Endometriosis: A Costly and Debilitating Condition
Our expert is Linda Giudice, PhD, MD, Professor and Chair of the Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco.
As always, if there is a topic that you would like to be covered, please let me know.
ENDOMETRIOSIS IS COMMON, DEBILITATING, AND COSTLY
Endometriosis is characterized by cells from the lining of the uterus growing outside the uterine cavity, most commonly on the peritoneum. Between 6% and 10% of reproductive age women have endometriosis, which is present in 50-60% of women with infertility and chronic pelvic pain. In terms of personal well-being, this is costly, not only for the woman, but her family as well. The estimated dollar cost for diagnosis and care in the United States is $22 billion annually.
DIAGNOSIS IS NOT EASY
Diagnosis is by laparoscopic surgery. Other methods that are less expensive and easier, such as blood or plasma markers, are being sought, but there is nothing, so far, that will diagnose the condition with high accuracy and low false positives. Fortunately, laparoscopic treatment can be performed at the same time as the diagnostic procedure, including removal of any visible endometriosis implants or scar tissue.
CAUSES OF ENDOMETRIOSIS
The cause of endometriosis is not entirely clear. However, since endometriosis is an estrogen-dependent disease, we are looking at chemicals in the environment that are endocrine disruptors, including organochlorine pesticides. A recent study of 248 women with endometriosis and 500 without endometriosis showed that those in the highest quartile for the presence of organochlorines had 2.5 times the risk of having endometriosis compared to those in the lowest quartile.
As the causes of endometriosis are not clear, we can’t be certain how to prevent it. However the indications that environmental toxins play a role are persuasive enough that we recommend avoiding exposure to these toxins, particularly during pregnancy or when the child is very young.
To understand the exposure to environmental toxins, including endocrine disruptors, consider that the average woman in the United States uses 13 personal care products each day, including: soap, shampoo, face cream, nail polish, and eye makeup. The Skin Deep Environmental Working Group database rates these products and others, by brand name, for their carcinogenic and reproductive effects. To assess the issues related to products that you and your family may be using, visit their website at: www.ewg.org/skindeep
The Endocrine Disruption Exchange (TEDX) is also a valuable resource for information on what various endocrine disruptors can do during fetal development. Their website is: http://endocrinedisruption.org
Some preventive steps that can be taken immediately include avoiding drinking bottled water that has been in a hot car for many hours. Heat can break down the bonds that keep BPA (bisphenol A) from migrating from the plastic into the water. Similarly, don’t heat foods in cans and don’t microwave food in plastic containers.
Your Patient May Benefit from THE Million Women March For Endometriosis
On March 13, 2014, women in Washington, DC, London, Berlin, and other cities will be marching to raise awareness about endometriosis and its effects on women and girls. Being with others with the same condition, and knowing that they are working to do something about it, can be empowering for a woman with endometriosis. For more information, women can go to: www.millionwomenmarch2014.org In addition, women may benefit from advocacy and professional groups that provide information about endometriosis, including the Endometriosis Association, the Endometriosis Research Center, Endometriosis Foundation of America, endometriosis.org, RESOLVE: The National Infertility Association, the American Society for Reproductive Medicine, and the American Congress of Obstetricians and Gynecologists
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Managing Polycystic Ovary Syndrome
Our expert, John E. Nestler, MD, is the William Branch Porter Chair of the Department of Internal Medicine at Virginia Commonwealth University (VCU) School of Medicine. He holds joint professorships in the Department of Obstetrics and Gynecology and the Department of Pharmacology and Toxicology. Dr. Nestler is also Program Director of VCU’s Center on Clinical and Translational Research in Polycystic Ovary Syndrome.
Dr. Nestler will be one of the presenters at Women’s Health 2014: The 22nd Annual Congress at the Grand Hyatt, April 4-6th in Washington, DC.
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POLYCYSTIC OVARY SYNDROME (PCOS) IS WIDESPREAD
PCOS is both the most common endocrinologic disorder in women of reproductive age, and the most common under-diagnosed and under-treated general health problem for women. Between one in 10 and one in 20 women of childbearing age has PCOS, and as many as five million women in the Unites States may be affected. It can occur in girls as young as 11 years old. If a young woman has eight or fewer menses a year, she has a 50-80% chance of having PCOS.
PCOS HAS MANY CONSEQUENCES
In the past, we tended to think of PCOS as a reproductive disorder or a cosmetic problem; today we know that it is a metabolic disorder with systemic effects. In addition to having infrequent or no menses, a woman with PCOS may have profound insulin resistance, and this in turn puts her at risk for a variety of additional medical problems. These include ten times the risk for type 2 diabetes in comparison with women without PCOS, and twice the risk for a fatal heart attack. Furthermore, her heart attacks are likely to occur at an earlier age. Additional consequences may include obesity and infertility. PCOS also involves producing too much testosterone. Having abnormal amounts of testosterone can cause excess facial and body hair, male pattern baldness, alopecia, and acne.
PREVENTING AND TREATING PCOS
The ideal way of treating the metabolic disturbances of PCOS, when possible, is through diet, exercise, and weight loss. However, it is becoming increasingly clear that most patients have a very difficult time losing weight and the rate of compliance with these kinds of regimens is low. Metformin, which is the most widely used drug for the treatment of type 2 diabetes, is also useful in the treatment of PCOS. It may increase ovulation, regularize menses, and reduce serum androgen levels, while also offering protection against the development of diabetes and heart disease.
ALL WOMEN WITH PCOS SHOULD BE SCREENED FOR DIABETES
Given the high risk for diabetes in women with this syndrome, they should be screened for type 2 diabetes regardless of weight. They should be given a glucose-tolerance test at the initial presentation and every 2 years thereafter. The appropriate test is a two-hour oral glucose tolerance test. This is preferable to the hemoglobin A1c, which is not as accurate in the case of women with PCOS.
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Screening for Mental Disorders
Our expert is Kathleen O’Leary, MSW, Chief, Women’s Mental Health Program, National Institute of Mental Health. She is a graduate of Smith College School for Social Work and has over 30 years of experience, not only as a researcher, but also as a social worker and therapist. She has both practical and theoretical insights into the issue of women and mental health.
As always, if there is a subject that you would like to have explored with a recognized authority who can provide information on current research and information that you can use in your practice, just let me know.
MENTAL DISORDERS IMPACT MEN AND WOMEN DIFFERENTLY
Women experience mental disorders at the same rate as men, but there are significant differences in which kinds of disorders are more prevalent in men and women. For example, women are 70% more likely than men to have a major depression in their lifetimes, and women are 60% more likely to experience an anxiety disorder. Furthermore, women who experience trauma can, depending on their genetics, be at greater risk for Post-Traumatic Stress Disorder.
SCREENING FOR MENTAL DISORDERS IS COST EFFECTIVE
In any given year, as many as one quarter of American adults will experience a diagnosable mental disorder, but only 36% of them will receive treatment. One of the many consequences of this is that undiagnosed mental disorders mean greater utilization of other healthcare resources. Often a patient with a mental health issue will see her provider many times with no relief, unless, and until, the underlying mental disorder is diagnosed and treated. Even with limited time with patients, mental health screening yields benefits for patients and healthcare systems. With the Affordable Care Act and with implementation of Mental Health Parity, mental health care should become both more available and more affordable.
TALKING WITH YOUR PATIENT CAN BE EFFECTIVE FOR SCREENING
For non-mental health providers, the conversation about mental health doesn’t have to be awkward. One approach is to state your observation if someone seems nervous or subdued. You could also start the conversation by asking questions such as, “Is anything worrying you?” or “Have you had any mood changes over the past few months?” Some people respond better to questions about stress, such as, “Is stress affecting your health in any ways?” You can follow up with, “Are these feelings interfering with your life?” or “Are the people around you noticing something in your mood or behavior that causes them concern?” History helps; you can ask, “Have you received treatment in the past for mood or anxiety problems?”
Before suggesting that a patient seek additional help, you can reassure her: “These kinds of mood or anxiety problems are very, very common and it helps to see someone with experience in these matters. We know that these are brain disorders and the treatments can usually make people feel better.”
You might even tell her that the NIH has funded a number of trials and it is known that the available therapies, whether medication, behavioral therapy, or talk therapy, have been proven to make a significant difference.
RESOURCES ARE AVAILABLE FOR REFERRALS
There are two federal websites that can refer you to licensed psychologists, psychiatrists, mental health nurses, and social workers. In the case of the HHS website, MentalHealth.gov, you can type in your state or ZIP code in the Treatment Locator: www.mentalhealth.gov/get-help/immediate-help/index.html. The Substance Abuse and Mental Health Services Administration website, SAMHSA.gov has a Treatment Referral Line and treatment locator: http://findtreatment.samhsa.gov/MHTreatmentLocator/faces/quickSearch.jspx. Also, in most states there are professional societies for these mental health care providers, and their websites are good resources. In addition to all of the above, you might consider trained pastoral counselors, since you may have patients who will be more at ease in this setting as opposed to a more clinical one.
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HIV/AIDS Vulnerability and Treatment in Women
Our expert is Gina M. Brown, MD. An obstetrician and gynecologist, Dr. Brown joined the NIH Office of AIDS Research (OAR) as a Medical Officer to manage Microbicides and Women’s and Girl’s research issues. Before joining the Office of AIDS Research, she served as the Chair of the NIH Office of AIDS Research Advisory Council (OARAC) for 2004 and has chaired the OAR Women and Girls working group.
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WOMEN ARE BIOLOGICALLY AT GREATER RISK THAN THEIR MALE PARTNERS FOR HIV INFECTION
During sex, the HIV virus is in the semen. HIV-infected semen can be present in the vagina for days after intercourse, putting a woman at risk for a longer period of time. In contrast, a man is at risk during the actual time of intercourse, but, afterwards, he no longer faces the lingering risk experienced by a woman.
Furthermore, a woman’s own genital tract immune system can be compromised if she has an STD, making her more vulnerable to HIV infection. During ovulation there may also be an increased window of vulnerability. In addition, women who are pregnant are at increased risk for HIV infection as a result of changes in the genital tract immune system.
THE STANDARD QUESTIONS ABOUT PARTNERS ARE NOT ENOUGH
Typically healthcare providers will ask about the number of sexual partners a woman has had. However, in many cases, a woman who becomes infected may have had only one or two partners in her life. The issue isn’t just the numbers of partners she has had, it is how many partners her husband/ partner has had. In high-risk communities, it is important to offer HIV tests to women even though they may have had few partners.
OBJECTIVES IN TREATING HIV-INFECTED INDIVIDUALS
The objective in treating an HIV-infected individual is to achieve undetectable viral loads. Few, however, actually achieve this, and women achieve this goal at a far lower rate than men. The Centers for Disease Control and Prevention looked at 1.2 million people with HIV and found that only 80% knew they were infected. Of these, only 62% were connected to HIV treatment; 41% were actively continuing in treatment; 36% were receiving antiretroviral therapy; and only 28% were able to adhere to their treatment well enough to achieve undetectable viral loads. The challenge for healthcare providers is to ensure that their patients with HIV are aware of their HIV status, get treatment, and adhere to the treatment. In the case of women, this is particularly problematic. At every stage of the “HIV/AIDS treatment cascade,” that is, the stages from knowing they have HIV to reaching an undetectable viral load, more women fall off the treatment cascade sooner and faster than men.
WOMEN MAY ADHERE LESS TO THEIR TREATMENT THAN MEN
Women may adhere less to their treatment than men because of the many other things going on in their lives. Often their HIV treatment may not be highest on their list of priorities. They may be contending with physical, emotional, or sexual violence, or substance abuse may be an issue. Part of the health care provider’s job is to know about these issues and to collaborate with other specialists such as substance abuse experts, social workers, or mental healthcare providers. Enabling women to adhere to their treatment program may involve a lot more than listening to their lungs, taking their blood pressure, and writing a prescription. Try to find out why an individual didn’t take her medication and then, if necessary, call on specialists in other fields to assist. It may take several specialists to enable the patient to adhere to her treatment.
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Our expert is Kimberly J. Templeton, MD, Professor of Orthopedic Surgery at the University of Kansas Medical Center. Dr. Templeton serves on the boards of the Academy of Women’s Health and the Sex and Gender Women’s Health Collaborative. She is immediate past-president of the U.S. Bone and Joint Initiative and she lectures and advocates for musculoskeletal health, nationally, especially for women.
My thanks to Sommer Hammoud, MD, from Thomas Jefferson University for suggesting this topic. If you have a topic that you would like to see covered, please let me know.
OSTEOARTHRITIS IS MORE THAN JUST A JOINT CONDITION
Osteoarthritis is one of the leading causes of disability in the U.S., but it is much more than just a chronic condition of the joints. Osteoarthritis interacts with other co-morbidities such as heart disease or diabetes and the result isn’t just additive, it is multiplicative. If someone is overweight, with hypertension and diabetes, one of the treatment modalities would be exercise, but if pre-existing knee pain prevents exercising, the lack of exercise may exacerbate being overweight which will often lead to more knee pain. This harmful cycle can continue unless the osteoarthritis is addressed.
KNEE OSTEOARTHRITIS AFFECTS WOMEN DIFFERENTLY THAN MEN
Women are more prone to osteoarthritis than men, especially in the knee. The cartilage in the joint is influenced by estrogen. In addition, a previous anterior cruciate ligament (ACL) injury, to which women are particularly prone, may put extra stress on the joint. The different leg alignment seen in women, compared to men, can also contribute to osteoarthritis. When women seek treatment, they are often in substantially worse shape than men who seek treatment and this complicates the situation. We have hard data from surveys showing that men seek surgery when, for example, they can’t play a favorite sport. In the case of women, it is more likely that they won’t seek treatment until they are close to being incapacitated. This is an issue because the worse condition they are in when offered treatment, the harder it is to come back to a baseline of health.
ASK YOUR PATIENT ABOUT KNEE PAIN
Women may not bring up the topic of knee pain, especially when they are focused on other issues, such as heart disease or diabetes. However, given that knee pain can have a large impact on other health conditions, the provider needs to be aware if the patient has a problem in this area. The danger is that when osteoarthritis is not addressed, the patient may become increasingly inactive. Whatever health conditions we are treating, it is important, as part of their treatment, to keep patients as active as we can.
MOTION IS LOTION
A patient may tend to be increasingly inactive because of her joint pain and yet one of the best things she can do for herself is to move. For instance, walking or swimming can strengthen her supporting muscles, and this will, in turn, help support her joints. She may also benefit from a formal exercise program designed by a physical therapist or an athletic trainer who can tailor the exercise to what she is able to do without over-stressing her joints. This exercise should focus on muscle strengthening, to help protect joints, as well as range of motion and cardiovascular conditioning.
ALTERNATIVES TO KNEE REPLACEMENT SURGERY
An exercise program, along with other treatment modalities, can sometimes make surgery unnecessary. The knee or knees may hurt, but with anti-inflammatory or other medications, the patient may be able to exercise. With improved muscle strength, coupled with even slight weight loss, the patient may feel better fairly quickly. The cartilage in a person’s knee is receiving 2 to 3 times their body weight with each step, so even a slight reduction in weight can have an important beneficial effect on overstressed joints. Even if surgery becomes necessary to improve pain and function, the patient will be able to recover more rapidly and have a better outcome.
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