Quartly Notes:

Breast Cancer:

Breast cancer is a leading cause of cancer in women, second only to lung cancer. There are 192,000 diagnoses per year with approximately 40,000 deaths per year due to breast cancer.

Decreasing the death rate from breast cancer:

Currently, the death rate from breast cancer has been shown to be most impacted by two main players: screening mammography and improved adjuvant treatment for breast cancer itself.

               Screening mammography – The American Cancer Society (ACS) recommends yearly screening mammograms in women from 40-84 years old.  On the other hand, the United States Preventive Services Task Force (USPSTF) recommends screening every other year in women 50-74 years old. Who gets to decide how often  women are screened has been left up to the practitioner to individualize based on perception of risk.

               Does screening mammography have the potential to increase the risk for cancer due to the radiation it imparts? Yes, BUT. While some studies have concluded that for every year a woman gets a mammogram, her risk for breast cancer increases an additional 1 %, research discussed at the 19^th Annual Primary Health Care for Women, presented by the University of Michigan Medical School surmised, “59-182 women’s lives are saved by mammography for every 1 breast cancer induced by radiation exposure.” Those are compelling numbers.

               Also, keep in mind that digital mammography (newer technology) has 25% less radiation compared to the older traditional mammogram equipment.

What are the downsides of annual mammographic screening?

Besides a small amount of radiation (remember, not enough radiation to offset the benefits of the number of lives saved by doing annual mammography) the new technology does tend to see more potential cancers than are actually there (false positives). This leads to more women being called back for more testing, more biopsies of normal tissue and more anxiety all around. The positives of more biopsies are that they are more likely to reveal precancerous changes that allow a woman to subsequently increase her vigilance for cancer in a particular area and thus catch a potential cancer earlier.

Thermography – thermography is technology that utilizes infrared light to identify thermal emissions that suggest potential risk markers. That is to say, thermography is another modality by which women can look for areas that might be at increased risk for breast cancer. Thermography (like mammography) does not diagnose breast cancer nor does it treat breast cancer, it is used to assist in detection of increased risk or the possible presence of breast cancer. It is FDA approved but currently not the recommended tool for annual screening whereas mammography is the recommended for women. Unlike mammography however, thermography does not involve any radiation exposure nor does it involve touching or compressing the breast tissue to be performed. It is not intended to be used instead of mammography but may be used as an adjunctive tool and in particular in young women who are not at the age of recommendation for annual mammograms, thermography can be a tool to allow them to look for abnormal breast tissue earlier. The inherent problem with thermography, a problem similar to any sensitive tool is that it may see abnormal activity that is not yet a cancer and hence cause increased anxiety until a cancer actually presents itself. Like any modality, it too can see false positives and false negatives. Similar to other modalities that look for breast cancer, it is a screening tool, meant to help women look for early changes in breast tissue that might lead to breast cancer. It is important for women to understand that thermography is not recommended to be used instead of mammography but as an adjunct to mammography as is ultrasound or MRI, each which also have their place in helping to look for breast cancer.

MRI and Ultrasound, when are they appropriate?

When an abnormality in breast tissue is perceived and a diagnostic mammography has been ordered the radiologist may feel an ultrasound and/or MRI might give additional information. I have also seen ultrasound used to delineate a cystic from a solid breast mass, however, more and more radiologists are choosing to use ultrasound more liberally as an additional tool to mammography in some women.

Quartly Notes

WHAT ARE BIOIDENTICAL HORMONES?

By Marianne Zakarian, MD FACOG

    As an obstetrician and gynecologist, I often get asked about bioidentical hormones, what they are and how they differ from the traditional hormones physicians have prescribed.

    Bioidentical hormones are simply hormones that have an identical composition to what our own body makes. They usually are made in a lab, but this is to be expected. There are hormones that are not made in a lab, but usually these are not bioidentical. Take for instance, the hormones that are from a pregnant mare's urine. These work well in our human bodies but are not bioidentical; that is to say, their composition differs somewhat from what our ovaries actually make, yet out bodies respond to these hormones nevertheless to a large degree. Plant based hormones are also not bioidentical usually. Our ovaries do not make estrogens, progesterones and testosterone that look exactly like the ones from plants. Once again, it is usually necessary to make the hormones in a laboratory setting so that their composition will be identical to the hormones our own bodies make and herein lies the term, “bioidentical.”

    Are bioidentical hormones “natural?” People often confuse the term “natural “ for bioidentical. The hormones from a pregnant mare are “natural” in that they come from an animal, in particular, they are natural to the pregnant mare. Plant based hormones are natural to plants. The bioidentical hormones made in a lab that are the exact chemical structure as the hormones our own bodies make, are therefore “natural” to our human bodies.

    Some people believe a substance is not natural if it has to be formulated and doesn't occur on its own in nature. If this is one's definition of natural, and this is a reasonable definition, then this kind of natural is not necessarily safer or healthier than a lab-formulated substance which may actually be more “natural” to our bodies than something that occurs naturally in nature as in plant-based hormones or those from a pregnant mare.

    Are bioidentical hormones better for women? The jury is still not out on that topic. One would think that a substance that is the exact composition of what our own body makes, might be better than a substance that our body just “responds” to, but is not something our body is capable of making an exact duplicate of.....but maybe this difference is not important. We still have studies looking at these differences. In the meantime, I can give you what little we do know and the rest is up to opinion.

    Last but not least, a woman should see her health care practitioner on a regular schedule and impart to him or her all vitamins, medicines and hormones she is on so that the health care practitioner may be aware of any potential risks, interactions and benefits that the patient may be subject to. The practitioner can help to optimize the patient's regimen and should be able to catch any problems as they arise, perhaps even prevent them from occurring and inform the patient of the latest findings related to the substances.

Quartly Notes

MENOPAUSE, WHAT ABOUT HORMONES?

The issue of hormone replacement therapy in women at or near menopause has been confusing at best to most patients. In an attempt to simplify and clarify the issue, I would like to briefly review the most up-to-date evidence by reviewing the history of hormone replacement studies. We have decades of evidence that estrogen is beneficial to not only improving the quality of life in women at or near menopause in that it helps decrease to or eliminate the troublesome more obvious symptoms of menopause such as hotflashes, insomnia, memory loss, vaginal dryness and associated painful intercourse, but we also have many years of evidence that estrogen, particularly oral estrogen, gives a significant amount of protection from cardiovascular disease and also dementia in healthy patients who begin taking estrogen at or near near menopause.

This protection goes on for many years. You might ask, how is this possible? You may have heard that estrogen increases the risk of stroke and dementia. Most recently, as a result of the many studies on estrogen and some seemingly conflicting information, a theory has emerged called "The Timing Hypothesis.” This postulates that women who are without preexisting atherosclerosis (hardening of the arteries leading to heart disease) evidenced by high cholesterol, diabetes, hypertension and obesity for example, are actually better off taking estrogen (particularly oral estrogen). Importantly, providing there is no atheroschlerosis present already, we have strong evidence that oral estrogen will actually protect women from developing this form of heart disease.

Women who become menopausal who choose not to take estrogen automatically begin to have an increase in the development of atherosclerosis related to aging and lack of estrogen protection. They also begin to lose bone mass (estrogen would protect them from this), and the vaginal tissue begins to thin and dry which will ultimately result in sex becoming too painful because of the tearing of the vaginal tissue that begins to occur with intercourse secondary to the drying vaginal tissue (estrogen prevents this).

We have many studies that also show that estrogen protects the brain. It makes sense when one realizes that dementia is related to aging and in particular to the age-related development of atherosclerosis (estrogen is a powerful protector of the brain), and now knowing that estrogen protects from the formation of atheroschlorosis, we can see that estrogen would subsequently protect the brain from dementia too. So why did some studies show that estrogen increases the risk of stroke and dementia?

This is an important point: if a woman ALREADY HAS atherosclerosis oral estrogen increases a substance in the body that can cause atherosclerotic plaque rupture (which leads to stroke and dementia)…BUT, IF A WOMAN IS HEALTHY, WITHOUT atherosclerosis, then some studies show that oral estrogen  might actually help PREVENT the development of heart disease (atherosclerosis) and dementia. So should women who already have heart disease (these are women more than 10 years after menopause – remember, they have had 10 years of no estrogen protection from heart disease, or women with high cholesterol, obesity, diabetes, high blood pressure) NOT TAKE ESTROGEN? At this point, studies are still being done but it may be that estrogen that is transdermal (gels, creams, patches, sprays) might NOT increase the substances in the body that cause heart disease.

To-date, out most studies suggest that transdermal estrogen (patches, gels, sprays) does not give the protection from heart disease that women who don’t already have heart disease get, but because it does not worsen it, if a woman needs estrogen and she already has signs of preexisting heart disease – again, these are women greater than 10 years after menopause not on hormones, or women with obesity, diabetes, hypertension, etc. at or near menopause, then transdermal estrogen might be another option....keep in mind, these are studies that need to be completed to know for sure, so at this point, this is speculation.

So why would such a woman want to take estrogen? Well, if she has had to stop having intercourse with her partner due to the painful dryness that a lack of estrogen causes, she might want to try a transdermal estrogen either vaginally or on the skin of her arms/abdomen, back or shoulders and this would very probably help her be able to have a moist vagina and therefore comfortable intercourse, or if she has hot flashes, insomnia, depression….than transdermal estrogen is another option to consider and might possibly help her with all of these things.

What about breast cancer risk? This is important. The big study that showed an increase in breast cancer on hormones used a non bioidentical progesterone. Does this matter? We don't yet have the answer to that yet, but are looking at it as a possible contributing factor.  Estrogen alone did NOT increase the risk of breast cancer but when combined with the progestin (progestin is the term used for a non bioidentical progesterone form), the risk of breast cancer was increased. We have studies that show that if a woman is using a progesterone (bioidentical), with or without estrogen, then her risk of developing a breast cancer may actually be LOWER, than a woman not on hormones.

CAVEAT: Oral estrogen, when begun at or near (within 10 years of) menopause in a healthy woman has been shown to be protective against the development of heart disease in contrast to a woman who chooses not to take estrogen at menopause who will begin to develop the natural changes leading to heart disease that aging and menopause deficiency increase. Oral estrogen protects: heart/blood vessels, brain, bones, lowers risk of colon cancer, protects the vagina from drying out, and several other benefits when used in an otherwise healthy woman at menopause. There is a possibility that bioidentical progesterone may be able to decrease a woman's risk for breast cancer or at least not increase it when compared to a progestin in combination with an estrogen (as that used in the Women's Health Initiative Study. More studies need to be performed for this to be concluded.

At this point in time, the recommendations guiding ob/gyns physicians are to offer hormone replacement therapy as an option to women suffering from vasomotor symptoms of menopause (hot flashes) or to women with menopausal vaginal atrophy and the discomfort associated with this problem (dry vagina). We are cautioned NOT to recommend hormone replacement therapy to decrease a woman's risk for heart disease, or to decrease her risk of osteoporosis or colon cancer as there are other medications and lifestyle changes that can address these issues.

My opinion? I believe that each woman should be approached individually with respect to whether she would benefit from hormone replacement therapy. There are many different modalities that may improve the quality of life in a menopausal woman that do not necessarily include hormones, but there are some women who will definitely benefit most from hormone replacement therapy and this should be a recipe (if you will) that is tailor-made for each individual woman, not a shot-gun approach to all. Whether bioidenticals are the answer is uncertain, and probably not the case of "better," but an alternative, again a personal choice to be made, with the goal to be the safest, lowest dose(s) of whatever regimen she chooses for the amount of time most beneficial to her. 

Relationships

This may seem to be a strange topic for an ob/gyn to bring up, but the reality is that not one day goes by that one or usually more patients bring up a relationship issue, and this is usually in the form of marital discourse.

Most people have had more than one significant other in their lives and so most of us understand the difficulties relationships can find themselves in. Most of us begin our relationship or marriage believing that our partner is the most wonderful person in our lives, our best friend, our lover, our “soul mate”, and it is not uncommon that we will tell our partner and vice versa that there is “not one thing we don't like about them”.

Then life steps in, usually in the form of young children, or sometimes job stress, or perhaps financial stress. As we let life step in between ourselves and our partner, thinking it is a temporary stress and that things will “get back to normal soon”, the distance between each of us expands insidiously and before we know it, we are nearing the point of no return. This is about the time my patients are telling me their marriage is in trouble, their husband is moving out, or they haven't been intimate for months-to-years, etc etc.

After the end on an 18 year relationship, I found myself wondering if I would ever have what it took to be successful in any relationship. I was extremely discouraged and felt a strong sense of failure. Without going into too much detail, I can say that we were no different than most couples in believing what we had was invincible and would weather our lifetime. Life gets in the way of those who are not vigilant and before long, the damage that is occurring can seem insurmountable.... but it doesn't have to be.

Over the last several years, I have read many books on relationships and various other personal growth books. This in no way makes me an expert, however, many of my patients have reported back to me that the few books I am about to list have been really enlightening and helpful with regard to their marriages.

I am a believer that multiple modalities can be very helpful, i.e., counseling, whether together or by yourself, “bibliotherapy” (reading books to help understand your relationship better), marriage encounters, etc, can all help, whether one at a time or separately.

A few books that I have found most helpful are as follows:

The Five Love Languages (Dr. Gary Chapman)

Why Marriages Succeed or Fail (John Gottman)

How to Improve Your Marriage Without Talking About it (Patricia Love, Steven Stosny)

The Proper Care and Feeding of Husbands (Dr. Laura Schlessinger)

These are only a few, but extremely powerful books. If I can end this note with any helpful words, I would say that if we just focus on our own weaknesses and not that of our spouses, we might be amazed at how fulfilling it is to try to be better and this allows our spouse the room to grow at his/her own pace.  Giving our spouse the benefit of the doubt as we would want it given to us, save your criticism for yourself but be on your own side in that you take the time to work on yourself and be better for you and your spouse. I know I want my life partner to believe in me, know I am doing my best, give me the benefit of the doubt, be tolerant of my faults, knowing I am well aware of them and don't need having them pointed out but also knowing I will never stop working to be better for myself and for the relationship. If I want these things, I need to be prepared to give them too. No one should be allowed to come in between you and your partner, not your family, friends, children, etc. It is too easy to forget this and if we can remember this we are headed in a great direction.

QUARTERLY NOTES

                                           COMBATTING AGE-RELATED BRAIN DETERIORATION    

One of the many complaints people have as they age is increasing forgetfulness and in general a decline in memory. I hear this frequently in my patients moving into their 40's and on. Some of this may be related to hormonal fluctuations (ie worsening premenstrual syndrome as one ages) but mild-moderate cognitive decline is also a consequence of aging.

In some cases, cognitive decline with aging is a precursor to what will ultimately become dementia and a significant number of Americans will will succumb to cognitive decline and eventually to dementia well before their bodies have given out. In some cases, the cognitive decline that occurs will ultimately lead to the debilitating condition known as Alzheimers or to an Alzheimer-like dementia.

In the October, 2011 article in Life Extension magazine, Dr. Braverman, MD notes that “dementia takes 15-20 years to develop; by 80-85 years of age, up to 50% of Americans will suffer from some form of dementia and by 70 or 80 years of age, nearly every one experiences some cognitive loss.

So how do we protect our brain function? There are several conditions associated with an increased risk of developing dementia. Obesity has been associated with an accelerated rate of brain atrophy and just being overweight in middle age can put an individual at a greater risk for increased cognitive decline. After studies were performed using MRI analysis techniques researchers were able to show that obese people literally have smaller brains than their age-matched controls. Conclusions made from more studies surrounding obesity and cognitive decline surmised that “obesity accelerates cognitive decline, damages attention, erodes memory and decreases the brain's processing speed.”

There is some research that shows women who have undergone surgical menopause and are not receiving hormonal replacement have increased rates of cognitive decline. Similarly, osteoporosis is also linked to increased cognitive decline with aging.

Various drugs accelerate cognitive decline. Some of these drugs include alcohol, tobacco, cocaine, heroin, and marijuana. All of these substances cause activation and neuronal release of dopamie. Dopamine has been called the “feel-good” molecule and people predisposed to abnormal cravings for the above substances often have impulsive behaviors associated to overeating and obesity. Glucose, interestingly enough also causes activation and release of dopamine.

Regular, moderate, exercise, particularly aerobic exercise has been assoicated with reduced odds of having mild cognitive impairment. Exercise also not only improves blood flow and hence oxygenation to the brain but also increases a neurotransmitter called serotonin. Deficiencies of serotonin often lead to depression, fatigue and poor sleep.

Other neurotransmitters involved in cognition and memory are acetycholine, dopamine, gamma-aminobutyric acid (GABA) and lastly brain-derived neurotrophic factor, all of which are increased with exercise and consequently allow for enhanced cognitive function.

In summary, a few simple non-pharmaceutical endeavors can go a long way in preserving our brain function and hopefully retard the age-related cognitive decline so many experience. Keeping our body weight down, exercising regularly, abstaining from high glucose foods and drugs associated with cognitive decline. Alcohol should only being consumed in small quantities if at all. If one doesn't drink, better to never start. My sharpest elderly patient population usually includes women who do not drink at all and never have. Many of us enjoy alcohol in moderation, but strict moderation is important if alcohol has to be a part of one's life since there is little redeeming value in more than small amounts of alcohol and as far as protecting oneself from cognitive decline, abstaining from alcohol is probably the most effective. Hormonal replacement can play an active role in protection from cognitive decline but without embarking off into another very complicated topic, hormonal replacement therapy is something that should be individualized in every circumstance by ones's health care provider.