Our expert is Harmony R. Reynolds, MD, Saul J. Farber Assistant Professor of Medicine, Cardiovascular Clinical Research Center, NYU Langone Medical Center. Dr. Reynolds specializes in Coronary Artery Disease and Women’s Heart Health. Don’t miss her talk at Women’s Health 2015: The 23rd Annual Congress, April 16-19, 2015, in Washington, DC.
NOT EVERYONE WITH AN ABNORMAL STRESS TEST NEEDS AN ANGIOGRAM OR REVASCULARIZATION
It may seem logical that opening a narrowed artery or bypassing it would prevent heart attacks and prolong life. However, recent clinical trials in stable patients, such as COURAGE and BARI-2D, show that stents and bypass surgery did not prolong life or prevent heart attacks in the stable patients studied. Most heart attacks are triggered by plaques which did not cause severe narrowing before the event.
Most angina is caused by plaques which cause significant narrowing. There is then a disconnect between the treatment of symptoms and the prevention of death and heart attack. The “rusty pipe” concept is not the best one for patients to understand coronary artery disease. In fact, soft plaque rather than “hardening of the arteries” may be the bigger concern. Women need to know that medications and lifestyle changes change plaque on a microscopic level to make it less dangerous, and that this is a major focus of treatment. Those with moderate to severe ischemia on a stress test may be eligible for the ISCHEMIA trial, which tests a routine invasive strategy of cardiac cath and revascularization plus medical therapy vs. a conservative strategy of medical therapy alone, with cath reserved for worsening symptoms or acute coronary syndromes. Learn more at www.ischemiatrial.org
WHEN WOMEN HAVE ACUTE CARDIAC COMPLAINTS, DON’T MISS THE OPPORTUNITY TO ADDRESS LONG-TERM RISK REDUCTION
Many women who complain of symptoms that may be cardiac in origin turn out to have a non-cardiac problem. Still, heart disease is the leading killer of women and attention to risk factor modification is important for everyone. Take the opportunity while she is thinking about her heart to educate your patient about the risk factors for heart attack and stroke, and give her concrete ideas about how to make changes in diet and lifestyle. This is some of the most important work we do as physicians! The woman who avoids a heart attack because of the time you spent telling her how to eat healthy and exercise may not know to thank you, but we all know what a big impact this one-on-one attention can have.
WOMEN CAN HAVE HEART ATTACKS THAT DON’T SHOW UP
IN AN ANGIOGRAM OR IN ST SEGMENT ELEVATION
Twenty-five percent of the heart attacks that women experience show no ST segment elevation or blockage. In contrast, only 3-10% of men have heart attacks without ST elevation or blockage. One explanation is that there was obstruction temporarily, with a totally blocked artery, but then the woman’s body was able to open it up again, but only after damage occurred. Another possibility is that damage occurred due to do a temporary blockage caused by vascular spasms that no longer show up by the time the angiogram is done. Still another possibility is that in women, the blood clot that forms on an active plaque may break up into the smaller vessels, that is, a level that’s too small for an angiogram to pick up. An angiogram that can show the trunk of the vascular tree and the big branches may not be fine-grained enough to show what’s going on at the microvascular level.
YOUR PATIENT SHOULD KNOW THAT A HEART ATTACK THAT DOESN’T REGISTER ON AN ANGIOGRAM OR IN ST SEGMENT ELEVATION
IS NOT A BENIGN CONDITION
While this is not quite as serious as more overt forms of heart attack, roughly 2% of women who have a heart attack without blockage or ST elevation will experience another attack in the next 1-12 months. There’s a temptation for her to dismiss this kind of attack, not taking it as seriously as she should. However, she should know that even if she didn’t have the typical symptoms in the hospital, she nevertheless did have a heart attack and that her treatment should include, as appropriate, the same medications and lifestyle changes that would accompany a more typical heart attack.
WOMEN NEED TO BE EDUCATED THAT WHEN THEY HAVE HEART ATTACK SYMPTOMS, MINUTES COUNT
There are many cases of women who are experiencing heart attack symptoms who delay going to the hospital so they can first take care of their loved ones, and some even try to clean the house before they leave for the hospital! Women need to learn that when it comes to the possibility of a damaged heart muscle or increased risk of death, the minutes really do count. There can be false alarms, but doctors and emergency rooms are ready for this and women are not “bothering” anyone by coming in with chest pain even if they are not sure if it is a heart attack. Given the seriousness of possible outcomes, this is what to recommend.
OF THE SEVEN MAJOR LIFESTYLE MODIFICATIONS, WORK WITH HER ON THE ONES SHE’S MOST LIKELY TO CHANGE
The American Heart Association lists seven health factors that can help prevent heart attacks. The Simple Seven are: Get Active; Eat Better; Manage Blood Pressure; Lose Weight; Reduce Blood Sugar; and Stop Smoking. However, asking her to take on all of these at once may be too hard for her. Instead, we recommend trying to discover which of the seven health factors she is most motivated to change. If she is not motivated to change a particular factor, you’re not going to get very far with her. Spend a couple of minutes with her finding the area where she is most motivated to change. Then help her set an easy goal, one so easy that she is sure to achieve it by the next visit. When she’s achieved that goal, go to the next step, and then the next and after a while, she will have achieved big changes in small increments.
RECOMMEND THE WEB SITE “MY LIFE CHECK” TO YOUR PATIENTS
The American Heart Association and the American Stroke Association have created a helpful website that’s consumer-friendly, easy to understand, and motivational. It’s called “My Life Check– Life’s Simple 7,” and your patient can find it at: http://mylifecheck.heart.org/Multitab.aspx?NavID=3&CultureCode=en-US.
Recommend that she visit it for additional encouragement and understanding.
MUSCULOSKELETAL PROBLEMS IN WOMEN
Our expert is Sheila Dugan, MD, Associate Professor of Physical Medicine & Rehabilitation, Rush Medical College, Chicago, IL. Dr. Dugan will be speaking at Women’s Health 2015: The 23rd Annual Congress, April 16-19, 2015, in Washington, DC. Be sure to register!
If there is a medical topic you would like to see explored here, please let me know!
CONSIDER MUSCULOSKELETAL PROBLEMS WHEN MAKING DIAGNOSES
When a woman comes in with pain, consider the possibility that her pain has a musculoskeletal cause. I’ve seen many cases of women who’ve been to as many as a dozen specialists over the years but none diagnosed the musculoskeletal problems that were causing the pain. These patients may feel depressed because of the pain but also worried about their sanity, given that the specialists haven’t been able to find what’s wrong. When these women get a correct diagnosis, it’s a life-changing experience for them.
WHEN MAKING A DIAGNOSIS FOR THE CAUSE OF PAIN,
TAKE THE PATIENTS’ HISTORY
As a typical example of why I take a patient’s history when she complains of pain, take the case of a woman who came into my office complaining of pain above her pubic bone. There are a number of tests that might seem appropriate in the absence of further information, such as a colonoscopy or checking for an ovarian cyst. However, if you take her history and learn that just recently she slipped on ice and fell, and then if you start touching the rectus abdominus, and you find that this is exactly where it hurts, and then when you ask her to hold a sit-up position and she tells you that this increases the pain, these are strong indications that the problem is muscular. Having taken her history, and taking anatomy into account, you may be able to get to a correct diagnosis rapidly without subjecting her to unnecessary, expensive, and time-consuming tests.
CHECK PELVIC FLOOR MUSCLES AFTER CHILDBIRTH
After delivery, it’s important to get a sense of how the pelvic floor muscles are recovering. Unfortunately, pelvic floor problems tend to be invisible and undertreated, and left untreated, they may set the woman up for urinary incontinence later in life. Urinary incontinence is the number one reason for women entering nursing homes, so doing something to prevent it early on is important. To check the pelvic floor muscles, palpate to see if the woman is having pain, and do this both through the vagina and the rectum. If there’s a problem, refer her to a pelvic floor physical therapist.
PRACTICE TRIAGE FOR MUSCULOSKELETAL PROBLEMS
Learning to figure out which problems need referral for surgical care and which can be treated in house is an important skill for the primary care provider. An anterior cruciate ligament (ACL) tear can be a devastating injury and is likely to require surgical care. On the other hand, many if not most knee problems can be treated in house. The reason to be careful about not sending knee patients for surgical care if they’re not true candidates for surgery is that the patient is likely to end up at the back of the line for treatment. In a hospital setting, I’ve come across patients who had waited for months before being seen.
ENCOURAGE EXERCISE AND GOOD POSTURE
Exercise and good posture are important at any age, but post-menopause, the costs of poor posture and lack of exercise show up in a significant increase in complaints of pain. Poor posture can result in compression fractures in the spine, and the habit of leaning forward can mean the arms aren’t hanging from the shoulders in the right position, and this in turn can mean rotator cuff pain. Further, the frailty associated with sarcopenia (muscle loss) and osteoporosis can be devastating. Exercise can slow both muscle loss and bone loss, and strengthening the back can mean better posture.
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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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