Author Archives: Dr Colin Holloway
We don’t know whether most medical treatments work, and we know even less about whether they cause harm
One of the reasons for this blog, which I have been running for the last 10 years, is to expose treatments which do more harm than good, and to encourage better health, lifestyle, nutrition and natural alternatives which are safer than many of the drugs that are routinely given. The Book “Hippocrasy” by Drs Buchbinder and Harris, exposes many of the treatments given by doctors with no benefit, and often harm, to patients. I highly recommend it.
We don’t know whether most medical treatments work, and we know even less about whether they cause harm – new study
Published: June 17, 2022 8.18pm AEST
- Jeremy Howick Professor and Director of the Stoneygate Centre for Excellence in Empathic Healthcare, University of Leicester
Jeremy Howick receives funding from the Medical Research Council (UK)
Only one in 20 medical treatments have high-quality evidence to support their benefits, according to a recent study. The study also found that harms of treatments are measured much more rarely (a third as much) as benefits.
Patients and doctors – and anyone who pays for them – need to know that medical treatments are safe and effective, but it’s an open secret in the medical field that not all treatments, including ones that are commonly used, are safe and effective. For example, antiarrhythmic drugs were widely prescribed in the belief that they would reduce heart attack deaths until a clinical trial found that they actually increased the risk of death.
In another example, putting infants to sleep on their stomach was recommended based on expert opinion that babies would be less likely to choke on their vomit until large studies found that stomach sleeping increased the risk of sudden infant death syndrome.
So how big is this problem?
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In the early 2000s, researchers estimated that between quarter and a half of treatments are supported by high-quality evidence. But these estimates are now out of date and used old methods (such as researcher opinion) to determine whether the evidence was high quality or not. More recently, in 2020, a more rigorous estimate was published and found that only 10% of medical treatments were based on high-quality evidence. However, this estimate was based on a small sample of 151 studies.
Meanwhile, some continue to insist that most treatments must work. How else can we explain that we live ten years longer than our great-grandparents? Yet the extension in lifespan is explicable at least partly by public health measures such as clean water, better nutrition and restrictions on smoking.
A more accurate picture
To resolve the controversy about the proportion of treatments that are based on good evidence, an international team of researchers from the UK (University of Oxford), US, Switzerland and Greece conducted a large study of 1,567 healthcare treatments. The sample included all treatments tested in Cochrane Reviews between 2008 and 2021. Cochrane Reviews are rigorous studies that amalgamate all available relevant evidence about treatments. They are often referenced in national and international healthcare guidelines.
The year 2008 was chosen as the cut-off because that was when Cochrane Reviews incorporated a system called grading quality of evidence and strength of recommendations (Grade) to rate how trustworthy the evidence is. Unlike the earlier estimates that often relied on opinions, Grade is more widely accepted and is used by over 100 organisations around the world. Using Grade results in a quality rating of high, moderate, low or very low.
The study revealed that 95% of treatments do not have high-quality evidence to support their benefits. Worse, the harms are reported in only about 33% of Cochrane Reviews.
It is particularly worrying that the harms of healthcare interventions are rarely quantified. For a doctor or patient to decide whether to use a treatment, they need to know whether the benefits outweigh the harms. If the harms are inadequately measured, an “informed choice” is not possible.
A potential limitation of the study is that Grade might be too strict. Doctors and patients may be happy to use treatments whose benefits are not supported by high-quality evidence as long as they are supported by moderate-quality evidence. Even if this is right, the study found that less than half of treatments are supported by high or moderate-quality evidence.
Patients with ailments for which there are no effective treatments may be willing to try treatments that are not yet even supported by low-quality evidence. The study should not be used to constrain these patients’ choices.
Also, the sample may not have been representative. In theory, treatments tested in recent Cochrane Reviews may be less effective or based on lower-quality evidence than older treatments. However, given the rigour of Cochrane Reviews, this seems unlikely.
In practice, doctors can use “off-label” treatments which are less likely to have been studied in Cochrane Reviews and generally have lower-quality evidence to support them. Despite these potential limitations, the study still showed that most treatments are not supported by high-quality evidence.
Doctors, patients and those who pay for them may wish to focus on treatments whose benefits and safety are established by high-quality evidence. Research funding should be allocated to generating high-quality evidence for treatments that are widely used but not yet supported by high-quality evidence about their benefits and harms.
Finally, potential harms should be measured with the same rigour as potential benefits. The evidence-based medicine community is correct to continue calling for higher-quality research, and also justified in their scepticism that high-quality evidence for medical treatments is common or even improving.
Are Mammograms Worthwhile for Older Women?
Some might be better off not knowing they have breast cancer because they are likely to die of other causes long before breast cancer would threaten their health.
Published Aug. 17, 2020Updated Aug. 17, 2021
The shutdowns and fears provoked by the Covid-19 pandemic threw a monkey wrench into many aspects of routine medical care, especially for older people justifiably wary about being exposed to the virus in a medical setting. While many facilities have now created “safe spaces” to resume in-person exams, some of the resulting postponements of routine checkups can have a major impact on the severity of an undetected or untreated disease and sometimes even the chances of survival.
One of these is screening mammography, especially for women 75 and older, a group to which I belong that has received conflicting advice for years about the need for, and ideal frequency of, routine breast exams.
On one hand, there’s no denying that breast cancer becomes increasingly common as women age and that finding this cancer in its early stages typically results in simpler and more effective treatment. Indeed, the earliest stage of invasive breast cancer has a five-year survival rate of 99 percent.
On the other hand, some older women might be better off not ever knowing they have breast cancer because they are likely to die of some other cause long before an undiagnosed and untreated breast cancer threatens their health and lives. Yet once a woman is told she has breast cancer after a routine mammogram, she faces a decision about treatment that can have a negative impact on her emotional and physical well-being.
Further complicating matters is the current inability of cancer specialists to say with certainty which breast cancers found on a mammogram may not warrant any treatment because they are too slow-growing to be life-threatening or may even have the potential to disappear on their own. A Norwegian study published in 2008 found fewer invasive breast cancers among women screened only once in six years than among a comparable group screened biannually for six years, suggesting that some mammogram-detected cancers in the latter group would have regressed spontaneously.
Although the incidence and mortality associated with breast cancer increase with age, there is some evidence to suggest that in general the disease in older women tends to be less aggressive and more likely to have a favorable prognosis. It is now possible to get a genetic test called Oncotype DX that predicts the risk of a breast cancer recurrence and the disease’s likely response to chemotherapy.
Given the many conflicting guidelines and confusing statistics, making a rational decision about screening can be quite challenging, especially for women who know others found to have curable cancers in their later years. Three of my friends over age 70 learned they had breast cancer just before or during the pandemic lockdown, leaving me — a 79-year-old breast cancer survivor of 21 years — uncomfortable about skipping my annual exam, which I’ve now scheduled for September.
The American Cancer Society guidelines for women with an average risk of developing breast cancer advises yearly mammograms starting at age 45 (or 40 if a woman prefers), changing to every other year (or every year if preferred) at age 55 and continuing every year or two for as long as they remain healthy enough to have a life expectancy of 10 or more years.
The U.S. Preventive Services Task Force, however, recommends stopping routine mammograms at age 75 regardless of a woman’s remaining life expectancy. Yet there are other professional guidelines recommending continued exams for women in generally good health who have a life expectancy of at least five years.
Then there are data from an analysis of 763,256 mammography screenings done between 2007 and 2017 that found cancer in 3,944 women, 10 percent of whom were 75 and older. The study’s author, Dr. Stamatia Destounis, radiologist at Elizabeth Wende Breast Care in Rochester, N.Y., reported that most of the cancers in the older women were invasive and of a grade that should get treated. Nearly two-thirds had the potential to spread and grow quickly.
Dr. Destounis told Healthline, “There are benefits of screening yearly after age 75. Mammography continues to detect invasive cancers in this population that are node negative and low stage, allowing these women to undergo less invasive treatment. The age to stop screening should be based on each woman’s health status and not defined by her age.”
At the same time, women are living longer and spending more of those added years productively and in reasonably good health. For them, Dr. Destounis said, finding early invasive cancers that can be treated with minimal surgery and postoperative therapy can mean a lot to the patients, their families and their communities.
Still, there is one fact that all older women should know: According to Diana Miglioretti, a biostatistician at the University of California, Davis, “There is no evidence from randomized controlled trials on whether screening women ages 75 or older reduces breast cancer mortality. Evidence suggests the benefits of screening are not seen until 10 years later.” She said there is also a risk of overdiagnosis that increases with age — finding a cancer that would not have harmed the woman in her lifetime.
In an interview, Dr. Mara A. Schonberg, internist at Beth Israel Deaconess Medical Center in Boston, echoed Dr. Miglioretti’s concerns. “Overdetection in older women is a problem, and even finding breast cancer is not always good. It takes at least 10 years of screening 1,000 women aged 50 to 74 to avoid one breast cancer death, and probably even longer in women over 75 in whom breast cancer tends to be more indolent. It’s not clear that all the aggressive treatment older women get is needed.”
Furthermore, among 1,000 women age 75 to 84 who continue to have mammograms for five years, 100 will get false alarms, creating anxiety and prompting a slew of tests that do not find cancer. With continued mammography, within five years three such older women in 1,000 will die of breast cancer, as against four women who do not have mammograms, Dr. Schonberg reported. She also noted that among women age 75 to 84 who die in the next five years, 12 times more will succumb to heart disease than to breast cancer.
To help women decide about whether continuing to get regular mammograms after age 75 is in their best interests, Dr. Schonberg and colleagues devised a decision aid, available in English and Spanish.
It asks 10 questions about age and health status, including body weight, physical ability, smoking history and pre-existing health conditions like diabetes. The lower a woman’s health risks, the lower her score, and the more likely that a mammogram may help her live longer.
Dr. Schonberg said she hopes that before handing their older patients prescriptions for a mammogram, doctors would first have them complete the decision aid.
This is the first of two columns on reducing breast cancer risk.
Jane Brody is the Personal Health columnist, a position she has held since 1976. She has written more than a dozen books including the best sellers “Jane Brody’s Nutrition Book” and “Jane Brody’s Good Food Book.”
Uterine Cancer Is on the Rise, Especially Among Black Women
The cancer eventually will become the third most common type among women, experts say. The mortality rate is highest among Black Americans.
June 17, 2022
Linda Collins had been in menopause for almost a decade when she started bleeding again. The bleeding was light — occasional spotting, really — and she barely gave it a passing thought.
When she finally went in for a checkup, her doctor refused to let her leave until she underwent a biopsy. Within days, Ms. Collins learned she had cancer of the uterus — and an especially aggressive form of it.
“I had no pain, no other symptoms, and I didn’t think seriously about it,” said Ms. Collins, 64, a retiree in the Bronx. “That was a mistake.”
Cancer of the uterus, also called endometrial cancer, is increasing so rapidly that it is expected to displace colorectal cancer by 2040 as the third most common cancer among women, and the fourth-leading cause of women’s cancer deaths.
The mortality rate has been increasing by almost 2 percent a year overall, with even sharper spikes among Asian, Hispanic and Black women, according to a recent study in JAMA Oncology. Despite the increase, there has been little public attention to the disease.
Overall survival rates are high when uterine cancer is detected early, but few women are aware that a change in menstrual bleeding, before or after menopause, is one of the main warning signs, along with pelvic pain and painful urination and intercourse.
Uterine cancer was long believed to be less common among Black women. But newer studies have confirmed that it is not only more likely to strike Black women, but also more likely to be deadly.
Black women die of uterine cancer at twice the rate of white women, according to a report in March from an expert panel convened by the American College of Obstetricians and Gynecologists.
The gap is one of the largest racial disparities observed for any cancer, the report said. Black women are also more likely to develop a form called non-endometrioid uterine cancer, which is more aggressive.
Among all populations, uterine cancer is being detected more often in younger women who are still in their childbearing years as well as in women who don’t have any of the known risk factors, such as obesity, infertility and never having been pregnant, said Dr. Shannon Westin, a gynecologic oncologist at the University of Texas MD Anderson Cancer Center in Houston.
When she first started caring for women with uterine cancer, she said, there were about 39,000 new cases a year. Now, there are more than 65,000 — and she has been in practice only 15 years.
“That’s a clear indicator we should be ringing the alarm bells,” Dr. Westin said.
Dr. Carol Brown, a gynecologic oncologist at Memorial Sloan Kettering Cancer Center in New York, called the surge in cases an epidemic.
“The striking statistic is that right now, in the year 2022, the number of women who will lose their lives to endometrial cancer in the U.S. is almost the same as those who will die of ovarian cancer, which is unbelievable to those of us in practice for the last 30 years,” said Dr. Brown, who is the center’s senior vice president and chief health equity officer.
The JAMA Oncology study analyzed racial trends in uterine cancer while correcting for hysterectomy rates. That’s important, because Black women have a higher rate of hysterectomies, said Megan A. Clarke, the lead author. (Women who have had a hysterectomy do not have a uterus, so they cannot develop endometrial cancer; including them in the calculus artificially lowers the incidence rate.)
“By making the correction for hysterectomy rates, we are more confident — the increase is real,” said Dr. Clarke, a fellow at the National Cancer Institute.
Black women represented just under 10 percent of the 208,587 uterine cancer cases diagnosed in the United States between 2000 and 2017, but they made up almost 18 percent of the nearly 16,797 uterine cancer deaths during that period, Dr. Clarke’s study found.
The uterine cancer death rate for Black women is 31.4 per 100,000 women ages 40 and up, compared with 15.2 per 100,000 for white women in the same age group, Dr. Clarke reported. (Comparable death rates for Asian American women were nine per 100,000, and for Hispanic Americans, 12.3 per 100,000.)
That makes uterine cancer an outlier, since progress has been made toward narrowing the racial gap in death rates from most cancers over the past two decades. Another National Cancer Institute report, published in JAMA Oncology in May, found that overall, death rates from cancer have declined steadily among Black Americans between 1999 and 2019, though they continue to be higher than those of other racial and ethnic groups.
The reasons for the increase in uterine cancer cases are not well understood. The most common form, endometrioid cancer, is associated with estrogen exposure, which is higher when obesity is present, and obesity rates have been rising in the United States.
But non-endometrioid cancer has increased in prevalence, too, and it is not linked to excess weight. Dr. Clarke’s study found that Black women are more likely to have this aggressive form of uterine cancer. They are less likely to be diagnosed early in the course of the illness, and their survival rates are worse no matter when they are diagnosed and what subtype of the cancer they have.
“At every stage of diagnosis, there are different outcomes,” said Dr. Karen Knudsen, chief executive of the American Cancer Society. “Are they getting access to the same quality of cancer care?” She has called for more research into the factors driving the trends.
The expert panel convened by the American College of Obstetricians and Gynecologists found racial and ethnic disparities in the care given to Black and Hispanic women with uterine cancer. They were less likely than white women to undergo hysterectomy, less likely to have their lymph nodes properly biopsied to see if the cancer had spread, and less likely to receive chemotherapy, even for a more threatening cancer.
Adrienne Moore, a respiratory therapist who is Black and lives in the Atlanta area, was 45 when she found out she had uterine cancer, but she said it took her almost a year to obtain the diagnosis. She went from one doctor to another complaining of heavy, very painful monthly bleeding that had started after several months without periods at all.
Ms. Moore, who is now 51, was uninsured at the time, and doctors she consulted dismissed her complaints as symptoms of perimenopause or fibroids.
After Ms. Moore purchased health insurance under the Affordable Care Act, she saw a gynecologist who performed another scan. It showed a thickening of the uterine wall, which can be suggestive of cancer, and the doctor immediately ordered a biopsy.
Three days later, the doctor called her to the office. “I knew what it was then. I knew it was cancer,” Ms. Moore said.
Ms. Moore said she is alive today because she was persistent. “If your body is telling you something, you’ve got to listen to it, and then you’ve got to get other people to listen to you,” she said.
Dr. Kemi Doll, a gynecologic oncologist at the University of Washington School of Medicine in Seattle, has been doing research for years to figure out why so many Black women die of endometrial cancer.
She has found that ultrasound scans that measure the thickness of the uterine wall are less accurate when patients have the more-lethal non-endometrioid type of uterine cancer, which is more common among Black women.
The scans are also less effective when women have uterine fibroids, which obscure the scanner’s view, she found. That may explain why Black women, many of whom suffer from uterine fibroids, are more often diagnosed later in the disease process, Dr. Doll said.
If thickening is not discovered, physicians will generally not go on to perform a biopsy to test for the cancer.
Premenopausal women who have erratic menstrual cycles may not recognize that they need to check for uterine cancer because they think of the irregularities as normal, Dr. Doll said. And women in perimenopause who expect abnormal bleeding may also not recognize when something is wrong, she said.
“We need to rethink our guidelines,” Dr. Doll said. Women who have abnormal cycles and unusual bleeding throughout their lives are at highest risk: “It is the abnormality of the cycle that increases the risk of endometrial cancer, because of the dysregulation of hormones.”
But the bigger problem, she said, is that there is so little public awareness. Women know they should have mammograms and Pap smears to screen for breast and cervical cancer.
“If someone found a lump in her breast, would she put off doing something? Everybody would tell her, ‘No, no, no, go right now,’” Dr. Doll said. Uterine cancer is four times as common as cervical cancer, she added, “and we have not had any national dialogue about it.”
When she gives women a diagnosis of uterine cancer, most say they have never heard of it, Dr. Doll added.
Treatment typically requires a complete hysterectomy, with surgical removal of the uterus, ovaries, fallopian tubes and cervix. Radiation and medication therapies may also be required, depending on the stage of the disease.
Having a hysterectomy can be life-altering for young women, plunging them into surgical menopause and possibly requiring hormone treatment to manage the side effects, and disrupting the plans of those hoping to have children.
Caught early, however, uterine cancer is considered highly curable. Angelyn Jackson, a 55-year-old elementary school teacher outside Atlanta, decided last summer to resume annual checkups disrupted by the pandemic. When she reported light bleeding, her gynecologist immediately checked her for uterine cancer.
Ms. Jackson got the diagnosis on July 8 and had a hysterectomy 20 days later, catching the disease at an early stage, she said. She is still being closely observed.
It has been three years since Ms. Collins’s hysterectomy and radiation therapy. She now goes out of her way to tell friends and acquaintances to immediately talk to their doctors about unusual bleeding or other symptoms like pain, bloating or sudden weight loss.
“I tell them, ‘Don’t wait, don’t wait. If it doesn’t feel right, if you don’t think it should be happening — check it out,’” Ms. Collins said. “I should have looked into it sooner.”
Scam or Not
Can Probiotics Boost Vaginal Health?
Pills and suppositories that promise to balance the vaginal microbiome are lining drugstore shelves and online marketplaces. But are they backed by science?
By Rachel E. Gross
April 27, 2022
Before there were vaginal probiotics, there was the yogurt douche. In the 1970s, a common home remedy for yeast infections and other irritating ailments was to soak a tampon in plain, unsweetened yogurt and insert it into the vagina. The same live bacteria that make yogurt beneficial for the gut, the thinking went, might also be good for the vagina.
Though yogurt douching never went commercially mainstream, the concept of infusing an ailing vagina with good bacteria has, in the form of vaginal probiotics. Sold in drugstores and online marketplaces and advertised on Instagram and in subway ads, many of these supplements (which can be taken orally or vaginally) claim to seed the vagina with friendly bacteria that can “restore feminine balance,” “prevent the intimate troubles” and “create an ideal environment for healthy microflora to flourish.”
Many of these product’s claims are vague, but some are more bold in their advertising, promising to prevent or treat common vaginal problems like yeast infections and bacterial vaginosis. But do they actually work? Here’s what we know.
How does the vaginal ecosystem get out of whack?
Think of the vaginal microbiome as a rainforest: a unique ecosystem teeming with microscopic life including bacteria, viruses and yeast. For many (though not all) premenopausal women, the dominant microbes are certain species of a bacterial group called Lactobacillus. Other members of this group live in the gut and ferment dairy products like yogurt and cheese.
But the Lactobacillus in the vagina are special. They’ve likely adapted over thousands of years to digest sugars shed by vaginal cells and spew out lactic acid, creating a mildly acidic environment that is inhospitable to bacterial invaders. This helps form a crucial barrier between you and not-you, protecting your reproductive tract from infection and disease.
Lots of things can disrupt vaginal Lactobacilli, including antibiotics, menstruation, douching, certain sexually transmitted infections and semen. When Lactobacilli numbers fall, other bacteria or yeast normally present in the vagina can overgrow, causing various types of imbalance.
One of the most common states of imbalance is bacterial vaginosis — an ecosystem shift away from Lactobacillus and toward a diversity of other bugs that thrive in low-oxygen environments. Its telltale signs include itchiness around the vulva, a thin gray-white discharge and a “fishy” odor. B.V. can also make you more susceptible to S.T.I.s like chlamydia, gonorrhea and H.I.V., and has been associated with preterm birth.
Currently, antibiotics are the only recommended treatment for symptomatic B.V., but experts say they’re an imperfect solution. Like a forest fire, they tend to wipe out not only the infection, but most of the vagina’s microbial inhabitants, leading to an imbalance that can lead to future infections. Vaginal probiotics, their makers claim, could be a simple and effective alternative, adding “good” microbes and strengthening the ecosystem before or during an infection.
So are vaginal probiotics the solution to yeast infections and B.V.?
They might be in the future. But the pills and suppositories available today have not yet been proven to work.
Based on what experts know, vaginal probiotics must satisfy two criteria to be effective: They should contain a vaginal strain, like Lactobacillus crispatus, that has been shown to protect against infection; and they should be inserted directly into the vagina.
Most of the products on the market, however, don’t check both of those boxes. Many oral and suppository probiotics contain bacterial species cultivated from the gut or from fermented foods that aren’t natural inhabitants of the vagina. “Biologically, I don’t think it makes a whole lot of sense,” said Catriona Bradshaw, a sexual health expert at Monash University in Melbourne, Australia, who researches bacterial vaginosis.
And the majority of vaginal probiotics on the market are oral capsules, which studies suggest are unlikely to alter vaginal flora. That’s because the bacteria would have to make the treacherous journey down through the gut, out the anus and then crawl their way over to the vagina.
“That is not happening,” said Jacques Ravel, a microbiologist at the University of Maryland School of Medicine who studies the vaginal microbiome. (Dr. Ravel is also chief scientist at LUCA Biologics, a biotech company developing probiotics for B.V. and preterm birth.)
A few products are meant to be taken vaginally — including FloraFemme vaginal probiotic suppositories ($50 for 6 capsules), VagiBiom suppositories ($66 for 30 suppositories) and Physioflor vaginal tablets ($27 for two tablets).
Some, but not all, of the suppositories available contain the right strains. But a larger issue with both oral and suppository probiotics (and the wider supplement market in general), is that none of these products have undergone the rigorous safety and efficacy testing required for Food and Drug Administration approval. The studies that do exist generally have small sample sizes, lack control groups and are not blinded or randomized.
“Most of these products don’t have the quality control that is required for actual pharmaceuticals,” Dr. Bradshaw said. “So you don’t really know what you’re putting in your mouth — or vagina, for that matter.”
In a 2020 review of studies on 22 vaginal probiotics taken as suppositories, all were found to be safe. Some even showed promise in preventing and treating B.V. However, none of the strains stuck around the vagina for long, meaning they were unlikely to be beneficial in the long run. They also did not prevent yeast infections.
“It just seems like such a great idea, right? It seems so logical,” Sharon Hillier, a microbiologist at Magee-Womens Research Institute who studies the vaginal microbiome and S.T.I.s., said of vaginal probiotics. “And yet study after study has failed to identify a real benefit for most of these products.”
Dr. Carolyn Ross, an OB-GYN and medical adviser for Stix, a company that sells vaginal probiotics among other women’s health products, said in an email that while the evidence on vaginal probiotics is limited, published studies do suggest “a beneficial effect of probiotics on the prevention of bacterial vaginosis.” She cited two meta-analyses that did note beneficial effects, but also cautioned that large, high-quality studies “are urgently needed” before broad conclusions could be drawn.
Bobban Subhadra, a microbiologist and chief executive of Biom Therapeutics, which makes vaginal probiotic suppositories, said that while his company has not yet published any studies on vaginal probiotic effectiveness, they have several in the works.
Some researchers are hopeful that better studies will bear out the potential of vaginal probiotics. “I do think it’s an area of great promise,” said Dr. Janneke van de Wijgert, an infectious disease researcher at Utrecht University in the Netherlands and lead author of the 2020 review. “But we’re not there yet.”
Is there anything I should take or do to ensure my vaginal microbiome is healthy?
In the future, there may be research-backed ways to strengthen the vagina’s bacterial defenses, possibly by combining effective probiotics with antibiotics or even by performing vaginal microbiome transplants.
But for now, experts simply don’t know enough about the vaginal microbiome to be able to reliably shift it in the direction of better health. So while vaginal probiotics are unlikely to hurt you, they also aren’t likely to help you — whether you have an infection or not. And unless you’re actively ailing, the best way to maintain “optimal feminine balance” is also the simplest: Don’t do anything special. And certainly don’t spend money on unproven treatments for your most intimate of landscapes.
“Women have enough things in this world to worry about,” Dr. Hillier said. “The bottom line is that it’s the doorway to your reproductive tract. Treat it with respect, and love it.”
Rachel E. Gross is a science writer based in Brooklyn and the author of “Vagina Obscura: An Anatomical Voyage.”
Which flu shot should I choose? And what are cell-based and ‘adjuvanted’ vaccines?
Published: June 16, 2022 6.01am AEST
- Tin Fei Sim Senior Lecturer, Curtin Medical School, Curtin University
Tin Fei Sim is affiliated with Curtin University and the Pharmaceutical Society of Australia.
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With Australians learning to live with COVID and resuming international travel, cases of influenza are steadily rising.
Getting a flu shot reduces your chance of catching the flu caused by four flu virus strains covered by the vaccine, and reduces the risk of severe complications and hospitalisations.
An annual flu vaccine is recommended for adults and children six months and older – unless you have a history of anaphylactic reactions to the vaccine or your doctor advises against it.
There are different brands and types of flu vaccines. So when booking in for your shot, your health provider will discuss the best option for you.
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What are the options?
If you’re over 65, you’re likely to be offered an “adjuvanted” (Fluad Quad) vaccine. Those aged over 60 can also access the high-dose vaccine (Fluzone High-Dose Quad).
If you want to avoid vaccines made with eggs, you can ask for a cell-based vaccine (Flucelvax Quad).
But for most other Australians, there isn’t much of a difference between brands – Vaxigrip Tetra, Fluarix Tetra, Afluria Quad, FluQuadri, Influvac Tetra – aside from their suitability for different age groups.
GPs and pharmacists will generally stock one or two of these brands or whichever their state or territory governments supplies.
Unlike in previous years, all eight flu vaccines available this year are “quadrivalent”, meaning each vaccine protects against four strains of flu viruses.
The strains are predicted to be the most commonly circulating strains, based on trends observed in the Northern Hemisphere winter.
Flu vaccines are “inactivated”, which means they don’t contain live viruses and can never give anyone the flu.
For people 65 years and older, “adjuvanted” or immune-boosting (Fluad Quad®) or high-dose vaccines (Fluzone High-Dose Quad®) are recommended, as older people tend to have weaker immune systems.
Vaccines work by activating a person’s own immune system. The “adjuvanted” vaccine activates a stronger immune response and is therefore more effective at preventing the flu in older age groups than the standard vaccines.
High-dose vaccines deliver a higher dose than standard flu vaccines and are also more effective than the standard vaccines at reducing transmission and preventing severe disease in older age groups.
Adjuvanted vaccines are free for over-65s under the National Immunisation Program.
If you’re 60 or over, you can choose a high-dose vaccine, although you may have to pay for it, depending on local government programs.
Cell-based vaccines don’t use eggs
The flu vaccines are either egg-based or cell-based. Traditionally, flu vaccines were egg-based, meaning the flu viruses were grown in fertilised hens’ eggs.
But people with egg allergies can safely get the egg-based flu vaccine. The amount of egg protein left in each vaccine at the end of the production process is less than 1 microgram, much less than the estimated amount of 130 micrograms required to cause an allergic reaction.
In recent years, newer medical technology has led to the production of cell-based flu vaccines. Here, the virus is grown in host cells. So people who wish to avoid egg products may choose a cell-based vaccine instead.
Currently, Flucelvax Quad is the only cell-based flu vaccine approved for use in Australia and is also suitable for children from two years of age.
This is because the viruses used to make cell-based vaccines are more similar to circulating wild flu viruses – and the closer it resembles the real thing, the more effective it is.
However, Flucelvax Quad isn’t currently funded under the National Immunisation Program, so you’ll need to pay yourself, even if you’re eligible for a free vaccine under the national program.
When is the best time to get vaccinated?
It takes seven to 14 days for our body to respond to a vaccine. Once you receive the vaccine, your body starts to recognise the four strains of flu viruses and starts to develop an immune response over the course of about two weeks.
Once this occurs, when you come into contact with one or more of these four strains of viruses, your body’s own immune response will be able to protect and prevent you from getting sick.
The flu season typically peaks in Australia between July to September. The vaccine will provide the highest level of protection for three to four months. So late May to early June is generally the best time to get it.
For people travelling overseas, your doctor or pharmacist can advise you on what’s best for you based on where and when you’re travelling.
The flu vaccine can also be given at the same time as most other vaccines, including COVID vaccines. It’s also safe – and recommended – in pregnancy.
Read more: Should I get the flu shot if I’m pregnant?
What are the side effects?
People may experience cold and flu-like symptoms for up to 24–48 hours after getting the vaccine. This shows the body’s immune response is kicking in and the vaccine is working.
You can take over-the-counter pain medications such as paracetamol or ibuprofen to relieve these symptoms.
Other common side effects may include local injection site reactions such as redness, mild swelling and tenderness. This should subside within 48 hours without any treatment. Applying ice or a cold pack can help.
Some people may develop more severe reactions, including anaphylaxis (a severe, life-threatening allergic reaction) in extremely rare circumstances. This is also why your doctor or pharmacist recommends waiting on-site for 15 minutes after vaccination for monitoring.
If you’ve had a severe reaction to any vaccine in the past, it’s important to tell your doctor or pharmacist
Six tips to improve your mental health
Published May 17, 2022 | Originally published on University of Alabama SOM News
According to a recent University of Alabama at Birmingham study, the pandemic increased the prevalence of people with depression or anxiety symptoms in America substantially — from about 11% of people in 2019 to close to 40% in 2021.
May is National Mental Health Awareness Month. UAB experts provide six ways to improve your mental health.
Limit your sources and amount of news intake
“Constantly listening to news and/or cable talk shows will only add to one’s anxiety in times of an outbreak or disaster,” said Laura Dreer, PhD, a clinical psychologist in the UAB Department of Ophthalmology and Vision Sciences. “While it’s important to stay updated, limiting updates to once a day will help you stay more in the moment and lower your stress levels. This is particularly important for parents with young children and to be mindful of keeping the news to a minimum.”
Streamline incoming news by picking a few reputable sources rather than relying on potentially unreliable social media.
Set boundaries for discussion topics
Often loved ones ask well-intentioned — or even targeted — questions that can be triggering, invasive or uncomfortable, and dodging conversations can feel overwhelming to those affected.
Write out and practice a few short statements that express boundaries. While it may be tempting to try to beat around the bush or sugarcoat attempts at establishing healthy boundaries to make it less upsetting for the other person, it is best to keep boundary statements short, respectful and clear:
- “That is not something I am open to discussing today.”
- “Please do not say things like that to me or around my children.”
Phrases like these can go a long way in communicating where the boundary is. In some situations where repeated attempts to draw healthy boundaries are made and a loved one continues to cross that line, it may be best to plan ahead to limit the amount of time at events that include the individuals or to gracefully exit the event if it becomes an issue in the moment.
Read a book
Read a positive book, a murder mystery or even a manual, as reading has proven health benefits. According to Scholastic, regular reading can decrease stress levels by up to 68% and can lengthen life by up to two years.
Get enough sleep
Another great way to improve mental health is to increase the number of hours and the quality of sleep.
“It can be tempting to stay up later, especially when there is a long to-do list,” Watson said. “But practicing good sleep hygiene can be a great tool to manage stress.”
According to the UAB Medicine Sleep/Wake Disorders Center, sleep-promoting behaviors include:
- No electronics one to three hours before bedtime. Electronics interrupt physiological sleep mechanisms and stimulate the brain. If you must be on your computer or phone at night, wear glasses that block blue light.
- A more sleep-friendly environment that may include dimmer lights, a cooler temperature and no television. Patterson says it is best to have a comfortable mattress and pillow, with no dogs, cats or children in the bed.
- Avoid heavy meals late in the evening. Indigestion and heartburn can interrupt sleep.
- Avoid caffeine three to four hours before turning out the lights, and no alcohol, nicotine or marijuana one to three hours before sleep. Insomnia is a primary sleep disorder in the United States, and these stimulants can prevent people from falling asleep.
- Daytime exercise. Even a small amount of daily aerobic exercise can improve sleep quality.
- A consistent bedtime. Shift workers have an especially hard time with this, but those on routine nights do better than those who do rotating shifts.
“Mindfulness means being fully present in the moment,” Dreer said. “It is easy for many of us to get caught up in things that have happened in the past or in the future while missing out on living in the present.”
Combat the pinging notifications and things vying for attention by practicing a bit of mindfulness at the start or end of your day — or even as a lunchtime break. Check out mindfulness platforms and apps that are easily accessible to practice meditation or breathing.
Add stretching into a fitness routine
Stretching is popular in fitness programs, athletic preparations and injury rehabilitation and beneficial for several muscle conditions. It is known to lessen stress, relieve headaches and backaches, and increase muscle flexibility and bone strength.
When stretching, UAB Medicine’s Orthopedic Services says the important things to consider are:
- Make sure the muscles are warm and pliable before pushing them to the limits of their range of motion. As part of a dynamic warm-up, that may include walking or very light jogging prior to going through a full functional stretching regimen.
- Correct technique. Once progress is made and a more aggressive stretching routine begins, remember that correct technique is a top priority. Work closely with a strength and conditioning professional whenever possible to perfect form before moving to advanced levels.
- Focus on the major areas of the body that help with mobility. These areas include calves, hamstrings, hips and thighs. For upper-body relief, use moves that stretch the shoulders, neck and lower back.
- Make the body’s muscles work, but do not stretch until it hurts. Proper stretches should never cause pain.
- Know the body’s limits. According to UAB Orthopaedics, some research has shown that stretching the muscles before they are warmed up can cause damage. Exercising first gets blood flowing to muscle tissue, making it pliable. However, that applies only to light physical activity, such as a quick walk, before stretching.
This article was originally published on University of Alabama SOM News.
Why are my hands and feet always cold? And when should I be worried?
Published: June 1, 2022 10.50am AEST
- Christian Moro Associate Professor of Science & Medicine, Bond University
- Charlotte Phelps PhD Student, Bond University
The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.
Republish our articles for free, online or in print, under Creative Commons licence.
Do you, or someone you know, often complain of having constantly cold hands and feet? In most cases, this is not a problem, and simply due to the body maintaining its temperature.
For our bodies, blood is a fantastic store of heat. By diverting blood to the skin, heat is transferred to the outside air, helping to cool us down. This is why we might look a bit “flushed” on a hot day.
On the other hand, when we are feeling cold, the blood vessels in our skin narrow so less blood is diverted there. Less blood means less warmth, and this becomes particularly noticeable in the hands and feet.
It’s a normal process, and shows that our body is doing its job of maintaining a normal internal temperature and protecting our organs.
Trusted, thoughtful and independent climate coverage needs reader support.
Normally, the feeling is only temporary. But if someone always has cold hands and feet, even when their body is quite warm, it could be a sign that something else is contributing.
Could there be other causes?
Anything that induces a narrowing of blood vessels can impact how warm your extremities feel.
This could be from causes such as Raynaud’s phenomenon, in which some blood vessels going to the extremities temporarily narrow.
People with Raynaud’s typically present with very pale and cold fingers or toes.
In some cases, it is not clear why people exhibit symptoms of Raynaud’s. In other instances, it may be a result of more serious underlying causes, such as an immune deficiency or associated with high blood pressure.
But other factors could also be behind unusually cold hands. Anything that blocks blood getting through the vessels can result in colder extremities.
For example, people with uncontrolled diabetes have a higher chance of fatty deposits forming inside blood vessels, making them narrow and hard, and inhibiting blood flow.
Trauma or tissue damage could also result in inhibited blood flow to the area. If someone has undergone hand or arm surgery, or had a past injury, it may impact how warm their extremities feel.
Another possible cause is anaemia, which can impair the transport of oxygen-rich blood around the body and result in cold hands and feet.
Smoking can also be behind a case of icy fingers and toes; nicotine causes the blood vessels to narrow and reduces blood flow.
When is it a concern?
Under normal circumstances, cold hands and feet are not a worry.
But just keep in mind that it’s due to a reduced blood supply reaching the extremities. Over time, this can result in brittle nails, dry or cracked skin, discoloured skin, and a feeling of tingling or numbness in the areas.
These regions may also be less sensitive when cold; and it can even become quite painful to use your fingers or feet when they are ice cold.
A reduced blood supply might make the hands and feet slower to heal if injured, potentially allowing infections to persist and grow.
Over time, inhibited blood flow can also damage the nerves as well. The impact on the nerves, alongside increased risks of infection, can sometimes result in the requirement for amputations.
So if consistently cold hands and feet are a worry, it’s always worth mentioning this to your family doctor.
What should I do about my cold hands and feet?
If you do start to feel a temporary chill in your extremities, stick to the basics. You can:
- pop on a pair of thick socks; this is also beneficial for sleep, as research shows warming up the feet can help with sleep quality
- wear gloves or mittens
- wash your hands in warm water and immediately dry them afterwards
- avoid abrupt changes in temperature by wearing layers of warm clothing to maintain your core temperature
- steer clear of air-conditioned rooms where possible and find cozy spots in the sun during the day.
In the long term, improving your circulation is key. It helps warm your hands and feet, by ensuring the body efficiently pumps blood to where it needs to go.
This can be achieved with daily exercise, moving around at regular intervals during the day, and stretching your arms and legs. And of course, maintaining a healthy diet.
This way, even if you get a temporary chill, you’ll be back to warm in no time!
LDN: A Game Changer for Many Patients – By Pamela W. Smith, MD, MPH, MS
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I have been using LDN for the last 8 years for a whole range of medical condition. Sometimes the results have been dramatic. Most of these patients had seen a number of doctors/specialists with varying results. Not everyone responds so well to LDN, but it is worth trying as it is so safe and does not interfere with other treatment given. A number of specialists are now starting to use it as well, which is good development.
LDN: A Game Changer for Many Patients
By Pamela W. Smith, MD, MPH, MS
I have been blessed to be a physician for 44 years. It is rare in my career that there is a drug that comes out that is a game-changer for many patients. Compounded low-dose naltrexone (LDN) is one of those medications.
Naltrexone has traditionally been used for drug overdose. Naltrexone is a reversible competitive antagonist at μ-opioid and κ-opioid receptors, which when used at standard doses of 50 to 150 mg was initially intended for use in opioid and alcohol use disorders.
In recent years, there have been novel and significant findings on the off-label usage of naltrexone in much lower dosage forms for many purposes. The following are some examples.1
- Immune modulator in autoimmune diseases
- Chronic pain control
- Weight loss
- Reduction of cytokine storm
Some of the proposed mechanisms of action include blockade of the opioid growth factor receptor (OGFR) axis, which normally stimulates B and T cell proliferation and stimulation of beta-endorphin and enkephalin release, which has anti-inflammatory effects on T and B cells.2 In addition, a study examined how LDN also helped to normalize immune system function.3 Moreover, low-dose naltrexone has shown promise to reduce symptoms related to chronic pain conditions such as fibromyalgia, inflammatory bowel conditions, and multiple sclerosis. The mechanism of action appears to be modulation of neuro-inflammation, specifically, the modulation of the glial cells and the release of inflammatory chemicals in the central nervous system.4 Consequently, LDN has also been shown to be very effective for pain control.5
Low-dose naltrexone has many references in the medical literature concerning its use in different diseases. This exposé will explore the use of LDN in a multitude of medical disorders.
Autoimmune Diseases That Are Not Dermatological Disorders
Consider using LDN for every patient with an autoimmune disease. For example, LDN has been reported to reduce not only self-reported pain in Crohn’s but also lower objective markers of inflammation and disease severity. The response rate of LDN in Crohn’s disease was over 80 % of the participants exhibiting significant improvement in several studies. 6-8 In another study, low-dose naltrexone induced clinical improvement in 74.5%, and remission in 25.5% of patients with inflammatory bowel disease. In addition, LDN directly improved epithelial barrier function by improving wound healing and reducing mucosal endoplasmic reticulum stress levels in yet another trial. The authors concluded that low-dose naltrexone treatment was effective and safe and could be considered for the treatment of refractory IBD patients.9
Low-dose naltrexone has also shown some promise in improving disease severity in multiple sclerosis (MS). LDN significantly improved mental health quality of life indices.10 Moreover, a 17-week randomized, double-blind, placebo-controlled, parallel-group, crossover-design clinical trial was conducted at two universities. A total of 96 adult patients ages 15 to 65 years with relapsing-remitting or secondary progressive clinically definite MS with disease duration longer than six months enrolled into a study. The study clearly illustrates that LDN is a relatively safe therapeutic option.11 Likewise, a trial involving MS patients revealed that the use of LDN resulted in inhibited cell proliferation.12
Rheumatoid arthritis is an additional autoimmune disease that LDN works effectively for. In a trial, in persistent LDN users, there was a 13% relative reduction in daily doses of all medicines and a 23% reduction of analgesics. Specifically, persistent LDN users had significantly reduced daily use of NSAID and opioids, and a lower proportion of users of DMARDs, TNF-alpha antagonists, and opioids. The results support the hypothesis that persistent use of LDN reduced the need for medication used in the treatment of rheumatic and seropositive arthritis.13
The discovery of the widely expressed transient receptor potential melastatin 3 (TRPM3) as a nociceptor channel substantially targeted by certain opioid receptors, and its implication in calcium (Ca2+)-dependent natural killer (NK) cell immune functions has raised the possibility that TRPM3 may be pharmacologically targeted to treat characteristic symptoms of myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS). The authors of a study reported that ME/CFS patients taking LDN have restored TRPM3-like ionic currents in NK cells. These data support the hypothesis that LDN may have potential as a treatment for ME/CFS by characterizing the underlying regulatory mechanisms of LDN treatment involving TRPM3 and opioid receptors in NK cells.14
Dermatological Disorders: Both Autoimmune and Non-Autoimmune Related
Dermatology is encountering increasing rates of autoimmune diseases manifesting in primary skin conditions that are difficult to treat without a risk of immunosuppression.
Hailey-Hailey disease, also calledbenign familial pemphigus, is a late-onset blistering disorder that affects the flexures. There are typically painful erosions and cracks in affected areas. Lesions generally begin between 20 and 40 years of age. Maceration and superinfections are frequent. The lesions are typically distributed symmetrically within intertriginous regions such as the retroauricular folds, lateral aspects of the neck, axillae, umbilicus, inguinal, and perianal regions. The disease is characterized by a chronic relapsing course with spontaneous remissions and multiple recurrences. Severe disease can be very frustrating and have a major psychological and social impact. Low-dose naltrexone has been shown to be an effective therapy.15
Lichen planopilaris is an inflammatory, primary cicatricial alopecia with several different patterns of hair loss. It is considered a follicular variant of lichen planus. Findings suggest that low-dose naltrexone is safe and effective in the treatment of Hailey-Hailey disease and lichen planopilaris. Furthermore, LDN successfully treated the pruritus associated with this and other dermatological disorders.16,17
Likewise, LDN has been shown to improve dermatologic conditions such as systemic sclerosis.18
In addition, a study revealed that the PI3K/AKT/mTOR pathway was significantly inhibited by 1% Naltrexone HCl in XemaTop™, suggesting protein synthesis was affected. The production of IL-6 was inhibited by 70% in drug-treated tissues. The results suggest that this compounded drug is efficacious in down-regulating molecular markers associated with the pathogenesis of psoriasis and provides a basis for a clinical evaluation of 1% Naltrexone HCl in XemaTop™ in psoriasis patients.19 Moreover, a patient with a history of psoriasis was treated with 4.5 mg of LDN during a flare-up. She showed significant improvement in her flare-up and psoriasis remission after only three months of 4.5 mg of LDN nightly.20 In another case report, a 60-year-old white female was successfully treated with LDN for her moderate plaque psoriasis over a six-month period. 21
Guttate psoriasis is aless common form of psoriasis. It manifests with numerous small, teardrop shaped, scaly plaques on the trunk and extremities. The etiology includes both environmental and genetic factors. It commonly arises three to four weeks following a beta hemolytic streptococcal infection. It is more common in children and adolescents than adults.22 LDN has been shown to be beneficial in a case report: 80% improvement was seen in two months.23
Atopic dermatitis is a pruritic, hereditary skin disorder and is the most common form of eczema. The life-time prevalence is 10% to 20% with many cases starting as a baby. Twenty percent to 40% of people continue to have atopic dermatitis as adults.24 A double-blind, placebo-controlled study studied 38 patients with eczema complaining of pruritus. The study found that LDN was more effective than placebo in the treatment of pruritus in patients with eczema.25
As you have seen, LDN likewise works wonderfully topically for itching. The objective of another trial was to correlate the clinical efficacy of topically applied naltrexone in different pruritic skin disorders to a change of epidermal μ-opiate receptor (MOR) expression. The findings supported by the biopsy showed regulation of MOR expression in the epidermis after treatment with topical naltrexone.26
Low-dose naltrexone has been shown to be a promising complementary medication for patients with a broad range of medical disorders as already discussed. Although not a proven cure, evidence from clinical trials supports LDN as being a valuable adjunct for disorders in which the immune system plays a centralized role. One of these diseases processes is cancer. Clinical trials have proposed a unique mechanism(s) allowing LDN to affect tumors, including non-small cell lung cancer, at the cellular level by augmenting the immune system.27,28
Moreover, it has been reported that at lower doses naltrexone is able to reduce tumor growth by interfering with cell signaling. Scientists evaluated the gene expression profile of a cancer cell line after treatment with low-dose naltrexone and assessed the effect that adapting treatment schedules with LDN may have on enhancing efficacy. LDN had a selective impact on genes involved with cell cycle regulation and immune modulation. Similarly, the pro-apoptotic genes BAD and BIK1 were increased only after LDN use. Continuous treatment with LDN had little effect on growth in different cell lines; however, altering the treatment schedule to include a phase of culture in the absence of drug following an initial round of LDN treatment, resulted in enhanced cell killing. Furthermore, cells pre-treated with LDN were more sensitive to the cytotoxic effects of a number of common chemotherapy agents. This data supports further the idea that LDN possesses anticancer activity, which can be improved by modifying the treatment schedule.29
Irritable Bowel Syndrome (IBS)
Forty-two IBS patients participated in an open-label study. Global assessment improved in 76% of the patients that used LDN. There were no significant adverse reactions.30
Low-dose naltrexone has been used off-label for treatment of pain and inflammation in multiple sclerosis, Crohn’s disease, fibromyalgia, and other diseases.31 At the low dosage level, naltrexone exhibits paradoxical properties, including analgesia and anti-inflammatory actions, which have not been reported at larger dosages.32-35
The mechanisms by which LDN might relieve pain are not all known. Among the several postulated explanations are that by blocking opioid receptors, LDN provokes a compensatory elevation of endogenous opioids.36,37 In addition, LDN attenuates inflammatory responses by blocking receptors on immune cells.38 It also reduces pro-inflammatory cytokines and superoxides.39-41 These effects appear to be unique at low dosage, compared to FDA-approved dosage for alcohol and opioid dependence.42 When used in doses of 1 to 5 mg, LDN acts as a glial modulator with a neuroprotective effect via inhibition of microglial activation. It also binds to toll-like receptor 4 and acts as an antagonist, therefore inhibiting the downstream cellular signaling pathways that ultimately lead to pro-inflammatory cytokines, therefore reducing inflammatory response. In addition, LDN has been found to be neuroprotective by modulating mitochondrial apoptosis.43
Low-dose naltrexone has been used in many disease processes for pain control.
- One study showed that LDN was an effective therapy for diabetic neuropathy.44
- Another study suggests that the novel TLR4 antagonists naloxone and naltrexone can each fully reverse established neuropathic pain upon multi-day administration.45
- LDN has been shown to be an effective treatment for fibromyalgia.46 LDN reduced fibromyalgia pain significantly greater than placebo in six out of the 10 women. While the pilot study was encouraging, it had limitations such as a single-blind design. To help validate the findings, a second study in 30 women with fibromyalgia was conducted. In that double-blind, crossover, counterbalanced study, 57% of the participants were observed to exhibit a significant (1/3) reduction of pain during LDN. At the end of the LDN treatment, half of the participants reported feeling “much improved” or “very much improved” from LDN.47 Moreover, in a 10-week, single-blind, crossover pilot trial the authors tested the immune effects of eight weeks of oral administration of low-dose naltrexone (LDN). They found that LDN was associated with reduced plasma concentrations of interleukin (IL)-1β, IL-1Ra, IL-2, IL-4, IL-5, IL-6, IL-10, IL-12p40, IL-12p70, IL-15, IL-17A, IL-27, interferon (IFN)-α, transforming growth factor (TGF)-α, TGF-β, tumor necrosis factor (TNF)-α, and granulocyte-colony stimulating factor (G-CSF). They also found a 15% reduction of fibromyalgia-associated pain and an 18% reduction in overall symptoms.48
- In a case report, the patient was a 35-year-old male who had experienced nonspecific left-side chronic low back pain for two years and many therapies had been tried. LDN successfully improved his refractory chronic low back pain.49
- Complex regional pain syndrome (CRPS) is a neuropathic pain syndrome, which involves glial activation and central sensitization in the central nervous system. The authors describe positive outcomes of two CRPS patients, after they were treated with low-dose naltrexone in combination with other CRPS therapies. Prominent CRPS symptoms remitted in these two patients, including dystonic spasms and fixed dystonia (respectively), following treatment with low-dose naltrexone. These patients had previously failed conventional therapies.50
Given the proposed dopaminergic mechanism of LDN, researchers examined its efficacy as augmentation for depressive breakthrough on pro-dopaminergic antidepressant regimens. LDN was shown to be beneficial for breakthrough symptoms of major depressive disorders that are already on antidepressants.51
Moreover, since LDN can upregulate endogenous opioid activity, it may also have a role in promoting stress resilience, exercise, social bonding, and emotional well-being, as well as amelioration of psychiatric problems such as autism and depression. It is proposed that LDN can be used effectively as a buffer for a large variety of bodily and mental ailments through its ability to beneficially modulate both the immune system and the brain neurochemistry that regulate positive affect.52
Low-dose naltrexone refers to daily dosages of naltrexone that are approximately one-tenth of the typical opioid addiction treatment dosage. In most published research, the daily dosage is 4.5 mg with the dose ramped up to this level over a three-week time frame—although the dosage can vary a few milligrams below or above that common value.53-55 Consequently, there are now many dosage forms used for low-dose naltrexone, including ultralow-dose naltrexone. The closely related concept of ultralow-dose naltrexone involves the use of microgram, nanogram, and picogram dosages of naltrexone co-administered with opioid analgesics.56
There are a few possible short-term side effects that may occur with the use of LDN: insomnia, vivid dreams, fatigue, loss of appetite, nausea, hair thinning, mood swings, and mild disorientation. They are usually dose dependent. Consequently, lowering the dose usually resolves the short-term symptoms. Potential long-term side effects include the following: possible liver and kidney toxicity, possible tolerance to the beneficial effects (rebound effect), and other unknown sequelae. Low-dose naltrexone is contraindicated in individuals with acute hepatitis, liver failure, and recent or current opioid use or alcohol abuse. Although, as previously mentioned, ultra-low-dose naltrexone is now being used judiciously if the patient is on a mild narcotic in limited cases.
LDN has been used by practitioners world-wide for many disorders. 57
There are many etiologies of inflammation. One of them is infection.58 Coronavirus disease 2019 (COVID-19) and the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) poses a particular risk to people living with preexisting conditions that impair immune response or amplify a pro-inflammatory response. Early identification of possible hyperinflammation in these patients, and all individuals, is fundamental in having effective therapies for patients with COVID-19 and post COVID-19 syndrome.59
A very important article points out that the critical point where progressive COVID-19 ensues, appears to center on loss of the immune regulation between protective and altered responses due to exacerbation of the inflammatory components. 60
In our practice, we use LDN to treat patients with all stages of COVID, from asymptomatic COVID to severe cases of COVID, to COVID-Long Haul Syndrome and have had excellent results.
Low-dose naltrexone plays a major role in the treatment of many different diseases. In the world of medicine, it is truly a game changer.
1 Li, Z., et al., “Low-dose naltrexone (LDN): A promising treatment in immune-related diseases and cancer therapy,” Int Immunopharmacol 2018; 61:178-84.
2. Strazzulla, L., et al., “Novel treatment using low-dose naltrexone for lichen planopilaris,” Jour Drugs Derm 2017; 16(11):1140-42.
3. Bihari, B., “Low-dose naltrexone for normalizing immune system function,” Altern Ther Health Med 2013; 19(2):56–65.
4. Kim, P., et al., “Low-dose naltrexone for chronic pain: Update and systemic review,” Curr Pain Headache Rep 2020; 24(10):64.
5. Patten, D., et al., “The safety and efficacy of low-dose naltrexone in the management of chronic pain and inflammation in multiple sclerosis, fibromyalgia, Crohn’s disease and other pain disorders,” Pharmacotherapy 2018; 38(3):382-89.
6. Smith, J., et al., “Therapy with the opioid antagonist naltrexone promotes mucosal healing in active Crohn’s disease: a randomized placebo-controlled trial,” Dig Dis Sci 2011; 56(7):2088–97.
7. Smith, J., et al., “Low-dose naltrexone therapy improves active Crohn’s disease,” Amer Jour Gastroenterol 2007; 102(4):820–28.
8. Smith, J., et al., “Safety and tolerability of low-dose naltrexone therapy in children with moderate to severe Crohn’s disease: a pilot study, Jour Clin Gastroenterol 2013; 47(4):339–45.
9. Lie, M., et al., “Low dose naltrexone for induction of remission in inflammatory bowel disease patients,” Jour Transl Med 2018; 16(1):55.
10. Cree, B., et al., “Pilot trial of low-dose naltrexone and quality of life in multiple sclerosis,” Ann Neurol 2010; 68(2):145–50.
11. Sharafaddinzadeh, N., et al., “The effect of low-dose naltrexone on quality of life of patients with multiple sclerosis: a randomized placebo-controlled trial,” Mult Scler 2010; 16(8):964–69.
12. Ludwig, M., et al., “Serum [Met5]-enkephalin levels are reduced in multiple sclerosis and restored by low-dose naltrexone,” Exp Biol Med 2017; 242(15):1524–33.
13. Raknes, C., et al., “Low dose naltrexone: Effects on medication in rheumatoid and seropositive arthritis. A nationwide register-based controlled quasi-experimental before-after study,” PLoS One 2019; 14(2):e0212460.
14. Cabanas, H., et al., “Potential therapeutic benefit of low dose naltrexone in myalgic encephalomyelitis/chronic fatigue syndrome role in transient receptor potential melastatin 3 ion channels in pathophysiology and treatment,” Front Immunol 2021; 12:687806.
15. Albers, L., et al., “Treatment of Hailey-Hailey disease with low-dose naltrexone,” JAMA Dermatol 2017; 153(10):1018-20.
16. Ekelem, C., et al., “Utility of naltrexone treatment for chronic inflammatory dermatologic conditions: A systematic review,” AMA Dermatol 2019; 155(2):229-36.
17. Jaros, J., et al., “Low-dose naltrexone in dermatology,” Jour Drugs Dermatol 2019; 18(3):235-38. 18. Fretch, T., et al., “Low-dose naltrexone for pruritus in systemic sclerosis,” Int Jour Rheuatol 2011; 2011:804296.
19. Kendice, I., et al., “In vitro evaluation of Naltrexone HCl 1% topical cream in XemaTop™ for psoriasis,” Arch Dermatol Res 2020; 312(2):145-54. LDN: A Game Changer for Many Patients References Complete References Townsendletter.com Subscribe Today!
20. Monasterio, E., “Low-dose naltrexone: An alternative treatment for erythrodermic psoriasis,” Cureus 2019; 11(1):e3943.
21. Bridgman, A., et al., “Treatment of psoriasis vulgaris using low-dose naltrexone,” JAAD Case Rep 2018; 4:827-29.
22. Saleh, D., et al., Guttate Psoriasis. Stat Pearls (Internet). Treasure Island, FL: StatPearls Publishing, 2022.
23. Muller, G., et al., “Compounded low-dose naltrexone for the treatment of guttate psoriasis: A case report,” Int Jour Pharm Compounding 2018; 22(4):270-78.
24. Habif, T., Atopic Dermatitis in Clinical Dermatology 5th Ed., St. Louis: Mosby, 2010.
25. Malekzad, F., et al., “Efficacy of oral naltrexone on pruritus in atopic eczema: a double-blind, placebocontrolled study,” Jour Eur Acad Dermatol Venereol 2009; 23(8):948-50.
26. Bigliardi, P., et al., “Treatment of pruritus with topically applied opiate receptor antagonist,” Jour Amer Acad Derm 2007; 56(6):979-88.
27. Miskoff, J., et al., “Low dose naltrexone and lung cancer: a case report and discussion,” Cureus 2018; 10(7):e2924.
28. Li, Z., et al., “Low-dose naltrexone (LDN): a promising treatment in immune-related diseases and cancer therapy,” Int Immunopharmacol 2018; 61:178–84.
29. Liu, W., et al., “Naltrexone at low doses upregulates a unique gene expression not seen with normal doses: Implications for its use in cancer therapy,” Int Jour Oncol 2016; 49(2):793-802.
30. Kariv, R., et al., “Low-dose naltrexone for the treatment of irritable bowel syndrome: a pilot study,” Dig Dis Sci 2006; 51(12):2128-33.
31. Ibid., Patten.
32. Gold, M., et al., “Naltrexone, opiate addiction, and endorphins,” Med Res Rev 1982; 2(3):211–16. 33. Bihari, B., et al., “Low-dose naltrexone for normalizing immune system function,” Altern Ther Health Med 2013;19(2):56–65.
34. Zagon, I., et al., “Opioid antagonist modulation of murine neuroblastoma: a profile of cell proliferation and opioid peptides and receptors,” Brain Res 1989; 480(1–2):16–28.
35. Smith, J., et al., “Low-dose naltrexone therapy improves active Crohn’s disease,” Amer Jour Gastroenterol 2007; 102(4):820–28.
36. Gold, M., et al., “Naltrexone, opiate addiction, and endorphins,” Med Res Rev 1982; 2:211-46.
37. Trofimovitch, C., et al., “Pharmacology update: Low-dose naltrexone as a possible nonopioid modality for some chronic, nonmalignant pain syndromes,” Amer Jour Hosp Palliat Care 2019; 36(10):907-12.
38. Liu, B., et al., “Neuroprotective effect of naloxone in inflammation-mediated dopaminergic neurodegeneration: Dissociation from the involvement of opioid receptors,” Methods Mol Med 2002; 79; 43-54.
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I’m getting older, how can I prevent falls?
Published: June 1, 2022 1.51pm AEST
- Anne Tiedemann Professor of Physical Activity and Health, University of Sydney
- Cathie Sherrington Professor, University of Sydney
- Kim Delbaere Senior Principal Research Scientist, Neuroscience Research Australia
Anne Tiedemann receives funding from the National Health and Medical Research Council.
Cathie Sherrington receives funding from the National Health and Medical Research Institute.
Kim Delbaere receives funding from the National Health and Medical Research Council. Kim Delbaere is the President of the Australian and New Zealand Falls Prevention Society.
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Falls are common. Each year one in every three people aged over 65 will fall. Around one in ten falls lead to serious injury. Most of us have a friend or relative who has experienced an injury from a fall and know what a life-changing event it can be.
The most common serious injuries are fractures and brain injuries. Falls can also result in a loss of confidence, which can lead to restriction of activity and a lower quality of life. Many older people never regain their pre-fall level of function and might even struggle to keep living by themselves.
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Why do we fall in older age?
Falls happen when there is a mismatch between our physical abilities and the immediate demands of the environment or activity being undertaken.
Falls become more common as we get older because as we age, there is a natural decline in muscle strength, balance and vision, all of which are important for helping us stay upright.
The risk of falls is increased by certain medical conditions (such as Parkinson’s disease, dementia and stroke) and certain medications (such as sleeping tablets).
But this doesn’t mean falls are inevitable.
Exercise makes the most difference
Exercise that aims to improve balance and leg strength is the most effective in preventing falls.
This means exercise that is carried out while standing (not while seated), with the feet positioned close together or while standing on one leg (if safe to do so), while performing controlled movement of the upper body (leaning and reaching movements, for example).
Balance training combined with strength training for the major muscle groups is most effective.
These exercises need to be tailored to individual abilities. Middle-aged people with good physical function will benefit from harder exercises (such as functional training at a gym or boot camp incorporating squats and step-ups).
Effective exercises for people with impaired physical function or frailty will follow the same principles but should be modified for safety and effectiveness. These include everyday activities such as standing up from a seated position without using arms for support, walking up and down stairs, walking in one line, stepping over obstacles or balancing on one leg.
For lasting impacts, it’s important this type of exercise is done often. The World Health Organization recommends incorporating these exercises two to three times a week as part of the 150-300 minutes a week of moderate activity recommended for improving health.
Not everyone enjoys exercising, which means some people struggle to prioritise it. It’s very important to know nobody is ever “too old” to start exercising, and benefits are gained at any age. But don’t hold off to start exercising either – the earlier we start to build our strength and balance, the better off we will be in our older years.
Starting small and building up the amount and intensity of activity, and choosing something enjoyable, are the best ways to start. If you can’t reach a high dose of exercise initially, any amount is better than nothing.
If you like exercising in a group, consider finding a local program and invite a friend along for added support and social connection. Your state government or local council should have their classes listed online.
If you’re not sure where to start, the best thing to do is to seek professional help to select exercises that suit your abilities and health conditions. Talk to your GP, local physio or exercise physiologist.
What else can we do to prevent falls?
In addition to exercise to improve balance and strength, other actions that can reduce the risk of falls include talking to your doctor or pharmacist to review your medications, seeing a podiatrist if you have painful feet, and maximising the safety of your home environment by installing adequate lighting and grab rails, and ensuring walkways are free from clutter and liquid spills.
Falls are not inevitable as we age. We need investment in strategies to help older Australians stay active and independent, and avoid falls. Despite knowing what works to avoid them, we have no national policy or strategy to implement and fund fall prevention programs. Doing so would not only help older Australians, but the budget bottom-line too.
How Long Does Menopause Last?
And how will I know when it’s over?
Credit…Aileen Son for The New York Times
- By Alice Callahan
- April 19, 2022
Q: How long does menopause actually last? And how do you know when (or if) you are done?
The “pause” in the term “menopause” might suggest that this phase of life is brief or temporary, little more than an annoying interruption. But in reality, the symptoms associated with menopause can last for a decade or more, and at least one symptom may never get better.
Technically, menopause begins after a woman’s final menstrual period, said Dr. Stephanie Faubion, director of Mayo Clinic Women’s Health. But because there’s no sounding trumpet to mark your final period, and menstrual cycles are often irregular during this time, health providers won’t usually diagnose menopause until you’ve gone a full year with no periods, Dr. Faubion explained. “Then, you’re postmenopausal for the rest of your life,” which may be as much as one-third to one-half of a woman’s life span, she noted.
In the United States, the average age of the final menstrual period is 52, according to the U.S. Department of Health and Human Services. But anything older than 45 is considered normal, and about 95 percent of women reach this milestone by age 55, said Dr. Faubion, who is also medical director of the North American Menopause Society.
However, the symptoms of menopause can begin several years before a woman’s final period and continue for years afterward. The intensity and duration of symptoms can vary a great deal, Dr. Faubion noted; some women experience little bother and others find that symptoms interfere significantly with their lives and work.
The first sign that you’re entering the menopausal transition is usually a change in your menstrual cycles; periods can become closer together or further apart, and bleeding may be lighter or heavier, said Siobán Harlow, director of the Center for Midlife Science at the University of Michigan School of Public Health. These changes can be unpredictable and unnerving, and in women who experience heavier periods, it’s possible to have a dangerous amount of blood loss, warranting medical care, Dr. Harlow said.
At the same time, fluctuations in estrogen can cause someone to “start having hot flashes and night sweats, or get a migraine headache, or not sleep well, or feel super irritable,” Dr. Faubion said. Then, they might have a few normal cycles and a respite in symptoms, followed by a resurgence, she said. An array of other symptoms can also occur with the menopausal transition, including depression, anxiety, brain fog, changes to skin and hair, joint pain and vaginal dryness.
Once you go 60 days without bleeding, you’re in what’s known as the late menopausal transition; from here, most women will have their final period within two years, said Dr. Nanette Santoro, a professor of obstetrics and gynecology at the University of Colorado School of Medicine. In this stage, “symptoms tend to ramp up, so if they were annoying in the early transition, they get a little worse,” she said.
Hot flashes, sometimes accompanied by night sweats, are among the most common menopausal symptoms, experienced by as many as 80 percent of women. In one 2015 study of about 1,500 U.S. women who experienced frequent hot flashes or night sweats, these symptoms lasted for an average of 7.4 years in all, usually beginning several years before their final period and continuing for an average of 4.5 years afterward. Women who began experiencing hot flashes earlier in the menopausal transition — before they hit the milestone of 60 days without a period — had to put up with these symptoms for longer, a total of 11.8 years on average. “If it begins early, it can be a very long, annoying menopause,” Dr. Santoro said, and given this, “you may want to seek help sooner rather than later.”
Of several racial and ethnic groups included in the 2015 study, women of Japanese and Chinese descent had the shortest duration of hot flash symptoms (an average of 4.8 and 5.4 years, respectively), and Black women had the longest, with an average of 10.1 years. In a study published in February, Dr. Harlow and her colleagues reviewed evidence that Black women in the United States also had, on average, earlier menopause and a greater incidence of depression and sleep disturbance associated with menopause when compared with white women. The authors proposed that these disparities could be linked, at least in part, to greater financial strain and life stress, experiences with discrimination and less physical activity — all of which, the authors noted in the study, “have roots in systemic racism.”
Most menopausal symptoms will eventually subside after an average of 7 to 9 years, but about a third of women will have symptoms for a decade or longer, Dr. Faubion said. A health care provider who is well-versed in menopause can help you navigate treatment options, including hormone therapy, which can make symptoms much more manageable, she added. (The North American Menopause Society maintains a searchable database of eligible providers here.)
Your Questions About Menopause, Answered
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What are perimenopause and menopause? Perimenopause is the final years of a woman’s reproductive years that leads up to menopause, the end of a woman’s menstrual cycle. Menopause begins after a woman’s final menstrual period.
What are the symptoms of menopause? The symptoms of menopause can begin during perimenopause and continue for years. Among the most common are hot flashes, depression and anxiety, genital and urinary symptoms, brain fog, and skin and hair issues.
How can I find some relief from these symptoms? A low-dose birth control pill can control bleeding issues and ease night sweats during perimenopause. Avoiding alcohol and caffeine can reduce hot flashes, while cognitive behavioral therapy and meditation can make them more tolerable.
How long does perimenopause last? Perimenopause usually begins in a woman’s 40s and can last for four to eight years. The average age of menopause is 51, but for some it starts a few years before or later. The symptoms can last for a decade or more, and at least one symptom — vaginal dryness — may never get better.
What can I do about vaginal dryness? There are several things to try to help mitigate the discomfort: lubricants, to apply just before sexual intercourse; moisturizers, used about three times a week; and/or estrogen, which can plump the vaginal wall lining. Unfortunately, most women will not get 100 percent relief from these treatments.
What is primary ovarian insufficiency? The condition refers to when their ovaries stop functioning before the age of 40; it can affect women in their teens and 20s. In some cases the ovaries may intermittently “wake up” and ovulate, meaning that some women with primary ovarian insufficiency may still get pregnant.
One symptom that typically doesn’t get better is vaginal dryness, which can also be accompanied by painful sex, greater urinary urgency and sometimes more frequent urinary tract infections, Dr. Faubion said. These symptoms only worsen with time, so it’s worth seeking treatment promptly. This may include over-the-counter lubricants or moisturizers or prescription vaginal estrogen treatments, she said.
Once you hit menopause, Dr. Santoro said, you’re technically in it for life. But you’ll know you’re done with the changes of menopause when its other symptoms improve. “They just go away,” and some women describe a feeling of “postmenopausal zest” at this stage, Dr. Santoro said. The hormonal fluctuations settle, and by the time women reach age 65 or 70, they are dealing more with the changes of aging than with changes in reproductive hormones, Dr. Harlow said.
And there are several upsides to going through menopause. Painful conditions like fibroids and endometriosis often improve, for example, and you no longer need to worry about periods or getting pregnant, Dr. Faubion said; though she emphasized that sexually transmitted infections remain a risk and a reason to keep condoms in your life.
In this sense, menopause is truly a midlife passage, and — while it can be longer and stormier than expected — you can look forward to relief on the other side.
Alice Callahan is a health and science journalist.