Author Archives: Dr Colin Holloway

Menopausal hormone therapy and breast cancer: what is the evidence from randomized trials?

Climacteric. 2018 Oct 9:1-8. doi: 10.1080/13697137.2018.1514008. [Epub ahead of print]

Menopausal hormone therapy and breast cancer: what is the evidence from randomized trials?

Hodis HN1, Sarrel PM2,3.

Author information

Abstract

The relationship between menopausal hormone therapy (HT) and breast cancer is complex and further complicated by misinformation, perception, and overgeneralization of data. These issues are addressed in this mini-review through the lens of the Women’s Health Initiative (WHI) that has colored the view of HT and breast cancer. In the WHI, unopposed conjugated equine estrogen (CEE) reduced breast cancer risk and mortality. In the WHI CEE plus continuously combined medroxyprogesterone acetate (MPA) trial, although the hazard ratio (HR) was elevated it was statistically non-significant for an association between CEE + MPA and breast cancer. In fact, the increased HR was not due to an increased breast cancer incidence rate in women randomized to CEE + MPA therapy but rather due to a decreased and unexpectedly low breast cancer rate in the subgroup of women with prior HT use randomized to placebo. For women who were HT naïve when randomized to the WHI, the breast cancer incidence rate was not affected by CEE + MPA therapy relative to placebo for up to 11 years of follow-up. The current state of science indicates that HT may or may not cause breast cancer but the totality of data neither establish nor refute this possibility. Further, any association that may exist between HT and breast cancer appears to be rare and no greater than other medications commonly used in clinical medicine.

Here’s what to look out for in your 40s, 60s, 80s and beyond

December 26, 2018 6.31am AEDT You’re another year older but that doesn’t have to mean poorer health. Lorene Farrugia

Authors

  1. Stephanie Harrison Research fellow, South Australian Health & Medical Research Institute
  2. Azmeraw T. Amare Postdoc researcher, South Australian Health & Medical Research Institute
  3. Jyoti Khadka Research Fellow, South Australian Health & Medical Research Institute
  4. Maria Carolina Inacio Director, Registry of Older South Australians, South Australian Health & Medical Research Institute
  5. Sarah Bray Registry of Older South Australians (ROSA) – Project Manager & Consumer Engagement Officer, South Australian Health & Medical Research Institute
  6. Tiffany Gill Senior Research Fellow, University of Adelaide

Disclosure statement

Maria Carolina Inacio receives funding from NHMRC (APP1148106) and MRFF (APP1152268).

Azmeraw T. Amare, Jyoti Khadka, Sarah Bray, Stephanie Harrison, and Tiffany Gill 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.

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Many diseases develop and become more likely as we age. Here are some of the most common conditions, and how you can reduce your risk of getting them as you clock over into a new decade.

Maintaining a healthy weight can reduce the risk of developing arthritis, coronary heart disease, and other common and related conditions, including back pain, type 2 diabetes, stroke, and many cancers. But almost one-third of Australians in their 40s are obese and one in five already have arthritis.


Read more: Arthritis isn’t just a condition affecting older people, it likely starts much earlier


From the age of 45 (or 35 for Aboriginal and Torres Strait Islanders), heart health checks are recommended to assess risk factors and initiate a plan to improve the health of your heart. This may include changing your diet, reducing your alcohol intake, increasing your physical activity, and improving your well-being.

Checks to identify your risk of type 2 diabetes are also recommended every three years from age 40 (or from age 18 for Aboriginal and Torres Strait Islanders).

If you don’t already have symptoms of arthritis or if they’re mild, this decade is your chance to reduce your risk of the disease progressing. Focus on the manageable factors, like shedding excess weight, but also on improving muscle strength. This may also help to prevent or delay sarcopenia, which is the decline of skeletal muscle tissue with ageing, and back pain.

Achieving and maintaining a healthy weight will set you up for decades of better health. Sue Zeng

Most people will begin to experience age-related vision decline in their 40s, with difficulty seeing up close and trouble adjusting to lighting and glare. A baseline eye check is recommended at age 40.

In your 50s

In your 50s, major eye diseases become more common. Among Australians aged 55 and above, age-related macular degeneration, cataracts, diabetes-related eye diseases and glaucoma account for more than 80% of vision loss.

A series of health screenings are recommended when people turn 50. These preventive measures can help with the early detection of serious conditions and optimising your treatment choices and prognosis. Comprehensive eye assessments are recommended every one to two years to ensure warning signs are detected and vision can be saved.

National cancer screening programs for Australians aged 50 to 74, are available every two years for bowel and breast cancer.


Read more: Women should be told about their breast density when they have a mammogram


To screen for bowel cancer, older Australians are sent a test in the post they can do at home. If the test is positive, the person is then usually sent for a colonoscopy, a procedure in which a camera and light look for abnormalities of the bowel.

In 2016, 8% of people screened had a positive test result. Of those who underwent a colonoscopy, 1 in 26 were diagnosed with confirmed or suspected bowel cancer and one in nine were diagnosed with adenomas. These are potential precursors to bowel cancer which can be removed to reduce your future risk.

To check for breast cancer, women are encouraged to participate in the national mammogram screening program. More than half (59%) of all breast cancers detected through the program are small (less than or equal to 15mm) and are easier to treat (and have better survival rates) than more advanced cancers.

In your 60s

Coronary heart disease, chronic obstructive pulmonary disease (a disease of the lungs that makes breathing difficult), and lung cancer carry the biggest disease burden for people in their 60s.

If you’re a smoker, quitting is the best way to improve both your lung and heart health. Using evidence-based methods to quit with advice from a health professional or support service will greatly improve your chances of success.

Quitting smoking is the best way to improve your health. Ian Schneider

The build-up of plaques in artery walls by fats, cholesterol and other substances (atherosclerosis) can happen from a younger age. But the hardening of these plaques and narrowing of arteries, which greatly increases the risk of heart disease and stroke, is most likely to occur from age 65 and above.

Exercise protects against atherosclerosis and research consistently shows any physical activity is better than nothing when it comes to heart health. If you’re not currently active, gradually build up to the recommended 30 minutes of moderate-intensity exercise on most, preferably all, days.


Read more: Too much salt and sugar and not enough exercise – why Australians’ health is lagging


Other potentially modifiable risk factors for stroke include high blood pressure, a high-fat diet, alcohol consumption, and smoking.

Your 60s is also a common decade for surgeries, including joint replacements and cataract surgery. Joint replacements are typically very successful, but are not an appropriate solution for everyone and are not without risks. After a joint replacement, you’ll benefit from physiotherapy, exercise, and maintaining a healthy weight.

The treatment for cataracts is to surgically remove the cloudy lens. Cataract surgery is the most common elective surgery worldwide, with very low complication rates, and provides immediate restoration of lost vision.

In your 70s

Many of the conditions mentioned above are still common in this decade. It’s also a good time to consider your risk of falls. Four in ten people in their 70s will have a fall and it can lead to a cascade of fractures, hospitalisations, disability and injury.

Osteoporosis is one cause of falls. It occurs most commonly in post-menopausal women but almost one-quarter of people with osteoporosis are men. Osteoporosis is often known as a silent disease because there are usually no symptoms until a fracture occurs. Exercise and diet, including calcium and vitamin D, are important for bone health.

Exercise and diet can improve bone health. Geneva, Switzerland

Older people are also vulnerable to mental health conditions because of a combination of reduced cognitive function, limitations in physical health, social isolation, loneliness, reduced independence, frailty, reduced mobility, disability, and living conditions.

In your 80s and beyond

Dementia is the second most common chronic condition for Australians in their 80s, after coronary heart disease – and it’s the most common for people aged 95 and above.

Many people think dementia is a normal part of the ageing process, but around one-third of cases of dementia could be prevented by reducing risk factors such as high blood pressure and obesity at mid-life.


Read more: Why people with dementia don’t all behave the same


Early diagnosis is important to effectively plan and initiate appropriate treatment options which help people live well with dementia. But dementia remains underdiagnosed.

Around 70% of Australians aged 85 and above have five or more chronic diseases and take multiple medications to manage these conditions. Effective medication management is critical for people living with multiple conditions because medications for one condition may exacerbate the symptoms of a different coexisting condition.

Hysterectomy causes sleep problems in menopause

Menopause. 2018 Nov 12. doi: 10.1097/GME.0000000000001257. [Epub ahead of print]

Sleep disturbance in women who undergo surgical menopause compared with women who experience natural menopause.

Cho NY1, Kim S2, Nowakowski S3,4, Shin C2,5, Suh S1.

Author information

Abstract

OBJECTIVE:

Women who undergo surgical menopause (SM) experience a relatively more acute and precipitous drop of estrogen compared with women who experience natural menopause (NM). Few studies, however, have compared sleep quality in women who experience natural versus SM.

METHODS:

Participants were 526 postmenopausal women (mean age 60.2 ± 7.64). All participants completed self-report questionnaires about insomnia symptoms, sleep-interfering behaviors, depression, sleep quality, and gynecological history. Analysis of covariance was conducted to compare women who experienced NM versus SM on sleep variables. Logistic regression analysis was used to determine whether NM or SM groups predicted insomnia status. Regression-based moderation analysis was conducted to explore the moderating effect of type of menopause on the relationship between sleep-interfering behaviors and insomnia symptoms.

RESULTS:

Among the sample, 81.6% (n = 429) reported going through NM and 18.4% (n = 97) reported going through SM. The SM group was significantly younger by 7.2 years (P < 0.001). Women in the SM group reported significantly worse sleep quality (P = 0.007), especially for sleep duration (P = 0.001) and habitual sleep efficiency (P = 0.010) compared with women in the NM group. Regression analysis indicated that individuals in the SM group were 2.131 (95% CI 1.055-4.303) times more likely to have insomnia compared with the NM group (P = 0.027). In addition, women in the SM group who displayed more sleep-interfering behaviors also had a higher severity of insomnia symptoms compared with women who experience NM (ß = 0.26, P = 0.03).

CONCLUSIONS:

Menopause can be both physically and psychologically challenging, but women who undergo SM experience worse sleep quality compared with women who experience NM, and may benefit from behavioral interventions.

Hormone therapy and breast cancer

Climacteric. 2018 Dec 17:1-4. doi: 10.1080/13697137.2018.1527305. [Epub ahead of print]

Hormone therapy and breast cancer: risk communication and the ‘perfect storm’.

Reid RL1.

Author information

Abstract

Many factors are considered when a woman estimates her personal risk of breast cancer. Common to most decisions are four separate influences that have convinced the public and many health-care providers that breast cancer is the greatest concern for menopausal women and that menopausal hormone therapy (MHT) is generally responsible.

Historically there have been well-documented situations in which big pharma and doctors have not put patient interests first.(Surptise, surprise – my comment.)

Conflicting reports about the safety of MHT and the media imperative to always increase readership by presenting a compelling scary story have created an underlying distrust of science, doctors, and MHT. Numerical and statistical illiteracy in the general population creates a situation where lotteries succeed despite astronomical odds and the risks of medical interventions are exaggerated by their description using relative, rather than absolute, risks.

Finally, mammographic overdiagnosis contributing to improved breast cancer survival has contributed to the ‘popularity paradox’ (more screening – more enthusiasm) especially among survivors and advocacy groups. As a result, worry about breast cancer has overshadowed concern about cardiovascular diseases as the major cause of death and disability in the later years. The ongoing challenge for clinicians dealing with menopausal women is to bridge the gap in risk perception with evidence-based common-sense advice.

Should you take probiotics when you’re on antibiotics?

Health Check: should you take probiotics when you’re on antibiotics?

We still don’t know what types of bacteria are truly beneficial. Andry Jeymsss/Shutterstock

If you take antibiotics, there’s a good chance you’ll also get diarrhoea.

Antibiotics kill harmful bacteria that cause disease. But they also cause collateral damage to the microbiome, the complex community of bacteria that live in our gut. This results in a profound, though usually temporary, depletion of the beneficial bacteria.

One popular strategy to mitigate the disruption is to take a probiotic supplement containing live bacteria during, or following, a course of antibiotics.


Read more: Healthy guts are swarming with bugs, so what do they do?


The logic is simple: beneficial bacterial in the gut are damaged by antibiotics. So why not replace them with the “beneficial” bacterial strains in probiotics to assist gut bacteria returning to a “balanced” state?

But the answer is more complicated.

There is currently some evidence that taking probiotics can prevent antibiotic-associated diarrhoea. This effect is relatively small, with 13 people needing to take probiotics for one episode of diarrhoea to be averted.

But these studies have often neglected to evaluate potential harms of probiotic use and haven’t looked at their impact on the wider gut microbiome.

Pros and cons of probiotics

The assumption that there is little downside to taking probiotics was challenged in a recent Israeli study.

The participants were given antibiotics and split into two groups: the first group was given an 11-strain probiotic preparation for four weeks; the second was given a placebo, or dummy pill.

The researchers found the antibiotic damage to the gut bacteria of those in the first group allowed the probiotic strains to effectively colonise the gut. But this colonisation delayed the normal recovery of the microbiota, which remained perturbed for the entire six month study period.

In contrast, the microbiota of the second group returned to normal within three weeks of finishing antibiotics.


Read more: Health Check: should healthy people take probiotic supplements?


This research exposes a perhaps unexpected truth: we still don’t know what types of bacteria are truly beneficial or even what constitutes a healthy microbiome.

The answer is unlikely to be that individual bacterial strains are particularly helpful.

It’s more likely a diverse community of thousands of different types of microbes working together can provide health benefits. This microbial community is as individual as each one of us, meaning there is not just one configuration that will result in health or illness.

So, it’s unlikely that the addition of one or even 11 strains of bacteria in a probiotic could somehow balance this complex system.

A more effective (but less palatable) alternative?

The Israeli study also explored an alternative approach to microbiome restoration.

One group of participants had their own stool collected and frozen prior to antibiotic treatment. It was then re-instilled into their gut at the end of the antibiotic therapy.

This treatment, known as autologous faecal transplantation, was able to restore the microbiome to original levels after just eight days. The other group took 21 days to recover.


Read more: Poo transplants and probiotics – does anything work to improve the health of our gut?


This approach has also been shown to effectively restore the gut microbiome following combined antibiotic and chemotherapy treatment. These patients are predictably at risk of serious complications, such as bloodstream infection, as a result of microbiome disruption.

Research currently underway will help us understand whether microbiome restoration with autologous faecal transplantation will translate into tangible benefits for these patients.

But such an approach would not be a realistic option for most people.

Feed the good bacteria

Good food for gut bacteria. Roosa Kulju

A more practical strategy to aid recovery is to provide the good bacteria in your gut with their preferred source of nutrition: fibre. Fibrous compounds pass undigested through the small intestine and into the colon, where they act as fuel for bacterial fermentation.

So if you’re taking antibiotics or have recently finished a course, make sure you eat plenty of vegetables, fruit and wholegrains. Your gut bacteria will thank you for it.

Knee osteoarthritis and menopausal hormone therapy

One of the many benefits of taking oestrogen in the menopause, is its very positive benefit to all the joints, especially knees.

Menopause. 2018 Dec 21. doi: 10.1097/GME.0000000000001280. [Epub ahead of print]

Knee osteoarthritis and menopausal hormone therapy in postmenopausal women: a nationwide cross-sectional study.

Jung JH1,2, Bang CH3, Song GG1,2, Kim C4, Kim JH1,2, Choi SJ1,5.

Author information

Abstract

OBJECTIVE:

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

METHODS:

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

RESULTS:

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

CONCLUSIONS:

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

Laugh a little.

When should you throw away leftovers?

By Merrimon Crawford

Author

  1. Enzo Palombo Professor of Microbiology, Swinburne University of Technology

Disclosure statement

Enzo Palombo receives funding from Dairy Food Safety Victoria.

Victoria State Government
Swinburne University of Technology

Refrigeration is the most important invention in the history of food. But while commercial and home refrigerators have only been used for the past 100 years or so, people have long used cool natural environments to store foods for extended periods.

Temperature is important for controlling microbial growth. Just as we find food wholesome, bacteria and fungi also enjoy the nutritional benefits of foods. They will consume the food and multiply, eventually “spoiling” the food (think mouldy bread or slimy lettuce).


Read more: How to keep school lunches safe in the heat


If the microbe can cause disease – such as Salmonella, Campylobacter, E. coli or Listeria – you’re at risk of food poisoning. Most disease-causing microbes can grow to dangerous levels even before the food is noticeably spoiled without changing the smell, taste or appearance of the food.

How to stop bugs growing in our food

All forms of life require a few basic things to grow: a source of energy, (sugar for us, sunlight for plants), oxygen (for higher forms of life), water and simple chemical building blocks that provide nitrogen, phosphorous and sulphur – and the correct temperature. Water is key, and denying it severely restricts microbial growth.

That’s why salt has long been used as a preservative for perishable foods like meats; salt binds the water and makes it unavailable to microbes. Acid can also be used (via pickling or fermentation), as most microbes don’t like acidic conditions.

Don’t delay – put it in the fridge as soon as you can. Gary Perkin/Shutterstock

Of course, cooking kills the microbes of concern, but they can contaminate and grow in the food afterwards.

If the food can’t be salted or pickled, or you have leftovers of cooked food, you’ll need to store the food at a temperature microbes don’t like. Refrigeration is the most effective and economical option.

Typically, the greater the moisture level, the more perishable the food. That’s why we can store dry foods (such as nuts) in the cupboard but high-moisture foods (such as fresh meat, vegetables) will quickly spoil if unrefrigerated.


Read more: Food safety: are the sniff test, the five-second rule and rare burgers safe?


How to store food safely

The “danger zone” is the temperature range between 5°C and 60°C, where most common food poisoning bacteria like to grow. To avoid the danger zone, keep hot foods above 60°C and store foods below 5°C.

The two-hour/four-hour guidelines can also help avoid food poisoning from leftovers. If perishable food has been in the danger zone for:

  • less than two hours, use it immediately or store it appropriately
  • two to four hours, use it immediately
  • longer than four hours, discard it.

So, if the food has been sitting on the table after a long lunch on a warm day, it’s probably best to discard or consume it soon afterwards.

If the food is OK, store it in small portions, as these will reach the right temperature sooner than larger volumes, before refrigerating or freezing.


Read more: Monday’s medical myth: leave leftovers to cool before refrigerating


Using some common sense, and understanding how microbes grow, can help avoid a nasty case of diarrhoea – or worse. All food business must comply with food safety standards but how we prepare, store and consume food in our homes is equally important in preventing food-borne illness

Olive oil consumption and human health: A narrative review.

Maturitas. 2018 Dec;118:60-66. doi: 10.1016/j.maturitas.2018.10.013. Epub 2018 Oct 26.

Olive oil consumption and human health: A narrative review.

Foscolou A1, Critselis E1, Panagiotakos D2.

Author information

Abstract

The potential health benefits of olive oil consumption, particularly within the context of the Mediterranean diet, have been extensively investigated. However, its specific health benefits remain to be confirmed. The aim of the present work is to review the scientific evidence regarding the specific impact of olive oil consumption on human health, including the prevention of cardiovascular disease, cancers, and diabetes mellitus. Ten related meta-analyses were reviewed to this effect. Olive oil consumption was found to be beneficial for several chronic non-communicable diseases (e.g. including cardiovascular disease, breast cancer and type 2 diabetes), whereas there were contradictory findings regarding its impact on several biomarkers.

In conclusion, the aggregated evidence supports the assertion that olive oil consumption is beneficial for human health, and particularly for the prevention of cardiovascular diseases, breast cancer, and type 2 diabetes mellitus.

Which medicines don’t go well with flying?

Which medicines don’t go well with flying?

Every day, more than 10 million people take a flight somewhere in the world. While flying is relatively safe, the unique environmental conditions can put passengers at risk if they’re taking certain medications.

These include any hormone-based drugs, like the contraceptive pill and some fertility medicines, and drugs used to prevent heart attack and stroke. Antihistamines should also not be used to help passengers sleep during a flight.

What makes flying different from other forms of travel?

While flying is one of the safest forms of travel, there are specific risks that come with air travel, regardless of the length of the flight.

Passenger planes are typically pressurised to the same atmospheric conditions that are found at 10,000 feet altitude. At that level, the effective oxygen level is only 14.3%, which is much lower than the 20.9% found at ground level.

An additional risk is reduced blood flow from a lack of movement and sitting in cramped conditions, unless of course you’re fortunate enough to be in business or first class. And finally, dehydration is also a common side effect of flying due to the lack of humidity in the air.

When these conditions are combined, it results in an increased risk of deep vein thrombosis, which is also known as DVT. This is a type of blood clot that occurs in the veins deep in the body and occurs most often in the legs. The development of a blood clot can result in blocked blood flow to the lungs, heart, or brain, which in turn can cause a heart attack or stroke.


Read more: Explainer: what is deep vein thrombosis?


Contraceptive pill and other hormone-based medicines

Given the inherent risk of a blood clot when flying, a passenger should use with caution any medication that can further increase the risk of a clot.

Some brands of contraceptive for women (tablet or implant formulation) are known to increase the chances of a blood clot, although the overall increase in risk is small. While it’s thought the major risk comes from the hormone estrogen, a review of all the medical evidence in 2014 showed there’s a risk of blood clot from all contraceptive medicines.

It’s important you talk to your doctor about flying if you take hormonal medicines. from http://www.shutterstock.com

Likewise, hormone replacement therapy, particularly those that include estrogen, or some fertility medicines, such as gonadotrophins, can increase the risk of a blood clot.

If you take one of these medicines, it does not mean you cannot fly, nor that you should necessarily stop taking the drug. Many millions of women fly while taking these medicines and suffer no ill effects.

But the risk is also increased if you have an underlying health condition that includes type II diabetes, heart disease, and prior heart attacks or strokes. As such, passengers who also take medications to help prevent heart attacks and strokes should consult their doctor or pharmacist before flying.

If you’re at increased risk of a blood clot, then an anti-platelet medication may be suitable for you. These medicines act by stopping the blood cells from sticking together and include prescription medicines such as warfarin and clopidogrel, and over-the-counter medicines such as low dose aspirin.

Antihistamines

Many passengers can have trouble sleeping when flying, especially on long-haul flights. Parents flying with young children can also be concerned about them not sleeping or being unsettled and annoying other passengers.

In these instances, many will turn to sedating antihistamines, like promethazine to try to induce sleep. But this is a bad option.

The Australian Medical Association specifically recommends parents do not do this, as sometimes it can have the reverse effect and make children less sleepy and more active. These types of antihistamines are also known to depress breathing, and in the low oxygen environment of the aircraft this can be especially dangerous.

If you feel you or another family member will need sedation when flying, don’t use an antihistamine. Consult your doctor or pharmacist for a more suitable medication. Examples include prescription sleeping tablets, such as melatonin, or natural remedies, such as valerian.


Read more: Prepare for a healthy holiday with this A-to-E guide


What to do before and during your flight

Before you fly, if you’re taking any form of medication, it’s recommended you meet with your doctor or pharmacist to discuss the suitability of your medicines. They may advise you there’s little risk for you, or if there is a risk, they may recommend a different medicine for the trip or recommend a new medicine to reduce the risk of blood clots.

During your flight, don’t take antihistamines, and reduce your chance of a blood clot by drinking lots of water, stretching in your seat, and moving about the cabin as much as is appropriate.

Finally, the effects of alcohol can be increased when flying – so drink in moderation, and try to avoid tea, coffee, and other caffeinated drinks as these can have dehydrating effects and make it harder to sleep.