Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Latest Posts

References for HRT post

These are the references for the post about HRT and “chemo brain:”


1. Gross J. Lingering fog of chemotherapy is no longer
ignored as illusion. New York Times April 29, 2007 p1.

2. Paganini-Hill A, Henderson VW. Estrogen replacement
therapy and risk of Alzheimer’s disease. Arch Intern Med 1996;156:2213-7.

3. Tang MX, Jacobs D, Stern Y, Marder K, Schofield P,
Gurland B, Andrews H, Mayeux R. Effect of oestrogen during menopause on risk
and age at onset of Alzheimer’s disease. Lancet 1996;348:429-32.

4. Manly JJ, Merchant CA, Jacobs DM, Small SA, Bell K, Ferin
M, Mayeux R. Endogenous estrogen levels and Alzheimer’s disease among
postmenopausal women. Neurology 2000;54:833-7.

5. Chung SK, Pfaff DW, Cohen RS. Estrogen-induced
alterations in synaptic morphology in the midbrain central gray. Exp Brain Res

6. Jones KJ. Steroid hormones and neurotrophsim:
relationship to nerve injury. Metab Brain Dis 1988;3:1-16.

7. Nilsen J, Diaz Brinton R. Mechanism of estrogen-medicated
neuroprotection: regulation of mitochondrial calcium and Bcl-2 expression. Proc
Natl Acad Sci USA 2003;100(5):2842-7.

8. Nilsen J, Brinton RD. Mitochondria as therapeutic targets
of estrogen action in the central nervous system. Curr Drug Targets CNS Neurol
Disord 2004;3(4):297-313.

9. Alvarez-de-la-Rosa M, silva I, Nilsen J, Perez MM,
Garcia-Segura LM, Avila J, Naftolin F. Estradiol prevents neural tau
hyperphosphorylation characteristic of Alzheimer’s disease. Ann NY Acad Sci

10. Singh M, Meyer EM, Millard WJ, Simpkin JW. Ovarian
steroid deprivation results in a reversal learning impairment and compromised
cholinergic function in female Sprague Dawley rats. Brain Res. 1994;644:305-12.

11. McEwen B, Alves S. Estrogen actions in the central
nervous system. Endocrin Rev 1999;20:279-307.

12. Kampen DL, Sherwin BB. Estrogen use and verbal memory in
healthy postmenopausal women. Obstet Gynecol 1994;83(6):979-83.

Shaywitz SE, Shaywitz BA, Pugh KR, Fulbright RK, Skudlarski P, Mencl WE,
Constable RT, Naftolin F, Palter SF, Marchione KE, Katz L, Shankweiler DP,
Fletcher JM, Lacadie C, Keltz M, Gore JC. Effect of estrogen on brain
activation patterns in postmenopausal women during working memory tasks. JAMA

14. Duff SJ Hampson E. A beneficial effect of estrogen on
working memory in postmenopausal women taking hormone replacement therapy. Horm
Behav 2000;38(4):262-76.

LeBlanc ES, Janowsky J, Chan BKS, Nelson HD. Hormone replacement therapy and
cognition. Systemic review and meta-analysis. JAMA 2001;285(11):1489-99.

Zandi PP, Carlson MC, Plassman BL, Welsh-Bohmer KA, Mayer LS, Steffens DC,
Breitner JC. Hormone replacement therapy and incidence of Alzheimer’s disease
in older women. The Cache County
Study. JAMA 2002

MacLennan AH, Henderson VW, Paine BJ, Mathias J,
Ramsay EN, Ryan P, Stocks NP, Taylor
AW. Hormone therapy, timing of initiation, and cognition in women aged older
than 60 years: the REMEMBER pilot study. (Research into Memory, Brain function
and Estrogen Replacement). Menopuase: The Journal of the North American
Menopause Society 2006;13(1):28-36.

Shumaker SA, Legault C, Rapp SR, and the WHIMS investigators. Estrogen plus
progestin and the incidence of dementia and mild cognitive impairment in
postmenopausal women: The Women’s Health Initiative Memory Study: A randomized
controlled trial. JAMA 2003;289(20):2651-62.

Shumaker SA, Legault C, Kuller L, et al. Conjugated equine estrogens and
incidence of probably dementia and mild cognitive impairment in postmenopausal
women: Women’s Health Initiative memory Study. JAMA 2004;291(24):2947-58.

This post originally appeared on Dr. Val’s blog at

Hormone Replacement Therapy: It Might Be Good For Your Brain?

Every now and then I have the pleasure of featuring a guest blogger – someone whose medical opinions are particularly intriguing or controversial.  Dr. Avrum Bluming submitted a really interesting post last month about cancer – and whether or not we scientists really do understand it fully.  In this post, Dr. Bluming reviews the scientific literature on Hormone Replacement Therapy, and finds some interesting evidence that estrogen might actually be good for the brain – to reduce the risk of dementia.  He also suggests that “chemo brain” – the mental fog associated with cancer therapy (especially breast cancer), may be caused by a rapid decrease in estrogen.  Read his comments carefully and let me know if you find his analysis convincing… And watch out for the passionate “zinger” at the end!


The April 29th 2007 issue of the Sunday New York
Times carried a front-page article about the mental fog following treatment of
cancer with chemotherapy.(1) This fog, referred to as chemo brain, usually
clears, but, in approximately 15% of treated patients, may persist for years,
according to the article. All the patients presented
in the article were women, most or all were breast cancer survivors, and the
article does state that a possible cause of chemo brain in these women may be
the lowered estrogen in their bodies, due to their being catapulted into
premature menopause by treatment. The article further states that abrupt
menopause leaves many women fuzzy headed in a more extreme way than natural
menopause, which usually develops gradually. The article goes on to say that
studies of chemo brain have been conducted, overwhelmingly among breast cancer
patients because they represent the largest group of cancer survivors and
because they tend to be sophisticated advocates, challenging doctors and
volunteering for research.

In 1996 a
14-year study concluded that estrogen replacement therapy may be useful for
preventing or delaying the onset of Alzheimer’s disease.(2)

In 1997 a Columbia University study reported a significant
reduction in the risk of Alzheimer’s disease among postmenopausal women taking

In 2000 that same group reported lower levels
of circulating estradiol, the most common form of circulating estrogen, among
women who developed Alzheimer’s disease compared to those who did not.(4)

has been reported to stimulate nerve growth and synapse formation.(5) (Synapses
are nerve to nerve connections), and to play a beneficial role in nerve response to injury.(6)

In 2003 researchers at the University
of Southern California
identified a mechanism for estrogen-mediated nerve cell protection, which
involved preventing the accumulation of calcium within the mitochondria of the
nerve cells.(7,8)

has also been shown to prevent the buildup of the abnormal chemical called
hyperphosphorylated tau protein, characteristic of Alzheimer’s disease.(9)

administered to female rats who have had their ovaries removed enhanced the
rats’ learning ability.(10,11)

administration to postmenopausal women has been associated with improved verbal

A 2001 analysis of 29 published studies concluded that hormone replacement therapy was
associated with a 34% decreased risk of dementia.(15)

A 2002 study from Johns Hopkins reported a 67% decreased incidence of Alzheimer’s
disease associated with hormone replacement therapy.(16)

A 2006 study from Stanford and the University
of Adelaide in Australia
concluded that early initiation of hormone replacement therapy, from around the
time of menopause may contribute to improved cognition with aging and may delay

One can
often selectively quote the medical literature to support a particular point of
view. However, in the face of all these previously quoted studies, one should
at least look skeptically upon the 2003 report from the Women’s Health
Initiative, which found that combination estrogen plus progestin hormone
replacement therapy increased the risk for dementia when started in women over
age 65. The study reported increased dementia as early as 12 months after
starting HRT, but no increased incidence of mild cognitive impairment
associated with HRT use.(18)   If HRT
were really harmful to the brain, a finding that goes against most of what we
think we understand about the beneficial effects of estrogen on brain function,
one would expect early cognitive impairment to become apparent before
full-blown dementia was encountered.

A June, 2004 update of that same study concluded that even estrogen alone increased the
risk for dementia. This update reported an increase in mild cognitive
impairment as well, but the results for mild cognitive impairment were not
statistically significant after women who had this impairment at the start of
the study were excluded from analysis.(19)

The report
on chemo-brain from the New York Times should force us to look again at the
role of estrogen in maintaining normal brain function. Throughout history, male
dominated societies have adopted practices harmful to women. These include foot
binding, genital mutilation, and withholding privileges such as the right to
vote, hold office, and participate in government and education activities. We
should not add premature elimination of HRT, based on facile conclusions and
conflicting data to this list.

Avrum Bluming,
Clinical Professor of Medicine
of Southern California

(References on next post)

This post originally appeared on Dr. Val’s blog at

5 Running Lessons

It was a beautiful day for a run today, 72 degrees, light
wind, clear blue sky and lush foliage… the trail was busier than usual, with
bikers passing me every few minutes.  But
otherwise, it couldn’t have been a better day.
My running partner recently left DC to spend a couple of months working
in Morocco,
and I swore to myself that I wouldn’t completely go to pot while she was
gone.  So I forced myself to get into my
gear and go for a solo run.  Being alone
gave me the chance to reflect on 5 running lessons…

Don’t compare
yourself to others
– there will always be someone better, faster, fitter,
stronger, smarter…  It’s important to be
content with who you are, and do the best with what you’ve got.  At least, this is what I told myself as I was
passed by the majority of joggers on the trail, dragging myself along to mile

Appreciate the beauty
of nature
– it’s so easy to take nature for granted.  I ran by a patch of mushrooms, and one had
been broken off its stalk and flipped over so I could see its little
vents.  How can a fungus know how to grow
into such a well organized structure?
How can the cells know to line up into soft, brown vents?  I don’t know… it seems pretty amazing to me
that one little organism can be so delicate, complex, and completely
independent.  It never asked anyone for
permission to be itself.  Meditating on
the whimsy and creativity that is abundant in the life around us can put things
into perspective.

Take responsibility
– no one’s going to help you get in shape.
It’s up to you to take care of your body.  I’m really bad at this – I don’t like to exercise
alone, and I sometimes put off getting in shape unless I have a partner for
accountability.  It’s as if I prefer to
delegate responsibility about my health to others.  I know that this is a common tendency in
medicine – where folks rely on their doctors, without taking responsibility for
applying their advice (for diet/exercise/medications) on a daily basis.

Exercise is a
life-long discipline
– as I thought about how hard it was to run, and how
heavy my legs felt, and how much easier all of this was just a couple of years
ago… I realized that exercise is not something you do every other weekend.  It really is best applied on a daily basis.  And being in shape is the result of
consistent hard work – so we have to focus our minds on making exercise a part
of our regimen, just as we make time to eat each day!

Don’t psych yourself
– part of your success or failure in exercising has to do with whether
or not you believe you can do it.  When
you’re running, you have to believe that you can make it the whole way… or that
you can run farther than you did last time.
The temptation is to quit when you start feeling a little tired, but you
have to keep going – encouraging yourself along the way with a positive
attitude.  Of course, if you really are
unable to make it (your heart rate is at its limit and you are breathing so
hard you can’t speak) then slow down.
But a lot of the time you’ll find that running an extra mile is a matter
of mindset, not physical capability.

Do you have running lessons to share?

This post originally appeared on Dr. Val’s blog at

Crosses to bear

Although these 3 stories are incredibly sad, they serve to
illustrate the realities of this imperfect world – and how heavy some “crosses”
are for people.  We should count our
blessings when things go right for us, and reach out to those who are suffering
in unimaginable ways…

From Hallway Four:  A
40 year old woman was seen for difficulty breathing and eventually diagnosed
with pneumonia and fluid-overload secondary to need for dialysis.  This
lovely lady had been diagnosed recently with kidney cancer of her right kidney
and had undergone nephrectomy (removal of the diseased kidney).
Ordinarily, this would still have left her with one good kidney, which is all
you need.  But, as luck would have it, this lady had donated her left
kidney to her ailing sister three years prior.

From Charity Doc: A father of a 7 y/o little boy brings him
into the ED last night reporting that his mother’s boyfriend had beaten him
black and blue with a belt, an assertion that the mother did not deny. The couple had
been divorced for a little over a year. On physical exam, the little boy had
indeed not been spared the rod at all. His buttocks and back were ecchymotic,
black and blue with scattered scabbed marks from numerous whippings and
beatings. It was unbelievable.  [Child
protective services ruled that the child should go home with the mother
because] the mother has legal custody of the kid and we can’t send him home
with his father.

From a story relayed at a Rehabilitation Medicine
: A set of conjoined twins were born fused at the hip.  They were sickly, sharing a circulatory
system that was insufficient to serve both of their needs.  The doctors had to make an educated guess as
to how to dissect the two apart from one another – there was only one set of
male genitals, and three legs.  They
carefully studied the anatomy and decided to part the twins, giving the
healthier appearing one two legs and the genitalia, leaving the other with only
one leg and no genitals.  Several weeks
after the surgery the first twin (with the 2 legs) died.  The second twin is still alive, is in his 20’s,
and has been in and out of jail for drug trafficking.

Makes our own problems seem pretty trivial, doesn’t it?

This post originally appeared on Dr. Val’s blog at

Kitty Rescued From Fire

Thanks to GruntDoc for posting a link to a heart warming story of a cat rescued by an EMS team in Britain.  Firefighters and ambulance crews were called to the scene of a house fire, and fortunately found no people inside.  They did, however, find the family pet – suffocating, wet and terrified – and brought the poor cat out to the street where they administered some oxygen.  Unsure of next steps, the crew asked for permission to transport the animal to the nearest 24 hour veterinarian hospital.  Being that there were no humans in need of the ambulance at that time, they were given permission to call ahead to the animal hospital and hand off the kitty to the vet team, who proceeded to save her life.

Let’s hear it for the compassionate EMS team who took the time to be kind to all creatures great and small…This post originally appeared on Dr. Val’s blog at

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

Read more »

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

Read more »

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

See all book reviews »