Summer Reading: Wendy at Menopause, the Blog recommends The Complete Guide to Women’s Health by Dr. Nieca Goldberg, the founder of Lenox Hill Hospital’s acclaimed center for women’s cardiac care.  The book’s sections on midlife issues are extraordinary, she explains:

Using case studies from her own practice, she does a particularly good job of explaining the changes that most women experience in mid-life to one degree or another (i.e. weight gain, changes in skin quality, vision and joint pain), and the problems you’re likely to bring to your physician’s attention. And that’s where she begins: how to choose the right doctor and how to be a good patient.

Dr. Goldberg covers a range of topics from urinary incontinence to breast health. But it’s her deep expertise in heart health that sets her apart from other physician-authors. She explains the connection between blood pressure and heart disease and emerging risk markers such as homocysteine, lipoprotein, and C-reactive protein that we should be aware of….Another chapter focuses on the endrocrine system, which is particularly relevant for menopausal women. With all the research I’ve done, I still learned a lot about adrenal hormones from this chapter alone.

About those cysts your doctor told you about… If you’re one of the estimated 1 in 10 American woman with polycystic ovary syndrome (PCOS), you may want to schedule a full  cardiac workup as menopause kicks in, according to a new study reported in the current issue ot “Vascular Health Risk Management,”

PCOS cases exhibit an adverse coronary heart disease (CHD) profile at an early age, including insulin resistance, dyslipidemia and increased central adiposity.

It can be hypothesized that the menopausal transition, whether natural or surgical, may provide an additional “insult”, resulting in greater cumulative risk to their vasculature. Coronary artery calcification (CAC), a measure of subclinical atherosclerosis (SCA), was measured by electron beam tomography in 149 PCOS cases and 166 controls (mean age 47.3 and 49.4 respectively).

Cases had a higher prevalence of CAC (63.1%) compared to controls (41.0%), (p = 0.037) after adjustment for age and BMI. A total of 22 cases and 39 controls had undergone natural menopause, 12 cases and 26 controls underwent surgical menopause (with biochemical confirmation) and 115 cases and 101 controls reported being currently premenopausal.

There was a significant difference in CAC values between cases and controls in all three-menopause categories including pre-menopausal, surgically induced and natural menopause (p < 0.001)….The data indicate that women with PCOS exhibit significantly increased CAC compared to controls after adjustment for age and BMI and menopausal status.

Whatever the results of your workup, it’s likely time (whether or not you have PCOS) to start getting serious about those anti-oxidants. And don’t lie about it!

Sleep problems: Your Mileage May Vary
. What time are you reading this? If it’s  3 a.m., you probably know you’re not alone. As Gayle Greene reports at Ms. (posted today on AlterNet), most women have a similar chaotic relationship to sleep, one that’s long been ignored by scientists:

A 2007 poll by the National Sleep Foundation found that 67 percent of women frequently experience sleep problems and 29 percent use some type of sleep aid at least a few nights a week. Other surveys have consistently found that nearly half again as many women as men complain of insomnia….

As with other conditions that affect more women than men and are not well understood, there’s a tendency to assume that the problem is psychological. When 501 physicians were interviewed about how they treated insomnia, they revealed that they asked an average of just two and a half questions, mostly about psychological problems. And since doctors believe it’s all in the head, there’s little impetus to research insomnia. In 2005, the National Institutes of Health spent less than $20 million on the condition, although it affects as many as a third of the U.S. adult population. Most of those funds were directed toward treating and managing the problem, while less than $4 million went to investigations of neurophysiological and neuroendocrinal mechanisms — the kind of basic research that might lead to an understanding of cause . . ..

As we’re exposed to monthly dips and surges in estrogen and progesterone throughout our reproductive years, the stress system stays primed for hyperreactivity, which gives us greater vulnerability to stress-related disorders. Men have higher rates of alcoholism, addiction, autism and schizophrenia, but women are more prone to panic disorder, generalized anxiety disorder, post-traumatic stress disorder and depression. Such differences arise during puberty, continue through the childbearing years and decline after menopause.

Such sleep issues, she adds, often affect women’s decisions about hormone replacement therapy. “Anecdotal reports suggest that many of those who stopped hormonal supplements started up again at a lower dose because, among other discomforts, they couldn’t sleep,” she writes.

One reason estrogen might help sleep is because of the way it interacts with certain neurotransmittal systems. It enhances the action of GABA (gamma-aminobutyric acid), the major inhibitory system of the brain, the system that sleeping pills augment to damp us down. It enhances the action of serotonin by decreasing the neurotransmitter’s uptake and making it more available, the way selective serotonin reuptake inhibitor antidepressants such as Prozac or Zoloft do. Or, it may be that hormone supplements simply keep hormone levels more constant, thereby eliminating the fluctuations that cause trouble. Then again, estrogen itself lowers body temperature, and that may be why it helps. Not enough is known.

Progesterone is also complicated. It raises temperature, yet has such a strong sedative effect that some researchers suggest women on HRT take their progesterone at bedtime. Anecdotal evidence suggests that it has a positive effect on sleep, but not in a simple way. (I have found that taking it at night disrupts my sleep, but that not taking it at all wrecks my sleep entirely.) More needs to be known.

Some researchers are already heeding Greene’s call to look more closely.  One is  Rush University Medical Center, whose seven-year Study of Woman’s Health Across the Nation (SWAN)  asked 3,000 women aged 42-52 to track their sleep patterns while noting a range of menopausal events. Not surprisingly, what they’re uncovering isn’t simple: the study found that increased “sleep difficulties” during perimenopause and the transition also varied significantly with respondents’ ethnic origins:

“Sleep difficulties, especially problems staying asleep, are relatively prevalent concerns among women going through the menopausal transition,” said Howard Kravitz, associate professor of psychiatry and preventive medicine at Rush University Medical Center and a principal investigator of the study. “Approximately 16% of postmenopausal women report having difficulty falling asleep and 41% report waking up frequently during the night.”

A Needle A Day – from Your OB/GYN? Jane Brody, the New York Times health writer who’s fearlessly chronicled her own and other women’s ways to better health from spinning class to olive oil, this week discussed growing questions as more and more non-celeb women choose to fight wrinkles by inject small doses of poison into their faces.

Even though botulinum toxin (better known as Botox) is one of the most powerful nerve poisons known, its rise as a medication in recent decades is not as startling as some might think. But all drugs, even the mildest over-the-counter medications, have unwanted side effects.

And as the number of uses for botulinum toxin grows along with the number of people who use it, healthy or otherwise, it is no surprise that reports of unwanted effects are growing, too… As Botox Cosmetic by Allergen, it is widely used by many women and men in affluent countries to relieve the visible ravages of age, at least temporarily.

A friend recently told me with slight exaggeration that “every woman” in Argentina in her 40s regularly had Botox injections to smooth out facial wrinkles, just as casually as she might have her hair dyed to hide the encroaching gray.

I can only wonder what these women will do in their 50s and 60s, when wrinkled skin is no longer confined to their faces. Given the prevalence of ageism and the perennially youthful images paraded before us in the media, there is no telling to what limits women — and some men — may go to in an effort to physically deny their age.

Brody notes that in February, the FDA issued a report on Botox’ adverse effects, the most serious of which have not occurred during cosmetic use but at much higher medical doses. Still, she added, there’s cause for concern and continued scrutiny:

Public Citizen, a consumer advocacy organization in Washington, has petitioned the drug agency to force manufacturers to warn doctors about the reported complications. The group reviewed the agency’s adverse-event reports and found 180 cases of serious effects like pneumonia and difficulty swallowing and breathing, as well as 16 deaths. In September 2005, the Centers for Disease Control and Prevention reviewed 1,437 adverse reports: 406 after medical use of Botox (217 of them serious effects) and 1,031 after cosmetic use (36 of them serious).

Meanwhile, as more OB/GYNs add Botox and similar procedures to their offerings, doctors are musing about the ethics of doing so, according to the Seattle-based think tank Women’s Bioethics Project.“Your cervix is normal, now let’s talk about Botox® for those frown lines,” jokes WBP director Kathryn Hinsch, as she notes the furor in “Do You Tip Your Doctor for Botox?”

In January 2004, the International Society of Cosmetogynecology was founded to educate and support OB-GYNs who are actively performing these procedures. Six years ago there were few resources to help GPs and FPs add cosmetic procedures to their practice, now there are a plethora of seminars, educational materials, and consultants available to transform one’s medical practice. The American Academy of Family Physicians itself offers continuing education courses on injectable cosmetic fillers, cosmetic lasers, chemical peels, microdermabrasion, and more.

To understand what’s driving the trend, we must look at why GPs, FPs and OB-GYNs would want to expand their practices to include cosmetic procedures. Over the last decade there has been downward pressure on physician income, dissatisfaction with managed care oversight, decreased job satisfaction, and increased liability concerns leading to some OB-GYNs to drop their obstetric care and others to leave the fields they were trained in all together. According to the American Medical Association, the effect of this discontent on the patient-physician relationship and the practice of medicine is yet unclear, but is cause for some concern.

The allure of revenue-enhancing procedures is seductive, notes Julie D. Cantor, MD, JD in her Virtual Mentor column, “Everyone wants a piece of the cosmedicine world, a ‘happy’ place where a full-time anesthesiologist can become a part-time aesthetician and ‘make a few bucks’ by wielding a laser at a beauty salon.”

Adding cosmetic procedures might be a ready remedy for a physician’s salary boost, but the potential ethical issues it raises are alarming: conflict of interest, exploitation of patient trust, and demeaning the practice of medicine to name just a few.

The discussion goes on to cite numerous voices pro and con, in text refreshingly clear of either academic or medical jargon. (Though there are footnotes: these are scientists, after all….)

New data on HRT and dementia, or a red herring? A small study (30 women) from the Centre for Female Health and Neurodevelopment at the Institute of Psychiatry, London tracked memory loss in women being treated for fibroids, and. Its researchers then presented their findings as evidence that HRT can help avert mental decline — but only if it’s given right at the start of menopause.

All were given drugs to stop their ovaries producing oestrogen – a condition that mimics the menopause.

MRI scans then monitored the women’s memories before surgery to remove the fibroids and after treatment.

The scans revealed the women’s memories worsened significantly when they were taking the drugs.

However, after these had worn off and oestrogen production resumed, memory function also returned to normal.

Dr Michael Craig, who presented the findings at the British Menopause Society conference in Manchester yesterday, said: ‘If you have HRT when the menopause starts, it may help keep your memory.

‘But if you leave it too late, then the damage is done.’

Most readers of this site may have winced the way we did at Craig’s sentence — and wanted to kick the folks at the Daily Mail who ended their story with it. Surely the British Menopause Society conference in Manchester, where the findings were presented, also featured far more complex findings, whose investigators would likely have not been so blithe or sound-bitable about them.

–by Chris Lombardi

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