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Menopause: defined as the permanent cessation of menstrual cycles, which is confirmed when the woman has not had a period for one full year. The average age is of menopause is 51.
Peri-menopause: the time period preceding menopause, which begins approximately 3-4 years prior to the woman's final menstrual period (FMP). Oftentimes women may experience a number of physiologic changes that may affect her quality of life.
Hormone: a substance released into the blood stream at one tissue site that will travel through the blood to a distant site where it exerts it effects. We will discuss 6 hormones:
Bioidentical hormones: hormones that are have an identical molecular structure to hormones naturally made by your body. NaPro providers will recommend this type of hormone supplementation for many reasons discussed below.
Menopausal Hormone Therapy (MHT): the practice of replacing a woman's hormones to treat her peri-menopausal and/or menopausal symptoms. NaPro providers prefer bio-identical hormones.
EARLY PERI-MENOPUASAL SYMPTOMS:
- In the early peri-menopausal phase, estrogen is HIGH and progesterone is LOW (Hint! giving you bioidentical progesterone in the post-Peak phase of your cycle may make you feel much better).
LATE PERI-MENOPAUSE to POST-MENOPAUSAL SYMPTOMS:
-Towards the end of peri-menopause and once menopause has passed (no period for one full year) estrogen is LOW and progesterone is LOW (Hint! treatment may be replacing both estrogen and progesterone using bio-identical hormone. I will also pay close attention to your bone health and recommend screening for Diabetes as well as Cardiovascular Disease).
The Swan Study (Study of Women's Health Across the Nation) followed 3302 women ages 42 to 52 for fifteen years, as they progressed through their reproductive lifespan, through perimenopause (ie: "menopausal transition") and into their post-menopausal years. The research was conducted in multiple academic centers across the nation beginning in 1996, which resulted in over 600 publications and book chapters by 2021. There are several other articles currently pending approval.
In 2012, Dr. Siobán Harlow and colleagues developed the STRAW Staging System (STaging of Reproductive Aging Workshop), using the SWAN data, which is now considered the gold standard method of characterizing the stages of the woman's reproductive years though late post-menopausal years. The STRAW Staging system categories changes in the menstrual flow, hormone levels, number of ovarian follicles and vasomotor symptoms.
Reproduced with permission from :Harlow SD, Gass, M, Hall JE, et al. Executive Summary of the Stages of Reproductive Aging Workshop + 10: Addressing the Unfinished Agenda of Staging Reproductive Aging. J Clin Endocrinology Metab 2012. Copyright 2012 The Endocrine Society.
Your appointments at MyCatholicDoctor with me will be one FULL HOUR in length. Generally speaking, NaPro appts will follow a typical protocol as outlined below. However, every individual is different and your situation may warrant a more expeditious process. Please know, the Creighton Model System (CrMS) is very important. Your CrMS chart will help direct me to what diagnostic tests and imaging tests should be done and what treatment plan would be most appropriate.
First Appt: I will take a comprehensive medical history and provide you with education about normal healthy reproduction and oftentimes about a condition I suspect you may have after we have talked a while.
I will order a pelvic ultrasound which I will ask you to schedule on day 5 of your next menstrual cycle. I will order a series of laboratory tests. Click the "laboratory tests" button below to learn more.
If you are still having periods, you will be asked to begin charting your menstrual cycles using the Creighton Model System (CrMS). Please choose a Fertility Care Practitioner (FCP) by clicking the "Fertility Care Practitioners" button below. The goal will be for you to chart your cycles for two mos, then we will draw post-peak hormone panels. You can read more about the hormone panels on the Patient Handout page (Handout#3).
If you are not cycling or you are having only three periods a year, I would start you on bioidentical progesterone replacement right away, which can help many symptoms, such as: insomnia, irritability, anxiety and depression. I will have you take the progesterone from the 1st day of the month through the 10th day of month, to simulate a natural rise and fall of progesterone and to induce monthly "withdrawal bleeds", which will get lighter and lighter as time moves forward. Women almost always feel great all month, even when taking their progesterone only ten days every mos.
More importantly, the monthly withdrawal bleeds will protect your endometrium from thickening, a condition known as "endometrial hyperplasia". Endometrial hyperplasia can easily become a pre-cancerous or even a cancerous condition of the uterus. Preventing endometrial thickening is the primary reason for giving you progesterone for only ten days every mos.
I personally do not believe in prescribing progesterone on a daily basis, as this prevents withdrawal bleeds, and logically thinking, which will accelerates your risk of developing early osteopenia/osteoporosis. due to inducing a very low estrogenic state earlier in life.
Please consider joining me as I pray for you here.
Second Appt: You will be asked to return to the office in 2 mos for a follow-up appointment to review the results of your imaging and laboratory tests. Together we will also review your Creighton Model System (CrMS ) chart to look for specific biomarkers which will help me make a diagnosis.
Please upload an image of your CrMS chart two days prior to all follow up visits and send to me via the portal.
Please add the length of your post-peak phase and your mucus cycle score (MCS) to the R-hand margin of the chart. Your Fertility Care Practitioner (FCP) will calculate your MCS for you.
During this appointment, you may be asked to begin some supplements and/or medications. If you are still menstruating, we will also discuss drawing a full set of hormone panels. We will make a decision if you should have a peri-ovulatory estradiol panel, a post-Peak estradiol & progesterone panel, or both panels.
Hormone Panels:
Many patients will be asked to consider working with a dietitian or a nutritionist to help optimize your reproductive health. Oftentimes I may also recommend a mental health appointment to help with anxiety, depression and/or disordered eating habits.
Third Appt: You will return to the office in 2 mos to review the results of your hormone panels as well as the biomarkers on your CrMS chart. Most often at this time I will have made one or more more diagnoses to identify the root cause of your symptoms. Together we will discuss a treatment plan, which will be implemented.
Follow Up Appts: You will return to the office every 2 months. During this time, I will conduct a comprehensive medical interview to ensure your symptoms have resolved, and to ensure you are responding well and not having any negative responses to the management plan. Depending on the individual patient and your individual diagnosis, I may need to monitor your progress with serial laboratory tests and/or serial imaging.
At any point in time, if a diagnosis has been made, treatment initiated, and/or you are satisfied with the medical management we have implemented, you can schedule annual or biannual visits, per your choice.
I will be asking you to tell me very specifically how much you are bleeding. An example of a "detailed flow" is: M, M, H, L, L, VL/B
TAMPON or PADS:
MENSTRUAL CUP MEASUREMENTS
**The Diva Cup comes in 20, 30 and 32 ml cups 32 being the largest but other cups may vary. 1 ml = roughly 1 cc
Other important information about your flow:
Again, only bioidentical hormones supplementation is offered. I commonly prescribe prometrium capsules, which are taken orally. The generic brand is just as good and ot costs much less. Prometrium (micronized progesterone) is truly a bioidendical hormone formulation which can be purchased through a regular retail pharmacy. This medication is generally well-tolerated. Some common side effects are quite pleasant, eg: you may feel more relaxed or sleepy and your might find your mood may improves. Some more unpleasant side effects may be: next-day fatigue, nausea, headaches, or dizziness. Most often the unpleasant side effects can be easily managed by taking the medication right before you lay your head down on the pillow and/or changing to a compounded formulation. Please know prometrium and generic progesterone capsules contain peanut oil, so you CANNOT take this if you have a peanut allergy.
Sometimes the Prometrium or generic micronized progesterone that is purchased will include a package insert which will "warn" of possible birth defects. However, this warning refers to progesterone substitutes that are often prescribed in oral contraception pills, not the bioidentical progesterone we are prescribing. NaPro providers, who were trained at the St. Paul VI Institute, have been safely prescribing micronized progesterone to many, many women to support pregnancies for over 35 yrs and they have not encountered problems.
If the oral medication is not strong enough or if the side effects are bothersome, we can try a vaginal suppository. This will be prescribed for you by a specialty pharmacy called a "compounding pharmacy". You can see a list of compounding pharmacies by viewing Handout #21 here.
Sometimes we will have to use progesterone injections. I will ask you to watch this instructional video and choose someone such as your spouse or a close relative who is willing to administer the injections to you. I would also recommend injections be administered in the upper-outer quadrant of the buttocks (shown in the video) and that you alternate sides. Common side effects of the injections are: soreness, itching and/or mild bruising at the injection site, especially if the injection is done too quickly.
Naltrexone (off-label use):
I do occasionally use the full 50 mg dose of naltrexone only in very severe cases. Most often I will recommend "Low-Dose Naltrexone" (LDN) for you namely b/c there has been some discussion among the medical community that if a patient has been on full dose naltrexone for many years, this may present a conundrum if the patient needs opioid medications to control severe pain, such as after a surgery or after a significant injury has been sustained. The concern is twofold:
My recommended treatment for most cases:
We would start at a very low dose and slowly titrate up to 8 mg and see how you feel. The 8 mg dose may be enough for most women. Again, in rare cases, we may continue uptitration to the full 50 mg dose. Naltrexone can only be purchased with a prescription. The Low doses capsules (4 mg to 8 mg) are only available through a compounding pharmacy. You can view a list of
compounding pharmacies that I frequently work with here.
A typical treatment titration regimen would be:
Rx# 1: naltrexone 4 mg:
#30 pills total for Rx # 1.
Rx#2: naltrexone 8 mg:
#60 pills total for Rx #2.
Rx#3: naltrexone 50 mg (available at either retail pharmacy or compounded)
#30 pills total for Rx #3.
*** If we agree on using the full dose, I will document you have been educated to the risks as noted above, and you would like to take this risk. Also, we would plan to use the full dose for only 4-6 mos.
Low dose naltrexone- Effects on medication in rheumatoid and seropositive arthritis. A nationwide register-based controlled quasi-experimental before-after study (pdf)
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DownloadCochrane Review- Low dose naltrexone for induction of remission in Crohn's disease (pdf)
DownloadSafety and efficacy of low dose naltrexone in a long covid cohort; an interventional pre-post study (pdf)
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