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Sunday, November 1, 2015

A Pill for the Healthy to Prevent Being Sick

Yes, pills are used for many healthy individuals to fight off risk, sort of like taking a vitamin. Generally speaking we think of most wellness care as eating better, exercising more, not smoking, and getting better sleep as part of  'therapeutic lifestyle changes.' But that's not enough power to fight off all the ravages of aging, genetics, and environmental damage, so perhaps turning to medication is what is going to be the most effective.

The polypill is one good example of a pill for the healthy to prevent getting sick. It is directed at prevention of cardiovascular disease. And in the September 4th issue of JAMA 2013 it's back in the news, although almost two decades have passed in the efforts to get a polypill that will really work. The polypill was proposed over 10 years ago by Drs Wald and Law in a study in the British Medical Journal, when it was tested the medication included  three half dosage anti-hpertension agents, with other agents including a intermediate-dose statin, a low dose aspirin and folic acid. With the research that was done showing about 80% reduction in heart attacks and strokes in individuals over the age 55 and older.

Too long going to the doc meant getting treated while sick. And now we expect treatment so we do not get sick. Gynos were ahead of the curve in that. Gyno doc visits at least introduced, in a mass market kind of way, the idea of screening for sickness. Our first success with screening with the pap test, although no pill really treated an  abnormal pap, then we began the pregnancy screening concept dubbed prenatal care, but it was pretty much only focused on pre-eclampsia that very specialized version of  high blood pressure in pregnancy at the get go. However, still in the USA most doc visits are aimed at treating the sick, with a mere nod to the concept of staying well or making you a whole lot better.

A wellness visit for women actually focuses on screening for disease, and still needs just a bit of a tweak more to focus on actually making you better. Show up at a normal weight and no obvious medical condition, no one will ever question your diet. Have a low blood pressure at your check up, were you ever told how to keep it there? Probably you have been told your health care provider to avoid secondhand smoke, perhaps a quick reminder about seat belts, wearing sun screen and using condoms. All designed to prevent illness, not to make you “even healthier.” And my favorite be healthier advice best nod to keeping you healthy beyond just exercising,…encourage sex (yes, for adults sex can be extremely healthy). In gynecology we have long touted the non-contraceptive health benefits of taking oral contraceptives, it specifically suppresses both ovulation and the uterine lining tissue, raising the blood counts and improving bone density even in the healthiest of users.

But how about taking this one step further, requiring anyone without contraindications to take at least 10 or twenty years of oral contraceptives? This strategy has been estimated to eliminate 80% of all ovarian cancers. What we have wondered about is this treatment of a pill to prevent ovarian cancer limited to just specific groups of women, or could we get this being effective for many groups of women?

One  new case-control study compared 207 women with hereditary ovarian cancer and a BRCA1 or BRCA2 mutation to 161 of their sisters without ovarian cancer. Any past use of oral contraceptives was associated with a reduced rate of  ovarian cancer by half if the woman got her pills for at least 6 years. And in another study they looked at women who weren't known to have the risky genes but had family members with cancer, and yes, they were protected more than lower risk women. Other small studies confirm the findings across all types of oral contraceptive pills. Only one study in Israeli Jewish women who showed that average patients were protected, but not the ones with the known family risk. But it may have not been as revealing a study because those studied were such a unique group for many reasons. So giving a birth control pill for those healthy women is very effective. What other kinds of pills should the healthy take? And going even farther to ward off disease would be to use pills to ward off high blood pressure and heart disease all together. . Using a pill to treat the entire healthy population, to help ward off disease would indeed be rather radical. But something to Gab about with your Gyno!

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