2 Gazette Health | Fall 2013
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Kimberly Bamber, Anna Joyce Anna Joyce Karen Finucan Clarkson Scott Harris Archana Pyati John Schmitz
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The birth rates for U.S. teens and women in their 20s declined to historic lows in 2012, while birth rates for women in their 30s and early 40s rose, the U.S. Department of Health and Human Services reported.
New Research on Drugs to Prevent
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Women who had “helpful” versions of both regions were about six times less likely to develop breast cancer than women who didn’t have these versions. “Our study reveals the first known genetic factors that can help predict which high-risk women should be offered breast cancer prevention treatment and which women should be spared any unnecessary expense and risk from taking these medications,” said study leader Dr. James N. Ingle of the Mayo Clinic. “We also discovered new information about how the drugs tamoxifen and raloxifene work to prevent breast cancer.” –NIH News in Health
Suffering from joint pain? Calcium and low doses of vitamin D probably won’t help. A study published in the Journal of the Academy of Nutrition and Dietetics found that neither provided relief of joint pain or swelling in women who had reached menopause. “We’re wearing down over time, and there’s not much to be done about it,” said Dr. Rowan T. Chlebowski, lead author of the study. –Vitamin D Council
Women Take Sleeping Pills More Often Women use prescription sleep aids more frequently than men. Five percent have taken a prescription in the last month to get some shut-eye, compared with 3 percent of men, according to data released in late August by the Centers for Disease Control and Prevention. Somewhere between 50 million and 70 million Americans suffer from sleep disorders like insomnia, which can not only hinder daily functioning, but also have a negative impact on overall health. However, long-term use of drugs to help with sleep also presents its own risks, including memory impairment.
CANCER RIBBON: PHOTODISC/THINKSTOCK; BABY FEET: BANANASTOCK/THINKSTOCK; JOINT PAIN: ISTOCKPHOTO/FSTOP123; SLEEPING PILLS: ISTOCKPHOTO/ ANDRESR
cientists found tiny genetic differences that can help identify women most likely to benefit from certain drugs to help prevent breast cancer—and who should avoid them. Women at high risk for breast cancer, such as those with a previous tumor or a family history of the disease, can take medications to lower their risk. These drugs include tamoxifen and raloxifene. But many women decide not to take them. The drugs don’t always prevent cancer, and in rare cases they can cause serious side effects. If doctors could better predict a patient’s response to therapy, women could make more informed choices. To learn more, National Institutes of Health-funded scientists analyzed the genes of women in a breast cancer prevention study. The women had taken tamoxifen or raloxifene for several years to reduce their risk for breast cancer. Two tiny genetic regions tended to differ between women who did and didn’t develop breast cancer while taking the drugs.
Supplements Won’t Help Joint Pain
Sjögren’s syndrome, an autoimmune disease that causes dry eyes and mouth, is nine times more common in women than men. -NIH News in Health
BREAST-FEEDING: ISTOCKPHOTO/ JOSEGIRARTE; EYE: ISTOCKPHOTO/IA_64
More Moms are Breast-feeding
reast-feeding rates have continued to rise over the past decade, according to recent data from the Centers for Disease Control and Prevention (CDC). “This is great news for the health of our nation because babies who are breastfed have lower risks of ear and gastrointestinal infections, diabetes and obesity, and mothers who breast-feed have lower risks of breast and ovarian cancers,” said CDC Director Tom Frieden, M.D. The percent of babies breast-feeding at 6 months increased from 35 percent in 2000 to 49 percent in 2010. The percent of babies breast-feeding at 1 year also
increased, from 16 percent to 27 percent, during that same time period, the CDC reported. In that same 10-year span, the percent of African-American babies being breastfed at 6 months doubled, reaching 36 percent, according to the Office on Women’s Health, part of the U.S. Department of Health and Human Services. If recommendations, such as breastfeeding for at least the first six months, were met entirely, it would save $2.2 billion in annual medical costs, Frieden said. A family could save between $1,200 and $1,500 annually on formula, according to the Office on Women’s Health.
Fall 2013 | Gazette Health 5
BY ARCHANA PYATI
6 Gazette Health | Fall 2013
sion; and fibromyalgia, a chronic condition that radiates throbbing pain throughout the body. Earlier this year, she endured a bout of pneumonia. Yet to look at Johnson, 43, is not to behold a sick person. Her skin glows, her smile is radiant and she seems to exude an inner peace. She is a motivational speaker and spoken-word poet. She has published books on selfempowerment and spirituality under the pen name Sanjo Jendayi, which she said means “one who appreciates her past and gives thanks.” She takes a variety of medications and has been through chemotherapy,
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and credits monthly massage therapy for playing a major role in her sunny disposition. “If I wasn’t receiving massage, I’d be bedridden by now,” she said at a recent session with Nichole Ruffin, a licensed massage therapist (LMT) and owner of Caressence Therapeutic Massage in Greenbelt. Long considered a ritual of pampering and female bonding, massage is now receiving greater recognition for its medical benefits. According to an American Massage Therapy Association consumer survey of 1,010 adults in 2012, 50 percent said their doctors encouraged them to get a massage.
The past 15 years have seen several research studies exploring the science behind massage’s impact on specific ailments and diseases. Massage encompasses a range of techniques, from Swedish massage’s gliding strokes and kneading to the penetrative and localized manipulation of deep tissue massage. Massage therapists receive their licenses from the states in which they choose to practice, and can pursue additional credentials from the National Certification Board for Therapeutic Massage & Bodywork. What we do know about massage is that it boosts endorphins and
eserie Johnson has suffered a battery of illnesses—some might say more than her fair share. Twelve years ago, the District Heights resident developed ankylosing spondylitis, a form of spinal arthritis possibly linked to an impaired immune system and characterized by pain and stiffness in the lower back and hips. Then came the diagnosis of sarcoidosis, another immune disorder that causes lingering inflammation in the lungs and other organs; lung cancer; hyperten-
One survey showed half of adults reporting their doctor encouraged massage.
Massage may help women trying to get pregnant.
FOR PREGNANCY AND INFERTILITY Since it adds significant weight to a woman’s body, pregnancy often leads to discomfort and even pain along the back, hips, neck and shoulders. Pressure from the uterus on veins connecting the limbs to the heart can create swelling in the hands and feet. In pregnant women, massage not only alleviates discomfort, but also moves excess fluids away from the limbs toward the center of the body, said Robbin Phelps, LMT and movement education therapist in Takoma Park. The pain in pregnancy is caused by tightness of the fascia, a connective tissue that wraps around muscles, enabling them to contract and expand and glide against each other. Phelps said massage softens the fascia, making it stronger and more pliable to support a woman’s expanding belly. Most therapists recommend positioning pregnant clients on their side after the second trimester, using pillows and bolsters for support. Additionally, massage reduces the emotional stress that can accompany pregnancy, Phelps said. “It’s very soothing for the pregnant mom to be quiet, to be tended to, and to have some peace and relaxation.” Massage can also benefit women who are trying to get pregnant. At Pulling Down the Moon, a Chicagobased holistic health center with a branch in Rockville, women receiving fertility treatments can participate in a four-step massage regimen. Various techniques—some of which are intended to increase blood flow to the pelvic organs—may help clients conceive, said Phelps, who practices at the center three days a week.
Infertility treatment can be hit or miss, so massage helps clients contend with the anxiety and uncertainty. “Pretty much all the women coming there don’t know why they’re not getting pregnant,” and are, therefore, open to alternatives like massage, said Phelps. FOR CANCER PATIENTS For years, massage was contraindicated for cancer patients due to an erroneous belief that increased blood circulation caused cancer cells to spread. This view was disputed by studies demonstrating the process by which cancer cells metastasized is too complex to be dictated by increased circulation alone. Still, the American Cancer Society, which endorses massage as an adjunct therapy for cancer patients, cautions against direct pressure on tumors or lumps until the question of how cancer spreads from these areas “is clearly answered,” according to the society’s website. Now, massage for cancer patients and survivors has become a growing subspecialty among massage therapists, who in 2007 formed the Society for Oncology Massage (S4OM) to offer special training to peers and education on how massage can relieve pain, side effects of chemotherapy and radiation and irritation of postsurgical scar tissue. Oncology massage is no different than regular massage, but usually employs lighter strokes, said Lee Anne Blank, LMT, owner of Massuage Associates in Rockville and a charter member of S4OM. Blank said oncology massage varies from client to client, depending on the diagnosis. For example, sessions may be shorter than the standard 50 minutes, positions are modified to accommodate chemotherapy ports or radiation burns and aromatic oils and lotions are never used on patients experiencing nausea. Cancer patients are at risk for developing blood clots, which therapists avoid touching since it could cause the clot to detach and move, a potentially fatal condition called an embolus, Blank said. At the continued on 14
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improves sleep, blood circulation and range of motion, and these benefits may alleviate symptoms associated with a range of conditions women experience—from cancer to pregnancy to chronic pain, several local massage therapists said. “The goal is not to think you can cure a client … [but] to help a client feel as comfortable as possible” as they undergo or recover from procedures and treatments, said Ruffin.
Fall 2013 | Gazette Health 7
The likelihood of a woman having the genetic mutations is usually 1 in 400.
ISTOCKPHOTO/FTWITTY; OPPOSITE PAGE: MIRIAM COHEN COURTESY OF HERSELF
GazetteHealth Health| |Fall Fall2013 2013 88 Gazette
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STRIKE Women with Faulty Genes Choose Preventive Mastectomies BY KAREN FINUCAN CLARKSON
iriam Cohen’s 47th birthday was bittersweet. “That’s the age my mother was when she died of breast cancer,” said Cohen, who underwent a preventive mastectomy in 2009. “Nothing is foolproof. There’s always a chance that something might manifest itself. But I reduced my risk of breast cancer significantly.” By about 95 percent, according to Nancy Markus, M.D., a breast surgeon at Shady Grove Adventist Hospital in Rockville. “When you look at risk reduction, a prophylactic mastectomy is as close to 100 percent as you can get,” she said. Of Ashkenazi Jewish descent, Cohen inherited a mutated version of the BRCA1 gene that makes its carriers about five times more likely to get breast cancer than women without the mutation, according to statistics from the National Cancer Institute (NCI). About 60 percent of women with the faulty gene develop breast cancer. “I always knew I was at high risk,” said the Rockville resident. “I didn’t live in fear of dying from breast cancer, but it was always in the back of my mind.” BRCA1 and another gene, BRCA2, are part of a class of genes known as tumor suppressors. Certain mutations to these genes strip them of their ability to suppress abnormal cell growth, so cancer is more likely to develop. The likelihood of a woman having the mutation is 1 in 400 unless, like Cohen, she is of Ashkenazi Jewish heritage, in which case it is 1 in 40, according to NCI.
COHEN IS AMONG A NUMBER OF WOMEN WITH the mutation who, after evaluating the odds, believe that the removal of their breasts may add years to their lives. This pre-emptive strike involves major surgery and, usually, breast reconstruction. That translates into hours in the operating room—often on more than one occasion—and weeks of recuperation, not to mention a risk of complications. It’s not something to be entered into lightly, said Sonya Kella, M.D., a breast radiologist at Shady Grove Adventist Hospital in Rockville and medical director of the Shady Grove Breast Center. A woman’s age, circumstances and life plans all come into play. “Having a double mastectomy may affect sexuality and alter your life,” she said. “A patient in her early 30s who wants to have children and breast-feed may opt for surveillance, whereas a woman who has completed childbearing may have a prophylactic mastectomy.” Aware of what the surgery involved, Cohen did not initially pursue the option after she tested positive for the gene mutation in 2002. Instead, the mother of two decided to undergo a prophylactic oophorectomy to remove her ovaries. Up to 40 percent of women with a BRCA gene mutation get ovarian cancer, according to NCI. The surgery has the added benefit of cutting breast cancer risk in half for premenopausal women with a BRCA mutation. That’s because the ovaries are the main source of estrogen in a woman’s body and excess estrogen is thought to contribute to certain breast cancers. For years, Cohen opted for increased surveillance rather than a mastectomy. The recommendations are “a physical exam every six months and an annual mammography,” said Markus. continued on 10
I didn’t live in fear of dying from breast cancer,
but it was always in the back of my mind.”
Fall 2013 | Gazette Health 9
A more natural breast reconstruction was actress Angelina Jolie’s goal.
BRCA, continued from 9
Should You Get Tested?
“These women are also eligible for an annual breast MRI.” The MRI detects cancer earlier by pinpointing areas in the breast with increased blood flow, which is necessary to support growing cells. Some women may be treated with tamoxifen, an infertility drug that stops or slows the growth of hormone-positive cancers by preventing estrogen from attaching to receptors on the cell. “You could treat a BRCA carrier with tamoxifen until she’s ready to have a mastectomy and give her a 50-percent risk reduction until she makes the leap,” said Markus. Generally, this drug may be as a preventive measure for up to 10 years, although there is a little data on how well it works long term because studies indicating its effectiveness are relatively recent.
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There have been many advances in this procedure in the last few years, and
the results can be beautiful.”
-Actress Angelina Jolie, who elected to have a preventive mastectomy earlier this year
Hampton pointed to some recent techniques that allow for the preservation of breast skin, as well as the nipple and areola. “The result is much closer to what we have normally.” A more natural breast reconstruction was actress Angelina Jolie’s goal. Prior to her February preventive mastectomy, she underwent a nipple delay, which, as she wrote in The New York Times, “rules out disease in the breast ducts behind the nipple and draws extra blood flow to the area” to maintain the nipple’s viability. “There have been many advances in this procedure in the last few years, and the results can be beautiful.”
WHILE THE NUMBER OF CANCER-FREE WOMEN with a BRCA gene mutation who undergo a prophylactic bilateral mastectomy has not been documented, there have been several studies showing an increase—by some accounts more than triple in the last 15 years—in the number of women who, after getting cancer in one breast, choose to have both removed. In a 2008 study published in the International Journal of Cancer, U.S. women had the highest rate—36.3 percent—of prophylactic mastectomies among carriers of the faulty BRCA1 and BRCA2 genes. “Some doctors are concerned that too many women are choosing the very aggressive step of … prophylactic mastectomy during or shortly after breast cancer surgery because they overestimate their risk of future breast cancer,” according to Breastcancer.org. But while the decision to have a preventive mastectomy can be difficult, many women appear content with their decision to undergo surgery. In a 2011 presentation at the annual meeting of The American Society of Breast Surgeons, Mayo Clinic researchers said they found 90 percent of women with cancer in one breast who chose to have both breasts removed were satisfied with their decision 20 years later. Studies reported in the Journal of Clinical Oncology showed satisfaction rates of 83 percent in 2005 and 86.5 percent in 2006. “I have zero regrets,” said Cohen. “Now that I’ve lived longer than my mom, I realize just how young she was when she died. I want to be here for my grandchildren.”
IT WAS A CHANCE MEETING WITH A FRIEND FROM college, now a breast surgeon outside of Philadelphia, that convinced Cohen to have a bilateral mastectomy. “Her basic message to me was that it wasn’t just that I could get breast cancer but that, if I got it, the outcome might not be good .... Cancer in women with the BRCA1 gene often manifests itself as triple negative.” “Triple negative is a more aggressive cancer,” said Regina Hampton, M.D., a breast surgeon with Signature Breast Care in Lanham and privileges at Doctors Community Hospital. Compared with other breast cancers, triple negative tends to grow faster, be less visible on a mammogram, spread to other parts of the body earlier and recur more often. Tamoxifen does not protect against this estrogennegative cancer. BRCA1 mutations are a risk factor for this type of cancer. “About 10 percent of triple negative cancers are found in BRCA women,” Hampton said. The day after lunch with her friend, Cohen decided to have a mastectomy. “I didn’t make an emotional decision. It was informed by my situation and knowledge. It was a factual, scientificbased decision.” In July 2009, at 46, Cohen had both breasts removed. “I’d read a lot about mastectomies, but nothing really prepares you for everything you have to deal with—pain, draining tubes, expanders,” she said. Four months later, Cohen had implant surgery to reconstruct her breasts. “You always know the implants are there; they’re not really part of your body …. But that’s OK. My breasts have never been a big part of who I am.” Improved reconstructive techniques may make the surgery “more palatable” for some women, said Hampton. “We now have more pleasing cosmetic procedures that offer great results, especially when compared to where we were 20 years ago. Then, the options we had to offer women in their 30s and 40s were horrible.”
Deciding whether to find out if you have BRCA1 and 2 genes with mutations that increase cancer risk is complex. The U.S. Preventive Services Task Force recommends that only women who meet very specific risk criteria be tested, which it says amounts to only 2 out of 100. That’s in part because results may be inconclusive. Many insurance companies require women to undergo genetic counseling prior to being tested, and sometimes insurance won’t cover the cost of the procedure. As you begin the conversation about whether to be tested with your doctor, your family and yourself, these websites may be good resources for information gathering: n www.cancer.gov/cancertopics/factsheet/ Risk/BRCA n www.mayoclinic.com/health/brca-gene-test/ MY00322 n ww5.komen.org/breastcancer/ genemutationsampgenetictesting.html
BY KAREN FINUCAN CLARKSON
t is relatively cheap, available over the counter and potentially able to reduce a woman’s risk of cancer, stroke and cognitive decline. But aspirin is not without its own risks. “Aspirin is an interesting drug, but it’s not for everyone,” said Reed M. Shnider, M.D., a cardiologist with Cardiology Associates, LLC in Olney. “And while some of the recent studies are interesting and show there may be some beneficial effects for women, they are not conclusive.” Since March, studies have linked aspirin to a reduction in the incidence of two types of cancer in women. A level of protection was noted by researchers at Stanford School of Medicine investigating aspirin’s effect on melanoma, a type of skin cancer. After analyzing data from 60,000
Studies have linked the drug to a reduced risk of two types of cancer in women.
Caucasian women ages 50 to 79, researchers found that those who took aspirin lowered their risk of developing melanoma by 11 percent at one year, 22 percent between one and four years and 30 percent at five years and beyond. The American Cancer Society (ACS) estimates that this year more than 31,000 women will be diagnosed with melanoma and 3,200 will die from it. Unlike the melanoma study where aspirin’s benefit was readily apparent, a study focused on colon cancer showed no risk reduction until after 10 years of taking the drug. Researchers at Brigham and Women’s Hospital and Harvard Medical School, who reviewed data from nearly 40,000 women 45 and older, found the incidence of colorectal cancer was 20 percent lower among those taking aspirin every other day. This year, more than 102,000 colon and 40,000 rectal can-
cers will be diagnosed and nearly 51,000 people will die from colorectal cancer—the third leading cause of cancer death in women, according to ACS estimates. THESE STUDIES, WHICH SHOW AN ASSOCIATION between a woman’s aspirin intake and reduction in disease risk, raise a number of questions. Chief among them is how does aspirin prevent certain cancers. There are theories but no answers, said Stephanie Trifoglio, M.D., an internist and geriatrician with Maryland Geriatric Medicine in Greenbelt. “Aspirin is both a platelet inhibitor and an anti-inflammatory. Either or both may be a mediator in cancer development,” she said. Another theory, put forward in a study of esophageal cancer released in June, suggests that aspirin’s effectiveness in fighting cancer continued on 17
Fall 2013 | Gazette Health 11
Uterine fibroids account for 4 out of 10 hysterectomies in the U.S. each year.
THE SILENT TUMOR Many Women Unaware They Have Uterine Fibroids
BY KAREN FINUCAN CLARKSON
hey afflict up to threequarters of women, yet most who have them experience no symptoms. Still, they account for 40 percent of the 600,000 hysterectomies performed each year in the U.S., according to the American Congress of Obstetricians and Gynecologists. They are uterine fibroids, noncancerous tumors that grow within the wall of the uterus. The term fibroid is a bit of “a misnomer,” said Elliece S. Smith, M.D., a gynecologist and cosmetic surgeon in Lanham with privileges at Doctors Community Hospital, in that the tumors “are actually made of smooth muscle, tightly bound.” The benign tumor is “distinct from the surrounding muscle of the uterus,” said James S. Powers, M.D., a Chevy Chase gynecologist and former chief of the division of gynecology at Suburban Hospital in Bethesda. “It tends to grow in very discrete spots.” Those spots—of which there are three—dictate what type of symptoms a woman may experience. Uterine fibroids cause symptoms in a quarter of reproductive-age women, according to the Center for Uterine Fibroids at Boston’s Brigham and Women’s Hospital. While pain is uncommon, according to Powers, other symptoms can detract from a woman’s quality of life.
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want to get pregnant. “Fibroids can sometimes interfere with the implantation of a fertilized egg,” said Powers. The rate of spontaneous miscarriage may be as much as 85 percent higher in women with fibroids than those without, according to a 2010 study in Reviews in Obstetrics & Gynecology. Fibroids that grow within the muscular wall of the uterus, known as intramural fibroids, can distort the shape of the uterus and also may cause longer periods with heavier bleeding. When these tumors get large enough, “they can cause the abdomen to poke out and the woman to look pregnant,” said Smith.
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Subserosal fibroids, which project to the outside of the uterus, may press on the rectum or bladder. “If the fibroid is posterior, it can cause constipation. If anterior, the result can be frequent urination,” Smith said. The two most common symptoms are abnormal uterine bleeding and pelvic pressure. Whereas normal menstrual periods typically last four or five days, seven or more days is not unusual among symptomatic women. “Women with fibroids also can have such heavy bleeding that they need to change sanitary protection frequently (perhaps every hour) or hesitate to participate in their normal activities for
FIBROIDS OFTEN ARE DISCOVERED by a gynecologist during an internal exam. A sonogram may be used to confirm the finding. In most cases, the patient is unaware of the fibroids’ existence, said Powers. Fibroids aren’t
THE LEAST COMMON FIBROIDS ARE those that grow into the inner cavity of the uterus, noted the Center for Uterine Fibroids. Submucosal fibroids, which represent 5 percent of these tumors, are more likely to cause prolonged, heavy menstrual bleeding and can be a problem for women who
Submucosal fibroids, which represent 5 percent of these tumors, are more likely to cause prolonged, heavy menstrual bleeding.
fear of socially embarrassing bleeding,” noted the Center for Uterine Fibroids’ website. Such bleeding can cause anemia, which can be a problem when treating fibroid patients, said Smith. Fibroids come in a variety of shapes and sizes, and where there is one, there probably are more. The average affected uterus contains six to seven fibroids, according to the Center for Uterine Fibroids. They can be as small as an apple seed or as large as a soccer ball, said Smith, and “neither pain nor bleeding is correlated with the size of the fibroid.” Fibroids, which occur primarily between the ages of 30 and 40, are about three times more prevalent in black women than in white women, according to the Center for Uterine Fibroids. The tumors tend to develop in African-American women at a younger age, grow more rapidly and be more likely to cause symptoms. The reason for the discrepancy between races is not understood, said Smith. Overweight and obese women are two to three times more likely to get fibroids, according to the National Women’s Health Information Center. That may be due to the fact that fat cells raise estrogen levels in the body and estrogen is known to promote fibroid growth. Diet, too, is a risk factor. Eating a lot of red meat and ham has been linked to fibroid development. Family history is also thought to play a role. The risk of fibroids is about three times higher for a woman whose mother had them.
Fibroids primarily occur between ages 30 and 40.
cancerous, but they can grow, albeit slowly. For that reason, physicians often follow a practice of watchful waiting. Fibroids shrink—disappearing completely or at least 50 percent, according to Powers—after menopause, when estrogen levels drop. Symptomatic women do not need to wait until menopause to shrink or eliminate fibroids. Treatment plans are tailored to the individual, said Smith, depending on the severity of symptoms, age, lifestyle and future plans. “Not everyone has the same symptoms; not everyone has the same plans for her uterus,” she said. “A 23-year-old who has not yet started her family will want more conservative treatment, whereas a 49-year-old has other options.” For women who wish to preserve their ability to bear children, there are a few options. “If the main complaint is heavy bleeding, birth control pills can make periods lighter and shorter,” said Smith. Although the low-dose pills contain estrogen, they do not appear to make the fibroids grow, Smith noted. Provera, a synthetic derivative of the hormone progesterone, can help reduce bleeding, according to Powers. The drug, taken 10 to 12 days per month, should be reserved for cases where periods are exceptionally heavy. Another medication, known as a gonadotropin-releasing hormone, may be prescribed to block the production of estrogen and progesterone. “It fools the body into thinking it is going through menopause so that fibroids shrink,” said Smith. The drug has significant side effects—“hot flashes, a dry vagina, all the things you associate with menopause,” she said. “It shouldn’t be taken for more than six months and should be used only as an adjunctive therapy to stop bleeding, get the blood count up, and deal with anemia so that the patient is in better shape for surgery.” A myomectomy surgically removes fibroids while leaving the healthy uterine tissue. The surgery does not prevent fibroids from recurring. Women whose fibroids were deeply imbedded in the uterus and become
pregnant sometimes need a cesarean section when delivering, according to the National Women’s Health Information Center. For women who are done bearing children, endometrial ablation can destroy the lining of the uterus. This can be done using heat, microwave energy, hot water or electrical current, according to the Mayo Clinic. “The result is no period or a scanty period,” said Smith. The procedure is done on an outpatient basis. During uterine artery embolization, “an interventional radiologist threads a catheter into the vessels supplying blood to the fibroid and blocks the supply,” said Smith. “It’s like your fibroid is having a heart attack, then dies and shrinks. It doesn’t go away, but it does get smaller.” The only way to cure fibroids is with a hysterectomy, which involves the surgical removal of the uterus. Most women with uterine fibroids can choose to keep their ovaries in order to avoid surgically induced menopause, noted the Mayo Clinic. If fibroids are small, the surgeon may be able to access the uterus through the vagina as opposed to cutting into the abdomen. Both are major surgeries involving several weeks of recuperation. Occasionally, the surgery can be done less invasively through the use of a laparoscope, according to the National Women’s Health Information Center. Research continues into less invasive and more effective ways to treat uterine fibroids, said Smith, pointing to studies exploring the use of ultrasound to shrink tumors. According to the National Institutes of Health, a recent finding suggests fibroid tissue is actually made of tangles of collagen and that certain drugs may be able to break apart the strands of protein or prevent them from forming. Such research will expand the options available to physicians so that they can “further refine and tailor treatment plans for patients,” said Smith. But, even today, some tailoring is possible. With uterine fibroids, “there’s no one size fits all.”
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MASSAGE, continued from 7 same time, massage on the hands and feet can help with the neuropathy— a tingling/numbness—brought on by chemotherapy. “What we’re trying to do is support someone’s immune system,” which is typically compromised by cancer treatment, Blank said. Chemotherapy, for example, depletes the number of infection-fighting white blood cells in bone marrow. Massage doesn’t replenish white blood cells, but increasing blood flow boosts a patient’s overall well-being, Blank said. A carrier of disease-fighting white blood cells, the lymphatic system is also a critical element of our immune response that can be damaged by cancer treatment. Not technically massage, lymphatic drainage is a popular technique therapists use on breast cancer patients whose lymph nodes have been removed during a mastectomy. These patients run a 50-percent chance of developing lymphedema, a
It doesn’t make the pain go away … but by the time the session is over, the pain may be in the 3 to 4 range,” on a scale of 1 to 10. -Nichole Ruffin, massage therapist
condition where a blockage prevents lymph fluid from draining, causing swelling and potentially infection, said Jill Nelson, LMT, certified lymphedema therapist and owner of Integrative Therapies in Bethesda. Lymphatic drainage, which involves gentle stretching of the skin, is designed to reverse the flow of lymph fluid so it’s redistributed through the body, said Nelson. “Lymphedema isn’t curable, but it’s manageable,” she said.
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FOR CHRONIC PAIN Of her many illnesses, Johnson described fibromyalgia as her “biggest challenge.” The pain is “deeply ingrained,” “constant,” and “feels like walking around with weights .... There are times when a hug hurts, when brushing my teeth hurts,” she said. Women make up almost 90 percent of the 5 million Americans who suffer from fibromyalgia, and their symptoms include fatigue, insomnia, widespread but diffuse pain, a tingling
sensation in their fingers, and “tender points” along the body that are painful when touched, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases. With Johnson and other clients with fibromyalgia, Ruffin doesn’t “go to the center” of a tender point, but will massage around it to release some of the pain. Clients, including Johnson, have reported better sleep, greater range of motion and an uplifted mood, Ruffin said. “It doesn’t make the pain go away … but by the time the session is over, the pain may be in the 3 to 4 range,” on a scale of 1 to 10, Ruffin said. Clients with multiple sclerosis (MS) also benefit from massage as it relieves tightness and muscle spasms, the results of a disease that attacks the central nervous system and disrupts communication between nerves and muscles. “What I do is a lot of stretching [since] she feels scrunched in,” said Ruffin of a client with MS. “She’s continued to do the things she wants to do, and she believes massage has helped her do it.”
The good news is that for many women, hair loss can be a short-term condition.
Women’s Hair Loss Common, Complex, Treatable BY SCOTT HARRIS
air loss is more common in men, but far more complex in women. A range of conditions can cause the problem, which, in turn, makes it fairly difficult to find a solution. Fortunately, doctors say a variety of treatment options are available. “Hair loss in men is well-known and far more prevalent, but it’s a problem for a lot of women as well,” said Brenda Pellicane, M.D., a dermatologist with The Dermatology Center, which has offices in Bethesda and Germantown. “Up to 50 percent of women in their 50s and 60s will have thinning hair. It’s just not talked about as much for women as it is for men.” According to the American Hair Loss Association (AHLA), women comprise 40 percent of all Americans struggling with some form of hair loss. For women, there are several possible causes of temporary or long-lasting alopecia, which is the medical term for excessive or abnormal hair loss, according to the AHLA. The good news for many women is that hair loss can be a short-term condition. Pregnancy and excessive stress are often the catalysts. Commonly prescribed medications, such as Zoloft and other antidepressants, the acne-fighting drug Accutane, painkillers including naproxen, and birth control pills, all can cause hair loss as a side effect, according to the AHLA. In these cases, simply reducing stress or changing medications can treat the problem. However, there are some instances where hair loss signals a deeper issue, requiring a deeper solution. One of these more prevalent causes, which
Women comprise 40 percent of those affects men as well as women, is androgenetic alopecia, struggling with some form of hair loss. known as male (or female) pattern baldness. As with most cases of women’s hair loss, the condition is characterized by thinning hair across the scalp, result, unable to grow hair. Though there is speculaespecially on the top or sides, while the front hairtion about the causes of CCCA, a definitive cause line remains intact. A change in the levels of the remains elusive. hormone dihydrotestosterone or DHT can trigger “CCCA occurs more in women of color, posthe hair loss, according to the AHLA. sibly because of grooming habits,” Callender said. “Usually we see this condition during or after “Things like the chemical relaxers or tight menopause, when the hormone starts to decrease,” braids might be behind it, but we really don’t said Valerie Callender, M.D., a dermatologist with know for sure.” Callender Dermatology & Cosmetic Center in Another cause of women’s hair loss is telogen Glenn Dale. “But it can also happen after puberty or effluvium. According to the AHLA, telogen effluwhen women are in their 20s.” vium is usually triggered by a traumatic event like African-American women, Callender said, are childbirth, surgery, a major infection or even extreme particularly susceptible to another condition known stress. For those with this condition, a chemical as central centrifugal cicatricial alopecia (CCCA). In change in the body switches hair from the growing CCCA sufferers, hair follicles are scarred and, as a or resting phase to the telogen, or continued on 18 GAZETTE.NET
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Cold feet can be a symptom of iron deficiency.
Are You Getting Enough
IRON? BY SCOTT HARRIS
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IRON-RICH FOODS INCLUDE: n n n n n n n
Chicken and turkey Dried lentils, peas and beans Fish Meats (liver is the highest source) Peanut butter Soybeans Whole-grain bread
Iron supplements can also help and are the fastest way to correct the problem. They may be especially appropriate for those with celiac disease and other intestinal disorders that make it difficult to absorb nutrients, according to Fortunato Greenberg. “If you’re deficient in iron, there’s nothing wrong with taking supplements, as long as you do it under a doctor’s supervision,” she said. “It’s the quickest way to raise your iron levels.” For those who may be iron deficient, a doctor can conduct a basic blood test to determine a patient’s hemoglobin levels or hematocrit—the percentage of the volume of blood comprised by red blood cells, according to the U.S. National Library of Medicine. Doctors can also test to determine the level of iron stores in the body, Snyder said.
Other sources include: n Oatmeal n Raisins n Prunes n Apricots n Spinach, kale and other greens -MedlinePlus
Sickle cell anemia and similar blood disorders can lead to heavier menstrual bleeding and iron deficiency. Doctors can also remove or shrink polyps and fibroids to help control menstrual bleeding, according to Snyder. However, there is a subset of women who do not have polyps, fibroids or blood disorders, and “just bleed heavily,” she said. In those cases, hormonal treatments, such as birth control medications, can help regulate menstrual cycles and reduce bleeding. As an alternative, the drug Lysteda is specifically designed to limit menstrual flows. A more permanent solution, according to Snyder, is endometrial ablation, in which the uterine lining is heated and destroyed to reduce menstrual flow, but which prevents women from becoming pregnant thereafter.
WOMAN: COMSTOCK/THINKSTOCK; FEET: ISTOCKPHOTO/ RUSLANDASHINSKY
old feet? It could mean more than a reluctance to walk down the aisle. Cold feet are a sign that you may be iron deficient, a serious, but highly treatable, condition that affects women more frequently than men. A body that lacks iron cannot produce the necessary amount of hemoglobin that red blood cells need to carry oxygen to the body’s tissues, according to the Mayo Clinic. And iron deficiency is the nation’s leading cause of anemia, according to the Centers for Disease Control and Prevention (CDC). Iron deficiency in and of itself does not necessarily cause health problems, but it can lead to anemia. According to the Mayo Clinic, common symptoms of iron deficiency anemia include fatigue, shortness of breath, cold hands and feet, headache, irritability, or the uncomfortable tingling and crawling in your legs experienced with Willis-Ekbom disease, also known as restless legs syndrome. Iron deficiency anemia can also carry risks for preterm or small babies when it occurs in pregnant women, according to the CDC. Causes can vary, but for most, it boils down to a simple common factor: not enough iron in the diet. “It happens because of blood loss, a poor diet and not getting enough nutrients, or problems absorbing iron,” said Kait Fortunato Greenberg, a nutritionist with the Greenbeltbased nutrition firm Rebecca Bitzer & Associates. “Women in particular are at risk because of heavy menstrual cycles, and women of childbearing age and nursing need twice as much iron.”
Women are generally more at risk isk than men, according to the Mayo ayo Clinic, because of the loss of blood ood during menstruation. And, pregnant ant women also need enough iron to share with their growing fetus. “Over time, in women with heavy avy menstrual bleeding, if they don’t ’t replenish their iron stores, they can become anemic,” said Diane Snyder, M.D., a gynecologist with Rockville-based Women’s Health Specialists. A normal menstrual cycle is seven n days or fewer, noted Snyder. Also known as menorrhagia, heavy menstrual bleeding is generally defined as bleeding that lasts more than seven days, she said. Soaking through a tampon or a thick pad in the span of an hour is another sign of the condition. Women between 19 and 50 generally need 18 milligrams per day of iron, according to the CDC. Those over 50 need 8 milligrams daily. Fortunately, iron deficiency is easy to diagnose. The problem is also very treatable, as iron is readily available to most Americans in several different forms. The most common source in the average diet is red meat, particularly beef and liver, according to Fortunato Greenberg. But that’s not an open invitation to pitch a tent in your local fast-food parking lot. “A lot of iron comes from red meat, but eating a lot of processed foods can be a problem,” she said. “Iron can be found in whole foods like lentils, fruits and vegetables, especially dark, leafy greens.” One key reason why whole foods help prevent iron deficiency is they often contain vitamin C. “The body can’t absorb iron without vitamin C,” Fortunato Greenberg said. “So get a good variety of fruits and veggies.”
ASPIRIN, continued from 11 comes from its ability to lower rates of DNA mutation. Aspirin’s anti-inflammatory properties may explain why the drug is widely believed to guard against Alzheimer’s disease. Increased brain inflammation is thought to be both a cause and result of that disease. How aspirin may protect women from cognitive decline is unclear, but a Swedish study out of the University of Gothenburg, published last October, suggested that it does. Researchers followed 681 women between 70 and 92 who were at high risk for heart disease and stroke. At the beginning of the study, the women took a series of memory and cognitive tests. When the tests were repeated five years later, the average score fell. But, the women who had consistently taken low-dose aspirin during the study increased their scores. The researchers, acknowledging that the mechanism behind aspirin’s protective effect is not fully understood, suggested that the drug “might influence cognitive decline by enhancing the cerebral blood flow.”
Stroke is known to lead to cognitive decline and aspirin lowers the risk of stroke by 17 percent in women over 65, said Shnider. “Under that age, there’s virtually no benefit. And, while aspirin reduces the incidence of stroke, there’s no perceived benefit when it comes to heart attack” in women. OTHER QUESTIONS THAT ARISE INCLUDE how much aspirin should a woman take and how often. When it comes to stroke prevention, “women benefit from low doses of aspirin, 80 to 100 milligrams every day or every other day,” said Shnider. The typical baby aspirin is 81 milligrams, regular strength is 325 milligrams and extrastrength is 500 milligrams. Low-dose—75 to 160 milligrams daily—is what the Swedish women were taking in the study that noted the drug’s effect on cognitive decline. Women in the colorectal cancer study took 100 milligrams. Of the women in the melanoma study, 75 percent took regular or extra-strength aspirin. What is most effective? “We don’t really know,” said Trifoglio. “Prevention is a relatively young field
Aspirin increases the risk of
gastrointestinal bleeding. … and actually being able to prevent disease is somewhat new. People want answers, but we don’t have them. We’re still figuring it out.” What they have figured out is that aspirin increases the risk of gastrointestinal bleeding. A meta-analysis, published in 2012 in JAMA Internal Medicine, put the risk at 70 percent for total bleeding events and 30 percent for “nontrivial” bleeding events. Another downside to aspirin use is that it may raise the risk of a hemorrhagic—or bleeding—stroke, said Shnider. The U.S. Food and Drug Administration has warned that the antiplatelet effect of low-dose aspirin can be negated by the concomitant use of ibuprofen. And, when aspirin and ibuprofen are regularly taken together, there’s a fourfold increase in the risk of
gastrointestinal bleeding, according to the Harvard Medical School. GIVEN ALL THE UNCERTAINTY AND possible side effects, should women take aspirin? For the vast majority under 65, the answer is no, said Trifoglio, noting that aspirin should be considered only if a woman is in a high-risk group—be it for stroke or cancer. “The benefit clearly must outweigh the risk,” she said. That could be the case, for example, if a woman has already suffered a stroke or has a strong family history of colon cancer. “My advice is not to worry too much about aspirin,” said Shnider, “and focus on lifestyle changes and surveillance—colonoscopies and blood pressure checks—to reduce your risk.” Lifestyle changes and routine screenings are the safest risk reducers for most women, said Trifoglio. “I’ve lived through so many studies that were misinterpreted … where people jumped on the bandwagon” prematurely. “These studies are interesting and food for discussion with your internist.”
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HAIR, continued from 15 shedding, phase, causing hair to fall out en masse. Because various other indirectly related circumstances can lead to this sort of hair loss, extensive tests are often needed. As a last resort, doctors can perform a scalp biopsy for further testing. “Effluvium is a systemic condition, so we need to work those patients up,” Callender said. “Anemia can cause it, so we do blood work to check your iron stores. If iron is low, that can cause effluvium.” To help determine whether hair loss is a cause for concern, Callender recommends a hair pull test. If 15 to 20 strands come out of the scalp after a gentle hair pull, a doctor’s appointment may be in order. However, it is normal, noted Callender, for women to naturally lose up to 100 strands of hair over the course of a given day. One symptom that is particularly worrisome is soreness or inflammation in the scalp. According to Callender, swelling in the scalp can cause scarring in the hair follicles, which exacerbates hair loss and may cause permanent problems. “For scarring conditions, the scalp can be tender and inflamed,” Callender said. “Inflammation in the scalp causes destruction of the hair follicle and permanent hair loss and scarring.” Though the causes can be complex and multifaceted, the condition is treatable. For those with female pattern hair loss, 2 percent minoxidil solutions, which are available over the counter as Rogaine, can help, though users must apply the solution three times a week indefinitely,
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according to both Pellicane and Callender, which can be an expensive and burdensome proposition. “It slows the hair loss, and can even help regrow a little of the hair sometimes,” Pellicane said. “But if you stop the treatment, the thinning starts again.” According to Pellicane, androgenblocking drugs like Aldactone can help in cases of androgenetic alopecia, though it is not recommended for women who are trying to get pregnant. Another treatment uses a laser comb with low-dose light beams to stimulate hair growth, Callender said. In addition, hair transplants are becoming increasingly more available for women. “Hair transplant technique is evolving and improving,” Callender said. “It’s easier with male hair loss because the area [where hair loss has occurred] is usually very open, but women have diffuse thinning, so the grafts have to be inserted between the healthy hair areas without damaging them.” Because of the complexities involved, experts recommend women who suspect they have a problem see a doctor, and the sooner, the better. “Even less-serious types can become more serious and cause permanent damage,” Pellicane said. “With any kind of hair loss, the sooner you get the diagnosis and start the treatment, the better your chances are.” An internist or other primary care doctor is a good first step, but eventually a patient may need to visit a dermatologist, depending on the nature of the condition. “You can have more than one cause, so the diagnosis really should be made by a dermatologist,” Callender said.
Just because a supplement is promoted as being natural doesn’t mean it’s safe.
Should You Take Supplements?
LIQUID LIBRARY/GETTY IMAGES/THINKSTOCK
hen you reach for that bottle of vitamin C or fish oil pills, you might wonder how well they’ll work and if they’re safe. The first thing to ask yourself is whether you need them in the first place. More than half of all Americans take at least one dietary supplement daily or on occasion. Supplements are available without a prescription and usually come in pill, powder or liquid form. Common supplements include vitamins, minerals and herbal products, also known as botanicals. People take these supplements to make sure they get enough essential nutrients and to maintain or improve their health. But not everyone needs them. “It’s possible to get all of the nutrients you need by eating a variety of healthy foods, so you don’t have to take one,” said Carol Haggans, a registered dietitian and consultant to the National Institutes of Health (NIH). “But supplements can be useful for filling in gaps in your diet.” Some supplements may have side effects, especially if taken before surgery or with other medicines, and can also cause problems if you have certain health conditions. The effects of some haven’t been tested in children, pregnant women and other groups. “You should discuss with your doctor what supplements you’re taking so your care can be integrated and managed,” said Dr. D. Craig Hopp, an expert in botanicals research at NIH. Dietary supplements are regulated by the U.S. Food and Drug Administration (FDA) as foods, not as drugs. The label may claim certain health benefits, but unlike medicines, supplements can’t claim to cure, treat or prevent a disease. “There’s little evidence that any supplement can reverse the course of any chronic disease,” said Hopp. “Don’t take supplements with that expectation.” Evidence does suggest that some supplements can enhance health in different ways. The most popular nutrient supplements are multivitamins, calcium and vitamins B, C and D. Calcium supports bone health, and vitamin D helps the body absorb calcium. Vitamins C and E are antioxidants—molecules that prevent cell damage and help to maintain health. Women need iron during pregnancy, and breast-fed infants need vitamin D. Folic acid—400 micrograms daily, whether from supplements or fortified food—is important for all women of childbearing age. Vitamin B12 keeps nerve and blood cells healthy. “Vitamin B12 mostly
comes from meat, fish and dairy foods, so vegans may consider taking a supplement to be sure to get enough of it,” Haggans said. Research suggests that fish oil can promote heart health. Of the supplements not derived from vitamins and minerals, “fish oil probably has the most scientific evidence to support its use,” Hopp said. The health effects of some other common supplements need more study. These include glucosamine (for joint pain) and herbal supplements such as echinacea (immune health) and flaxseed oil (digestion). Many supplements have mild effects with few risks. But use caution. Vitamin K, for example, will reduce the ability of blood thinners to work. Ginkgo can increase blood thinning. The herb St. John’s wort is sometimes used to ease depression, anxiety or nerve pain, but it can also speed the breakdown of many drugs—such as antidepressants and birth control pills—and make them less effective. Just because a supplement is promoted as being natural doesn’t necessarily mean it’s safe. Comfrey and kava, for example, can seriously damage the liver. “It’s important to know the chemical makeup, how it’s prepared and how it works in the body—especially for herbs, but also for nutrients,” said Haggans. “Talk to a health care provider for advice on whether you need a supplement in the first place, the dose and possible interactions with medicine you’re already taking.” For vitamins and minerals, check the Percent Daily Value (DV) for each nutrient to make sure you’re not getting too much. “It’s important to consider the DV and upper limit,” said Haggans. Too much of certain supplements can be harmful. Because supplements are regulated as foods, not as drugs, the FDA doesn’t evaluate the quality of supplements or assess their effects on the body. If a product is found to be unsafe after it reaches the market, the FDA can restrict or ban its use. “Products sold nationally in the stores and online where you usually shop should be fine,” said Dr. Paul M. Coates, director of NIH’s Office of Dietary Supplements. “According to the FDA, supplement products most likely to be contaminated with pharmaceutical ingredients are herbal remedies promoted for weight loss and for sexual or athletic performance enhancement.” NIH recently launched an online Dietary Supplement Label Database at dsld.nlm.nih.gov. –NIH News in Health
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Gazette Health - Fall 2013 Edition, Montgomery County, Maryland