integrative gynecology


Cancer can be a scary topic, but one type – cervical cancer – represents a real clinical success story. Over the millennia, we’ve graduated to a fuller understanding of how the immune system figures in this disease, which was once the second most common cancer in women.

The cervix is the bottom part of the uterus – and we’ve known about cervical cancer since Hippocrates first described it in 400 B.C. We’ve also known that this type of cancer has been associated with sexual contact since 1842, when a physician in Italy described a difference in cervical cancer incidence between abstinent nuns and other women. (This was before we knew even what caused the sexual infection.)

Thanks to the development of the Pap smear (for Papanicolaou), the 1950s and 1960s showed a decrease in the incidence of cervical cancer. We still didn’t know what caused the sexually- transmitted infection, but we could screen for pre-cancer stages and treat it before it became cancer. Thanks to this strategy, by 1994 the incidence was down to 8 cervical cancer cases per 100,000 women in the U.S.

And now another huge breakthrough is the identification of HPV (human papilloma virus) types as the major cause of cervical cancer. The viral types were first isolated in the 1980s; we can now screen for HPV types which are responsible for both cervical cancer (called high risk HPV types) and genital warts (called low risk HPV types). Most people with healthy immune systems can fight off the virus within two years. But when the immune system is already compromised, the body has limited ability to fight off infection, and cancer may develop. A lifetime use of condoms will decrease the risk of cervical HPV infection by 70 to 80% but will not affect the risk to infection elsewhere on the body.

Although we know a lot about the life cycle of the HPV virus, we are still isolating more and more types of the virus and understanding where it chooses to infect both men and women. Three vaccines are also available. One is a “bivalent” vaccine that protects against the two most common high risk HPV types. One is a “quadrivalent” vaccine that protects against the two most common high risk HPV types and also protects against two HPV types that are responsible for 90% of external genital warts. A newer vaccine targets nine different HPV types – hoping to expand the effectiveness of the vaccine. The key to success with these vaccines is to administer the doses before sexual activity begins, which is one reason it is recommended for girls and boys ages nine to 26.

In addition, to keep the immune system strong on a daily basis, it’s smart to live a healthy lifestyle, including good nutrition, regular exercise, good sleep patterns and taking nutritional supplements if needed.

 

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From the Functional Medicine Forum – this little tidbit about a high dose of Vitamin D prior to the menstrual cycle. BE AWARE: Vitamin D is fat soluble – if your levels are above 45, you should NOT do this!

Vitamin D levels are frequently found to be low among the patient population and such insufficiency is related to myriad health conditions. Thus, repletion of D levels is often a goal of functional medicine treatment strategies. Now a new study shows that even in women not conventionally considered to be vitamin D deficient, a one-time megadose of vitamin D can ease menstrual pain for two months and perhaps beyond.

An Italian study published this week in the Archives of Internal Medicine details a small randomized, placebo-controlled trial of ultra-high dose vitamin D for women with a history of severe menstrual cramps. Twenty women aged 18-40 took a one-time dose of 300,000 IU of vitamin D (cholecalciferol) five days before their next expected period while twenty others received placebo. After two months, patin scores decreased 41% among the treatment group, while there was no significant change in pain scores among the placebo group.

Specifically, fifteen of the women in the treatment group experienced a reduction in self-reported pain scores of at least two points on a standard visual analog 10-point pain scale when compared to their previous four menstrual cycles. The greatest reduction in pain was seen among women who had the highest baseline pain scores. Just four of the placebo group showed any improvement compared to their baseline cycles.

Further, none of the women in the treatment group reported needing to use NSAID pain relievers to treat their menstrual pain while eight in the placebo group reported using NSAIDs.

The women were tested for vitamin D levels before the study and only women with plasma levels below 45ng/ml were allowed to take part. Study participants also could not be taking vitamin D, calcium, or oral contraceptives. They were allowed free used of NSAIDs during the trial but were asked to report their use of such medication.

Menstrual pain is thought to be dependent on uterine prostaglandins, which are synthesized from pro-inflammatory omega-6 fatty acids. The authors propose that vitamin D may act as an anti-inflammatory agent in multiple ways, including regulating expression of the genes involved in prostaglandin signalling.

Though the researchers excluded patients with high vitamin D levels, the cutoff of 45 ng/ml is well above the limit for frank deficiency. Thus, it is plausible that a mechanism beyond simple repletion of D levels is responsible for the analgesic effect. There will certainly be more to come from this line of research investigating vitamin D for pain relief.

http://archinte.ama-assn.org/cgi/content/extract/172/4/366

 “If every day is an awakening, you will never grow old. You will just keep growing.” – Gail Sheehy

 

What is your perception of aging? Do you see aging as an awakening, as Gail Sheehy states? Can you acknowledge the occasional “wear and tear” on your body but reframe it in a positive way? I asked friends to describe what they liked about getting older; some people mentioned feeling more comfortable in their bodies as they aged. Some friends noted that as they have aged, they are more comfortable speaking up and stating an opinion. Others told me, after witnessing the death of loved ones, they clearly saw that life is short and precious and that small gestures of kindness and love often have had the biggest impact on their lives.

It isn’t difficult to read articles in the medical literature about aging that chronicle a gloomy erosion of health and wellness. But consider these aging facts:

  • Mammography is a more effective and sensitive screen in our aging breasts. As the connective tissue and milk ducts and glands are replaced by fatty tissue, the lower breast density improves the accuracy of the mammography screen. Also, less compression and less radiation is needed to adequately screen the less dense breasts. The next time you notice that “sag” in the mirror, smile and know it is a positive development!
  • The cyclic hormonal fluctuations of estrogen and progesterone throughout our reproductive lives are eventually replaced by a low level of hormones with less of a fluctuation; this results in fewer menstrual migraines and less premenstrual syndrome (PMS).
  • Better yet, we know that that lifestyle modifications in the area of nutrition, stress management and exercise work well in our bodies at any age! There are now several studies that show that regular walking or exercises with weights will increase bone density in postmenopausal women.

Dan Buettner, in his book The Blue Zones, looked at areas of the world where a higher percentage of the population live longer and healthier lives. Places like Okinawa, Sardinia, Loma Linda and Costa Rica all had “pockets of longevity” where people lived well into their 90’s without major illnesses. In studying these areas, Buettner noted several lifestyle similarities among these diverse ethnic groups including: eating more vegetables versus protein and processed foods, drinking red wine in moderation, a regular spiritual practice or religious participation, regular exercise or daily movement, having a healthy social network, regular vacations and making family a priority.

Maybe all of that is the definition of “making every day an awakening!”

I thoroughly enjoyed the opportunity to talk to the breast cancer support group at the Jewish Family Services Center here in Dallas this week. This was my second visit with them and again I was impressed by the intelligence, passion and generosity of the women who are drawn to this program. This time I was introducing the idea of an integrated approach to anxiety and depression. According to the National Institute of Mental Health, the prevalence of depression in the general population in 2008 (the latest year for which statistics are available) is 6.7% of the adult population and the prevalence in women is 8.1%. Adding the diagnosis of breast cancer understandably bumps the prevalence slightly higher.

I reviewed the current pharmaceutical and nutraceutical approaches to depression and anxiety and also led the group through some paced breathing and the quick coherence technique of HeartMath. One woman announced that the breathing exercise made her feel calmer than she’d been all day!

During the discussion, one women raised the question about Tamoxifen and anti-depressants. Her oncologist told her that only a few anti-depressants could be prescribed to women on Tamoxifen. Since this is relatively new information, I’ve been researching the claim for the group and decided to post my findings here in the blog.

The concern stems from a study done in Ontario that was published in the British Medical Journal (Kelly CM et al. BMJ 2010 Feb 8:340). This reference is available on PubMed. The researchers looked at women over 66 who were on Tamoxifen and found that the mortality rate was higher in women on Paxil (paroxetine) versus some of the other antidepressants. The reason appears to be that Tamoxifen is broken down in our livers by an enzyme called cytochrome P450 2D6 (the name of this enzyme is often shortened to cyp2D6). Some medications including Paxil are also broken down by cyp2D6. If someone has a genetic variation such that this enzyme is not as efficient, they are often called poor metabolizers. This genetic variation is called a “snip” for the abbreviation single nucleotide polymorphism. If they are poor metabolizers, they will be unable to break down the Tamoxifen effectively and its benefit will be “blocked” by medications that use this pathway. (sort of like musical chairs and everyone is competing for the same seat) Paxil is metabolized by this pathway, so is Thorazine, Prozac, miconazole (a yeast medicine), and quinidine – to name just a few. If a medication has no inhibition or a weaker inhibition of cyp2D6, the Tamoxifen will be broken down more efficiently – for that reason the authors suggest Celebrex or Lexapro because they don’t compete as strongly for cyp2D6.

I read a review article by Kathleen Pritchard which was published in Breast Cancer Research Vol 12 Supp 4 (also on PubMed) and she notes that there are studies that refute the claim – one from Denmark, for example, and states that the final answer isn’t really known as far as SSRI’s and Tamoxifen. Some people are suggesting that we should test the urine for endoxifen (a break down product of Tamoxifen) and make sure that the drug is being effectively metabolized. This isn’t the standard of care as yet, nor is checking women to see if they have genetic SNP’s in their detox genes.

I’ve done the gene testing on people if they note a lot of side effects from a long list of medicines or if we’re suspicious of a problem. The testing is fairly expensive ($500 to $1000 depending on which genes we test) and is NOT covered by insurance. Another wrinkle in the discussion, whenever genetic screening comes up, is how likely is a SNP? We know from population studies of the SNP’s for cyp2D6 that about 6% of Caucasians are “poor metabolizers” of this gene. Other ethnic groups show poor metabolizer rates of 3.3% (Black North Americans), 8.4% (French), 7.7% (Southern Germans) and practically 0% in Korean and Chinese populations.

So, the take home message is Tamoxifen and anti-depressants can mix – but choosing a medicine that is less likely to interrupt the enzyme cyp2D6 is probably a good idea. Or better yet, learn coherence training and get regular acupuncture treatments!

Until next time, be well!

While this election cycle is playing out, the news is currently full of  pitched discussions on contraception and women’s health.  I’m posting an article here that I wrote a few years ago that was also published in my book, “Finding Grace and Balance in the Cycle of Life: Exploring Integrative Gynecology.” 

First, the numbers. Statistics show that the average American woman wants to give birth to two children during her reproductive life. Since her fertility stretches from her teens to her upper 40’s, this represents several decades of a monthly decision about pregnancy. The Allen Guttmacher Institute reports that among the 42 million fertile, heterosexual, sexually active women who do not want to become pregnant, 89% use contraception of some type during their reproductive years.

To achieve the control of this many cycles, she must use a contraceptive method for roughly three decades.  The type of contraception is generally age-specific. Younger women mostly use condoms or birth control pills, while women over 35 years of age are more likely to use female sterilization.

Are contraceptive options uniformly safe, easy to use and available to all women and their partners who wish to use them? The short answer is no. And here’s an important point: We know that the health of both women and their children is improved when contraception is available to space pregnancies and assist in the prevention of sexually transmitted infections. We also know that the worldwide access to contraception and family planning is closely tied to promoting economic growth and social stability. But this very personal decision has been questioned and debated a lot lately – especially when the question of payment for the options is considered. The truth of our pharmaceutical pricing is that the same pack of birth control pills can be anywhere from $2.00 at a clinic to $40.00 without insurance coverage.

I’ve recognized the controversy around contraception since my early medical school days. My classmates and I all received free materials from a local organization that had a strong opinion about contraception and family planning services. As my practice experience continued, I learned how to ask questions so that I could learn at the yearly office visit if contraceptive advice was desired without offending a woman who felt contraception was not in line with her religious beliefs. There are excellent resources available through the Couple to Couple league for natural family planning information. (www.ccli.org) If this appeals to you, stop reading now. The rest of the article is for women or couples who do not want to rely on this method of family planning.

Women have an array of methods for preventing pregnancy. Barrier methods such as male condoms are widely available and relatively inexpensive. Their first year contraceptive failure rate can vary from 2% in a “perfect user” to 17.4% in a “typical user”. Condoms can decrease (although not eliminate) the spread of sexually transmitted infections. They are relatively easy to use with rare side effects. A female condom has been on the market for a few decades; its cost ($4.00) is roughly four times the price of a male condom.

The FDA first approved the birth control pill in the 1960’s. The formulation and strength of synthetic estrogens and progestins have varied from pill to pill. The first year contraceptive failure rate for the pill varies from 0.3% for a perfect user to 8.7% for an average user. The pill works by adding synthetic estrogen and progestin hormones throughout a menstrual cycle to mimic early pregnancy and prevent ovulation or egg release during the cycle. In addition to preventing pregnancy, there are also non-contraceptive benefits to using the pill. The lifetime risk of ovarian cancer is decreased in women who have used the pill for at least three months. Menstrual cycles are lighter; menstrual cramps are less intense for women on the pill. The pill can also effectively treat acne and some other skin conditions.

On the other hand, there are downsides to the pill. There is an increased risk of blood clots and stroke in pill users – this risk increases in smokers. The pill is less effective in women with a body mass index (BMI) over 27 (equivalent to a 5’4” tall woman weighing 160 pounds or more). In addition, the lower dose pills require a regular pill-taking routine. Lower hormone levels from missing a pill, taking it late or taking a medication that increases the clearance of the hormones from the body can lead to spotting and/or an unplanned pregnancy. The birth control pill does not prevent sexually transmitted diseases.

Because of the inconvenience of daily pill consumption, drug manufacturers have offered three month injections, five year implants (no longer on the market), vaginal rings, and patches (no longer on the market). There is also a formulation that skips the “monthly” cycles and change the bleeding pattern to quarterly.

Intrauterine devices (IUD’s) are designed to prevent pregnancy by mainly preventing fertilization (changing cervical mucous to prevent sperm penetration). There are currently two types of IUD’s on the market. They’re inserted in the uterus during a pelvic exam in your physician’s office. Most women who choose the IUD like the convenience and have had at least one child. The disadvantages of the method are the risk of infection and potential sterility. The risk is essentially non-existent when both partners are monogamous and committed to the relationship.

Tubal ligation and vasectomy can be performed once a couple’s family size is complete. The failure rates are low for both procedures; risks are slightly higher for tubal ligation because it is done at a surgery center with general anesthesia while the vasectomy is done in the physician’s office with local anesthesia. Permanent sterilization shouldn’t be scheduled unless a couple is certain that they never want to conceive.

All the contraceptive options have risks and benefits. Ideally it’s a shared decision after a thorough review of options by your physician, nurse practitioner or midwife. It is NOT, however, a decision that should be made by your Senator or Congressman or President!