoms of premenopause or menopause are: irritability, fatigue, insomnia, muscle aches, joint pain, hot flashes, symptoms of depression, anxiety symptoms, digestive disorders, heart palpitations, urinary problems, loss of libido, vaginal dryness, osteoporosis, increase in bad cholesterol and triglycerides, weight gain, hair loss, etc. Menstrual irregularities, heavy bleeding and increased premenstrual syndrome are also observed during premenopause.

    Few people know that female hormones (17 β-estradiol and progesterone) are hormones that carry out the most functions in humans. This explains the vast diversity of signs and symptoms of premenopause or menopause.

    Female hormone therapy is the most effective treatment for treating the signs and symptoms of premenopause or menopause. This is logical because hormone therapy treats the cause! I definitely prefer bioidentical female hormone therapy, in adequate doses.

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    What is bio-identical female hormone therapy?

    Bio-identical female hormone therapy is composed of transdermal 17 β-estradiol and progesterone. The term “female” refers to two major hormones produced by the ovaries (progesterone and 17 β-estradiol), while the term “bio-identical” means “identical to what the human body produces” (in this case, the ovaries).

    Therefore, the treatment using bio-idential female hormone therapy consists of giving back to women the same hormones their ovaries no longer produce, or do not produce in sufficient quantities, in order to achieve well-being and health.

    I prefer bio-identical hormones marketed by pharmaceutical companies, due to issues of effectiveness, quality and safety. These hormones are made from sterol analogues present in the soybean.

    The preventive aspect of using bio-identical female hormone therapy (e.g., preventing osteoporosis, cardiovascular disease and Alzheimer’s disease) concerns me the most. Scientific information suggests that hormone therapy should be started early in women in order to reap its multiple benefits.

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    What differentiates non bio-identical female hormone therapy from bio-identical female hormone therapy?

    Many scientific studies unequivocally reveal significant differences between non bio-identical and bio-identical hormone therapy. It is surprising that these differences are hardly ever publicized. This ignorance is the cause of distressing and shocking confusion.

    In July 2002, following the publication of the results stemming from the first component of the Women’s Health Initiative (WHI) study, many women stopped their hormone therapy. In this study, the hormones used – the CEE (conjugated equine estrogens) and MPA (medroxyprogesterone acetate) – are very different than the hormones produced by the ovaries. In fact, the two major ovarian hormones are 17 β-estradiol and progesterone.

    At this point, I want to emphasize that few people are aware of the real conclusions that can be drawn from the WHI study. The only statistically significant risk found in the WHI study is an increased risk of venous thromboembolism. This increased risk is due to the foreign nature of the hormones used (CEE and MPA), as well as the fact that estrogen had been administered orally. (Besides, oral contraceptives also increase the risk of venous thromboembolism). The second point to remember is that the increased risks (statistically insignificant) of coronary heart disease and breast cancer are not associated with CEE, but are solely linked to MPA. MPA is an artificial substance, that is, it does not exist in nature. In my opinion, MPA must be banned from female hormone therapy – MPA is not progesterone and it may even have an anti-progesterone effect outside the uterus. The third point to remember is that, in women who started hormone therapy before the age of 60 years (CEE with or without MPA), researchers observed a statistically significant decrease in mortality. Finally, the fourth point to remember is that the benefits of hormone therapy are attributable to estrogen. The benefits of estrogen (observed in the WHI study) include the prevention of osteoporosis and a reduced risk of coronary heart disease, colorectal cancer and breast cancer. In my opinion, it is very important to restore the reputation of estrogen.

    Interestingly, scientific evidence shows that bioidentical female hormones (transdermal 17 β-estradiol and progesterone) dosed for hormone therapy, in addition to their invaluable benefits, do not carry the risks associated with CEE and MPA.

    CEE are not 17 β-estradiol

    CEE (e.g., Premarin®) contain several different estrogen compounds isolated from pregnant mare’s urine and are administered orally. In CEE, about half the estrogen is in the form of estrone sulfate.
    CEE may increase the levels of triglycerides, C-reactive protein and certain coagulation factors. These increases are associated with a higher risk of cardiovascular and thromboembolic diseases, among others.
    Transdermal 17 β-estradiol (gel and patch), in physiological doses, does not produce these adverse effects. Furthermore, it can even reduce the levels of triglycerides and C-reactive protein.

    MPA is not progesterone 

    MPA (e.g., Provera®) is a progestin that may have adverse effects on cardiovascular and brain health. MPA is also likely to increase the risk of breast cancer and possibly other types of cancer.
    On the contrary, scientific evidence shows that progesterone has a protective effect against cardiovascular diseases, cerebral diseases and even breast cancer (and possibly other types of cancers).

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    I am menopausal. I have been taking bio-identical female hormones for a few weeks and I am bleeding. Is this normal?

    At the Centre, we observe that about 25% of menopausal women taking bio-identical female hormone therapy on a regular basis will bleed in the weeks or months following the start of hormone therapy.

    This is often due to an adjustment period where your body must adjust to the new levels of female hormones.

     

    To learn more...
    If you are menopausal, your blood level of estradiol is low and thus your cells have many estrogen receptors. By taking of 17 β-estradiol, the number of your estrogen receptors will decrease, as it was the case before menopause.
    During this adjustment period, your endometrium may have had time to proliferate, and therefore cause bleeding. It is a perfectly normal reaction.

    What should I do?

    • Cease taking your progesterone (Prometrium) for 1 day.
    • Reduce your dose of 17 β-estradiol (Estrogel or patch).

    For example, for those using Estrogel, you can reduce the amount of gel by half. For those using a patch (e.g., Estradot or Climara), apply a patch with a low-dosage formulation of 17 β-estradiol (Dr Demers usually prescribe more than one dose during your visit).

    If your bleeding is more abundant than a normal menstruation, cease taking your hormones until your bleeding stops, and afterwards, resume your hormone therapy with a lower dosage of 17 β-estradiol. Consult a physician if there is haemorrhaging or persistent bleeding.

    If, with your lower dosage of 17 β-estradiol (gel or patch), you experience symptoms of menopause, you can gradually increase your dose of 17 β-estradiol until your symptoms are adequately relieved.
    Also ensure that you are taking both hormones correctly.

    Did you know that...
    After your period of adaptation, three reasons can explain the persistence of your uterine bleeding. The first two reasons are much more frequent.
    • Your blood levels of estradiol and progesterone are not balanced. The results of your blood test will guide me in adjusting the dosage of your hormones. I will also verify if you are properly taking both your hormones or if there are any interactions with other drugs or natural products.
    • Your ovaries produced 17 β-estradiol.
      The quantity of estradiol that is added to the amount provided by your gel or patch may cause your endometrium to proliferate and thus cause bleeding.
      Do not be surprised: your ovaries can produce 17 β-estradiol even if you are menopausal. As a rule of thumb, the more recent your menopause is and the younger you are, the more plausible this hypothesis becomes.
    • Presence of a uterine problem.
      In the presence of unexplained uterine bleeding, Dr Demers will investigate to determine whether there is an underlying uterine pathology (endometrial hyperplasia, fibroids, polyps, cancer...).

     

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    I am 57 years old and have been menopausal for 5 years. I have never taken hormones and I would like to take them to treat my symptoms of menopause, as well as to prevent osteoporosis and other health problems. Is it too late to start?

    No. However, there are two important points to know.

    1) To relieve your symptoms of menopause, such as hot flashes and vaginal dryness, it is never too late.

    2) To prevent health problems, there is an important basic principle to remember:
    The more you delay the start of your female hormone therapy following an occurrence of significant hormone deficiency, the less preventive the hormone therapy will be. The deficit in female hormones promotes the progressive development and potentially irreversible cell damage such as the formation of atheromatous plaques in your arteries, the formation of amyloid-β substance in your cholinergic neurons and the demineralization of your bones that can lead to cardiovascular disease, Alzheimer’s disease and osteoporosis respectively.

     

    Did you know that in the WHI study...
    In the group of women who started hormone therapy before the age of 60 years (CEE with or without MPA), researchers found a statistically significant decrease in the mortality rate of 30%.

    In the group of women who began taking CEE before the age of 60 years, there was a 20% reduction in the risk of diseases (all causes combined) – more specifically a reduced risk of coronary heart disease, fractures, breast cancer, colorectal cancer and mortality.

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    In the information leaflets provided with Estrogel and Prometrium, I read all the possible serious side effects of these drugs. Since then, I am afraid to take my hormones. Should I be?

    It is greatly important for you to know that the serious side effects reported in the information leaflets stem from the results observed in the WHI study. Let me remind you that bioidentical hormones were not used in this study; however, CEE (conjugated equine estrogens) and MPA (medroxyprogesterone acetate) were used. In addition, these hormones were given to women with an average age of 63 years, which does not correspond to the clinical reality where, in most cases, women who start hormone therapy are at the beginning of their menopause. A detailed analysis of this study is the subject of Chapter 2 of my book Hormones au féminin : Repensez votre santé.

     

    Remember that...
    The only statistically significant adverse effect in the WHI study is the increased risk of venous thromboebolism.
    This increased risk due to the fact that the hormones used were different than female hormones and that estrogen was administered orally.

    What are the real side effects of bio-identical female hormones?

    The main side effects of 17 β-estradiol are: breast tenderness, bloating, febrile sensation and uterine bleeding.
    As for Prometrium, the main side effects are nausea, dizziness and fatigue.
    Their side effects are generally attributable to the adjustment period when taking new medications (these effects are temporary), or even due to inadequate or unbalanced hormone levels, hence the great importance to measure hormone levels.

    In fact, bio-identical female hormone therapy (transdermal 17 β-estradiol and progesterone), in adequate and balanced doses, offers several incredible benefits for the well-being and health of women.

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    Should I stop taking my bio-identical female hormones after five years of use?

    The Society of Obstetricians and Gynaecologists of Canada recommends that women stop hormone therapy after five years of use and only resume therapy if symptoms persist. According to the Association of Obstetricians and Gynecologists of Quebec (guide sent to physicians in 2009), hormone therapy can be an excellent second choice for the treatment of osteoporosis, and there is no absolute time limit.

    The recommendation to cease hormone therapy after five years of use stems mainly from the results of the first component of the WHI study. I encourage you to read again Chapter 2 of the book Hormones au féminin: Repensez votre santé, because it is the interpretation of this study that created a state of panic.
    Few people are aware of the second component of that study, as well as the meta-analysis of the first component of the study, which shed different and even more reassuring insight.

    As for the risk of breast cancer, I also invite you to read Chapter 7 of my book Hormones au féminin: Repensez votre santé because the risk of breast cancer is wrongly associated to a high level of estrogen. Not only will you notice that estrogen has not been proven to be carcinogenic, but also that the risk of breast cancer is not associated with higher blood levels of estradiol. On the contrary, it is the deficit in estradiol, the deficit in progesterone, excess insulin, some progestins (e.g., MPA), excess alcohol and the lack of exercise that are associated with the increased risk of breast cancer.

     

    Did you know that...
    The main risk factor for breast cancer is aging, and female aging is closely associated with a decline of estradiol and progesterone levels in the blood.
    The average age at the diagnosis for breast cancer is 62 years. At this age, women have a very low estradiol level, which is generally about five times lower than the level measured in men!

    My opinion is as follows...

    For women who feel well, I have no scientific and logical arguments that could justify stopping the use of transdermal 17 β-estradiol (patch or gel) and progesterone (Prometrium), especially when prescribed in adequate doses.
    On the contrary, I know many reasons for encouraging women to continue their hormone therapy. In fact, the evidence shows the judicious use of bioidentical female hormones has multiple benefits. For example, among women who started early, bioidentical female hormone therapy has a protective effect against cardiovascular disease, osteoporosis and Alzheimer’s disease.

     

    Did you know that...
    Cardiovascular diseases are responsible for the vast majority of deaths among women. Nearly one in two women will die from cardiovascular disease.
    As for fractures due to osteoporosis, they are responsible for more deaths than ovarian and breast cancer combined.
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    I would like to take bio-identical female hormones. Do you know any physicians in my area who prescribe them?

    In Hormones au féminin : Repensez votre santé, on pages 113 and 114, you will find a list of bio-identical female hormones available in Canada. In Chapter 13, I explain how to prescribe bio-identical female hormone therapy in accordance with art and science. Ask your family physician if he or she wants to prescribe these hormones.

    The expertise that I developed relates specifically to hormone assays. One of my main objectives that I set for myself is researching hormone assays that optimize the many benefits of female hormones in the well-being and health of women.

    In the tab Dr. Sylvie Demers – Centre ménopause-andropause Outaouais, you will find the names of the satellite clinics of the Centre menopause-andropause Outaouais. Since June 2010, we are pleased to announce the opening of a menopause-andropause clinic in Quebec city under the banner of Institut privé de chirurgie inc., which will provide the highest standards of care to women and men.

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    Are bio-identical female hormones covered by the RAMQ?

    Bio-identical female hormones are considered exception drugs by the RAMQ.
    In order for the 17 β-estradiol transdermal patch to be covered by the RAMQ, the patient must exhibit one or more contraindications to estrogen administered orally, or that the latter is ineffective. As for progesterone, there are two conditions: the patient must have a uterus, and she must also exhibit a significant intolerance to MPA.

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    What is andropause?

    Andropause is defined as a clinical syndrome associated with a decrease in testosterone levels in men. Testosterone in men is mostly produced by the testes (~ 95%) and to a lesser extent, by the adrenal glands (~ 4 to 5%).

    With age, there is usually a significant decrease in the production of testosterone by the testes. According to the U.S. study MMAS (Massachusetts Male Aging Study), published in 2002, 40 to 65% of men aged between 40 and 70 years had a testosterone level low enough to experience symptoms such as decrease of desire, erectile dysfunction, irritability, sadness, fatigue and loss of pleasure.

    Testosterone is a hormone responsible for a multitude of functions.  Testosterone acts in the brain, muscles, bones, blood vessels, adipose tissue, red blood cells and prostate, among others. Testosterone is also necessary for libido, erectile function and normal ejaculation.

    About erectile dysfunction in...
    • Andropause: The origin of the problem is the declining rate of testosterone production by the testes.
    • Erectile dysfunction: The origin of the problem is due to an impairment of the vessels (atherosclerosis) or the nerves of the penis. Erectile problems may also be a side effect of drugs (such B-blockers) or of psychological etiology. Viagra, Cialis and Levitra are the main treatments for erectile dysfunction.

    Andropause and erectile dysfunction can coexist, especially since the frequency of these two conditions increase with age.

    The specific treatment of andropause is to provide testosterone so that man’s testosterone levels return to the physiological range, which can correct or improve his symptoms.

    I prefer to administer testosterone transdermally (gel) or orally (capsule). According to current scientific information, male hormone therapy given transdermally or orally in adequate doses is well tolerated, would not be hepatotoxic, and would not cause aggressive behaviour.  Fears that this treatment promotes the development of prostate cancer are currently not justified. Furthermore, the administration of bio-identical testosterone (e.g.: Androgel seems to have beneficial effects on the cardiovascular and cerebral systems, in addition to the proven positive effects on muscles, fats, bones and sexual function.

    As a clinical doctor and researcher in andropause and menopause, my goal is for men and women to benefit from the current medical knowledge by making it accessible to their health and general well-being.

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