Premenopausal Women with Low Bone Density
Our expert is Elizabeth Shane, Professor of Medicine and Vice Chair of Medicine for Clinical and Epidemiological Research at Columbia University’s College of Physicians and Surgeons. Her research interests include premenopausal osteoporosis, bone disease associated with HIV/AIDS, bone loss due to medications and gastrointestinal diseases, and the use of high-resolution imaging to investigate the effects of various drugs and diseases on bone quality and strength.
You can hear Dr. Shane at the upcoming conference, Women’s Health 2015: The 23rd Annual Congress, April 16-19, 2015 in Washington, DC.
LOW BONE DENSITY CAN OCCUR IN PREMENOPAUSAL WOMEN
Although osteoporosis is mostly a disease of older women, under certain circumstances, premenopausal women may also be vulnerable. There are disease states and medications that cause low bone density in premenopausal women including: celiac disease, cystic fibrosis, rheumatoid arthritis, epilepsy, eating disorders, and any disease with increased inflammation. In addition to diseases and medications that can cause low bone density, certain lifestyle habits such as smoking, excessive drinking, inadequate calcium and vitamin D, and insufficient exercise, may contribute to or exacerbate premenopausal bone loss. Some cases are genetic. In others, the cells that form new bones do not function well. Fractures can also affect women in the third trimester of pregnancy or during breastfeeding. In other cases, we just don’t know the cause.
TESTING FOR LOW BONE DENSITY IN PREMENOPAUSAL WOMEN
In most cases, we discourage premenopausal women from having bone density exams. For one thing, it’s difficult to interpret the results in a younger woman. Even though she may be at the lower end of the bell-shaped curve for bone density, that doesn’t necessarily mean a woman is at short-term risk for fractures. Further, a thin, petite woman may have a falsely low reading because the scan is two-dimensional, capturing height and width, but not the depth of a bone. Also, small women don’t need large bones because their bones are not bearing a lot of weight. On the other hand, there are situations in which measuring bone density is highly appropriate. If a premenopausal woman has any of the diseases that are known to have a bad effect on the skeleton, or if she has had a fracture that’s not easily explained by the degree of trauma (a low-trauma fracture), then a bone density scan should be performed. A low-trauma fracture is defined as one that occurs with trauma equivalent to a fall from standing height or less, for example, a woman who breaks a bone after a fall on a sidewalk. This is in contrast to a high-trauma fracture that comes from falling down a flight of stairs or a motor vehicle accident.
WHEN A MEDICAL EVALUATION IS NEEDED
In cases where there is an unexplained broken bone, and low bone density is found on a bone density scan, it is very important do a thorough medical evaluation to make sure that there isn’t a treatable underlying cause. Celiac disease, for example, can be asymptomatic and may only present with fractures. Diagnosing an unsuspected underlying disease, such as asymptomatic celiac disease, and treating it specifically is much more effective than treating the low bone density itself. If a woman has celiac disease, it is usually much more effective to put her on a gluten-free diet than to give her medications to increase bone density.
LIFESTYLE APPROACHES TO TREATING LOW BONE DENSITY
If an individual has low bone density but no fractures, I usually recommend some lifestyle changes along with observation rather than medications. Lifestyle changes that may help prevent fractures and improve bone density include: quitting smoking, reducing or eliminating alcohol use, and engaging in plenty of weight-bearing exercise, such as walking, jogging, running, dancing, or using an elliptical machine. Interestingly, lifting weights doesn’t have a large effect on bone density, even though it’s a good thing to do for other reasons.
The individual should make sure she’s getting adequate calcium and vitamin D, preferably from her diet. WebMD has useful information on sources of dietary Vitamin D and calcium, http://www.webmd.com/food-recipes/guide/calcium-vitamin-d-foods. However, too much calcium could be harmful, so she should make sure that the total between diet and supplements is not much more than 1000 mg per day. Similarly, too much Vitamin D can also be harmful. I usually recommend 1000 IU daily and then adjust to maintain the blood level at around 30 ng/ml.
BE CAUTIOUS ABOUT PRESCRIBING MEDICATIONS FOR LOW BONE DENSITY
Prescribing medications for women of childbearing age who have low bone density is complicated because some medications can cross the placenta. Biophosphonates are a Category C drug, meaning they should be avoided in pregnancy. Teriparatide and denosumab should not be used during pregnancy. To further complicate the issue, bisphosphonates may persist in the bones long after the patient is no longer taking them, and can still cross the placenta even after they are discontinued. A woman of childbearing age should agree to use contraception if it is medically necessary to treat her low bone density pharmacologically.
FIBROIDS: MEDICAL AND SURGICAL MANAGEMENT
Our expert is Linda Bradley, MD, Professor of Surgery and Vice Chair, Department of Obstetrics and Gynecology, at the Cleveland Clinic. Dr. Bradley has also served on the Cleveland Clinic’s Board of Governors and chaired the Ob/Gyn section of the National Medical Association. She was selected by Ladies’ Home Journal as one of the top six female physicians in the U.S.
Be sure to register for Women’s Health 2015: The 23rd Annual Congress, April 16-19, 2015 in Washington, DC. I look forward to meeting you there!
FIBROIDS ARE VERY, VERY COMMON
In the U.S., 80% of women who come from the African diaspora, including women from the Caribbean and South America, have or will have fibroid tumors. Even in the case of the ethnicity with the lowest prevalence, women of Asian descent, 40% will have fibroids. We know these statistics from MRIs, ultrasound, and autopsies of, for example, women who die in car accidents.
NOT ALL FIBROIDS REQUIRE TREATMENT
The odds of a uterine mass being malignant are approximately 1 in 350. Assuming that you know you are not dealing with a malignancy, it is important not to over-treat fibroids, given that treatment itself can create problems such as scar tissue, bleeding, or wound infection Often a woman may have fibroids, even large ones, and still be asymptomatic, or if she has symptoms, they may not be personally distressing. Further, we do not know how fast or even if her fibroids are going to grow. An additional consideration is that during menopause, as her estrogen and progesterone decrease, her fibroids will shrink and her symptoms are likely to disappear on their own.
SOME FIBROIDS WILL REQUIRE TREATMENT
When a woman is having symptoms that interfere significantly with her quality of life, it is a different story and she will need treatment. A woman with fibroids may experience any or all of the following: heavy, irregular, or prolonged bleeding; cramps; urinary frequency; constipation; painful intercourse; difficulty conceiving; and premature labor. In addition, while a normal uterus is about the size of a lemon, fibroids can cause it to enlarge to the size of a watermelon.
MANY SURGICAL CHOICES ARE AVAILABLE
For a woman who would still like to have children, there are uterus-preserving surgeries for removing fibroids. If a woman has four or fewer fibroids, she may be able to have them removed with robotic or laparoscopic surgery, using small incisions. There is also hysteroscopic surgery, which is performed through the vagina. However, depending on the number and position of the fibroids, she may instead need an open myomectomy with a larger incision.
Another treatment used to destroy fibroids without surgery is using ultrasound waves to break down the fibroids. Fibroids can also be treated by killing the fibroid tissue, using extreme cold (cryomyolysis) or myolysis, which uses a high-frequency electrical current to shrink the fibroid by blocking its blood supply. Myolysis was FDA-approved a little over a year and a half ago, but as of now, there are only a small number of physicians trained to perform it.
For women who do not want future pregnancies, and who have long-lasting and severe symptoms, surgical removal of the entire uterus may be an option.
PHARMACOLOGICAL HELP FOR SPECIFIC FIBROID SYMPTOMS
For severe cramps, high-dose ibuprofen can help. For severe bleeding, tranexamic acid can be useful. However, because of its side effects, it shouldn’t be taken for more than 5 days. Low-dose oral contraceptive pills can help, and a longer-lasting approach is a levonorgestrel-releasing IUD, which is good for 5 years.
FOR MORE INFORMATION:
* The American College of Gynecologic Laparoscopists’ website, www.aagl.org, is a good source for information on minimally invasive procedures to offer patients.
* The American College of Obstetricians and Gynecologists website also has useful information: www.acog.org also has useful information.
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SUBSTANCE ABUSE AND WOMEN – THERE’S A LOT YOU CAN DO
Our expert is Samuel A. Ball, PhD, professor of psychiatry at the Yale University School of Medicine where he is the scientific director of the Psychotherapy Development Research Center and the Women’s Health and Addictive Behavior Faculty Scholars Program. Dr. Ball is also president and chief executive officer of The National Center on Addiction and Substance Abuse at Columbia University (CASAColumbia).
Be sure to register for Women’s Health 2015: The 23rd Annual Congress, April 16-19, 2015 in Washington, DC.
SUBSTANCE ABUSE IS LIKELY TO AFFECT MANY OF YOUR PATIENTS
At any given time in the U.S., about 15% of the population has a diagnosable substance use disorder. The lifetime rates are nearly 30%. At some point over the course of 4 years of college, nearly half of students may have a diagnosable disorder. In view of these statistics, be alert to the fact that many of your patients may have a substance abuse problem, whether it’s prescription medications, street drugs, alcohol, or nicotine.
WOMEN HAVE SPECIFIC VULNERABILITIES RELATING TO SUBSTANCE ABUSE
Substance abuse greatly increases the odds of a woman’s being a victim of sexual violence and/or domestic abuse. In the case of women as mothers, substance abuse impacts their pregnancies and their ability to function in their maternal role. Also, the same amount of a drug or alcohol taken by a woman is likely to cause more physical damage than it would to a man. In addition, the time it takes from the onset of use to actual physical impairment is generally faster for women than for men.
YOUR PATIENT MAY TRY TO HIDE HER ADDICTION
She may feel stigmatized by her addiction and be unwilling to bring it up. If you see medical symptoms that are related to substance abuse such as liver, coronary, or breathing problems, use these as an entryway to a discussion of alcohol, drugs, or smoking. Make your evaluation nonjudgmental, like any other medical condition. Try to let her know that you’re not casting blame and that she’s safe talking about it with you. Let her know that you view this as a medical disorder that impacts her life and needs treatment.
EVEN TEN MINUTES OF DISCUSSION CAN HAVE A BIG IMPACT
For an individual who is not severely addicted but is over-using, there’s strong evidence that a physician’s simply spending five or ten minutes recommending that she cut down or stop can really help. A follow-up conversation within a month makes this intervention even more effective. On the other hand, if the addiction is severe, refer your patient to a specialist. Check her insurance plan to find out who are the providers for mental health and addiction issues.
ATTITUDES TOWARDS PRESCRIBING OPIOIDS HAVE CHANGED
Ten years ago, the attitude was that we should be aggressive about treating pain. In some cases, patients were told that taking a painkiller was similar to taking blood pressure medication, and it was simply something to take from now on.
The problem with this approach is too many people became addicted. Individuals may find that they require higher and higher doses to achieve the same degree of relief. There’s also some evidence that long-term opioid use actually makes individuals more sensitive to pain.
An additional problem is accidental overdosing, as can happen when a patient experiences severe pain and doubles or triples the dose. Maybe she also took a drink to relax, or she was taking some other medication as well. She falls asleep and never wakes up.
Health care providers need to be cautious about prescribing opioids. There are appropriate uses, for example, immediately following surgery, or in cases such as severe cancer-related pain. However, when possible we suggest other approaches to pain management. For example, with chronic back pain, some combination of the following may be helpful: relaxation and coping skills training; rest; physical exercise; physical therapy; and non-narcotic anti-inflammatory medications. Antidepressant medications may also sometimes be helpful.
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HPV Risk and Cervical Cancer
Our expert is Mona Saraiya, MD, MPH. She joined the Centers for Disease Control and Prevention as an Epidemic Intelligence Service officer in the Division of Reproductive Health in 1995, and is currently a medical officer and Associate Director in the Division of Cancer Prevention & Control’s Office of International Cancer Control.
To hear more from Dr. Saraiya, be sure to attend Women’s Health 2015: The 23rd Annual Congress, April 16-19, 2015 in Washington, DC. She’ll be one of the many outstanding presenters.
MANY WOMEN ARE MISSING THE BENEFITS OF SCREENING AND VACCINATION FOR CERVICAL CANCER
In spite of the fact that cervical cancer screening is one of the greatest achievements in cancer prevention, too many women still die from the disease. Eight million women in the United States between the ages of 21 and 55 were not screened in the period between 2007 and 2012, and almost half of this group have never been screened. This amounts to 11.4% of the population. In the case of women with no health insurance, the figure rises to 23%, and for those with no regular health care provider, it is 25%. The proportion of inadequately screened women is higher among older women, Asians, Pacific Islanders, American Indians, and Alaska Natives.
Further, only one in three girls age 11-12 are getting the human papillomavirus (HPV) vaccination, and only one in seven boys in that age group have received the vaccination. HPV vaccination and cervical cancer screening combined could prevent nearly 93% of new cervical cancer cases.
BE CAREFUL TO SCREEN AT THE APPROPRIATE AGES AND TIMES, SO AS NOT TO OVERSCREEN
While many women do not receive the screening they need, there are also women who are overscreened. In 2012, for the first time three major organizations involved with cancer prevention (the American Cancer Society, U.S Preventive Services Task Force [USPSTF], and the American Gynecological and Obstetrical Society) have come together on recommendations for screening. They recommend a Pap smear every three years for women ages 21-65 years. Or, in the case of women ages 30- 65 years who want to lengthen the screening interval, they recommend screening with a combination of a Pap smear and HPV testing, and this combination can be done every 5 years. The USPSTF gives these approaches an A rating, that is, “There is high certainty that the net benefit is substantial.” In contrast, according to the USPTSF, screening more frequently or screening with younger or older women in the absence of other risk factors carries a “moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.” In spite of this knowledge, some women are screened more frequently than is desirable, and some are screened when they are outside the range of the ages at which they’ll benefit from the tests.
VACCINATION PLAYS A MAJOR ROLE IN DECREASING THE BURDEN OF CERVICAL CANCER
Persistent HPV infection is responsible for the majority of cervical cancers. Like the common cold, HPV can spread easily, although unlike colds, HPV is spread through sexual contact. It is important to note that it does not require penetration to spread, given that one can get HPV through skin-to-skin contact. The good news is that most women who get the virus will clear it within two years. The bad news is that they may become re-infected many times, or if they have a weakened immune system, they may be unable to clear it. Under the wrong circumstances, the virus may cause abnormal cell changes or lesions that if untreated can progress to cancer. There are several stages during which this chain of events can be interrupted: vaccination prevents HPV infection from occurring; screening allows detection of the virus and/or cell changes; and follow-up of abnormal results can also prevent the disease from progressing.
MAKE SURE TO STAY ON TOP OF ABNORMAL HPV AND PAP RESULTS
Once a woman has an abnormal diagnosis, education on appropriate follow-up and treatment is essential. This is especially true for African-American women. While Hispanic women have the highest rate of new cases, African-American women are the most likely to die. The problem is follow-up, and the cause of this can be an access, cultural, or insurance issue. No woman should die of this preventable disease, so take special care that each of your patients gets the necessary follow-up.
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DIABETES IN WOMEN: IMPROVING OUTCOMES
Our expert is Kirsten Gill Hairston, MD, Associate Professor, Endocrinology & Metabolism, Maya Angelou Center for Health Equity, Center for Diabetes Research, Wake Forest Baptist Medical Center. Her clinical interests include diabetes management, pituitary gland disorders, obesity treatment, and thyroid disease
To learn more from Dr. Hairston, be sure to attend Women’s Health 2015: The 23rd Annual Congress, April 16-19, 2015 in Washington, DC. She’ll be one of the many outstanding presenters.
If there is a medical topic you would like to see explored here, please let me know!
BE AGGRESSIVE WITH PREVENTION
When you screen, be aggressive in responding to what the numbers show. If a woman’s fasting glucose is a little on the high side, say between 100 and 125, have a conversation with her, explaining that there’s cause for concern and we need to do more than just “watch it.” Tell her that the numbers mean she could be on her way to having diabetes, but it doesn’t have to be that way. Tell her, “I want to work with you on your diet and exercise so your condition doesn’t progress to actual diabetes.” Let her know that losing just 10% of her body weight and changing her diet may help prevent the disease from progressing.
GESTATIONAL DIABETES IS A WARNING SIGN FOR POSSIBLE FUTURE DIABETES
Since pregnancy is an insulin-resistant state, it can reveal that the woman has issues with glucose regulation. After the baby is born, your patient may revert to her former state of having no evidence of elevated blood sugar. However, she is at higher risk for developing diabetes, so it is worth being aggressive in managing her weight and diet. Action at this point can prevent future problems.
ENCOURAGE POSTMENOPASUAL WOMEN TO EXERCISE
Postmenopausal women are apt to experience a decrease in lean muscle mass. This is unfortunate because muscle mass is critical in glucose regulation. Added to this, changes in estrogen mean postmenopausal women have a tendency to develop abdominal fat, which in turn is linked with increased risk for insulin resistance and type 2 diabetes. Diabetes then creates increased risk for cardiovascular disease; if a woman has diabetes, it is the equivalent of already having had one heart attack. A good exercise program can help counteract all of these risk factors.
FOCUS ON WHAT IS DOABLE
We often find that because of her caretaker role, a woman allows her own health to slip. Given that she has multiple demands on her time and energy, it’s important to have a realistic conversation with her about what she actually will be able and willing to do. With a particular individual, you may not get perfect adherence, but there are probably at least some areas where she can improve. Maybe she cannot eliminate the stressors in her life, but with the help of a counselor, she may be better able to cope with them. Maybe she is not up for cooking different meals for herself and her husband, but perhaps she can change the menu to include lean protein as opposed to fatty proteins. Maybe she will follow her medication regime if instead of having to keep track of her blood glucose five times a day, you reduce it to twice a day. Look for improvements that can be made.
WITH WEIGHT CONTROL, REMIND YOUR PATIENTS ABOUT “THE WHOLE PACKAGE”
She probably knows that to lose weight, she needs to get rid of more calories than she is taking in. However, it often happens that she does not take into account “the whole package.” She’ll run and maybe burn 800 calories, or spend an hour vigorously participating in a Zumba class, but then she stops by a fast food restaurant and blows it all in a few minutes. I tell people that in order to burn the calories from two slices of regular bread, they will need to walk for an hour. And by the way, I don’t mean a casual stroll, I mean walking at a good clip.
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