1. Medcan Women’s Health Forum It’s The Menopause! Wilfred M Steinberg MD FRCSC University of Toronto St Michael’s Hospital

3. It’s a New World

4. What Does it All Mean?

6. When Does It Start? Or End?

7. Perimenopause…not a disease

8. What Changes Occur in the Menopause ? Smith T, et al. J Soc Obstet Gynaecol Can 2001 Urogenital atrophy Menopausal symptoms Vasomotor symptoms Mood disturbances Bone loss and fractures Cardiovascular disease Alzheimer’s disease Breast cancer Colon cancer

9. Progression of Symptoms

10. Are you aware?

11. Cognitive Changes

12. Body Changes

13. Range of Emotions

14. Anyone you Know?

15. Menopausal Changes?

16. Some Weird Changes

17. Unappreciated Symptoms

18. Can I Still Get Pregnant?

19. Fertility Rates & Age

20. Who are you going to trust?

21. Does this resonate for you?

22. Be an Intelligent Consumer

23. Plants for menopausal Rx Isoflavones Have estrogen-like effects, so …be aware.. Black Cohosh, Wild Yam Soy

24. Herbs: Traditional and Chinese

25. Myth #1: “Natural Hormones are Safer :

26. Myth #2: Compounded Bioidentical Hormones Work Better than Brand Rx Hormones. There is no scientific support for an advantage of these compounds over common commercially produced preparations. Mary M. Gallenberg, M.D Mayo Clinic Mary M. Gallenberg, M.D

27. Natural Hormones -FDA H&W Approved

28. Newton KM, et al. Ann Intern Med 2006;145:869-79. Reproduced with permission. Multibotanical + soy Multibotanical HT * * 8 7 6 5 4 3 2 1 0 Baseline3 mo6 mo12 mo Vasomotor Symptoms Per Day * * * Placebo Black cohosh What really works? 351 women Adjusted mean number of vasomotor symptoms per day, by study group

29. My Favourite Natural Treatment

30. Non Hormonal Remedies Significantly reduced the number of hot flushes compared with placebo 66.6% reductions from baseline Hot flush severity and number of nighttime awakenings were significantly reduced American Journal of Obstetrics & Gynecology, February 2009

31. Myth #3: Since Compounded Bioidentical Hormones Are Natural, They are Safer Than Other Hormones.” They're produced in doses and forms that differ from those in FDA- approved products BUT..with no quality assurance standards

32. KEEPS: Kronos Early Estrogen Prevention Study 2012 Estrogen and progestogen therapy started soon after menopause, not only relieve symptoms, but appear safe. No increase in blood pressure, no effects on atherosclerosis, No increase in breast cancer or uterine cancer, No effects on blood clots associated with stroke and myocardial infarction.

33. Options :Menopausal Symptoms Lifestyle changes:.some benefit  Regular exercise, diet, nonsmoking, moderate alcohol, BMI <32 Herbal remedies:..minimal benefit  Dong quai, ginseng, black cohosh, soy isoflavones, red clover, Goji j Medical therapies:major benefits  Estrogen, progestin,  gabapentin, clonidine  SSRI / SNRIs

34. 7-year ET* 5 years of CCEPT use 10 years of CCEPT use 15 years of CCEPT use Late menopause (10-year delay) Body mass index (BMI) (10 kg increase) Alcohol consumption (2 drinks/day) Lack of regular exercise Weight gain after menopause (20 kg or more) * Risks for Breast Cancer in Perspective * Baseline no HT use 45/1,000 women 50–60 years† Additional cancers per 1,000 women 0 20 30 10 40 50

35. Healthy is the New Sexy

36. In postmenopausal women, the quality of the relationship and the presence of sexual problems in the partner are probably as important as are hormonal change in the maintenance of sexual interest and response.

37. What Else May be Going On? urinary incontinence, depression, dementia, arthritis, stroke and breast cancer Family crisis

38. Menopause or Depression? loss of or diminished sex drive lowered sexual desire and sexual activity loss of energy fatigue lethargy tiredness lack of concentration

39. Vaginal Atrophy Thick, healthy, well-estrogenized lining of the vagina Thin, dry lining of vagina due to menopause (after estrogen loss) superficial parabasal intermediate The North American Menopause Society. Menopause. 2007;14:357-369

40. Most Important Sex Organ in Women

42. What happens 5 years after menopause?

43. Testosterone For Post Menopausal Women?

44. Androgel Off Label Use in Women AndroGel contains testosterone, a Schedule III controlled substance as defined by the Anabolic Steroids Control Act. AndroGel is supplied in non-aerosol, metered-dose pumps.. AndroGel is also supplied in unit-dose aluminum foil packets in cartons of 30

46. Hot Then(1959) Still Hot Now (2014)