Transcript
Are hormones the only best tools to Are hormones the only best tools to drive women into drive women into
a healthy a healthy geronarche geronarche ? ?
by
Manuel Neves-e-Castro,M.DManuel Neves-e-Castro,M.D.Clinica de Feminologia HolisticaClinica de Feminologia Holistica
Lisboa/PortugaLisboa/PortugalE-mailE-mail: : manuel@neves-e-castro.org manuel@neves-e-castro.org
WebsiteWebsite: http://neves-e-castro.pt: http://neves-e-castro.pt
The 5The 5thth International Symposium of the International Symposium of the Portuguese Menopause SocietyPortuguese Menopause Society
Porto, October 2011Porto, October 2011
Hormonal TreatmentsHormonal Treatmentsare very goodare very good
for symptom reliefto improve quality of life
for the prevention of some diseases
For some in menopause, For some in menopause, hormones may be the only optionhormones may be the only option
“There is no alternative treatment that works very well, whether it’s a drug or over-the-counter herbal preparation.”
Dr. Deborah Grady
But…But…Hormonal Treatments Hormonal Treatments
are far from being enoughare far from being enough…
• To maintain a climacteric woman in good health
• To add more years to her life• To add more life to her coming years
The “stay-in-good-health” issue The “stay-in-good-health” issue Good counselling techniquesGood counselling techniques
by
Manuel Neves-e-Castro,M.DManuel Neves-e-Castro,M.D.The 6th Amsterdam Menopause SymposiumThe 6th Amsterdam Menopause Symposium
SeptemberSeptember 2010 2010
A good counselling techniqueA good counselling technique
is to demonstratedemonstrate and persuadepersuade women that
• lifestyle modifications are independent of the use of drugs, and may
• diminish the need to use drugs to prevent diseases and preserve Health
I shall talk about...
• Life Style Medicine• Aging• Genetics• Psychosomatics• Hormonal and non-Hormonal treatments
before...
showing you...the
Take-Home Messages
“Our main goal, as attending physicians of postmenopausal women, is the maintenance of their health and the primary and secondary prevention of the diseases, which are more prevalent after age 50”.
Neves-e-Castro M. When hormone replacement therapy is not possible. The Management of the Menopause. The Millennium Review, Parthenon 2000:91-102.
What is a menopausal womanWhat is a menopausal woman? she is an individual with a name
she is a woman in distress caused by symptoms and psycho-sociocultural influences
she is a woman who is growing in age
she is a woman who became hypo estrogenicMNC
menarche menopausemenopause
PubertyPuberty rreproductive years eproductive years ClimactericClimacteric
Infants adolescents adults aged old
quality of lifequality of life
morbiditymorbidity
postmenopausepostmenopause
gerontarchegerontarche
FertilarcheFertilarche FertilpauseFertilpause
ChronobiologyChronobiology
The Time Table of a Woman’s Life SpanThe Time Table of a Woman’s Life Span M.Neves-e-Castro,2008M.Neves-e-Castro,2008
compression
geronarchegeronarche
“ The Compression of Morbidity The Compression of Morbidity “
Fries JF et al. 1981Fries JF et al. 1981
Physical activity, the compression of morbidity, Physical activity, the compression of morbidity, and the health of the elderlyand the health of the elderly
Fries JF. Journal of the Royal Society of Medicine 1996;89:64-68
Physical activity, the compression of morbidity, Physical activity, the compression of morbidity, and the health of the elderlyand the health of the elderly
Fries JF. Journal of the Royal Society of Medicine 1996;89:64-68
As a mid-agedmid-aged woman:
She will suffer from the process of
natural agingnatural aging, both from a biological and
a psychological perspective.MNC
If she is a 50 year old lady…If she is a 50 year old lady…
and still has this car, made in 1960,1960,
the same year of her the same year of her birth !birth !
What would she do with it What would she do with it to increase its to increase its longevitylongevity??
Maintenance strategies !
Regenerative attitudes !
This means that…This means that…
she must follow
Life Style MedicineLife Style Medicine Regenerative MedicineRegenerative Medicine
LIFESTYLE MEDICINELIFESTYLE MEDICINE: TREATING THETREATING THE
CAUSES OF DISEASECAUSES OF DISEASE
Mark A. Hyman, MD; Dean Ornish, MD; Michael Roizen, MD
ALTERNATIVE THERAPIES, NOV/DEC 2009, VOL. 15, NO. 6;12-14
90% of people die due to errors in life styledue to errors in life style
Wellness?Wellness?
What isWhat is WellnessWellness?? WellnessWellness is more than simply the absence of illness It is instead a state of It is instead a state of optimal health optimal health including all including all aspects of our Beingaspects of our Being : :
BodyBody, , MindMind and SoulSoul..
http://www.integrative-medicine.com.au
Lifestyle MedicineLifestyle Medicine
is defined as the “evidence-based practice of assisting individuals and families to adopt and sustain healthy behaviors that can improve health and quality of life.”
Lianov L and Johnson M. JAMA 2010;304(2):202-3
The principles of Lifestyle MedicineLifestyle Medicineare foundational to
health promotion,health promotion,
disease prevention disease prevention and chronic disease managementchronic disease management.
Lianov L and Johnson M. JAMA 2010;304(2):202-3
Lifestyle MedicineLifestyle Medicine
The practice of lifestyle medicine covers
primary preventionprimary prevention (preventing a disease from developing),
secondary preventionsecondary prevention (modifying risk factors to avert the disease) and
tertiary preventiontertiary prevention (rehabilitation from a disease state and prevention of recurrence).
Lifestyle MedicineLifestyle Medicine
requires the patientrequires the patient
to changechange their high risk health behaviors
to adoptadopt a lifestyle that includes health behaviors that will help to reverse the pathology and or reduce the likelihood of disease progression.
Lifestyle modifications Lifestyle modifications included aincluded a
lowfat (10% of calories from fat),whole foods, plant-based diet high in fruits,vegetables,unrefined grains,legumes, andlow in refined carbohydrates;
moderate aerobic exercisemoderate aerobic exercise (walking 30 min/day, 6 days/week);
stress managementstress management (gentle yoga-based stretching, breathing, meditation, imagery, and progressive relaxation techniques 60 min/day, 6 days/week), and a 1-h group support session once per week.
PHYSICIAN COMPETENCIES FOR PRESCRIBINGLIFESTYLE MEDICINELIFESTYLE MEDICINE
Physicians cannot abdicate their responsibility Physicians cannot abdicate their responsibility for effecting behavior change in their patients for effecting behavior change in their patients and for leading change within their practices.and for leading change within their practices.
Lianov L and Johnson M. JAMA 2010;304(2):202-3
‘‘Lifestyle Medicine’Lifestyle Medicine’
ExerciseExercise and and nutritionnutrition are the ‘penicillin’ of are the ‘penicillin’ of Lifestyle Medicine;Lifestyle Medicine;
psychologypsychology is the ‘syringe’ is the ‘syringe’
through which these are delivered.
Egger G, Binns A and Rossner S. Med J Aust. 2009 Feb 2;190(3):143-5.
Minimum amount of physical activity for Minimum amount of physical activity for reduced mortality andand
extended life expectancy
15 min a day or 90 min a week of moderate-intensity exercise
might be of benefitmight be of benefit
Wen CP et al –The Lancet ,2011(1 Oct) 378(9798):1244-1253
PHYSICIAN COMPETENCIES FOR PRESCRIBINGLIFESTYLE MEDICINELIFESTYLE MEDICINE
the majority of physicians are not following the majority of physicians are not following these guidelines,these guidelines, citing lack of knowledge, skill, or confidence in counselling patients about lifestyle interventions.
Lianov L and Johnson M. JAMA 2010;304(2):202-3
Lifestyle Medicine Lifestyle Medicine can prevent risk factorscan prevent risk factors
• We are today using only medicines to modify risk factors but we are not looking we are not looking at what causes risk factors.at what causes risk factors.
• Women’s health must be primarily the Women’s health must be primarily the medicine of lifestyles medicine of lifestyles
Differences between conventional Differences between conventional and “Lifestyle Medicine” approachesand “Lifestyle Medicine” approaches
Egger G, Binns A and Rossner S. Med J Aust. 2009 Feb 2;190(3):143-5.
Effect of Intensive Lifestyle Changes on Effect of Intensive Lifestyle Changes on Endothelial Function andEndothelial Function and
on Inflammatory Markers of Atherosclerosison Inflammatory Markers of Atherosclerosis
Intensive lifestyle changes have been shown to
regress atherosclerosis,regress atherosclerosis,
improve cardiovascular risk profiles, improve cardiovascular risk profiles, and
decrease angina pectoris and cardiac decrease angina pectoris and cardiac eventsevents.
Dod HS et al. Am J Cardiol 2010;105:362–367
Combined impact of lifestyle factors on mortality:Combined impact of lifestyle factors on mortality:prospective cohort study in US womenprospective cohort study in US women
even modest differences in lifestyle
can have a
substantial impact on reducing mortality.
Van Dam RM, Li T, Spiegelman D et al.BMJ 2008;337:a1440
The recent INTERHEARTINTERHEART study of 30.000 patients from 52 countries
found that
almost 95% of coronary heart diseasealmost 95% of coronary heart disease
could be prevented by changing diet and could be prevented by changing diet and lifestyle.lifestyle.
And the only side effects are beneficial ones.
Ornish D et al. The Journal of Urology 2005;174:1065-1070
Brown CH, Baidas SM, Hajdenberg JJ, et al. Lifestyle interventions in the prevention and treatment of cancer. American Journal of Lifestyle Medicine. 2009;3(5):337-348
AGING …AGING …
Is aging a disease ?Is aging a disease ?
The fact that genes explain only part of individual varibility in aging means that aging
75%75% must be accounted for by other factorsmust be accounted for by other factors::
- life style variables
(nutrition, exercise)
- powerful effects of environment
(effects on older age)
Anti-Aging ?Anti-Aging ?
One cannot stop aging One cannot stop aging ...One cannot stop growing older ... but
One can prevent One can prevent senescence senescence !
Restricting caloric intakeRestricting caloric intake
Is the most proven method to Is the most proven method to extend lifeextend life
Avoid high caloric foodsTry short term fasting
Undereating is anti-aging Undereating is anti-aging !!
Lifestyle and nutrition, caloric restriction,mitochondrial health and hormones: Scientific interventions for anti-aging
Vitetta L and Anton B;Clinical Interventions in Aging 2007:2(4) 537–543
Vitetta L and Anton B; Clinical Interventions in Aging 2007:2(4) 537–543
Mediterranean Diet, Lifestyle Factors, and 10-Year Mortality in Elderly European
Men and Women
Among individuals aged 70 to 90 years, adherence to a mediterranean diet lifestyle is associated with a more than 50% lower rate of all-causes and cause-specific mortality.
Knoops K et al. JAMA 2004;292:1433-9
Okinawa IslandOkinawa Island: A model of “healthy” aging
The exceptional longevityexceptional longevity of the Okinawa population may result from a combination of favorable factors and not only genetic determinants.
Nguyen C. NPG Neurologie-Psychiatrie-Geriatrie 2008;8(43):35-41.
Okinawa IslandOkinawa Island: A model of “healthy” aging
The association of a protect environmentprotect environment with a way of life which combines specific
food habits, low energy intake, physical activities, stress reduction, good familial support and rich social relations could explain this exception despite the low income in
this population.
Nguyen C. NPG Neurologie-Psychiatrie-Geriatrie 2008;8(43):35-41.
Anti-Aging ?Anti-Aging ?
Anti-senescence ?Anti-senescence ?
Is to prevent Is to prevent
Biological age Biological age to be greater than to be greater than
Chronological ageChronological age
There are two forms of age There are two forms of age ::chronological agechronological age i.e. how old you are in how old you are in years years
and and
biological agebiological age whereby the cells of some the cells of some individuals are older (or younger) than individuals are older (or younger) than suggested by their actual age. suggested by their actual age.
Issued on 07 February 2010 by University of Leicester at http://www2.le.ac.uk
Dr. E. Blackburn,
Nobel Laureate 2009
The best characterized function of the The best characterized function of the telomeric complex is to protect the telomeric complex is to protect the chromosome ends from degradationchromosome ends from degradation
Werner C, Hanhoun M, Widmann T, et al. J Am Coll Cardiol 2008;52:470–82
TelomersTelomers• The little tips of chromosomes get shorter
every time a cell divides,and this shortening is a mark of cellular aging.
• If they get short enough,the cell dies or stops dividing
• Exercise correlates with longer telomers,as does levels of omega-3 fatty acids in the blood
Elizabeth BlackburnNobel Laureate 2009
Genes reveal 'biological aging'
From birth, every time a cell divides, the telomeres get shorter and there is some evidence that people with shorter telomeresthat people with shorter telomeres, , may be at higher risk from age-related illnessmay be at higher risk from age-related illness.
Feb.2010 at http://crabsalloverhealth.blogspot.com/
• Telomerase repairs and lengthens telomeres, which cap and protect the ends of chromosomes housing DNA.
• As people age, telomeres shorten and cells As people age, telomeres shorten and cells become dyingbecome dying.
Published on 16th Sept.2008 at http://crabsalloverhealth.blogspot.com
TelomersTelomers
These cellular clocks,known as telomers,may act as barometers of wether a person will remain healthy or not
Elizabeth BlackburnNobel Laureate 2009
Clean living slows “cell aging”Clean living slows “cell aging”
It is the damage and death of cells that causes aging and disease in people.
Several factors such as smoking, obesity and a sedentary lifestyle are associated with shorter-than-average telomeres.
Published on 16th Sept.2008 at http://crabsalloverhealth.blogspot.com
Sedentary life 'speeds up aging' Sedentary life 'speeds up aging'
Leading a sedentary lifestyle may make us genetically old before our time, a study suggests:
A A study of twinsstudy of twins found those who were physically found those who were physically active during their leisure time appeared biologically active during their leisure time appeared biologically younger than their sedentary peers. younger than their sedentary peers.
Story from BBC NEWS:http://news.bbc.co.uk/go/pr/fr/-/2/hi/health/7212698.stm
Published: 2008/01/29
Leukocyte telomere length is preserved with aging in Leukocyte telomere length is preserved with aging in endurance exercise-trained adults and related to maximal endurance exercise-trained adults and related to maximal
aerobic capacityaerobic capacity
• LTL is preserved in healthy older adults who LTL is preserved in healthy older adults who perform vigorous aerobic exerciseperform vigorous aerobic exercise and is positively related to maximal aerobic exercise capacity.
• This may represent a novel molecular mechanism This may represent a novel molecular mechanism underlying the "anti-aging" effects of maintaining underlying the "anti-aging" effects of maintaining high aerobic fitness.high aerobic fitness.
Larocca TJ, Seals DR, Pierce GL. Mech Ageing Dev. 2010;131(2):165-7
Increased telomerase activity and Increased telomerase activity and comprehensive lifestylecomprehensive lifestylechanges: a pilot studychanges: a pilot study
Ornish D et al. Lancet Oncol 2008; 9: 1048–57
Telomerase activity in peripheral-blood mononuclear cells
Ornish D et al. Lancet Oncol 2008; 9: 1048–57
Lifestyle medicine Lifestyle medicine stimulates telomerase stimulates telomerase thus avoiding DNA damage and
maintaining chromossomal integrity.
the incorporation of new lifestyles may lead to a better compliance and better outcomes
in terms of health and longevity
What else ?What else ?
Vitamin DVitamin D for Cancer Prevention: for Cancer Prevention:
Global PerspectiveGlobal Perspective
Garland CF, et al
Ann Epidemiol 2009;19:468–483.
Vitamin D for Cancer Prevention: Global Vitamin D for Cancer Prevention: Global PerspectivePerspective
Raising the minimum year-around serum 25(OH)D level to 40 to 60 ng/mL (100–150 nmol/L) would prevent
• 58,000 new cases of breast cancer and • 49,000 new cases of colorectal cancer each year, and • ¾ of deaths from these diseases in the USA and Canada.
There are no unreasonable risks from intake of 2000 IU per day of vitamin D3
Garland CF et al. Ann Epidemiol 2009:19(7);468-483
Relative risk of breast cancer mortalityRelative risk of breast cancer mortality
Garland CF et al. Ann Epidemiol 2009:19(7);468-483
Colon Cancer-free survivalColon Cancer-free survival
Garland CF et al. Ann Epidemiol 2009:19(7);468-483
Relative risk of colon cancer mortalityRelative risk of colon cancer mortality
Garland CF et al. Ann Epidemiol 2009:19(7);468-483
and don’t overlook…and don’t overlook…
The MIND !The MIND !
psychopsycho
somasoma
A womanA woman
environmenenvironmentt
environmenenvironmentt
Exactly how psychological and social factors, personal beliefs, and stress affect the development of disease continues to be studied.
It is known, however, that the mind and body communicate constantly. .
what the mind thinks, perceives, and what the mind thinks, perceives, and experiences is sent from our brain to the rest experiences is sent from our brain to the rest of the bodyof the body..
Depression and CancerDepression and Cancer
DepressionDepression also affects components of immune function that may affect cancer may affect cancer surveillance.surveillance.
Spiegel D. Biol Psychiatry 2003; Vol 54(3):269-82
Effect of a psychosocial treatmentEffect of a psychosocial treatment on survival on survival of patients with metastatic breast cancerof patients with metastatic breast cancer
Survival from time of randomisation and onset of intervention was:
- a mean 36.6 (SD 37.6) months in the intervention group
- compared with 18.9 (10.8) months in the control group.
Spiegel D. Lancet 1989; 2(8668):888-91
A A stress response stress response pathway pathway regulates regulates DNA damageDNA damage… …
through β(2)-adrenoreceptors and β-arrestin-1
The human mind and body respond to stress… by activating the sympathetic nervous system and secreting the catecholamines adrenaline and adrenaline and noradrenalinenoradrenaline in the 'fight-or-flight' response.
Hara Mr et al. Nature 2011 Aug 21.
A A stress response stress response pathway pathway regulates regulates DNA damageDNA damage… …
through β(2)-adrenoreceptors and β-arrestin-1
When chronic… epidemiological studies strongly indicate that chronic stress leads to that chronic stress leads to DNA damage. DNA damage.
Hara Mr et al. Nature 2011 Aug 21.
A A stress response stress response pathwaypathwayregulates regulates DNA damageDNA damage… …
through β(2)-adrenoreceptors and β-arrestin-1
This stress-induced DNA damage may promote :
ageing,ageing, tumorigenesis,tumorigenesis, neuropsychiatric conditionsneuropsychiatric conditions
Hara Mr et al. Nature 2011 Aug 21.
A A stress response stress response pathwaypathwayregulates regulates DNA damageDNA damage… …
through β(2)-adrenoreceptors and β-arrestin-1
“Our results … reveal how DNA damage may reveal how DNA damage may accumulate in response to chronic stress”.accumulate in response to chronic stress”.
Hara Mr et al. Nature 2011 Aug 21.
Chronic stress - reduces telomere lenght maintenancereduces telomere lenght maintenanceA SOBERING THOUGHT ...
“Every stress leaves an indelible scar and the organism pays for its survival after a stressful situation by becoming a litle older”. (Hans Selye)
PsychosomaticsPsychosomatics
The Relaxation ResponseThe Relaxation Response
Benson Institute for Benson Institute for Mind Body MedicineMind Body Medicine
the relaxation response is a physical state of deep the relaxation response is a physical state of deep rest that changes the physical and emotional rest that changes the physical and emotional responses to stressresponses to stress (e.g., decreases in heart rate, blood pressure, rate of breathing, and muscle tension).
When When eliciting the relaxation response::• Your metabolism decreases Your metabolism decreases • Your heart beats slower and your muscles relax Your heart beats slower and your muscles relax • Your breathing becomes slower Your breathing becomes slower • Your blood pressure decreases Your blood pressure decreases • Your levels of nitric oxide are increased Your levels of nitric oxide are increased
Hormones…Hormones…are not forgoten !are not forgoten !
Why so much interest in HRT?Why so much interest in HRT?
• To improve quality of life?• To prevent diseases?
Interventions investigated…
OnlyOnly “ “hormonehormone replacement therapyreplacement therapy”!...
• Too Too much concernsmuch concerns and and interestinterest about HRT about HRT
• Too Too little attentionlittle attention to the to the life styleslife styles that that prevent risks, diseases and increase longevityprevent risks, diseases and increase longevity
Updated IMS recommendations Updated IMS recommendations onpostmenopausal hormone therapy andpreventive strategies for midlife health
D. W. Sturdee and A. Pines on behalf of the International Menopause Society Writing Group
CLIMACTERIC 2011;14:302–320
Symptomatic changes in postmenopause Symptomatic changes in postmenopause with with different methods of hormonal therapydifferent methods of hormonal therapy
HT should be initiated for relief of symptoms through suitable selection of the route of administration and drug that has the greatest effect on the predominant symptoms of each patient, for which medical evaluation was sought.
Hernandez-Valencia M et al. Open Journal of Preventive Medicine 2011
Vol.1, No.2, 20-24
Individualizing Hormone Therapy to Minimize Risk
Estrogen is a medication that can decrease mortality, decrease cardiovascular disease, decrease osteoporosis fracture, urogenital atrophy and dementia. Strategies to minimize risk include initiation of therapy within 10 years of menopause or under 60 years of age, using low-dose estrogen, adding a low-dose progestin in women with a uterus, and use of transdermal therapy in women with risk factors for cardiovascular disease.
Donna Shoupe. Women's Health. 2011;7(4):475-485.
Timing of hormone therapy,Timing of hormone therapy, type of menopause, and type of menopause, and
coronary disease in women coronary disease in women
Shufelt CL et al. Menopause 2011;18(9):943-950
HRT and breast cancer risk:HRT and breast cancer risk: a realistic perspective
It should be remembered that women using CEE alone showed a significant decrease in breast cancer risk in the WHI trial and follow-up. Even if combined estrogen-progestogen HRT did cause an increase in breast cancer risk, and this is not proven, the magnitude of that risk is small, and less than that risk less than that risk seen with many seen with many lifestyle factorslifestyle factors.
HRT is a benefit, not a risk, HRT is a benefit, not a risk, for those women requiring it.for those women requiring it.
Stevenson JC, Hodis HN, Pickar JH, Lobo RA; Climacteric (Aug 2011)
Thus,
Studies based ONLYONLY on the use of hormones
do not reflect good clinical practice!...
MNC
Menopausal hormonal treatmentsMenopausal hormonal treatments are are very good but ...
Treatments without hormonesTreatments without hormones may also be very good for a woman’s health
MNC/02
Therefore…Therefore…
and in
conclusion…conclusion…
Please remember:
Our main target is
Mature Woman’s Health and
Disease Prevention
by all means,
drug and non-drug related.
MNC
The gynecologist is becoming
the woman’s family doctor.
MNC
To knowTo know
the the disease that a woman hasdisease that a woman has is as important asis as important as to knowto know the the woman who has the diseasewoman who has the disease
William Osler
Let us not medicalize the Menopause..
instead…
Let us Let us holisticallyholistically approach the approach the Climacteric and aging womenClimacteric and aging women.
MNC
Holistic Model
The aim of the therapy is not only to produce a physical cure but also
to cure whole person.
Ruiz R, et al. La incorporacion de um nuevo modelo en medicina: consequencias teórico-práticas. Aten Primaria 1992;10:629-34
I am not a Menopauselogist…
instead
my Speciality (?!...) is
Women’s Holistic HealthWomen’s Holistic Health
The The Take Home Take Home MessagesMessages
1. Promote changes in Life Style Life Style : they avoid risk factors that cause Diseases.
2. See if you can make the Biological Age Biological Age to be younger than the Chronological Age.
3. Promote Mental HealthMental Health,proper NutritionNutrition and frequent ExerciceExercice ,based on what one knows about the Telomers.
4. Give Vitamin DVitamin D to everybody5. Remember that EstrogensEstrogens are the best treatment for
Vasomotor Symptoms and to improve Quality of Life.6.6. Hormonal Treatments Hormonal Treatments have more benefits than risks if
started early in the postmenopause7.7. The The Wellness of a Woman Wellness of a Woman is the is the TARGETTARGET ! !
And...as I told you before,And...as I told you before,
The best Anti-Aging (?)The best Anti-Aging (?) (Anti-Senescence !)(Anti-Senescence !) Treatment Treatment
isisThe practice of GOOD MEDICINEThe practice of GOOD MEDICINE
therefore...we must learn…
how to practice a GOOD MEDICINEGOOD MEDICINE
Because…there is Because…there is
NONOMenopausal Menopausal Medicine !Medicine !
M.Neves-e-Castro,2011
and now...and now...
and now...and now...
as Sir Winston Churchill said in as Sir Winston Churchill said in a speech, at the end of a War...a speech, at the end of a War...
I also say, I also say, at the end of the at the end of the
Menopause WarMenopause War......
This is not the end...This is not the end...nor even the begining of nor even the begining of the end.the end.
But it is, perhaps,But it is, perhaps,the end of the begining !the end of the begining !
He was the Beginer
ProfessorRobert B.Greenblatt
OH9900
A WomanA Woman
in the in the autumnautumn of her life of her life
deserves an deserves an indian summerindian summer rather thanrather than a a winterwinter of a of a discontent discontent ...
Robert B Greenblatt
Thank you for your attention
read me in http://neves-e-castro.pt
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