Often there is a sense of helplessness.

Patients commonly are on medications for treatment of high blood pressure, elevated cholesterol, diabetes, and depression. The medications are good at controlling these problems yet the patient still does not feel well. There is a sense of confusion.

“Why don’t I feel healthy if the medications are controlling the problems?” Well, unfortunately medications only treat or prevent diseases. They do not provide health.  Good health is more than the absence of disease.

What is good health?

The word “health: comes from the Old English word “hale” which means “wholeness, being whole, sound or well.” It requires the attention to mind, body, and soul. When all three are attended to in a positive way then good health follows. They are all interconnected.  Truly good health cannot be realized if attention is only given to one or two of the three.

It is not my place to counsel or lecture on the soul, that is best left to one’s religious or spiritual guide. It is, however, an important aspect to health. Challenging the mind in various ways throughout life is extremely important. Age is not an excuse not learn new things or to develop new skills. Finally attention the body through proper diet, exercise, and rest is perhaps the part of the equation that people have the most difficulty with.

A recent study (Annual Report to the Nation for Research of Cancer) in the Journal Cancer as reported in the Wall Street Journal showed a direct link between obesity and lack of physical activity with the increased occurrence of breast, uterine, pancreatic, kidney, and lower esophageal cancers. In addition, people who are diagnosed with these cancers have a poorer response to therapy if they are obese and physically inactive. Incidence of heart disease, diabetes, and hypertension are directly linked to these also.

The secret to good health is not even a secret. Health cannot be found in a pill, magical supplements, a 10 min exercise routine 3 days a week, or in any of the myriad of “secrets” hyped on the internet. In comes down to the same things we learned in ninth grade health class, eat a healthy balanced diet, exercise on a regular basis, maintain optimal weight, don’t smoke, don’t drink to excess, get a proper amount of sleep.

Easily 50% of health problems are preventable if we take care of ourselves. It just takes effort and discipline. The rewards are tremendous. Vitality, energy, positive outlook, and “good health” are the payoff. Put another way, exercise is cheaper than medications and without the side effects.

Jerry Maguire had it right: Help me…help you!

Doctors can treat disease but they can’t make you healthy…that is up to each individual. “Health and Happiness” are a choice. Not a gift bestowed on some and not others. You are not helpless. Your healthful happiness just takes effort and perseverance.

Remember always, you are in control.

Part II

The Pap smear is a simple cost effective screening test that has been highly successful in reducing the frequency and deaths related to cervical cancer.  It is part of the evaluation that a woman should have at her annual exam. Last month’s article described what the Pap smear is, how it is obtained and who should have it performed. This month’s article will discuss understanding the results, how abnormal results are followed, and possible treatments.

Understanding the Results

The terms used to describe the findings of a Pap smear can be confusing if you are not familiar with how they are used. Most women initially are only interested in whether their test is normal or not. If told that it is not normal then fear of cancer is the next thought. Fortunately cancer is an extremely rare finding on a Pap smear. Typically an indeterminate (ASCUS) result or a precancerous result is found. Precancerous changes are known as Squamous Intra-epithelial Lesions (SIL). There are several descriptive categories under SIL:

            Normal (negative):  No evidence of cancer or precancer cell

Atypical squamous cells of undetermined significance (ASCUS):  This is the most common abnormal finding on Pap smears. May indicate the presence of cancer cells and should be followed by HPV (Human Papilloma Virus) testing.

Squamous Intraepithelial Lesion (SIL): Denotes a precancerous change associated with a HPV infection. It is divided into low grade (LG-SIL) and high-grade (HG-SIL) changes. Low grade SIL is mild precancer cells that often will resolve without treatment. High grade-SIL is more advanced precancer cells or noninvasive cancer cells that require treatment.

Dysplasia: This term is another common way of describing findings similar to SIL. Mild dysplasia is synonymous with LG-SIL. HG-SIL includes moderate dysplasia, severe dysplasia, and carcinoma-in-situ.

Atypical Glandular Cells (AGC): Potentially precancer cells lining the cervical canal which leads into the cervix.

Cancer: Abnormal cells that may have extended deeper into the cervix or beyond.

How is an abnormal result followed?

It must be remembered that the Pap smear is a screening test; it suggests that there is a problem. What‘s required after any abnormal screening test is a diagnostic test, one that tells you whether the abnormality actually exists and how severe it is. The diagnostic tests after an abnormal Pap smear includes colposcopy, biopsy, and endocervical curettage (ECC). This combination of diagnostic tests are easily performed in your doctor’s office with no or minimal discomfort.

Colposcopy: This is an examination of the cervix by your doctor using a magnifying instrument that enables better visualization of the surface of the cervix. It allows visualization of abnormal cells that cannot be seen with the naked eye. A speculum is placed into the vagina just like with the Pap smear to expose the cervix.

Biopsy: Small bits of tissue are obtained from the abnormal areas that are then sent for pathologic evaluation. It is the obtaining and evaluation of this tissue that provides the diagnosis and then guides treatment decisions.

Endocervical curettage (ECC): Cells are gently obtained from the canal leading into the uterus. This is done to make sure no precancer or cancer cells are extending higher off of the cervix.

What is the follow up to an abnormal Pap smear?

What is described in this section is a generalization of how abnormal Pap smears should be followed. Each patient’s particular circumstances may require a different management path.

            ASCUS-HPV negative: Repeat Pap smear in 6-12 months

            ASCUS-HPV positive: Colposcopy with possible biopsy and ECC

            Low grade-SIL & High grade-SIL: Colposcopy with biopsy and ECC

What is the treatment?

Obviously the treatment will depend on the results of the biopsy. If the biopsy shows only low-grade changes or mild dysplasia this can be handled in one of two ways. It may be safely followed every 6 months with repeat Pap smears over a couple of years to see if it will spontaneously revert to normal. The other option is to perform an excision of the abnormal cells by LEEP conization.  LEEP stands for Loop Electrosurgical Excision Procedure. This is a simple office procedure that removes the abnormal cells with a 95% success rate.

Most high-grade changes and moderate-to-severe dysplasia can also be treated in the office by LEEP conization with the same success rate. Depending on the severity of the changes, a Pap smear should be repeated every 3 to 6 months until 3 consecutive normal results are obtained. At this point annual Pap smears can be resumed.

Cervical cancer could probably be completely eliminated if women would have Pap smears performed on a regular basis. It typically takes a few years for cervical cancer to develop from normal cells. Having annual or biannual Pap smears would allow ample opportunity to find precancer cells and allow for a simple office treatment before invasive cancer develops.

Part 1

The Pap smear is the single most effective screening test ever developed in medical history. It was designed to diagnosis precancerous and cancerous changes of the cervix. The Pap smear was first developed by Dr. George Papinicolaou in 1928 and introduced clinically in 1943. With the onset of widespread use in the 1980’s the incidence of cervical cancer has fallen from 32.6/100,000 women to 5.7/100,000 women; that is an 83% decline in occurrence. Death from cervical cancer in 2008 fell to 1.7/100,000 women. The only reason the incidence is still as high as it is results from some women choosing not to have the test performed. Cervical cancer could be eliminated if every woman would have regular Pap smears. This simple test has saved more lives and prevented more suffering than any other.

What is the Pap smear?

The Pap test is a simple procedure that tests for cancerous cells on the cervix; it is not meant to detect any other type of cancer. The cervix is the part of the uterus that extends into the vagina. Thin flat cells cover the outer portion of the cervix; tall glandular cells line the endocervical canal (the passage into the uterus). Where these two types of cells meet is the area most susceptible to cancerous changes and is where the Pap smear samples the cells.

How is the Pap smear obtained?

A small instrument, known as a speculum, is gently placed into the vagina allowing the cervix to be visualized. A small plastic spatula obtains cells from the outer portion of the cervix and a narrow soft brush obtains cells from the endocervical canal. These cells are then placed into a solution that is sent to a national lab for evaluation. Results typically take 7 to 10 days to return. The test itself only takes seconds to perform and should be mostly painless; pressure is the typical sensation described. The more relaxed you are the easier it is to have performed.

Who should have a Pap smear?

Cervical cancer is a sexually transmitted disease caused by the human papilloma virus (HPV). HPV is a large group of viruses that is extremely common. Most sexually active people have been exposed to it and may be infected with it without any symptoms. It is easily transmitted; the cells on the cervix at the juncture of the flat cells and glandular cell are especially susceptible to infection. When HPV is combined with smoking, having multiple sexual partners, or a history of sexually transmitted diseases (STDs) cervical cancer risk is significantly heightened. There are different recommendations as to when a Pap smear should first be done and who should have this test; most recommend every 1 to 3 years. Certainly once a young women becomes sexually active she should begin annual checkups with her gynecologist and begin receiving Pap smears on a regular basis. Those considered to be high risk should certainly have a Pap smear performed annually. Some high-risk characteristics are having a history of prior cancerous cervical changes, having multiple sexual partners, and a prior history of sexually transmitted diseases (STDs). Women who are in a monogamous relationship and have had 3 consecutive normal annual Pap smears can safely reduce the frequency to every 3 years. If you had a hysterectomy for noncancerous reason, and had the cervix removed, you may not require a Pap smear any longer. On rare occasions, however, the vaginal lining may develop precancerous changes so I prefer my patients with a hysterectomy still have one every 3 years. Since every woman’s situation is different the frequency of the Pap smear should be tailored to your specific needs. This is something you and your doctor should decide.

My greatest fear in telling women that they only need a Pap smear every 3 years, or not at all, is many women think they do not need an annual exam any longer. The Pap smear is only one small part of the exam. Remember it does not screen for ovarian, uterine, vaginal, or vulvar diseases or cancers. At the annual exam a complete medical, family, and social history is obtained along with a complete physical examination including the breast exam. This allows for the detection of many other health problems before they develop into something more serious.

Next month’s article will complete the discussion of the Pap smear. I will discuss understanding the results, follow up testing for abnormal results, and treatment recommendations.

As kids often do, Jessica is pointing out something very important that we as adults too often forget: the way that we choose to approach our daily lives can have a dramatic impact on our health and sense of well being. Strange as it may sound, simply smiling more often can have a wonderful effect on how you feel overall.

Not too many years ago, researchers at the University of Alberta and the University of Missouri proved that very point through a study on the power of positive disposition. The report was cited in a wonderful book by Malcolm Gladwell, The Tipping Point, as an example of how little things in life can make a big difference.

The universities recruited a large group of students and told them they were conducting market research for a company who made high-tech headphones. Students were each given a headset and told that the company wanted to test to see how well the headphones worked when the listener was in motion — dancing up and down, say, or moving his or her head. All of the students listened to songs by Linda Ronstadt and the Eagles, and then heard a radio editorial arguing that tuition at their university should be raised from its present level of $587 to $750.

A third were told that, while they listened, they should nod their heads vigorously up and down. The next third were told to shake their heads from side to side. And the final third were told to keep their heads still.

When they were finished, all the students were given a short questionnaire, asking them about the quality of the songs and the effect of the shaking. However, slipped in at the end was the question experimenters really wanted an answer to: “What do you feel would be an appropriate dollar amount for undergraduate tuition per year?”

Researchers found that students who kept their heads still were unmoved by the editorial. They felt that a tuition amount of $582 was about appropriate. Those who shook their heads from side to side as they listened to the editorial wanted tuition reduced on average to $467 a year. And those who were told to nod their heads up and down, meanwhile, found the editorial to be very persuasive. They suggested a tuition increase, on average, to $646.

The simple act of moving their heads up and down–even if for another reason entirely–was sufficient to cause students to recommend a tuition policy that would take money out of their own pockets.

As an obstetrician and gynecologist for 25 years, I’ve become keenly aware of the role a positive outlook can play in a person’s health. Remaining positive helps you better deal with stress. And it also provides a foundation for an energetic approach to daily living.

Recognizing just how important your sense of happiness is, I’m very proud of the work we’re doing at NaplesHealth to offer services designed to bring a smile to your face. We are the region’s leading provider of Laser Skin Care Solutions to help you look and feel your very best.

Now that spring is here, we invite you to explore the many ways NaplesHealth can help bring a smile to your face. To begin, give us a call at 330-722-7664 for your free VISIA computerized skin analysis. Together with you, we’ll be happy to tailor a treatment plan designed to unveil in your bathroom mirror the most beautiful, youthful, and positive you.

Keep smiling–

Dr. Naples

The holidays are over and as we return to the routine of our daily lives we begin to remember that it is winter in northeast Ohio, the glow of sunshine is more difficult to find.  The days are shorter and sunshine is scarce. Most people retreat to the warmth of their homes, rarely venturing outside resulting in rare exposure to the sun. This deprivation of sunshine, besides affecting our mood, can cause vitamin D deficiency. Vitamin D plays a significant role in the normal functioning of all major organ systems and therefore its deficiency adversely affects our health.

The major source of vitamin D is through sunshine.  Dietary sources of vitamin D are through vegetables (vitamin D2) and animal source (vitamin D3).  Vitamin D3 is synthesized in the skin through exposure to ultraviolet-B (UVB) light.  The activated form of vitamin D3 binds to receptors in tissues throughout the body to influence their functioning and ability to repair itself. In modern society sunlight exposure is limited by design (fear of skin cancer) and necessity (most work now is done in doors). Studies on young professionals revealed that 32% are deficient in vitamin D.  Aging only worsens this problem. As we get older our skin has reduced ability to synthesize vitamin D; older adults require three-times the amount of sun exposure as younger adults to maintain normal vitamin D levels. Up to 90% of older adults are deficient in vitamin D. Why is this important?

Vitamin D has long been recognized as being important in skeletal health and prevention of osteoporosis. It helps with the absorption of calcium in the intestine and helps maintain steady blood levels of calcium. It has also been shown to have anti-proliferative effects on malignant cells meaning it prevents or slows the growth of cancer. This includes very common cancers such as cancer of the breast, prostate, colon, and leukemic cells. Many epidemiologic studies have shown reduced incidence and mortality from these cancers in areas with a sunny climate or in populations taking vitamin D supplements. Low vitamin D levels also have an adverse effect on the immune system. Inflammatory bowel disease and rheumatoid arthritis are examples of conditions of an abnormal immune system in which patients often have vitamin D deficiency. Vitamin D deficiency has an adverse effect on the cardiovascular system increasing risk for heart attacks and stroke. It also contributes to the development of diabetes by contributing to insulin resistance.  Vitamin D deficiency contributes to postmenopausal syndromes of osteoporosis, muscle weakness, falls, fractures, depression, cognitive impairment, and dementia.

Because vitamin D deficiency is associated with multiple significant health problems it is not unreasonable to measure its level once a year, especially in older individuals who live in a northern climate. A simple blood test for vitamin 25 (OH) D and parathyroid hormone (PTH) should be drawn. Normal levels for 25(OH) D is higher in older individuals than the young because resistance to its effect occurs as we age. This resistance is reflected by elevated levels of PTH. Achieving and maintaining normal levels of vitamin D may lower the risk for breast and colon cancer by as much as 80%. The daily requirement of total vitamin D is 3,000 to 5,000 units per day, most of which is obtained by the sun. As a generalization most adults should take 1,000 to 2,000 units (IU) of vitamin D3 daily. An individual’s exact amount of dietary supplement varies depending on age, sun exposure, and other health conditions. The required daily oral intake of vitamin D may range between 2,000 to 10,000 units per day. It is best to have testing done by your physician to help determine what is the correct amount for you.

Vitamin D is not the “magic” pill that will provide good health and prevent disease but it is an important part of the equation. As always a healthy lifestyle of a balanced diet, regular vigorous exercise, sufficient sleep, and avoidance of tobacco and excessive alcohol will give you the best chance of having a long and healthy life.  And here is hoping our mild winter lasts and the sun keeps shining!

Osteoporosis is a condition that needlessly robs many people later in life, mostly women, of their independence, diminishes their quality of life, and prematurely shortens their life. Osteoporosis had a devastating effect on my own family. It essentially stole the last fifteen years of my mother’s life. When younger she stood five feet seven inches tall, by the time she died she wasn’t even five feet tall. My father couldn’t hug her without breaking a rib; even minor falls resulted in serious fractures.  With early attention to bone health, osteoporosis can be prevented. With early diagnosis, osteoporosis’s devastating effects can be prevented or greatly diminished.

Women who are over fifty, or have gone through menopause, have a very high risk for osteoporosis. This condition causes one out of every two women over fifty years old to suffer a bone fracture at some point in their life. Vertebral compression fractures are often silent, causing progressive loss of height and significant back pain. Hip fractures lead to major surgical treatment and nursing home admissions from which many women never recover. Osteoporosis is the progressive loss of bone mass resulting in weakening of the bone strength and increased susceptibility to fracture. It is a silent disease in which women lose up to 20% of their bone mass in the first five years of menopause.

Healthy bones are in a constant state of renewal; old bone is removed and new bone is being formed. The cells that build bone are positively influenced by estrogen in women. With the withdrawal of estrogen after menopause these bone building cells, osteoblasts, slow down but the cells that remove old bone (osteoclasts) keep on working resulting in progressive loss of bone mass. Currently in the United States, 10 million women have osteoporosis and another 34 million have low bone mass or osteopenia. Unfortunately, there are no early physical warning signs that osteoporosis is developing. The first sign of the disease is often a low trauma resulting in a fracture of the hip, wrist, or spine.

Women who are at most risk for osteoporosis are those who are menopausal, have slight stature, smoke cigarettes, drink alcohol, have a family history of osteoporosis, on chronic corticosteroid medications, and cancer patients. As with other common health conditions, like heart disease and diabetes, it often can be prevented or reduced with a healthy active lifestyle. Eating a healthy balanced diet, exercising on a regular basis, having adequate calcium and vitamin D intake, avoid smoking and excessive alcohol will result in healthier bones and greater bone mass.

Diagnosis of osteoporosis is based on a DXA bone density test. This is a special x-ray evaluation of the bone, usually of the spine and left hip. This test is completely painless and usually can be completed within ten minutes. I typically will order this test in my patients shortly after menopause to have a baseline level and to determine if early bone loss is present so preventive measures can be initiated in hopes of avoiding the use of medication.

Fortunately many very good medications are available for the treatment of osteoporosis. Unfortunately, the only thing many women know about osteoporosis is the potential side effects of these medications.  The most commonly prescribed family of medications for osteoporosis is bisphosphonates (Boniva, Fosamax, Actonel, and Reclast.) These medications act by slowing down the activity of the cells that removes bone (osteoclasts.) People hear about drug side effects of acute jaw necrosis or atypical fractures of the thigh bone. Jaw necrosis is most often seen in cancer patients and is extremely rare. Atypical fracture of the femur (thigh bone) may occur after 5 years of use. This allows the safe use of the medication for five years while realizing its benefits. At five years, the medication can be stopped for a two-year drug holiday or switched to another medication such as raloxifene (Evista.)  Evista belongs to a different family of bone sparing medications that also has the advantage of lowering a woman’s risk for breast cancer.  On average bisphosphonates lower the risk of fracture by 30 to 50 percent. By comparison, the risk of these side effects is miniscule. In other words, the risk of not taking the medication is significantly greater than the risk of taking it.

In summary, healthy lifestyle for prevention of osteoporosis includes smoking avoidance, low alcohol consumption, regular exercise, and daily intake of calcium 1200 mg/day and vitamin D3 1,000-2,000 units daily. Treatment of osteoporosis includes all the items for prevention with the addition of one of the many safe and effective medications. For more information please visit www.napleshealth.com/resources-on-menopause.

The concern most women have with a late pregnancy is related to birth defects and chromosomal abnormalities. Down syndrome is the most common chromosomal abnormality seen in later pregnancies. Children affected with this syndrome are affected by varying degrees of mental retardation and physical birth defects such as heart anomalies. Every pregnancy, no matter the age of the mother at conception, has a chance to result in a baby with Down syndrome or some other chromosomal anomaly. The risk steadily increases with age. At age 25 the risk is 1 in 1250, at age 30 it is 1 in 1000, at age 35 it increases to 1 in 400, and at age 40 it is 1 in a 100.  What is important to realize, however, is that the odds always favor the birth of a baby without Down syndrome or any other chromosomal anomaly. The reason is that most pregnancies with a chromosomal problem end in a miscarriage. First and second trimester screening tests are available that recalculate the risk levels noted above. Diagnostic tests in the first trimester (chorionic villus sampling) and second trimester (amniocentesis) are also available. The diagnostic tests have an associated risk of causing a miscarriage, in a normal pregnancy, in the range of 1 in 100 to 1 in 500. Many women who choose to do testing will do the screening test first to see if their risk is significantly lowered. If it is lower, many will forego the diagnostic test to avoid the possibility of causing a miscarriage.

Another risk of pregnancy later in life is the higher chance of miscarriages. Miscarriage in women age 35 to 45 occurs much more frequently, ranging from 20% to 35%, as compared to only 10% in women in their twenties. Other conditions with higher rates include gestational diabetes (twice as high in woman after 35,) high blood pressure and pre-eclampsia, premature delivery, low-birth weight babies, twins, and stillbirth. When risks like this are put in print, it exaggerates their likelihood. The fact is most pregnancies in women after forty proceed normally and safely. These complications, if they do occur, can most often be managed and controlled in a safe manner. Certainly a woman pregnant after forty can expect to be followed more closely during the pregnancy with serial ultrasounds to monitor the baby’s growth and well-being. The mother will also be closely monitored to identify any developing health problems.

Often, I have patients ask me if a late in life pregnancy is too risky or too dangerous. Risk tolerance is an individual decision. The role of your obstetrician is to clearly explain what the risks are and to explain what the likelihood is of those complications occurring. But it is also extremely important to consider all the positives associated with the pregnancy, the joy and happiness this child can offer to your life. Too often we focus on the negatives and not the positives. If the positives outweigh the negatives then the risk is worth it. There are no guarantees in life. Whether we think about it or not, as soon as our feet hit the floor in the morning we are exposed to risk. Some risks are just worth it.

*An easy in-office procedure

You have reached the point in your life that you are confident your family is complete.  You and your husband have 4 beautiful children; the youngest is now 5 years old.  Next year she will begin school and you wish to resume your career.  Since her birth you have used a birth control pill for contraception.  This worked nicely in preventing pregnancy but the pill however is not something that you feel comfortable continuing into your forties.  A permanent form of contraception is appealing but you really don’t want surgery.  So what choices do you have?

Essure is a permanent sterilization procedure performed in the office and can be completed within 10 minutes. No hormones, cutting, burning, or anesthesia is required.  A small scope is passed through the vagina and cervix into the uterus (honest this doesn’t hurt!) enabling the tubal openings to be visualized. 

Small, flexible micro-inserts or plugs are placed into the tubes. It takes about 3 months for these plugs to heal into place. At that time a simple x-ray test is performed to make sure the tubes are completely occluded.  It is recommended that the pill or some other form of contraception be used until this x-ray is completed.  This procedure has been FDA-approved since 2002.  It is 99.8% effective and is the only birth control method with zero pregnancies.

Read more about this procedure which was recently highlighted in The Cleveland Plain Dealer’s Health and Fitness section.

 http://www.cleveland.com/healthfit/index.ssf/2011/09/nonsurgical_option_for_sterili.html

The combination of these two words strikes fear in most women.  Breast cancer is the number one health concern for women after the age of forty.   It is not, however, the number one health issue that affects women.  Lung cancer is the number one cause of cancer deaths in women, heart disease is the number one cause of all deaths, and osteoporosis is the number one disease that afflicts women.   If breast cancer is not the primary cause of death or even the primary illness that affects women, why is it so prominent a health concern?   Breast cancer is a very personal disease; it can alter a woman’s self image, confidence, and causes her to confront her own mortality.  It often strikes at a younger age than any of the other conditions mentioned above.  Breast cancer is the second leading cause of cancer deaths among women; it is the most frequently diagnosed cancer in women except for skin cancer.  A women’s life time risk for developing breast cancer is 1 in 8; the risk increases with age. The 10 year risk at age 40 is I in 69, 1 in 42 for women at age 50, and 1 in 29 at age 60. Over 250,000 women are diagnosed with invasive or noninvasive breast cancer each year; more than 40,000 women die of breast cancer yearly.  These are certainly very unsettling statistics but there is good news. There has been steady improvement in breast cancer survival over the past 2 decades. This improved survival rate has resulted from earlier detection and improved treatments.

From the early 1990’s there has been increased awareness, detection, and survival of breast cancer due to programs like the “Susan B. Komen Race for the Cure” and “Breast Cancer Awareness Month.” Recommendations for women to begin monthly self breast exams at age 30, annual or biennial screening mammograms at age 40, and annual mammograms at age 50.  Recently the United States Preventive Services Task Force (USPSTF), which is a government supported organization, made drastic changes in these screening recommendations. The USPSTF recommended that women with no genetic predisposition to breast cancer no longer do self breast exams, that screening mammograms not begin until age 50, only be performed every 2 years until age 75, and then discontinued after age 75. Five percent of breast cancers occur in women before the age of 40 and 20% occur before the age of 50. Why make such drastic changes in the recommendations for screening when the previous recommendations have produced such good results? They felt that self breast exams led to excessive anxiety and too many unnecessary tests.  Earlier mammogram screening required testing too many women in order to diagnose one woman with breast cancer; basically screening at an earlier age is not cost effective. Unfortunately this is the kind of analysis that we are going to see much more of in the future with national health care reform. The cost of tests and treatment will play an out of proportioned role in health care decisions.  Fortunately the outcry from the public and medical professionals about these changes has caused them to be retracted for now.

Currently the recommendations, therefore, are the same. Women should continue to do monthly self breast examinations; for women who are still menstruating this should be done on the last day or 2 of the menses. During the examination the woman should concentrate on the normal appearance and constituency of her breast. Once familiarity is achieved changes would more easily be recognized and an evaluation by your doctor would be important. Things to be on the lookout for during the self exams are lumps, dimpling in the skin, other changes in the skin appearance, or spontaneous nipple discharge. Screening mammograms should begin every 1 to 2 years at age 40 and yearly at age 50.  It is important to realize that mammograms are not 100% accurate; there are limitations to every test. If a change in the breast examination is noted either by you or your doctor it should continue to be followed even if the mammogram is negative. This may require alternative type testing, biopsy, or simply repeat examination by your doctor in a few months.

Every woman is at risk for breast cancer simply for the reason that she has breasts. The fact that there is no family history of breast cancer does not free a woman from the possibility. In my own family I have 2 sisters who had breast cancer. These are the first occurrences on either side of the family. Testing for genetic predisposition with testing for BRCA1 or BRCA2 genetic mutations is important if there is a history of breast cancer in close family members on either side of the family. This is a simple blood test. The risk for breast cancer increases with age, in women who went through early puberty or late menopause, women who had no children or who delayed childbirth until after age 30, and in obese women.

Breast cancer is a fairly common and worrisome disease but women are not defenseless.  By following screening recommendations, doing monthly self breast exams, and having yearly examinations by your physician earlier detection of breast cancer is possible.  Earlier detection improves survival and limits the extent of surgery necessary. Often breast preservation is possible thereby limiting self image concerns, discomfort related to surgery, and enables a return to a normal life style sooner. The risk for breast cancer can be reduced by maintaining normal body weight, eating a healthy balanced diet, exercising regularly, and limiting alcohol consumption and smoking.

In last month’s article “In Defense of Estrogen” I tried to explain how estrogen therapy for treatment of menopausal symptoms is a good and safe therapy for the majority of women.  Estrogen is the only treatment proven to address the myriad symptoms associated with menopause and is the most effective treatment for hot flashes and night sweats.  Medications such as Effexor, Neurontin, and natural supplements with phytoestrogens found in soy, black cohash, etc. may diminish hot flashes but not to the same extent as estrogen nor do they treat other problems associated with menopause. During the perimenopausal transition, ovarian production of estrogen, progesterone, and testosterone firsts begins to fluctuate and eventually stops altogether. The initial and most obvious results of this are irregular bleeding, intermittent hot flashes and night sweats, concentration difficulties, sleep disturbance, and fatigue. The long term result from the lack of estrogen may result in an increased risk for heart disease, stroke, osteoporosis, colon cancer, macular degeneration, urinary urgency, vaginal dryness, redistribution of fatty tissue to the abdomen, diminished sex drive, changes in skin appearance, and insulin insensitivity with possible development of diabetes. Estrogen receptors are contained in tissue throughout the body, that is why there is such a widespread impact from menopause and reduced estrogen production.

The “Woman’s Health Initiative” (WHI) study first released in 2002 was looking at estrogen to see if it should be given to all menopausal women to lower their risk for heart disease which is the number one cause of death in women after menopause. This study determined that it was not safe to recommend it uniformly to all menopausal women. What was lost in the release of the results is that it is a safe and effective treatment for the majority of women for specific indications. In other words, the woman and her doctor need to consider the risks and benefits for that particular individual to see if the benefits outweigh the risks. In the vast majority of women the benefits do outweigh the risks.

What are the risks associated with estrogen use? The biggest fear that women have concerning estrogen is that it causes breast cancer. The WHI study showed an increased occurrence of breast cancer in women who used a combination of estrogen and progesterone (EPT) for 5 years; there was no increased occurrence of breast cancer in women who took only estrogen replacement. In those women on EPT it is more likely that the EPT unmasked already existing breast cancer and did not actually cause breast cancer. The increased occurrence also was not large. The baseline risk for a woman 51 years old of developing breast cancer in her lifetime is 2% or in other words she has a 98% chance of not developing breast cancer. The increased occurrence with EPT is 25% which means her new lifetime risk for developing breast cancer is 2.5% or she now has a 97.5% chance of not developing breast cancer in her lifetime. You can see that this possible increased risk of developing breast cancer on EPT is extremely small.  Even this level of risk is now being questioned. The other most common risk associated with estrogen use is the development of blood clots that may result in pulmonary embolism or stroke. This risk is of a similar magnitude as the risk of breast cancer, higher but not excessive. Another risk of estrogen therapy is uterine cancer in women who still have their uterus; the addition of progesterone prevents this risk. In women who have had a hysterectomy, there is no proven benefit of taking a progesterone hormone after menopause.

What are the benefits of estrogen therapy? The main benefit, and the only approved indication, of estrogen therapy is for the treatment of symptoms of the perimenopausal transition and early menopause. It should not be used to primarily prevent heart disease or dementia. It is highly effective in reducing hot flashes, night sweats, mood changes, sleep disturbance, and any other symptoms that result from diminished estrogen production.  Estrogen is also approved for the prevention of osteoporosis. Osteoporosis is the most common condition afflicting women after menopause. Women lose the highest percentage of their bone mass in the first 5 years of menopause. Estrogen therapy is effective in preventing this loss. Other benefits of estrogen therapy are the prevention of vaginal dryness that occurs after menopause which leads to discomfort with intercourse. It also reduces the occurrence of hyperactive or irritable bladder, lowers a woman’s risk for colon cancer, reduces the accumulation of fat tissue around the waist, helps maintain the health and vitality of the skin, and reduces macular degeneration.

Estrogen replacement, like everything else we do in life, has risks and benefits. What each woman needs to determine is do the benefits of taking estrogen outweigh the risks; it is a quality of life decision.  This is a decision that should be made with the assistance of her doctor. The lowest effective dose of estrogen should be used for the shortest time period necessary to help with the transition through menopause. Certainly some women will choose to remain on estrogen indefinitely because they feel better on it. This is acceptable as long as they are aware of the potential risks verses the benefits. Women who definitely should not use estrogen are those who have a history of previous breast cancer,  a genetic predisposition to breast cancer, uterine cancer, heart disease, stroke, blood clots, or a blood disorder that predisposes them to clots.