Welcome to Our New World
When I started writing my Birth Book (available online), I began it with “Welcome to My World”. Our worlds have changed since then… Thinking about what to say now had me drifting off into many topics that I’d like to discuss, but instead I’ll try to focus on what is happening more immediately. We’re all living in a pandemic and political world that is changing our lives in so many ways…. Here’s what’s most relevant for us re: my practice
My decision to move to an office based ob/gyn practice has literally moved me to some new locations while the practice has developed. I am grateful to the docs who allowed me to share their offices and the friends and clients who have followed me on this adventure. I am now pleased to report that I have found and leased a new location that is all ours. Address is 240 La Casa Via, Suite 100, Walnut Creek, CA 94598. Turn onto La Casa Via from Ygnacio Valley Road as did those of you old enough to remember our offices across the street from John Muir Hospital; this time continue on La Casa Via past the hospital; just past the construction going on up the street look to the right side of the street and you’ll see a large white granite sign with the 240 address on it; turn in there and you will find parking. Go up the walk-way into the main atrium where the John Muir Wound Center is on the left and our office is on the right. Enter and we will happily greet you and begin your care. As you all know too well, medical care has had to take safety precautions to keep us all safe. Please wear your mask, maintain safe distances from others and practice good hygiene; hand sanitizers are readily available, and hopefully we will all be vaccinated soon. One of my patients sent me a cartoon of a woman on her hands and knees with her rear facing a computer and labeled the communication “Ob/Gyn 2020”!! The moral here however is that is very difficult to care for many ob/gyn patients and concerns virtually. My office has been able to continue in person care without problems; I have been vaccinated and will continue to provide for you as best I can while devoting the time to explain the status and plans for your care without having you feeling rushed in and out of the office. I am appreciative of the heroic work and efforts of other “front-line” medical and other providers who daily work through the life -threatening challenges we have had and remain exposed to. Your personal safety and care are our priority.
My office is able to provide evaluation and care of basic women’s health care and concerns with appropriate referrals for ancillary services and concerns that require a higher level of care. Vaginal pelvic ultrasound and gynecologic instruments are available for gynecologic concerns. Specifically we provide:
General and Annual gyn care including paps and mammogram referrals
Evaluation and treatment of abnormal or concerning pap smears
Evaluation and treatment of menstrual concerns or irregular vaginal bleeding
Individualized contraceptive counseling and management
Infertility or fertility evaluation, counseling and initial treatment as indicated and/or referral to higher levels of care
Individualized counseling and care for contraceptive failures or errors, unplanned first trimester pregnancies, or adoption referrals
Evaluation and treatment of sexually transmitted disease concerns
Initial evaluation and potential treatment of pelvic pain
Individualized menopausal or perimenopausal education, counseling and treatment
Please review the information available on my web site regarding menopause. As with most gyns, my patient population has aged with me. I have recently completed two extensive trainings in menopausal physiology and treatment options. During these trainings I have reviewed my prior understanding of menopause and its treatment options, and I now understand that many of the recommendations I had learned were based on older studies that are no longer relevant.
Menopause treatment options are systemic or regional. Regional options treat common local concerns such as vaginal atrophy related to estrogen depravation as the ovaries become depleted of eggs. Vaginal atrophy or thinning can be associated with vaginal discomfort with intercourse (dyspareunia) or increased vaginal discharge. Local vaginal estrogen supplementation can significantly reverse this issue. Vaginal estrogen treatments can help reverse these changes without significant systemic absorption and risks. Even patients with estrogen sensitive cancers can utilize these local treatments.
There are many estrogen receptors distributed throughout the bodies of women and men. Turning off these receptors by decreasing and eliminating estrogen production at menopause is associated with a myriad of symptoms and exacerbation of many acute and chronic disease processes including cardiovascular disease, dementia, rheumatism, osteoporosis, depression, prostate and other cancers, and a series of mood disturbances. Menopausal women and Andropausal men experience sleep deprivation, mood swings and disorders, a lack of sexual interest or ability to respond sexually, malaise, and general dysfunction. It appears that the God or Goddess in charge of hormonal function was “old school” and anticipated that humans would have been devoured by the dinosaurs before menopause or andropause developed…
We now live in an age where the life stage following menopause- (death) – is generally often delayed for over 30 years by advances in medical care and some improved health habits. The medical subspecialty related to “healthy aging” is now established and rapidly growing. Medical specialties promoting personal aesthetics and life styles are prospering. The many years after children leave the nest are increasing, and successful relationships can be revived and prosper personally and intimately with replacement and optimization of hormonal balances within the body. We will not live forever, but we can enjoy, learn and experience more of the benefits life has to offer. Yes life can be difficult, but if you’re able to pay attention, it is stimulating, exciting, rewarding and filled with love, hope, opportunity and promise. We cannot necessarily control it all, but we can control our response to it and what we pay attention to. Menopause no longer has to be a pre-death and disabling condition, but rather the “pause that refreshes”.
Many of the studies on which currently accepted menopausal treatment limitations are based were accomplished with outdated dysfunctional hormones, and their results were and are inappropriate. The primary Women’s Health Initiative Study published in 2002 utilized Premarin as its estrogen for study as it was the only estrogen readily available at the time.. Premarin is made from pregnant horse urine!! Receptors for this estrogen might be appropriate for pregnant horses, but they fall short of the bioidentical estrogens (the hormones with the same chemical configurations manufactured by the human body) available today…
Newer studies utilizing bio-identical hormones repudiate the findings of the older studies and demonstrate reversal of many of the symptoms and chronic disease progressions we have unfortunately come to inappropriately accept with menopause.
Bioidentical hormones are now commercially available in pills, creams, shots, sublingual trochees and pellets. Most of these estrogen delivery options can be relatively effective, but the estrogens are delivered erratically with associated rising and falling systemic levels, require ongoing scheduled dosing and are generally not as effective as pellets. Pellets are small bio-identical FDA produced hormones. Specific individually calculated prescriptions of potential estrogen, testosterone and progesterone are locally, quickly and painlessly introduced into abdominal or gluteal fatty areas in the office. These achieve a sustained individualized hormonal level lasting 3-4 months in females and 6-8 months in males.
Testosterone is generally thought of as “the main male hormone”, but women also utilize testosterone to turn on (or back on) hormonal engines throughout the body. Within cells testosterone is converted to estrogen and thus provides a safer method of turning on estrogen receptors and engines. Certain cancers including breast and ovarian can be stimulated by estrogens but not necessarily by testosterone. Testosterone has been used to treat breast cancer, but its use in this area has been generally been replaced by other more effective cancer cell destroyers. Pellets have been used clinically since the 1940s, and studies have shown them associated with a decreased incidence of breast cancer, Alzheimer’s syndrome, cardiovascular disease (the current #1 killer of men and women). Sexual libido and performance are improved along with mental focus, decreased depression and anxiety. You can’t even listen to CNN these days without hearing about the “magic” pill now available to men without even a doctor visit or exam…
Recommendations for use of hormone supplementation in men and women have been dramatically changing. Following the 2002 Women’s Health Initiative Study initial recommendations were for the lowest dose of hormonal therapy for the shortest time…. Risks of breast cancer and stroke were falsely demonstrated by the study and the cover of Time magazine displayed a frustrated concerned menopausal woman asking “
What do we do now??. Gyn offices were filled with menopausal women with this question and alternative less effective treatments were offered. It took only a few months before these same women returned symptomatic and demanding a better solution.
Many or most physicians have yet to be trained in and accepting of the benefits and newer recommendations regarding bio-identical rather than synthetic hormone replacement therapy. When I was in medical school there was even a major debate demanding the removal of the term hormonal replacement therapy and changing it to hormonal therapy. Insurance and drug companies now still send out regular notices to physicians warning that they are providing hormonal replacement to older women over 65. Many of these women return to their gynecologist or primary physicians upset because discontinuing hormonal replacements can often result in the return of menopausal symptoms including night sweats, painful intercourse (yes, “older“ women can still enjoy and participate in “intimate“ relationships they have developed over years of partnerships) and too often discontinuation of hormonal replacement therapy will result in reversal of the many other benefits these replacements have provided . These women often resort to obtaining hormonal prescriptions through various Canadian or other out of country pharmacies, thus saving costs for insurance companies and medical plans and passing them on to the patients. The results of pellet therapy are often life changing; men and women feel they have discovered- or rediscovered- a relative “fountain of youth”.
There are side effects and contraindications to the use of hormones. The most common side effects of testosterone are some occasional hair growth and acne, particularly in patients historically susceptible to skin or racial issues. My experience has been that such changes are minor compared to the benefits received and are generally resolved with an occasional plucked hair or rarely even laser hair removal treatments if indicated. Absolute contraindications currently are certain estrogen dependent breast, uterine or other such cancers or significant clotting disorders. Individuals with significant psychological issues such as bipolar or major psychiatric diagnoses or with other concerns noted will generally require co-management with their other primary providers.
As noted, there are medical, training, societal and organizational lags before the benefits of pellet therapy will be fully accepted and adopted by medical, legal, pharmaceutical, governmental and insurance agencies despite overwhelming studies and personal trials demonstrating safety and effectiveness when correctly administered (and not by radio adds rapidly mumbling disclaimers with the ads). Many recognized organizations are reviewing and altering their opinions and recommendations regarding bioidentical hormone replacement therapy. The American Heart Association has recently published regarding statements describing the significant negative effects of menopause on heart disease and the importance of initiating hormonal therapy soon after menopause for prevention of cardiovascular disease. The North American Menopausal Society has revised its recommendations from lowest dose for shortest interval to essentially what is felt to be indicated. Currently pellet testosterone therapy remains off-label use and is thus not covered by traditional insurances. There are however an increasing number of reputable medical companies and providers who have been trained by reputable and established companies as well as cohorts of women and men who have been impressed by the results they have experienced. I have personally been trained by Pellecome and Evexias, two of the major players, and have attended lectures by Bio-T, another long time provider and training company. Costs for these services for women are generally around $400 for pellet insertions which last 3-4 months and lab or counseling charges which may be reimbursable by insurance. Male charges are in the $800 range but last 6-8 months, thus making them comparable with female costs and compatible with ongoing daily coffee expenses. Patients generally easily get used to feeling and functioning better, and they are quick to call when the beneficial effects begin to wear off…
For those of you wavering, our office is offering a trial of a testosterone supplement injection for screened appropriate patients. This involves a simple injection of testosterone during a routine gyn exam and results in an abbreviated experience of some potential effects. This is like a “taste” rather than a treatment. Pellet treatments generally achieve significantly higher blood levels which peak at 5-6 weeks and are measured at that time to assist in future dosage treatments along with recorded symptomatic recorded experiences. Testosterone levels are maintained for 3-4 months in women and 6-8 months in men. Supplement injected effects will generally last 4-6 weeks and can be used to determine whether you want to move to pellet therapy.
Thank you for taking the time to share these experiences with me. I look forward to your visiting us at our new renovated office and continuing our shared care and experiences.
Louis Klein, M.D.