“No link between hormone therapy and all-cause or cause-specific death rates in the
Women’s Health Initiative
Those of us who have practiced gynecology as long as I remember very well the day that the Women’s Health Initiative (WHI) results were made public. It was July, 2002, and the news was unexpected. The Women’s Health Initiative was a study started in 1994 to determine if hormone therapy (given as conjugated equine estrogen and medroxyprogesterone acetate) would prevent cardiovascular disease in women between the ages of 50-80. Previous data were consistent with cardiovascular benefits for women who took hormones, so this study was initially hopeful. Instead, the initial data demonstrated that there were more heart attacks, strokes, blood clots, and breast cancer in women on the therapy. There were less osteoporotic fractures and colon cancer, but the risks outweighed the benefits. That day, many women stopped hormones and chose to tolerate their menopausal symptoms, rather than accept these additional risks.
In the last 15 years, the researchers have continued to collect data, and stratified the results related to age. Women in their 50’s had fewer risks than women in their 70’s. In the last 15 years, there has been broader use of transdermal estrogen and bioidentical progesterone, which may have a different safety profile. Many years later, researchers compared mortality statistics for women who took hormones in the WHI, vs. women who were taking placebo.
The study reported today in the Journal of the American Medical Association, looked at mortality rates for women who participated in the WHI.
Among 27,000 women who were randomized to hormones or placebo who on average took hormones for 5-7 years, and were followed up for 18 more years, the mortality rates were statistically equivalent. This included mortality for all causes, including heart disease and cancer.
Although it is not recommended that women take hormones to prevent chronic diseases, this data suggests that if women choose to take hormones to help them through the menopausal transition, long-term mortality rate is not affected. This is good news!
A decision to take hormone therapy is an individual decision made by a women and her physician, taking into account her medical history, physical findings, and family history.
Marilyn Jerome, MD
Foxhall OB-Gyn Associates
JAMA, 2017: 318 (10), 927-938
Menopausal Hormone Therapy and Long-Term All-Cause and Cause-Specific Mortality,
The Women’s Health Initiative Randomized Trials, JoAnn Manson, MD, DrPH, Aaron K. Aragaki,MS, Jacques E. Rossouw, MD, et al
Did you ever consider that working may be beneficial to your health? There is now data that demonstrates that working longer may increase your longevity.
In 2016, a study was published in the Journal of Epidemiology and Community Health which demonstrated that healthy people who retired one year later than those in the control group, decreased their risk of dying during the study period, which lasted 18 years, by 11%. Retirees who had health problems also lived longer if they postponed their retirement. A French study linked later retirement with a decreased risk of dementia and Alzheimer’s disease.
It could be that a job that you enjoy may be associated with more social connections, increased physical activity, and provide a purpose, creative outlet or a challenge. All of these factors have been associated with improved health.
Not all studies agree. In an Australian study published in the Journal of Economics, researchers
linked overall health to longevity, with no benefit of a later retirement. Of course, health problems my be a reason that people retire, a factor that may affect some of the study models. Your work environment may make the difference. A person who works in a positive work environment that is challenging and fulfilling may have very different health effects than a person who works in an environment that is stressful or hostile, causing physical or psychological stress.
Many women in their later working years need a change. They may choose to take advantage of more flexible work schedules such as working part-time or working from home when possible. Finding a position that is less demanding, with less management responsibility can often decrease stress. Some women may look at their careers, having achieved their goals, and switch careers entirely, doing something different that arose from an interest, hobby, or previous work experience. Becoming a consultant in your field offers an opportunity to use your skills and contacts, and manage your work schedule as you wish.
Dr. Nicole Maestas, who is an associate professor of health care policy at Harvard Medical School, feels that working longer can increase financial security and in some cases, improve health. She believes that women should try to remain engaged in the workforce as long as possible.
When to retire is a complex decision which depends on many factors including finances, health, and a person’s individual work situation. Now it appears that there is at least some data that working longer may be good for your health!
Harvard Women’s Health Watch, Volume 25, Number 1, September 2017
It used to be that you would take an aspirin if you had a headache or pain. Then doctors began to appreciate that aspirin could prevent strokes and colon cancer. Many studies now look at the benefits of taking aspirin preventatively. But is it right for you?
Although there are benefits to taking aspirin, there are risks also. Aspirin can irritate the stomach and cause gastrointestinal bleeding and stomach pain. People who take aspirin may bleed or bruise more if they are injured. As in many medical decisions, the risks and benefits must be weighed.
Your doctor should evaluate your risk factors for heart disease and stroke, and weigh them against risks of bleeding that include uncontrolled hypertension, ulcers, or other conditions that make it more likely you might bleed. For those with a history of a heart attack or documented coronary artery disease, and without risks of bleeding, benefits usually outweigh the risks. The use of aspirin for those without documented heart disease is another question. There is evidence to support using aspirin in adults aged 50-59 who have a 10% or greater risk of heart disease in the next 10 years. For those under the age of 50, or older than age 70, individual risk factors need to be assessed.
To prevent colon cancer, it seems that one must take aspirin for 5-10 years before the benefit becomes apparent. There is some evidence that aspirin may decrease breast cancer risk, but not enough evidence to recommend it at this time.
An app has been developed by Dr. JoAnn Manson and her colleagues the Brigham and Women's Hospital in Boston. The app is called Aspirin Guide and it is free.The app is meant to help clinicians determine if low dose aspirin for the primary prevention of atherosclerotic cardiovascular disease. The app uses patient specific information to determine scores for the risk of heart disease and bleeding. It asks for your age, sex, history of gastrointestinal bleeding, blood pressure and cholesterol levels, and certain medications. It is very easy to use, and is a good starting point for a discussion with your physician.
Marilyn C. Jerome, MD
Harvard Women's Health Watch, Volume 25, Number 1, September 2017
Aspirin Guide, an app developed at Bringham and Women's by Samia Mora, MD,
JoAnn Manson, MD, and Jeffrey Ames, BS
You may be facing a hysterectomy for a benign disease such as endometriosis, fibroids, or heavy bleeding. You are pre-, peri-, or postmenopausal, and you are not having any more children.
You may have had a friend who had ovarian cancer and you know it is a miserable disease: difficult to detect at an early stage, requiring a complex surgery, rounds of chemotherapy, and high rates of recurrence and mortality. Your doctor may present to the you option of just taking your ovaries out while “we are there.” It will add nothing to your recovery, so why not?
Here are the reasons to very carefully consider this decision.
Premenopausal women who lose their ovaries suffer immediate loss of all ovarian hormones. After menopause, ovaries do not produce estradiol, but they do produce the androgens (male hormones) testosterone and androstendione. These androgens are converted in body fat and muscle to estrone, the postmenopausal estrogen. Estrone does have benefits.
Removing the ovaries has been shown to increase the risk of heart disease which is the major cause of death in women. While 16,000 women die of ovarian cancer each year, 500,000 die of heart disease, and 50,000 women die each year within one year of a hip fracture. Studies have shown that removal of ovaries after the age of 50 increases the risk of having a heart attack by 40%. Another study demonstrated that removing ovaries after the age of 50 increased the risk of osteoporotic fractures by 54%. The mortality for hip fractures doubled.
The risk of ovarian cancer in the general population is 1/70, or about 1.4%. This statistic does not apply to women who are BRCA mutation carriers, and those who had a mother or sister with ovarian cancer. Their risk is higher. If you have a hysterectomy and leave the ovaries behind, the risk of needing to go back at a later date and have those ovaries removed is about 5%.
A study was done to postulate the excess risk of death due to removing the ovaries in women age 50-54 who were not at high risk for ovarian cancer, heart disease, osteoporosis, stroke and breast cancer. The study determined that the probability of surviving to age 80 was 62% if the ovaries were retained, vs. 54% if they were not. The difference in mortality far outweighed the risk of dying from ovarian cancer which was 0.5%. The survival advantage was about 4% in women aged 55-59 year of age, but after the age of 64 there was no survival benefit to retaining the ovaries.
The study did not take into account the decrease in the quality of life benefits of loss of hormones that include hot flashes, night sweats, mood changes, decline in cognitive function, poor sleep quality, decrease in well-being, depression, and a decrease in sexual desire and function. Although hormone replacement can alleviate symptoms, studies do no demonstrate that the adherence to medication is low.
We now know that there are serious health risks to early menopause, surgical or natural. In 2008, the American College of Obstetrics and Gynecology, ACOG, recommended that retaining ovaries in premenopausal women undergoing hysterectomy for benign disease be strongly considered, unless there are identified genetic risks. A study published in the Journal Menopause this month, demonstrated a very high incidence of removal of the ovaries despite the recommendations of ACOG. Although hormone replacement after oophorectomy may mitigate some of the adverse outcomes, many women worry about the effects of estrogen and are not adherent long-term. The decision to remove ovaries can be a very personal decision made between a woman and her doctor, based on many factors. Consider your options carefully, as the long term consequences can be very significant.
Menopause, The Journal of the American Menopause Society, Volume 24, Number 8, August 2017. Inappropriate oophorectomy at the time of benign premenopausal hysterectomy, A.S, Mahal, et al.
ObGyn.net: September 30, 2011
Benefits of Ovarian Conservation at the Time of Hysterectomy for Benign Disease, William H. Parker, MD
From the New York Times by Tara Parker-Pope, July 25, 2017
Much of the scientific research on resilience — our ability to bounce back from adversity — has focused on how to build resilience in children. But what about the grown-ups?
While resilience is an essential skill for healthy childhood development, science shows that adults also can take steps to boost resilience in middle age, which is often the time we need it most. Midlife can bring all kinds of stressors, including divorce, the death of a parent, career setbacks and retirement worries, yet many of us don’t build the coping skills we need to meet these challenges.
The good news is that some of the qualities of middle age — a better ability to regulate emotions, perspective gained from life experiences and concern for future generations — may give older people an advantage over the young when it comes to developing resilience, said Adam Grant, a management and psychology professor at the Wharton School of the University of Pennsylvania.
“There is a naturally learnable set of behaviors that contribute to resilience,” said Dr. Grant, who, with Sheryl Sandberg, the chief operating officer of Facebook, wrote the book “Option B: Facing Adversity, Building Resilience and Finding Joy.” “Those are the behaviors that we gravitate to more and more as we age.”
Scientists who study stress and resilience say it’s important to think of resilience as an emotional muscle that can be strengthened at any time. While it’s useful to build up resilience before a big or small crisis hits, there still are active steps you can take during and after a crisis to speed your emotional recovery.
Last year Dr. Dennis Charney, a resilience researcher and dean of the Icahn School of Medicine at Mount Sinai in New York City, was leaving a deli when he was shot by a disgruntled former employee. Dr. Charney spent five days in intensive care and faced a challenging recovery.
“After 25 years of studying resilience, I had to be resilient myself,” said Dr. Charney, co-author of the book “Resilience: The Science of Mastering Life’s Greatest Challenges.” “It’s good to be prepared for it, but it’s not too late once you’ve been traumatized to build the capability to move forward in a resilient way.”
Here are some of the ways you can build your resilience in middle age.
■ Practice Optimism. Optimism is part genetic, part learned. So if you were born into a family of Eeyores, you can still find your inner Tigger.
Optimism doesn’t mean ignoring the reality of a dire situation. After a job loss, for instance, many people may feel defeated and think, “I’ll never recover from this.” An optimist would acknowledge the challenge in a more hopeful way, saying, “This is going to be difficult, but it’s a chance to rethink my life goals and find work that truly makes me happy.”
While it sounds trivial, thinking positive thoughts and surrounding yourself with positive people really does help. Dr. Steven Southwick, a psychiatry professor at Yale Medical School and Dr. Charney’s co-author, notes that optimism, like pessimism, can be infectious. His advice: “Hang out with optimistic people.”
■ Rewrite Your Story. When Dr. Charney was recovering from the shooting, he knew that his life was forever changed, but he reframed the situation, focusing on the opportunity the setback presented. “Once you are a trauma victim it stays with you,” he said. “But I knew I could be a role model. I have thousands of students watching my recovery. This gives me a chance to utilize what I’ve learned.”
Study after study has shown that we can benefit from reframing the personal narrative that shapes our view of the world and ourselves. In expressive writing studies, college students taught to reframe their college struggles as a growth opportunity got better grades and were less likely to drop out. A Harvard study found that people who viewed stress as a way to fuel better performance did better on tests and managed their stress better physiologically than those taught to ignore stress.
“It’s about learning to recognize the explanatory story you tend to use in your life,” Dr. Southwick said. “Observe what you are saying to yourself and question it. It’s not easy. It takes practice.”
■ Don’t Personalize It. We have a tendency to blame ourselves for life’s setbacks and to ruminate about what we should have done differently. In the moment, a difficult situation feels as if it will never end. To bolster your resilience, remind yourself that even if you made a mistake, a number of factors most likely contributed to the problem and shift your focus to the next steps you should take.
“Telling yourself that a situation is not personal, pervasive or permanent can be extremely useful,” Dr. Grant said. “There is almost no failure that is totally personal.”
■ Remember Your Comebacks. When times are tough, we often remind ourselves that other people — like war refugees or a friend with cancer — have it worse. While that may be true, you will get a bigger resilience boost by reminding yourself of the challenges you personally have overcome.
“It’s easier to relate to your former self than someone in another country,” said Dr. Grant. “Look back and say, ‘I’ve gone through something worse in the past. This is not the most horrible thing I have ever faced or will ever face. I know I can deal with it.’”
Sallie Krawcheck, a former Wall Street executive, said that after a very public firing, she reminded herself how fortunate she still was to have a healthy family and a financial cushion. While she has never studied resilience, she believes early challenges — like being bullied in middle school (“It was brutal,” she said) and going through a painful divorce — helped her bounce back in her career as well. “I just believe in comebacks,” said Ms. Krawcheck, who recently founded Ellevest, an online investment platform for women. “I see these setbacks as part of a journey and not a career-ending failure. There was nothing they could do to me on Wall Street that was as bad as seventh grade.”
■ Support Others. Resilience studies show that people are more resilient when they have strong support networks of friends and family to help them cope with a crisis. But you can get an even bigger resilience boost by giving support.
In a 2017 study of psychological resilience among American military veterans, higher levels of gratitude, altruism and a sense of purpose predicted resiliency.
“Any way you can reach out and help other people is a way of moving outside of yourself, and this is an important way to enhance your own strength,” said Dr. Southwick. “Part of resilience is taking responsibility for your life, and for creating a life that you consider meaningful and purposeful. It doesn’t have to be a big mission — it could be your family. As long as what you’re involved in has meaning to you, that can push you through all sorts of adversity.”
■ Take Stress Breaks. Times of manageable stress present an opportunity to build your resilience. “You have to change the way you look at stress,” said Jack Groppel, co-founder of the Johnson & Johnson Human Performance Institute, which recently began offering a course on resilience. “You have to invite stress into your life. A human being needs stress; the body and the mind want stress.”
The key, Dr. Groppel said, is to recognize that you will never eliminate stress from your life. Instead create regular opportunities for the body to recover from stress — just as you would rest your muscles between weight lifting repetitions. Taking a walk break, spending five minutes to meditate or having lunch with a good friend are ways to give your mind and body a break from stress.
“Stress is the stimulus for growth, and recovery is when the growth occurs,” said Dr. Groppel. “That’s how we build the resilience muscle.”
Dr. Pauline Maki discussed menopausal changes in cognition and mood.
Many of us need to lose weight, and if you are 20, 30 or many more pounds above your ideal weight, the goal may be daunting. The reality is that as little as a 5% weight loss can have very significant health benefits. Why not have a smaller initial goal, knowing that you are making great strides in your overall health?
From webmd.com this week:
1. You can take 40 pounds of pressure off of your lower body joints by losing 10 pounds. That translates into less risk of arthritis and joint damage. Excess body fat
also increases inflammation in your body that cause damage to your organs.
2. Weight loss and exercise can decrease the chance of getting type 2 diabetes. If your already have diabetes, lowering your blood sugar can result in less tissue damage. Thirty minutes of moderate exercise 5 times weekly is recommended.
3. A healthy diet can lower your LDL (bad) cholesterol, but sometimes medication is needed to achieve your cholesterol goal. Increasing your HDL, the good cholesterol, is achieved by exercise and decreasing body fat.
4. Weight loss can lower your triglycerides, the fatty particles in your body that transport fat for energy. Lower triglycerides can lower your risk of heart attacks and stroke.
5. Weight loss can lower your blood pressure. Decreasing dietary intake of salt also helps.
6. Weight loss can decrease belly fat and chemicals it produces that makes your body
resistant to insulin, which makes it harder to metabolize glucose, leading to diabetes.
7. Cancers related to excess body weight include breast, colon, liver, kidneys, ovaries, cervix, and prostate. Less body weight may decrease hormones linked to these cancers.
8. Sleep apnea is more common in people who are overweight, because they have more
tissue in the back of the neck that can block the airway. Sleep apnea is related to cardiac problems.
9. A study demonstrated that those who lost 5% of their weight slept on average 22 minutes longer each night.
10. Weight loss may affect mood. This may be due to sleeping better, or changes in body image.
11. Weight loss of 10% may decrease inflammatory substances produced by fat cells that can lead to heart disease, arthritis and strokes.
How can you get started? Make some simple changes in your diet: eat more fruits and vegetables, lean meat, more seafood, beans, nuts and seeds. Replace refined grains with whole grains, and cut down on portions. Exercise at least 30 minutes 5 times per week, and add resistance training. Always, check with your doctor before making changes in your diet and exercise, as you may have health needs that are individual to you. Good luck!
You may not have all the vaccinations you need! Grandparents please note!
Immunizations are important to individuals, as well as to the public health. Immunizations decrease the severity and death from infectious diseases, but many adults are under-vaccinated. There are many reasons for this, including lack of knowledge by doctors and their patients regarding the recommendations, multiple caregivers for an individual (who is in charge of the big picture), and concerns regarding insurance coverage, reimbursement, co-pays, etc. It all leads to the fact that many adults do not have the vaccines that they should.
Here are the recommendations of the Advisory Committee on Immunization Practices of the United States. (ACIP)
Hepatitis A and B:
Hepatitis A and B can cause acute and chronic infections that can lead to death and serious illness. Children are now vaccinated for hepatitis A, but unvaccinated adults who have risk factors should be vaccinated. Risk factors include men who have sex with men, drug users, people with chronic liver disease, and travelers to countries that are high risk.
Hepatitis B vaccine is recommended for adults with more than one sexual partner in six months, healthcare personal, people with end-stage renal disease, and those who are seen in STD and HIV testing centers. Children are routinely vaccinated.
Human papilloma virus:
The human papilloma virus is associated with cervical, vulvar and vaginal cancer in women, anal and oral/ pharyngeal cancers in men and women, and cancer of the penis in men. In the US, the vaccine is approved for women up to the age of 26. Three doses of the vaccine are given over a six month period of time. In Canada, the vaccine can be given to women who are at risk up to the age of 45. A physician my consider prescribing the vaccine to women older than age 26 if she is deemed to have missed the window of opportunity and is at high risk. Because the vaccine is not FDA approved for this age group, the cost is usually not covered by insurance
A flu vaccine is recommended yearly for everyone older than 6 months of age. Those who are healthcare workers, the elderly, and the immunocompromised are especially at risk. The vaccine changes yearly in accordance with which strains of the virus are considered to be the most likely
contagions for the coming season. The vaccine should be given by October, but those who remain unvaccinated may obtain the vaccine through the winter flu season.
Pneumonia vaccine: pneumococcal vaccine
Strep pneumonia causes about 500,000 cases of pneumonia in the US yearly. All adults greater than the age of 65, and those younger than 65 who are immunocompromised or at risk, should be vaccinated. Two vaccines are available, the timing and sequence should be determined by your physician.
Tetanus and Tdap:
Trap is a vaccine that includes tetanus toxoid, diphtheria toxoid, and acellular pertussis.
This vaccine is recommended once in an adult’s lifetime, versus previously getting tetanus and diphtheria every ten years. This Tdap vaccine is recommended for adults greater than the age of 65, and all healthcare workers. Also, and this is important to GRANDPARENTS, if you anticipate close contact with an infant, you should have the vaccine to prevent the transmission of pertussis. This vaccine can be given even if you have had a tetanus shot recently.
Shingles vaccine: herpes zoster
The shingles vaccine is important to obtain over the age of 50 (FDA recommendation) or 60 (ACIP recommendation). Shingles causes a rash and can cause severe pain in older adults, leading to marked disability and hospitalizations. Contraindications to the virus are pregnancy, immunodeficiency, and chronic steroid use. This vaccine is very effective in reducing the morbidity from the shingles virus.
As with all medical advice, your individual needs for a particular vaccine should be determined by your physician after assessing your medical history.
NAMS PRACTICE PEARL: Immunizations for Adult Women, August 1, 2016
by Stephanie S. Faubion, MD, and Lisa C. Larkin, MD
We have all heard of the benefits of the Mediterranean diet and olive oil. A new study from Temple University now demonstrates the potential of additional benefits for the brain, including prevention of Alzheimer’s disease.
Dr. Domenic Pratico of Temple University demonstrated that the consumption of olive oil protects memory and learning ability and reduces the formation of amyloid plaques and neurofibrillary tangles in the brain, which are hallmarks of Alzheimer’s disease. It seems that the EVOO activates a process called autophagy, which is the process by which cells clear out debris and toxins that accumulate in the brain and cause neuron cell dysfunction.
The studies were performed in animal models. The animals, which typically developed the hallmarks of Alzheimer's disease, demonstrated dramatic differences in neurologic behavior between the group fed EVOO vs. the control group. Even more dramatic were the microscopic differences in the nerve cell and their connections with other nerves. The activation of the autophagy process in the animals who were fed the olive oil led to the preservation of memory and synaptic integrity.
Dr. Pratico plans to study the effects of EVOO on animals that have already developed Alzheimer’s disease to see if there is a curative potential.
One more reason to make extra-virgin olive oil a staple in your kitchen!
Reference: Extra-virgin olive oil preserves memory and protects brain against Alzheimer’ study
Annals of Clinical and Translational Neurology, June 21, 2007
Dr. Domenico Pratico, Professor, Department of Pharmacology and Microbiology, Center for
Translational Medicine, Lewis Katz School of Medicine, Temple University