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Does Cancer Risk Really Linger After HRT (Hormone Replacement Therapy)?

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I must admit that I was a bit skeptical of the conclusions drawn by the media about the latest analysis of the Women’s Health Initiative (WHI) data. The WHI study has generated many different spin-off articles about hormone replacement therapy and its potential link to breast cancer. This latest review suggests that the increased risk for cancer persists up to five years after stopping HRT treatment for menopausal symptoms. I asked Revolution Health expert and past president of the American College of Obstetricians and Gynecologists, Dr. Vivian Dickerson, to help us put this new article into context.

Dr. Val: What does this new study contribute to our understanding of the risks of HRT?

Dr. Dickerson: First of all the women in this study were not on estrogen alone (the usual treatment for women who have had hysterectomies). Their HRT consisted of a combination of Premarin (estrogen) and Provera (progesterone).  The original study indicated a slightly higher (barely statistically significant) increased risk for cardiovascular disease (CVD) and a statistically significant increased risk in breast cancer (but relative risks were less than 1.5 for both, which is very small).

Now all this new analysis tells me is that the CVD risk appears to extinguish or become negligible after three years though there is still an increase in breast cancers (compared to placebo) but the difference was not statistically significant. This is interesting in that it does add some plausibility to the claim that the reason breast cancer rates declined so significantly in the year(s) after WHI is because of all the women who quit taking HRT. It doesn’t prove anything, but just more grist for the mill. (Unfortunately I don’t see sub-group analyses of the women who chose to continue HRT after the end of WHI and those who quit from the treatment group.)

The study authors used some fancy math to demonstrate that there was a statistically significant increase in all-cause mortality (including breast cancer) for the women in the HRT group. Since the relative risk is so low, all they can say is that there is no reason to use HRT as a protective or primary preventive measure against heart disease, which we’ve known for many years now.

Dr. Val: Would you change your HRT recommendations based on this new analysis of the WHI data?

Dr. Dickerson: I wouldn’t change a thing that I am doing or counseling. These data are weak and the differences are not robust in any parameter.

***

So there you have it, ladies. No need for heightened alarm based on this analysis of the WHI data, especially if you have never been on the Premarin/Provera cocktail. It would be really helpful to compare breast cancer rates in women who stopped HRT versus those who continued it after the initial WHI data were released. Let’s keep our fingers crossed that this subgroup analysis is next up for publication.

Addendum: My friend and HRT expert, Dr. Avrum Bluming, kindly wrote me an email to further underscore the dubious nature of this study’s findings. Here’s what he said:

“The paper reads more like a lawyer’s presentation then a scientific article (i.e. it makes points followed by the disclaimer that the findings represented are not statistically significant—but the points have been registered). Instead of concluding that the very small increased risk of harm associated with estrogen and progesterone combination therapy (reported in the original studies, which were of questionable significance in the first place) are not found 2+ years after HRT was stopped, they find new risks (lung cancer) to allow them to conclude that administration of HRT results in delayed increased risks.”This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Can You Control Your Destiny? Parents of Triplets Unsuccessful

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This is a cute story that caught my eye – a couple used in-vitro fertilization (IVF) to become pregnant, and they specifically asked their doctor to implant only one embryo to make sure that they did not have multiple births. In the end, that one embryo split twice, causing identical triplets to grow inside the uterus. All three baby boys were born healthy at 35 weeks gestation.

I asked Revolution Health fertility expert, Dr. Rani Abbasi, to help me to understand if there was any greater risk of twinning in the IVF process. Interestingly, there are some new techniques used to help insure implantation of embryos that can also increase the chances of identical twins forming. I don’t know if this couple’s doctor used either technique, but I thought I’d explain them to you because the MSNBC report might lead you to believe that this event was extremely rare (they quote 200 million to one) when in fact it may not be quite THAT rare.

There are two methods that fertility specialists can use to increase the chances of implantation for a single embryo. First, incubating the embryo in an extended culture (for 5 days rather than the usual 3) makes it more likely that the transfer will implant in the uterus. However, since the embryo is two days older at the time of transfer, it has a higher likelihood of splitting into two, causing identical twins.

Second, some fertility experts use a technique called “assisted hatching” which also improves the likelihood of implantation of an embryo. This involves making a small nick in the embryo’s outer zone (I think of it as an egg shell) to facilitate the cells breaking out of the protective outer coating and implanting in the uterine wall. When the nick is made, it is also possible for a single cell to fall out (rather than the group of cells, called a blastocyst, exiting together) and become its own fetus.

So ultimately, it’s possible that the techniques used by this couple’s doctor to insure a successful implantation of one embryo increased the chance of splitting of that same embryo, resulting in triplets. Granted, the chance of this happening is still rare – and it’s ironic since the couple was doing all they could to avoid twins or triplets – but it’s not nearly as rare as the chance of a random woman having identical triplets outside of IVF.

For more information about twins and triplets, check out my recent podcast interview with pregnancy expert Dr. Mary D’Alton. And for those of you who believe that you can control your destiny, this story should give you pause!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Hepatitis A Spread by a Bartender in New York City?

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Some Hollywood celebrities are up in arms after having been notified of their exposure to hepatitis A through an infected bartender at a trendy New York City club. Those who come in contact with a known virus carrier may prevent infection if they’re vaccinated early. Hepatitis A causes less severe liver disease than its blood-bourne cousin, hepatitis C, but it’s still a formidable foe. (For more information about hepatitis A and its symptoms, check out this article.)

I interviewed Revolution Health consultant and world-renowned liver expert, Dr. Emmet Keeffe, about this outbreak:

Dr. Val: What is the likelihood that people could catch hepatitis A from an infected bartender?

Dr. Keeffe: The hepatitis A virus is transmitted between persons by the fecal-oral route (think unwashed hands after a bathroom break, or drinking water that has come in contact with human sewage). Also this particular virus is very hardy and can live on counter tops and surfaces outside the body for longer than many viruses. Because hepatitis A is found in very high concentrations in an infected persons’ stool, a tiny bit of stool on the hands actually contains large amounts of the virus and can therefore be quite infectious. Although previous outbreaks have primarily been associated with food handlers, there is no reason why a bartender might not also spread hepatitis A virus.

Dr. Val: Yuck. Would a vaccine be effective in preventing hepatitis A after someone’s already been exposed? How quickly after exposure should one get the vaccine?

Dr. Keeffe: The standard recommendation for individuals potentially exposed to hepatitis A is passive immunization using immune globulin administered within 2 weeks of exposure, which is 85% effective in protecting against illness. This is the recommendation for household or sexual exposure, but not generally recommended for “common source outbreaks” (like exposure to food handlers or bartenders), which are usually recognized only after they are well into their course. However, with early recognition, such as the NY case, immune globulin may make good sense. After hepatitis A vaccination, protective levels of antibodies to hepatitis A virus do not appear until 2-4 weeks after vaccination. Thus, active immunization with hepatitis A is used for preexposure prophyaxis, such as in international travelers to areas where hepatitis A is common, but not for postexposure prophylaxis.

Dr. Val: What is the hepatitis A vaccine exactly?

Dr. Keeffe: Hepatitis A vaccine is an injection, which is administered at baseline followed by a booster in 6 to 18 months. Two relatively similar and effective vaccines are licensed in the United States: Havrix and Vaqta.

Dr. Val: What should the bartender do if he has hepatitis A? Can he still work? When can he come back to work?

Dr. Keeffe: To protect the public, the bartender should not work until he has fully recovered. He is most infectious during the late incubation and early illness stage, when excretion of hepatitis A virus in feces is the highest.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Fluoride: Should It Be In Our Water System?

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I read a recent article about an ongoing debate in Great Britain: whether or not to include fluoride in the water supply. In the United States, we began adding tiny amounts of this naturally occurring substance to the water supplies over 60 years ago. In fact, as much as 75% of the drinking water in the US is artificially fluoridated, and the purpose is to improve the health of our teeth. I was wondering what the research shows about the need for additional fluoride in our diet, and if there are any risks posed by fluoridation of our water supplies. I asked Revolution Health dental expert, Dr. Andres Garcia, what he thought about this issue. Here are his thoughts:

Dr. Val:  Is there compelling evidence that adding fluoride to our water system is beneficial for teeth?

Dr. Garcia: Numerous studies by the ADA have shown that a decrease in cavity exposures of 20-40% can be expected when water is fluoridated in communities. In 1999, the CDC listed fluoride as one of the ten great public health achievements of the 20th century.  The current goal by the USPHS (U.S. Department of Health and Human Services) is to have 75% of the drinking water in the U.S. fluoridated to optimum levels by 2010.

Dr. Val: how do people get the benefits from fluoridated water exactly?

Dr. Garcia:You get the benefits from drinking fluoridated water in two ways, systemically and topically.  Systemically, small children ingest fluoride as the teeth are forming.  The fluoride is incorporated into the enamel and causes the enamel to be stronger and more resistant to decay.  After the teeth have erupted, fluoride has a topical action.  Fluoride from toothpaste, water, or other sources bathe the teeth, and the fluoride ions reverse tooth damage from decay and harden the enamel to resist further decay.  The optimum fluoride intake is a combination of ingestion of fluoride before the teeth erupt and subsequent topical application after eruption.

Dr. Val: Is there any risk associated with too much fluoride?

Dr. Garcia: Fluoride toxicity can occur if people are exposed to high concentrations of the substance over long periods of time, though the water supply is closely monitored to ensure that the concentrations are well within acceptable limits.  Fluoride toxicity is called “fluorosis.”  If toxic amounts of fluoride are ingested when a child is young, the teeth will be weakened when they form.  (This is counter intuitive because small amounts of fluoride strengthen the teeth, but large amounts weaken the teeth.) When the teeth erupt into the mouth, the enamel is very thin and breaks easily.  The teeth are also prone to cavities.  They will have a brown “mottled” appearance.  Bones are also susceptible to fluorosis.  Excess fluoride is stored in the bone, and the bones can be brittle and more prone to fractures.

Dr. Val: So if small amounts of fluoride are good for us, why are the British so hesitant to add it to their water supplies?

Dr. Garcia: Many European countries, such as Britain, have been slow to adopt fluoride supplementation due to high levels of other natural sources providing an adequate amount of fluoride in the diet.  Tea has been shown to contain from 1ppm to 6.5ppm fluoride concentration.  In the U.S., the recommended concentration of fluoride is 1.0-1.2ppm/day as recommended by the USPHS.  So regular tea drinkers get enough fluoride naturally. There is also strong anti-fluoride opposition in the public with fears of “forced immunization” and possible adverse health side effects.

Dr. Val: Should people living in areas where the water supply is not fluoridated take additional steps to get more fluoride?

Dr. Garcia: Areas that lack fluoridated drinking water should seek other sources for optimal fluoride intake.  The best way is to contact your dentist or pediatrician.  Supplements in the form of pills or topical gels can be prescribed to supplement a lack of fluoride.  Care must be taken to avoid over supplementation.  If the community receives its drinking water from an underground source, they may already be ingesting a higher level of fluoride than is necessary. Toothpaste is also a good source of fluoride.  Care must be used in infants as they swallow the toothpaste unknowingly.

Dr. Val: What about those additional fluoride treatments that I had as a child? Are those really necessary?

Dr. Garica: Fluoride should only be used in individuals at high risk for cavities.  Kids with braces, a high caries rate, adults with xerostomia, these are ideal candidates for fluoride use.  I have all patients learn about fluoride and they make a choice for themselves.  I personally will not use anything stronger than an OTC toothpaste for myself and family.  Fluoride is a known toxic substance that irreversibly binds to the hard tissues of the body.  I am wary of the long term effects of any non essential diet supplement.  It is equal to taking antibiotics constantly to stave off a possible infection.   Good oral hygiene will keep an individual cavity free.  Only in rare cases is someone genetically predisposed to cavities.  It is usually a consequence of diet (refined foods) and poor oral hygiene that causes the decay.

For more information, check out Revolution Health’s Dental Health Center

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

Making Sense of the ACCORD Study: Doctors Should Treat People, Not Numbers

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Much to the dismay of scientists, policy makers, and health care administrators, good medical decision making is not always black and white. I understand and sympathize with our desire to distill complex disease management issues into specific, easily measured variables. But unfortunately, the human body is exceedingly complex, and willfully resists reductionist thinking.

The recent ACCORD trial (which was designed to quantify the value of aggressive glucose management in a diabetic population) actually demonstrated a higher mortality rate in the intensive treatment group. What? That’s right, people were more likely to die if they had been randomized to the group that used all means necessary to keep blood sugars in a near normal range.

Now, this does NOT mean that it’s a bad thing for diabetics to keep tight control of their blood sugars, but it MAY mean that if they have to take high doses of multiple drugs to get them to that aggressive goal, the negative drug side effects may collectively outweigh their benefits.

I spoke with Dr. Zachary Bloomgarden, a renowned diabetes expert, to discuss his interpretation of the trial results. Here is a snippet from our interview:

My feeling is that this study shows that there is an art to medicine, and that patients can’t be managed via cookbook methods to treat their disease. If a person can control their blood sugar to an A1c of 6.0 without using too many medications, then that might be a good goal for him or her, but if you have to take high doses of several pills to get to that same goal (and therefore experience all the unfavorable additional side effects from taking them like weight gain, fluid retention, and potential arrhythmias) then it might not be appropriate in that case.

Ultimately, it takes a personalized approach by an experienced physician to determine the best treatment plan for an individual patient. One size doesn’t fit all – that’s part of my
take away from this study.  We still
certainly want all people with diabetes to do as well as they can with blood
sugar as well as blood pressure, cholesterol, and the myriad other markers of
control of the disease.

And so my plea is that in our race to ensure “quality care for all” in this country, we take a moment to consider that real quality may not be about getting every patient to the same blood test target, but to get every patient to a primary care physician who can apply evidence based recommendations in a personally relevant way. Cookbook medicine is no substitute for good clinical judgment. Let’s invest in our primary care base, and make it financially viable for them to spend the time necessary to ensure that their patients are on individually appropriate therapeutic plans. I hope our next President will appreciate the critical role of primary care in a healthy medical system.

Addendum: a like-minded fellow blogger weighs in on the study

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

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