Author Archives: Dr Colin Holloway

The Importance of BioIdentical Hormones


Natural Red HeadThe Importance of BioIdentical Hormones


by Jeffrey Dach MD


  In a previous article, we discussed the safety of bioidentical hormones.  This article answers the question, why are bioidentical hormones important?  What do they do and why do we need them?


What is a bioidentical hormone?

First of all, let us look at the definition of a bioidentical hormone,  and how they differ from the synthetic hormones offered by the mainstream medical system.

Left Image: Natural Redhead courtesy of Wikimedia Commons

How is a Synthetic Hormone Different from A Bioidentical Hormone?

Bioidentical hormones are the hormones that exist in the human body naturally.  Synthetic hormones are these very same human hormones that are chemically altered.

Why Chemically Alter a Human Hormone?

The drug company hires chemists to alter the structure of human hormones in the laboratory so the drug company can obtain a patent on the new chemical structure, which is a new drug.  This alteration is required in order for the drug company to obtain a patent which gives exclusive marketing rights to the drug company.  The patent is necessary to protects profits.  Because of a quirk in our patent laws, only chemically altered substances can be patented.  Natural substances like human hormones cannot be patented, and are therefore generally not as profitable to manufacture.

Chemically Altered Hormones Are Monsters Chemically Altered Hormones are Monster Hormones

Hormones fit onto their receptors just like a “lock and key”, so any slight alteration of their chemical structure creates a “monster hormone”.   These resulting “monster hormones” are never found in the human body or anywhere else in nature.  The reality is that these synthetically altered monster hormones should never have been approved for marketing and sale to the American People, and yet that is exactly what your mainstream medical doctor will offer you if you ask for hormones.

Left Image: Boris Karlof in Frankenstein 1931 Courtesy of Wikimedia Commons.  Respresents Monster Hormones.

Examples of a chemically altered hormone
(see below):

 

Bioidentical Progesterone    Above Right: Chemical alteration (see red side group) creates a monster hormone called Provera, a synthetic altered version of progesterone.

Why do we use the word bio-identical to describe natural human hormones?

You are probably wondering why do we use the word, “bioidentical”?  That’s an excellent question.  I can remember back when I was in first year medical school learning biochemistry at the University of Illinois in Chicago.  Our class used Lehninger’s classic textbook of biochemistry.  Lehninger never used the word, bio-identical hormones, because all hormones are by definition, bioidentical hormones.  They simply used the word, “hormone”.  Using a word like “bioidentical” was simply redundant and unnecessary for a biochemistry textbook, as it should be today.

The Information War and Terminology

Years ago, after the invention of synthetic monster hormones, an information war was launched by the drug industry creating confusion in the public and even among medical professionals about the difference between natural human hormones and synthetic monster hormones.  Because of this information war, we must now use the terminology, “bioidentical” hormones which really means human hormones in order to different these from the monster altered hormones.

So it is an embarrassment to medical science that we are forced to use the word “bio-identical” for natural hormones found in the human body.  We shouldn’t feel that we are forced to do this.  It should be sufficient to  use the same old names in the biochemistry text books.  The simple word  “hormone” should suffice.  Yet here we are again finding ourselves using the word “bio-identical hormone” thanks to the “Information War” going on between natural medicine and the drug industry.

How do Hormones Work?

Hormones are messengers that attach directly on to the DNA of trillions of our cells and influence gene expression.

See diagram below showing hormone attaching to DNA in the Nucleus:

Hormones attach to Receptors and to DNA
Hormones Bind to DNA and Turn on Protein Synthesis

The hormone enters the cell, attached to a receptor, and then enters the nucleus of the cell where it binds directly to the DNA.  Once bound to the DNA, the hormone messenger turns on DNA expression of protein synthesis.   DNA contains the source code for the manufacture of proteins.  The Hormone is a messenger that tells the DNA to produce these proteins.

Why Are Proteins Important ?

Proteins are the major building block for the human body, and all life for that matter.  Proteins serve a variety of functions.  For example, “structural” proteins make up the structural elements of the body such as bones, skin, arteries, hair, connective tissue, ligaments, tendons, muscles.  Other proteins called enzymes are involved in energy production.  There are proteins involved in communication, neurological function,  and cognition called  neurotransmitters.  There are proteins involved in the immune system called antibodies, and the list goes on.  The types of proteins are a very important part of the makeup of the organism.

Regenerative and Reparative Proteins

We need a constant supply of proteins to repair the body’s wear and tear.  A marathon runner, for example, suffers wear and tear on the tendons, ligaments and muscles used in the marathon run.  Recovery time after a marathon depends on the speed of repair of these injuries.  During recovery,  new proteins and new cells are manufactured and used for repair.

Diagram below shows the hormone (red molecule at upper left) entering cell, attaching to the DNA, and turning on protein synthesis.(see below)

New Cell Layers Needed for Life

In order to live, we need to make new cells.   As our older cells and cell layers age and eventually die, we must have the ability to manufacture new cells.  Examples are blood cells that must be replaced by the bone marrow every 90 days, the skin cells that slough off as the outer layer to be replaced by new layers of cells underneath.  The gastrointestinal lining is generated at the basal cell layer.  THese basal cells mature as they migrate to the surface where they eventually live out their life span, die and slough off.

All of the parts of our bodies are require new cells to replace old ones.  These new cells are made of proteins , so regeneration of new cell layers requires the DNA to be “turned on” to make these new proteins and cells.

Hormone Levels Decline with Age

We know from observational studies that hormones levels decline with age.  Starting around age 50, hormones levels decline to low levels.  In women, this is sudden decline in hormone levels is called menopause around age 50 with cessation of ovulation.  In men, hormonal decline after age 50 is called andropause,  with a gradual in testosterone levels.

Chart of Life Span from 1600 to 2010. (see below)


Above chart courtesy of : Broken Limits to Life Expectancy Jim Open and James W.Vaupel

Starting around 1820, the time of the Industrial Revolution, we see a linear increase in life span.  I suspect this is due to the improved living standards, better nutrition and mass production of goods and services.  Before 1900, most people did not live past 50, so hormonal decline was not an issue.  However, after 1900, an increasing population was living longer after the age of 50 with hormonal decline.  This is an even greater trend now, with the largest over 50 population in the history of western civilization.  All of these people are living with hormonal decline, and the accompanying degenerative diseases associated with hormonal decline.

Lack of Reparative Proteins Leads to Degenerative Diseases of Aging

Without the hormone message attached to the DNA, which turns on DNA expression and protein synthesis, we all begin to suffer from the lack of reparative and regenerative proteins leading to the degenerative diseases of aging.

Natural Medicine will provide bioidentical hormone replacement which will serve to prevent or reverse these degenerative diseases of aging.  Here is a list with the mainstream drug treatment offered.

List of the Degenerative Diseases                 Drugs Used

 Osteoarthritis  Naprosyn, Ibuprofen
 Osteoporosis  Fosamax Actonel
 Atherosclerotic
Vascular Disease
 Lipitor
 Cognitive Dysfunction  Aricept
 Immune System Dysfunction  Cipro, Z-pack
 Loss of Libido  Viagra
 Depression  Prozac, Zoloft


Degenerative Disease Means Great Profits for Drug Companies

The major drug companies make most of their profits on blockbuster drugs aimed at one of the above degenerative diseases of aging.

BioIdentical Hormones Prevent Degenerative Diseases of Aging

Since all of these degenerative diseases are directly caused by hormonal decline, they can be prevented or reversed (at least partially reversed)  with the use of bio-identical hormones, representing direct economic competition with the drug industry which sells a drug for each degenerative disease (see above chart).

Natural Medicine Means Lost Profits for the Drug Industry

If bio-identical hormones were widely used, this would mean massive lost sales and lost profits for the drug industry.  It is not difficult to understand why there is animosity and competition between the drug industry and natural medicine, and especially between the drug industry and natural bioidentical hormones, with a raging information war going on.

For more on this topic, read my previous articles:

The Safety of Bio-Identical Hormones

Water Droplet Impact Jeffrey Dach MDThe Safety of Bio-Identical Hormones

by Jeffrey Dach MD
Are Women’s Bio-identical hormones safe? Bio-identical hormones exist naturally in the human body, so it is axiomatic that these are safe.  However, we are interested in a slightly different question. What is the safety of bio-identical hormones as routinely used in medical practice?  Let’s try to answer this question.

The Safety of Water compared to Bio-Identical Hormones

Water is safe, beneficial and required for health.  Yet, even so, drinking excess amounts of water causes death from Fatal Water Intoxication.(1)

Left Image: Water with Droplets Courtesy of Wikimedia

Similarly, just like water, bio-identical hormones are safe and beneficial when used at proper dosages.  Like excessive water, excessive hormone dosage may result in their own adverse side effects.  Excess estrogen, for example, causes fluid retention, breast sensitivity and enlargement, and  disordered mood.

Humans Have Bio-Identical Hormones.

Another answer to the safety question is that bio-identical hormones are found in the human body naturally.  Any harmful substance in the human body would impair survival, and over millions of years of evolution would be eliminated by natural selection.  This is the basic concept of Darwinian evolution which is accepted by mainstream medical science.

A 50 Million Year Medical Experiment

Consider the following medical experiment, performed over the last 50 million years with the help of our friend, Darwinian evolution.(2)  Bio-Identical Hormones have been present in the human body for 50 million years, and we humans are still here on the planet.  I would consider that a successful medical experiment, wouldn’t you?

Either Excess or Deficiency of Anything Can be Harmful

One of our routine labs tests called the Chem Panel measures electrolytes and glucose levels in the blood. The body automatically maintains these within narrow ranges to maintain health.  If levels deviate above or below these normal ranges, this causes a serious health disturbance.  For example elevated potassium levels causes cardiac arrest.  Magnesium deficiency causes muscle spasm and arrythmia. Excessive amounts of Vitamins A and D are toxic.  Hormones levels enjoy a considerably wide range of acceptable limits.  Even so, a deficiency or an excess of women’s bio-identical hormones can produce adverse symptoms.  This is called estrogen deficiency/excess, and progesterone deficiency/excess, and they each have typical signs and symptoms easily recognized.(3)

Common Signs of Estrogen Deficiency (4)

Mental fogginess
Forgetfulness
Depression
Minor anxiety
Mood change
Difficulty falling asleep
Hot flashes
Night sweats
Temperature swings
Day-long fatigue
Reduced stamina
Decreased sense of sexuality
Lessened self-image and attention to appearance
Dry eyes, skin, and vagina
Loss of skin radiance
Feel balanced 2nd part of cycle
Sagging breasts and loss of fullness
Pain with sexual activity
Weight gain
Increased back and joint pain
Episodes of rapid heartbeat
Headaches and migraines
Gastrointestinal discomfort
Constipation

Common Signs of Excess Estrogen (takes longer to notice)

Breast tenderness or pain
Increased breast size
Water retention, fingers, legs
Impatient, snappy behavior, but with clear mind
Pelvic cramps
Nausea

Common Signs of Progesterone Deficiency

No period at all (no ovulation)
The period comes infrequently (every few months)
Heavy and frequent periods (large clots, due to buildup in the uterus)
Spotting a few days before the period. (Progesterone level is dropping)
PMS
Cystic breasts
Painful breasts
Breasts with lumps
Most cases of endometriosis, adenomyosis, and fibroids.
Anxiety, irritability, nervousness and water retention

Above list courtesy of Uzzi Reiss MD OB GYN. (4)

No Reported Adverse Events from Bio-Identical Hormones

Over-the-counter pain pills (NSAIDs) such as aspirin, naproxen and ibuprofen are considered fairly safe.  After all, you don’t need a prescription to buy them, yet they cause an estimated 16,500 deaths in the US annually, mostly from gastric bleeding.(5)  Compare this to no reported adverse events from bio-identical hormones last year, according to an FDA press conference January 2008.(6)

Do Bio-Identical Hormones Cause Breast Cancer?(7)

Eiffel Tower Jeffrey Dach MDThe answer is no. According to the French Cohort study, there is no increase in breast cancer in women using bio-identical hormones.(8)  However, having said that, avoiding excess environmental estrogens as well as excessive estrogen levels from any source, is the key to preventing breast cancer.(9)  My previous article covers our program for breast cancer prevention which includes iodine supplementation, Indole-3-carbinol and fiber. To read about this, see: Iodine Prevents Breast Cancer (10)

Left Image: Eiffel Tower Paris France Courtesy of Wikimedia Commons

Do Bio-Identical Hormones Cause Heart Disease ?

Again, the answer is no. A study of CAT calcium scores by JoAnn E. Manson in the June 2007 JAMA actually showed less heart disease in the women taking unopposed estrogen (they had hysterectomies and were not given the synthetic progestins).(11)  These same results had already been published 2 years previously in a calcium score study by Budoff in J Womens Health 2005. (12)

Compounding Pharmacy statement

In Australia, the Pharmacy Board stipulate the minimum professional practice guidelines that apply to the field of compounding. These standards ensure that the ingredients are of a quality standard and purchased through reputable suppliers, that an appropriately trained professional is preparing the product and that a number of checks are in place to ensure accountability. These are minimum standards. Larger more established compounding labs like the Dallas Parade Compounding Pharmacy (compoundingpharmacy.com.au), go several steps further in the quality assurance of compounded medications.

Dallas Parade Compounding Pharmacy is a member of the Professional Compounding Chemists of America/Australia (PCCA) Standards Program. The Standards Program stipulates operating procedures for all aspects of compounding and includes requirements for independent testing of products made in our lab. At Dallas Parade Compounding Pharmacy, we only buy ingredients through PCCA, who supply the highest quality pharmaceutical grade ingredients that undergo the most rigorous testing in the industry.

We are one of only a handful of compounding pharmacies in Australia who meet the strict criteria of the PCCA Standards program, providing a level of confidence in the quality and safety of our compounded medications that significantly exceeds what is required by the Pharmacy Board guidelines.

Compounded HRT and the Sunday Newspapers.(part 2)

 My blood pressure has settled down since reading the article on HRT (specifically compounded HRT) causing cancer in the Sunday Papers. Those of you who follow my blogs, which should be all of you, will know that I have repeatedly published studies from reputable journals about the safety of the hormones that I use, in the way that I use it. I am also aware that not all doctors have the experience and knowledge that I do, and some do not prescribe bioidentical hormones (BHRT) in a safe or proper manner. Some doctors have jumped aboard the BHRT bandwagon without the required skills. These doctors have given the BHRT a bad name generally. I suspect the article is mostly aimed at these doctors. However, “cowboy”operators occur everywhere, and not only medicine.
Oestrogen should never be given to someone who has a uterus, without progesterone.  Oestrogen on its own can cause endometrial cancer. I am surprised at the number of times I have seen women who have not received progesterone, only oestrogen, from their doctors. This is a recipe for disaster. The amount of progesterone also needs to be adequate to have the protective effect. This is best monitored by regular blood testing. Saliva testing is not adequate and part of the poor practices I am talking about. For 25 years I have used Micronised Progesterone (natural progesterone) as being the safest and best form of progesterone. I have been attacked by the medical establishment, at conferences and the media for the use of “”unsafe and untried BHRT.”  Now a commercial Micronised Progesterone is available in Australia, and it has suddenly being hailed as the safest and best form of progesterone. The hypocrisy is amazing.
The other issue is how hormones are given. The safest and best way is transdermal, as a troche or a cream. Doctors who give it in any other way risk increasing the cancer rate. Also, the evidence is that BHRT should be continuous ( no week off) as any monthly break from the BHRT can increase the uterine cancer rate.
I have repeatedly mentioned that some compounding chemists are not as good as others – just as not all bakeries have the same quality of products.  For this reason it is important that you use one of the recommended pharmacies, because I have found them to have the best services and quality of hormones.
As I mentioned yesterday, I have only had one women develop endometrial cancer in the last 25 years, and this can be verified by authorized researchers from my database on my computer of all the women I have treated with BHRT over the last 25 years.
Finally, articles like the one on the weekend, do a great disservice to women, as it will scare many women away from taking HRT of any sort. These women will suffer a decreased quality of life, and many a premature death from avoiding HRT. The article below, from the American Journal of Public health and Yale university(how much more prestigious does that get) gives the actual figures, which are very concerning.
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.

Author information

1
Departments of Obstetrics and Gynecology and Psychiatry, Yale University School of Medicine, New Haven, CT, USA. philip.sarrel@yale.edu

Abstract

OBJECTIVES:

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

METHODS:

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.

RESULTS:

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).

CONCLUSIONS:

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.

 

Cancer Prev Res (Phila). 2014 Oct;7(10):1045-55. doi: 10.1158/1940-6207.CAPR-14-0054. Epub 2014 Jul 28.

Progesterone inhibits endometrial cancer invasiveness by inhibiting the TGFβ pathway.

Author information

1
Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
2
Division of Gynecologic Oncology, and Gynecologic Cancer Translational Research Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland.
3
Department of Obstetrics and Gynecology and Women’s Health Integrated Research Center, Inova Fairfax Hospital, Falls Church, Virginia.
4
Division of Gynecologic Oncology, North Shore University Health System, University of Chicago, Evanston, Illinois.
5
Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Department of Molecular and Cell Biology, Uniformed Services University of the Health Sciences, Bethesda, Maryland. viqar.syed@usuhs.edu.

Abstract

Increased expression of TGFβ isoforms in human endometrial cancer correlates with decreased survival and poor prognosis. Progesterone has been shown to exert a chemoprotective effect against endometrial cancer, and previous animal models have suggested that these effects are accompanied by changes in TGFβ. The goal of this study was to characterize the effect of progesterone on TGFβ signaling pathway components and on TGFβ-induced protumorigenic activities in endometrial cancer cell lines. Progesterone significantly decreased expression of three TGFβ isoforms at 72 hours after treatment except for TGFβ2 in HEC-1B and TGFβ3 in Ishikawa cells. Progesterone treatment for 120 hours attenuated expression of the three isoforms in all cell lines. Progesterone exposure for 72 hours reduced expression of TGFβ receptors in HEC-1B cells and all but TGFβR1 in Ishikawa cells. Progesterone reduced TGFβR3 expression in RL-95 cells at 72 hours, but TGFβR1 and βR2 expression levels were not affected by progesterone at any time point. SMAD2/3 and pSMAD2/3 were substantially reduced at 72 hours in all cell lines. SMAD4 expression was reduced in RL-95 cells at 24 hours and in HEC-1B and Ishikawa cells at 72 hours following progesterone treatment. Furthermore, progesterone effectively inhibited basal and TGFβ1-induced cancer cell viability and invasion, which was accompanied by increased E-cadherin and decreased vimentin expression. An inhibitor of TGFβRI blocked TGFβ1-induced effects on cell viability and invasion and attenuated antitumor effects of progesterone. These results suggest that downregulation of TGFβ signaling is a key mechanism underlying progesterone inhibition of endometrial cancer growth.

Compounding Pharmacies

 

I have asked some compounding chemists to respond to the attack on their integrity. Here is the reply from ACPharm (which many of you use)

Here is some information about Compounding and it’s regulations in Australia.

Compounding in Australia is regulated by the state governments and require that a registered pharmacist is the owner. Pharmacists need to ensure they abide by the Professional Practice Standards which include regulations regarding compounding and the supply of compounded products to the public on prescription. All ingredients must be purchased from TGA approved suppliers and the appropriate protocols must be followed to ensure a quality product to the customer.
Smaller compounders are not as highly regulated and may not be following the guidelines correctly, however larger more experienced compounders have strict Standard operating procedures to ensure a high quality product is obtained with each compound. Many larger compounders like ACPHARM QLD also send the raw materials to third party labs to test to ensure the potency and quality of the ingredients before it is used. ACPHARM QLD also test all compounding methods and the end product to ensure it is properly mixed and maintains its integrity until it’s best before date.

Regards,
Jack

Compounded HRT and the Sunday Newspapers.

This old perennial issue raises it head again. What a Beat up. A direct quote from the article: “However, when News Corp searched the database it found six adverse events reports linked to compounded progesterone, including three cases of endometrial (uterine) cancer, three cases of vaginal haemorrhage, one case of breast cancer and one case of endometrial hyperplasia (precancerous thickening of uterine tissue).”

So from the article, they have found 6 cases of adverse events using compounded progesterone. That would be from many hundreds of thousands of women using compounded hormones in Australia. I will repeat a blog I carried some years ago here:

FDA admit no adverse report on Bioidentical HRT

One of the criticisms of Bioidentical HRT is that it is not FDA approved. It does not need to be, as it is not synthetic. It is interesting however that there has never been a complaint of an adverse event to the FDA – yet there are numerous adverse event report about the synthetic HRT. Here is part of a transcript from a recent Press conference run by the FDA.

The FDA had a press conference on BHRT. They generally were negative about BHRT.Here is one of the questions put to Kathy Anderson of the FDA (USA):

 

“Anna Matthews(Reporter): Hi. Couple of questions; one is have you guys received any reports of adverse events or other harm to patients from these products?

Kathy Anderson: Sorry, this is Kathy Anderson. With your respect to your question about whether we received any adverse event reports, we have not.”

 

Furthermore, the article did not mention the amount of damage done by synthetic HRT :

Prempro Causes Breast Cancer  and Loses Court Case with Huge Punitive Damages

by Jeffrey Dach MD

A 112 million dollar punitive is a very loud statement.  It states that the jury was outraged by the “wanton and reckless” conduct by Wyeth.  112 Million Dollars in punitive damages was awarded to two breast cancer victims who took Wyeth’s synthetic hormone, Prempro, all the while thinking it safe. The jury was outraged that Wyeth ignored and suppressed evidence that Prempro causes breast cancer. Wyeth paid consultants and ghostwriters of medical journal articles to play down concerns about breast cancer, and declined to study known risks. Once again, company profit was placed ahead of patient safety. This is the tip of the iceberg, as another ten thousand cases are waiting for their day in court.

Premrpro is similar to premarin or premia, as used in Australia.

I have been using these compounded products for the last 25 years, and have had 1 case of uterine cancer in that time. She was cured by a hysterectomy and is still fine today.Endometrial thickening can occur in women, with or without hormones, and, as the article stated, may be caused by obesity.

I will have more to say on this topic tomorrow.

Looking after a dying loved one at home? Here’s what you need to know

Looking after a dying loved one at home? Here’s what you need to know

Caring can be very rewarding for both the carer and the patient. from shutterstock.com

 


When someone dies at home, everyone in the family is affected. Looking after a relative who is at the end of their life can be enormously rewarding, but carers have many unmet information and support needs. This can take a toll on their physical and emotional health.

Here are some tips if you are looking after someone nearing the end of their life.

1. Look after yourself

Carers looking after someone with a life-threatening illness have higher levels of emotional distress, including depression and anxiety, than the general population. It’s important you look after yourself.

Self-care might mean finding time to take a break from caring by signing up for yoga classes where calming breathing techniques are practised, or seeking counselling or support groups.


Read more: How to get your stress levels in check


Caring can be very rewarding for both the carer and the patient. Research shows caring can make people feel closer to those they’re caring for. Carers often feel proud that they have been able to look after someone in their last years, months or days of life.

It can be a positive experience to think about the rewards of caring, like spending more time together or knowing you’re making a difference to a loved one at a difficult time.

It’s important you look after yourself.

2. Get informed

Caring for a relative at the end of life is likely a new experience. Many carers are learning on the job and often don’t feel practically or emotionally prepared for the task. Research consistently shows carers want to know how to safely carry out practical caring tasks, like moving the person in and out of bed, preparing suitable meals, and giving medication.

Emotional tasks might include listening to the patient’s worries and helping the patient write down their preferences for care and treatments in an advance care plan. When patients have an advance care plan, carers report less stress because key decisions have already been made and documented.


Read more: What you need to know about advance care directives


Palliative care services often have support groups or information sessions, which help carers feel more prepared and better informed. Such groups help meet carers’ information needs. They also increase self-efficacy (the belief of being able to personally succeed in caring tasks).

Recently, distance learning has been offered to carers and evidence shows this helps them feel more prepared to carry out their duties.

A carer’s emotional tasks might include listening to the patient’s worries. from shutterstock.com

3. Ask for help

Many current approaches to supporting people nearing the end of life involve working with whole communities. Known as compassionate communities, these approaches are based on the concept it is not just up to an individual carer, or the health service, to look after people approaching the end of life. Support can be everyone’s responsibility, from pharmacists, librarians and teachers to employers and colleagues.

Apps, such as Care For Me, and websites can help co-ordinate help from friends, family and the community. The website Gather My Crew offers a way for carers to list tasks they need help with, to take some of the pressure off themselves.

4. Talk about it

When someone is critically ill or dying, family members often decide not to share their worries with each other. Psychologists call this protective buffering. People do it to try to protect their family and friends from worrying more.

Although it is well-intended, protective buffering can make people feel less close. It’s OK to share worries with each other. Being able to talk about feelings means being able to deal together with the difficult things like pain or fear.

Talk about your anxieties. from shutterstock.com

Using the “d” words (death and dying) can be difficult, and is an outright taboo in many cultures. Find language that suits you: be direct (death), or use metaphors (pass away) or less direct phrases (getting sicker) so that you can talk about worries together.


Read more: Passed away, kicked the bucket, pushing up daisies – the many ways we don’t talk about death


5. It’s OK to think about the future

It’s hard to balance feeling positive and feeling sad about the person approaching the end of their life. Many family members and carers say they feel guilty for thinking about the future or making plans for after the person has died.

But research in bereavement has shown it’s normal and healthy to move between focusing on the here and now, and on the life after the caring role ends. This might be reassuring if you’re the kind of person who doesn’t always want to face emotions head on – distracting yourself by thinking about the future is actually a natural and healthy thing to do.

New Guidelines Advise Less Frequent Pap Smears

New Guidelines Advise Less Frequent Pap Smears

The annual Pap smear, a cornerstone of women’s health for at least 60 years, is now officially a thing of the past, as new national guidelines recommend cervical cancer screening no more often than every three years.

In recent years, some doctors and medical groups, including the American College of Obstetricians and Gynecologists in 2009, began urging less frequent screening for cervical cancer. Even so, annual Pap smear testing is still common because many women are reluctant to give up frequent screening for cervical cancer.

The new guidelines, issued on Wednesday by the United States Preventive Services Task Force, replace recommendations last issued in 2003 and use more decisive language to advise women to undergo screening less often. Other groups, including the American Cancer Society, released similar recommendations on Wednesday. The new guidelines were published in Annals of Internal Medicine.

“We achieve essentially the same effectiveness in the reduction of cancer deaths, but we reduce potential harm of false positive tests,” said Dr. Wanda Nicholson, a task force member and an associate professor of obstetrics and gynecology at the University of North Carolina at Chapel Hill. “It’s a win-win for women.”

Cost is not a factor in the task force recommendations. Instead, its members focus on the effectiveness of a screening test to reduce cancer deaths, balanced against the potential harms that accompany the screening. The worry about frequent Pap smear screening is that tests can result in a large number of false positives that lead to sometimes painful biopsies and put women at risk for pregnancy complications in the future, like preterm labor and low-birth-weight infants.

The new guidelines focus on four key areas, including frequency of screening, age at which women should begin screening, age at which women should stop screening, and testing for human papillomavirus, or HPV, which can cause cervical cancer.

Under the new recommendations, the task force says women should be screened with a Pap smear no more than every three years. In 2003, the language was weaker, recommending screening “at least every three years,” which left the door open for annual tests.

In addition, women now are advised to begin screening at age 21 regardless of sexual history, and the task force specifically recommends against screening women younger than 21. In 2003, the advice to women was to start screening within three years of sexual activity, but no later than 21.

The task force also recommends against screening women over the age of 65, as long as they have had adequate prior screening and are not otherwise at high risk for cervical cancer. That advice has not changed since 2003.

Finally, the group also recommends against regular HPV screening for anyone under 30. In 2003, the task force said it did not have enough evidence to make a recommendation about HPV testing. It now says the test is unnecessary because many women exposed to the virus will eventually eliminate the virus without any intervention.

“HPV in women under 30 is highly prevalent but also highly transient,” Dr. Nicholson said. “Women under 30 may get infected with HPV, but they have a high likelihood of clearing that infection on their own, and it not causing any long-term change to their cervical tissue.”

HPV testing should be used in certain cases where women receive atypical test results from a Pap smear. In addition, the task force said that women over 30 who do not want to undergo a Pap test every three years could instead opt for a Pap test every five years along with an HPV test.

The task force recommendations apply only to healthy women. They do not change the advice for women who have unusual symptoms, an unusual Pap test result or a history of dysplasia, cervical cancer, H.I.V. or other illnesses.

Fitness versus fatness: which matters more?

Fitness versus fatness: which matters more?

November 9, 2015 10.05pm AEDT .

A metrobus driver performs squats at Rio de los Remedios metrobus station in Mexico. To combat growing obesity, lawmakers have introduced a new campaign encouraging physical activity. Edgard Garrido/Reuters
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Authors
Tammy Chang
Assistant Professor, Family Medicine, University of Michigan

Caroline R Richardson
Associate Professor of Family Medicine , University of Michigan

Disclosure statement

Caroline R Richardson receives funding from NIH, VA,BCBSF, RWJF, AJPM, NEJM. She has recently been or is currently affiliated with the University of Michigan and the Ann Arbor VA.

Tammy Chang does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond the academic appointment above.

There is a longstanding debate in the research community about the importance of fitness versus fatness in health. Are exercise and improving fitness more important than eating well and maintaining a healthy weight?

Some researchers argue fatness does not affect health as long as you are fit, which means your heart and lungs are strong. And national campaigns like Let’s Move are focused on exercise for health without a specific focus on weight loss.

But for people who are obese, losing weight might be more important to their overall health than focusing on fitness. In fact, evidence shows that exercise alone is not an effective way to lose weight. Rather, effective weight loss is mostly about what you eat, though it should also include exercise.

As family physicians, we see obese patients who have heard the message to “just be fit” and have added 10-15 minutes of walking to their daily routine or have bought a Fitbit to track their physical activity. We applaud these efforts.

But for many obese people, the message that physical activity is more important than managing weight is not only unhelpful but also not true. When it comes to health and wellness, fatness can matter more than fitness. And of course, for most people, fatness is related to fitness, because excess weight can make exercise much harder.

How are fitness and fatness are linked?

Multiple studies have looked at fitness and obesity as two separate entities because they are seemingly separate concepts: one measures how well your heart and lungs work to supply oxygen to your muscles while the other is a measure of your body height and weight.

However, the measures of fitness and fatness are both influenced by how much you weigh. Because of the way fitness is calculated, for two people with the same oxygen-transferring power, weighing more typically means lower fitness.

Likewise, what researchers mean by fatness is really body mass index (BMI), a measure of body fat based on height and weight. People are often surprised at what is considered normal weight. To be in the normal weight range, a person who is 5’7″ needs to weigh less than 160 pounds. If this same person weighs over 190 pounds, he or she would be considered obese.

Strictly speaking, obesity does not mean you are automatically unfit. There are obese people who run every day, and then there are thin people who couldn’t run a mile for their life. A muscular individual can also be considered obese, because muscle weighs more than fat, and be very fit.

But these are exceptions, not the rule. Studies show that when someone is categorized as obese, the likelihood of them being fit is very low. So in our society, being obese still generally means lower fitness.

Extra weight can make it harder to move.
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Fatness makes it harder to improve fitness

For people who are obese, focusing on losing weight is a better place to start than just focusing on fitness. That’s because extra weight can make it harder to move, and thus harder to exercise. Obese individuals often have a difficult time doing physical activity due to body size, limited mobility and joint pain.

Physiologically, it is more difficult for an obese individual to do the same amount of exercise as a healthy-weight person because of the extra weight they carry. Heavier people need more oxygen to do the same exercise as a healthy-weight person. Some obese people report that even walking can seem tough. Fitness is just harder to achieve if you can’t move easily.

Fatness decreases your quality of life

The debate around fitness and fatness centers on studies that show that compared to normal weight-fit individuals, unfit individuals had twice the risk of mortality regardless of BMI. But as these studies show, a relatively small proportion of people are fit and obese.

But mortality is not the only issue. Obesity has been shown to predict diabetes, heart disease, liver disease and a whole host of health problems that may require taking daily pills or having daily injections, or lead to invasive procedures. Even if a higher BMI does not predict earlier death, this does not mean that it “doesn’t matter” to your health.

While exercise can and does improve health, for people who have health conditions like diabetes or fatty liver disease, exercise alone won’t make a huge difference in reversing these conditions. However, these conditions can be improved or even resolved with weight loss (decreasing body fat).

Fatness also has a lot of other implications outside of strictly health effects. For family physicians like us that care for obese patients, the most heartbreaking stories are from obese patients who can’t go on roller coasters with their children or can’t keep themselves clean due to their size.

Increasing physical activity without losing weight will not likely improve these patients’ lives. To improve their health and quality of life, it is important to exercise every day, eat healthy food and, most importantly, lose some weight.

State of the evidence 2017: an update on the connection between breast cancer and the environment.

The evidence is clear – we need to live simpler and more natural lives, trying to avoid all the chemicals, plastics and other toxic substance we seem unable to do without.
Environ Health. 2017 Sep 2;16(1):94. doi: 10.1186/s12940-017-0287-4.

State of the evidence 2017: an update on the connection between breast cancer and the environment.

Abstract

BACKGROUND:

In this review, we examine the continually expanding and increasingly compelling data linking radiation and various chemicals in our environment to the current high incidence of breast cancer. Singly and in combination, these toxicants may have contributed significantly to the increasing rates of breast cancer observed over the past several decades. Exposures early in development from gestation through adolescence and early adulthood are particularly of concern as they re-shape the program of genetic, epigenetic and physiological processes in the developing mammary system, leading to an increased risk for developing breast cancer. In the 8 years since we last published a comprehensive review of the relevant literature, hundreds of new papers have appeared supporting this link, and in this update, the evidence on this topic is more extensive and of better quality than that previously available.

CONCLUSION:

Increasing evidence from epidemiological studies, as well as a better understanding of mechanisms linking toxicants with development of breast cancer, all reinforce the conclusion that exposures to these substances – many of which are found in common, everyday products and byproducts – may lead to increased risk of developing breast cancer. Moving forward, attention to methodological limitations, especially in relevant epidemiological and animal models, will need to be addressed to allow clearer and more direct connections to be evaluated.