The patient: Mary, a youthful modern dance instructor in her late 60’s, wants to retain her vitality.
Why she came to see me: She’s been successful at dealing with the symptoms that have characterized her menopause by eating balanced meals and dancing vigorously in her classes and off-time. Now that her hot flashes are mild and rare and her mood is less challenged, she wants to be sure to maintain her muscle strength, flexibility, bone density, and sexual function. She was perplexed that, despite all that she was doing, vaginal dryness had become an issue. She has always enjoyed a passionate relationship with her husband and doesn’t want the changes commonly associated with menopause (vaginal dryness and low libido) to “stand in her way.” Mary had been researching non-pharmaceutical support for menopausal women and had many questions for me about supplementation and bioidentical hormone treatments that would be safe and effective.
How I evaluated her: I had her do an overnight fast prior to her initial one-hour appointment and asked her to bring past lab work results, a list of symptoms and concerns, and a listing of her diet and activities for the preceding week. In my physical exam of Mary, I focused on her areas of concern and on exam elements that were likely to have been ignored by her previous doctors. Some interesting elements of this exam included:
- A retinal exam to look for early signs of vascular plaque formation (most medical doctors leave this exam to the realm of ophthalmologists, but I believe that it should be part of the routine screening physical done by the general practitioner).
- Blood pressure evaluation, looking for issues with change in posture.
- A simple test for oxygen saturation involving speed of return to normal color of her nail beds following gentle compression.
- Pelvic exam. I performed a routine pelvic exam but added a feature to the PAP test called a “maturation index” that helps assess estrogen and progesterone adequacy.
We then chose which blood tests to run to screen for general health problems and agreed to have her collect a 24-hour urine sample to evaluate her current hormonal status. This analysis of both her sexual and adrenal hormones was necessary for helping her to maintain sexual function, bone density, and evaluate her future vulnerability. I also ordered a bone density study to be performed by a local diagnostic radiology facility.
How we addressed this problem: Mary and I reviewed her test data when she returned to my clinic three weeks later. The maturation index from her otherwise-normal PAP showed decreased hormonal effects—explaining her reporting dryness and mild painful intercourse. I prescribed vaginal suppositories of the hormone DHEA to remedy. The bone density results were somewhat low for a woman her age, showing mild osteopenia. Given her level of activity, we both thought that this should be addressed and improved upon. I prescribed a high-potency calcium-and-magnesium supplement and additional vitamin D. The levels of active hormones and related compounds as assessed in the urine test showed some lowered levels of hormones, for which I prescribed supplements with bioidentical hormones and other beneficial nutrients.
The patient’s progress: During our follow up visits, we worked on Mary’s diet, increasing protein intake…and exercise routines, recommending that she wear thinner footwear when she jogs to increase the bone-building benefit of this weight-bearing, high-impact activity. Her bone loss had stabilized when we repeated the bone-density scan after six months. She reported increased energy and stability and remarked that she had no further issues related to intimacy. In another six months, we will repeat the hormone panel and address any remaining findings. We plan to continue our sessions, both in-person and via telephone, at least every six months or more frequently if she feels it necessary, and to coordinate care with her other healthcare providers.