Mammograms continue to be the gold standard for breast cancer screening. How often to do these tests for average risk women is debatable depending on the health organization that you follow or discuss with your health practitioner. This site can be helpful https://ww5.komen.org/BreastCancer/BreastCancerScreeningforWomenatAverageRisk.html.

Many facilities also now offer a breast Tomosynthesis test along with your mammogram, which does make the screening more sensitive to finding breast cancer lesions. This 3-D mammogram may find up to 47% more cancers in women with dense breasts according to a Norway study in 2012. But be aware that it delivers twice as much radiation than traditional mammograms and the breast is compressed for about 48 seconds compared with about 20 seconds for a standard exam. Ouch!!

The question many women are asking is if they should get a breast MRI or when that would be indicated. Investigators performed an observational study in which they used > 2 million images from 6 breast cancer surveillance consortium registries to evaluate biopsy and pathology results after screening mammography and compared that with breast MRI. They looked at women with and without personal histories of breast cancer.

Results showed more high-risk benign (non-cancer) lesions involving biopsies with breast MRI than with mammogram regardless of personal history of breast cancer. Overall, biopsy rates were fivefold higher for MRI than mammography.

Recommendations are that women should not undergo routine breast MRI for cancer surveillance unless they meet certain criteria which includes:

1. Strong family history of breast cancer
2. Oncogenic hereditary mutation
3. Extremely dense breasts
4. High-risk lesions such as lobular carcinoma in situ

Of course, discuss recommendations with your practitioner to determine the best screening for you.

Reference: Buist DSM et al. Breast biopsy intensity and findings following breast cancer screening in women with and without a personal history of breast cancer. JAMA Intern Med 2018 Feb 12; [e-pub]. (https://doi.org/10.1001/jamainternmed.2017.8549).

 

Some of you may have seen this report on TV or scanned through it while reading the paper. It is worth discussing because the concerns lie in not just birth control pills but in any device containing synthetic Progestin, which is different than Progesterone (not synthetic).

This Danish study followed 1.8 million women of childbearing age for more than a decade drawing data from national prescription and cancer registries. During that time, over 11,000 cases of breast cancer were found. The researchers concluded that women using hormones experienced a 20% increase risk of developing breast cancer compared to nonusers. In other words, for every 100,000 women using hormonal birth control, there are 68 cases of breast cancer annual, compared to 55 cases a year among nonusers. The risk also increased with age and varied by formulation. Limitations in the hormonal birth control study include the fact that physical activity, breast feeding and alcohol consumption which can influence breast cancer risk were not accounted for.

The link between birth control pills and breast cancer has always been somewhat controversial. But this is the first study that looked at the risks associated with current low dose birth control pills and devices in a large population. These devices include Progestin implants (Nexplanon) and intrauterine devices (IUD) that release Progestin. The research suggests that the hormone Progestin may be raising breast cancer risk. Thats an important thing to remember because the thought has always been that estrogen causes cancer. And this is not the only time that Progestin has been implicated in the risk of breast cancer.

One of the most popular studies that shed some light on this subject was the 2002 Women’s Health Initiative (WHI) Trial. This study evaluated the use of conventional hormone replacement therapy (HRT) in the form of oral conjugated estrogens and oral medroxyprogesterone acetate (MPA). There was quite a shock over the negative outcomes of this study which included increased cardiovascular and cerebrovascular (stroke) disease, breast cancer, and thromboembolic events (blood clots). We finally dug deeper in the research to find some of the causes.

The first potential cause is the oral ingestion of estrogen. When you take estrogen in a pill form it is presented to the liver in a much more direct concentrated way. The liver synthesizes certain proteins such as clotting factors, sex hormone binding globulin and thyroid-binding globulin. What does that mean?? It means oral estrogen, whether it be a birth control pill or oral HRT stresses the liver and produces inflammatory proteins and more clotting factors. Of course this is dependent on the amount of estrogen consumed. Synthetic hormones also produce unfavorable metabolites that have the potential to change DNA that raises breast cancer risk.

The second issue is progestin (synthetic) vs natural progesterone. There are many studies that indicate that medroxyprogesterone acetate is detrimental to cardiovascular function. A popular study known as the Postmenopausal Estrogen/Progestin intervention (PEPI) trial, found that at the end of 3 years, oral estradiol increased HDL (good cholesterol) by 7%, but this increase was reduced when MPA was added. Oral progestins also under go a substantial first-pass effect on gut and liver metabolism. Is it the progestin metabolites themselves that increase the risk of breast cancer or the fact that progestins turn on estrogen receptor expression that allows more estrogens to be shunted down “bad” pathways?

Women who stayed on these hormones for 10 years or more experienced a 38% increase in their risk for developing breast cancer compared to nonusers. In contrast, there was no increase in breast cancer risk for those using hormones for less than 1 year. That being said, these types of birth control methods in general are safe, effective and accessible options for many women. Perhaps women can change to a different form of non-hormonal birth control, such as an IUD without hormones (Paraguard), condoms or a diaphragm.

Talk to your doctor or practitioner about the pros and cons of different types of contraceptives. A hormonal birth control method may be fine for now, but you may want to reassess its use as you get older or if you have been using a hormonal form for more than 10 years.

Birth Control Pills Still Linked to Breast Cancer, Study Finds – The New York Times: “”

 

The Women’s Health Initiative (WHI) study from 2013 seems like a long time ago but it’s impact is still reverberating throughout the health community as well as with women’s  feelings about hormone replacement therapy (HRT). The take-away message at that time was:  ‘hormones are bad;  they cause heart disease, blood clots and breast cancer and even dementia. Go off of them because the consequences and risks are way worse than any benefits they may have’. Well…things have changed since then.

Where do I begin?

First, we need to remember that the average age of women in the study was 63 years. Most women start HRT in their 50’s. The number of women who developed breast cancer was statistically insignificant compared to those that were not on HRT. Second, there was a difference in those women starting hormones that were within 10 years of menopause onset which showed less adverse effects than those who started later. Third, the majority of women whom developed dementia were over the age of 85. Research shows that 1 out of 2 people over the age of 85 develops dementia.

This study was a large NIH-funded placebo-controlled randomized trial and evaluated only those women on oral estrogen (Premarin) or estrogen-progestin (Prempro) pills. That is to say that HRT comes in many shapes and sizes… topical, vaginal, creams, gels, sublingual trouches and patches. These forms were not tested and studies have shown that these forms of hormones are safer and better tolerated than oral.

Investigators of the WHI reported a 13-year cumulative follow-up of mortality in the 27,347 women who participated in the study. They found that prior use of oral hormones when initiated by women aged  <60 or within 10 years of starting menopause did not affect risk for overall, cardiovascular, or cancer mortality. These findings support guidance from the North American Menopause Society and the Endocrine Society which endorse HRT for symptomatic management in recently postmenopausal women without contraindications.

In my practice I reassure my recently menopausal women that initiating HRT can not only help with bothersome symptoms (hot flushes, insomnia, cognitive impairment, low libido, vaginal dryness), but can delay or prevent degenerative diseases such as osteoporosis. I use only bio-identical hormones and prefer to use topical options for women. The important thing is to individualize treatment for each woman.

Reference: Kaunitz, A. Extended Follow-up of Mortality in WHI Participants: Continuing Reassurance About Hormone Therapy. Journal Watch: Women’s Health                         October 2017; p. 80.

Dysmenorrhea is a condition in which women experience pain during menstruation. One of the explanations can be due to the excess production of prostaglandins causing increased uterine contractions. Up to 90% of reproductive women around the world experience this menstrual pain at some point in their lives. Younger women struggle more than older women and it can lead to absenteeism to the tune of about $2 billion annually.

Common treatments are usually NSAID’s (Advil, ibuprofen) that reduce prostaglandin production through Cyclooxyrgenase-2 (COX-2) inhibition. But some women either prefer not to or cannot tolerate these medications. One alternative is ginger root. This is a spice that is used around the world and has been shown to inhibit COX-2 and has a role in reducing pain and inflammation.

A review of literature was conducted which included randomized trials investigating the effect of ginger powder on young women aged 13-30 years old. Women were excluded if they  had irregular cycles, were using hormones, oral or uterine contraceptives, or had a history of  pregnancy. Dosing was 750-2000 mg ginger powder capsules per day for the first 3 days of the menstrual cycle. Results of the studies suggested that ginger powder given during the first 3-4 days of the menstrual cycle was associated with a significant reduction in pain.

There are many options (dietary changes, fish oils, Niacin, B6 and magnesium, curcumin, etc) in reducing pain and improving quality of life for women suffering from dysmenorrhea. Using ginger capsules is one safe choice and one more thing that you can add to your arsenal.

Reference: Ebbert, J. Dysmenorrhea and Ginger, Familypracticenews.com. march 15, 2017, p. 15

 

 

This new administration has started out with a bang! A journey that’s taking the American people in an uncertain spiral to the “bad, old days”.

As I watched the “pro-life” march on T.V., I couldn’t help but get frustrated with their inaccurate message…. If they reverse Roe vs Wade and make abortion illegal, then it will somehow go away?!  No-oooo!!  It won’t go away. It will just lead to unsafe procedures for women to terminate their pregnancies. This administration wants to eliminate funding to Planned Parenthood and other facilities that perform abortions. What they don’t realize is that by eliminating funding to facilities that perform abortions, they are also eliminating the resources for these women to be educated and receive effective birth control.  If women don’t receive effective birth control, then they are more likely to have an unintended pregnancy that leads to abortion.
With no funding, we find women performing their own abortions leading to unsafe procedures that leads to infection, illness and even death.
Taking away Roe vs Wade doesn’t take away abortions. It makes these procedures unsafe.

More then 5000 American women died each year as a direct result from unsafe and largely self-induced abortions before Roe vs Wade. Now, with the legalization of abortion, less than 1 in every 100,000 women who use a medical abortion die making it safer than childbirth according to the World Health Organization!

According to the CDC, the rate of abortions has continued to decline through the 1990’s with the total number, rate and ratio of reported abortions decreasing by 5% from 2012-2013.

So if you take away funding (and the Affordable Care Act), the rate of abortions will go up with women using unsafe practices and the rate of deaths will also increase. This will increase our national health care costs in trying to save women from these unsafe procedures that could have been prevented. The primary method for preventing unsafe abortions is less restrictive abortion laws and greater contraceptive use and education!
Please don’t let us go back to the “bad old days”. We have come so far…

I have contacted my local senators and I ask that you do the same. I have asked that they please respect women and their reproductive rights.

This means open access to safe, legal, affordable abortion and birth control for all people, regardless of income, location, or education.