September 2010

Q. I need some advise on the type of doctor I should be seeing; my previous doctor had passed away and she was a family doctor. I have high blood pressure and I was seeing another doctor (an internist)for the past year and she could not get my B/P under control. She is now going to another practice. I have a very very difficult time with medicine and usually bad reactions. It seemed she would try to get my B/P under control but didn't seem she could handle other concerns that would come up. For instance I had a cold which turned into a respiratory infections then bronchitis, 3 months later and 5 antibiotics it finally cleared up.

Would you suggest I see a Family or a General Physician. I'm not sure an interinst is right for me. However, I do not know the difference in a Family or General Physician. I want someone that can handle other problems beside my B/P.

A. You are right that you need someone to help you manage your blood pressure and other medical problems. Although I am trained in Internal Medicine, an excellent Family Physician or Internist would be great for you. The bottom line is that your physician takes your concerns seriously, is willing to work with you in a collaborative arrangement, and is available when you need them. I know it is not always easy to find such a practitioner. An excellent nurse practitioner who collaborates with a strong physician would also be great.

Q. I RECENTLY READ YOUR BOOK (WHICH I THOUGHT WAS VERY INFORMATIVE) REGARDING WOMEN AND OUR NEEDS. I RECENTLY HAD A HYSTERECTOMY IN NOVEMBER 2008, I WAS DIAGNOSED WITH ENMETRIODOSIS. ALL OF MY ORGANS WERE REMOVED. I AM NOW IN MY SECOND YEAR OF SURGICAL MENOPUASE ( THE TERM YOU USE IN YOUR BOOK). i HAVE BEEN SUFFERING FROM VAGINAL DRYNESS, INSOMNIA, AND OTHER HORRIBLE MENOPAUSAL SYMTOMS.

AS I READ YOUR BOOK YOU WERE SPEAKING ABOUT DIFFERENT HORMONES YOU ARE TAKING, HOWEVER I HAVE A HIGH RISK OF CANCER IN MY FAMILY, MY SISTER DIED FROM BREAST CANCER AND MY OTHER SISTER WAS DIAGNOSED WITH OVARIAN CANCER. AS YOU SEE I CANNOT TAKE HRT ( SYNTHETIC ESTROGEN) I AM CONCERNED WITH HEART DISEASE, AND BREAST CANCER. MY DR. RECOMMENDED I TAKE ESTROVEN BECAUSE IT IS NATURAL, BUT NOW MY LIVER ENSMES ARE HIGH, SHE ALSO SUGGESTED I STOP TAKING NATURAL PROGESTERONE, SHE STATED DOCTORS DO NOT RECOMMEND PROGESTERONE AFTER MENOPUSE.

AS I BEGAN TO READ YOUR BOOK YOU STATED IN YOUR BOOK TAKING OF PROGESTERONE WITH ESTROGEN WILL MAINTAIN A SAFE BALANCE. MY QUESTION TO YOU IS WHAT DO YOU SUGGEST FOR ME? THE ESTROGEN I TAKE HELPS MINIMIZE MY HOT FLASHES AND NIGHT SWEATS, BUT DOES NOTHING FOR MY SEX LIFE, THE VAGINAL DRYNESS, AND PAIN. I ALSO NOTICED I DO NOT HAVE SEXUAL URGES ANYMORE, I DO NOT THINK ABOUT SEX, AT ONE TIME I LOVED SEX. CAN YOU PLEASE HELP ME?

A. You asked me a number of questions and will try to answer as best as I can. But first, how old are you? If you are young, less than 40-45 years old, I would agree that taking estrogen is important to reduce your risk of heart disease, osteoporosis, and improve the quality of your life. However your family history leads me to ask if anyone in your family was tested for the BRCA1 or BRCA2 gene? Did your parents or grandparents or other relatives have cancer of any type? Your sisters both had cancers that are common - and occasionally linked to the BRCA genes. If you receive genetic counseling and are test positive for the gene, then your decisions will be different.

Because you no longer have your uterus, you do NOT need progesterone and I too would advise you not to take it. There are side effects and there is no need for you to balance out hormones in a uterus since you no longer have it. if you are young and/or experiencing low estrogen symptoms, then estrogen in the "systemic: form - either patch or gel makes the most sense in the lowest dose possible - there are fewer side effects and less likely to impact your liver. However until your doctor diagnoses the cause of your abnormal liver tests, estrogen would be somewhat of a concern. A fatty liver from being overweight is a very common cause of mildly abnormal liver tests.

You present lots of pros and cons for estrogen - and I hesitate to give you specific advice as you can surely understand. I suspect much of your reduced libido is related to lower testosterone (from removal of your ovaries) - but unfortunately testosterone treatment in the form of a compounding pharmacy prepared plant based cream (commonly called bioidentical hormones) may also be a small concern until your liver changes are explained. Vaginal cream or tablets of estrogen would have little if any impact on your liver and concerns about your breast yet would help a lot with your vaginal dryness.

My best advice is that you see a specialist such as an internist who can work with you to get on the safest and effective regimen for you.