Our expert is Sherry McKee, PhD Clin, Associate Professor of Psychiatry at the Yale School of Medicine, Director of the Yale Behavioral Pharmacology Laboratory, and Clinical Director of the FORDD Addiction Clinic. Her research interests include behavioral pharmacology, alcohol, tobacco, and gender differences.
If there is a topic that you would like to be addressed in this blog please let me know. Smoking cessation was suggested as a topic by pulmonologist, Molly Lee Osborne, MD.
THE SCOPE OF THE TOBACCO PROBLEM
Smoking-related diseases remain the number one preventable cause of death in the United States. Worldwide, tobacco use causes more than 5 million deaths per year and, in the United States, there are approximately 430,000 deaths per year from tobacco-related diseases. To get an understanding of the magnitude of the U.S. death rate, consider that this is the population of Miami or Atlanta. In addition, 50,000 individuals in the U.S. die from secondhand smoking exposure and 25% of these are children.
GENDER DIFFERENCES IN RISKS ASSOCIATED WITH TOBACCO USE
Women face damaging health disparities when it comes to risks associated with the use of tobacco. A study of 2.4 million people showed that female smokers were at 25% greater risk for cardiovascular disease than male smokers and they were also more at risk for several kinds of cancers, including lung cancer. Lung cancer is the leading cause of cancer-related deaths in women. In addition, women face sex-related risks, such as complications with their menstrual cycles, higher rates of infertility, complications of pregnancy and, after the child is born, their children have double the risk of Sudden Infant Death Syndrome.
THE MEDICATIONS AVAILABLE FOR SMOKING CESSATION ARE LESS EFFECTIVE FOR WOMEN
To stop smoking is the single most important change a woman can make to improve her health—yet women have more difficulty in stopping than men. The success rate for stopping smoking has been lower for women every year since the federal government began keeping records in the 1960s. Men are more likely to smoke for the reinforcing properties of nicotine, while women, in contrast, are more likely to smoke to regulate mood and relieve stress. The problem is that all of the FDA-approved medications target the nicotinic receptors.
WOMEN NEED TO BE AWARE OF THE FACTORS THAT CONTRIBUTE TO THEIR SMOKING
Women are more likely to smoke to alleviate stress and other types of negative emotions, including those associated with depression. Women may have stronger cravings at certain points in their menstrual cycles. They may be afraid of weight gain. In order for women to deal effectively with their smoking, they need to understand the factors, in addition to nicotine craving, that contribute to their smoking and find alternative ways to manage those factors.
ACCEPTING THAT THERE WILL BE WEIGHT GAIN CAN BE SURPRISINGLY HELPFUL
Smoking will raise a woman’s metabolism by 10%, typically, and when this artificially high metabolism is withdrawn, a woman who is trying to stop smoking may experience weight gain. This is one of the reasons why the relapse rate for women who try to stop smoking is high. However, there is news that offers hope. One study examined women smokers who were concerned about weight gain when they stopped smoking. Women (n=219) were divided into three groups: a standard cessation group; a dieters’ group; and a cognitive restructuring group. In the cognitive restructuring group, the women were told that they might gain a modest amount of weight, but they would be much healthier in the long run if they were tobacco free. In other words, they were told to accept weight gain as a possibility, if not a likelihood, and that gaining a few pounds was not a reason to relapse. The surprising result of this study was that the women who gave themselves permission to gain some weight were the ones who were most successful at stopping smoking and gained less weight when compared to the standard cessation group.
MOST PEOPLE WHO STOP SMOKING DO IT “COLD TURKEY”
Many people are able to stop smoking on their own. Significant health problems are likely to develop 20 to 25 years after a person starts smoking, so it is often a person in her 40s who decides to stop. While it would be better if she never started smoking, or gave up earlier, the motivation is high by the time she is at risk for a debilitating disease. FDA-approved medications for smoking cessation may not be as effective for women as for men, but they are still worth trying. Various forms of nicotine replacement and Zyban generally double cessation rates and CHANTIX can triple rates of cessation.
LET YOUR PATIENT KNOW ABOUT THE QUITLINE
The toll free number from the CDC, 1-800-QUIT-NOW will connect your patient to her state’s Quitline directly. All states have quitlines in place with trained coaches who provide information and help with smoking cessation.
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Our expert is Patrick Young, MD, FACP, FACG, Director of the Division of Gastroenterology, Uniformed Services University of the Health Sciences.
As always, if there is a topic that you would like to see covered in the blog, just send me an e-mail.
WOMEN HAVE MORE PROBLEMS WITH CONSTIPATION
Women often face a “two-hit” problem with constipation. First, their colons are longer than those of men, by as much as a foot or more, even though the average woman is smaller than the average man. This means that the longer colon has to fit in a smaller space, which creates more twists and turns, causing the stools to move more slowly. Second, pregnancy puts strain on the nerves and muscles of the perineum, and this can cause changes in anatomy and function that damage the area and may make bowel movements difficult.
THERE IS A WIDE RANGE IN NORMAL FREQUENCY FOR BOWEL MOVEMENTS
The normal range for bowel movements is from three times a day to once every three days. If a patient has a bowel movement only once every three days, but it is easily passed and she doesn’t feel bloated or otherwise unwell, that may be what is normal for her. Also, there is no evidence for the notion that an individual needs to have a bowel movement every day to “clear out the toxins.” For that matter, there is no evidence that colonics “to clean the bowel” do any good, and there is some evidence that they may be harmful.
FIND OUT WHAT YOUR PATIENT MEANS WHEN SHE SAYS SHE IS CONSTIPATED
Not all constipation is created equal, and it is worth understanding what your patient means when she says she has a problem with constipation. As health care providers we tend to be number focused. However, if the bowel movements are within the normal range of frequency, the issue may not be the frequency, but rather the process may be unsatisfactory for her. Possibly she is feeling bloated or there is pain. She may have hard stools, have to strain to have a bowel movement, or may not feel that she has emptied her bowel completely. All of these are forms of constipation.
USE OF LAXATIVES
A condition called “cathartic colon,” which occurred in patients who used senna alkaloids for constipation, was once thought to exist. The theory was that long term use of the medication caused changes in the muscles and nerves of the colon, making the patient dependent on the medications. After all, when the patients stopped using the senna alkaloids, they became constipated again, sometimes worse than before. Today, however, this is no longer considered to be the case. It is analogous to patients with high blood pressure. If the patient has high blood pressure and is put on a blood pressure medication, the blood pressure will normalize. If the patient stops taking the blood pressure medication after a period, it is predictable that their blood pressure will increase again, perhaps worse than before. This is not because the patient was “dependent” on the blood pressure medication; it is because the patient has a condition that requires medication. I rarely start patients on senna alkaloids for constipation, but this is because there are better tolerated medications. If I have a patient who tells me, “I’ve been taking stimulant laxatives for years and they work,” I don’t try to get her to stop taking them.
Several lifestyle factors may help to reduce the risk of constipation. First, the daily diet should include 25 grams of fiber, preferably in the form of a diet rich in fruits and vegetables. Adequate hydration is also important. Exercise may help to some degree, but the evidence for this is not strong. Timing of bowel movements to the periods when the colon is stimulated to move, such as after meals, is also helpful for many people. If a person experiences sudden onset constipation, particularly after the age of 50, a medical evaluation is important as this may represent something more than simple constipation.
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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.
Be sure to let me know if there is a topic that you would like covered in the MP Post.
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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