I often get asked about excess hair on may of my female patients. They worry whether the testosterone in their scripts may be causing this. I do monitor the levels closely to make sure they remain within the normal boundaries. Below are the various causes of excess hair growth.
Hirsutism (HER-soot-iz-um) is a condition of unwanted, male-pattern hair growth in women. Hirsutism results in excessive amounts of coarse and pigmented hair on body areas where men typically grow hair — face, chest and back.
The amount of body hair you have is largely determined by your genetic makeup. Hirsutism may arise from excess male hormones called androgens, primarily testosterone. Or hirsutism may be due to an ethnic or family trait.
A combination of self-care and medical therapies provides effective treatment for many women with hirsutism.
Until puberty, your body is covered with fine, colorless hairs called vellus hairs. When you begin to sexually mature, male sex hormones called androgens help vellus hairs on certain areas of your body become dark, curlier and coarser hairs called terminal hairs. Unwanted terminal hair growth in women (hirsutism) can result from excess androgens or from an increased sensitivity of hair follicles to androgens.
About half the women with mild hirsutism have high androgen levels. Hirsutism that’s severe is usually due to high androgen levels. Conditions that can cause high androgen levels include:
- Polycystic ovary syndrome. This common condition is caused by an imbalance of sex hormones that may result in irregular periods, obesity, infertility and sometimes multiple cysts on your ovaries. Polycystic ovary syndrome is the most common identifiable cause of hirsutism.
- Cushing’s syndrome. Cushing’s syndrome is a condition that occurs when your body is exposed to high levels of the hormone cortisol, a steroid hormone involved in your body’s response to stress. It can develop when your adrenal glands — small hormone-secreting glands located just above your kidneys — make too much cortisol, or it can occur from taking cortisol-like medications over a long period. Increased cortisol levels disrupt the balance of sex hormones in your body, which can result in hirsutism.
- Congenital adrenal hyperplasia. This inherited condition is characterized by abnormal production of steroid hormones, including cortisol and androgen, by your adrenal glands.
- Tumors. Rarely, an androgen-secreting tumor in the ovaries or adrenal glands may cause hirsutism.
- Medications. Some medications can cause hirsutism. One such drug is danazol, which is used to treat women with endometriosis.
Sometimes, no identifiable cause
Excessive hair growth in women with normal androgen levels, regular menstrual periods and no other underlying conditions is called idiopathic hirsutism — meaning that there’s no identifiable cause of the disorder. This occurs more frequently in certain ethnic populations, such as women of Mediterranean, Middle Eastern and South Asian ancestry.
On the 25th Sept I had a blog about “how to stop hospitals from killing us” I gave my own experience of the possible harm to my son, prevented by my prompt intervention in his treatment. Now we hear about the death of Lillian Lane, a patient of Redcliffe Hospital, who died from an overdose of painkillers given because she allegedly had 2 medication charts. This was allegedly missed by the staff and doctors. My point: Patients and relatives – be vigilant. Ask questions. Check everything. Mistakes happen – health workers do harm patients – none of us is perfect. Read my post again to remind yourself what can be done to avoid these accidents. Also read the blog I posted about making sure that any test you have actually get seen by the doctor concerned.
Understanding weight gain at menopause.
Women’s Health Research Program, Department of Epidemiology and Preventive Medicine, Monash University , Melbourne , Australia.
ABSTRACT Objective The aim of this review was to summarize the literature regarding the impact of the menopause transition on body weight and body composition. Methods We conducted a search of the literature using Medline (Ovid, 1946-present) and PubMed (1966-2012) for English-language studies that included the following search terms: ‘menopause’, ‘midlife’, ‘hormone therapy’ or ‘estrogen’ combined with ‘obesity’, ‘body weight’ or ‘body composition’. Results Whereas weight gain per se cannot be attributed to the menopause transition, the change in the hormonal milieu at menopause is associated with an increase in total body fat and an increase in abdominal fat. Weight excess at midlife is not only associated with a heightened risk of cardiovascular and metabolic disease, but also impacts adversely on health-related quality of life and sexual function. Animal and human studies indicate that this tendency towards central abdominal fat accumulation is ameliorated by estrogen therapy. Studies mostly indicate a reduction in overall fat mass with estrogen and estrogen-progestin therapy, improved insulin sensitivity and a lower rate of development of type 2 diabetes.
Conclusion The hormonal changes across the perimenopause substantially contribute to increased abdominal obesity which leads to additional physical and psychological morbidity. There is strong evidence that estrogen therapy may partly prevent this menopause-related change in body composition and the associated metabolic sequelae. However, further studies are required to identify the women most likely to gain metabolic benefit from menopausal hormone therapy in order to develop evidence-based clinical recommendations.
OVERDIAGNOSIS EPIDEMIC – Today, Stacy Carter presents a philosophical view of over-diagnosis and what can be done to change how things stand. Recently a friend told me a story about her dad. Fit and well, he had a PSA test during a general medical check-up. The PSA test is controversial: many, including…
OVERDIAGNOSIS EPIDEMIC – Today, Stacy Carter presents a philosophical view of over-diagnosis and what can be done to change how things stand.
Recently a friend told me a story about her dad. Fit and well, he had a PSA test during a general medical check-up. The PSA test is controversial: many, including its inventor, say it should never be used to screen for cancer.
My friend’s dad’s PSA test started him on a path to prostate cancer diagnosis and surgery. The surgery made him incontinent. Humiliated by accidents, he couldn’t be far from a toilet so could no longer coach soccer or go on his daily long walk with friends. He became socially isolated and sedentary. He put on weight. And he developed diabetes.
Now his health is worse, but it’s not only his health that has been affected. Other aspects of his well-being – attachment to his friends and the ability to live the life he wants – have been undermined. His story is, sadly, not unusual, except for one thing.
The hospital where he was treated called him in to apologise for operating unnecessarily and harming him. Both he and his clinicians concede he was over-diagnosed (the disease would not have produced symptoms or shortened his life) and over-treated (he received treatment he didn’t need.)
The popularity of screening
In one British study, men described turning up to their GP determined to have a PSA test. In an Australian one, women worried that expert disagreement on PSA testing might discourage men from being screened. Most respondents to a US survey were enthusiastic about cancer screening, with 73% saying they’d rather have a full-body CT scan than $1,000 cash. Many thought it was irresponsible for healthy adults to avoid cancer screening.
We’re not just willing to go fishing for diseases. Some of us think it’s a moral obligation. And this is not surprising given two commonly accepted characteristics of contemporary Western society: we expect to be able to predict and control the future, and we tend to see health as an individual responsibility.
Benefits and harms
Moral obligation is the territory of ethics. So how should we think about the ethics of over-diagnosis in healthy people?
We need to start by weighing benefits against harms, but this is harder than it seems.
The benefits of tests and treatments are often overstated (so straight-talking interpretations like these are invaluable). Evidence is contested, uncertain and incomplete. Harms, in particular, are under-studied, and they’re not only physical.
If we are diagnosed (say, with cancer), we see ourselves differently. And a diagnosis can affect future generations. A cancer diagnosis in a parent can mean their child is declared “high risk” for developing cancer, potentially changing his or her medical care, insurance status, and self-concept for life.
Sometimes doctors or policymakers impose these harms on us, but not always. If patients demand tests or treatments, clinicians must trade-off possible harms against their duty to respect the choices and goals that matter to us. When decision-makers try to reduce harms by limiting services, they are often met with community outrage.
This passion is understandable. Unlike my friend’s dad, most over-diagnosed and over-treated people falsely believe they were saved from death by timely intervention. So it makes sense that they would altruistically defend others’ right to be saved.
We’re all in this mess together: trying to be good citizens, control the future, and wrestle with the uncertainty of science. It’s a difficult challenge, but it’s not impossible.
In 2007 in New Zealand, researchers gathered 11 women aged 40 to 49 together to consider the evidence on mammographic breast cancer screening in women their age. At the beginning, all 11 women supported screening. After two days of briefing and deliberation, ten out of 11 were against. We can’t replicate this process for everyone and every test, but it shows the power of good information and reasoned debate.
So what should we do? It depends on the disease and the treatment, and so on the evidence, however uncertain. But it also depends on our vision of a good society.
Over-diagnosis and over-treatment have arisen mostly from a high-tech chase after ever-more-finely-dissected risks in healthy individuals. There’s increasing concern that this chase is doing little for our health, and that the good it does is at the expense of people like my friend’s dad.
It’s not just these active harms we should worry about. We should also be concerned about the opportunity costs. We’ve known for decades that the best way to improve health is to improve the basics, like the food supply, the built environment, and the fairness of our social and economic systems. Changes like these are good for everyone’s health, and especially for the health of the least well off.
And such changes can only be achieved through collective effort. Perhaps the solution to over-diagnosis and over-treatment includes changing the way we think about ourselves: less as individual disease time-bombs, and more as members of a community, with a shared responsibility to work together to make it easier for everyone to be healthy.
OVER-DIAGNOSIS EPIDEMIC – We kick off the second week of this series with Jenny Doust looking at some drivers of over-diagnosis in general practice. It’s easy to dismiss general practice as being about minor illnesses requiring little clinical acumen. We see patients with the common symptoms of life…
We are funded by CSIRO, Melbourne, Monash, RMIT, UTS, UWA, Canberra, CDU, Deakin, Flinders, Griffith, La Trobe, Murdoch, QUT, Swinburne, UniSA, UTAS, UWS and VU.
OVER-DIAGNOSIS EPIDEMIC – We kick off the second week of this series with Jenny Doust looking at some drivers of over-diagnosis in general practice.
It’s easy to dismiss general practice as being about minor illnesses requiring little clinical acumen. We see patients with the common symptoms of life – coughs, fevers, backache and abdominal pain. Most of these are transitory and, for the large proportion, medical intervention makes little difference.
The diagnostic skills of a general practitioner, however, need to be as acute as those of House MD. Among all the children we general practitioners see with diarrhoea, we need to be able to pick the one with Crohn’s disease requiring urgent surgery. Among all the women who complain of feeling tired, we need to isolate the one who has life-threatening Addison’s disease. And among all the teenagers with flu-like symptoms, we need to find the one with a lymphoma in his chest.
These are all patients I have seen during my time as a general practitioner and they remind me constantly to take every person who walks through my door seriously.
The most common reason general practitioners are sued is because of missed diagnoses. Missed diagnoses also invoke a strong sense of professional failure. So how can general practitioners manage in this sea of uncertainty?
One way is to perform more tests. This is also popular with patients, who perceive that tests ensure nothing serious is missed. What is not well understood by patients (and sometimes also by clinicians) is the potential harm from testing.
The most obvious harm is the cost and resources required; we would quickly overwhelm the health system if we performed an MRI on every patient with back pain. A strong system of primary care results in a health-care system that’s both more efficient and less costly because primary-care physicians are skilled at filtering those with severe disease needing further tests, from those with self-limiting illnesses.
But even in Australia, with its highly trained general practice workforce, this skill is often under-appreciated.
Harms of testing
Less well understood are the harms due to the inherent inaccuracy of testing. By the laws of statistics, when the likelihood of a disease is very low, most positive test results will be false positives. We see this most clearly in screening programs, where most abnormal screening results will not have the disease on follow-up testing. This causes only minor harm if there is a follow-up test. But it is of much greater consequence if tests are assumed to be accurate and too much faith is put in the results.
The greatest harm from the increased use of testing, however, is not costs, resources or false positives. Rather, it’s the problem of over-diagnosis.
Clinicians and patients both believe that finding a disease earlier in its process means it will be more successfully treated. But there’s increasing evidence that finding disease early or at a milder stage has paradoxical harmful effects, even reducing survival and quality of life.
Wider availability of more sophisticated tests results in “incidentalomas”, incidental findings that would not have otherwise been diagnosed. The detection of thyroid cancers, for instance, has more than doubled in the past 30 years. But most of these diagnoses are incidental findings from imaging.
If the earlier detection of these cancers improved prognosis, you would expect to see a decline in the mortality rate from thyroid cancer. But the mortality rate has sadly been constant in this time.
Even more problematic is the widening of the definition of diseases and the lowering of disease thresholds. Examples of expanding definitions include chronic kidney disease, diabetes, and even the diagnosis of cancers, such as breast and bladder cancer.
We assume patients who are now included in the wider definition benefit from treatment as much as those using the old definition. In fact, we are likely to believe that they will benefit more as we have caught the disease early. But all medical treatments cause harm. And when patients with milder disease are treated, it becomes more likely that the potential harm of medical treatment will outweigh the benefits.
Wider disease definitions become self-reinforcing – we find more and so we test more. And because we have now included milder patients in our disease group, we are misled by the perceived improvement in patient survival and the reduction in disease complications in our new patient group.
Right now, we are in the midst of a perfect storm – a population that is increasingly anxious about health, doctors who don’t want to miss a diagnosis, a pharmaceutical industry that profits from widening the definitions of disease and a health system that rewards over-testing and fails to acknowledge the harms that can result from it.
We have set up a group to look for solutions to this problem, including a conference in 2013, but the answers are far from clear. Given the pervasive nature of over-diagnosis, solutions will need to involve all layers of the health-care system, including policy makers and key clinical opinion leaders.
As a general practice physician, I am hoping we will be able to spend less time labelling patients with an ever increasing number of “diseases” and to spend more time working with them on solving their health problems.
PSA screening and prostate cancer over-diagnosis
OVER-DIAGNOSIS EPIDEMIC – We finish our first week of this series with Robert Burton, Christopher Stevenson and Mark Frydenberg examining prostate cancer screening. Scientific oncology started with the creation of the modern microscope, which provided the basis for the modern pathologic study of cancer…
OVER-DIAGNOSIS EPIDEMIC – We finish our first week of this series with Robert Burton, Christopher Stevenson and Mark Frydenberg examining prostate cancer screening.
Scientific oncology started with the creation of the modern microscope, which provided the basis for the modern pathologic study of cancer in the late 19th century, and established the “fatal cancer” myth. As [one researcher] arguing (http://www.guardian.co.uk/commentisfree/2011/aug/02/breast-cancer-screening) against breast cancer screening put it, “since then, without pause for thought, the microscopic identification of cancer according to the classic criteria has been associated with the assumed prognosis of a fatal disease if left untreated.”
Earlier this week, an article in this series looked at the adverse effects of breast cancer screening. Today, we will examine the role of screening in the over-diagnosis of prostate cancer.
The fatal cancer myth began to unravel a century later. A 1993 study for instance, noted that prostate cancer was unique because “the frequency of histologically (pathologically) confirmed invasive cancer at autopsy greatly exceeds the prevalence of clinically significant carcinoma during life.”
The authors then affirmed that in no other malignancy was there such a vast reservoir of undetected cases that may never be clinically significant or cause death. They also noted that up to 40% of all men might be treated for prostate cancer but only 8% would ever have a cancer large enough to be diagnosed and only 3% would die of it.
Over-diagnosis of cancer is the detection of asymptomatic cancers that will not become clinically significant and cause disease or death in the patient’s lifetime. How many men have prostate cancer that might never come to light without screening and are therefore at risk of over-diagnosis?
A 2010 review of a 1996 study found that microscopic asymptomatic prostate cancers had been detected in 525 men of various ages killed in motor vehicle accidents in the United States (U.S). The findings indicated that this type of cancer could affect approximately a third of American men aged 30 to 39 years, increasing to about 70% at age 70 to 79 years.
Looking at these figures, together with similar autopsy studies, the authors of the review concluded prostate cancer was likely detectable in between 30 to 70% of men over 60 years old.
And a 2009 Australian study of prostate tissue, sampled from 133 cadavers referred for coronial autopsy, found invasive prostate cancer in about a quarter of the 70 men aged 50 or more years.
It seems over-diagnosis of prostate cancer was already inevitable by the time the Prostate Specific Antigen (PSA) blood test was introduced for prostate cancer screening in Australia in the late 1980s, because it could detect cancers that had previously gone undiagnosed.
Winds of change
In July 2012, the U.S. Preventive Services Task Force (USPSTF) found that “The mortality benefits of PSA-based prostate cancer screening through 11 years are, at best, small and potentially none, and the harms are moderate to substantial”. The task force recommended against PSA-based screening for prostate cancer, stating that the recommendation applied to men in the general U.S. population, regardless of age.
The recommendation was based on an analysis of the evidence from trials of PSA screening in the U.S. and Europe, but mainly on the 2009 report of the European randomised controlled trial (RCT), where 182,000 men aged 50 to 74 years from seven European countries were randomised to either PSA testing every two to seven years or to usual care.
This report was updated in 2012 with an average follow-up of 11 years. It found a statistically significant reduction (21%) in prostate cancer mortality in the population of men invited to screen and a 29% reduction in those who were actually screened.
But this reduction in mortality came at a cost. The authors reported that to prevent one death from prostate cancer at 11 years follow-up, 1,055 men would need to be invited for screening and 37 cancers would need to be detected. The USPSTF also noted that there was convincing evidence PSA-based screening led to substantial over-diagnosis of prostate tumours.
The amount of over-diagnosis of prostate cancer is an important concern because men with cancers that would remain asymptomatic for the remainder of their lives cannot benefit from screening or treatment.
Based on our analysis of trends in prostate cancer incidence (new cases per year) since PSA testing began in the late 1980s, over 75,000 Australian men who might never have known they had prostate cancer may have been turned into prostate cancer patients, possibly for only a small benefit.
At the same time, the men were exposed to the potential harms (incontinence, impotence) of unnecessary treatment. These harms can be avoided if the prostate biopsy shows that they have low-risk disease and are then managed by active surveillance, rather than immediate treatment of their cancer.
Deaths from prostate cancer have fallen by approximately 13,000 during that same time. Some men can be saved by early detection and treatment but others clearly do not benefit.
Performing PSA tests on everyone leads to substantial over-diagnosis. But not performing PSA tests at all would inevitably lead to under-diagnosis of some men who may have been cured by early detection and treatment. Before consenting to undergo PSA screening, men should understand that while there are possible, if modest, benefits to getting tested, they may be exposed to substantial harms from over-diagnosis and over-treatment.
2 September 2012, 6.23am AEST
The perils of pre-diseases: forgetfulness, mild cognitive impairment and pre-dementia
OVER-DIAGNOSIS EPIDEMIC – David Le Couteur discusses recent changes in the definition of dementia and their ramifications. The pattern of over-diagnosis is the same for many diseases: we screen healthy people and those with minimal symptoms; we use sophisticated technologies that detect early or minor…
OVER-DIAGNOSIS EPIDEMIC – David Le Couteur discusses recent changes in the definition of dementia and their ramifications.
The pattern of over-diagnosis is the same for many diseases: we screen healthy people and those with minimal symptoms; we use sophisticated technologies that detect early or minor abnormalities that may not progress; and we treat people with these abnormalities on the assumption that this will prevent significant illness and death.
The downside of all this medical intervention is that we’re exposing healthy people to the potential harms of diagnosis, investigation and treatment without any certainty about long-term benefits. Indeed, there’s a growing unease that this trend is being driven by the financial benefits of creating a larger market for drugs rather than genuine health gains.
I work in geriatric medicine and over the last few years, I have seen how the changing definitions of dementia and Alzheimer’s disease has insidiously been leading to over-diagnoses.
Screening the healthy
Let’s start with the schema of over-diagnosis: are we screening healthy people and those with minimal symptoms? Yes. In the past, we diagnosed older people complaining of minor memory impairment with “benign senescent forgetfulness”, and told them that it didn’t require any further action. It was, after all, benign.
But this terminology progressed to “mild cognitive impairment (MCI)” and now (more ominously), to pre-dementia and pre-clinical Alzheimer’s disease. We are also being encouraged to screen older people for any memory impairment because this has now been defined as a pre-disease or early disease.
The screening tools are usually simple questionnaires, such as the mini-mental state examination (MMSE). There’s variability in how well the assessments are performed, and forgetting the date or stumbling on a repetition task can lead to a diagnosis of mild cognitive impairment. But how many of these people actually progress to dementia?
Most studies show that only one in ten cases of mild cognitive impairment progress to dementia each year, and many improve. One study that followed outcomes for ten years concluded – “The majority of subjects with MCI do not progress to dementia at the long term.”
Yet all of these people will potentially be faced with the stigma of a dementia diagnosis and its consequences – paternalism, incapacity and loss of autonomy. And then there’s the fear of impending dementia, which can generate stress and despair.
Are we using sophisticated technologies to detect early or minor abnormalities? Yes. In attempt to improve the diagnosis of early dementia, we now have a range of investigations to detect the earliest cases before symptoms have developed. These include brain scans and measurement of biomarkers in the fluid that surrounds the brain.
The gold standard for such diagnoses is post-mortem brain pathology. Alzheimer’s disease is characterised by deposits of a protein called amyloid in plaques between brain cells and another protein called tau in tangles within the cells. But the relationship between amyloid plaques and the clinical features of dementia lessens as people age.
Many older people with the characteristic pathology of Alzheimer’s disease didn’t have any features of dementia at post mortem or memory problems when they were alive. On the other hand, the majority older people with dementia have multiple changes in their brains including those related to ageing and vascular disease. So the characteristic pathology of Alzheimer’s disease is not very useful in diagnosing dementia in the largest group of people with dementia, the elderly.
Are we treating these early abnormalities on the assumption that this will prevent the development of dementia? Yes, in some cases.
There are two groups of medicines available for the symptomatic treatment of Alzheimer’s disease (cholinesterase inhibitors and memantine). Although these drugs have not been proven to have any effect on influencing the progress of dementia, review articles in some medical journals promote the possibility of their “disease-modifying activity” and the need for early treatment with these medicines.
And it’s important to add that a trial of one of these medicines attempting to show a reduction in the conversion from mild cognitive impairment to dementia found that it actually increased the death rate.
The medicines are only funded by the Pharmaceutical Benefits Scheme (PBS) for moderately severe Alzheimer’s disease but undoubtedly some people will be using them (and probably a variety of alternative therapies as well) in the hope that they will delay dementia.
And there are other industries aiming to profit from the diagnosis of mild cognitive impairment (or early and pre-clinical dementia) by selling various brain fitness technologies ranging from video games to mobile phone apps.
Dementia is a tragic illness that places enormous burden and demands on patients, families and society. There’s no question of the value of increasing recognition of the care needs of people living with dementia, and for more research funding. These are essential because effective treatment and prevention of dementia will have a dramatic impact on the human race. But the growing emphasis on early diagnosis of dementia, mild cognitive impairment and preclinical dementia in everyday practice (with the subsequent risk of over-diagnosis and its consequences) seems to be giving the disease, not the patient, greater priority and importance.