Monthly Archives: August 2019

Here we go again- HRT and Breast Cancer risk.

There has been media coverage of a study by Professor Emily Banks that says HRT increases menopausal women’s risk of breast cancer (BC). This comes up frequently, as women are naturally concerned about any connection between the two. This means I will spend the next month reassuring my patients that the way I do it is very safe, and I will explain the reason I can say that below.

The study published in today’s media had a number of problems with it – they used mainly synthetic progestogen, and not natural progesterone. I have known (from many published studies, so it is no secret) that the synthetic progesterones increase women’s rick of BC. Natural progesterone does not. So why would any doctor give it to menopausal women? Beats me. Ask them for an explanation.

Secondly, most of the hormones used were in pill form. We have known for many years the HRT must be given transdermally (creams, patches or troches), and not as a pill. So why do doctors use oral forms of HRT (Like Livial, Xyvion, estalis, Kliovance, Kliogest, Femoston, Progynova, Premarin) Beats me. Ask them for an explanation.

Third factor – using one size fit all means many women get the wrong dose of hormone – tailoring the dose has to be better, so women get the lowest dose that works for them.

Personal experience – I have been using these BHRT for the last 25 years, in over 4500 women, and doing a statistical study of these women, I get about 4% BC incidence. BC occurs in about 13% of Australian women, so I know that there is no increase in BC in the women I treat – in fact the opposite. Unfortunately some of my patients do end up with BC – but it is below the national incidence.

Now lets look at the opposite – lives saved. Most women die from heart disease (estimate about 50%), not BC. HRT reduces women’s risk of heart disease significantly, so it actually saves lives. Then there is the quality of life issues, relationships saved and general well being on HRT.

Here are the relevant articles which I have published before: note they come from impeccable sources: You can find anything on the internet, so information should only come from respected medical journals, internationally respected researchers, and grade 1 universities.

Climacteric. 2012 Apr;15 Suppl 1:3-10.

What’s new in hormone replacement therapy: focus on transdermal estradiol and micronized progesterone.

Simon JA.


Department of Obstetrics and Gynecology, George Washington University, Washington, DC 20036, USA.


The original conclusions of the Women’s Health Initiative study have been questioned as a result of the availability of age-stratified data. Initial concerns regarding the risk of coronary heart disease (CHD) in association with the use of hormone replacement therapy (HRT) have been replaced with concerns regarding thromboembolic disease, encompassing venous thromboembolism (VTE), particularly in younger postmenopausal women, and stroke, particularly in older women. The original publication of the study results led to a dramatic decrease in the use of oral HRT; however, the use of transdermal HRT has increased over recent years.

 Guidelines from the North American Menopause Society, the Endocrine Society, the International Menopause Society, and specific guidelines from the Menopause and Andropause Society for the management of menopausal women with a personal or family history of VTE all contain positive statements regarding both transdermal estradiol and micronized progesterone.

Unlike oral estrogens, transdermal estradiol has been shown not to increase the risk of VTE, or stroke (doses ≤ 50 μg), and to confer a significantly lower risk for gallbladder disease. Unlike some progestogens, progesterone is also not associated with an increased risk of VTE, or with an increased risk of breast cancer. Based on these data, which are now included in the guidelines, the use of transdermal estradiol and micronized progesterone could reduce or possibly even negate the excess risk of VTE, stroke, cholecystitis, and possibly even breast cancer associated with oral HRT use

They reviewed all the guidelines form the major medical bodies that deal with hormones, and concluded that using transdermal oestrogen and micronised progesterone is the safest form of HRT.  Micronised is the form of natural progesterone used in Bioidentical HRT. This is not to be confused with progestogens, which is used mainly in the synthetic forms of HRT Progestogens largely are known as Provera, {Medroxyprgesterone acetate- MPA: or Norethisterone (Primolut-N).

This is the most recent medical publication re safety of HRT:Menopause. 2016 Jul 25. [Epub ahead of print]

Reduced risk of breast cancer mortality in women using postmenopausal hormone therapy: a Finnish nationwide comparative study.

Mikkola TS1, Savolainen-Peltonen H, Tuomikoski P, Hoti F, Vattulainen P, Gissler M, Ylikorkala O.

Author information

  • 11Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland 2Folkhälsan Research Center, Biomedicum, Helsinki, Finland 3EPID Research Oy, Espoo, Finland 4Information Services Department, National Institute for Health and Welfare, Helsinki, Finland.



Data are controversial on the impact of postmenopausal hormone therapy (HT) on breast cancer mortality. We analyzed nationwide Finnish data on breast cancer mortality risk in women using HT consisting of estradiol-only therapy (ET) or estrogen-progestogen therapy (EPT).


In total, 489,105 women using HT in 1994 to 2009, traced from the nationwide reimbursement register, were followed from the HT initiation (3.3 million cumulative exposure years) to breast cancer death (n = 1,578 women). The observed deaths were compared with those in the age-standardized background population.


The breast cancer mortality risk was reduced in all HT users with exposure for at most 5 years (standardized mortality ratio 0.56; CI 0.52-0.60), more than 5 to 10 years (0.46; 0.41-0.51), or more than 10 years (0.62; 0.56-0.68). A significantly larger risk reduction was detected in the 50 to 59 years age group (0.33; 0.29-0.37) compared with 60 to 69 (0.64; 0.59-0.70) or 70 to 79 (0.78; 0.69-0.87) years age groups. The death risk reductions in ET users tended to be larger in all age groups compared with EPT users, with a significant difference only in the 70 to 79 years age group (0.66; 0.57-0.76 vs 0.88; 0.77-1.00). The age at HT initiation, regardless whether ET or EPT, showed no association with breast cancer mortality.


In the Finnish unselected population, breast cancer is fatal in 1 of 10 patients. Our data imply that this risk is prevalent in 1 of 20 patients with history of HT use. This is an important message for women considering or already using HT.Menopause. 2015 Sep;22(9):976-83. doi: 10.1097/GME.0000000000000450.

Estradiol-based postmenopausal hormone therapy and risk of cardiovascular and all-cause mortality.

Mikkola TS1, Tuomikoski P, Lyytinen H, Korhonen P, Hoti F, Vattulainen P, Gissler M, Ylikorkala O.

Author information



Data on the health benefits and risks of postmenopausal hormone therapy (HT) are derived mainly from the use of conjugated equine estrogens. Estradiol-based regimens may have a different risk-benefit profile. We evaluated the risk of death caused by coronary heart disease (CHD), stroke, or any disease among users of estradiol-based HT regimens in a nationwide study in Finland.


A total of 489,105 women who used HT from 1994 to 2009 (3.3 million HT exposure years), as indicated in the nationwide reimbursement register and the national Cause of Death Register, were followed. A total of 28,734 HT users died during follow-up; among the deaths, 3,843 were caused by CHD and 2,464 were caused by stroke. Mortality risk in HT users with varying duration of exposure (≤1 y, >1 to 3 y, >3 to 5 y, >5 to 10 y, or >10 y) was compared with that in an age-matched background population.


Risk of CHD death was significantly reduced by 18% to 54% in HT users and was positively related to HT exposure time. Risk of stroke death was also reduced by 18% to 39%, but this reduction was not clearly related to HT exposure time. Risk of all-cause mortality was reduced in HT users by 12% to 38%, almost in linear relationship with duration of exposure. All these risk reductions were comparable in women initiating HT before age 60 years and women initiating HT at age 60 years or older.


In absolute terms, the risk reductions mean 19 fewer CHD deaths and 7 fewer stroke deaths per 1,000 women using any HT for at least 10 years.

Am J Public Health. 2013 Sep;103(9):1583-8. doi: 10.2105/AJPH.2013.301295. Epub 2013 Jul 18.

The mortality toll of estrogen avoidance: an analysis of excess deaths among hysterectomized women aged 50 to 59 years.

Sarrel PM1, Njike VY, Vinante V, Katz DL.

Author information

1 Departments of Obstetrics and Gynecology and Psychiatry, Yale University School of Medicine, New Haven, CT, USA.



We examined the effect of estrogen avoidance on mortality rates among hysterectomized women aged 50 to 59 years.


We derived a formula to relate the excess mortality among hysterectomized women aged 50 to 59 years assigned to placebo in the Women’s Health Initiative randomized controlled trial to the entire population of comparable women in the United States, incorporating the decline in estrogen use observed between 2002 and 2011.


Over a 10-year span, starting in 2002, a minimum of 18 601 and as many as 91 610 postmenopausal women died prematurely because of the avoidance of estrogen therapy (ET).


ET in younger postmenopausal women is associated with a decisive reduction in all-cause mortality, but estrogen use in this population is low and continuing to fall. Our data indicate an associated annual mortality toll in the thousands of women aged 50 to 59 years. Informed discussion between these women and their health care providers about the effects of ET is a matter of considerable urgency

There’s no evidence caesarean sections cause autism or ADHD

There has been reports in the media today that Caesareans can cause Autism. This article helps.

Caesarean delivery alone does not contribute to the odds of a child developing autism or ADHD. Aditya Romansa

There’s no evidence caesarean sections cause autism or ADHD

August 29, 2019 6.03am AEST


  1. Andrew Whitehouse Bennett Chair of Autism, Telethon Kids Institute, Univeristy of Western Australia, University of Western Australia

Disclosure statement

Andrew Whitehouse receives funding from the National Health and Medical Research Council, the Australian Research Council and the Autism CRC.


University of Western Australia

University of Western Australia provides funding as a founding partner of The Conversation AU.

A new study that combines data from over 20 million births has found that a caesarean section delivery is associated with autism spectrum disorder (autism) and attention-deficit hyperactivity disorder (ADHD).

However, the study does not indicate that caesarean section deliveries cause autism or ADHD. The truth is much more difficult to decipher, and provides an excellent case study for the old adage that correlation doesn’t equal causation.

Read more: Clearing up confusion between correlation and causation

Remind me, what are these disorders?

Autism and ADHD are what we call neurodevelopmental disorders. This means they have clear differences in behavioural development, which we presume are due to brain differences.

In the case of autism, behavioural differences occur in the part of the brain primarily responsible for social and communication development. For ADHD, these differences affect the ability to control and direct attention.

The exact reasons why the brain develops differently are not entirely clear. Studies in twins, which are able to help us understand the role of genetic and environmental influences on a given trait, have shown that both autism and ADHD involve a large genetic component.

However, these studies have also indicated that environmental influences, such as bacterial or viral infections during pregnancy, may play a role in the development of these conditions, most likely through interactions with genetic make-up.

Read more: What causes autism? What we know, don’t know and suspect

What did this study find?

The association between certain caesarean sections and autism has been known for close to two decades. Any possible link with ADHD has received comparatively less research, but there have still be numerous studies in this area.

Today’s study, published in the journal JAMA Network Open, combines all of the studies conducted previously into a single analysis. This “meta-analysis” then allows the researchers to come up with a single estimate of how strong the association between caesarean sections, autism and ADHD may be.

The researchers were looking for a pattern that warrants further investigation.

In this case, the meta-analysis included over 20 million people. It found children born via caesarean section had an increase in odds of being diagnosed with autism or ADHD in early childhood.

The associations were scientifically robust, but very small. Children delivered via caesarean section were 1.33 times more likely to be diagnosed with autism and 1.17 times more likely to be diagnosed with ADHD.

When the prevalence of these conditions is already relatively low (around 1% for autism, and 7% for ADHD), this increase in odds is not substantial. In the instance of autism, this is a shift in odds from a 1% prevalence to 1.33%. This shift is not consequential and certainly does not call for any change in our clinical practice.

Read more: What you need to know to understand risk estimates

This association was similar for children born by either elective or emergency caesarean section.

But what does it mean?

The temptation with findings like this is to draw a causal link between one factor (caesarean section) and the other (autism or ADHD). Unlike so many other areas of science, the conclusions are easily understood and the implications appear obvious.

But the simplicity is deceptive, and says more about our desire for simple answers than it does about the truth of the science.

The studies included in this meta-analysis used a branch of science called epidemiology, which is concerned with how often conditions and diseases occur in different groups of people and why, and how to prevent or manage them.

Read more: Epidemiology and the media

Epidemiological studies survey a large population and find a pattern of results that indicate a certain factor may be coinciding with a certain disease more often than we would expect by chance.

In this case, there is the observation that people with autism or ADHD are more likely to be born by caesarean section than we would otherwise typically expect.

But this kind of epidemiological study is unable determine if one factor (caesarean section) causes another (ADHD or autism).

There are two key reasons why.

First, we can’t rule out that a third factor may be influencing this association. We know, for example, that caesarean sections are more common for pregnant women who are obese and older, and who have a history of immune conditions such as asthma.

All of these factors have also been linked with an increased chance of having a child with autism, and it is entirely possible – and some would argue, probable – that it is more likely these factors underlie the relationship between caesarean section and neurodevelopmental disorders.

The link might be due to other factors such as the mother’s age or weight. Christian Bowen

The second reason is that these kind of epidemiological studies are unable to provide what scientists call “a mechanism” – that is, a biological explanation as to why this association may exist.

A mechanism study in this area may be to explore biological differences in newborns either born via vaginal or caesarean delivery, and understand how these differences may lead to atypical behavioural development.

Without a strong body of evidence from these kinds of studies, there is simply no scientific basis for concluding a causal link between caesarean section and neurodevelopmental disorders.

So what should we take away from this study?

The study provides a strong basis for concluding there is a statistical association between caesarean section delivery on one hand, and autism and ADHD on the other. But that’s about it.

Why this link exists remains unknown, but it is almost certain that a caesarean delivery alone does not contribute to the odds of a child developing autism or ADHD.

Instead, it is likely that other pregnancy factors play a role in this relationship, as well as genetic factors that may interact with the environmental influences during pregnancy to contribute to brain development.

Read more: ADHD prescriptions are going up, but that doesn’t mean we’re over-medicating

Should I take Fish oil supplemen

Although the evidence for the heart benefit is not clear, the reason I recommend fish oil supplement is for the joint (arthritis) and brain benefits. Any heart benefits are a bonus. I take 12 grams fish oil daily (6 capsules am, 6 caps pm.)

Despite new findings, the jury is still out on whether omega-3 supplements reduce heart attacks

November 15, 2018 6.01am AEDT Omega-3s reduce the risk of blood clots and are anti-inflammatory. from


  1. Garry Jennings Professor of Medicine, University of Sydney

Disclosure statement

Garry Jennings receives funding from the National Health and Medical Research Council.He is affiliated with the National Heart Foundation, Sydney Health Partners (University of Sydney) and Baker Heart & Diabetes Institute..


University of  Sydney

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

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A recent widely-reported study has reignited debate around whether omega-3 supplements reduce the risk of heart attack and stroke. The study showed a particular form of omega-3 oil lowered the risk of people with heart disease experiencing a major “end point” event by 25%. This end point is one or a combination of several serious issues such as fatal or non-fatal heart attack, stroke, angina (chest pain) and coronary surgery.

The REDUCE-IT trial included more than 8,000 participants and was presented at the American Heart Association Scientific Sessions in Chicago and published in the New England Journal of Medicine. It was the largest randomised controlled trial (where one group is given the intervention tested and another a placebo and the results are compared) performed to-date testing the benefits of omega-3 supplements for heart disease.

Read more: Randomised control trials: what makes them the gold standard in medical research?

But before you buy fish oil supplements from the local pharmacy, there are some things to be aware of. The drug tested, Vascepa, wasn’t a standard over-the-counter fish oil capsule. Vascepa is made from a highly refined component of fish oils (icosapent ethyl) and the participants received a very high dose (4 grams per day). This is far more omega-3 than most people take with fish oil capsules. Vascepa is available on prescription in the US but not everywhere, and not in Australia.

The study participants either had cardiovascular disease and were aged over 45, or were at high risk of cardiovascular disease and aged over 50. Those at risk had diabetes and at least one other risk factor. The results apply best to people with similar characteristics to the study group and cannot necessarily be generalised more broadly.

Nevertheless, it was a pretty good study performed by reputable investigators across 11 countries with convincing results. So, what does this mean for the see-saw of advice offered on whether to take or not to take fish oil supplements to prevent major heart issues?

Not everyone with heart disease would necessarily benefit from the supplements participants received in the trial. from

A bit of history

In the early 2000s medical authorities were recommending fish oil supplementation for people who had experienced a cardiovascular event such as a heart attack or stroke.

At that time, two large randomised controlled trials reported that eicosapentaenoic acid supplements (which contained EPA and docosahexaenoic acid (DHA)) significantly reduced fatal heart disease. EPA and DHA are the major oils found in fish oil supplements and are called omega-3s.

In 2017 the American Heart Association was more circumspect, noting that the dramatic benefits seen earlier were less evident in subsequent trials. But supplements were still recommended for certain people with heart or vascular disease.

By early 2018, the tide seemed to have turned completely as a widely publicised study concluded there was little evidence for the benefit of fish oil supplements in preventing heart disease. The study was a systematic review, which combined the results of ten trials testing fish oil supplements (at a lower dose than the REDUCE-IT trial), involving 77,917 older adults at high risk of cardiovascular disease.

Read more: Health Check: fish oil, anyone?

So, what are we to believe? A well-conducted randomised controlled trial or a systematic review of all the evidence? An RCT is considered gold standard by guideline committees. A well-done systematic review or meta-analysis is also considered as providing powerful evidence.

So, what’s the verdict?

The trials in the systematic review varied widely in design, dose, patient population, end points and the validity of lumping them all together is questionable. Also, finding no evidence of benefit is not the same as finding no benefit, particularly in some people under certain conditions that may be lost in the overall analysis. Plus, the results are not just a reflection of the treatment under examination but also of the quality of the studies included.

REDUCE-IT was funded by the manufacturer. There is no other way it would have been done and if the results stand up it could save millions of lives, but some will question the veracity of the findings because of the funding source. So, all of this leaves certainty of whether supplements are good for heart health up in the air.

It’s still a fact that cold water fish are good for you. from

Fortunately (and as far as we know) some “truths” remain. Eating fish is still good for you. The origin of the fish is important, not only to avoid contaminants but also because the omega-3 content and relative amounts of EPA and DHA varies. Cold water, oily fish such as salmon, sardines, mackerel, trout and tuna contain the most.

If you cannot eat fish, there are plant sources of omega-3s found in some nuts and vegetable oils such as canola, chia, flaxseed, and soy. These have not been studied as extensively as those of marine origin.

Read more: How Australians Die: cause #1 – heart diseases and stroke

Omega-3s including over the counter capsules have definite biological effects. They reduce triglycerides (the type of fat that contributes to hardening of the arteries) and the risk of blood clots, and are anti-inflammatory. These changes are mostly seen at higher doses.

The evidence will evolve further but, in the meantime, and based on a recent evidence review, the National Heart Foundation recommendations don’t advise health professionals to routinely recommend omega-3 supplements for heart health. It does advise health professionals consider the use of omega-3 supplements for those with high triglyceride levels and as an additional treatment for heart failure.

And lastly, everyone should include two to three serves of fish per week in their diet.

Menopausal mood swings can signal more serious mental illness

Menopausal mood swings can signal more serious mental illness

Most women expect to experience the effects of hormonal changes when they come to menopause and many anticipate increased irritability and mood swings. But mood swings that can be just an annoyance for some women can develop into something more serious for others.

Menopause usually begins around the age of 50, when the body’s production of oestrogen and progesterone slows. This can leads to a range of effects such as hot flushes, vaginal dryness, breast tenderness and trouble sleeping. These symptoms can last around five years.

Read more: Chemical messengers: how hormones change through menopause

Menopausal hormone fluctuations can have a significant impact on women’s mental health, with some women more vulnerable to these changes than others. These mental health problems require specific treatment and support.

Depression and anxiety

Women are two to four times more likely to have an episode of major depression during menopause than at other times in their lives.

Although some women can have an episode of depression for the first time during menopause, women with a history of recurrent depression are up to 4.5 times more likely to experience another episode of depression at the start of menopause than other women at this stage of life.

Anxiety disorders (generalised anxiety disorder, panic disorder and social anxiety disorder) are the most common of the mental health problems, with around 25% of the population experiencing one in the last 12 months.

But despite anxiety symptoms and panic attacks being commonly reported during menopause, little is known about their link with menopause.


Oestrogen has a protective effect against psychotic symptoms for women, due to its modulating effect on the neurotransmitter dopamine.

Excess dopamine is one of the neurological changes seen in patients with schizophrenia, a mental illness that causes episodes of delusions and hallucinations.

Read more: Trick or treat? Alternative therapies for menopause

Women with an existing diagnosis of schizophrenia may be at increased risk of an episode as their production of oestrogen decreases.

While the causes of schizophrenia are a complex mix of genes, your early development and stress, some women develop schizophrenia for the first time after menopause.

Eating disorders

Eating disorders affect women across their lifespan, and often begin at the first major period of hormonal change: puberty.

But researchers are beginning to understand the hormonal changes that occur during menopause also increase the risk of developing an eating disorder, such as anorexia, bulimia and binge eating.

Once again, the increased risk is due to fluctuations in oestrogen, which plays an important role in how we regulate our food intake, affecting feelings of hunger, satiety after eating and weight gain.


Bipolar disorder is a serious mental health disorder affecting up to 2% of Australians. It causes bouts of severe depression and episodes of increased energy, known as mania.

Our research found that women with bipolar disorder may be uniquely affected by menopause in many ways. Disturbances in sleep due to hot flushes, for instance, can affect the onset of depression and mania.

Planning for good mental health

It is important for women with a history of mental health conditions to plan their mental health care when menopause begins.

Women without a history of mental illness should be aware of the risks and talk to their GP prior if they notice persistent changes in mood, or other concerning symptoms.

GPs can prescribe medication and refer to psychologists for Medicare-subsidised counselling, or to psychiatrists for more specialised care.

Read more: A shift in social attitudes can make menopause a positive experience

Mindfulness, cognitive behavioural and behaviour-based therapy for natural and treatment-induced menopausal symptoms

BJOG. 2019 Feb;126(3):330-339. doi: 10.1111/1471-0528.15153. Epub 2018 Mar 15.

Mindfulness, cognitive behavioural and behaviour-based therapy for natural and treatment-induced menopausal symptoms: a systematic review and meta-analysis.

van Driel CM1,2, Stuursma A1,2, Schroevers MJ3, Mourits MJ1, de Bock GH2.

Author information



During menopause women experience vasomotor and psychosexual symptoms that cannot entirely be alleviated with hormone replacement therapy (HRT). Besides, HRT is contraindicated after breast cancer.


To review the evidence on the effectiveness of psychological interventions in reducing symptoms associated with menopause in natural or treatment-induced menopausal women.


Medline/Pubmed, PsycINFO, EMBASE and AMED were searched until June 2017.


Randomised controlled trials (RCTs) concerning natural or treatment-induced menopause, investigating mindfulness or (cognitive-)behaviour-based therapy were selected. Main outcomes were frequency of hot flushes, hot flush bother experienced, other menopausal symptoms and sexual functioning.


Study selection and data extraction were performed by two independent researchers. A meta-analysis was performed to calculate the standardised mean difference (SMD).


Twelve RCTs were included. Short-term (<20 weeks) effects of psychological interventions in comparison to no treatment or control were observed for hot flush bother (SMD -0.54, 95% CI -0.74 to -0.35, P < 0.001, I2  = 18%) and menopausal symptoms (SMD -0.34, 95% CI -0.52 to -0.15, P < 0.001, I2  = 0%). Medium-term (≥20 weeks) effects were observed for hot flush bother (SMD -0.38, 95% CI -0.58 to -0.18, P < 0.001, I2  = 16%). [Correction added on 9 July 2018, after first online publication: there were miscalculations of the mean end point scores for hot flush bother and these have been corrected in the preceding two sentences.] In the subgroup treatment-induced menopause, consisting of exclusively breast cancer populations, as well as in the subgroup natural menopause, hot flush bother was reduced by psychological interventions. Too few studies reported on sexual functioning to perform a meta-analysis.


Psychological interventions reduced hot flush bother in the short and medium-term and menopausal symptoms in the short-term. These results are especially relevant for breast cancer survivors in whom HRT is contraindicated. There was a lack of studies reporting on the influence on sexual functioning.


Systematic review: psychological interventions reduce bother by hot flushes in the short- and medium-term.

© 2018 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.

HRT: some unresolved clinical issues in breast cancer, endometrial cancer and premature ovarian insufficiency.

Womens Health (Lond). 2013 Jan;9(1):59-67. doi: 10.2217/whe.12.61.

HRT: some unresolved clinical issues in breast cancer, endometrial cancer and premature ovarian insufficiency.

Author information

Department of Obstetrics & Gynaecology, University of Cape Town Faculty of Health Sciences, Anzio Road, Observatory, Western Cape, 7925, South Africa.


Many important issues regarding HRT and the management of postmenopausal women are unresolved and require ongoing consideration and some explanation. HRT is only one of many factors affecting the risk of breast cancer and the risk of breast cancer is not increased in past users of HRT. There is seemingly a paradox in the effect of body weight and HRT on breast cancer risk. It is unclear whether the benefit of giving progestin with estrogen to prevent endometrial cancer in HRT outweighs the increased risk of breast cancer. Sequential HRT may not fully prevent endometrial cancer, and continuous combined regimes are to be preferred. The prevention of the consequences of premature ovarian insuffiency, both immediate and long term, has been neglected, and a strong case can be made for estrogen replacement therapy in all women with premature ovarian insuffiency, particularly following bilateral oophorectomy.

An Online Survey of Hypothyroid Patients Demonstrates Prominent Dissatisfaction.

This important study from a very reputable source, tells us something that most of my thyroid patients have known for a very long time, and is also discussed on the thyroid internet discussion groups – people do better on the natural thyroid (DTE- desiccated thyroid extract) Hopefully this study from this influential group will change the negative attitude most specialists have to the natural thyroid use. As I have pointed out before, presidential hopeful Hillary Clinton is on the natural thyroid (see my web-site) so she must know something that most endocrinologists don’t

Thyroid. 2018 Jun;28(6):707-721. doi: 10.1089/thy.2017.0681. Epub 2018 Apr 5.

An Online Survey of Hypothyroid Patients Demonstrates Prominent Dissatisfaction.

Peterson SJ1, Cappola AR2, Castro MR3, Dayan CM4, Farwell AP5, Hennessey JV6, Kopp PA7, Ross DS8, Samuels MH9, Sawka AM10, Taylor PN4, Jonklaas J11, Bianco AC1.

Author information

11 Division of Endocrinology and Metabolism, Rush University Medical Center , Chicago, Illinois.22 Division of Endocrinology, Diabetes, and Metabolism, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania.33 Division of Endocrinology, Mayo Clinic , Rochester, Minnesota.44 Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine , Cardiff, United Kingdom .55 Division of Endocrinology, Diabetes and Nutrition, Boston Medical Center/Boston University , Boston, Massachusetts.66 Division of Endocrinology, Beth Israel Deaconess Medical Center , Boston, Massachusetts.77 Feinberg School of Medicine, Northwestern University , Chicago, Illinois.88 Thyroid Associates, Massachusetts General Hospital , Boston, Massachusetts.99 Oregon Clinical and Translational Research Institute, Oregon Health and Science University , Portland, Oregon.1010 University Health Network and University of Toronto , Toronto, Canada .1111 Division of Endocrinology, Georgetown University , Washington, DC.



Approximately 15% more patients taking levothyroxine (LT4) report impaired quality of life compared to controls. This could be explained by additional diagnoses independently affecting quality of life and complicating assignment of causation. This study sought to investigate the underpinnings of reduced quality of life in hypothyroid patients and to provide data for discussion at a symposium addressing hypothyroidism.


An online survey for hypothyroid patients was posted on the American Thyroid Association Web site and forwarded to multiple groups. Respondents were asked to rank satisfaction with their treatment for hypothyroidism and their treating physician. They also ranked their perception regarding physician knowledge about hypothyroidism treatments, need for new treatments, and life impact of hypothyroidism on a scale of 1-10. Respondents reported the therapy they were taking, categorized as LT4, LT4 and liothyronine (LT4 + LT3), or desiccated thyroid extract (DTE). They also reported sex, age, cause of hypothyroidism, duration of treatment, additional diagnoses, and prevalence of symptoms.


A total of 12,146 individuals completed the survey. The overall degree of satisfaction was 5 (interquartile range [IQR] = 3-8). Among respondents without self-reported depression, stressors, or medical conditions (n = 3670), individuals taking DTE reported a higher median treatment satisfaction of 7 (IQR = 5-9) compared to other treatments. At the same time, the LT4 treatment group exhibited the lowest satisfaction of 5 (IQR = 3-7), and for the LT4 + LT3 treatment group, satisfaction was 6 (IQR = 3-8). Respondents taking DTE were also less likely to report problems with weight management, fatigue/energy levels, mood, and memory compared to those taking LT4 or LT4 + LT3.


A subset of patients with hypothyroidism are not satisfied with their current therapy or their physicians. Higher satisfaction with both treatment and physicians is reported by those patients on DTE. While the study design does not provide a mechanistic explanation for this observation, future studies should investigate whether preference for DTE is related to triiodothyronine levels or other unidentified causes.

More effective and less invasive: how breast cancer treatment has evolved since the 1950s

More effective and less invasive: how breast cancer treatment has evolved since the 1950s

We’ve come a long way since the 1950s in our understanding of breast cancer and how to treat it. from

Treating breast cancer with a very high dose of chemotherapy doesn’t improve survival any more than if using a standard dose. A recent Cochrane review has put the final nail in the coffin of decades of research debunking the antiquated idea that, if only we could give a high enough dose of chemotherapy, we could cure breast cancer.

Cochrane investigators evaluated 14 randomised controlled trials showing treatment outcomes for women given very high-dose chemotherapy, compared with those given a standard dose. The studies involved 5,600 women with early but poor prognosis breast cancer, some of whom were followed for up to 12 years.

The definitive review found that not only are side-effects greater with higher doses, some women actually died from high-dose treatments; the worst kind of lose-lose situation.

High-dose chemotherapy aggressively attacks cancer cells as well as damaging normal blood cells. It is only technically feasible when used together with bone-marrow transplants that restore healthy blood cells to the body. The transplantation procedure is in itself a very traumatic and expensive experience.

Our new understanding that more isn’t better when it comes to chemotherapy is familiar, mirroring the evolution of surgery approaches to breast cancer that, a few decades ago, were far more radical than now.

We compared 14 studies involving over 5,000 women. from

From then to now

In the 1980s, there was a lot of excitement about the possibilities of chemotherapy. After several clinical trials, the consensus was clear: giving chemotherapy to women after surgery for breast cancer reduced the risk of the cancer recurring, as well as the risk of those women dying of breast cancer.

Today, we realise breast cancer is not a one-size-fits-all disease. Some fast-growing breast cancers respond well to chemotherapy, while some slow-growing cancers are more sensitive to oestrogen. The latter will respond better to hormone-blocking treatments, while other types may need no further treatment beyond surgery and radiotherapy.

The vogue in the 1950s and 1960s was the idea that “if it comes back then it means you didn’t do a big enough operation”. In that era, increasingly radical surgery was carried out, involving removing not only the breast but also all the underlying chest muscles and lymph nodes under the arm. Known as a radical mastectomy, this was a very deforming procedure.

In the 1950s and 60s, radical mastectomies were carried out often. from

As evidence emerged, individual surgeons became more conservative with their operations. But it wasn’t until properly conducted randomised trials were collated in the 1990s, that the consensus was reached that long-term survival was identical in women who had a radical mastectomy and those who had a lumpectomy followed by radiotherapy.

A lumpectomy, also known as wide local incision, involves taking just the breast lump out. It is now done in about 60% of all breast cancer cases. The other 40% of more advanced cases are treated with a modified or simple mastectomy, with no muscle removed, which makes reconstruction easier.

The fact that a smaller operation led to similar survival meant the true cause of recurrence was not failed surgery but microscopic spread that developed early in the disease process, even before the surgeon has done her work.

Hence the concept of drug therapies: either intravenous chemotherapy or hormone-blocking treatments (mainly tablets) to mop up those stray cells after surgery. Trials started in the 1970s and 1980s and matured by 1990, when many of these treatments became standard therapy.

Death rates from breast cancer in Australia and the rest of the developed world rose until the 1990s. In Australia, they peaked in 1990 at 31.6 deaths per 100,000 people and started to fall, reaching 20.4 per 100,000 by 2013. At the same time, breast cancer incidence had actually increased, from 94.9 in 1990 to 118.3 per 100,000 in 2012. 2000, combined efforts of researchers in both the lab and clinic have led to further refinements in treatment. On the surgical side, randomised trials have proved the safety of smaller operations to deal with lymph glands in the armpit, where breast cancer cells tend to spread initially.

It used to be the case that all the glands were taken out, but surgeons can now identify the critical one or two glands that might first be affected by cancer, known as sentinel nodes, and remove them. If they are clear, no further surgery is needed. This results in much less shoulder problems and arm swelling than before.

Personalised treatment

Drug therapies have also improved, with new ways of delivering better chemotherapy drugs with less nausea and vomiting. New drugs that target particular parts unique to the cancer cell are more effective and less toxic.

HER2 breast cancers used to be the most feared diagnosis. from

A practical example of this is the use of new antibodies with barely pronounceable names to target a particular subset of breast cancers called “HER2 positive” cancers. These cancers have too much of a protein called HER2 on their cell surfaces, which is the target for the drug. Just like the antibodies we make to kill bacteria, we design drug antibodies to kill cancer cells with lots of HER2 protein on them.

HER2 positivity used to be the most feared breast cancer diagnosis, but women with these cancers can now achieve very low recurrence rates with a combination of post-operative chemotherapy and the antibody trastuzumab. Randomised trials across the world, including Australia, showed that while giving chemotherapy in this situation halved the risk of recurrence, adding trastuzumab halved the risk again.

Trastuzamab (brand name Herceptin) was listed in 2006 on the Pharmaceutical Benefits Scheme and is now available to all Australian women with HER2-positive breast cancer. Another antibody, pertuzumab, was more recently added to the PBS and is also used to control cancers that have spread beyond the breast.

Breast cancer still affects a lot of women (and a small number of men), but it kills fewer. While much has been achieved, much more is still to be learnt. The key to success is high-quality clinical trials that test the results of laboratory findings.

The latest findings speak to the constant need to test new treatments carefully and reliably, preferably with large, international randomised controlled trials.

What’s new in the world of postmenopausal sex?

Curr Opin Obstet Gynecol. 2016 Oct;28(5):449-54. doi: 10.1097/GCO.0000000000000311.

What’s new in the world of postmenopausal sex?



The purpose of this review is to describe new terminology for vulvovaginal atrophy and female sexual dysfunction and to highlight recent findings related to vaginal moisturizers, lubricants and prescription estrogen preparations.


Sexual health is a marker for overall health. A minority (40%) of healthcare providers routinely ask about sexual problems and its impact on quality of life. New terminology by the American Psychiatric Association divides female sexual disorders into three categories: arousal/interest disorder, orgasmic disorder and genital pain and penetration disorder. First-line therapy for genitourinary syndrome of menopause includes over-the-counter vaginal lubricants and moisturizers, followed by topical estrogen formulations. Progesterones are generally not needed when topical low-dose estrogen is prescribed. A systemic selective estrogen receptor modulator, designed specifically for genitourinary menopausal symptoms, is an option for patients who do not tolerate local estrogen.


Female sexual dysfunction is prevalent and causes distress, particularly among women at midlife. Although hypoactive sexual desire disorder may be the most prevalent dysfunction, dyspareunia and pain, particularly related to genitourinary and vulvovaginal atrophy, are also very common. Over-the-counter lubricants and prescription strength estrogen formulations are generally effective and well tolerated.

5 things you probably didn’t know about stress

Medical myth busters: 5 things you probably didn’t know about stress

Liz Meszaros, MDLinx | August 06, 2019

Everyone feels stress at some time in their lives—some, chronically. And while the internet is abuzz with stress-busting techniques, perhaps the key to successfully handling stress would be to first understand exactly what it is—and what it isn’t.


The physical symptoms of stress can include feeling anxious, being short of breath, or feeling run down.

To that end, MDLinx has rounded up some of the more well-known misconceptions about stress in the hopes that knowing what you are up against may help you deal with it more effectively.

Stress is always bad. Healthy stress—also known as adaptive stress or eustress—is actually beneficial, and can release endorphins and temporarily boost your performance. Unlike harmful stress, healthy stress causes the blood vessels to dilate instead of constrict. This increased blood flow to the brain, muscles, and limbs makes us feel pumped both emotionally and physically, and ready to “adapt” to meet the challenge at hand.

In response to emergency situations, stress is your body’s response to danger, and can help you focus, sharpen your vision, or give you strength. Stress is what helped our prehistoric forebears escape from predators. So, while we may not be fighting saber-toothed tigers anymore, a car accident, for example, will evoke the same response. Stress also comes into play when we have to make quick decisions, meet deadlines, or even make it to a board meeting on time. It’s what helps us meet challenges successfully.

Plus, without stress, things like roller-coaster rides, first dates, or the first day on a new job would all be boring. Without the “good” stress, our motivations, sense of meaning, and excitement for life would disappear.

Stress is universal. Stress is different for everyone, with different causes and different manifestations. Stress does not arise from circumstances or occurrences, but from our thoughts about them. That is why it is different for everyone—people have different emotional reactions to the same circumstances. For example, you may be stressed out by having to attend an industry cocktail party after a long day of seeing patients, while another doctor may be excited and happy to attend the same event, seeing it as a break and something to look forward to. 

Changing the way you perceive stressors, therefore, is key to reducing stress.

Stress is directly related to the hours you work. The more hours you work, the more stress you will have. This is simply not true. Those who love what they do will have less stress despite working more hours than those who may dread going in to work. The difference in stress levels depends on one’s attitude, rather than on the hours worked. Again, same stressor, different attitude.

Try to love what you do for a living, and if you don’t, it may be time to seriously consider a change.

Stress only needs attention when you develop major symptoms. The physical symptoms of stress can include feeling anxious, being short of breath, or feeling run down. Mental symptoms include feeling overwhelmed, disorganized, or having difficulty concentrating. Minor symptoms include excess stomach acids and headaches. But these are only a few manifestations. According to the American Institute of Stress, there are as many as 50 common symptoms of stress.

You may not even realize that what you are feeling are symptoms of stress, but you are doing yourself a disservice if you ignore even minor symptoms. Not managing your stress can lead to major symptoms, such as high blood pressure or even a heart attack.

Listen to what your body and your mind are trying to tell you, before you do develop major symptoms.

Stress management means eliminating all stress. While reducing stressors in your life is one of the goals of stress management, it’s important to realize that no one can totally eliminate all stress. Undertaking a stress-management program with this goal in mind would only create more stress.

Instead, focus your stress-management efforts on eliminating the stressors in your life that you can control, and developing strategies to manage those you cannot. The basic goal you should have in mind is maintaining your balance, and being confident that you can handle what will come.

If you get off-kilter, use stress-relief techniques to get you back to a balanced and calm frame of mind.

Here are five tips from the American Psychological Association, supported by psychological research, to help you manage your stress over both the short and long terms:

  • Take a break from whatever is stressing you out,
  • Exercise,
  • Smile and laugh,
  • Get social support, and
  • Meditate

Remember, stressors in your life, both good and bad, are inevitable. But with a little confidence and stress-management work, you can regain your equilibrium.