Monthly Archives: June 2019

You can’t get influenza from a flu shot – here’s how it works

You can’t get influenza from a flu shot – here’s how it works

June 25, 2019 6.11am AEST


  1. Allen Cheng Professor in Infectious Diseases Epidemiology, Monash University
  2. Katherine Kedzierska Academic, Microbiology and Immunology, University of Melbourne

Disclosure statement

Allen Cheng receives funding from the Commonwealth Government and holds research grants with the National Health and Medical Research Council. He is the Chair of the Advisory Committee for Vaccines and the Co-Chair of the Australian Technical Advisory Group on Immunisation.

Katherine Kedzierska receives funding from the National Health and Medical Research Council, and from the Australian Research Council.


Monash University
University of Melbourne
Victoria State Government

Influenza is a moving target for vaccines. Each year, up to four different strains circulate, and they are constantly evolving to escape our immune system.

So rather than childhood jabs giving long lasting immunity, we need annual flu shots to provide optimal protection against influenza.

But while you might sometimes get sick after having a flu shot, it’s a myth that having a flu shot can give you the flu.

A quick history of the flu vaccine

Influenza vaccines were first developed in the 1930s and 1940s, starting with the isolation of the influenza virus.

Back then, we learned there were many different influenza strains. To be effective, early research showed the vaccine needed to be matched to the circulating strains, and to be able to stimulate a response from the immune system.

Read more: When’s the best time to get your flu shot?

The process to produce modern influenza vaccines now occurs on a much more refined and industrial scale. Hundreds of thousands of influenza viruses are collected by hundreds of national influenza centres around the world.

From these, four strains are selected for the annual flu vaccine, based on the viruses that are circulating at that time, how well the vaccines activate the immune system, how the strains are evolving, and the effectiveness of previous vaccines.

Modern flu vaccine development is slow and labour-intensive process. hotsum/Shutterstock

Most modern vaccines are manufactured by growing large quantities of live virus – mostly in chicken eggs or less commonly animal cells – which are then purified, deactivated and split into smaller components. These vaccines are inactive and cannot replicate.

There are also two new “enhanced” vaccines that are used in older people, who don’t tend to respond as strongly to vaccines: Fluzone High Dose and Fluad, which is designed to better stimulate immunity and draw immune cells to the site of vaccination.

Read more: High-dose, immune-boosting or four-strain? A guide to flu vaccines for over-65s

How the immune system fights the flu

The human immune system has several strategies to protect against infection. For viral infections such as influenza, the key strategy is known as adaptive immunity. This part of the immune system can “remember” previous exposure to pathogens.

When you get an influenza infection, the virus enters and hijacks the machinery of the host cell to replicate itself, before releasing these copies to infect more cells.

T lymphocyte cells of the immune system can recognise this viral incursion. T cells protect against further spread of the virus by activating pathways that cause infected cells to trigger a “suicide” process.

Another strategy the body uses is to produce antibodies, which are molecules produced by B cells that recognise components of the viral capsule. These antibodies work by sticking to the surface of the influenza virus to prevent it spreading and facilitating disposal.

Flu shots help mount a quicker defence

On a first exposure to a pathogen, our B cells take at least two weeks to ramp up production of antibodies. However, on subsequent challenges, antibody production occurs much more quickly.

Influenza vaccines harness this arm of the immune system, known as “humoral” immunity. By “practising” on viral components, vaccines allow the immune system to react more quickly and effectively when faced with the real virus.

The flu shot takes about two weeks to start protecting you against influenza. DonyaHHI/Shutterstock

So why do you sometimes get sick after a flu shot?

There are several reasons why you might feel a bit off after getting your flu shot.

First, your flu shot only protects you against influenza and not other respiratory illness which might causes similar cold or flu symptoms. This includes RSV (respiratory syncytial virus), which is common in late autumn and early winter.

Read more: Sick with the flu? Here’s why you feel so bad

Second, stimulating the immune system can result in symptoms similar to that of influenza, although much milder and short-lived. These include local inflammation (redness, pain or swelling at the site of the vaccine) and more general symptoms (fever, aches and pains, tiredness).

Third, vaccine-induced protection isn’t complete. In some years, the vaccine is not well matched to circulating strains. Usually this is due to mutations that may develop in circulating strains after the vaccine strains are selected.

The flu vaccine also doesn’t “kick in” for two weeks after vaccine administration. In some people, particularly those who are older and those who have weakened immune systems, antibody production is not as strong, and the level of protection is lower.

Despite this, studies have consistently shown that vaccinated people are less likely to get influenza or complications from the flu than those who aren’t vaccinated.

Read more: Flu vaccine won’t definitely stop you from getting the flu, but it’s more important than you think

A better way to protect against the flu

A problem with current vaccines is the reliance on eggs, which results in a relatively slow and labour-intensive production process.

Current work is aiming to speed up this process by using different technologies so that vaccine manufacturers can react more quickly to changes in circulating viruses.

The “holy grail” for influenza vaccines is to stimulate an effective immune response to a component of influenza that doesn’t change each year, so annual vaccination is not required.

These efforts have proved elusive so far.

Read more: The Holy Grail of influenza research: a universal flu vaccine

A better strategy might be to harness T cell immunity. Recent work has shown that a type of T cell, known as “killer” T cells, can recognise other parts of the influenza virus, and therefore can provide broad protection against seasonal and pandemic strains.

But while we wait for a better alternative, getting an annual flu shot is the best way to avoid the flu.

Can I prevent food allergies in my kids?

Can I prevent food allergies in my kids?

With the rise in food allergies over the last ten to 20 years, parents are understandably concerned about what – if anything – can be done to reduce the chances of their child developing a food allergy. Expectant mums often ask whether there’s anything they should eat, or avoid eating, to reduce the risk of food allergy in their child.

In the past, some guidelines recommended mums avoid eating “allergenic” foods (foods that commonly cause reactions in individuals with food allergy) during pregnancy and breastfeeding. This advice has now been removed because it hasn’t prevented food allergies in the child. So what do we know (and not know) about the link between foods eaten during pregnancy and food allergies in children?

Read more – Curious Kids: How do we get allergic to food?

What is a food allergy?

There are many different types of reactions to foods. Those involving the immune system are classified as allergies.

The type of allergy most studied is called “IgE-mediated” food allergy (IgE refers to immunoglobulin – the antibodies produced by our immune system). In IgE-mediated food allergy, the immune system responds to a particular food or foods in the same way it would respond to something dangerous. It causes symptoms that we call an allergic reaction. Food allergy can occur to a wide range of foods, but common culprits are peanut, tree nuts, egg, milk, soy, wheat, fish and shellfish.

For people with this type of food allergy, reactions generally occur rapidly, sometimes within minutes of ingesting the food. Common symptoms include hives (raised wheals that resemble mosquito bites), vomiting, and swelling of the lips, eyes, or face. Less commonly, reactions can involve the airways or circulation, resulting in potentially life-threatening symptoms like difficulty breathing, wheezing or collapse.

Peanuts should be introduced before one year of age. from

In Australia, IgE-mediated food allergy now affects around one in every ten babies, and around one in 20 older children. It usually develops in infancy or early childhood, and can be lifelong.

Read more: Food allergies linked to overactive immune system at birth

Can we prevent children from developing food allergy?

The normal response to eating a food is “tolerance”. In other words, the immune system sees the food as harmless and does not mount a response. Interventions to prevent food allergy aim to promote the development of tolerance.

Ten years ago, no one knew how this could be achieved. Since then, there have been major advances. Perhaps the most important is the recent discovery by researchers in the UK that peanut allergy can be prevented in some children who are at high risk of developing it.

In a study in which 600 children with eczema or egg allergy were randomly assigned to either eat or avoid peanut, those who started eating peanut earlier (before they were one year old) were less likely to have peanut allergy at age five than those who avoided peanut. Studies have also shown eating egg earlier may protect against egg allergy, although this protective effect does not appear to be as strong as for peanuts.

As a result of this study, parents are now advised to introduce foods like peanut and egg to infants before one year of age.

Read more: Introduce eggs and peanuts early in infants’ diets to reduce the risk of allergies

Although this is an important advance in knowledge, the research also showed this isn’t effective for everyone. Some children develop food allergy very early in life, too early to benefit from being given foods like peanut before one year.

It’s also clear infant diet isn’t the only factor that determines whether a child develops a food allergy, since most children do not develop food allergy regardless of the age when foods like peanut and egg are first given. And some children develop food allergy even with an optimal diet.

Maternal diet and food allergy

Immune responses to foods like egg and peanut can be detected in some infants in the first few months of life, before these foods are introduced into the infant diet. This means food allergy prevention might need to start earlier than previously thought.

A recent study in mice reported that milk from mothers exposed to egg protein protected offspring from developing allergic reactions to egg. This protection was strongest when the mothers were exposed to egg proteins during both pregnancy and breastfeeding. At the moment it’s not known whether this is also the case in people.

Read more: What are allergies and why are we getting more of them?

The Australasian Society of Clinical Immunology and Allergy does not recommend excluding allergenic foods during pregnancy or breastfeeding.

We don’t know yet whether eating more of foods like peanuts or eggs in pregnancy can reduce the risk of the child developing a food allergy. But answers should be available soon. A study led by researchers at the University of Western Australia is about to look in detail at how the amount of egg and peanut eaten by mums relates to their child’s risk of having an egg or peanut allergy.

This is a large study which will take several years to complete, but hopefully we will be able to provide evidence-based advice for maternal diet, the same way we can for infant diet, very soon.

Sick with the flu? Here’s why you feel so bad

Sick with the flu? Here’s why you feel so bad

June 14, 2019 6.16am AEST You might feel terrible. But your runny nose, sore throat and aches are signs your body is fighting the flu virus. And that’s a good thing. from


  1. Stephen Turner Professor, viral immunology, Monash University

Disclosure statement

Stephen Turner receives funding from the National Health and Medical Research Council of Australia, the Australian Research Council and the National Institutes of Health Centre of Excellence for Influenza Research and Surveillance.


Monash University
Victoria State Government

“You never forget the flu”. This is the title of the Victorian health department’s current campaign, which highlights people’s recollections of having the flu.

‘The flu knocked me out for weeks’, part of the Victorian health department’s winter flu campaign. Vic Dept Health & Human Services

Phrases include “I’ll never forget the pain of the fever”, “the flu flattened me”, “the flu knocked me out for weeks”.

This gives the impression that when you have the flu, you know you have it. What makes the flu so memorable is the severe symptoms. These include fever, aches and pains, a sore throat, runny nose, cough, and feeling weak and lethargic.

But what causes the flu? And why are the symptoms so severe?

Read more: Health Check: how long should you stay away when you have a cold or the flu?

What causes the flu?

Influenza is caused by a virus, a small microbe that needs to enter our cells to replicate and produce more viruses. The influenza virus infects cells that line our airways and so is easily transmitted via the spread of droplets released when we sneeze or cough.

Coughs, sneezes and the other symptoms we feel after getting the flu, are largely due to our bodies fighting the infection.

Read more: I’ve always wondered: why is the flu virus so much worse than the common cold virus?

The immune response is a double-edge sword

When you are infected with the flu virus, your innate immune system kicks in. Special receptors recognise unique parts of the virus, triggering an alarm system to alert our bodies that an infection is under way.

This produces a rapid but non-specific response — inflammation.

Read more: Explainer: what is the immune system?

Inflammation results from the action of small proteins called cytokines. A primary role of cytokines is to act locally in the lung to help limit the initial infection taking hold.

They can also make their way into the circulation, becoming systemic (widespread in the body) and act as a “call to arms” by alerting the rest of the immune system there is an infection.

Unfortunately, your body’s inflammatory response, while trying to fight your infection, results in the flu symptoms we experience.

Inflammation can trigger increased mucus production. Mucus (or phlegm) is a sticky substance that helps capture virus in the lungs and upper airways. The increased amount of mucus in the airways can trigger coughing and/or sneezing, and can lead to a runny nose. This helps expel the virus from our body before it can infect other airway cells.

Read more: Health Check: what you need to know about mucus and phlegm

Inflammation also results in an increase in body temperature or fever, which creates an inhospitable environment for the flu virus to replicate.

While an increased body temperature helps fight the infection, it also results in you feeling colder than usual. That’s because you feel a greater temperature difference between your body and the outside environment.

This can induce rapid muscle contractions in an effort to heat you up. This is why you can feel like you can’t stop shivering while at the same time burning up.

Read more: Monday’s medical myth: feed a cold, starve a fever

Finally, some of these inflammatory molecules act directly on infected cells to stop the virus replicating. They can do this by either interfering with the replication process directly, or alternatively, by actually killing the infected cell.

One of these factors is tumour necrosis factor alpha (TNF-alpha). While its actions limit where the flu virus can replicate, its side effects include fever, loss of appetite and aching joints and muscles.

Calling in the big guns

Inflammation induced by the innate response also helps alert the adaptive immune system that there is an infection.

While innate immunity provides an immediate, albeit non-specific, response to viral infection, it is the adaptive immune response that can efficiently clear the infection.

The adaptive immune system consists of specialised white blood cells called T and B cells that when activated provide a highly specific response to infection.

Your flu symptoms are likely the result of your body fighting off infection with the the tiny flu virus. from

Activation of flu-specific T and B cells in tissues called lymph nodes results in the generation of hundreds of thousands of clones, all specific for the flu virus. These can migrate into the lungs and specifically target the virus and its ability to replicate.

This enormous expansion of T and B cell numbers in response to infection results in swelling of the lymph nodes, which you can feel under your armpits or chin, and which can become sore.

Flu-specific T cells are also a source of the inflammatory molecule TNF-alpha and help fight influenza infection by killing off virus-infected cells. Both actions can contribute to the flu symptoms.

Why can flu become a serious problem?

Our ability to see off a flu infection requires a coordinated response from both our innate and adaptive immune responses.

If our immune system function is diminished for some reason, then it can prolong infection, lead to more extensive damage to the lung and extended symptoms. This can then result in secondary bacterial infections, leading to pneumonia, hospitalisation and eventually death.

Then there are people whose immune system doesn’t work work so efficiently who are particularly susceptible to the flu and its complications. These include:

  • the very young, whose immune system is still yet to mature
  • the elderly, whose immune system function wanes with age
  • people with other conditions where immune function might be compromised, or be taking medication that might suppress the immune system.

Preventing the flu

Washing your hands and covering your mouth when coughing and sneezing are simple things we can all do to reduce the chance of catching the flu in the first place.

And getting the flu vaccine activates your adaptive immune response to induce the sort of immunity efficient at protecting us from infection.

With the flu season well under way, prevention is our best bet that you won’t be saying “Remember the time I got the flu”.

Knee osteoarthritis and menopausal hormone therapy in postmenopausal women

Another one of the benefits of oestrogen to menopausal women. I have known and repeatedly told my patients that oestrogen is good for all joints, and helps to slow down the natural deterioration that occurs with age. There are other studies like this one which show the same thing. Combing oestrogen with fish oil, turmeric and cinnamon all have advantages for joints. Using them and keeping them active also slows down the onset of osteoarthritis.

Knee osteoarthritis and menopausal hormone therapy in postmenopausal women

a nationwide cross-sectional study

Jung, Jae Hyun, MD, PhD1,2; Bang, Cho Hee, RN, MS3; Song, Gwan Gyu, MD, PhD1,2; Kim, Cholhee, PT, MS4; Kim, Jae-Hoon, MD, PhD1,2; Choi, Sung Jae, MD, PhD1,5Menopause: June 2019 – Volume 26 – Issue 6 – p 598–602 doi: 10.1097/GME.0000000000001280 Original Articles Buy

Objective: The incidence of osteoarthritis (OA) increases after menopause, and may be related to hormonal changes in women. Estrogen deficiency is known to affect the development of OA, and menopausal hormone therapy (MHT) is suggested to be related to the development of OA. However, the relationship between knee OA and MHT remains controversial. The association between knee OA prevalence and MHT was investigated using large-scale national data.

Methods: Data were collected from 4,766 postmenopausal women from the Korea National Health and Nutrition Examination Survey (2009-2012). MHT was defined as regular hormone medication for ≥1 year, and demographic and lifestyle variables were compared between the MHT and non-MHT groups. Knee OA was defined according to symptoms and radiographic findings.

Results: In the multiple logistic regression models, the OA odds ratio was 0.70 for the MHT group (95% confidence interval 0.50-0.99), compared with the non-MHT group.

Conclusions: The prevalence of knee OA was lower in participants with MHT than in those without MHT.

Is it time to remove the cancer label from low-risk conditions

Is it time to remove the cancer label from low-risk conditions?

Many people associate the word cancer with major illness or death. Shutterstock

Over the past few decades, our understanding of cancer has changed. We now know some cancers don’t grow or grow so slowly that they’ll never cause medical problems.

But the way we label disease can harm. The use of more medicalised labels, including cancer, can increase levels of anxiety and the desire for more invasive treatments.

Given this growing evidence, my colleagues and I argue in The BMJ today that it may be time to stop telling people with very low-risk conditions that they have “cancer” if they’re unlikely to be harmed by it.

Our understanding of cancer has changed

Cancer screening for people who have no symptoms and the use of increasingly sensitive technologies can lead to overdiagnosis – a diagnosis that causes more harm than good. Overdiagnosis is most common in breast, prostate and thyroid cancer.

Read more: Most people want to know risk of overdiagnosis, but aren’t told

Thyroid cancer diagnoses, for example, have dramatically increased in developing countries. This has mainly been driven by an increase in the detection of papillary thyroid cancers. These are a sub-type of thyroid cancer which are often small (less than 2cm in size) and slow-growing.

But death rates from thyroid cancer remain largely unchanged. And tumour growth and spread in patients with small papillary thyroid cancer who choose surgery are similar to those who just monitor their condition.

In fact, autopsy studies spanning over 60 years show thyroid “cancers” have always been common but often went undetected and didn’t cause harm.

Impact of the cancer label

Many people associate the word cancer with major illness or death. It can be frightening to hear. This association has been ingrained by public health messaging that cancer screening saves lives.

Although this promotion has had the best of intentions, it has also induced feelings of fear and vulnerability in the population. It has then offered hope, through screening.

After decades, this messaging has resulted in highly positive attitudes towards cancer screening and early treatment. It has also led to an increased, sometimes unwarranted, desire for surgery.

Several studies show the cancer label, and the use of medicalised labels in various other conditions, leads to higher levels of anxiety and perceived severity of the condition, as well as a greater preference for invasive treatments.

The increased desire for more aggressive treatments has been shown clinically in ductal carcinoma in situ (DCIS) of the breast (sometimes known as stage O breast cancer). Women are increasingly choosing mastectomy and bilateral mastectomy (removal of one or both breasts) rather than lumpectomy (removal of the lump), even though these treatments do not change their odds of dying of breast cancer.

Read more: Treating ‘stage 0’ breast cancer doesn’t always save women’s lives so should we screen for it?

Similarly, in localised prostate cancer, active surveillance has been a recommended management option for a number of years, which means monitoring the condition and not providing immediate treatment. But men are only beginning to avoid immediate treatment and follow active surveillance at similar rates to men who choose surgery or radiation.

There is also evidence and informed speculation that melanoma in situ (also called stage 0 melanoma), small lung cancers, and some small kidney cancers may similarly be considered low risk and subject to overdiagnosis and overtreatment.

A strategy to reduce overdiagnosis and overtreatment

Removing the cancer label is one strategy that has been proposed in recent years by international cancer experts to reduce overdiagnosis and overtreatment in some low-risk conditions.

The cancer label has previously been removed when there was clear evidence the condition was low-risk and very unlikely to cause harm. In 1998, “papilloma and grade 1 carcinoma of the bladder” was re-labelled to “papillary urothelial neoplasia of low malignant potential”. The word carcinoma, which is another way of saying cancer, was dropped.

More recently, reference to “cancer” was removed from a sub-type of papillary thyroid cancer, which is identified after surgery. This was done to eliminate the need for ongoing follow-up and reduce any potential patient anxiety.

Read more: Informed Aussies less likely to want a prostate cancer test

It’s vital we learn from these past examples. We also need to establish a formal evaluation of the impact that removing the cancer label will have on clinical practice and patient outcomes, to drive effective reform.

Ultimately, removing the cancer label will create controversy and take time. But the end result should better support appropriate evidence-based care for both future and current patients

Heading back to the office? Bring these plants with you to fight formaldehyde (and other nasties)

Heading back to the office? Bring these plants with you to fight formaldehyde (and other nasties)

Humans have built high-rises since ancient Roman times, but it wasn’t until the 20th century that they became the default work space for a significant slice of the world’s workers. While these buildings are certainly efficient, they can cause real health issues.

Office buildings, where many Australians spend much of their time, are even worse than apartment buildings. Cubicles in offices usually consist of partitions made of particle board and vinyl carpet, synthetic flooring, a particle board desk and plastic or synthetic office chair, mostly lit by artificial lighting. The lucky few get natural light and a view from a window, but poor ventilation still spreads germs.

Read more: Why apartment dwellers need indoor plants

One excellent way to combat both sick days and stress is by filling your office with plants. Ideally, you want plants that will “scrub” the air of pathogens, improve the office’s mix of bacteria, and survive in low light with little care.

Fight formaldehyde (and other nasty chemicals)

One of the many chemical compounds given off by synthetic office furnishings is formaldehyde, which can irritate the mucous membranes of the eyes, nose and throat, and also cause allergic contact dermatitis.

Irritation of the eyes and upper respiratory tract, as well as headaches, are the most common reported symptoms of exposure to formaldehyde toxins. Other harmful chemicals in the office may include benzene, ethylbenzene, toluene and xylene, and even ammonia from cleaning products. High levels of carbon dioxide breathed out by a roomful of colleagues can give the room that “stuffy” feeling, particularly if there is no air conditioning.

Indoor plants will purify the air, reducing volatile organic compounds, including formaldehyde.

A NASA clean air study tested common indoor plants for the ability to filter pollutants, and found many are very effective at removing multiple kinds of organic compounds from the air (this chart is very handy for finding high performers).

To best remove indoor pollutants, try for one medium-sized plant per 2.2 square metres. Look for species with large leaves (the more leaf surface area, the more efficient it is).

Improve indoor bacteria balance

There are already trillions of bacteria in high-rise offices, but only a limited amount come in through open windows and air conditioning from the outdoor environment. Most of the bacteria, fungi and viruses come from people; we leave behind a microbial cloud from our skin wherever we go.

The office environment then creates new habitats for microbial communities that may be quite foreign to human skin, and may not be good for your health.

Beneficial bacteria on indoor plants and in their soil are an important addition to the office, stabilising the ecology of the built synthetic environment.

Plant-associated bacteria could also help to avoid outbreaks of pathogens by enhancing microbial biodiversity and balancing the complex network of the ecosystem. A wholesome balance may reduce the incidence of viral illness and the number of sick days among staff.

It’s not just the size of the plant that’s important here. Larger pots mean more root mass and soil surface for helpful bacteria and root microbes.

Beat stress

Over the past 30 years, research has shown that green spaces promote public health, and that contact with nature can shift highly stressed people to a more positive emotional state. One study identified eight ways people perceive green urban spaces (described as Serene, Space, Nature, Rich in Species, Refuge, Culture, Prospect, and Social) and confirmed the importance of considering plant life when creating public places.

Offices, particularly those with many people, poor ventilation or low natural light, should also consider plants and green spaces a necessity.

There are a few basic principles for a good office plant. It must be hardy and easy to maintain, and able to survive without water over weekends (or when the regular plant-carer goes on holiday). Many plants will do the most good in cubicles and spaces away from windows, so they need to be adapted to low light.

It’s also a good idea to avoid plants that flower extravagantly, which may cause allergic reactions. Check with your colleagues before introducing new plants.

Read more: Hay fever survival guide: why you have it and how to treat it

Some of the best all-rounders across these categories are Devil’s Ivy, Bamboo Palm, Kentia Palm, Variegated Snake Plant (also known as mother-in-law’s tongue), and the Peace Lily, but there are many beautiful plants that will improve your atmosphere and mood.

So if you’re heading back to work in an office soon (or know someone who is), why not bring along an indoor plant?

Ovarian cysts: types, symptoms and treatment

Latest News » Blog » Ovarian cysts: types, symptoms and treatment

Ovarian cysts: types, symptoms and treatment

Ovarian cysts are fluid-filled sacs that develop on the ovary. Ovarian cysts are common and can occur in women of all ages. Most ovarian cysts present with little or no discomfort, are harmless and resolve spontaneously within a few months.

By contrast, ovarian lesions that are solid (not fluid filled) cannot be called cysts.

In premenopausal women cysts are common and develop under the influence of sex hormones during a women’s normal menstrual cycle. Each month, the ovary grows tiny sacs (follicles) that hold the eggs. A functional cyst develops when the ovary fails to release an egg or when a follicle in the ovary continues to grow after an egg has been released. These cysts usually resolve without treatment.

Non-functional cysts are less common and are cysts that grow without the influence of hormones. The exact causes are unknown.

  • Dermoid cysts: Sac-like benign growths on the ovaries that can contain hair, fat, teeth, bone and other tissue. Growing teeth in the ovaries sounds strange but dermoid cysts develop from ‘totipotential germ cells, sometimes referred to as ‘master cells’ because of their ability to mature into any type of tissue.  These cells can become over stimulated in women during their reproductive years (mainly 30s).
  • Cystadenomas: Benign growths that can develop on the outer surface of the ovaries. They can be filled with a transparent, watery fluid or can be filled with mucus.
  • Endometriomas: Tissues that normally grow inside the uterus can develop outside the uterus and attach to the ovaries. Endometriomas occur due to a condition called endometriosis.
  • Polycystic ovarian syndrome (PCOS) stands for ovaries with innumerable tiny ovarian cysts. These cysts do not normally need to be removed, but women with PCOS may need treatment for other PCOS problems.


Symptoms can differ in women. Depending on its size, some cysts cause pain and in functional cysts the pain will ease soon. Large cysts can cause persisting pain and discomfort, pelvic pressure, bloating or fullness and also urinary frequency. Irregular menstrual periods are not usually related to an ovarian cyst.

Endometriomas develop mostly in women below the age of 50 years and may be associated with painful periods.

shutterstock women talking2


Ovarian cysts typically are diagnosed during a pelvic examination or a pelvic ultrasound. The ultrasound will help to assess its nature.

Is the cyst cancerous?

Overall, less than 1% of new growths on or near the ovary are related to ovarian cancer.

There is no 100% reliable test if an ovarian cyst is harmless or ovarian cancer. However, a few tests can be done to assess the risk of a cyst being malignant (cancer) or benign.

  1. Patient age: Ovarian cancer mainly affects women after the age of 50 years.
  2. The ultrasound will show if the ovarian cyst is purely cystic (a simple cyst) or if it contains some solid elements. The risk of a simple ovarian cyst to be cancerous is only 1% or less. Most patients would be happy to be reassured.
  3. Tumour marker blood tests: There are some blood tests your doctor can request and the result of the blood test will help professionals to estimate the risk of cancer.
    1. CA125 is the most widely used and most useful blood tumour marker.
    2. CA19.9 is another blood tumour marker that would detect mucinous tumours.
    3. HE4 is a marker that is useful to detect endometriosis and endometriomas.
    4. In young women, a totally different set of tumour marker needs to be taken to assess the risk of non-epithelial ovarian cancer.

In summary, a women less than 50 years of age, with a simple ovarian cyst (no solid elements) and a low CA125 blood test has a very low risk that her ovarian cyst could be malignant.

Complications of ovarian cysts

Ovarian cysts, such as dermoids in particular can grow large causing ovarian torsion. This is rare but occurs when a large cyst causes an ovary to twist around its own blood supply or move from its original position.  Ovarian torsion can also decrease or cut off the blood flow to the ovaries, resulting in severe acute pain. Ruptured cysts can cause intense pain and internal bleeding. Ovarian torsion and ruptured cysts require immediate treatment.


Ovarian cysts in premenopausal women typically resolve themselves. In postmenopausal women cysts are often non-functional. In postmenopausal women if a cyst grows or changes in appearance, then surgery to remove the cyst may be recommended to explore and exclude ovarian cancer.

In young women, the surgery may involve removing only the cyst. If the cyst is small and appears non-cancerous the cyst alone is removed laparoscopically through several small incisions near the navel. If the cyst is large or appears suspicious for cancer, it may be necessary to have an open incision through the abdomen. Having one ovary removed will not cause women to go through menopause and does not cause infertility.

In menopausal women, I recommend removing the entire ovary (and not simply the cyst). In these women, it is also important to remove the ovarian cyst without spilling any cyst fluid. Should the cyst be cancerous, I would like to see the content of the cyst contained and not disseminated in the abdominal cavity. The majority of these procedures can be done laparoscopically with a hospital stay of 1 night.

For suspicious cysts and ovarian masses, I recommend a frozen section examination. This means that I invite a pathologist into the operating theatre who will snap freeze the tissue and examine whether there is cancer while the patient is still asleep.

Three reasons to get your stress levels in check in 2019

Three reasons to get your stress levels in check in 2019

Adrenaline allows us to act quickly.

When we’re acutely stressed, the fight-or-flight system jumps into action, sending a surge of adrenaline through the body. This product of evolution dramatically increases our reaction speed and once allowed us to escape or fight a predator.

But our bodies are not designed to cope with ongoing activity of these stress pathways.

The psychological effects of stress – such as irritability, loss of appetite, and difficulty sleeping – are obvious to anyone who has been under pressure. But stress also has subtle, underlying effects on almost every part of the body, including the heart, gut and immune system.

Here are just three reasons to get your stress levels in check this year.

1. You’re at risk of a heart attack

When activated, the fight-or-flight system causes blood pressure to spike and redirects blood flow away from non-essential parts of the body and into the muscles.

Consistently high blood pressure or frequent spikes strain the coronary arteries serving the heart. Higher blood pressure with each beat causes arteries to slowly stiffen and become clogged, which impedes blood flow to the heart.

One study found people who were chronically stressed, either in their work or home life, were more than twice as likely to have a heart attack than those who weren’t.

Read more – Health Check: what do my blood pressure numbers mean?

Another effect of stress on the cardiovascular system is hyper-responsiveness. When a person is suffering low but persistent levels of stress, their response to an added source of stress is much more intense than normal, leading to larger spikes in heart rate and blood pressure.

Again, the increased blood pressure damages blood vessels and increases the chances of blockages and heart attacks.

2. Your bathroom habits are unpredictable

The same systems that increase blood pressure and heart rate during stress also cause food to be digested more slowly.

Chronic stress can make you constipated or have diarrhoea. Marcella Cheng/The Conversation, CC BY-ND

The chemicals produced by the stomach and intestines change when you’re stressed. Food gets broken down in different ways and the body may have difficulty absorbing the nutrients from it. This can lead to constipation, diarrhoea and general intestinal discomfort.

Chronic stress has also been linked to more serious diseases such as irritable bowel syndrome and inflammatory bowel disease. While the reasons for this still aren’t clear, it’s thought that chronic stress causes bowel disease by increasing inflammation from intestinal immune cells called mast cells.

Read more: So you think you have IBS, coeliac disease or Crohn’s? Here’s what it might mean for you

Treatment for these diseases usually revolve around managing the painful and uncomfortable symptoms instead of addressing the underlying cause. However some therapies, such as the hormone melatonin, work by reducing the effects of stress on the gut.

3. You’re more likely to get sick

We’ve long known that stress makes people more vulnerable to catching minor illnesses but we’ve only begun to understand how stress affects the immune system over the past few decades.

Students who were less stressed when receiving the vaccination had a better immune response than their anxious peers. Marcella Cheng/The Conversation, CC BY-ND

The best examples of this come from a study of chronically stressed carers who look after patients with Alzheimer’s disease, and another of medical students in the middle of their exam period.

When given the flu vaccine, the stressed caretakers had a lower immune response to the vaccine than normal.

Conversely, when the medical students in the middle of their exam periods were vaccinated against hepatitis, the students with better social support and lower levels of stress and anxiety had a much better immune response to the vaccine than other students.

In other words, when the participants were stressed, their immune system didn’t function as it should to recognise and defend against the virus. The same occurs for colds and flus, other viruses, bacterial infections and even cancer.

Read more – Explainer: what is the immune system?

When stress causes the immune system to break down, a bug that might have been under control can suddenly start flourishing. Once a person begins feeling sick, their stress levels will likely rise and make it harder for the immune system to fight off the disease. This prolongs the illness and increases the risk it will be passed on to another person.

How to reduce your stress levels

There are many strategies available to reduce the effects of stress, but their health benefits have only recently started to be researched and understood over the past few decades.

An interesting example of this came from an experiment in 2002, where subjects were given injections of artificial adrenaline to increase their blood pressure and heart rate. But when one of the subjects got bored and started meditating, their heart rate suddenly dropped back to normal, even with the researchers attempting to increase it artificially.

Meditation helps some people lower their blood pressure. Marcella Cheng/The Conversation, CC BY-ND

This finding was applied in a 2008 study, where researchers took newly diagnosed breast cancer patients and enrolled them in a mindfulness-based stress-reduction program that focused on breath awareness, meditation and yoga.

After eight weeks of participation in the program, the immune systems of the women had all made a remarkable recovery, and were functioning just as well as a healthy person’s immune system. The women also reported feeling much more optimistic about their future, as well as feeling more connected with their family and friends.

Read more – Mindfulness: how to be in the moment … right here, right now

Interestingly, short bursts of acute stress can be beneficial to immune function, particularly of that associated with exercise. While solid evidence is still lacking in humans, mice received a huge benefit from frequent exercise while fighting off melanoma.

In the end, it comes down to being aware of your stress levels, and what works for you to get your stress in check. You might be surprised at just how many of your bodily functions benefit from you being a bit more relaxed.


NEWSLETTER From Dr Studd.( He is Founder and Vice-President of the National Osteoporosis Society and has been a Council Member of the Royal College of Obstetricians and Gynaecologists for 12 years and a Past-President of the Section of Obstetrics and Gynaecology at the Royal Society of Medicine. In 2005-2007 Professor Studd was Chairman of the British Menopause Society. In 2008 he was awarded the Blair Bell Gold Medal of the Royal Society of Medicine which is given every five years for the obstetrician/gynaecologist who has made the greatest lifetime contribution to the specialty. )

January 2019

Dear ‘patient’It has nearly been one year since my last newsletter which is not good enough. I do apologise because I should be in contact every six months to give you an update of what is happening in the HRT world.Last week there were some articles in the newspapers suggesting that some HRT preparations are safer than others. In particular it was singled out that oral oestrogens being associated with a slight increase of heart attacks, and deep vein thrombosis. This risk has been known for many years whether it is HRT for the menopause or the birth control pill for younger women because oral oestrogens pass through the liver where they are metabolised with the releases of hepatic coagulation factors which elevated the risk of thrombosis. Transdermal hormones do not have this effect and do not have this risk. I am sure that none of my patients reading this newsletter will ever have been prescribed oral oestrogens by me or my colleagues and that you are all having transdermal oestrogens whether in the form of gels, implants or occasionally patches.

Twenty-five years ago I founded, together with Dr Alan Dixon, the National Osteoporosis Society which has done such good work. In February this year its status will be elevated to the Royal Osteoporosis Society and we must thank our patron the Duchess of Cornwall for being such a great supporter of this cause. However, things are not so straightforward because it has essentially been taken over by bone physicians who are nervous about hormone therapy even though they would regardthemselves as endocrinologists!The NOS literature on 1osteoporosis will stress the importance of bisphosphonates (without mentioning their awful side-effects) and Strontium which similar bad side-effects or parathormone an eighteen-month course at enormous expense. But down on the list there is a paragraph on HRT which is associated with the risk of breast cancer, strokes and heart attacks. Given this false information any woman would choose an alternative to HRT. Happily, those risks are untrue but are the product of the totally flawed 2004 Women’s Health Initiative which used the wrong patients, the wrong age group, using the wrong hormones, the wrong dose administered in the wrong route.

As I have mentioned in previous newsletters the authors of this NIH funded work costing one billion dollars and still counting have mostly disassociated themselves with the conclusions. Several are lecturing all over the world apologising for their part in this academic scandal and the damaging effect that it has had on millions of women. In this study they used oral not transdermal oestrogens, the patients were obese, hypertensive, diabetic, and the conclusions revealed at a press conference before many of the co-authors had even seen the finished paper and certainly many days before we were able to read it in scientific journals and analyses the data and conclusions.The NOS has just had their three-day international conference with not one lecture on hormones. Nor was there a single company that makes hormones in the exhibition room.The program consisted of life-style choices, exercise, weight bearing exercises, prevention of falling and of course a discussion of every non-hormone medication available.This is so disappointing as the most effective and safest way to treat and prevent osteoporosis is to give many years of transdermal oestrogens which also will have a beneficial effect upon mood, on sleep, libido with a decrease in heart attacks, stroke probably Alzheimer’s and yes, no increase in breast cancer.

I have been fighting this fight for all of twenty-five years but there is still a long way to go before physicians who fear HRT recognise that this is the safest and most effective way of preventing 2osteoporosis and treating low bone density. This is regardless of age. Young women with premature menopause or anorexia usually have low bone density and need this therapy. Women at the time of the menopause, if found to have low bone density, need this therapy and certainly women over the age of sixty-five, with demonstrable low bone density by bone density scans, need transdermal oestrogens for many, many years.

We have dozens of patients in their eighties and the oldest is a spritely ninety-five-year-old who travels from foreign lands to see us for her six-monthly implant of oestradiol and testosterone.Apart from the obvious value for menopausal symptoms and low bone density the place in the treatment of various “psychiatric” problems needs further study before more women are messed up with inappropriate antidepressant or anti-psychotic medication. The role of oestrogens, testosterone and progesterone in the causation of menopausal, postnatal and premenopausal depression are recognised by all – even psychiatrists but they have not taken the next logical step of treatment by hormones. This is the next huge challenge.Currently virtually all psychiatrists use antidepressants for these conditions, changing or adding different medication with rarely any benefit but they produce weight gain and loss of libido which only adds to the despair. The cyclical depression, anxiety and headaches of PMS or PMDD are often misdiagnosed as bipolar disorder with personality problems. These are almost invariably cured with transdermal oestrogen gels or implants but the psychiatric option is for antidepressants, lithium or worse ECT.

It is one of the medical scandals of the age as psychiatrists will not consider treating depression in women with oestrogen, bone physicians and rheumatologists will not treat osteopenia and osteoporosis with oestrogens, neurologists do not treat cyclical menstrual migraine with oestrogens, sleep experts aware that hot flushes night sweats and panic attacks are treatable with oestrogens are effective for these symptoms fail to progress to solving the problem with HRT. Perhaps we need the help of articulate “celebs” who can deliver this message to the neglected victims of this ignorance. I have Carol Vorderman’s permission to briefly tell her story which she has told herself many times on TV and radio. After a happy life and successful career she fell apart with profound depression at the age of 55. By then it had been a problem for 6 months. Before that she was well with no hint of depression – now she had suicidal thoughts. She started transdermal estradiol and the depression vanished after 2 days and hasn’t returned during the 3 years of oestrogen and testosterone therapy. She never wants to stop. Now she is determined to inform the public who can then approach their GPs with the story and evidence from my web site and suggest – no demand – that the doctor at least considers the use of transdermal oestrogen rather than the easy but usually ineffective prescription of antidepressants.

Over the last 30 years I have created a unique clinic which specialises in studying the value of hormone therapy particularly oestrogen, testosterone and progesterone. This relates of course to the menopause and the massive problem of osteoporotic fractures in all the women as well as the use of these hormones in the frequent problems of depression, anxiety, insomnia and loss of libido which is so common in women in this age group. This interest has been supported by a great deal of original research when I was at Kings College Hospital and Chelsea and Westminster hospital. Details of this research can be found on my website. This website contains information which can be printed off and given to your general practitioner and your psychiatrist (but they won’t listen).I have been fortunate to have the support in the clinic of two of my former research fellows: Michael Savvas who is now the senior consultant at Kings College Hospital and Neale Watson who is a senior gynaecologist at Hillingdon Hospital. They are experts and very well informed about the effects of hormones in the causation of the problems in women and equally knowledgable about the best way of correcting these disorders. They have been a great help to me over the last three years in the practice and are becoming very popular with patients. I will probably reduce my work to two day’s work a week but it is time for me to move on and spend more time writing and fighting shrinks. I will always be contactable and frequently in Wimpole St but please stick around with my two partners if I am not always available because you will find no better advice on hormone therapy anywhere in the country.With best wishes

John STUDD, DSc, MD, FRCOG Professor of Gynaecology

How do we manage overdiagnosis/overtreatment in breast screening?

Clin Radiol. 2018 Apr;73(4):372-380. doi: 10.1016/j.crad.2017.09.016. Epub 2017 Nov 23.

How do we manage overdiagnosis/overtreatment in breast screening?

Wallis MG1.

Author information


Overdiagnosis is the inevitable flip side of early detection resulting in unnecessary labelling of well women with a diagnosis of cancer and possible unnecessary treatment. Overdiagnosis occurs because breast cancers have different rates of growth and slow-growing cancers are preferentially detected by screening. Some of these slow-growing screen-detected cancers may never have been clinically apparent during an individual’s lifetime. Evaluating the benefits and risks of screening are complex, but this has been performed for the UK population by an independent review led by Professor Marmot. It might be possible to limit overdiagnosis by identifying women with “low-risk disease” earlier, either at the point of screening when additional investigations could be delayed (possibly for ever) so that they are not subjected to additional diagnostic tests, or at the point of diagnosis. Both these options would require major re-education of clinicians and the public who would need to accept that screening is “deliberately ignoring a cancer”. There is a long surgical history of reducing the burden of treatment, which continues today with trials of management of the axilla and reducing or even omitting radiotherapy for low-risk disease. The Low Risk Ductal Carcinoma In Situ trial (LORIS) has started to identify a group of breast cancer patients who could avoid surgery and be offered active monitoring. We need to consider planning a similar trial for low-risk invasive breast cancer.