Monthly Archives: July 2017

HRT and blood clots

This study further adds to the evidence that it is how you take oestrogen, that can result in a blood clot. (VTE). Taken as a pill, it increases the chance of a clot. If taken transdermally (Cream, troche, patch) it does not increase the risk of a blood clot.
doi: 10.1097/GME.0000000000000611
Original Articles

Risk of venous thromboembolism associated with local and systemic use of hormone therapy in peri- and postmenopausal women and in relation to type and route of administration

Bergendal, Annica MD, PhD; Kieler, Helle MD, PhD; Sundström, Anders PhD; Hirschberg, Angelica Lindén MD, PhD; Kocoska-Maras, Ljiljana MD, PhD


Objective: The aim of the study was to assess the risk of venous thromboembolism (VTE) associated with systemic hormone therapy according to type and to route of administration and the risk of VTE associated with locally administered estrogen.

Methods: In this case-control study, conducted in Sweden between 2003 and 2009, we included 838 cases of VTE and 891 controls with a mean age of 55 years. Controls were matched by age to the cases and randomly selected from the population. We used logistic regression to calculate odds ratios (ORs) with 95% CIs and adjusted for smoking, body mass index, and immobilization.

Results: Current use of any hormone therapy was associated with an increased risk of VTE (OR 1.72, 95% CI 1.34-2.20). For estrogen in combination with progestogen the OR was 2.85 (95% CI 2.08-3.90), and for estrogen only the OR was 1.31 (95% CI 0.78-2.21). In orally administered estrogen combined with progestogen, the OR was slightly, but not significantly, higher among users of medroxyprogesterone acetate (OR 2.94, 95% CI 1.67-5.36) than among norethisterone acetate users (OR 2.55, 95% CI 1.50-3.40). Transdermal estrogen combined with progestogen was not associated with VTE risk (crude and imprecise ORs ranging from 0.87 to 1.16). For local effect of estrogen, there was no association with VTE risk (OR 0.69, 95% CI 0.43-1.10).

Conclusions: The risk of VTE risk is higher in users of systemic combined estrogen–progestogen treatment than in users of estrogen only. Furthermore, the risk of VTE was lower for women who used local estrogen than among those using oral estrogen only. Transdermal estrogen only treatment and estrogen for local effect seem not to be related to an increased risk of VTE.

Would you rather not know if you have an inherited, increased risk of cancer?

Would you rather not know if you have an inherited, increased risk of cancer?

I recently read an article of a personal account of a woman who was diagnosed with a BRCA gene mutation and the difficult decisions she now faces with having positive results.  A BRCA gene mutation can lead to increased risk of cancer, particularly breast or ovarian in women. Genetic testing for both BRCA or Lynch syndrome in Australia involves a simple collection of sputum.

This article that I read contained a number of lessons that could be of value to our readers.

1. If you will have a gene test you will get results. And with those results may come knowledge, but also more questions and uncertainty. It is a personal decision that should be made after you have talked to a medical professional experienced with BRCA or Lynch about what having the test means, potential benefits and consequences, and how you will cope with the results. Knowing the result may reduce any stress and anxiety that comes from not knowing in some patients; in other patients a test can cause anxiety.

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2. Results will give you a choice of actions. Risk-reducing surgery is effective, but may cause physical and emotional problems for some. To prevent gynaecological cancer, screening and prevention is ineffective; surgery virtually eliminates that risk. To reduce the breast cancer risk, options of surgery versus screening are available. Colonoscopies are also effective to reduce colon cancer mortality. With a positive result you can also make additional lifestyle changes to lower your risk, such as physical activity and a healthy diet.

3. Unfortunately, ovarian cancer screening is fraught with problems. A lot of cancers are not detected by the blood test CA125 because certain cell types (e.g., clear cell) do not produce CA125 and shed it into the blood stream. Ultrasound is also not reliable because small lesions that should be detected are frequently missed. On the other hand, harmless and non-canorous (normal) medical conditions will display a high CA125 count or come up as suspicious on ultrasound.

4. Half of BRCA carriers do not show a family history of cancer. This means that only testing those who have a family history of cancer would miss half of the true BRCA and Lynch carriers.

5. The BRCA test is only $400 in Australia at present (was up to $4,000 until recently).

7. Hormonal replacement after risk-reducing surgery is safe. If the uterus is preserved, HRT would require oestrogen plus progesterone. If the uterus is removed as part of risk-reducing surgery, only oestrogen, which is the safer of the two, needs to be supplemented.

8. Life is not a trial run. It’s real. In the end, there is no right or wrong answer about what you should do and it is a decision only you can make. However, once a decision is made you should make sure that you are perfectly happy with it and stand by it, regardless of what the later outcome will be.

Lower Death Risk for Vascular Dementia than for Alzheimer’s Disease with Postmenopausal Hormone Therapy Users.

J Clin Endocrinol Metab. 2016 Dec 1:jc20163590. [Epub ahead of print]

Lower Death Risk for Vascular Dementia than for Alzheimer’s Disease with Postmenopausal Hormone Therapy Users.

Author information

  • 11 University of Helsinki and Helsinki University Hospital, Obstetrics and Gynecology, Haartmaninkatu 2, 00029 Helsinki, Finland.
  • 22 Folkhälsan Research Center, Biomedicum, Haartmaninkatu 8, 00029 Helsinki, Finland.
  • 33 EPID Research Oy, Metsänneidonkuja 12, 02130 Espoo, Finland.
  • 44 National Institute for Health and Welfare, Mannerheimintie 166, 00271 Helsinki, Finland and Karolinska Institute, Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Stockholm, Sweden.



There are conflicting data on postmenopausal hormone therapy (HT) and the risk of vascular dementia (VD) and Alzheimer’s disease (AD).


We analyzed the mortality risk attributable to VD or AD in women with a history of HT use. Design, Patients, Interventions and Main Outcome Measures: A total of 489,105 Finnish women using systemic HT in 1994-2009 were identified from the nationwide drug reimbursement register. Of these women, 581 died of VD and 1057 of AD in 1998-2009. The observed deaths in HT users with <5 or ≥5 years of exposure were compared with those having occurred in the age-standardized female population. Furthermore, we compared the VD or AD death risk of women who had started the use of HT at <60 versus ≥60 years of age.


The risk of death caused by VD was reduced by 37-39% (<5 or ≥5 years of exposure) with the use of any systemic HT, and this reduction was not associated with the duration or type (estradiol-only or estradiol-progestin combination) of HT. The risk of death caused by AD was not reduced with systemic HT <5 years of use, but was slightly reduced (15%) if the HT exposure had exceeded 5 years. The age at systemic HT initiation of <60 versus ≥60 years did not affect the death risk reductions.


Estradiol-based HT use is associated with a reduced risk of death both from VD and AD, but the risk reduction is larger and appears sooner in VD than AD

New study shows more time walking means less time in hospital


New study shows more time walking means less time in hospital

February 20, 2017 6.10am AEDT

Disclosure statement

Ben Ewald has received funding from NH&MRC to conduct research promoting physical activity, and is a member of the group Doctors for the Environment Australia.


University of Newcastle provides funding as a member of The Conversation AU.

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In my practice as a GP, I have been impressed by a few energetic and active 80 year olds who remain in good health while many their age have succumbed to various chronic diseases. So in 2005, when the University of Newcastle established a large community based health study of people aged 55 to 80, I made sure we recorded the participants’ physical activity in detail.

A decade later, we can report the influence of physical activity on the need for hospital care as published in the Medical Journal of Australia today.

We used pedometers to record daily step counts, giving a much more precise measure of activity than the usual self-report questionnaires. Median daily step counts ranged from 8,600 in the youngest to 3,800 in those over 80 years, and weekend days had on average 620 fewer steps than weekdays.

The inactive people (taking 4,500 steps per day) averaged 0.97 days of hospital care per year. The more active people (taking 8,800 steps per day) needed only 0.68 days of care per year. In our analysis we adjusted for the effects of age, sex, the number of illnesses people had when they started, smoking, alcohol intake and education.

We wondered if the causation might be running the opposite direction. That is, that sick people walk less rather than activity preventing illness. To test this idea, we repeated the analysis ignoring all hospital admissions in the first two years of follow up to remove the immediate effects of serious illness. The difference is shown in the graph below.

The association extends right across the range of activity levels, showing any activity is good for health, and the more the better. The participants in our study wore the pedometers from morning until night, so a lot of what we recorded as steps was general activity around the house or the workplace, not necessarily continuous walking. Recent research shows any that activity is better than sitting down, so even light activity is protective of health. Pedometers don’t capture swimming or cycling accurately, but these things make up a small part of daily activity.

Looking at why these patients were in hospital, more active people had fewer admissions for cancer and diabetes, but surprisingly, there was no difference for heart disease. We suspect that might be due to a gap in the data for heart admissions to private hospitals for a few of the years.

What if everyone got walking?

The difference of 0.29 hospital days per year between the inactive and active people is about a 30% reduction. Does this mean if we could get everyone in the population taking 8,800 steps per day we could shut a third of all hospital beds, and send a third of all doctors and nurses off to practice their golf swing? Unfortunately not.

It turns out our study sample is a rather healthy lot, requiring less hospital care than the average for their age. Compared to our average value of less than one day per year of hospital care, figures from the Australian Institute of Health and Welfare for 2014-15 show Australians between 55 and 85 years required 14.2 million days of hospital care, or 2.65 bed days per person.

Getting in 40 minutes of walking a day would reap big rewards in overall health. from

Whether increasing activity would be of more or less benefit across the whole of the Australian population is unclear. It may be that the general population would have even more to gain from physical activity than our study participants, or it may be that they have serious chronic diseases that make increased activity impossible.

Let’s imagine for a moment that something changes the walking habits of all Australians, so everyone is walking at least 8,800 steps per day – maybe a combination of a Fitbit craze and an oil shortage that sends petrol to A$10 a litre. What effect would this have on health services?

Considering only the people aged over 55, at a minimum it would reduce the need for hospitalisation by 975,000 bed days per year, for a saving of $1.7 billion dollars. Given there are health benefits at other ages, and the less healthy Australians not represented in our study could benefit more, the actual benefit is likely to be even greater.

An extra 4300 steps per day is not much. It’s just 40 minutes walking, which might include going to the shops, picking up kids, or taking the stairs at work. It doesn’t have to be “exercise”, although higher intensity activity for those who enjoy it has greater health benefits.

With governments searching for ways to reduce spending, and 16% of the federal budget being spent on health, tackling physical inactivity of individual patients, as well as ensuring our urban centres are walking- and cycling-friendly would make a major difference.

Can vitamins supplement a poor diet?


Health Check: can vitamins supplement a poor diet?

September 12, 2016 3.29pm AEST
There are things that come from plants that aren’t in multivitamins. from

To the rescue come vitamin and mineral supplements, but can they deliver on their promises and are they for everyone?

Who needs a supplement?

When writing about supplements, a glib approach is to state we can get everything we need from food, so we don’t need them. Eat your veggies. Don’t take supplements. End of story.

That isn’t the whole story, though. Already, our food supply is fortified with folic acid, iodine and thiamin to prevent serious public health issues related to conditions arising from deficiencies of these nutrients in some groups of people. So the rationale of needing to supplement for best health has some validity, but is underpinned by our generally poor eating habits to begin with.

There are groups of people for whom vitamin and mineral supplements would be recommended. Women planning pregnancy can benefit from a range of nutrients, such as folic acid and iodine, that reduce the risk of birth defects. People with limited exposure to sunlight would certainly be advised to consider a vitamin D supplement.

Frail and aged people are candidates as well due to food access problems, chewing and swallowing difficulties, absorption problems and medication. People with malabsorption problems, some vegetarians and people following chronic low-calorie diets all make the list as well. And, of course, people with a clinically diagnosed deficiency could all benefit from supplementation.

Why nutrients from food are better than from supplements

So should everyone take supplements “just in case”? Not so fast. Taking multivitamins as a nutritional insurance policy may be an issue for more than just your wallet. Seeing a supplement as a solution may contribute to neglecting healthy food choices, and this has bigger consequences for long-term health.

Food is a complex mix of vitamins, minerals and phytochemicals (plant chemicals). Phytochemicals are an important component of food and help to reduce the risk of conditions such as heart disease, type 2 diabetes and some cancers. Vitamin and mineral supplements do not provide the benefits of phytochemicals and other components found in food, such as fibre.

Whole foods usually contain vitamins and minerals in different forms – for example, vitamin E occurs in nature in eight different forms – but supplements contain just one of these forms.

We should get all of our vitamins, minerals and phytochemicals from vegetables, but that’s if we’re eating them. from

If you look at habits linked to long-term health, it is eating plenty of plant-based foods that comes out on top, not so much taking supplements. This meta-analysis of 21 multivitamin-multimineral supplement clinical trials failed to find any benefit of improved life-expectancy or lower risks of heart disease or cancer from taking supplements.

The promise of possible benefits from supplements takes the focus from what really does promote better health and less chronic disease: eating a varied diet with plenty of minimally processed plant-based foods, regular activity, drinking within guideline recommendations and not smoking.

For a healthy adult, if supplements are used, these should normally be taken at levels close to the recommended dietary intake. High-dose supplements should not be taken unless recommended under medical advice.

Formulations of multivitamins vary between manufacturers, with further market segmentation due to products aimed at different genders and life stages. For example, a multivitamin targeting women of childbearing age will likely be higher in iron than one for adult men. The government’s recommended dietary intakes for each vitamin and mineral are set out by gender and age, and manufacturers generally mirror these recommendations in their formulations.

Although taking too much of certain vitamins or minerals can be harmful, the doses present in multivitamins are typically low. After all, you can only pack so much of each nutrient into a multivitamin pill, and often it is not even close to the recommended dietary intake.

Vitamin and mineral supplements can’t replace a healthy diet, but a general multivitamin may help if your diet is inadequate or where there is already a well-supported rationale for you to take one. If you feel you could be lacking in certain vitamins and minerals, it is better to look at changing your diet and lifestyle first, rather than reaching for supplements.

Increased Cardiovascular Mortality Risk in Women Discontinuing Postmenopausal Hormone Therapy.

I do not recommend hormone holidays, as I see no need for it, and it may lead to a return of symptoms, and may have deleterious effects. The study below is one of those negative effects.

Increased Cardiovascular Mortality Risk in Women Discontinuing Postmenopausal Hormone Therapy. – PubMed – NCBI

J Clin Endocrinol Metab. 2015 Dec;100(12):4588-94. doi: 10.1210/jc.2015-1864. Epub 2015 Sep 28.

Increased Cardiovascular Mortality Risk in Women Discontinuing Postmenopausal Hormone Therapy.

Author information

  • 1Department of Obstetrics and Gynecology (T.S.M., P.T., O.Y.), Helsinki University Hospital, 00029 Helsinki, Finland; Folkhälsan Research Center (T.S.M.), 00250 Helsinki, Finland; EPID Research Oy (H.L., P.K., F.H., P.V.), 02130 Espoo, Finland; National Institute for Health and Welfare (M.G.), 00271 Helsinki, Finland; and Nordic School of Public Health (M.G.), 40242 Gothenburg, Sweden.



Current guidelines recommend annual discontinuation of postmenopausal hormone therapy (HT) to evaluate whether a woman could manage without the treatment. The impact of HT on cardiovascular health has been widely studied, but it is not known how the withdrawal of HT affects cardiovascular risk.


We evaluated the risk of cardiac or stroke death after the discontinuation of HT. Design, Patients, Interventions, and Main Outcome Measures: Altogether 332 202 Finnish women discontinuing HT between 1994 and 2009 (data from National Reimbursement register) were followed up from the discontinuation date to death due to cardiac cause (n = 3177) or stroke (n = 1952), or to the end of 2009. The deaths, retrieved from the national Cause of Death Register, were compared with the expected number of deaths in the age-standardized background population. In a subanalysis we also compared HT stoppers with HT users.


Within the first posttreatment year, the risk of cardiac death was significantly elevated (standardized mortality ratio; 95% confidence interval 1.26; 1.16-1.37), whereas follow-up for longer than 1 year was accompanied with a reduction (0.75; 0.72-0.78). The risk of stroke death in the first posttreatment year was increased (1.63; 1.47-1.79), but follow-up for longer than 1 year was accompanied with a reduced risk (0.89; 0.85-0.94). The cardiac (2.30; 2.12-2.50) and stroke (2.52; 2.28-2.77) death risk elevations were even higher when compared with HT users. In women who discontinued HT at age younger than 60 years, but not in women aged 60 years or older, the cardiac mortality risk was elevated (1.94; 1.51-2.48).


Increased cardiovascular death risks question the safety of annual HT discontinuation practice to evaluate whether a woman could manage without HT.

Menopause, estrogens and frailty.


Gynecol Endocrinol. 2013 May;29(5):418-23. doi: 10.3109/09513590.2012.754879. Epub 2013 Feb 6.

Oestrogen is a hormone that just keeps giving to peri- and menopausal women. Frailty (also known as Sarcopenia – loss of muscle tissue) is common in older women. Oestrogen can help to avoid, or reduce, the effect of this muscle wasting. I have published previously all the other benefits of oestrogen at this time, and the safety of it in menopausal women.

Menopause, estrogens and frailty.

Author information

Nordic Bioscience – Biomarkers and Research (Part of CCBR Group), Herlev, Copenhagen, Denmark.


The controversy surrounding the results from the Women’s Health Initiative (WHI) trials published a decade ago caused a significant decline in the use of menopausal hormone replacement therapy. However, these results have been vehemently contested and several lines of evidence suggest that in perimenopausal and non-obese women, estrogen therapy may indeed be of benefit. There is ample proof that menopause causes a loss of musculoskeletal tissue mass and quality, thereby causing a loss of health and quality of life. There is also solid evidence that hormone replacement therapy in itself prevents most of these effects in connective tissue in itself. Besides the independent, direct effects on the musculoskeletal tissues, estrogen deficiency also reduces the ability to adequately respond and adapt to external mechanical and metabolic stressors, e.g. exercise, which are otherwise the main stimuli that should maintain musculoskeletal integrity and metabolic function. Thus, normophysiological estrogen levels appear to exert a permissive effect on musculoskeletal adaptations to loading, thereby likely improving the outcome of rehabilitation following critical illness, musculoskeletal trauma or orthopedic surgical therapy. These effects add to the evidence supporting the use of estrogen therapy, particularly accelerated gain of functional capacity and independence