About 6- 15% of myocardial infarctions (heart attacks) are associated with nonobstructive coronary disease on angiography. This means that far less than 50% of heart attacks are due to blocked arteries. Also, these types of heart attacks occur more commonly in women.

A multinational study was done in which investigators enrolled 170 women with myocardial infarction with nonobstructive coronary arteries (MINOCA). These women were scheduled to undergo cardiac magnetic resonance imaging (MRI) and coronary optical coherence tomography (OCT). The OCT test uses infrared light to acquire cross-sectional images of the coronary artery using an intravascular catheter. This allows it to have a higher resolution than intravascular ultrasound.

In 145 women who underwent OCT, 67 had a possible or definite culprit lesion, such as plaque rupture or layered plaque. In 116 women who had an MRI, 62 had an ischemic (reduced blood flow) pattern of abnormalities and 24 had a nonischemic pattern, such as myocarditis or nonischemic cardiomyopathy (heart disease causing an enlarged heart). Overall,  A cause for MINOCA was identified in 98 women, with an ischemic etiology in 74, and nonischemic in 24 women.

This study shows the benefit of using multiple imaging tests to identify the mechanism of MINOCA in most cases. It showed almost two thirds of cases related to an ischemic cause, despite the absence of severe obstructive coronary disease by angiography. Women tend to have microvascular disease which affects them four times more than men. They also have different symptoms of myocardial infarction than men. Both genders can exhibit symptoms of chest pain or discomfort but women are more likely to experience shortness of breath, nausea/vomiting and back or jaw pain. It’s best for physicians to order multimodality imaging especially for women with these symptoms to prevent the progression of a heart attack.

Reference: Reynolds, HR et al. Coronary optical coherence tomography and cardiac magnetic resonance imaging to determine underlying causes of MINOCA in women. Circulation 2020 Nov 14; [e-pub]. (https://doi.org/10.1161/CIRCULATIONHA.120.052008).

Dementia is a concern for all of us as we age. Almost 2/3 of Alzheimer disease (AD) cases occur in women which indicates that this condition may be influenced by sex-specific factors. Researchers used data from a prospective cohort study (following a group of similar individuals over time who differ with respect to certain factors) looking at cognitive function and aging in Cache County, Utah. Investigators used data among 2114 women baseline age over 65, primarily white and an average 13 years of education. The factors they reviewed were estimated lifetime exposure to estrogen, both endogenous (years of ovulation) and exogenous (years of menopause hormone therapy) as well as timing of when hormone replacement was initiated.

Estrogen exposure was analyzed relative to cognitive status based on a modified Mini Mental State Exam conducted 3 times over 12 years of followup. Other variables that could influence the outcome included education level, APOE genotype, exercise, overall health. body mass index, depression status, type of hormone therapy, and age.

Longer exposure of estrogen exposure (both endogenous and hormone therapy use) were associated with prevention of age-related cognitive decline. Starting hormone therapy within 5 years of menopause onset was associated with better late-life cognitive function compared with delayed initiation of hormone therapy.

A prospective Finnish study also suggested that starting hormone therapy soon after menopause and continuing it long term reduced the risk for AD. This U.S. analysis now provides further support for this hypothesis that hormone therapy (initiated soon after menopause) can provide cognitive benefits.

Reference: Matyi, JM bet al. Lifetime estrogen exposure and cognition in late life: The Cache County Study. Menopause 2019
Dec; 26:1366.
Liu JH. Does estrogen provide “neuroprotection” for postmenopausal women? Menopause 2019 Dec; 26:1361.
Neurology 2017; 88:1062.

Sexual dysfunction is a prevalent problem among adult women. According to a large nationwide study in the U.S., 5% of women had arousal problems that caused distress or concern. Between 17% and 45% of postmenopausal women say they have pain with intercourse. Among older adults, 23% of women ages 57 to 80 said they did not find sex pleasurable and 5% have a problem achieving orgasm. Sex drive decreases gradually with age in both men and women but women are more likely to be affected. The answer for many postmenopausal women is vaginal estrogen, which is the main hormone that is depleted in vaginal tissues. This treatment can be very effective. But many women prefer not to use hormones.

One option for women is a patented formula that has been used for years in European countries called Ristela. It is a blend of nutritional ingredients shown to improve sexual function in women. This product was presented at the International Society for the Study of Women’s Sexual Health Annual Meeting 2019.

The formulation is composed of Pycnogenol (French Maritime Pine Bark extract), amino acids L-Arginine and L-Citrulline, and a propriety rose hip extract. Pycnogenol is a powerful antioxidant that has been studied in more than 160 clinical trials. It works synergistically with the other ingredients to enhance nitric oxide production and enhance blood flow. Nutrients and oxygen are also able to reach sensitive tissues in the body including the reproductive organs and brain. Research suggests that Ristela improves overall sexual function including vaginal dryness.

Three clinical trials were done in which 263 women on Ristela were reviewed. The studies were 60 days long and used the total score on the Female Sexual Function Index (FSFI). This is a questionnaire that assesses sexual domains such as sexual desire, arousal, orgasm, satisfaction and pain. All women had moderate sexual dysfunction as determined by their baseline FSFI scores. Total antioxidant capacity, and plasma free radicals were scored by measuring oxidative inhibition, reactive oxygen metabolites, and antioxidant potential in the plasma. The FSFI scores improved in all trials in the Ristela group vs the control group. The third trial was conducted in 100 healthy premenopausal women, ages 37-45. After 1 month, total median FSFI score increased by 85.5% in the Ristela group vs 35.3% in the control group. After 2 months, scores increased by 121.4% in the Ristela group vs. 31.5% in the control group (p<0.0001). There were no adverse reactions using Ristela. The first trial was conducted in healthy postmenopausal women (ages 45-55) and the second trial included healthy peri-menopausal women (ages 40-50). Both trials showed significant improvement in FSFI scores in the Ristela groups.

Ristela is a safe, effective treatment option for improving sexual response in pre, peri and postmenopausal women. Talk to your practitioner in how to order this product. Samples are dispensed in physician offices with instructions on ordering.

Reference: Shifren, JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women. Obstet Gynecol 2008; 112:970-978.
Parish, S., Kellogg-Spadt, S. A review of cli ical study data on Ristela, a supplement blend for improved sexual function in women. Poster presentation at the International Society for the Study of Women’s Sexual Health Annual Meeting 2019. Abstract published: Journal of Sexual Medicine 2019.

Combined hormonal oral contraceptives (CHC) have been around since the 1960’s. Concerns about the estrogen component in them and whether they impair bone formation in teenage girls has risen especially since this is the age that bone formation is so crucial.
Researchers conducted a meta-analysis (examined data from several independent studies on the same subject) to compare changes in bone density determined by duel-energy x-ray absorptiometry (DEXA) in healthy adolescent users and nonusers of estrogen-progestin CHC. There were 9 studies that involved a total of 1535 adolescents aged 12-19 years. Pooled analysis showed that the use of estrogen-progestin CHC was associated with significantly lower bone density at 24 months.

So even though findings confirm concerns that combined birth control pills negatively effect bone density in adolescents, I’m not sure we can blame it all on the estrogen component. The dose of hormone that may cause this effect wasn’t clear in the study. Even though the American Academy of Pediatrics are endorsing long-acting reversible contraceptive (LARC) options as being safer and effective, we need to remember that at least one progestin only option (Depo-provera) has been studied and was related to lower bone density. The contraceptive implant known as Nexplanon is also a synthetic progesterone. Both of these progestins are systemically absorbed which is why they are so effective in preventing pregnancy, but do they also effect bone density?

I believe it is still unclear which contraceptive method is best in reference to protecting bone health. We need to consider the costs and benefits of all of these methods. For instance, injectable contraceptives and implants provide effective longterm birth control yet do not involve a daily regimen. So for a women who may not remember or be able to take a pill at the same time daily, an oral birth control pill would not be the choice for her and would increase her risk of an unintended pregnancy. A LARC would be best for this particular patient but I would screen her for other risk factors for bone loss. This includes checking a Vitamin D level, evaluate her calcium and mineral intake as well as her gut health (to make sure she has healthy absorption), and increase weight bearing and strength training exercises.

Screening teens for bone health is always a good idea, but is essential for girls that desire ANY hormonal contraceptive. This will determine a baseline which then can be monitored yearly.

Lopez LM, Grimes DA, Schulz KF, Curtis KM; Chen M. Hormonal contraceptives and bone health in women. Cochrane.org.2014 June.
Goshtasebi A et al. Adolescent use of combined hormonal contraception and peak bone mineral density accrual: A meta-analysis of international prospective controlled studies. Clin Endocrinol (Oxf) 2019 Jan 7; [e-pub].

Breast feeding has documented benefits for both mother and baby (NEJM JW Women’s Health Jul 9 2014; [e-pub] and Am J Obstet Gynecol 2014; 211: 424.el). So when women are choosing birth control methods, it’s important to know the options regarding the effects of hormonal contraception on breast feeding performance, as well as ease of use and safety. The best time to talk about contraceptive options with your practitioner is during your pregnancy.

The CDC has recently updated the U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC), which provides guidelines on the safety of available birth control choices for women with specific health conditions. Updates for breast feeding women were included based on risk for venous thromboembolism (VTE) and postpartum days. For instance, using combined oral birth control pills is not recommended within 21 days of delivery (rated category 4) due to the excess risk of VTE. It’s best to wait beyond 12 weeks postpartum to reduce the mother’s risk for blood clots. On the other hand, all progestin-only contraceptive methods are rated category 1 (low risk/no restrictions) or category 2 (advantages of the method generally outweigh its theoretical or proven risks) for breast-feeding women.

Here are some of the best options for breastfeeding moms:

1. Lactational Amenorrhea- This offers an effective temporary method of contraception (until menses return or milk substitutes are introduced). When women do not menstruate, they (usually) do not ovulate and cannot get pregnant. Some women will choose an additional method of contraception even while breast feeding exclusively to make sure they are protected from pregnancy…which I think is a good idea.

2. IUDs- There are several types of IUD’s which are safe and very effective. Some contain copper and others contain a hormone known as progestin, which is a synthetic progesterone. They can be used for many years and all can be removed as soon as you are ready to get pregnant again. An IUD can be placed in the uterus within 10 minutes of placental delivery which is very convenient, but risk for expulsion is higher when inserted this early. Many women prefer to wait until their 6-week follow-up appointment.

3. Implant, Shot, and Progestin-Only Pill- All 3 of these methods use the synthetic hormone Progestin. You can use any of these methods immediately after delivery. The implant is the most effective birth control available; even more effective than sterilization!!. Pregnancy can be achieved after removal of the implant. The Depo shot is also very effective as long as you are able to get the injection (given in the arm or buttocks) every 3 months. The progestin-only pill is least effective than the implant or shot mainly because there is more room for human error. The pill needs to be taken the same time everyday, which can be difficult when you have a baby to care for. A new option for women outside the U.S. is a progestin-only vaginal ring that is effective for about 1 year.

4. Emergency Contraception (EC)-This contraception is used only if your regular method of birth control has failed (forgotten pill, broken condom). If you are 17 years or older, you can get EC pills (Levonorgestrel) at the pharmacy without a prescription. Take them within 3 days of unprotected sex. A prescription-only EC pill, ulipristal acetate can be used up to 5 days after unprotected sex. Ulipristal is more effective than nonprescription EC. Small amounts of ulipristal has been found in breast milk so pumping and discarding breast milk is advised for 24 hours after taking ulipristal EC.
The most effective EC is having a copper IUD placed within 5 days after unprotected sex. This also provides you with a continuing and effective birth control method.

There are many safe and effective contraceptives choices after childbirth and when breastfeeding. Talk to your practitioner before having your baby to discuss your preferences when the time comes.

References: Chen, M, Schwarz, E. New guidance on contraception while breast-feeding, JWatch.org October 2016. p.77.
Curtis KM et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep 2016 Jul 29;65:1.