Monthly Archives: June 2015

What is a placenta?

8 April 2015, 2.36pm AEST

Explainer: what is placenta?

An incredibly complex and important organ in its own right, the placenta is only found in mammals. And how it functions has the potential to have profound effects on the lifelong health of the developing foetus.

The placenta plays a critical role in pregnancy, fetal development and health throughout life. Remy Sharp/Flickr, CC BY-SA

An incredibly complex and important organ in its own right, the placenta is only found in mammals. And how it functions has the potential to have profound effects on the lifelong health of the developing foetus.

The placenta exists solely during pregnancy, and plays a crucial role in nurturing and protecting the foetus throughout gestation. It’s connected to the foetus via the umbilical cord and attached to the wall of the womb, allowing for essential exchanges of nutrients, gases and waste with the mother’s circulation.

Placenta is composed of maternal and foetal parts, which are known as the basal and chorionic plates, respectively. Nutrients are exchanged through the maternal blood entering the foetal section, but maternal and foetal blood don’t actually mingle; they’re separated by arteries and capillaries.

Interestingly, the placenta has a gender matching that of the foetus, indicated with the presence of either XX or XY sex chromosomes. But placental sex is not used to test fetal gender as that would require invasive surgical tests and add unnecessary risk to the pregnancy.

In the beginning

The placenta begins developing once the embryo is implanted into the wall of the uterus. During the nine months of pregnancy, it increases in size and performs several vital functions. It regulates the exchange of nutrients for foetal growth and development, the exchange of gases including oxygen and carbon dioxide, and hormone secretion.

It also protects the foetus from toxins and infections as well as the mother’s immune system, which would otherwise regard it as a foreign invader. This is a critical aspect of placental physiology; if the mother’s immune system rejects the foetus, it will spontaneously abort.

In order to prepare the developing foetus for the world it will inhabit after pregnancy, the placenta is very sensitive to the mother’s environment. It’s able to adjust its functions in response to external cues, such as the mother’s diet or environmental pollutants, which can then alter foetal development.

The placenta begins developing once the embryo is implanted into the wall of the uterus. Louise Woodcock/Flickr, CC BY-NC

Maternal diet plays a major role in foetal development; studies show eating a balanced diet of fruit, vegetables, and lean meat helps reach a good birth weight. But exposure to pollutants, such as car exhaust fumes, can have a negative impact and may increase the risk of the child developing asthma.

Permanent changes to the developing foetus’s physiology during development is known as foetal programming. And variations in the development of organs and systems within the foetus may increase lifetime susceptibility to cancer, heart disease, allergies and other diseases.

The mechanisms underlying these susceptibilities are incredibly complex and we’re only now beginning to understand them. One of them is epigenetics, which changes foetal gene expression, altering the physiology and functioning of the foetus throughout life.

What can go wrong

Placental disorders can cause serious health complications during pregnancy for both the foetus and mother. They can result in abnormal foetal development, growth restriction, malformations, miscarriage or stillbirth, and may even endanger the mother’s life.

Because the placenta keeps forming throughout pregnancy, abnormalities in its structure and implantation into the uterine wall can happen at any time. Placental abruption, for instance, occurs in approximately one in a 100 pregnancies. Abruption is either the partial or full detachment of the placenta from the uterine wall. And it can deprive the foetus of oxygen and nutrients, potentially leading to preterm birth or stillbirth.

One of the most common disorders of pregnancy is pre-eclampsia, which occurs in 3% to 7% of all pregnancies; it’s the leading cause of maternal health complication and death. Characterised by high blood pressure and protein in the urine, pre-eclampsia can lead to permanent vascular and metabolic damage in the mother.

The exact cause of the disorder is unknown, but it’s thought several factors including poor diet, high body fat, a history of high blood pressure and genetics may all play a role. Abnormal placental development and function is thought to be another major contributing factor.

If left untreated, pre-eclampsia can develop into eclampsia, which is characterised by cerebral fluid build-up and seizures. Once the placenta is removed, pre-eclampsia and eclampsia end.

Out of the several thousand mammalian species, humans are among only a handful that don’t regularly consume the placenta. Kom bo/Flickr, CC BY

The placenta can become infected by bacteria, viruses or parasites which can lead to abnormal foetal development, preterm birth or foetal death. This occurs mostly in developing countries such as Africa, where the malaria parasite contributes to 100,000 deaths annually as a result of severe foetal growth restriction.

Finally, cancer of the placenta, known as choriocarcinoma, occurs in approximately one in 20,000 to 40,000 pregnancies. This cancer usually spreads to lungs and while it can be life-threatening, the cure rate is over 90%. It’s very responsive to chemotherapy, which is given after the baby is born.

Cultural significance

The placenta has little cultural value in Western countries; it’s often unrecognised by parents as being fundamental for a healthy and successful pregnancy. So, it’s usually discarded after childbirth.

But some other cultures hold great respect for this uniquely temporary organ, and have the mother eat it, in a practice known as human placentophagy. According to traditional Chinese medicine, for instance, the placenta is thought to rejuvenate the body after childbirth.

This practice has recently become more popular in Western culture but remains highly controversial, mostly due to the cannabalistic nature of the act. There are few scientific studies examining the benefits of placentophagy, but it’s worth noting that out of the several thousand mammalian species, humans are among only a handful that don’t regularly consume the placenta.

Different cultures hold a variety of beliefs about the placenta. Indonesian and Malaysian cultures consider the placenta to be a sibling of the newborn, for instance. And, in China, it’s thought to be its first and finest clothing. They all have a deep reverence and appreciation for the placenta and its ceremonial role in the birthing event.

The placenta plays a critical role in pregnancy, foetal development and health throughout life. It may only be a temporary organ, but plays some of the most important roles in sustaining early life.

Are my memory lapses normal or could this be Alzheimer’s disease?

13 April 2015, 2.26pm AEST

Health Check: are my memory lapses normal or could this be Alzheimer’s disease?

From time to time, we all misplace our keys or forgets someone’s name, at least for a few minutes, and we worry about “getting Alzheimer’s”.

Around one in nine people aged over 65 has Alzheimer’s disease. marco monetti/Flickr, CC BY-ND

From time to time, we all misplace our keys or forget someone’s name, at least for a few minutes. This may prompt worry about “getting Alzheimer’s”, particularly if we have an older parent who was afflicted by this disease.

It’s easy to see why people are concerned. Around one in nine people aged over 65 has Alzheimer’s disease. One in three over 85 has the disease. The risk increases with age and has a genetic component.

The traditional view is that if you are younger than 65, with no impact on your daily routine on a regular basis, your memory lapses are not usually caused by Alzheimer’s disease.

These lapses are more likely due to poor sleeping habits, especially sleep apnoea (which periodically reduces oxygenation of the brain), low rates of satisfaction at work and high levels of alcohol consumption.

However, if you or your family members are worried about your memory, see your family doctor. They will check your thyroid function, nutritional status and current medications, among other things, which may affect cognitive function.

Your doctor will then test your memory with a screening tool such as the the Montreal Cognitive Assessment. This identifies people with memory or other cognitive complaints, such as looking for words, or for your car in the parking lot, and delays in making decisions.

The wild card now is that Alzheimer’s pathology in the brain starts 20 years before symptoms, when amyloid builds up in the brain. This is the first step in a cascade of events leading to dementia.

While amyloid builds up outside the neurons in the brain, twisted strands of a protein called tau form inside the neurons. This damages and kills off neurons. Eventually the brain is no longer able to compensate for the damage.

Symptoms begin with memory loss and confusion. But by the time cognitive decline is detected, the disease has already taken hold. Later, the damage in the brain impairs basic bodily functions, such as swallowing.

Fortunately the strategies that researchers are investigating to prevent Alzheimer’s disease are already accessible to all of us:

1) Reduce your vascular risk factors in mid-life: exercise regularly, reduce your weight and don’t smoke. This also helps control high blood pressure, high cholesterol and diabetes if you already have these conditions.

These vascular risk factors can block and harden the arteries, which impairs the body’s ability to pump oxygen- and nutrient-rich blood to the brain and other organs.

2) Keep you mind busy, preferably with social interactions.

At a population level, a higher level of educational attainment reduces the risk of Alzheimer’s disease later.

Some people may be more forgetful because of their genetic make-up, including the presence of a gene called Apolipoprotein E 4 (ApoE 4), which is involved in carrying cholesterol in the bloodstream.

Another gene called HMGCR, which acts like a natural statin, may cancel that risk. Researchers are now testing an old cholesterol-lowering drug to see if it can mimic that protective gene.

Another high-risk group is those who already have a substantial amount of amyloid in their brain. Australian researchers are investigating whether amyloid antibodies, given intravenously once a month, can combat this decline.

Back to your memory lapses. Surprisingly, many people are still unsatisfied when told that they do not have Alzheimer’s disease, since this does not change the fact that they have memory lapses.

But don’t go looking to attention-enhancing drugs such as methylphenidate, as there is little data to support its use. Nor is there any evidence to support the use of Alzheimer’s drugs cholinesterase inhibitors (donepezil, rivastrigmine, galantamine) and memantine.

Much better advice is to get physically and socially active. This will immediately improve your memory and may prevent Alzheimer’s disease in the long run.

Also check:

1,What is Alzheimer’s disease?

Cancer linked to menopause drug in new report

I still get women seeing me who have been put on Premarin, or one of its variants (Premia) by their own doctor or specialist. I despair when there is so much evidence that the Bioidentical HRT is much safer and better, in spits of the pharmaceutical industry’s attempts to knock it. One of the reasons for this blog is to put the information in front of you as to the evidence as to the best and safest form of HRT.

Cancer linked to menopause drug in new report

Leading epidemiologist points finger at Premplus, but manufacturer denies claim.

Rose Scarff, 70, of Hamilton is part of a class action lawsuit alleging hormone replacement therapy drugs caused her breast cancer.

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Rose Scarff, 70, of Hamilton is part of a class action lawsuit alleging hormone replacement therapy drugs caused her breast cancer.

Popular menopause drugs made in part from estrogen found in the urine of pregnant horses have caused breast cancer in thousands of Canadian women, according to allegations in a new report by the Canadian Cancer Society’s top epidemiologist.

“The body of evidence to date overwhelmingly points to a causal connection between the use of Premplus and the development of invasive breast cancer in women,” the society’s Prithwish De wrote in a report to be filed in a Canadian class-action lawsuit against drug manufacturer Wyeth Canada, now owned by Pfizer.

The drug manufacturer states that its products are “safe and effective when used as directed” and they do not cause breast cancer. A trial date is set for October in a Vancouver court.

According to the report, hormone replacement therapy was the main risk factor in an estimated 12,000 new Canadian breast cancer cases detected between 1994 and 2006 at a time when Wyeth’s products, Premarin and Premplus, dominated the market. The drugs remain on the market, but in more recent years they have contained strong warnings and are also prescribed in lower doses.

In the lawsuit against Wyeth, women like Hamilton’s Rose Scarff, 70, say they were not properly warned of breast cancer risk when the drugs — prescribed to relieve menopausal symptoms such as hot flashes, night sweats and vaginal dryness — were packaged by the drug firm and prescribed by doctors.

“I never suspected there was anything wrong with taking it,” said Scarff, who developed an aggressive form of breast cancer after taking combined hormone replacement therapy continuously for 10 years.

Like millions of other women in North America, Scarff said she wanted to recapture a youthful zest extolled in health literature — “you’d feel like a younger woman,” Scarff recalled of articles about menopause relief treatments — as she entered menopause at age 49.

American courts have dealt with these allegations for years. Pfizer, which in 2009 acquired Wyeth, has paid $1.7 billion to settle nearly all of the 10,000 hormone replacement therapy claims against the drug manufacturer. Pfizer said it makes no admission of liability in the American settlements.

Since 2004 Health Canada has revised the product safety information for the drugs to list potential side effects including coronary heart disease, gynecologic cancers, breast cancer and dementia.

Two medications, Premarin and Premplus, are at the core of both De’s study and a Canadian class action suit for which he was hired as a hormone replacement therapy expert. The estrogen in the drugs comes from the urine of pregnant mares, mostly produced by a Pfizer plant in Manitoba.

Pharmaceutical giant Pfizer responded for comment on the civil suit with an email to the Star stating that “the court has made no ruling on the merits of any class member’s claim.”

In pleadings filed in response to the class action claims, Wyeth Canada (now a division of Pfizer) states that “Premarin and Premplus do not cause breast cancer.”

“The cause of breast cancer is not known. The vast majority of women who take hormone therapies such as Premarin and Premplus do not develop breast cancer,” according to the pleadings filed by Wyeth Canada in a British Columbia court.

The Wyeth documents also note Premarin and Premplus “are proven treatment options for menopausal symptoms and postmenopausal osteoporosis.”

Premarin is a very old drug that went on the market in Canada and the United States about 70 years ago. Premarin contains the equine estrogen hormone extracted from pregnant mare urine. Its name has long been considered a play on its plentiful natural source — PREgnant MARe urINe — but Pfizer staff could not confirm that is true.

Premplus is a combination product containing the equine estrogen and another hormone called progestin in a single medication. Premplus was approved for sale in Canada in 2000. Premarin and progestin can also be prescribed for use as separate tablets.

There are about 2,000 horses stabled at 20 Pregnant Mare Urine (PMU) ranches in Manitoba and Saskatchewan. Back in the 1990s, at the height of the drugs’ popularity, Wyeth had approximately 25,000 to 30,000 mares producing urine, according to a finding of fact in a U.S. patent lawsuit where Wyeth successfully sued to protect a trade secret.

Pfizer contracts ranchers to collect the urine for initial processing at its plant in Brandon, Man. To amass the urine, mares are kept in stalls with flexible pouches hanging between their hind legs to capture every drop.

Foals are removed from the mother when they are young. Some horse welfare advocates claim the PMU offspring often end up in a slaughterhouse. In response to slaughter claims, the ranching association stated its members “are contractually obligated to sell their horses to productive markets” in which horses can be competitive, ridden for pleasure or used to work on farms.

The ranching association website reports 50 per cent of foals are sold privately, 30 per cent go to auction and 20 per cent are purchased by breeders.

Women responded enthusiastically when Premarin came to market, making it the top-selling menopause drug in North America.

Gross sales of Premarin in the United States grew from over $500 million to in excess of $2 billion during the period of 1992 to 2001, according to Wyeth’s 2002 patent lawsuit submissions in a Minnesota court. The Star was unable to find Canadian sales information.

The Canadian class action suit follows years of litigation (thousands of cases with similar breast cancer claims) launched against Pfizer in the United States. Pfizer has won some of those suits, lost others and settled many.

Pfizer paid victims $1.7 billion (U.S.) to settle nearly all 10,000 hormone replacement therapy claims against it as of Dec. 31, 2013, according to the pharmaceutical manufacturer’s most recent annual financial report. The settlements included breast cancer, ovarian cancer, stroke and heart disease claims.

The Canadian class action was filed in 2004 by Dianna Stanway, a 68-year-old woman from Sechelt, B.C., and is only now coming to court.

Stanway, the lawsuit’s leading claimant, alleges she developed breast cancer after using Premarin in combination with the hormone progestin for about eight years. She, on behalf of 209 plaintiffs and others who can still join, are suing Wyeth Canada for general and punitive damages, costs and other relief as the court sees fit. No dollar amount is listed in the suit.

Stanway’s allegations include: Wyeth suppressed study results that indicated “significant health risks” associated with Premarin and Premplus use; Wyeth failed to conduct proper drug safety testing; the company oversold the drugs’ effectiveness; long-term use was promoted when the drug maker knew that serious risks outweighed their “limited benefits” and that Wyeth “deliberately chose to value their own profits over public safety” by its conduct.

In its response to the allegations, Wyeth states in its pleadings that “for the vast majority of women, the potential risks associated (with Premarin and Premplus) are outweighed by the benefits of treatment.” Wyeth provided information on risks to doctors and “acted appropriately” at all times when testing, manufacturing and marketing the drugs, the pleadings state.

The allegations have not been tested in a Canadian court. Similar claims about Pfizer’s family of hormone replacement therapy drugs have been tried in American courts.

For example, in 2007 a Philadelphia jury found Prempro — a Pfizer product — caused breast cancer in an Arkansas woman who took the medication from 1999 to 2001 and awarded her $1.7 million in compensation. In 2010, another Philadelphia jury rejected a claim that Prempro caused breast cancer in two Pennsylvania women.

A written statement from Pfizer to the Star said the American settlements are confidential “but they do not contain admissions of liability.”

“The company believes it has strong defences to the claims in this litigation and has prevailed in a substantial number of the cases that have gone to trial. Any previous settlements are a desire by the company to focus on the needs of patients and prescribers,” the statement said.

As part of the Canadian lawsuit, Prithwish De was hired by the plaintiff’s law firm, Klein Lyons, to produce a report. In addition to De’s role with the Canadian Cancer Society, he is an associate professor of epidemiology at the Dalla Lana School of Public Health at the University of Toronto.

De reviewed national and international studies of women using the Wyeth products named in the legal claim in his 25-page report for the lawsuit.

Hormone replacement therapy, used in combination prescriptions like the Wyeth products, was the major risk factor in new breast cancer cases among Canadian women from 1994 until 2002, De writes, referring to research from a 2010 Canadian study he reviewed for his report.

By the 1990s, red flags were popping up regarding health concerns related to Wyeth’s menopause medications, according to information filed by lawyers in the class action.

The world’s first extensive, long-term randomized controlled trial study was commissioned by the U.S. National Institutes of Health in 1991. De describes randomized controlled trials as the gold standard of clinical drug testing.

The Women’s Health Initiative study involved 16,000 healthy post-menopausal women aged 50 to70 who had not had a hysterectomy. Half the women took combined hormone replacement therapy drugs, the other half had placebos. The study was halted prematurely in 2002; researchers feared there were more risks (such as breast cancer, blood clots, strokes) than benefits among the group using the hormone replacement therapy drugs. The women’s study also reported the medications’ beneficial effects, such as reduced risk of colorectal cancer and fewer fractures.

De notes the dramatic decline of combined hormone replacement therapy use began in 2002 after the Women’s Health Initiative published findings from its long-term study about the medications’ serious side effects (including breast cancer).

Scarff said she believes her breast cancer was tied to hormone replacement therapy. “I’m positive that was the cause of it,” she said.

Mary Ormsby can be reached at mormsby@thestar.ca or 416-869-4373

Midlife Fitness Linked to Cancer Risk and Mortality

Commentary:  The beneficial effects of exercise on cardiovascular disease prevention are well appreciated.  The beneficial effects of exercise on cancer prevention are less well known, but equally important. This study adds to the current body of literature that shows that exercise helps decrease the incidence of many types of cancers.1   The American Cancer Society has estimated that one-third of the more than 572,000 cancer deaths that occur in the United States each year can be attributed to diet and physical activity habits. Physical activity may reduce the risk of cancers of the breast, colon and endometrium, advanced prostate cancer, and possibly, pancreatic cancer.2 –Neil Skolnik, MD

Midlife Fitness Linked to Cancer Risk and Mortality

Results from the Cooper Center Longitudinal Study
April 7, 2015

Cardiorespiratory fitness (CRF) in midlife is inversely associated with incident lung and colorectal cancer, but not prostate cancer, according to a prospective observational cohort study of 13,949 men with a baseline fitness examination in the Cooper Center Longitudinal Study.

Researchers used age- and sex-specific distribution to define fitness groups as those with low (lowest 20%), moderate (middle 40%), or high (upper 40%) CRF.

Compared with the low CRF group, the adjusted hazard ratios for incident cancers among men with high CRF are as follows:

• Lung: 0.45

• Colorectal: 0.56

• Prostate: 1.22

In addition, high CRF in midlife was associated with a 32% risk reduction in cancer-related deaths among those diagnosed with cancer at Medicare age, and a 68% reduction in cardiovascular mortality following a cancer diagnosis.

Citation: Lakoski SG, Willis BL, Barlow CE, et al. Midlife cardiorespiratory fitness, incident cancer, and survival after cancer in men: The Cooper Center Longitudinal Study. JAMA Oncol. doi:10.1001/jamaoncol.2015.0226. 

 

1.  Spring B, Ockene JK, Gidding SS, Mozaffarian D, Moore S, Rosal MC, et al; American Heart Association Behavior Change Committee of the Council on Epidemiology and Prevention, Council on Lifestyle and Cardiometabolic Health, Council for High Blood Pressure Research, and Council on Cardiovascular and Stroke Nursing. AHA – Science Advisory: Better population health through behavior change in adults. Circulation. 2013 Nov 5;128(19):2169-2176. doi: 10.1161/01.cir.0000435173.25936.e1.

2. Kushi LH, Doyle C, McCullough M, Rock CL, Demark-Wahnefried W, Bandera EV, et al; American Cancer Society 2010 Nutrition and Physical Activity Guidelines Advisory Committee. American Cancer Society Guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin. 2012 Jan-Feb;62(1):30-67. doi: 10.3322/caac.20140

Golden staph: the deadly bug that wreaks havoc in hospitals

9 April 2015, 6.06am AEST

Golden staph: the deadly bug that wreaks havoc in hospitals

Which of the following conditions would you prefer to have during your next stay in hospital? A. Staphylococcus aureus (Golden Staph) bloodstream infection; or B. a heart attack?

Staph aureus bloodstream infection has a 12-month death rate of between 20 and 35%. Joe Techapanupreeda/Shutterstock

Take this quick medical pop quiz: which of the following conditions would you prefer to have during your next stay in hospital? A. Staphylococcus aureus (golden staph) bloodstream infection; or B. a heart attack?

I am guessing most non-medical readers voted for the Staph option and, if my experience is anything to go by, the majority of medical readers will have also made a microbial choice.

The disturbing truth is that a Staph aureus bloodstream infection has a 12-month death rate of between 20 and 35%, compared with 3-5% for a heart attack in hospital. Although antibiotic-resistant Staph aureus (MRSA) infections carry a slightly higher death rate, even the drug-sensitive Staphs are among the most potent of pathogens.

Staph aureus lives on our skin and in our nose where it usually causes no harm. But if we are admitted to hospital and have an intravenous catheter inserted through our skin, the Staph aureus can be carried on the tip of the needle into the vein.

Usually our immune system mops up any stray microbes but the reason for coming to the hospital in the first place may have weakened our defences. Infections such as pneumonia, the effects of cancer and its treatment, diabetes, drugs that suppress the immune system and surgery make us more vulnerable to hospital-acquired infections.

Very sick patients often require long-term intravenous access through central venous catheters (which are inserted into a large vein at the chest, neck or groin). These carry a higher risk of infection than small peripheral cannulas, usually inserted in veins of the hand or arm.

Patients with bloodstream infections develop chills, fever, headache, muscle and back pain and may go on to develop failure of one or more organ systems.

The complications of Staph aureus bloodstream infections (which, going back to our quiz, include a heart attack) may take weeks or months to develop; by the time the patients who survive have been discharged from the intensive care unit, the original infection may have been forgotten.

The national benchmark for Staph aureus bloodstream infections is two cases per 10,000 patient days. surasaki/Shutterstock

Today the National Health Performance Authority released its report on health care associated Staph aureus bloodstream infections in Australia in 2013-14. This is the third year the data has been reported nationally and the news is mildly encouraging. In 2013-14, there were 1,621 bloodstream infections caused by Staph aureus, which is 100 fewer than in 2012-13.

Nearly 90% of the infections occurred in the 115 major and large Australian public hospitals. To make sensible comparisons, hospitals are grouped by their size and the complexity of the patients they treat. Patients with burns, cancer, HIV and those who have undergone surgery are considered to be more vulnerable to infection.

For the 36 major Australian hospitals with more vulnerable patients, the average rate of infection was 1.28 per 10,000 patient bed days, although the rate was more than three time higher in some of these hospitals than in others. At the 40 major hospitals with fewer vulnerable patients, the average rate was 0.78 per 10,000 patient days.

The agreed national benchmark is less than 2.0 per 10,000 patient days and only a handful of hospitals exceeded this rate.

While these data show that the risk of Staph aureus infection for an individual patient is low, when considered across the entire health system it reveals an important and costly problem.

These figures only relate to infections that have been acquired in a health-care setting. Staph aureus can also originate in people in the community who have had no contact with the health system and these infections also carry a high risk of death.

There isn’t much we can do to reduce community Staph aureus blood stream infections but we can influence the number of hospital-associated infections – as these data so happily show. One important reason for the reduction is the increasing compliance of health-care workers with hand hygiene.

Nurses’ hand hygiene compliance is at 85.5%. topseller/Flickr

The most recent data from Hand Hygiene Australia show that average compliance in Australian hospitals is now 81.9% across the five “moments” of hand hygiene. Even my recalcitrant doctor colleagues have lifted their game – from an average of 59.6% in 2011, they have now reached 70.2% (which, I am ashamed to say, is still 15.3% behind our much cleaner nursing colleagues).

Other reasons for the reduction include the implementation of protocols for the insertion, maintenance and early removal of central venous catheters and, possibly, the increased preference for peripherally inserted central catheters.

Staph aureus is only one of many bacteria that can invade the bloodstream but, for the moment, it is the only centrally monitored and reported bacteria in Australia. Gram-negative bacteria such as E. coli are increasingly common causes of serious infections and antibacterial resistance is arguably a more important problem in these organisms. We need to watch this medical space.

Nevertheless, the modest 6% reduction in the number of bloodstream infections indicates that something as banal as keeping your hands clean can make a real difference. The 100 hospitalised patients who didn’t get a Staph aureus blood stream infection last year will never know how lucky they were.

The ART of deception – IVF success rates are not what you think

This article is an indictment of the IVF industry. This information should be more widely known. When I think of all the couples I have known who have gone in for IVF with great hopes and enthusiasm, just to be dashed again and again – and broke to boot. Very sad.
June 22, 2015 6.19am AEST

The ART of deception – IVF success rates are not what you think

From “Joyful new mum Sonia Kruger” to the “back-to-front love story” of sperm donor romance, IVF patients across the country are being told their fairy tale ending is just an embryo transfer away.

Many Australians may not be as lucky with their IVF treatment as joyful new mum Sonia Kruger. Nine Network/AAP

From “Joyful new mum Sonia Kruger” to the “back-to-front love story” of sperm donor romance, IVF patients across the country are being told their fairy tale ending is just an embryo transfer away. But for every artificially conceived bundle of joy to make the headlines, there are many everyday Australians who have not been so lucky.

Many patients’ lack of success may have more to do with their IVF (in-vitro fertilisation) provider than with their pathology. With the gap between success rates at the highest- and lowest-performing clinics widening each year, it’s time for all fertility clinics to disclose their results to patients.

In Australia, assisted reproductive technology (ART) clinics are required to report success rates to the Australian & New Zealand Assisted Reproduction Database (ANZARD). The National Perinatal Epidemiology and Statistics Unit and the Fertility Society of Australia (FSA) then jointly collaborate to produce a yearly ANZARD report.

Clinics are told where they rank in an IVF “league table”, however, this is not released publicly and clinics only know their own result.

The most recent ANZARD report from 2012 (published in 2014) revealed IVF success rates varied dramatically between clinics. From 35 clinics across Australia and New Zealand the live birth success rate ranged from 4.0% at one clinic to 30.9% at another. No-one knows which clinic is which, and no-one knows why success rates varied so considerably between providers.

However, it was not just last year’s report which revealed alarming results. In 2011, success rates were as low as 3.6%. The year before that it was 4.4%. The year before that it was 4.5%.

In comparison, the overall live delivery rate in 2012 for the middle band of clinics was between 13.3% and 19.6%, and the top performing clinic achieved a live delivery rate of 30.9%.

Year after year, the poor performance of Australia’s worst IVF clinics fails to be explained. Yet these figures raise serious concerns about the practices of the clinics responsible. The issue is there is no obvious plausible scientific explanation for IVF success rates in the single digits. On their own, without clarification, these sorts of figures are simply outrageous and unacceptable.

Transparency, accountability and responsibility in IVF clinics are essential measures to protect vulnerable patients. from shutterstock.com

Many top-ranking clinics have argued for the release of the ANZARD league table. They claim comparisons between clinics are entirely valid and patients should be able to make an informed decision about where they spend their money. It is also consistent with the approaches used in the United Kingdom and the United States. The Fertility Society of Australia, however, remains officially opposed to doing so.

Criticism of the society’s stance on this issue is gaining momentum. As a membership organisation, its interests are conflicted. On the one hand, the society needs to represents its members, even the poor performing ones. On the other hand, it is responsible for overseeing the industry and accrediting IVF clinics through its Reproductive Technology Accreditation Committee (RTAC).

Monash IVF director Dr Richard Henshaw recently accused the society of working against the best interests of patients to protect its worst performing members. He wants the league table released. Others want poor performing clinics shut down. Neither appears to be happening.

What is also confusing about the society’s continued stance on suppressing this table is that so much of it is already in the public domain. Most clinics report success rates on their websites which they claim are either taken directly from the ANZARD report, or independently released by the clinics themselves. If the results published on clinic websites correlate with the results in the ANZARD report, there should be nothing to hide.

Although the release of the league table may not give patients a clear picture of the likelihood of success in their specific circumstances, it would allow them to compare clinics and make an informed choice about where they want to spend potentially tens of thousands of dollars. This is important because it’s an open secret that the quicker a patient gets pregnant, the less money they spend on their treatment.

If there is no incentive for clinics to improve their results, why would they bother? Medicare, private health insurers and patients themselves all pick up the ever-increasing tab and it doesn’t make good business sense to lose what would otherwise be a return customer. Therefore measures to encourage transparency, accountability and responsibility are essential for the protection of vulnerable patients.

As the IVF sector becomes more corporatised, companies are required to balance their obligations to both patients and shareholders. Although there is no evidence that IVF providers have failed to reconcile these tensions, it is an issue that policymakers need to take seriously going forward. Perhaps the IVF industry would be best served by an independent regulator rather than a membership association with a clear conflict of interest.

The ANZARD report revealed that 12,000 babies were born in 2012 following assisted reproductive treatment in Australia and New Zealand. While this no doubt contributed to many happy new parents, sadly it seems, there should have been more.

  • Roderick Davidson

    logged in via email @gmail.com

    Good article, my wife and I tried IVF, it cost $14,000 and was unsuccessful. Protecting low performers is entrenching low performance and ultimately benefits no-one.

  • Steve Hindle

    Steve Hindle is a Friend of The Conversation.

    logged in via email @bigpond.com

    This article has certainly been an eye opener, I had no idea the success rate of the industry was so low. Clinics with consistent “success” outcomes around 4% are operating more as cruel scams than medical centres. That the FSA wants these clinics kept secret does sound like a good reason for it to be replaced by an industry regulator.

    As for the bigger picture, it would be moving in the right direction to encourage and support single women and couples to have children at a younger age.

 

Sleep Apnoea- silent killer.

6 April 2015, 8.50am AEST

Health Check: here’s what you need to know about sleep apnoea

Often the cause of snoring, sleep apnoea is actually a serious condition that can have a big impact on health and the development of chronic diseases.

People with sleep apnoea often complain of daytime sleepiness, and have difficulty concentrating. oohander/Flickr, CC BY-NC

Sleep apnoea is a condition where people repeatedly stop breathing while asleep. People with sleep apnoea often complain of daytime sleepiness, difficulties concentrating, and they tend to have high blood pressure. The people around them usually complain about their nightly snoring, gasping, and choking noises.

About 5% of people have treatable moderate or severe sleep apnoea, which means they stop breathing 15 times or more times per hour while asleep. A larger number of people – as many as 20% of middle-aged folk – have mild sleep apnoea, which means they stop breathing around five to 15 times an hour. Although this may sound pretty scary, it’s still not clear that this mild version causes ill health.

Left untreated, sleep apnoea will not only shorten your life by hastening a string of illnesses, it may also increase your risk of suffering from depression. And the general sleepiness of people with the condition is thought to as much as triple their risk for car accidents and injury.

Stroke risk

The prevalence of sleep apnoea increases in ageing societies that are getting heavier, along with other age and obesity-related diseases. But studies from around the world show your risk of developing these diseases is strongly influenced by whether or not you have sleep apnoea in the first place. In particular, the condition has been linked to stroke and cancer.

The consequences of stroke can range from between temporary inconvenience to serious life-altering disability and death. Smoking, cholesterol, and high blood pressure are three key causes of stroke that you can control. And, unfortunately, sleep apnoea has a big impact on the latter.

The condition causes your daytime blood pressure to increase a little bit over the long term. And, while you’re asleep, it causes massive spikes in blood pressure. Sleep apnoea also might make your ability to process cholesterol a little less efficient.

So it’s not terribly surprising that studies from Spain, the United States, and Australia have all found people with untreated sleep apnoea are three times more likely to have a stroke.

And cancer

One of the more surprising recent research findings is sleep apnoea’s influence on cancer risk. Researchers really weren’t expecting to find this because we’d always thought sleep apnoea mainly influenced heart disease.

The families of people with sleep apnoea often complain of their snoring, gasping, and choking noises. Joshua Hayworth/Flickr, CC BY-SA

But in study after study from around the world we’ve seen that sleep apnoea increases the risk of cancer as well. And this association is not explained by other known cancer risks.

At this stage, we don’t think sleep apnoea causes cells to become cancerous. It might be that if you have a few cancer cells in your body, the constant up and down of oxygen levels in your blood while you sleep causes those cells to grow more quickly. So instead of having a cancer that you never even realise you have or a slow-growing one, you get a faster growing and more aggressive version.

It’s yet to be confirmed but melanomas are thought to be particularly likely to proliferate quickly when you have sleep apnoea.

Some good news

Being the harbinger of bad news isn’t much fun so I’d like to give you some good news now. If you’ve only got mild sleep apnoea, or you just snore a bit, you probably don’t have an increased risk of illness.

In fact, if you have mild sleep apnoea, you might be able to manage your risk quite effectively with dietary changes, which will improve your overall heath and stop you from developing a more severe version of the condition.

If you’ve got severe sleep apnoea, it’s really serious but still treatable, so it’s time to see a sleep doctor and get something done about it. More good news: if you do have severe sleep apnoea and you get it treated, your risk is much, much lower.

What all this adds up to is that sleep apnoea needs to be taken seriously; it’s not just a nuisance snoring condition. Not only will treatment help make you feel better, it will also reduce your risk for all kinds of attendant bad things from happening.

Hormone Replacement Therapy HRT Does NOT Cause Breast Cancer

Hormone Replacement Therapy HRT Does NOT Cause Breast Cancer

Horse Premarin estrogen WHI Jeffrey DachHormone Replacement Therapy HRT Does NOT Cause Breast Cancer, New Study

by Jeffrey Dach MD

In March 2012, a new study concluded that hormone replacement (HRT) with estrogen DOES NOT INCREASE RISK for breast cancer.  This report appeared in Lancet Oncology and provided data on the 11.8 year follow up on the  Women’s Heath Initiative Study which was originally published in JAMA in 2004. (1-4)

The Original 2004 WHI Report – 6.8 years of Follow Up

The original WHI study (second arm) enrolled about 10,000 women after hysterectomy.  Half were given placebo, and the other half were given Premarin ( a horse estrogen) Premarin is also called CEE for Conjugated Equine Estrogen.

23% Less Breast Cancer

The original report in JAMA 2004 included 6.8 years of follow up showing  23% less invasive breast cancer in the Premarin treated group (also called CEE) compared to placebo group . There were  94 breast cancer cases in the estrogen hormone group (CEE) and  124 cases of breast cancer in the placebo group.

Less Heart Disease- Less Hip Fracture

In addition, there was 9% less heart disease, and 39% less hip fracture in the estrogen hormone treated group.

Problems With Blood Clots

The Premarin pill caused increased clotting (hypercoagulable state) resulting in increased stroke and pulmonary embolus in the Premarin Pill users, which caused early termination of the study.  This is one reason why topical estrogen is preferable to pill form estrogen.  Topical delivery of estradiol (bioidentical estrogen) does not cause increased coagulability, does not increase risk for CVA or stroke, is safer and the preferred delivery route.

11.8 years of Follow Up on the WHI Women – Still 23% Reduction

The original WHI group of women were followed for an additional 6 years, for a total of 11.8 years of follow up, and this data was reported in Lancet Oncology by Garnet L Anderson PhD, and Rowan T Chlebowski (3,4).

Here is what they found:

After 11.8 years of follow up, the Premarin (horse estrogen) had 151 cases of invasive breast cancer and the placebo group had 199 cases.  This represents a 23% reduction in breast cancer in the hormone treated group. This was statistically significant. (P=.02) See below data chart (blue circle) for Figure 5 of the JAMA article.

Estrogen Group Had 63% Reduction in Mortality From Breast Cancer

In addition, in the estrogen hormone treated group, there was a 63% per cent reduction in death from breast cancer.  16 women died from invasive breast cancer in the placebo group,  compared to only 6 in the hormone treated group.

Figure 5. Data Page from JAMA Study (click on image to enlarge):

Fig 5_Data PAge WHI 11 Year Follow up JAMA Jeffrey Dach MD joc15023f5

The above image courtesy of Fig 5 Data Page for the 2011 JAMA report for the estrogen only WHI second arm.  All age groups had a 23 % reduction in breast cancer (blue circle).

Editorial by Howell and Cuzick

In an editorial in the same issue of Lancet Oncology, the Drs Anthony Howell and Jack Cuzick review the findings and conclude that the benefits of estrogen HRT include:

1) reduced risk of coronary artery disease and reduced risk of heart attacks

2) Reduced Risk of All Cause Mortality with improved survival numbers in the hormone treated group.

3) They advise women to avoid PremPro (the combined HRT pill ) which adds in a synthetic progestin, as the synthetic progestin IS associated with increased breast cancer.

Here is the quote fromDrs Anthony Howell and Jack Cuzick:

Young women (50—59 years) taking oestrogen were significantly less likely to have coronary heart disease, myocardial infarction, and death from all causes, not only with respect to older women but also placebo controls of the same age. Observational and WHI studies agree on the increased risk of breast cancer with combined hormone replacement therapy (including a progestin). “…. “The WHI investigators should be congratulated for providing insight into the value of conjugated equine oestrogens and young women can be reassured of the low risks and potentially striking benefits,”

Chemical structure of Premarin (left) compared to Human Bioidentical Estrogen (right) courtesy of wikimedia commons:

PremarinEquilnConjugatedEquineEstrogenHorseEstradiolBioidenticalHormone

Above Left Image: Equilin – Premarin (Horse estrogen CEE) Above Right Image:Human Estradiol

The NIH Should Study Human Bioidentical Estradiol and Progesterone

The WHI study showing the Estrogen reduces risk of breast cancer, reduces heart disease, reduces risk of hip fracture, and other and health benefits was done with Premarin, a horse estrogen.

You might ask the obvious question, “Why Did The Study Not Use Estradiol”, which is a human hormone (a bioidentical hormone)?   Why use estrogen from a horse when human estradiol in available?   The answer is obvious.  The NIH is a branch of the government and the government is controlled by the Pharmaceutical industry which makes Premarin.  We need the NIH to do studies for the benefit of the people, not the drug industry.  We need to repeat the WHI study using estradiol and progesterone, and never again victimize women with the carcinogenic PremPro pill ( Premarin and Provera) which was shown to cause breast cancer and heart disease.

Bioidentical Hormones Are Safe and Do Not increase Risk of Breast Cancer

In retrospect, the Lancet Oncology findings have been known for decades.  Bioidentical Hormone users are healthier and live longer than non-hormone users.  Bioidentical Hormones do not cause increased breast cancer risk, and are associated with all the health benefits shown in the Women’s Health Initiative (second arm) for women using estrogen alone.  Premarin is not human, but it is natural. A much more better HRT program is the combination of human bioidentical estrogen available as Bi-Est (Estradiol and Estriol), with the addition of Progesterone a human bioidentical hormone.  This is the program we use in our office.

Articles with related interest:

The Safety of Bio-Identical Hormones

The Importance of BioIdentical Hormones

Bioidentical Hormones Prevent Arthritis

Bioidentical Hormone Estrogen Prevents Heart Disease

Morning Rounds With Steven Economou MD

Waking Up from the Synthetic Hormone Nightmare

Jeffrey Dach MD
7450 Griffin Road Suite 190
Davie, Florida 33314
954-792-4663
http://www.jeffreydach.com/
http://www.drdach.com/
http://www.naturalmedicine101.com/
http://www.truemedmd.com/
http://www.bioidenticalhormones101.com/

Links and References:

2011 WHI Follow Up Study shows less breast cancer in homone users.

1) jama.ama-assn.org/content/305/13/1305.abstract
JAMA. 2011;305(13):1305-1314. Health Outcomes After Stopping Conjugated Equine Estrogens Among Postmenopausal Women With Prior Hysterectomy A Randomized Controlled Trial Andrea Z. LaCroix, PhD; Rowan T. Chlebowski, MD, PhD;et al for the WHI Investigators

Over the entire follow-up, lower breast cancer incidence in the CEE group persisted and was 0.27% compared with 0.35% in the placebo group (HR, 0.77; 95% CI, 0.62-0.95).

Original 2004 JAMA Report of Second Arm WHI

1A) http://jama.ama-assn.org/content/291/14/1701.full
JAMA. 2004;291(14):1701-1712.
Effects of Conjugated Equine Estrogen in Postmenopausal Women With Hysterectomy
The Women’s Health Initiative Randomized Controlled Trial ,The Women’s Health Initiative Steering Committee* by Garnet L. Anderson, PhD, WHI Clinical Coordinating Center, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, M3-A410, Box 19024, Seattle, WA 98109

5200 women CEE, 5200 placebo, with 7 year follow up

Cancer. Invasive breast cancer,
23% lower rate in the CEE group than in the placebo group (26 vs 33 per 10 000 person-years)
94 CEE   124 placebo and this comparison narrowly missed statistical significance (P = .06).

Results  CEE vs placebo (average follow-up 6.8 years):
CHD, 0.91 (0.75-1.12) with 376 cases;
breast cancer, 0.77 (0.59-1.01) with 218 cases; (94 CEE and  124 placebo)
stroke, 1.39 (1.10-1.77) with 276 cases;
PE, 1.34 (0.87-2.06) with 85 cases;
colorectal cancer, 1.08 (0.75-1.55) with 119 cases; and
hip fracture, 0.61 (0.41-0.91) with 102 cases.

————————————————————–

Editorial JAMA

2) jama.ama-assn.org/content/305/13/1354.full
Editorial – JAMA. 2011;305(13):1354-1355.

Short-term Use of Unopposed Estrogen A Balance of Inferred Risks and Benefits by Emily S. Jungheim, MD, MSCI; Graham A. Colditz, MD, DrPH

Idiotic statement – the previously quoted studies used progestins.

“the reduced incidence of breast cancer persisted. This finding is inconsistent with a longstanding, corroborated body of evidence  7,8? and raises the possibility that other important factors modify documented risks and benefits of estrogen therapy among these long-term WHI participants. ”

WHI Follow Study Lancet Oncology

3) www.thelancet.com/journals/lanonc/article/PIIS1470-2045%2812%2970075-X/abstract

The Lancet Oncology, Early Online Publication, 7 March 2012

Conjugated equine oestrogen and breast cancer incidence and mortality in postmenopausal women with hysterectomy: extended follow-up of the Women’s Health Initiative randomised placebo-controlled trial

Prof Garnet L Anderson PhD, Prof Rowan T Chlebowski MD b, Aaron K Aragaki MS a, Prof Lewis H Kuller MD c, Prof JoAnn E Manson MD d, Prof Margery Gass MD e, Elizabeth Bluhm MD f, Prof Stephanie Connelly MD g, Prof F Allan Hubbell MD h, Prof Dorothy Lane MD i, Lisa Martin MD j, Prof Judith Ockene PhD k, Prof Thomas Rohan MBBS l, Prof Robert Schenken MD m, Prof Jean Wactawski-Wende PhD

Methods Between 1993 and 1998, the WHI enrolled 10,739 postmenopausal women from 40 US clinical centres into a randomised, double-masked, placebo-controlled trial. Women aged 50—79 years who had undergone hysterectomy and had expected 3-year survival and mammography clearance were randomly allocated by a computerised, permuted block algorithm, stratified by age group and centre, to receive oral conjugated equine oestrogen (0·625 mg per day; n=5310) or matched placebo (n=5429). The trial intervention was terminated early on Feb 29, 2004, because of an adverse effect on stroke.

(It is well known that oral estrogen pills cause hypercoagulable state and increased  stroke risk)

Follow-up continued until planned termination (March 31, 2005). Consent was sought for extended surveillance from the 9786 living participants in active follow-up, of whom 7645 agreed. Using data from this extended follow-up (to Aug 14, 2009), we assessed long-term effects of oestrogen use on invasive breast cancer incidence, tumour characteristics, and mortality. We used Cox regression models to estimate hazard ratios (HRs) in the intention-to-treat population.

Findings: After a median follow-up of 11·8 years (IQR 9·1—12·9), the use of oestrogen for a median of5·9 years (2·5—7·3) was associated with lower incidence of invasive breast cancer (151 cases, 0·27% per year) compared with placebo (199 cases, 0·35% per year; HR 0·77, 95% CI 0·62—0·95; p=0·02) with no difference (p=0·76) between intervention phase (0·79, 0·61—1·02) and post-intervention phase effects (0·75, 0·51—1·09).

In subgroup analyses, we noted breast cancer risk reduction with oestrogen use was concentrated in women without benign breast disease (p=0·01) or a family history of breast cancer (p=0·02).

In the oestrogen group, fewer women died from breast cancer (six deaths, 0·009% per year) compared with controls (16 deaths, 0·024% per year; HR 0·37, 95% CI 0·13—0·91; p=0·03).

Fewer women in the oestrogen group died from any cause after a breast cancer diagnosis (30 deaths, 0·046% per year) than did controls (50 deaths, 0·076%; HR 0·62, 95% CI 0·39—0·97; p=0·04).

Interpretation

Our findings provide reassurance for women with hysterectomy seeking relief of climacteric symptoms in terms of the effects of oestrogen use for about 5 years on breast cancer incidence and mortality. However, our data do not support use of oestrogen for breast cancer risk reduction because any noted benefit probably does not apply to populations at increased risk of such cancer.

Editorial in Lancet  Oncology MArch 2012

4) www.lancet.com/journals/lanonc/article/PIIS1470-2045%2812%2970110-9/fulltext?_eventId=login

The Lancet Oncology, Early Online Publication, 7 March 2012

Oestrogen and breast cancer: results from the WHI trial by Anthony Howell and  Jack Cuzick

Young women (50—59 years) taking oestrogen were significantly less likely to have coronary heart disease, myocardial infarction, and death from all causes, not only with respect to older women but also placebo controls of the same age. Observational and WHI studies agree on the increased risk of breast cancer with combined hormone replacement therapy (including a progestin). 

“The WHI investigators should be congratulated for providing insight into the value of conjugated equine oestrogens and young women can be reassured of the low risks and potentially striking benefits,”

—————————————

News Media  –   LA Times

5) www.latimes.com/health/la-he-estrogen-breast-cancer-20120307,0,1238385.story

Estrogen taken alone is linked to lower breast cancer risk by By Shari Roan, Los Angeles Times March 7, 2012

An analysis finds that women who took the hormone by itself after menopause had a reduced risk of developing breast cancer. ”’ Dr. Rowan T. Chlebowski, an investigator at the Los Angeles Biomedical Research Institute in Torrance and chief of medical oncology and hematology at Harbor-UCLA Medical Center.said : ”

Estrogen alone for the period we studied seems to be pretty safe and maybe even beneficial.” Researchers followed 7,645 women from the original group of almost 11,000 participants for almost five years to see what happened to them after stopping estrogen therapy. The study found that women who took estrogen had a 23% reduced risk of breast cancer compared with those who took a placebo. Among the women who did develop breast cancer, those who took estrogen had a 63% reduced risk of dying from the disease compared with those who took a placebo.

———————————-
Internal Medicine News
6)
www.internalmedicinenews.com/specialty-focus/oncology-hematology/single-article-page/estrogen-protects-against-breast-cancer-long-after-treatment.html

Estrogen Protects Against Breast Cancer Long After Treatment By: MARY ANN MOON, Internal Medicine News Digital Network |

MedicalXpress  News

7) (link removed)

Estrogen-only HRT continues to protect women against breast cancer long after they have stopped March 6, 2012 in Cancer

Women who use the oestrogen-only form of hormone replacement therapy (HRT) appear less likely to develop breast cancer in the longer term, according to new research published Online First in The Lancet Oncology. A follow-up study of over 7500 women from the Women’s Health Initiative (WHI) trial who took oestrogen for about 6 years and then stopped has found that they are over 20% less likely to develop breast cancer and remain significantly less likely to die from the disease than those who never used HRT, a period of nearly 5 years after stopping treatment.

New York Times

8) well.blogs.nytimes.com/2011/04/05/estrogen-lowers-risk-of-heart-attack-and-breast-cancer-in-some/
Estrogen Lowers Breast Cancer and Heart Attack Risk in Some By TARA PARKER-POPE April 5, 2011,

Dr. Chlebowski previously led research that showed cancer risks associated with combination hormone therapy, but he says the new data on estrogen alone show that in certain women, estrogen use to relieve menopausal symptoms is a “good choice.”

CBS News

9)  www.cbsnews.com/8301-504763_162-57392262-10391704/estrogen-pills-reduce-breast-cancer-risk-in-study-of-menopausal-women/

Estrogen pills reduce breast cancer risk in study of menopausal women By CBS News Staff “Estrogen on its own appears to be safe,” said Dr. Anthony Howell, professor of medical oncology at the University of Manchester, who co-authored a commentary in the same issue.

10) www.suzannesomers.com/Blog/post/My-Response-to-New-York-Times-Blog-by-Tara-Pope.aspx

My Response to New York Times Article by Tara Pope by Suzanne Somers 4/6/2011

This is my response to Tara Pope’s article yesterday in the New York Times. I have no idea if they will print my letter but I thought you’d like my perspective. Her article follows my response. Ms. Pope ignores the existence of biodidentical hormone replacement therapy.

11) www.huffingtonpost.com/2012/03/07/estrogen-breast-cancer_n_1326626.html Estrogen Lowers Breast Cancer Risk In Some Women By MARIA CHENG 03/ 6/12

www.drugs.com/news/estrogen-only-therapy-may-reduce-breast-cancer-risk-36841.html

Estrogen-Only Therapy May Reduce Breast Cancer Risk TUESDAY March 6, 2012 — Some women who take estrogen-only hormone replacement therapy to stave off hot flashes, night sweats and other symptoms of menopause may be at lower risk for developing breast cancer down the road, a news study says.

12) kwgn.com/2012/03/08/study-estrogen-treatment-may-protect-against-breast-cancer-5/

Study: Estrogen treatment may protect against breast cancer Posted on: March 8, 2012, by Nina Sparano, DENVER — Estrogen, a hormone known to fuel breast cancer, may actually protect against the disease. According to a new study women taking Hormone Replacement Therapy (HRT) are more than 20-percent less likely to develop breast cancer and had a reduced risk of dying from the disease.

More than 7,600 women taking HRT were studied. Women who took estrogen-only for six years and then stopped taking the hormone showed the reduced risk. The new study, published in the journal Lancet Oncology, provides the strongest evidence yet that estrogen alone not only lowers breast cancer risk for a sustained time for some women but curbs the chances of dying from the disease.

13) Broken link removed

14) www.mnn.com/health/fitness-well-being/stories/breast-cancer-risk-reduced-by-estrogen-only-hormone-replacement-th

Breast cancer risk reduced by estrogen-only hormone replacement therapy  By Rachael Rettner, MyHealthNewsDailyTue, Mar 06 2012

15) www.cancernews.us/2012/03/estrogen-therapy-helps-reduce-breast.html

Friday, March 9, 2012 Estrogen therapy helps reduce breast cancer risk in some patients Dr Susan Love

16) blog.dslrf.org/?p=497 Estrogen and Breast Cancer: It’s Complicated! The conventional wisdom is that estrogen causes breast cancer.

17) www.webmd.com/breast-cancer/news/20120306/estrogen-after-hysterectomy-lowers-cancer-risk

Estrogen After Hysterectomy Lowers Cancer Risk? Experts Say the Decision to Use Hormone Replacement Is a Still Complicated One By Brenda Goodman, MA WebMD Health News

Compared to women taking a placebo, women who took estrogen had a 23% reduced risk of invasive breast cancer. That means 151 women got breast cancer in the estrogen group compared to 199 women assigned to the placebo. Women taking estrogen also had a 63% reduced risk of dying from breast cancer compared to women on the placebo. Overall, there were six deaths in the estrogen group compared to 16 in the placebo group.

———————————–

studies which show that estrogen causes breast cancer (????) They included progestin use which DOES CAUSE breast cancer….

18) http://www.ncbi.nlm.nih.gov/pubmed/10213546
Lancet. 1997 Oct 11;350(9084):1047-59.

Collaborative Group on Hormonal Factors in Breast Cancer .
Breast cancer and hormone replacement therapy: collaborative reanalysis of data from 51 epidemiological studies of 52,705 women with breast cancer and 108,411 women without breast cancer. Lancet. 1997;350(9084):1047–1059. (They used HRT which included synthetic progestins)

19) jama.ama-assn.org/content/265/15/1985.abstract?ijkey=06f571a5446b23abb354db5b6d9ca9c885a60cef&keytype2=tf_ipsecsha

A meta-analysis of the effect of estrogen replacement therapy on the risk of breast cancer. Steinberg KK ,Thacker SB, Smith SJ,et al The increase in risk was largely due to results of studies that included premenopausal women or women using estradiol (with or without progestin), studies for which the estimated relative risk was 2.2 (CI, 1.4 to 3.4) after 15 years. (Again progestins were included)

Million Women Study

20) jnci.oxfordjournals.org/content/103/4/296.full
Breast Cancer Risk in Relation to the Interval Between Menopause and Starting Hormone Therapy by Valerie Beral, Gillian Reeves, Diana Bull, Jane Green and for the Million Women Study JNCI J Natl Cancer Inst (2011) 103 (4): 296-305.

Among current users of estrogen-only formulations, there was little or no increase in risk if use began 5 years or more after menopause (RR = 1.05, Breast cancer risk was statistically significantly increased in users of estrogen-only hormonal therapy if use began before or less than 5 years after menopause (RR = 1.43, 95% CI = 1.35 to 1.51, P < .001), whereas if such use began 5 years or more after menopause, breast cancer risk was not increased (RR = 1.05, 95% CI = 0.89 to 1.24, P = .6). among current users of estrogen–progestin formulations (RR = 1.53 )

—————————————————-
WHI First ARM – PREMPRO
Estrogen (premarin) plus Progestin (Provera –PremPro DOES CAUSE BREAST CANCER

21) http://win.menopausaitaliana.it/Chlebowski 3243 JAMA.pdf

http://jama.ama-assn.org/content/289/24/3243.short

JAMA. 2003;289(24):3243-3253

Influence of Estrogen Plus Progestin on Breast Cancer and Mammography in Healthy Postmenopausal Women – The Women’s Health Initiative Randomized Trial
by   Rowan T. Chlebowski, MD, PhD; et al      for the WHI Investigators

Main Outcome Measures  Breast cancer number and characteristics, and frequency of abnormal mammograms by estrogen plus progestin exposure.

Results  In intent-to-treat analyses, estrogen plus progestin increased total (245 vs 185 cases; hazard ratio [HR], 1.24; weighted P<.001) and invasive (199 vs 150 cases; HR, 1.24; weighted P = .003) breast cancers compared with placebo.

The invasive breast cancers diagnosed in the estrogen plus progestin group were similar in histology and grade but were larger (mean [SD], 1.7 cm [1.1] vs 1.5 cm [0.9], respectively; P = .04) and were at more advanced stage (regional/metastatic 25.4% vs 16.0%, respectively; P = .04) compared with those diagnosed in the placebo group.

After 1 year, the percentage of women with abnormal mammograms was substantially greater in the estrogen plus progestin group (716 [9.4%] of 7656) compared with placebo group (398 [5.4%] of 7310; P<.001), a pattern which continued for the study duration.

Conclusions  Relatively short-term combined estrogen plus progestin use increases incident breast cancers, which are diagnosed at a more advanced stage compared with placebo use, and also substantially increases the percentage of women with abnormal mammograms. These results suggest estrogen plus progestin may stimulate breast cancer growth and hinder breast cancer diagnosis.

———————————————————–

22) www.youtube.com/watch?v=ze2Y742NTSo

2010 SABCS Interview with Rowan T. Chlebowski, M.D., Ph.D. discusses WHI Data

23)  www.youtube.com/watch?v=0APKwNLC3Bk
laura esserman breast cancer video sept 2011 mammography screening how can it help and what are its limitations. key is cancer biology. Beast cancer is not one disease

Jeffrey Dach MD
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Why is it so hard to trust science?

I believe in science, because I like to use things that are proven to work and are safe. For example, I would not have an operation without an anaesthetic, or refuse an antibiotic for pneumonia. So why are so many people antiscience, and perfer quackery instead?

Joel Achenbach: Why is it so hard to trust science?

Stacey Innerst/Special Contributor

There’s a scene in Stanley Kubrick’s comic masterpiece Dr. Strangelove in which Jack D. Ripper, an American general who’s gone rogue and ordered a nuclear attack on the Soviet Union, unspools his paranoid worldview — and the explanation for why he drinks “only distilled water, or rainwater, and only pure grain alcohol” — to Lionel Mandrake, a dizzy-with-anxiety group captain in the Royal Air Force.

Ripper: “Have you ever heard of a thing called fluoridation? Fluoridation of water?”

Mandrake: “Ah, yes, I have heard of that, Jack. Yes, yes.”

Ripper: “Well, do you know what it is?”

Mandrake: “No. No, I don’t know what it is, no.”

Ripper: “Do you realize that fluoridation is the most monstrously conceived and dangerous communist plot we have ever had to face?”

The movie came out in 1964, by which time the health benefits of fluoridation had been thoroughly established and anti-fluoridation conspiracy theories could be the stuff of comedy. Yet half a century later, fluoridation continues to incite fear and paranoia. In 2013, residents of Portland, Ore., one of only a few major American cities that don’t fluoridate, blocked a plan to do so. Opponents didn’t like the idea of the government adding “chemicals” to their water. They claimed that fluoride could be harmful to human health.

Actually fluoride is a natural mineral that, in the weak concentrations used in public drinking-water systems, hardens tooth enamel and prevents tooth decay — a cheap and safe way to improve dental health for everyone, rich or poor, conscientious brushers or not. That’s the scientific and medical consensus.

To which some people in Portland, echoing anti-fluoridation activists around the world, reply: We don’t believe you.

We live in an age when all manner of scientific knowledge — from the safety of fluoride and vaccines to the reality of climate change — faces organized and often furious opposition. Empowered by their own sources of information and their own interpretations of research, doubters have declared war on the consensus of experts. There are so many of these controversies these days, you’d think a diabolical agency had put something in the water to make people argumentative.

Science doubt has become a pop-culture meme. In the recent movie Interstellar, set in a futuristic, downtrodden America where NASA has been forced into hiding, school textbooks say the Apollo moon landings were faked.

In a sense this is not surprising. Our lives are permeated by science and technology as never before. For many of us, this new world is wondrous, comfortable and rich in rewards — but also more complicated and sometimes unnerving. We now face risks we can’t easily analyze.

We’re asked to accept, for example, that it’s safe to eat food containing genetically modified organisms because, the experts point out, there’s no evidence that it isn’t and no reason to believe that altering genes precisely in a lab is more dangerous than altering them wholesale through traditional breeding. But to some people, the very idea of transferring genes between species conjures up mad scientists running amok — and so, two centuries after Mary Shelley wrote Frankenstein, they talk about Frankenfood.

The world crackles with real and imaginary hazards, and distinguishing the former from the latter isn’t easy. Should we be afraid that the Ebola virus, which is spread only by direct contact with bodily fluids, will mutate into an airborne superplague? The scientific consensus says that’s extremely unlikely: No virus has ever been observed to completely change its mode of transmission in humans, and there’s zero evidence that the latest strain of Ebola is any different. But type “airborne Ebola” into an Internet search engine, and you’ll enter a dystopia where this virus has almost supernatural powers, including the power to kill us all.

In this bewildering world, we have to decide what to believe and how to act on that. In principle, that’s what science is for. “Science is not a body of facts,” says geophysicist Marcia McNutt, who once headed the U.S. Geological Survey and is now editor of Science, the prestigious journal. “Science is a method for deciding whether what we choose to believe has a basis in the laws of nature or not.”

The scientific method leads us to truths that are less than self-evident, often mind-blowing and sometimes hard to swallow. In the early 17th century, when Galileo claimed that the Earth spins on its axis and orbits the sun, he wasn’t just rejecting church doctrine. He was asking people to believe something that defied common sense — because it sure looks like the sun’s going around the Earth, and you can’t feel the Earth spinning. Galileo was put on trial and forced to recant.

Two centuries later, Charles Darwin escaped that fate. But his idea that all life on Earth evolved from a primordial ancestor and that we humans are distant cousins of apes, whales and even deep-sea mollusks is still a big ask for a lot of people.

Even when we intellectually accept these precepts of science, we subconsciously cling to our intuitions — what researchers call our naive beliefs. A study by Andrew Shtulman of Occidental College showed that even students with an advanced science education had a hitch in their mental gait when asked to affirm or deny that humans are descended from sea animals and that the Earth goes around the sun. Both truths are counterintuitive. The students, even those who correctly marked “true,” were slower to answer those questions than questions about whether humans are descended from tree-dwelling creatures (also true but easier to grasp) and whether the moon goes around the Earth (also true but intuitive).

Shtulman’s research indicates that as we become scientifically literate, we repress our naive beliefs but never eliminate them entirely. They nest in our brains, chirping at us as we try to make sense of the world.

Most of us do that by relying on personal experience and anecdotes, on stories rather than statistics. We might get a prostate-specific antigen test, even though it’s no longer generally recommended, because it caught a close friend’s cancer — and we pay less attention to statistical evidence, painstakingly compiled through multiple studies, showing that the test rarely saves lives but triggers many unnecessary surgeries.

Even for scientists, the scientific method is a hard discipline. They, too, are vulnerable to confirmation bias — the tendency to look for and see only evidence that confirms what they already believe. But unlike the rest of us, they submit their ideas to formal peer review before publishing them. Once the results are published, if they’re important enough, other scientists will try to reproduce them — and, being congenitally skeptical and competitive, will be very happy to announce that they don’t hold up. Scientific results are always provisional, susceptible to being overturned by some future experiment or observation. Scientists rarely proclaim an absolute truth or an absolute certainty. Uncertainty is inevitable at the frontiers of knowledge.

That provisional quality of science is another thing a lot of people have trouble with. To some climate-change skeptics, for example, the fact that a few scientists in the 1970s were worried about the possibility of a coming ice age is enough to discredit what is now the consensus of the world’s scientists: The planet’s surface temperature has risen by about 1.5 degrees in the past 130 years, and human actions, including the burning of fossil fuels, are extremely likely to have been the dominant cause since the mid-20th century.

It’s clear that organizations funded in part by the fossil fuel industry have deliberately tried to undermine the public’s understanding of the scientific consensus by promoting a few skeptics. The news media gives abundant attention to such mavericks, naysayers, professional controversialists and table thumpers. The media would also have you believe that science is full of shocking discoveries made by lone geniuses. Not so. The boring truth is that science usually advances incrementally, through the steady accretion of data and insights gathered by many people over many years. So it has with the consensus on climate change. That’s not about to go poof with the next thermometer reading.

But industry PR, however misleading, isn’t enough to explain why so many people reject the scientific consensus on global warming.

The “science communication problem,” as it’s blandly called by the scientists who study it, has yielded abundant new research into how people decide what to believe — and why they so often don’t accept the expert consensus. It’s not that they can’t grasp it, according to Dan Kahan of Yale University. In one study, he asked 1,540 Americans, a representative sample, to rate the threat of climate change on a scale of zero to 10. Then he correlated that with the subjects’ science literacy. He found that higher literacy was associated with stronger views — at both ends of the spectrum. Science literacy promoted polarization on climate, not consensus. According to Kahan, that’s because people tend to use scientific knowledge to reinforce their worldviews.

Americans fall into two basic camps, Kahan says. Those with a more “egalitarian” and “communitarian” mindset are generally suspicious of industry and apt to think it’s up to something dangerous that calls for government regulation; they’re likely to see the risks of climate change. In contrast, people with a “hierarchical” and “individualistic” mindset respect leaders of industry and don’t like government interfering in their affairs; they’re apt to reject warnings about climate change because they know what accepting them could lead to — some kind of tax or regulation to limit emissions.

In the U.S., climate change has become a litmus test that identifies you as belonging to one or the other of these two antagonistic tribes. When we argue about it, Kahan says, we’re actually arguing about who we are, what our crowd is. We’re thinking: People like us believe this. People like that do not believe this.

Science appeals to our rational brain, but our beliefs are motivated largely by emotion, and the biggest motivation is remaining tight with our peers. “We’re all in high school. We’ve never left high school,” says McNutt. “People still have a need to fit in, and that need to fit in is so strong that local values and local opinions are always trumping science. And they will continue to trump science, especially when there is no clear downside to ignoring science.”

Meanwhile, the Internet makes it easier than ever for science doubters to find their own information and experts. Gone are the days when a small number of powerful institutions — elite universities, encyclopedias and major news organizations — served as gatekeepers of scientific information. The Internet has democratized it, which is a good thing. But along with cable TV, the Web has also made it possible to live in a “filter bubble” that lets in only the information with which you already agree.

How to penetrate the bubble? How to convert science skeptics? Throwing more facts at them doesn’t help. Liz Neeley, who helps train scientists to be better communicators at an organization called Compass, says people need to hear from believers they can trust, who share their fundamental values.

She has personal experience with this. Her father is a climate-change skeptic and gets most of his information from conservative media. In exasperation, she finally confronted him: “Do you believe them or me?” She told him she believes the scientists who research climate change and knows many of them personally. “If you think I’m wrong,” she said, “then you’re telling me that you don’t trust me.” Her father’s stance on the issue softened. But it wasn’t the facts that did it.

If you’re a rationalist, there’s something a little dispiriting about all this. In Kahan’s descriptions of how we decide what to believe, what we decide sometimes sounds almost incidental. Those of us in the science communication business are as tribal as anyone else, he told me. We believe in scientific ideas not because we have truly evaluated all the evidence but because we feel an affinity for the scientific community. When I mentioned to Kahan that I fully accept evolution, he said: “Believing in evolution is just a description about you. It’s not an account of how you reason.”

Maybe — except that evolution is real. Biology is incomprehensible without it. There aren’t really two sides to all these issues. Climate change is happening. Vaccines save lives. Being right does matter — and the science tribe has a long track record of getting things right in the end. Modern society is built on things it got right.

Doubting science also has consequences, as seen in recent weeks with the measles outbreak. The people who believe that vaccines cause autism — often well-educated and affluent, by the way — are undermining “herd immunity” to such diseases as whooping cough and measles. The anti-vaccine movement has been going strong since a prestigious British medical journal, the Lancet, published a study in 1998 linking a common vaccine to autism. The journal later retracted the study, which was thoroughly discredited. But the notion of a vaccine-autism connection has been endorsed by celebrities and reinforced through the usual Internet filters.

In the climate debate, the consequences of doubt are likely to be global and enduring. Climate-change skeptics in the U.S. have achieved their fundamental goal of halting legislative action to combat global warming. They haven’t had to win the debate on the merits; they’ve merely had to fog the room enough to keep laws governing greenhouse gas emissions from being enacted.

Some environmental activists want scientists to emerge from their ivory towers and get more involved in the policy battles. Any scientist going that route needs to do so carefully, says Liz Neeley. “That line between science communication and advocacy is very hard to step back from,” she says. In the debate over climate change, the central allegation of the skeptics is that the science saying it’s real and a serious threat is politically tinged, driven by environmental activism and not hard data. That’s not true, and it slanders honest scientists. But the claim becomes more likely to be seen as plausible if scientists go beyond their professional expertise and begin advocating specific policies.

It’s their very detachment, what you might call the cold-bloodedness of science, that makes science the killer app. It’s the way science tells us the truth rather than what we’d like the truth to be. Scientists can be as dogmatic as anyone else — but their dogma is always wilting in the hot glare of new research. In science it’s not a sin to change your mind when the evidence demands it. For some people, the tribe is more important than the truth; for the best scientists, the truth is more important than the tribe.

Joel Achenbach is a science reporter for The Washington Post. His email address is joel.achenbach

@washpost.com. A version of this essay appears in National Geographic’s March issue.

To Lose Weight, Eating Less Is Far More Important Than Exercising More

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People working out on Manhattan’s Lower East Side last week. Exercise is beneficial for numerous reasons, but it’s not the best way to lose weight, many studies have shown. CreditTodd Heisler/The New York Times

One of my family’s favorite shows is “The Biggest Loser.” Although some viewers don’t appreciate how it pushes people so hard to lose weight, the show probably inspires some overweight people to regain control of their lives.

But one of the most frustrating parts of the show, at least for me, is its overwhelming emphasis on exercise. Because when it comes to reaching a healthy weight, what you don’t eat is much, much more important.

Think about it this way: If an overweight man is consuming 1,000 more calories than he is burning and wants to be in energy balance, he can do it by exercising. But exercise consumes far fewer calories than many people think. Thirty minutes of jogging or swimming laps might burn off 350 calories. Many people, fat or fit, can’t keep up a strenuous 30-minute exercise regimen, day in and day out. They might exercise a few times a week, if that.

Or they could achieve the same calorie reduction by eliminating two 16-ounce sodas each day.

Proclamations that people need to be more active are ubiquitous in the media. The importance of exercise for proper weight management is reinforced when people bemoan the loss of gym class in schools as a cause of the obesity epidemic. Michelle Obama’s Let’s Move program places the focus on exercise as a critical component in combating excess weight andobesity.

Exercise has many benefits, but there are problems with relying on it to control weight. First, it’s just not true that Americans, in general, aren’t listening to calls for more activity. From 2001 to 2009, the percentage of people who were sufficiently physically active increased. But so did the percentage of Americans who were obese. The former did not prevent the latter.

Studies confirm this finding. A 2011 meta-analysis, a study of studies, looked at the relationship between physical activity and fat mass in children, and found that being active is probably not the key determinant in whether a child is at an unhealthy weight. In the adult population, interventional studies have difficulty showing that a physically active person is less likely to gain excess weight than a sedentary person. Further, studies of energy balance, and there are many of them, show that total energy expenditure and physical activity levels in developing and industrialized countries are similar, making activity and exercise unlikely to be the cause of differing obesity rates.

Moreover, exercise increases one’s appetite. After all, when you burn off calories being active, your body will often signal you to replace them. Research confirms this. A 2012 systematic review of studies that looked at how people complied with exercise programs showed that over time, people wound up burning less energy with exercise than predicted and also increasing their caloric intake.

Other metabolic changes can negate the expected weight loss benefits of exercise over the long term. When you lose weight, metabolism often slows. Many people believe that exercise can counter or even reverse that trend. Research, however, shows that the resting metabolic rate in all dieters slows significantly, regardless of whether they exercise. This is why weight loss, which might seem easy when you start, becomes harder over time.

This isn’t to say that exercise plays no role. There are many studies that show that adding exercise to diets can be beneficial. A 1999 reviewidentified three key meta-analyses and other randomized controlled trials that found statistically significant, but overall small, increases in weight loss with exercise.

A meta-analysis published last year found that, in the long term, behavioral weight management programs that combine exercise with diet can lead to more sustained weight loss (three to four pounds) over a year than diet alone. Over a six-month period, though, adding exercise made no difference. Another systematic review from last fall found similar results, with diet plus exercise performing better than diet alone, but without much of an absolute difference.

All of these interventions included dietary changes, and the added weight-loss benefit from activity was small. Far too many people, though, can manage to find an hour or more in their day to drive to the gym, exercise and then clean up afterward — but complain that there’s just no time to cook or prepare a healthful, home-cooked meal. If they would spend just half the time they do exercising trying to make a difference in the kitchen, they’d most likely see much better results.

Many people think of dieting as a drastic and rigid change, with a high risk of putting the pounds back on. What is more likely to succeed is gradual change, made in a much more sustainable way. I also don’t mean to make it seem that weight loss with diet is easy and exercise is hard. They’re both hard. The challenge of a slowing metabolism, and the desire to eat more, occurs in both cases, although dietary change still works better than exercise.

But I can’t say this enough: Exercise has a big upside for health beyond potential weight loss. Many studies and reviews detail how physical activity can improve outcomes in musculoskeletal disorders, cardiovascular disease, diabetes, pulmonary diseases, neurological diseases anddepression. The Academy of Medical Royal Colleges declared it a “miracle cure” recently, and while I’m usually loath to use that term for anything in medicine, a fairly large evidence base corroborates that exercise improves outcomes in many domains.

But that huge upside doesn’t seem to necessarily apply to weight loss. The data just don’t support it. Unfortunately, exercise seems to excite us much more than eating less does. After all, as a friend said to me recently, “The Biggest Loser” would be really boring if it were shot after shot of contestants just not overeating.