Wednesday, August 20, 2014

HPV Shots Protection Holds For Many Years in Young Women and In Young Men

The CDC is trying for figure out why more women are not taking advantage of the HPV Vaccine. Rebecca B. Perkins, MD, from the School of Medicine, Boston University, Massachusetts, and colleagues sent a 15-item questionnaire to 1000 ACOG members. Of the 366 obstetrician/gynecologists who completed and returned the questionnaires, 92% reported offering vaccination to patients, but only 27% of their eligible patients were vaccinated. The most highly cited barrier to vaccination was refusal by parent or patient.

Friday, August 15, 2014

How Physicians Define 'Normal' For the Thyroid Gland

Thyroid disease is on the rise, not due to increased numbers of patients with any different thyroid levels than they ever had, but due to physicians treating more of the mildly elevated TSH patients.
And the mild elevation is determined by a mere formula stating that normal means everyone except the top 2.5% or the bottom 2.5%, this is what a statistician would term the "95% confidence level" . For patients and their physicians the trouble with numbers, when it comes to the thyroid, is that it is not linked to symptoms such as depression or fatigue.Nor is treatment of mild elevation linked to weight changes. It has been shown that treating patients with mildly elevated thyroid can prevent that patient from ever having overt hypothyroidism. In her editorial in JAMA, Dr. Ann Cappola, one of the associate editors, points out that too many patients are being prescribed thyroid when their numbers are only slightly off, and that there is no clear benefit for this type of treatment. Over treatment with too much thyroid medication, however, is not safe. Women have special considerations with thyroid management, especially if they are pregnant. And women who have been treated with too much thyroid replacement have been reported to have abnormal heart rhythms and bone fractures. The point is ultimately to work with your physician to achieve levels that correlate with optimal health. You want medicine, not math, to determine your personal thyroid management.

Thursday, August 14, 2014

For Cases of Prepremature Menoapsue Women Need To Check Their Chromosomes, Their Thyroid, and Their Adrenal Glands, Not Just Their Estrogen Levels

The condition of premature menopause is a potentially serious disorder with consequences on more than just the ovaries, but can affect the thyroid gland as well as the adrenal gland. A working group from European Society of Human Reproduction and Embryology drafted the first international guidelines for managing premature ovarian insufficiency trying to address this issue. They have pointed out that some individuals who have POI  actually have chromosome disorders such as Turner's syndrome (X0) that should be identified prior to undergoing IVF or other fertility procedures like donor eggs. A young woman having irregular periods or occasionally hot flashes, in her 30s, may be given a diagnosis of menopause, but it's not always true that she's actually transitioned permanently though menopause. The normal age of menopause is menopause occurring the age of 40. Menopause before 40 has been called premature, or premature ovarian failure (POF), or Premature ovarian insufficiency (POI). The understanding physicians have had previously was that the ovaries have a set number of eggs, and when a woman’s eggs are all used up then we go into menopause. We have a preset number of eggs (genetically), we can lose eggs when we have disease of the ovaries or surgery of the ovary, and those things can cause individual cases of premature menopause. But something was discovered to be off in the thinking of most cases of POF. As far back as 1996 we discovered that even if the whole picture appears to be premature menopause, in research settings when the patients underwent ovarian biopsies they were actually found to still have eggs and follicles left, thus some hope for pregnancy (or some risk for pregnancy if you are trying to not get pregnant). It is not just running out of eggs, something else must be occurring to put a woman into early menopause. The newest thought is that some  with POI, do not have the full blown syndrome, but just go into a phase where their eggs won’t respond well, but they actually do exist. In some women it’s that their pituitary FSH no longer works to wake up any eggs, in others it apparently was a type of self induced (auto-immune) inflammation. Networks of white cells called lymphocytes would invade the ovary and this is perhaps why the eggs wouldn’t respond.So this is the reason some women can transiently go into menopause, but actually recover and begin to have normal cycles again.The women who have POI may or may not be able to have donor eggs to be able to have children, and the current guidelines for this condition are undergoing extensive review.

Tuesday, August 12, 2014

New Colon Cancer Test Approved

The US Food and Drug Administration (FDA) today approved Cologuard (Exact Sciences Corporation), a stool-based colorectal cancer (CRC). Finding colon cancer in the early stages is so important because it is very preventable in the precancer stage, and very treatable in the early stage. Colonoscopy is still going to be the best way to determine if cancer is or is not present and this new test won't replace colonoscopy.
Cologuard analyzes stool specimens for evidence of blood or evidence of DNA pieces that are shed by precancerous polyps or actual colon cancer.Like colonoscopy the test is designed as a screening test for individuals over the age of 50. Risk factors for colon and rectal cancer include those with inflammatory bowel conditions, those with prior colon or rectal cancers, and those with family history of cancer cases that include bowel cancers. You can also protect yourself against colon cancer by eating fruit and vegetables, increasing fiber and increasing your physical activity. World Health Organization study showed that for ever 10 grams of fiber you increase per day you lower your colon cancer risk by 10%.In this WHO study only whole grain fiber was protective. For diet and nutritional advice, and how to balance competing nutritional needs, see your women's health primary care provider to discuss.

Monday, August 11, 2014

Stop Forgetfulness By Positive Thinking

You were relating a story about one of your favorite books, and sure enough, you cannot remember the author, or the title, or the main character, or all three! Frustrating, but so common. The end of a long day, preoccupation with other things, or even plane old not putting enough effort into those word, time or place associations that help our memory was probably at fault. For some menopausal women, however, there are other medical issues.
It turns out that if you think you are on your game, then you are. The research from the Seattle Midlife Women’s Health Study showed that 60% of women in the menopausal transition report decreased memory function over the past few years, including forgetfulness. The Decision at Menopause study was also relied upon for some of their findings.  Yet their studies also revealed an effect on perception of your function as it actually correlates to your memory function. Positive attitude again comes through as an important indicator of success.Of course it's easier to have a positive attitude if your gyno confirms that is warranted, so don't skip the yearly visits, she has things to say to your about how to keep sharp and keeping positive!

No Hormones, No Hot Flashes

For women with hot flashes they are treatable. Severe symptoms will require medication, for those with mild symptoms they should try life style and simple modifications like your diet, your activity, your clothing, and your weight. Paced breathing is one of the best strategies to try, but you need to do it twice a day, and it's best if also combined with muscle relaxation techniques. As part of dietary modification look at your caffeine intake which definitely can worsen symptoms. When a bit of extra exercise and a bit of weight management doesn't work, look to medications. Hormones are a good alternative for many women and they likely will work the best for large populations of women. However we know that not everyone is a candidate for hormone solutions to hot flashes and we have other therapies that are used both on and off label. Brisdelle, which is 7.5 mg of paroxetine has become the first prescription, non-hormonal therapy for moderate to severe hot flashes associated with menopause. Not all women are suitable for this therapy, some medications such as SSRIs for depression can serve a dual purpose of treatment of hot flashes. The newest hormonal therapy, actually is a very unique combination of new medications, called Duavee. Untreated hot flashes have significant effects on moods and memory and weight as well as other health consequences and it's time your gabbed with your gyno to decide what to do.

Next Breast Cancer Genes Identified and Coded

Working off the hypothesis that almost all cancer is ultimately mediated through changes in our genes, researchers have decided to classify genetic changes as Categories I, II, and III. Category I genes are the most strongly associated with the diseases they have been linked to and Category III genes associated with either the disease only slightly, or perhaps we just don't understand them well enough to be categorized as more significant. This is different from the typical categories we talk about which are based on cell types and cell behavior. Dutch reasearchers found another gene that is rare, but can also lead to increased cancer incidence as does the BRCA1 and BRCA2 genes. In a recent report the new gene was revealed. This gene is the genetic defect that leads to many cancers and cancers at a young age, so in the carriers of this gene earlier mammograms are going to be recommended. The gene is called multiple endocrine neoplasia type 1 (MEN1) is caused by gene defects MEN1 tumor-suppressor gene and has previously been identified as the cause of various GI and endocrine tumors. Another genetic defect has been reported to be associated and that is called PALB2 gene. The top researcher in onclogy have begun to talk about Next Generation Sequencing (NGS) is a method of genomic analysis that can be used to detect mutations in select genes that predispose women to hereditary breast and/or ovarian cancer, and this panel is much more extensive than the panels used in the past looking primarily at BRCA1/2 testing. NGS panel testing may be an answer for the over 80 percent of those who undergo testing for mutations in the major breast cancer susceptibility genes  receive a negative, or uninformative result to their tests. The NGS tests used are expanding all the time, from the original 21 tests that were offered when this technology was invented. Cancer prevention involves more than just living well, eating well, and exercising well, it means working closely with your primary care physician to understands your personal risks and how to lower them. Genetic testing may in fact be right for you.

Sunday, August 10, 2014

Faint Positive Pregnancy Tests

Pregnancy testing has come a long way in the past 100 years! But still women have questions about their home pregnancy test. Often it is confusing if that home pregnancy test just shows a very faint line. In fact that faint line is probably accurate, but perhaps you tried to test too soon. We all are a bit impatient, but remember that fertilized egg won't implant for a few days after conception Nopregnancy test, no matter how accurate will  prove yet you have a healthy on going pregnancy. This is why repeat testing over several days has become popular. One hundred years ago, it really took 2-3 months to determine if you were pregnant. In Marianna Wheel's popular Harpers book of 1914 called Before the Baby Comes she cautioned that "cold and change of climate (among other things) can cause you to skip your period, but if not that, and you skip two successive menstrual periods [you] may be fairly positive of your condition [pregnant]!" But skip ahead a century, and now we have a plethora of medical grade tests available directly to consumers, but there are still questions as to which test! Women will tell you they've often taken that pee test to see if they are pregnant! And though women want to rely on the information they get from their home tests, what they ask is it more accurate to actually take a blood test at the gyno office to see if they really are pregnant. I get a lot of questions: like 'I looked later and saw a faint second line' and that is not according to your package instructions on the urine pregnancy tests. So the question patients ask is which test to get and for the most part the gynos just say, be sure to get any pregnancy test if you suspect you are pregnant. As the sooneryou know you are pregnant the sooner you can make those health choices that will come up daily! But what most patients and physicians mean is getting a test for those substances that we can test for in the urine or in the blood. Probably it would be more rhetorically (grammatically?) accurate to say that a real pregnancy test is one where you can truly verify the pregnancy itself…like a transvaginal ultrasound...because that is the baby, not just a substance made by the placenta, which is what we are testing in the pee or the blood. But that requires a bit more patience as it takes awhile, at least a month or more into the pregnancy, for those ultrasound tests to be positive. Mostly though, the first test of pregnancy in your pee or your blood is a test for HCG or human chorionic gonadotropin. This is a substance made by placentas. HCG is secreted into the blood stream and then excreted out into the urine. And companies have developed extraordinarily accurate tests to determine the presence of HCG as early as possible in a pregnancy. And typically blood testing can pick up very minute levels and is very accurate. But now and then individuals (yes, rarely men too) can have circulating substance that shows a positive HCG test that is not HCG at all. It has been nick named “phantom” HCG. It is another antibody that is similar enough to the HCG molecule that it binds to the test agents and reads positive. Usually it only reads falsely positive in blood. These molecules tend to be large, and may not actually be spilled intact into the urine. So oddly, the negative urine test is more accurate in this case, and can reveal the true nature of the so called “phantom” HCG, or positive ‘pregnancy’ test when in fact there is no pregnancy. How common is this? I used to say rare, but some studies quote rates of 1-2% of the population may have these antibodies that may read this way on a test. So don’t just assume that blood tests are “better,” some interpretation is important for every test you ever take! And as we say to all the gals, gabbing with your gyno is the best way to solve these dilemmas!

Saturday, August 9, 2014

Pregnancy After Uterine Ablation

Endometrial ablation treatments to control heavy menstrual bleeding render the uterus infertile, or we should say they typically render the uterus inhospitable for pregnancy. Women who have an endometrial ablation should not try to get pregnant and should be using effective contraception. The endometrial ablation technique often fails to render the uterus infertile, gynos always insist on having their patients use contraception after the procedure.The  endometrial ablation techniques are designed to eliminate the endometrial tissue (the lining tissue) of the uterus, either residual tissue or regeneration of the tissue is relatively common. The use of hormones can make this regneration of tissue more likely. When endometrial lining regeneration occurs women have been both at risk and voluntarily undergoing pregnancy after endometrial ablation in greater and greater numbers. In a recent Clinical Opinion by the Society of Maternal-Fetal Medicine they point out that one of the risk factors for having serious bleeding from the placenta in pregnancy. This bleeding after ablation in pregnancy due to a rare placental abnormality acreta (the placenta growing abnormally deep or through the wall of the uterus is pregnancy after an endometrial ablation. The actual statistical risk of this occurring is not known. It is more likely if other factors have occurred: prior C-sections prior uterine surgeries including curettage or uterine fibroids. There are known ultrasound appearances that can be a partial tip off, but the signs can be hard to see. The condition usually is not a problem until the pregnancy is being ended: such as during the delivery. Personal consultation with your gyno before a pregnancy is always best.

Friday, August 8, 2014

Wanting To Please Your PHysiican

I've seen more and more talk about the effectiveness of the administration of placebo. With the implication that placebo care is no care at all. And not so, because as patients and physicians we care very much which is at the root of the "pleasing principal." As a gyno I feel that just knowing the origin of this fascinating phenomenon's term explains the essence of placebo to me. The phrase I Shall Please is powerful, and it is the the meaning of the Latin verb placere. Placere in the plural is the derivative of the word placebo. Most of us mentally think of the phrase, "placebo pill" when we think of the word placebo, but is is not just a pill it is an entire physiologic process that acts to produce the responses seen when a placebo is administered. More correctly, the "I Shall Please" process is a 'placebo effect." It is why administration of the placebo medication in research trials almost universally produces salutatory treatment results as opposed to typical untreated patients.And the key to the phrase is the interaction. It is that inexplicable bond between health care provider and patient, it is thus explained by Leon Eisenberg to be a "healing response" or a "response to care", in fact he emphasizes that it is an important response. We of course knew this in Avicenna's time, a 11th century Persian physician who wrote over 450 documents on medicine, including the fact that the treatment will not work unless the physician believes in it and conveys that to the patient. So the pleaser has to get that feedback from the pleased, so I prefer to call this a "healing dynamic" as well as a treatment response!

Thursday, August 7, 2014

Ebola Cannot Be Prevented, But Vaccinations Are Still Critically Important to Keep Current

Protecting ourselves from illness is a complex process: unfortunately, not just a shot: but nutrition, improvement of our immune system, exercise, hand washing, limiting exposure when possible all are an integral part of avoiding disease. We cannot prevent Ebola by vaccination, but then again there are many diseases we can prevent. Vaccinations are invaluable however, and I have always urged patients to take full advantage of them, and that means rechecking with your health care provider regularly. Vaccination has eradicated small pox, and hopefully polio will be the next to go. We have talked about eradicating cervical cancer, and sexual health has to be added to the list of behaviors that contribute to the eradication of cervical cancer! Flu shots are only about 62 % effective in the 2013 flu season in sophisticated viral studies, although improvements, mentioned below, are coming for 2014. Most women can take most vaccines, but there are some contraindications to getting vaccinated. The CDC has announced changes in the vaccination policy. For pregnant moms there is a policy change in what is called the Tdap vaccine.  Tdap which stands for, the tetanus, diphtheria, acellular pertussis vaccine, comes on the heels of pertussis (whooping cough) outbreaks, including in our community in Illinois, as well as in other communities across the United States. The new recommendation is to vaccinate pregnant women in each and every pregnancy in the third trimester, preferably between 27 and 36 weeks. This includes pregnant women who have been vaccinated previously. Tdap vaccination according to the label is FDA approved for adults as single use only, so repeat maternal vaccination is considered an off-label use. Tdap booster is recommended universally for all adults, including those aged 65 years and older. There has been a change to the flu vaccine as well. Influenza vaccination is recommended for everyone, each year, over 6 months of age. That still stands, but there has been a name change. Instead of TIV, which stands for trivalent inactivated influenza vaccine, the new name is IIV -- inactivated influenza vaccine. There are situations where there is individual risk for vaccinations, and those should be determined by your own providers. For instance those who had Guillian-Barre syndrome within 6 weeks of a prior influenza vaccine might be told not to get the vaccination, and similarly some people with egg allergies cannot take live virus vaccines. Starting next year, many manufacturers will transition from a trivalent formulation that covers 2 strains of influenza A and 1 strain of influenza B to a quadrivalent formulation that doubles the coverage for these strains. For more complete information, speak with your own gyno, and additionally you can turn to the CDC website, the FDA website, or perhaps the Vaccine advisor.

Exercise, Lower Cholesterol, and Take Vitamin D: For Alzheimer's Prevention!

Not strictly a gyno topic, but a topic such as brain function as we get older, and brain function improvement are some of the most important and common questions I get asked as a physician, so it is a topic I do like to think and write about. As a normal consequence of aging we get a decline of thinking function. For a few of us a bit of word searching and forgetfulness will eventually translate into full blown dementia. And we want to prevent it. We should no longer think of Alzheimer’s as an older person’s disease, but the ultimate result of brain changes that occur one to two decades before the signs of clinical symptoms. Alzheimer's Disease was named for Dr. Alois Alzheimer who lived from Civil War days until 1915. He studied Auguste Deter who had delusions of jealousy, which progressed into full blown case of what is now known as Alzheimer's. When his now famous patient died the autopsy found a very atrophic brain. Risk of Alzheimer’s today is same as a century ago. In the 20th century was the nominative believe that senile dementia was a consequence of hardening of the brain vessels. By the 1970s the thinking was shifting from blood flow to a disease of damage to brain cells of a degenerative disease. And today 60-70% is caused by this degeneration of brain cells and small vascular disease. Norman Rockwell died of Alzheimers in 1970, as did Rita Hayworth in 1987, and given the devastation of this condition her family members targeted this disease for awareness. Barry Goldwater and Ronald Regan each had Alzheimer's. Charlston Heston died of this disease in 2008, actor Peter Falk secummed just this year. Alzheimer’s Association founded in 1980. The first most important discovery of the pathology was that beta-Amyloid protein was discovered by George Glenner and Caine Wong. Next in 1976 Tau Protein was identified as also being in the damaged nerve cells. Microtubular structure in neurons (brain cells) are destroyed by the tau protein, which is is normally destroyed as it appears. The first genetic link was found in 1987, showing that there is a mutation of the amyloid precursor protein (APP). We cannot yet use this knowledge to treat patients, but we are hoping it will lead to a cure. Now we know at least 5 genes are involved in the development of this disorder in patients. APOE-e4 allele variant copy in 50% of all cases. The thought is that both age and genetic predisposition work in the affected brains to accumulate amyloid –B. Once enough of these abnormal substance accumulate then the brain cells cannot fire as well, some inflammatory reactions are set in motion, and eventually what happens is neuronal death. If you have enough brain cells that have died off the full blown clinical syndrome of Alzheimer's occurs. And once again we think that anything that clogs the brain blood flow can set this process in motion. Keeping your cholesterol low and eliminating extra plaque build up in the brain is important, and normal levels of vitamin D are required as well, but if the process will occur anyway one thought is to fight it by having a better brain to start with! So brain teasers are important! There has been some progress in the testing for the early stages of disease, but mostly with MRIs and spinal taps and not really tests we can order in the gyno office! So for now, we have to be as proactive as we can and eating right, sleeping well, and exercising, are all part of that!

Wednesday, August 6, 2014

Every Day Health Hints

When did you last sterilize your nail tools, or vacuum your mattress, beat your down comforter, or switch the baking soda box in your fridge? Health is not just avoiding  sweets and fats, increase exercise, drink more water, and take vitamins as simple home remedies, there are other everyday tasks that make us healthier and smarter.. But many women are missing opportunities to do simple things that can increase their health. You're thinking 8 hours of sleep, reapplying sun screen, more flossing, check the basement for radon, and disinfecting your cell phone; and yes, these are quick simple health fixes as well. Literally there are hundreds of things you can do, but here is a list of another 10 simple things that women can do to enhance their everyday health:
1. Do not use aerosol sprays or if you use, use in open spaces, this includes not spraying kids with sun screens, it's not a good idea.
2. Change your pillow at least every 1-2 years (accumulates germs)
3. Own masks and gloves so that you can use around chemicals, or offer to ill friends who might insist on coughing non stop when visiting
4. Do not keep medications past expiration dates
, but don't worry too much about 'green' cleaning, most of it is not exactly necessary
6. Keep pets well washed and groomed
7. Check house plants as hidden sources for mold
8. Mix your own: what ever you can salad dressings, veg dips, anything you have has preservatives that are good to avoid
9. Read cooking books and think about new and varied diets, each food has it's own mix of nutrients and basically there are no end to suggestions on this topic!
10. More sex, it makes our endorphins high!
Thinks that don't work: avoiding chocolate for prevention of acne, not verified in health studies!

Saturday, August 2, 2014

Your First Period May Predict Your Lifetime Hormone Levels

Age of menarche, or our first period, has been studied from a variety of health issues. It is the first episode of shedding the lining of the uterus, also called the endometrium. One's fertility, one's propensity to pre and post menopausal breast cancer risk, and one's fertility, and even your risk of diabetes, seems to be linked to earlier menarche. In terms of breast cancer risk, the numbers are fairly dramatic. With almost a 10% less risk of premenopausal breast cancer for each year delay compared to average that a woman has her first period. Endometriosis and endometriosis associated pain have been linked with the age of menarche as well. It turns out that age of menarche is not just associated with the extra year or two of early cycles. Women with early menarche have higher overall hormone levels during all their reproductive years. Which may then explain the long term effects of getting an early menstrual period. And women are getting earlier and earlier menstrual periods, we have gone from an average age of almost 13 to average age of under 12. Weight achieved at that age is thought to be part of that equation. When talking to your gyno, discuss your reproductive life plan, and what risks you may be presented with based on your life of menstrual periods, and whether you have had too much hormone exposure.

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Uterine Fibroid Study

If you are a female between the ages of 18 and 50 years old and are experiencing abnormal bleeding due to uterine fibroids, you may be able to take part in the VENUS research study, testing an investigational medicine. Qualified participants will receive study-related medical evaluations and care at no cost. If interested, please call 217-356-3736.

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