News June 20, 2006 Position Statement June 2006 ANZCOG Male to female transsexualism - Word document Male-to-female transsexualism: Laparoscopic pelvic floor repair of prolapsed neovagina Australian and New Zealand Journal of Obstetrics and Gynaecology 2006; 46: pp254-260   Laparoscopic hysterectomy and ureteric injury References will be supplied on demand May 18, 2005 Comment on WHI-May 2005 September 11, 2004 Today is the anniversary of the destruction of the World Trade Centre in New York and the loss of so many lives. It is then with great pleasure that I seek to redress the balance of such a bad memory with good news that has the capacity to save lives. My research into the effect of testosterone on breast cancer incidence has been published and the full text article is to be found on this website. In addition, Professor Gelfand has written in the same journal an editorial that is supportive of the findings. The research findings do not prove that the addition of testosterone in women taking hormone therapy will reduce their breast cancer rate to normal, but rather is strongly suggestive that this may be the case. Proof of this contention will be difficult and expensive and will be a long time coming. In the meantime I am happy to work on the assumption that testosterone is effective in making HT safer and the woman taking oestrogen may feel reassured. If my conclusions are correct, then there is no need to limit the duration of exposure to HT to five years as has been widely suggested. One other finding should be noted and that is the apparent effect of progestogens. Progestogens are given to protect the woman against oestrogen induced uterine cancer. The evidence is increasing and supported in my research findings that while progestogens may protect against uterine cancer, they increase the risk of breast cancer. This adverse effect is through the direct stimulation of the breast and by interfering with the protective effect of testosterone. The answer to this dilemma apart from the obvious solution of hysterectomy is to place a Mirena* intrauterine system into the cavity of the uterus. This has the effect of bringing the progestogen into the organ where it is required rather than soaking the whole woman with the hormone. Links to the article and editorial are, Breast cancer incidence in postmenopausal women using testosterone in addition to usual hormone therapy Menopause: The Journal of The North American Menopause Society Vol. 11, No. 5, pp. 531-535 It might be wise to consider adding androgen to the estrogen or estrogen-progestin regimens in the appropriate patients Menopause: The Journal of The North American Menopause Society Vol. 11, No. 5, pp. 505-507 ABC Study (56kb) ABC Study Editorial (40kb) September 11, 2003 Position Statement Rev 10/09/03 ABC Study Poster Final Revision July 1, 2002 Testosterone Titbits March 21, 2003 The data on the apparent beneficial effect of testosterone in reducing breast cancer in women on HRT has been accepted for presentation in America.  These data will be placed before the annual meeting of the Endocrine Society in Philadelphia in June this year.  I hope to be there in person to explain the outcome of the Study. The title of the paper was: Breast Cancer Incidence in Australian Women Using Testosterone in Addition to Estrogen Replacement.   March 13, 2003 It has been a busy six months as we dealt with the issues arising from the WHI Trial publication.  Happily the new knowledge arising from the trial has now been assimilated into practice and a new confidence is being restored to the use of Hormone Replacement, or as it has been renamed ‘Hormone Treatment’ (HT). There are some new products that I would draw to your attention.  The MIRENA intrauterine system has now been placed on the PBS.  This is a useful progestogen bearing ‘IUCD’ that replaces the need to take progestogen by mouth and avoids thereby the common side effects of that medication.  It has the added benefit of being contraceptive and deals effectively with that worrying uncertainty of fertility in the perimenopausal years. The IMPLANON device for contraception in the younger woman has risen in popularity to become ‘top of the pops’ and perhaps this is because of it’s convenience lasting for three years, being very cheap, and should enable most women to become free of menstrual bleeding. Transdermal testosterones are in development and currently under trial.  These are both skin patches and oral sprays not to mention of course the skin creams that suit women looking for a ‘softer’ effect than implants.   September 2, 2002 Further Reflections on The Women's Health Initiative Trial Result Essentially this trial was stopped because of the rise in the rates of breast cancer but at the same time, perhaps to some people’s surprise, the rates of coronary artery disease and stroke rose rather than fell. The initial and essential point to understand is, to ask oneself whether this was a primary preventive trial or a secondary preventive trial. All of the scientific and observational evidence in the past has pointed towards a protective effect of oestrogens in the development of cardiovascular disease. Following on the HERS Trial however, there may have emerged the understanding that the woman who already has cardiovascular disease may not be protected in quite the same way. The latter would have been an attempt at secondary prevention after the disease has become established, in contrast to the scientific evidence for primary prevention in a woman who has clean arteries. What type of study was this WHI Trial? It is essential to look at the sort of woman who was recruited into this trial. It should be firstly understood that the average age at recruitment was 63 years and going up to the maximum age of recruitment of 79 years. These were not younger, immediately menopausal women but an older group of women in whom the expectation might be that they already had cardiovascular disease. There are other patient characteristics that would be of concern. 50.4% had previously smoked cigarettes, or were currently smoking. 69.5% were overweight in terms of a BMI of greater than 25, while 34.2% were morbidly obese with a BMI of greater than 30. 35.7% were under treatment for hypertension and 12.5% were under treatment for an elevation of their cholesterol. This was clearly not a healthy group of women. The trial therefore, was looking at a mix of primary and secondary prevention and therefore, should not be quoted as being authoritative in a purely primary preventative conclusion. Returning for a moment to the question of breast cancer. The conclusion seems to have been made that these problems emerged after 5.2 years of exposure to oestrogen and progestogen. However, 26.1% were in fact current uses of oestrogen for up to ten years or longer and with a three month washout period before starting the trial. This duration of treatment in a quarter of the patients makes a mockery of recommendations that a five-year exposure is the only safe length of time for oestrogen exposure. In any event, since the publication of the Beral study, it has been our clear understanding that while the rates of breast cancer may rise; the mortality from the disease actually falls below that of untreated women. There has been very little publicity given to the conclusion about the falling rates of hip fracture and a perhaps surprising degree of protection against bowel cancer. There are a number of worrying areas in terms of potential litigation vulnerability. There are as always the sins of omission and commission. Perhaps the breast cancer incidence will be of little consequence since I would assume that most practicing doctors would have already got that piece of information under their belt and carefully advise their patients accordingly. The question of the incidence of cardiovascular disease perhaps needs somewhat more careful evaluation than we have been accustomed to in the past. The essential thing here is to try to establish whether the asymptomatic woman already has diseased arteries and if not, what her risk for developing a problem may be. What is of the greatest concern to me is the doctor who throws up his hands and declares that he is never going to prescribe hormones again. The problem here firstly, is that oestrogen has a very long 'washout' interval and during that time, the endometrium is open to unopposed stimulation with the risk of hyperplasia or even malignant change. I can imagine that many of these women are going to develop irregular bleeding, with evidence of hyperplasia, require hysteroscopy and D&C or even hysterectomy should they go on to develop a malignancy. In truth, the risk of malignancy is probably quite small and takes some years to develop. Nonetheless, there are going to be some rather unhappy women who may complain that they were not warned about this kind of problem when giving away hormones altogether, whether by their own choice or at the instigation of their physician. The important point here is that even if the woman ceases her oestrogen replacement, in the presence of a uterus she must continue the progestogen until all signs of withdrawal bleeding ceases. On the contrary, a woman who is entirely healthy and has clean arteries and who is denied oestrogen replacement may also have grounds for complaint that her protection from cardiovascular disease has been withdrawn. Most of my patients who are reasonably intelligent have worked out most of this for themselves and concluded whether to continue or to cease their hormones. Some of our patients however, are sufficiently intellectually challenged that they will find it impossible to grasp perhaps slightly difficult concepts. They are likely to say something like "I will leave it to you doctor" or " I do not care what you are saying, I am going to go off the hormones". Indeed, in the occasional patient the panic reaction is such that they are unable to listen to a reasoned explanation. This is an emotional reaction and needs to be handled with care, with the essential point being that the doctor needs to maintain a contact so that he can gain access to her reasoning when the panic reaction subsides. Briefly, with reference to natural therapies, I have downloaded a copy of an excellent paper written by Dr Maida Taylor from San Francisco in which she discusses very clearly and in some detail this whole question. This is a very useful document at a time when our patients may be seeking some other form of relief other than the ‘synthetic doctor inspired’ recipe. August 14, 2002 In the Breast Cancer Study, there were in fact only 7 cancers and not 8 as previously concluded (careful review found that one patient had been recorded twice). This compares to 12 cancers in a similar number of women in the general South Australian population or 14 if they were all taking oestrogen replacement without testosterone. These data are under intense scrutiny by my American colleagues working at the same institution (National Institute of Health, Bethesda, Maryland) whence the recent publication emanated that has given rise to so much anxiety about Hormone Replacement Therapy. August 13, 2002 Dr. Jones will be speaking at the Adelaide Meridian, North Adelaide, on Wednesday August 21 from 6:00 - 7:30 pm, on behalf of "Fitness on the Park." Please call (08) 8267 1887 to book. Statement of the education subcommittee of the Australasian Menopause Society on the first report of the Women's Health Initiative. July 10, 2002 The news from the WHI Study about HRT is of some concern to women taking HRT. This will require full discussion with our patients. It should be noted that the full details are not yet published making it difficult to fully evaluate the conclusions drawn by the researchers. I hope to be able to read the publication by the next Menopause Meeting on the 24th July and be in a position to make some comments by that date. I would encourage you to attend that meeting. July 1, 2002 Hormone Replacement and Breast Cancer Prolapse Repair February 4, 2002 Please see Contacts for doctors who are willing to consider Testosterone Therapy. I would be happy to include on this page the names and contact details of other like-minded practitioners. February 4, 2002 "Testosterone and Breast Cancer" has been updated with new information. October 24, 2001 Wednesday 24th October is the tenth anniversary of the first stapling laparoscopic hysterectomy that I undertook in South Australia. This 'red letter' day has gone largely unremarked and that is a shame since this procedure has been claimed by me to be the safest form of hysterectomy. This I have published as: . The lack of recognition is sad but maybe I will have to await the verdict of history. In the meantime, my reward is that of satisfied patients. August 9, 2001 MORE ABOUT TESTOSTERONE AND BREAST CANCER There has appeared in the medical press a most interesting piece of basic scientific work by Jian Zhou. This is published in The FASEB Journal. 2000;141725-1730. This laboratory research may lend some support to the concept that the use of testosterone in women using HRT may reduce their risk for breast cancer. I have extracted the following comment from Dr Zhou's conclusions in his paper. In summary, the present data show that addition of androgen to estrogen treatment reduces mammary epithelial proliferation and ER expression, suggesting that androgens may protect against breast cancer, by analogy with progesterone's protective effects on the uterus. Androgens have actually been used to treat breast cancer with some success in the past. If androgen is in fact protective, then conventional menopausal hormone replacement regimens may promote breast cancer risk both by increasing estrogens and decreasing endogenous androgens. Oral estrogen therapy reduces free androgen levels by stimulating increased hepatic production of sex hormone binding globulin, and by suppressing LH, which drives ovarian androgen production after menopause. These considerations suggest that balanced estrogen/androgen 'replacement' therapy may be beneficial to menopausal women. March 16, 2001 LAPAROSCOPIC HYSTERECTOMY SAFEST SURGERY I have published my final report on this technique in the journal, Gynaecological Endoscopy (December 2000- <2000: vol 9. pp.373-378>). The article reports the rates of complications in the first 500 laparoscopic hysterectomies and concludes that as a surgical technique it compares favourably with coventional vaginal and abdominal hysterectomy. There is little doubt in my mind that it will become the operation of choice when hysterectomy becomes necessary. This conclusion applies not only to the safety of the procedure but also to the rapid recovery experienced. If you send me your email address, I would be happy to send you the full text of the article. November 11, 2000 TESTOSTERONE AND BREAST CANCER PLEASE NOTE THAT THIS INFORMATION IS NOT YET 'PEER REVIEWED' AND SHOULD BE READ WITH CAUTION The A-Z of Testosterone Treatment (new) The "ABC" Study - Testosterone Effect on Lipids, Bone Density and Breast Cancer Incidence (new) I have made the observation over the years that breast tenderness caused by the use of oestrogen is reduced by the use of testosterone. The thought occurred as to whether this might be accompanied by a reduction in the incidence of breast cancer. In an attempt to investigate this I undertook a retrospective study of 512 patients receiving oestrogen and testosterone in the menopause over 12 years. There were 8 cases of breast cancer recorded in my patients for the duration of the study. Reference to data taken from The Cancer Registry of South Australia would lead me to conclude that there would have been 12 cases of cancer in a comparable group of the general population. It is estimated that 39.5% of these women in the South Australia population were current consumers of oestrogen replacement and 60% were 'ever users'. While there might appear to be a reduction in the risk to my treated patients, statistical analysis (life table analysis) does not, however, confirm that there is a demonstrable reduction of the incidence of cancer but simply that there is no increase in the cancer incidence. Study patients: 10-year breast cancer free survival rate for patients in the trial was 97.41% with a 95% confidence interval of 95.53% to 99.29%. Comparative group: expected 10-year breast cancer free survival rate is 97.52%, almost identical to that actually observed   Bone densities were observed to increase significantly, Lumbar Spine 1-3 years % gain = +10.6% p=0.07 NS Neck of Femur 1-3 years % gain = +6.4% p = 0.02   There was no adverse effect on the improvement in cholesterol status as would be anticipated from the use of oestrogen replacement. Total cholesterol % reduction = -12.7% (approx) LDL-c (damaging) % reduction = -19.8% (approx) HDL-c (protective) % increase = +3.7% (approx)   It should be emphasised that retrospective data collection, such as this, is on the lowest rung of reliability in scientific study and statistical analysis. The purpose of the study was to draw attention to a possible benefit in using this hormone for menopausal patients electing to receive Hormone Replacement Therapy and to encourage a more formal and controlled study of the effect of testosterone in conjunction with oestrogen replacement. September 7, 2000 There has just been launched a new product, Livial (Tibolone). This is a new substance that has an oestrogenic, progestogenic and testosterone effect. This seems to be almost too good to be true but I have been watching the emergence of this agent (ORG OD 148) in the research literature over the past few years and it appears to be withstanding the rigorous scientific testing. It has earned a good reputation in its use overseas. I have yet to get personal experience in its use. It is yet another option that you might care to consider. There has been a flood of enquiries about the new hormone patch that has been publicised on the television. This is the Estalis patch. It employs a delivery system for oestrogen identical to the Estraderm MX patch. What is new is that it can also deliver progestogen transdermally. Progestogen must be used in a woman who seeks HRT and still retains her uterus. Progestogens are poorly tolerated generally with a significant incidence of adverse side- effects. It is hoped that the new patch will permit the woman to avoid these problems while at the same time maintaining the protection from cancer of the uterus that is achieved by progestogen. The patch comes in different strengths and the progestogen can be taken 'continuous' or 'cyclic', depending on whether the woman wishes to avoid cyclic bleeding.