Dearest: My guest tonight is OB-GYN, Dr. Phillip Warner, M.D., Power Surge's very popular, "Ask Dr. Warner." Dr. Warner has been in private practice for 30+ years. He is the former director of the Menopause Institute of Northern California. Today, Dr. Warner practices at The New Dimensions Medical Group near Sacramento, California. He is a Diplomat of the American Board of Obstetrics and Gynecology, a member of the North American Menopause Society, and has done clinical research for the pharmaceutical industry.

Dr. Warner's special interest is in hormone imbalance therapy. The use of hormones when indicated, should be in the form of bio-identical hormones, which are natural to the human female. He found that a number of his patients did not respond well to the standardized treatment. By individualizing treatment, Dr. Warner was able to dramatically improve his patients' quality of life. Much of Dr. Warner's career has been spent empowering women through education and individualized treatment to stay healthy with alternative therapies including nutritional supplements, herbal therapy, acupuncture and good dietary intake. These therapies, combined with weight control, exercise regimens, stress reduction and avoidance of toxic substances, can lead to a longer symptom-free post menopausal life.

Dr. Warner wrote: "The prescribing of oral Premarin by physicians for estrogen deficiency has evolved over the years as an automatic "Pavlovian" response without any thought to giving individual treatment. Premarin is not a "natural" substance in human consumption, nor is it the best choice of treatment despite its wide usage. The notion that a substance derived from horses is "natural" to the human female is a tribute to 50 years of successful advertising." Dr. Warner's commitment to research, patient education, and individualized treatment, led to his current role providing specific consultation to patients.

You've been graciously giving of your time for five years to answer questions as Power Surge's "Ask Dr. Warner," so it's truly a pleasure to finally welcome you to one of our guest chats and talk to you in person!

Phillip Warner, M.D.: Thanks so much for asking me. It's great to be here.

Dearest: Dr. Warner, let me start off by asking you what the difference is between synthetic hormone therapy, such as Premarin, PremPro and Provera and naturally compounded bio-identical hormones.

Phillip Warner, M.D.: The main differences between the commercial preparations as you mentioned and bioidentical hormones are that the bioidenticals are processed from plants and the hormone is identical in molecular structure to the human hormones. Therefore, what goes into the body with bioidentical hormone use is identical to what the body was making.

When Premarin and other counterfeit substances are used, they may cause long-term health problems such as increased heart attack risk, increased stroke risk and increased breast cancer risk.

Dearest: I've noticed that PremPro is doing a great deal of advertising again. I wonder if we've learned from the abrupt halting of the WHI (Women's Health Initiative) Study (which used PremPro) in 2002 which was to continue to 2005. Do you think it's changed the way conventional health care practitioners treat and prescribe for their menopausal patients, or now that the initial "scare" is over, are doctors minimizing the significance of the findings of the WHI Study?

Phillip Warner, M.D.: You ask an excellent question.

I feel that the significance of these findings may be modified by the fact that the emphasis is on the counterfeit hormones such as PremPro and should be taken for only the shortest period of time and the lowest dose. The smallest possible dosage is 0 (zero) and the shortest time is 0 (zero), so they shouldn't be used at all.

There should be no reason to use these counterfeits when we have the bioidenticals which can be prescribed by any physician. These will help prevent any long-term problems and alleviate symptoms.

EastKilbride: Is dry burning mouth related to menopause? I take estrogel and progesterone cream but it doesn't help the dry mouth. This is my only problem. Any solutions?

Phillip Warner, M.D.: Dryness of the mouth can be due to a variety of causes. A visit to the dentist would be in order.

Deficiency in human estrogen, especially estradiol, can effect mucous membranes. Dryness of the vagina, the bladder which can cause painful urination and dryness of the lining of the eyes which can cause eye pain and problems with contact lenses.

Dryness of the mouth can be a factor of estrogen deficiency, but it can also be a side effect of many medications and drugs.

Dearest: Which brings me to the question - don't you think that every woman should NOT automatically attribute everything she's experiencing during her perimenopausal years to menopause?

Phillip Warner, M.D.: I think if one is assessing the problems of any patient, she is presenting an array of symptoms. It is possible that these symptoms can occur due to a multitude of problems. If she is perimenopausal or menopausal, there are symptoms that are commonly occurring and are attributable to deficiency in hormones. The doctor must decide if the patient's symptoms fall within the category of things we see during perimenopause or menopause.

The bottom line is that when one gives bioidentical hormones and the symptoms subside -- that is the final proof.

Kvan: I had surgical hysterectomy at age 45. I am now 46. My doctor prescribed the Vivelle Dot patch supplemented with soy. Any suggestions? This seems to be working, but what is the longevity of taking it?

Phillip Warner, M.D.: Were your ovaries removed?

Kvan: Yes.

Phillip Warner, M.D.: Since your ovaries were removed, you are menopausal and have no production of estrogen, progesterone or testosterone from the ovaries. It is important to replace these hormones.

The Vivelle patch uses estradiol, which is a good thing. However, there is no testosterone or progesterone in that patch, so there is still a deficiency in the other hormones. And a patch does not have the proper absorption physics to allow the hormones into the body.

The most important thing is that you have not replaced all of your hormone deficiency with the patch. The best form of treatment for menopause, especially after surgical menopause, with the ovaries removed, is to use bioidentical hormones by prescription in exact doses tailored to you as an individual.

Again, the hormones should include estrogens, progesterone, and testosterone given in the best method that suits your particular problems.

JoannaRosa: I started perimenopause at 45. I am now 49 and have not had a period for 2 years, but I have severe migraines since 45, what can I do for the migraines?

Phillip Warner, M.D.: You have raised the issue of migraine headaches in a menopausal women and that brings up a very interesting area of discussion.

First of all, headaches, in general, are many types. You have to be sure that you're dealing with migraines, not from other sources. If we're going to look at migraines due to hormonal difficulties, they should be cyclic and occur at a specific time in the menstrual cycle. If a woman is menopausal, the headaches may take on a different occurrence and may be daily. They are generally due to a decreasing level of estrogen production, or an absence of production of estrogen.

Over many years, I have dealt with hundreds and hundreds of migraine patients. I have prescribed estradiol and it will alleviate the migraine headaches. Estradiol is the bodies own Imitrex, which is a drug that is commonly prescribed. Imitrex was patterned on estradiol and works on the blood vessels to the brain.

JoannaRosa: I get the headaches 4 to 5 times a week, I take Cafergot, it works most of the time, should I try Estradiol?

Phillip Warner, M.D.: Cafergot is another prescription drug which uses ergotamine with caffeine. It is not as effective as Imitrex but works in the same way.

Once again, estradiol does a better job than either of these drugs.

MRB: I didn't have a period for 6 months and now I have been bleeding for 3 weeks. Is this normal and would I be a good candidate for natural hormone treatment? I am 52.

Phillip Warner, M.D.: At 52 years of age, you are a candidate for being menopausal. Because you've been bleeding for 3 weeks, you are most likely deficient in progesterone production but are making estrogen in small amounts. This is quite common in the process of having the ovaries shut down.

You would benefit from bioidentical progesterone in the correct dose which will stop the bleeding. However, you must be very careful to rule out a problem with the uterus itself such as a tumor, a polyp or some other abnormal condition. Checking for these is indicated before starting bioidentical hormone replacement.

Dearest: We know that during perimenopause, especially, women can have erratic periods / excessive, heavy bleeding. At what point does heavy bleeding fall into the "excessive" category and when should women with excessive bleeding contact their health care clinician?

Phillip Warner, M.D.: Excessive amounts of bleeding can be different for different people. If it causes a lower blood count, that is excessive.

If it is persistent, such as daily or almost daily, or very heavy, it is more suspicious of problems in the uterus and would require a visit to the health care practitioner.

I don't think anyone can put a number on the days of bleeding. The word excessive has to be attached to whether it is effecting the person's blood count. It is a nuisance, though.

MsApples: All my female genitalia is disappearing, more everyday. I have had no intercourse for 3 years because of pain. My hair is half gone. I have been using bio-identical hormones for 6 months now. I had a total hysterectomy in 1993. Do you have any theories?

Phillip Warner, M.D.: You are menopausal with an estrogen deficiency. You need to have your hormones replaced in adequate amounts for YOU to replace your vaginal response and loss of hair.

SunnyFlorida: Will bioidentical hormones interfere with Synthroid or change the dose you need? My major complaints are vaginal dryness, weight gain, slightly anemic. No periods for 8 years. I've never been never on hormones other than Estring.

Phillip Warner, M.D.: Bioidentical hormones are referring to using estrogen, progesterone and testosterone - the ovarian hormones. They do not exert any effect on the use of any thyroid replacement hormones.

However, progesterone, specifically, can accelerate the benefits from thyroid replacement and result in a decrease in the dosage of the thyroid medications

Dearest: Dr. Warner, under what circumstances would a woman NOT be a candidate for any type of hormone therapy?

Phillip Warner, M.D.: I am so glad that you asked this question.

I will describe for you the patient who will not need hormone replacement therapy. She is menopausal. She has a genetic background where her parents and grandparents lived into their 90's. She is disciplined and exercises regularly. She is a vegan, so has no excessive saturated fat intake. She is happily married to a wonderful husband and children who have turned out perfectly well. She is perfect, has no stress and is not in need of hormone therapy.

In my 40 years of OB-GYN practice, I have never met this woman!

Dearest: So, for the woman who isn't *perfect* as you describe, you believe that most women who are peri or postmenopausal should be on bioidentical hormones?

Phillip Warner, M.D.: I do believe that is the case, but of course, one has to look at the individual patient for contraindications. Remember, we are talking about using only hormones that the woman has already produced. It is difficult to think of any medical condition that would be harmed by having the woman's own normal ovarian production returned.

To take this one step further - if there is such a medical condition, and the woman is not menopausal, the indication would be to remove the woman's ovaries.

Dearest: So, for women with a history of gall bladder disease, blood clots, family history of stroke, heart disease, et al - you're recommending bioidentical hormones in proper doses. Please elaborate.

Phillip Warner, M.D.: The absence of ovarian hormones, menopause, results in long-term health risks. The absence of ovarian hormones results in long-term health risks such as increase in heart attack risk, breast cancer, colon cancer, stroke, Alzheimer's, mental deterioration.

The leading cause of death in women after the age of 60 is not breast cancer but heart attack. The reason for that is that the woman is deficient in her own estrogen.

When that is treated with counterfeit hormones such as PremPro, the risks are increased as shown by the WHI (Women's Health Initiative) study. When one uses proper doses of bioidentical hormones, the risks are decreased.

So, the greater the risk in a menopausal women, the greater her need for a bioidentical hormone replacement. This has been proven again and again. Women without estrogen have heart attacks much more often than those with.

Mar1554: I am on Tri-Est via my internist after I did all of the research. I need testing now and need to know how to proceed. What testing might be indicated? I had an hysterectomy (uterus only) at age 25. I am 54 now. How long should I stay on the hormones?

Phillip Warner, M.D.: Once you are menopausal, ovaries shut down or removed, you are menopausal forever. The ovaries never restart. Therefore, you need to have your hormones replaced forever.

TriEst is 3 estrogens. The E1 (estrone) is not desirable now, so we usually prescribe Biest which is estradiol (E2), and estriol (E3).

Mar1554: Is periodic blood or saliva testing needed?

Phillip Warner, M.D.: No, we go by the symptoms of the patients, not blood or saliva samples.

EastKilbride: Is Estrogel bio-identical? Is Bi-est or Tri-est a better HRT? I have been on HRT for 7 years and am 50 now. How much Androgel is safe to take? I took it and my levels went very high (30). I took one patch a day which was too much.

Phillip Warner, M.D.: Estrogel is a new product made by Solvay Pharmaceuticals. It is bioidentical estradiol and can be used by rubbing on the skin. It is no better or worse than other bioidenticals but its dose is limited by what the company puts in the container. The cost is much greater than hormones from compounding pharmacies. If you have insurance, and your co-pay is small, it might be less expensive.

Androgel is bioidentical testosterone and is limited in range but it's only available in pre-determined doses which cannot be individualized.

CKVK43: I am having bone-chilling coldness. Is there such a thing as a cold flash with no feelings of heat? My thyroid is normal. I just started Vivelle and compounded progesterone. I am deep in perimenopause. I have also had hot flashes.

Phillip Warner, M.D.: Cold flashes aren't part of perimenopausal symptoms. However, if they're preceded by times of warmth, they are like the person who has sweated and the evaporation can cause coldness.

Other than this, see your internist or medical practitioner.

Marlo: HI! I have been menopausal for six years in July. My hot flashes are subsiding. I drink Revival Soy. My problem is my off balance feeling and my joints hurt. I want to start on bio-identicals, but I have a few varicose veins in my leg and on my foot. I am afraid of blood clots. Also have a PVC (Premature Ventricular Complex), but are bio-identicals good for the heart? How about the progesterone cream?

Phillip Warner, M.D.: Progesterone cream is very good for varicose veins.

Revival Soy is an excellent source for menopausal symptoms.

Varicose veins aren't a contraindication for bioidenticals but rubbing the progesterone cream directly on them can help.

Dearest: Curious, but would you recommend other modalities of bioidentical hormones, such as transdermal, sublinguals, patches, etc., as opposed to taking a pill - due to the way it's digested and absorbed by the liver via the first pass?

Phillip Warner, M.D.: In using bioidenticals, you must individualize the dose to the patient and the modality of therapy. Absolutely, we use non-oral preparations when indicated.

Only about 50% of hormone replacement patients swallow the pills successfully. The main alternative modalities that we use are sublingual tablets and transdermal preparations.

Dearest: Dr. Warner, wonderful answers! Thank you for taking the time tonight to field our questions about menopause, hormones and related midlife health issues. If anyone has additional questions for Dr. Warner, just point your Web browser to www.power-surge.com/asktheexperts.htm. If you're interested in a visit to Dr. Warner's Sacramento office, you can call him at 530-749-8511.