Saturday, December 8, 2007

Women Positive About Aging

A recent poll on women on their attitudes towards aging showed that many said the best was yet to come. Please, read more:

Monday, December 3, 2007

CHP Lorain Spirit of Women Wins National Recognition

Mario Sertich, MD, introduced the spirit of women to the Lorain Community Hospital. This organization aims at bringing women's attention to different programs in the community hospital. Please, read on:

Monday, November 5, 2007

Gardasil Vaccine Protects Older Women.

Gardasil, the new Human Papilloma Virus vaccine approved for use in women aged 9 -26 years, in recent studies has been found to effective in women older than 27 years. It is effective up to age 45 years. I have had many of my older patients inquiring about the use of the Gardasil vaccine in older women. This is good news for those older women who are not already infected by the Human Papilloma Virus.

Monday, October 1, 2007

Raloxifene (Evista) Approved for Lowering Breast Cancer Risk in Postmenopausal Women

The FDA has approved Raloxifene to be used in two groups of women, namely those with osteoporosis and those at high risk of having breast cancer. This drug is like Tamoxifen that is currently used as prophylaxis in women with breast cancer. However, unlike Tamoxifen, Raloxifene does not cause cancer of the uterus. Both of them can cause hot flashes and clots in the veins. Unlike drugs like Fosamax or Actonel, Raloxifene does not prevent hip fractures. This is a boon to women with a history of osteoporosis in their spine and with a family history of breast cancer.

Tuesday, July 10, 2007

Loop Electrosurgical Procedure (LEEP) and the Risk of Premature Labor.

Abnormal Pap smear can be classified as low grade disease or high grade disease or cancer of the cervix. The treatment of the low grade disease may involve observation with Pap smears or freezing of the cervix. The high grade diseases are usually treated with removal of the affected area of the cervix by LEEP (Loop Electrosurgical Procedure). The treatment of cancer of the cervix is radical hysterectomy depending on the stage of the disease.

The benefit of the LEEP procedure in the treatment of precancerous disease of the cervix is that it removes the diseased cervix which is examined by a pathologist to determine the severity and the extent of the disease.

I had a patient who had severe dyspalsia on the cervix for which she had LEEP procedure. She got pregnant. At 13 weeks, I discussed cervical cerclage with her becasue of her short cervix. She had to see another physician because of insurance issues. The new physician refused to place the stich in the cervix. At 24 weeks she went into premature labour and had to stay off work throughout the pregnancy.

It is therefore interesting that a recent study in Danish pregnant women looking at the relationship between previous LEEP procedure and subsequent risk of preterm labor showed that women who had LEEP procedure had 2x chance of having premature labor.

If you have had LEEP procedure, you should let your obstetrician or midwife know about it. Your caregiver may measure the length of your cervix in early pregnancy with ultrasound to determine whether your cervix needs to be stitched or not. If your cervix is long enough to hold the baby, you may still have your baby early and hence you need to be followed up closely.

Reference:
Acta Obstet Gynecol Scand. 2007; 86(5):596-603

Saturday, June 30, 2007

Antidepressants In Pregnancy. Are they Safe?

Depression is a common condition that afflicts women. Depressed pregnant women are at risk of preterm labor and worsening of their depression. Hence, treatment of these patients is important. That is why two recent articles that appeared in the New England Journal of Medicine about drug treatment of depression in pregnancy are important.

Previous studies implicated the selective serotonin reuptake inhibitors (SSRI's) like Paxil, Prozac and Zoloft in causing birth defects. These two new studies agree that the SSRI's have low risk of causing fetal abnormalities. Pregnant women who have depression should take comfort that they can take the SSRI's without having to worry about having abnormal babies. The abnormalities found in previous studies are rare.

Reference: New England Journal of Medicine.

Sunday, June 24, 2007

Depressed Women May Have Premature Babies

A study done in England on depressed pregnant women showed the severely depressed women who were not taking medications had premature labor.

That depression produces stress hormones is exemplified by this study. Dr. O'Keane, a perinatal psychiatrist at the King's College in London measured corticotrophin releasing hormone (CRF) in 25 depressed pregnant women who were not on any antidepressant medications and 35 pregnant women who had no depression.

Levels of CRF and cortisol, hormones related to stress and also produced  by the placenta in pregnancy were found to be higher in women with depression.

While none of the mothers that were not depressed had premature deliveries, on the average, the depressed mothers had their babies 2 days earlier and 3 of them had premature deliveries.

During the follow up visit, the babies whose mothers had depression had high levels of cortisol in their saliva, a sign that their mothers' stress had effect on them..

The study involved a few patients. More studies are needed to elucidate the findings of this interesting small study. The take home message is that depressed pregnant patients' stress may have effect on their unborn babies. The effect may even continue after delivery. Hence pregnant women who are depressed should be treated with antidepressants despite the fear that some of the antidepressants may have effect on the newborn babies.

 

Reference: From issue 2599 of New Scientist magazine, 14 April 2007, page 18

Saturday, June 23, 2007

Estrogen Therapy is good for the Young Postmenopausal Woman’s Heart.

The estrogen therapy controversy has not been put to rest yet. The WHI study that was highly publicized showed that postmenopausal women who took estrogen did not benefit from the estrogen replacement therapy and may even be at an increased risk of having heart disease.

In 1994, the Women Health Initiative trial using estrogen alone showed no adverse effect from the estrogen therapy. That study was stopped prematurely.

A study published by Manson and her colleagues in the most recent New England Journal of Medicine showed that estrogen therapy in younger women (50 -59 years), who have recently undergone hysterectomy with removal of their ovaries and hence have had surgical menopause, have protection against heart disease by keeping the lumen of the blood vessels open. Without the estrogen, calcium is deposited in the walls of the blood vessels thus causing narrowing.

The take home message is that in women who have had hysterectomy with removal of their ovaries in their 40’s to early 50’s, estrogen replacement therapy may be beneficial to the heart as it slows down the narrowing of the blood vessels.

Sunday, May 13, 2007

Oral Sex Is Not Free. It Can Cause Throat Cancer.

A study which is appearing in this week's New England Journal of Medicine showed that both men and women who claimed they had six or more oral sex partners during their lifetime had about 9x increased risk of having cancer of the base of the tongue or the tonsils. The Human Papilloma Virus (HPV) was the culprit. In the study, the participants who had HPV infection were 32 times more likely to develop this type of oral cancer than those without the HPV infection.

The Gardasil vaccine contains 4 types of HPV viruses, namely 16 and 18 that cause about 70% of all cervical cancers and 6 and 11 that cause genital warts. In this study, of the 100 cancer patients enrolled, 72 had HPV 16. Two major risks that promote throat cancer are smoking (3 times greater) or drinking (2.5 times greater). These cancers are more common in men than in women. Does it mean that to prevent oral cancer in men who practise oral sex, these men should be offered the Gardasil vaccine? Only more studies can tell.

Between 12,000 and 15,000 new cases of oral and pharynx cancer are diagnosed each hear. 3000 people die form it. Dr. Robert Haddad, clinical director of the Head and Neck Oncology Program at the Dana-Farber Cancer Institute has seen younger men in their 30's and 40's getting this cancer. The bottom line is that since men don't know which women will have cancer causing viruses in their vagina, they should avoid oral sex as the price has become too much to ignore.

Reference:
New England Journal of Medicine (NEJM)

Cervical Cancer Vaccine May Prevent Precancerous Changes on the Cervix

An article published in the May 10th New England Journal of Medicine showed that young women not infected with Human Papilloma Virus HPV 16 and 18 who were vaccinated with the Gardasil vaccine had a lower occurrence of the high grade precancerous diseases on the cervix than those who were vaccinated with placebo.

The study was done on 12,167 women aged 15-26 years who had not been previously infected with the HPV. Thus the vaccine, if given to young women who have not already been exposed to the Human Papilloma Virus, is effective in preventing cervical dysplasia in women that will be apparent within years rather than decades.

"Human papillomavirus types 16 (HPV-16) and 18 (HPV-18) cause approximately 70% of cervical cancers worldwide,"

Laura A. Koutsky, PhD, from the University of Washington in Seattle, and colleagues from the FUTURE II study group.

Reference:N Engl J Med. 2007;356:1915-1917.

Sunday, May 6, 2007

Gonorrhea -The Super Bug

Gonorrhea, the second most notifiable disease in the US, is rapidly becoming resistant to Fluoroquinolones, such as Cipro according to the CDC. Physicians are advised to use the last line of defense, the Cephalosporins. In the April 13th issue of the Morbidity and Mortality weekly, the Center for Disease Control reported there was 13% overall resistance. In some areas 39% of the bug is resistant to the Fluoloquinolones. On the basis of this evidence the CDC

"No longer recommends the use of Fluoroquinolones for the treatment of gonococcal infections and associated conditions such as pelvic inflammatory disease."

Wednesday, May 2, 2007

Mend Your Bones with One Shot per Year

"Preventing hip fractures remains the holy grail of treating osteoporosis, as we know that six months after a hip fracture, nearly a fifth of patients will be dead."

David Reid

University of Aberdeen


A study on brittle bone disease (Osteoporosis) published in the recent edition of the New England journal of Medicine showed that once a year injection of a drug called Zoledronic Acid effectively treated osteoporosis compared to pills. This will be convenient than taking daily or weekly or even monthly pills for the treatment of osteoporosis (brittle bone disease) that afflicts many postmenopausal women.

Saturday, April 28, 2007

Australian Women Seeking Vaginal Plastic Surgery

Many unmarried Australian women are seeking plastic surgery to improve the look of their vulva according to Dr. Colin Moore, a plastic surgeon who has been performing this kind of surgery for about 30 years.

Dental Care In Pregnancy Can Prevent Premature Labor

Gum disease has been found to cause heart disease because of the increased production of the C-Reactive Protein. The level of the C Reactive Protein decreases when the gum disease is treated. It is therefore interesting to find that a similar mechanism can affect the outcome of childbirth.

A recent study that appeared in the American Journal Of Obstetrics and Gynecology showed that gum disease can cause premature labor. Among 1020 pregnant women who were followed in pregnancy, 28.6% women with moderate to severe periodontal disease had preterm delivery as compared to 11.2% of women with no periodontal disease. The authors concluded that gum disease in pregnancy is a predictor of premature labor.

Hence dental care should not stop in pregnancy. It will be more prudent for women who want to get pregnant to see their dentist to give them a clean bill of dental health before they get pregnant.

Reference:

Offenbacher et al

Obst Gynec. 2006, 107:29-36

Saturday, April 21, 2007

Hormone Replacement Therapy Linked To Ovarian Cancer.

Ovarian cancer is a deadly disease. Up till now there has not been any significant test to screen for the disease in its early stages. The recent finding from a British study that appeared in the Lancet is frightening since its use may have resulted in a thousand deaths since 1991. The study was from the million women study. 30% were current users of hormone replacement therapy and 20% were past users. Current users had 1-2 fold greater risk for ovarian cancer than never user. The highest risk was for serous tumors in women with epithelial cancer, with current users at 1.53 times the risk as never users. The consensus is that current advice to take estrogen replacement therapy will not change however women should take hormone replacement therapy for a short time.

Tuesday, April 17, 2007

Polycystic Ovarian Disease-A Common Health Hazard

Question:

I am a 28 year old married woman who has been trying to have a baby for the past 4 years. I have had 2 miscarriages within the first 6 to 8 weeks of my pregnancy. Recently my periods have become irregular and scanty, I am gaining weight at a fast rate. Over the past month I have gained 10 pounds of weight. I am growing hair on my chin and my belly wall. I also have zits on my face. It looks like I have a become a teenager all over again. What is going on with my body? Can I ever have a baby?

Answer:

You may have polycystic ovarian disease. I see many women your age with your symptoms. Most of them have polycystic ovarian disease. Your weight gain, increased hair growth, irregular bleeding and recurrent pregnancy loss are common in people with PCO.

The cause of polycystic ovarian disease is not known for sure. However, many people who are affected by the disease have increased male hormones which lead to insulin resistance. In the presence of adequate insulin levels the muscles for example cannot utilise the insulin available. The muscles need the insulin to help them use the blood sugar. The insulin resistance does not affect every tissue. Some tissues retain their sensitivity to the insulin while others like the muscles develop insulin resistance. The proteins that bind and carry the sex hormones decrease because they have been used to carry the excess male hormones floating in your body.The body compensates by increasing the production of more male hormones.

Women with PCO do not ovulate or if they ovulate they do so infrequently. They therefore have difficulty in getting pregnant. When they get pregnant they tend to have miscarriages, diabetes mellitus and high blood pressure.

I suggest you discuss your condition with your doctor. She may examine you and look for tell tale signs of PCO such as acne, increased facial and body hair, skin tags around your neck, velvety dark discoloration around your neck and under your breasts, increased hair on your anterior abdominal wall and your face, increased body mass index. She may do blood tests to exclude other diseases such as thyroid disease.

If you have polycystic ovarian disease, your doctor may give you metformin, which has been found to help treat PCO and decrease early pregnancy loss. If the metformin alone does not help you get pregnant, your doctor may add clomid. Your doctor may also give you the clomid alone without the metformin. You may have to stay on the metformin for at least 3 months when you get pregnant.

Sunday, April 15, 2007

Your Obesity May be Genetic - Obesity Gene Discovered.

A recent article that appeared in the Journal, Science, showed the discovery of obesity gene. A UK research team, led by Dr Andrew Hattersley of Peninsula Medical School in Exeter, has discovered a gene variant that occurs in over half of people of European descent that they think helps to regulate the amount of fat in the body. Obesity is linked to diabetes mellitus. People with diabetes mellitus have a particular variant of an FTO gene which was also linked with increased body weight.

The variant making people fatter differed from the other version of the FTO gene by a single mutation in the DNA sequence. People with one copy of the "fat" FTO variant had 30% chance of being obese compared to people without the gene. Those carrying two copies of the variant had a 70% increased risk of being obese, and were on average 3kg (6.6lb) heavier than a similar person with no copies. This finding helps to understand why some people cannot loose weight in spite of all attempts to loose weight.

Saturday, April 7, 2007

Cardio Pulmonary Resuscitation In Patients Who Have Had Recent Heart Attack. Is It Necessary?

Many people do not like to give mouth to mouth resuscitation to a stranger who has had a heart attack. A recent article in the Lancet, a British Medical Journal claims that mouth to mouth resuscitation is not necessary in heart attack victims because their blood contains enough oxygen to sustain them for several minutes until the heart recovers. Chest compressions are far better than rescue breathing which requires regular pauses in the chest compressions.

The authors believe the benefit from continuous chest compressions far outweighs that from so-called "rescue breathing", which necessitates regular pauses in the compressions. Studies show less than a third of people who collapse in public are helped by people because of the “yuk” factor. If people realize that they don’t have to give mouth to mouth resuscitation they will be more willing to help a heart attack victim. On the other hand near drowning patients will need chest compression and mouth to mouth resuscitation

"The forward blood flow that you get from pumping on the chest is so marginal that if you stop for anything it's bad for the brain," Gordon Ewy

Reference:

The Lancet 2007; 369:920-926

DOI:10.1016/S0140-6736(07)60451-6

Articles

Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study

SOS-KANTO study group

Friday, April 6, 2007

Maternal Fish Consumption in Pregnancy Provides “Brain Food” For Baby’s Brain


"Seafood is the main food source of omega-3 fatty acids, which are essential for optimum neural development. However, in 2004, the FDA and the Environmental Protection Agency advised women who were pregnant or might become pregnant to limit seafood intake during pregnancy to 340 g per week (less than three portions) to avoid exposure to trace amounts of neurotoxins, especially methylmercury"

Judith Groch

Many of my patients are afraid of eating fish because of the fear that they will ingest too much mercury to affect the developing baby's brain. This deprives them of the Omega 3 Acid that is good for the development of the baby's brain. It is therefore very encouraging that a recent Lancet article summarized in Medpage Today, showed evidence to the contrary. According to many pregnant women, this is serious enough for them not to eat fish in pregnancy.

"A U.S. survey showed that two-thirds of Americans believe that 1,000 to 100,000 U.S. children are poisoned by mercury from eating fish every year. In fact, Drs. Myers and Davidson said that there has never been even one child with prenatal mercury poisoning from consuming fish documented outside Japan." Judith Groch

Joseph Hibbeln, MD of the National Institute of Alcoholic Abuse and Alcoholism and colleagues, showed that:

"After adjustment, maternal seafood intake during pregnancy of less than 340 g per week was associated with an increased risk at age eight years of the child being in the lowest quartile for verbal IQ (no seafood consumption, odds ratio [OR] 1.48, 95% CI 1.16-1.90; some seafood, 1.09, CI 0.92-1.29; overall trend, P=0.004), compared with mothers who consumed more than 340 g per week. At seven years, low maternal seafood intake was also associated with an increased risk of suboptimum outcomes for prosocial behavior 1.44 (CI 1.05-1.97) for no seafood consumption versus more than 340 g/week. Overall, the investigators said, the higher the maternal seafood intake, the less likely the infant was to have a poor score. At ages up to 3.5 years, scores were also lower for fine-motor skills, communication, and social development, they reported. Maternal seafood consumption reached a mean of 235 g a week, resulting in estimated weekly intakes of zero to 15.6 g, and a mean intake of 1.06 g of omega-3 fatty acids a week. " Judith Groch

Hence it is important that pregnant women know that fish, the major source of Omega 3 Acid is important for the development of the baby's brain. The benefits far outweigh the risks of Mercury poisoning from seafood. A risk largely attributed to fatty fish.


"Additional source: The Lancet

Source reference:

Hibbeln, JR, et al "Maternal seafood consumption in pregnancy and neurodevelopmental outcome in childhood (ALSPAC study): an observational cohort study" Lancet 2007; 369: 578-585. "



"Additional source: The Lancet

Source reference:

Myers, GJ, Davidson PW "Maternal fish consumption benefits children's development" Lancet 2007; 369: 537-539."

Cancer Of The Ovary-Screening Test for Women Is In The Horizon

Ovarian cancer is one of the most difficult cancers to diagnose in its early stages. It does not have any specific symptoms and most patients are diagnosed in the advanced stages when the results of treatment are poor. On the other hand when they are diagnosed in its early stage the five year survival rate is about 90% as compared to 20% in the late stage.

Up till now there have not been any significant screening tests such as Pap smear to screen for cervical cancer. According to Alisa Leisa, MD of Yale University, a highly sensitive blood test comprising of six biological markers can be used to detect the disease in its early stages. The positive predictive value is 93% in the test population and a negative predictive value of 99.2%. Yale University is currently enrolling women at high risk of ovarian cancer and healthy controls.

Tuesday, April 3, 2007

Is Testosterone Too Much of a Good Thing for Women’s Health?

I see many women in my office complaining of decreased libido. Most of these women are in the middle age with its change in hormones and life's uncertainties. In our world we are used to taking medications for anything that bothers us. Many life changes can decrease women's desire for sex. However, tell the modern woman that her stress from the fear of loosing her job is causing her decreased libido and she will seek another physician who would be prepared to slap the testosterone patch on her without much protest. A recent article in the Star Tribune shows that testosterone is not a panacea for women suffering from decreased libido.

Sunday, March 25, 2007

Genital Herpes in Pregnancy-A Health Hazard for the Baby

Question:

I got married a week ago and I have missed my period. I saw my doctor who did a pregnancy test and pelvic ultrasound and told me I was 6 weeks pregnant. Two weeks ago I started having painful urination and multiple blisters on my vulva. My doctor diagnosed me with genital herpes and started me on medications. I have finished the treatment but I am supposed to take the medication throughout the pregnancy. Is my baby going to be alright?

Answer:

Genital Herpes is a common sexually transmitted disease which is under diagnosed because sometimes patients with the disease don’t have any symptoms. In your case, your doctor did the right thing by treating you and giving you medication to prevent recurrent infections during your pregnancy and after delivery. Your husband has to have blood test to ensure that he does not have the disease. If he has it he should also be treated as he may have outbreaks and transmit the disease to you again. I will suggest that even if his test is negative you should use condoms for sexual intercourse.

The effect of the infection on the new born baby is severe. About 80% of the babies may be infected by the virus at birth if untreated. Hence if you are found to have the disease at the time of your delivery, you would be delivered by cesarean section to prevent the baby from being infected by the virus. Other prevention measures include giving you prophylactic antiviral medications to suppress the infection during the pregnancy. Three medications are available for treatment. Valacyclovir and Famciclovir would be more convenient as prophylaxis than Acyclovir because of convenience in their dosing.

Since many people with genital herpes don’t know they have the disease, it will seem to be reasonable to screen all pregnant women for genital herpes with blood test. This way, if their test is positive, they would receive prophylactic medication to prevent possible herpes infection in the pregnancy and the postpartum period.

Saturday, February 3, 2007

Your Pelvic Pain May not be Endometriosis





Question
:

I am a thirty year old woman with 2 children. Over the past few years I have been battling pelvic pain with no help in sight. My gynecologist did a laparoscopy on me and found no endometriosis.

My symptoms include painful intercourse both at the entrance and deeper part of my vagina. I wake up at night many times to go to the bathroom. My doctor has treated me with antibiotics on many occasions for bladder infections without improvement. I have been scheduled to have hysterectomy with removal of my ovaries. What should I do?

Answer:
Your condition is not unique. I recently saw a 21 year old woman who has had hysterectomy with removal of her ovaries because of pelvic pain presumed to be pelvic endometriosis. I often see women in my practice who have been variously treated for pelvic pain without relief.

They tend to have pain with sexual intercourse, frequency of urination during the day and at night. They may have associated pain at the entrance of the vagina. Many would have been treated for pelvic endometriosis, diverticulitis or recurrent urinary tract infections without improvement of their condition. Usually these patients have Chronic Interstitial Cystitis. The pain may flare up during menstrual periods and mimic pelvic endometriosis.

We don't know the cause of the disease though some theories of its causation exist. It can affect men but it is more common in women with devastating consequences since it affects sexual activity and sometimes prevents the patients from working. Most patients I see at the office have been variously treated for pelvic endometriosis, recurrent urinary tract infections, pelvic inflammatory disease and diverticulitis.

My approach to diagnosis is to ask the patient about frequent urination, pelvic pain and painful intercourse. I then examine them specifically looking for tenderness at the entrance of the vagina and the bladder, backed by the Interstitial cystitis questionnaire (PUF). I obtain urine for culture and cytology to exclude bladder infection and cancer. I do not do the potassium sensitivity test which can be painful in the office setting. If the urine tests are negative, I treat the patient with 3 medications.
  • The first is Elavil (Amitryptiline) that blocks the nerve endings and treat pain.
  • Atarax (Hydroxyzine) that prevents allergies in the bladder.
  • Elmiron that coats the bladder to treat the condition.
The last counseling I give to the patient is to draw their attention to certain foods that can cause allergies in the bladder and aggravate their condition. Most patients do well if they take their medications and avoid foods that can aggravate the bladder.

Tuesday, January 9, 2007

States Making Gardasil Available For Children

The Texas legislator, in the next session, will consider girls entering the sixth grade to be given the Gardasil vaccine. Parents can apply for exemption if they don't want their children to receive the vaccine. Meanwhile, New Hamshire this week is distributing the Gardasil to doctors and clinics to be given to girls and women 11 to 18.

Sunday, January 7, 2007

ACOG Recommendations Women's Care

The American College of Obstetricians and Gynecologists recently has recently recommended these tests to be done on women:
  1. Women 19-64 should be screened for HIV regardless of their risk factors
  2. Women in the childbearing age should plan their pregnancy
  3. Women 50 and over should have screening for colon and rectal cancer
  4. Women aged 9-26 years should receive the HPV Vaccine
  5. Whooping cough vaccine has been added to the Tetanus Diphtheria and the Meningitis vaccine. The vaccine should be given between 11 and 16 and every 10 years thereafter till age 64