Roy Jackson, MD

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       “Good morning to everyone.  Today we’re speaking from the FIGO  meeting in Washington, D.C. and I’m honored to have with me Professor  Bruno Lunenfeld who is from Israel.  I am Dr. Roy Jackson, a  gynecologist from Vancouver, Canada.  Professor Lunenfeld, it’s an  absolute honor to be with you today, I’ve read your textbooks and your  articles and have followed your career in reproductive endocrinology.  I  understand in speaking with you today that your interests are still  very much in reproductive endocrinology and your interests are changing  to encompass some other areas.  Are there new advances in reproductive  endocrinology that you’re talking about at today’s meeting or are you  presenting any other topics?”
       
       

   “Yes, in reproductive endocrinology yesterday at the Presidential  lecture, I talked about the future of       gonadotropins.  We are now in an era going to the quality of life  and, therefore, we need more patient friendly approaches than before,  not just curative or preventive but also patient friendly.  So I talked  about the future of the needless injections of recombinant at this age  and I talked on the possibility in the future of having oral  gonadotropins available which are Pepto emetics.  I think we’re already  at a stage where with animal experiments we can show that we’ve got very  small compounds that enable about 300 daltons which can have  gonadotropin activity also by the oral route and, of course, the new  development of the GnRH antagonists.  You know that in February 2001 we  are having the 6th International Meeting on Gonotrophic Releasing  Hormones, Agonists, and Antagonists in Reproduction in Cancer, and there  again, we will hear a lot of new things about antagonists which really  will slowly replace the antagonists in many, many subjects.”
       
       

 “Now  Professor Lunenfeld, I understand that you’ve had this tremendous  interest in reproductive endocrinology as you’ve described and you  presented the papers today.  You never rest, and you have a new interest  that I’m very excited to be able to hear about.  Maybe you can share  with us this new interest that we have as gynecologists have looked  after women and our focus has been women.  I understand now that you’re  looking at a different aspect.  Can you tell us more about this?”
       
       

  “Yes, about thirty-five years ago I was together with Bob Grimlot when  the Menopause Society was created.  When I retired from my clinical work  at the Sheba Medical Center in Israel seven years ago, I decided that  we men are underprivileged.  Men live seven years less than women live,  and men have health problems and rarely are not aware of them.  Women go  for prevention, and women are trained for prevention.  Women have their  gynecologists and confidantes, and they can talk with them about many,  many personal things.  Men don’t have a men’s health physician.  They go  to the urologist for repair, and they go to the internist for repair.   They don’t go for prevention because from the very, very beginning the  mother will tell a boy – ‘You’re a boy; you are not suppose to cry.  You  shouldn’t be like a girl running because you have some pain.’  Women  are geared for prevention; they’re healthy when they go to the  gynecologist to remain healthy.  They’re healthy when they go during  their pregnancy to the obstetrician in order to have a healthy and good  pregnancy, and they go with their child to the pediatrician in order to  keep the child healthy.  Men only go for repair so women use the health  service fifty-percent more than men but men cost the health service much  more because they go too late.  Men don’t talk about their diseases but  we got lucky because indirectly with the era of       Viagra, men suddenly started talking and opened this up.  Five  years ago in London we registered the International Society for the  Study of the Aging Male called       ISSAM.  It’s actually a website; it’s issam.ch and we already had  two World Congresses.  About 300 people came to the first World Congress  together with the World Health Organization in Geneva.  This year in  February of 2000, we had 750 people come, and the next Congress will be  in Berlin in 2002, and we expect about 1,500 people.  So I think the  awareness is coming around, men are ready to go and talk about their  health problems.  We have our own journal, The Aging Male, and I can  tell you that the first gender specific health report was published by  the World Health Organization together with ISSAM in the March issue of  The Aging Male, and it’s actually the first health report on men.”
       
       

 “Now as  gynecologists, we’ve always worried about cardiovascular disease,  osteoporosis, and libido problems that women have suffered from.  Do you  think this impacts and has implications on men as well?”
       
       

   “Certainly, just like estrogens protect women from Alzheimer’s disease,  osteoporosis, and cardiovascular disease, estrogens also metabolize from  testosterone and protect men in the same way.  In women there is a big  problem, with menopause suddenly and abruptly estrogen production  ceases.  In men lytic function goes down but slowly, therefore, men  still produce testosterone until a very late age and this testosterone  can be metabolized into estrogens.  That’s why osteoporosis and  Alzheimer’s disease in men occurs later so we have an advantage here.   We could of course increase our advantage if men would be ready to look  after themselves, exam themselves, go to the doctor for prevention, and  try to do this because many things can be done.  We have evidence-based  medicine today which can show the effect of testosterone, we have lots  of research going on       dehydroepiandrosterone, and there is lots of research going on in  the effect of glucosamine and aging.  But what we have today and what we  can do is physical exercise.  Physical exercise alone - if we talk of  aerobic/anaerobic instruction - can already be an enormous help to keep  people fit and healthy.”
       
       

 “So who do  you foresee doing the preventative healthcare for men?  Who’s going to  provide this healthcare - is it going to be the family doctor, the  urologist, or the gynecologist, and is our population base going to  change?”
       
       

   “Look, maybe the gynecologists is a subject because what happens many  times is that the woman comes to the gynecologist and tells him, ‘You  have helped me so much, you’ve given me HRT, I’m doing very well now but  what about my husband?’  So he will probably be the first person to  hear about the problem but he’s not geared for the urology problems men  have, and not for the cardiovascular or the psychological problems.  I  think we will have to slowly create a men’s health physician, this could  start from urology but this would mean that urology like gynecology  thirty-five years ago would have to go in what we call medical urology.   They would have to learn more about internal medicine, the urologist  would have to learn more about endocrinology, and they would have to  learn more about social and psychological problems.  I think maybe in  the future there will be some kind of medical urologist who will be at  least in the first part of the next century a men’s health physician but  probably later we will have to create a pure men’s health physician.”
       
       

 “Now maybe in  closing, Professor Lunenfeld, we often refer to the menopausal woman as  the mature woman because of the fact that it’s more politically correct  to refer to them as the mature woman.  Do you think we’re now going to  be referring to these men as the mature men?”
       
       

   “But my main final message is use it or lose it.  It is true for the  brain, it’s true for the muscle, and it’s true for the penis.”
       
       

 “Professor  Lunenfeld, I thank you very much for the privilege of sharing some very  exciting information with us today, and I do hope you enjoy your stay in  Washington, D.C.”
       
       

  “Thank you very much.”
       
       

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OBGYN.net Conference CoverageFIGO 2000 INTERNATIONAL FEDERATION of GYNECOLOGY & OBSTETRICS: Washington DC, USA

The Aging Male

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  "I       am here with Dr. Lunenfeld, and I remember the wonderful discussion and       breakfast we had back in Geneva. I am so excited that you let me know that       we will have an opportunity to meet in Geneva again. Can you tell us a       little bit about the conference that is going to be coming up in       Geneva?"
       
       

  "Dr.       Perloe, I am glad you enjoyed the meeting in Geneva and I am happy to       inform you that the 6th International Congress on GnRH Analogues in Cancer       and Human Reproduction will again take place in Geneva on February 8-11,       2001. It will be a very interesting meeting because at that time we hope       to be able to arrive at a consensus on the role of GnRH analogues in the       treatment options of endometriosis and in the management of uterine       fibroids. The use of cyclic 'add-back,' as well as adjunctive therapy in       patients treated with GnRH analogues for extended periods, will be       discussed. I am sure there will be long and heated debates on the use of       agonists via antagonists. We will learn the advantages and disadvantages       of agonists and antagonists, and I hope it will become clear when agonists       should be used and when to use antagonists.
       
       Furthermore I hope we will also come to a consensus on what the three most       important challenges for ART procedures are: to increase pregnancy rates,       decrease high-order multiple pregnancies, and avoid and manage       hyperstimulation. Also, concerning cancer and particularly prostate       cancer, new information will be made available in Geneva.
       
       The above are only a few topics to demonstrate to you why I think the next       meeting in Geneva in 2001 will be extremely interesting and will have a       very strong impact on our medical practices. Now, on to your question       concerning today's management of endometriosis with antagonists... For the       time being, there are no long-acting antagonists on the market. Since the       medical treatment of choice for hormone-dependent endometriotic lesions is       the administration of long-acting depot preparations of GnRH analogues,       long-acting GnRH agonists will remain the only therapeutic option.       Long-acting GnRH antagonists should become available for clinical use in       about three or four years, but for now, there is no question that the       long-acting GnRH agonists are the first line of treatment of any       hormone-dependent endometriotic lesion.
       
       As to your question concerning uterine fibroids, I think there is a       consensus - or at least I believe there will be after Geneva, 2000 - that       the primary treatment of most uterine fibroids will be with GnRH analogues       prior to surgery. I am sure most of my colleagues even today agree that,       following GnRH analogue treatment, there is a definite decrease in fibroid       size and decrease in blood loss. In many instances it will allow surgery       through the vaginal route. As I said previously, for the time being there       are no long-acting antagonists on the market and long-acting GnRH agonists       will remain the only therapeutic option."
       
       
       

  "It       appears that the initial protocols in the initial results from Dr.       Felderbaum's study suggest that while you are using less FSH, you may       shorten the number of days by using an antagonist and lower the risk of       hyperstimulation. I'm not yet convinced that the pregnancy rates will be       better. Is that enough to get us to switch from a analogue to an       antagonist?"
       
       

  "You       are perfectly right. I agree that both Felderbaum (multiple-dose protocol)       and Olivienne (single-dose protocol) have clearly demonstrated that GnRH       antagonists such as cetrorelix and ganirelix prevent premature LH surges,       are safe and effective, and reduce treatment time and the amount of       gonadotropins necessary for successful ovarian stimulation. Fertilization       rates obtained are comparable to those obtained with GnRH agonists       protocols. If GnRH antagonists will be replaced in the future, all GnRH       protocols remain an open question. We have insufficient data, for example,       on the use of GnRH antagonists in PCOD patients."
       
       

  "Markus       and Edwards have suggested in their early work that a three-month trial or       three months pretreatment with analogue may improve the outcome in IVF.       What are your thoughts on that, and is there more data available now that       clarifies that picture?"
       
       

  "In       my opinion, this is true only for PCOD patients and this is probably one       of the reasons that you get similar effects if you pre-treat for one or       two months with some of the oral contraceptives. I know we will get some       more good data in Geneva in February of 2001."
       
       

  "I       think one of the things that's exciting to me in the PCOS patient is the       difference in vascular flow patterns. There's increased stromal flow,       there's decreased follicular flow, there's increased VEGF, there's       diminished blood flow in the endometrium, and these may all be factors.       Many people are utilizing metformin for ovulation induction, and we've had       in our program a number of successes in deliveries. Some people are even       suggesting that we continue using metformin to lower insulin levels and       maintain it during the pregnancy, suggesting that the diminished blood       flow or the destruction in blood flow associated with hyperinsulinemia may       be a factor in miscarriage. Do we need to look at that in the IVF patient,       and do you believe that insulin may play a role? Are you aware of any       other studies that are working on that role right now?"
       
       

  "Thank       you for enlightening me. I have heard about some of these studies, but I       have no personal experience. But the results make sense - they're logical.       We know, for instance, from a study done by Dr. Steve Frank in London that       when we reduce weight in some of the obese patients, insulin levels go       down and pregnancy rates are improved. We are planning a symposium on this       subject in Geneva during the GnRH meeting. I hope it will       materialize."
       
       

OBGYN.net Conference CoverageFrom First Congress on Controversies in Obstetrics, Gynecology & Infertility Prague CZECH REPUBLIC - October, 1999

Endometriosis and Infertility

       "One of the confusing things that we see headlines on is male       menopause and the cause. I'm confused about what I ought to be calling it,       and what really is going on with males as they age. Do we need to be       concerned about this?"
       
       

       "Yes, I think so because I think it's quite clear today that there is       no male menopause. Males don't have menstruation - there is no stopping of       menstruation - and I'm very surprised why even the term "male       menopause" came up. To me there's nothing clinical, I just think it's       the wrong term. I also think andropause is really responsible for creating       this term which is wrong, because it's not only the androgens which go       down, we know it's dehydroepiandrosterone sulfate, the adrenal androgen       that goes down. We know that hormone secretion, melatonin secretion, and       estrogen secretion goes down. So I think with what we actually have is a       partial endocrine deficiency syndrome of the aging male, which I would       call "PEDAM" - partial endocrine deficiency of aging male. This       I think would be the correct scientific name. Today people like to call       it, "PADAM" - partial androgen deficiency or andropause because       actually the only product on the market today are testosterones. We know       very little about dehydroepiandrosterone although I'm quite sure it is       very important. We know very little on the condition of cortisol, which we       know is very important on this whole effect and bad on muscle composition       on osteoporosis. We know very little about melatonin. We know that all the       medicines used today in food additives are used less because the half life       is very, very short. We need well-standardized melatonin, which can remain       eight hours and really simulate the physiological effects to get a good       sleep. Because we know that under melatonin we have this slow wave sleep,       which is a sound sleep, and during that sound sleep we get secretion of       cortisol hormone. So I think a good sleep with secretion of cortisol       hormone could be the solution but for the time being there is no       standardized melatonin available. Cortisol is expensive but I think in       many countries it is forbidden for athletes which is a mistake - so many       studies have to be done in order to prove this. Now why do many countries       like the word hypogonadism in their aging male because all these products       - the testosterone products - are set for hypogonadism so if you go back       to the word hypogonadism in the aging male, you've less problems in the       registration of products which are readily available."
       
       

       "The other factor is dealing with insurance companies. A normal       physiological condition may not be one that they want to cover and coming       up with a CPT or ICD-9 code that warrants the condition or diagnoses it.       Is this the sort of thing that men are coming to physicians and       complaining about or do you see this as a standard part of the physician's       evaluation of the male? I mean, with women we have good evidence that we       can prevent heart disease, that we can prevent osteoporosis, and we can       improve sleep and do a little on hot flashes. A man doesn't have hot       flashes to come in that immediately disrupts his life, and we don't have       the obvious indication that we are improving health."
       
       

       "I thank you very much for this question because I think I have the       exact answer which you need here. Women go for prevention, they have       gynecologists who are their confidant, and they can discuss with him all       kinds of things. They are geared for prevention, they go to the ob-gyn       when they are healthy and when they are pregnant. They are geared for       prevention, when they have a child, they immunize the child - they will       try to keep it well. They will maintain health. Men only go for       operations. They don't have a physician, and they don't have men's health       physicians. We have to go to the urologist, and we have to teach the       urologist - don't put your finger in only like this for the prostate, also       put the finger in straight to look for colorectal cancer. So I think we       have to teach awareness to men that they should go also for prevention. We       know that in Western Europe, nearly 20% of women have a clinical breast       examination, self-examination, or mammography - but something - to check       for breast cancer. Only 0.3% of men make a PSA - a prostate specific       antigen - examination which we can predict cancer expression five years       before. So why shouldn't men from fifty onwards have at least one digital       examination a year together with a PSA - this would prevent things. So I       think here we need to create awareness, and we need to create a men's       health physician, and this exam and the International Society of the Study       of the Aging Male are really doing this. I very much hope you would come       to Geneva, and you will see how much data exists already but it's spread       all around. I think Geneva in February 2000, the 9th through the 13th, may       be one place where the gap will start closing itself, and you will be able       to see a little bit clearer picture."
       
       

:  “Good afternoon, ladies and gentlemen.  I’m here today in Florida and we’re at the American Association of Gynecological Laparoscopists annual meeting.  It’s my pleasure to have with me Dr. Paul Indman who is from California and is an extremely well known gynecologist in the endoscopy area.  Today we’re going to be talking about women who present to the gynecologists with abnormal bleeding or persistent bleeding in the area of menorrhagia.  Dr. Indman, how long have you been working now in the area of endoscopy?” 

:  “I’ve been working in endoscopy even as a resident and doing hysteroscopy for over fifteen years.” 

:  “What percentage of your practice would you say is orientated towards women who have dysfunctional uterine bleeding or should we say abnormal bleeding as a problem?” 

:  “A large percentage of my practice is comprised of women who bleed, they may be referred by friends.  We’ve done a number of studies in which we’re treating bleeding by various methods.  It often amazes me that women who are bleeding have been to three, four, or six doctors, had procedures, had D&C’s, they’re still bleeding, and nobody knows why they’re bleeding.  They’re putting up with it, maybe even going to the emergency room, and their bleeding isn’t diagnosed so I see a lot of that.” 

:  “In terms of diagnosis of the bleeding, what’s some of the key factors in your approach to how you diagnose the bleeding?” 

:  “Diagnosing abnormal bleeding is not difficult, there’s some basic questions.  First of all, could someone be pregnant because if someone’s pregnant and you don’t know it, that’s a problem, so we’ll almost always do a pregnancy test.  Are they ovulating - many women have a history – I haven’t had a period for three months and then I have a heavy period.  Typically, they’ve not ovulated, that’s fairly simple so we need to evaluate the hormone status.  If it’s not clear from the history, often, I’ll have a woman take a temperature chart just like for fertility, we look at that several months later, and we can easily see without any blood test whether someone’s ovulating.  Also, most importantly, we assess the uterus.  The uterus is bleeding, how do we do that – as a basic first visit test we’ll always look with the vaginal probe ultrasound.  It’s amazing, I’ll see women who’ve been to a number of doctors over a period of years and now it’s a game to see how many seconds it will take to diagnose why they’re bleeding.  Often it’s less than ten seconds with a vaginal probe ultrasound, we take a look and find a fibroid right in the middle of the uterus, this is why they’re bleeding, and it’s been overlooked for years.  They may have been in the operating room twice for D&C’s but nobody’s evaluated what’s going on inside the uterus.” 

:  “What do you think about those patients that are receiving a D&C or dilatation and curettage as their investigative procedure for the bleeding?” 

:  “The old fashioned - let’s go in the hospital or just do a scrapping has been obsolete for twenty years.  If someone is hemorrhaging, we can often stop the bleeding by vacuuming out the uterus, which takes a few seconds.  We can look and it will help us be sure there’s not cancer in the uterus but a D&C will not see fibroids.  A D&C will not necessarily get out polyps and it’s totally blind so to me the D&C is something long, long overdue to be buried other than an office suction D&C to treat heavy bleeding.” 

:  “In your experience, what percentage of the uterine cavity is missed when you do a D&C?” 

:  “We have to look at studies because it’s been shown that the D&C and the most complete D&C’s at best will assess 50% of the endometrial cavity but you miss 20%-30% of polyps, submucous myomas, and often you just don’t have an answer.  So I think it’s helpful to use a combination of procedures, one is an ultrasound, which is very helpful, and the vaginal probe can easily be done by the gynecologist in the first visit.  Very honestly, with all due respect to my radiology colleagues, some are good at reading them and some are not.  They can come in with an ultrasound in their hand and we’ll still look because holding this and looking at it in real-time in motion gives me information that I can’t otherwise get.  Looking at a static ultrasound is like looking at a few frames or a movie review and trying to assess the movie.  You need to see this in real-time.  If the endometrial cavity is totally normal on ultrasound and it’s a young woman, I found that the chances of finding anything in the endometrial cavity are very, very low.  We may not do anything else but as we get older, and I’ve looked at this data in over 250 patients and this has been published, as we get into the 30-40 and especially the 50-60 age group, the vast majority of patients have disease within the endometrial cavity.  Often we can get an idea of what it is with the ultrasound and then we can look at it with a hysteroscope, not necessarily in the first visit.” 

:  “What concerns me most is the fact that a large number of gynecologists are still relying on a D&C as the primary procedure to diagnose abnormal bleeding.  They’re not turning to more innovative techniques such as a vaginal probe, saline infusion sonography, or diagnostic hysteroscopy for that matter.  How do we as opinion leaders or how do you as an opinion leader in the area of endoscopy in women’s healthcare, how are we going to change that to the providers of healthcare around the world and in the United States to make them realize the importance of a better assessment of the uterine cavity in women that are bleeding?” 

:  “That’s an excellent question that I’ve been asking myself for the last 15-20 years.  I think what motivates physicians is patient demand, and I think as long as women lie down and have a blind D&C, they’re going to keep getting blind D&C’s.  Just as if they lie down to have an ovarian cyst removed through a laparotomy, they’ll keep getting that instead of having it removed through the laparoscope.  Now there’s some that do require laparotomy but most can be managed with telescopes so I think women need to be educated.  We’ve tried to work with physicians.  The data is there, it’s clear, there’s not a single article in the literature that supports the use of the blind D&C, not a single one.” 

:  “So if the data is there and, therefore, the data has been there for several years, we can assume indirectly that we as a group of physicians may have been somewhat ineffectual in delivering the results of that data to the public and to women in general.  Therefore, maybe sources such as the Internet are going to change this as women turn to the Internet for their source of healthcare information.  Do you agree with some of those comments?” 

:  “Absolutely, I think the Internet will help women become informed.  Let me give you an idea, when we were treating cervical disease, precancerous disease of the cervix, I saw a woman who had a baby a few months ago and she had a little baby at home.  Her physician told her that she needed a hysterectomy and I said - yes, a hysterectomy will work but we can take five minutes with my laser and we’ll treat that and the results are just about as good.  So we did that and her physician took my next course in laser surgery.  Until women say - okay, if you can’t look in my uterus in the office and that’s as basic as looking in my ear if I have an earache, I mean nobody would think of scrapping an ear if it hurts, you look in it. So doctor, if you’re a specialist in gynecology and you can’t look in my uterus, I’ll go to a doctor who can.  And there are a lot of us around who can.  Until women do that, they’re going to keep getting what they’ve been getting.” 

:  “Where are women going to get that information, and how are we going to disseminate that information?” 

:  “I think women are going to have to ask around.  Right now there’s the Internet, and they’re going to have to ask physicians in the community if they do this procedure and if they don’t, could they refer them to someone who will.  Often it takes a lot of research to find someone and find someone who’s skilled in it.” 

:  “Dr. Indman, I think that draws to a close our interview, and it’s been an absolute pleasure hearing from you on an approach to abnormal bleeding.  Hopefully, we will be able to share this information that you’ve given us today with women who will be able to be more discerning in their choice of healthcare.” 

OBGYN.net Conference CoverageFrom American Association of Gynecological LaparoscopistsOrlando, Florida, November 2000

Author | Roy Jackson, MD

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