Until the results from the Women’s Health Initiative became known, one can say that the most basic premise of improving the health of women during midlife was the preventive treatment with hormone replacement therapy (HRT). Estrogen treatment was believed to prevent osteoporosis, heart disease and, possibly, many other ailments of middle and old age, such as Alzheimer’s disease and others. Yet, the data from the Women’s Health Initiative, even if still somewhat controversial, dampened the enthusiasm for HRT to a very significant degree because they suggested that estrogen therapy neither prolonged life, nor significantly decreased overall disease. Indeed, the opposite appeared to be the case: routine HRT appeared to increase certain risks.

The consequence was one of the most radical shifts in national health care guidelines, when the prior recommendation, - of HRT for everybody-, practically overnight changed to a recommendation which states that HRT should be offered in the lowest effective dose and for the shortest period of time possible. Moreover, HRT should be consistent with a woman’s individual treatment goals (i.e., her own, specific needs) and risks (i.e., her own, specific medical circumstances), and therapy should be periodically reevaluated (i.e., changes in individual risk/benefit considerations have to be considered on an ongoing basis).

MRI, of course, in principle follows these guidelines. We, however, also very strongly believe that many symptomatic women will greatly benefit from HRT and we, therefore, have no hesitation to prescribe HRT when we feel it is indicated. Where our approach, however, differs from that of many others, is in the individualization of care and follow up, which our patients receive. For example, we will not prescribe HRT without first assuring ourselves that there are no medical contraindications in a given patient. Such assurances will require that we evaluate risk factors in every patient before a prescription is issued. In cases of hormone replacement, this may include the testing for thrombophilias, to detect a risk for blood clotting, the evaluation of lipid profiles, to define cardiovascular risk, the evaluation of liver and renal functions to assess the body’s ability to eliminate drugs in timely fashion, etc.

Every medication has potential side effects. Long term follow up is, therefore, essential whenever a medication is prescribed for longer periods of time. At MRI, your treatment will determine your follow up schedule and you will never be left unattended for prolonged periods of time, without anybody assessing your progress.

The prevention of bone loss clearly represents one of the most important preventive services for the middle aged woman. In a 2004 publication the U.S. Surgeon General estimated that 34 million women in the U.S. suffer from osteopenia and 10 million from outright osteoporosis. The former is, of course, a milder form of bone loss, while the latter represents the more severe, end stage of loss of bone mass. Bone mass can be measured through the evaluation of bone mineral density (BMD) in selected bones. BMD is believed to be normal if it lies within one standard deviation (SD) of mean for young adults. A woman is considered to suffer from osteopenia if she is 1-2.5 SD below the young adult mean and suffers from osteoporosis if her BMD is more than 2.5 SD below that level. If, in addition, she suffers from fragility fractures, she is considered to suffer from severe osteoporosis.

Each year, approximately one million women suffer osteoporotic bone fractures, many resulting in life-long disabilities, some even in death. The financial toll on individuals and society, in general, is, of course, enormous.

The prevention of bone loss in middle aged women is, therefore, of considerable importance. Fortunately, this has been well recognized by government and industry over the last two decades. Modern instrumentation allows now for a more accurate diagnosis of bone mass through bone densitometry and the pharmaceutical industry has developed a variety of remedies which now allow us to treat bone health much more successfully. Patients at MRI will receive a proper diagnostic work up, followed by appropriate medical therapeutic support, to assure maximal bone health for the long-term.

Breast cancer screening is another major responsibility in the middle-aged woman since breast cancer represents, of course, the single most frequently diagnosed cancer in females of this age group. Like with many other malignancies, the prognosis of breast cancer is closely linked to how early in the disease process it is found. In contrast to many other cancers, however, breast cancer does lend itself to early diagnosis. Consequently, while we do not intend to usurp the diagnostic prerogatives of primary physician in the area of breast disease, we see it as our responsibility to reconfirm that MRI patients follow a maximal breast cancer screening protocol, involving regular self- examinations, breast examinations by qualified physicians, mammography and other ancillary testing, where indicated.

Preventive services, of course, also include the maximal prevention of cardio-vascular disease. After menopause, women are at increased risk to develop coronary artery disease and, indeed, the mortality from myocardial infarction in women exceeds that of males. For many years, HRT was believed to protect women from cardio-vascular events. This very general assumption has, however, as we discussed above in more detail, recently been questioned by the Women’s Health Initiative. A more recent study added, however, a level of complexity to the results from the Women’s Health Initiative when it suggested that patient selections in the former study may have biased results. This newer study, indeed, suggests that HRT may not be that bad for the female heart, after all, since the effects of HRT on the heart appear to vary, depending on the female age when HRT is first prescribed.

These findings are potentially of great importance because preventive efforts to minimize the risks from cardio-vascular disease should, of course, be aggressively maintained in women of perimenopause and menopause. The most recent data now, turning the results from the Women’s Health Initiative once again on their heads, suggest that HRT, if given at still relatively young ages (i.e., when most needed to quell symptoms in the perimenopausal period) may, indeed, be cardio-protective after all (see also “What Important Studies Suggest” above). Only when give later, 10 or more years after the onset of menopause, does HRT really appear to increase the risks of cardiovascular events.

The maintenance of cardiovascular health, however, depends on other factors, as well. In another study of the Women’s Health Initiative, published in February of 2006, this government-sponsored research effort, once again, appeared to create a level of confusion within the scientific community, which then, of course, carried over into the lay media and the public. In a study, due its size (many thousands of women), costs (hundreds of millions of dollars) and length (eight years) widely touted as the ultimate study study on the topic, investigators concluded that a low fat diet, in comparison to an average fat diet, did neither reduce in postmenopausal women the risk of heart disease, nor the risks of either colon or breast cancer. Like prior studies from the Women’s Health Initiative, this study was, however, immediately attacked by other experts for its design since the reduction in fat intake in the study group was, by many, considered inadequate. Critics of the study, therefore argued that, based on such a minimal reduction in fat intake, one, indeed, could not expect to see outcome changes in only eight years of follow up.

Preventive care, therefore, still should involve the monitoring of blood lipid levels (and, if elevated, their treatment). Equally important is, however, the prevention of dangerous drug interactions, the search for thrombophilias and, in general, the promotion of a healthy life style of good nutrition and exercise.

Preventive services, however, also extend to other aspects of general health, such as skin, eye and dental care, weight maintenance, dietary restrictions, plastic surgery, exercise, relaxation techniques, psychological support, Yoga, Pilates and other medical services which will contribute to an overall improvement of well being for the middle-aged woman. MRI, of course, cannot offer all of these services on site. However, through affiliated organizations (see “Affiliates” below) we have established many collaborative arrangements, available to our patients upon request.

We place special emphasis on discovering genetic risks towards breast cancer, often found in high risk populations, such as Ashkenazi Jews, and in women with close family members who have come down with breast malignancies. In such patients we recommend aggressive genetic testing and enhanced monitoring, or even prophylactic breast removals, where an elevated genetic risk has been confirmed.