The word epidemic is tossed around by the media quite easily…. it’s a scary word that sells news. Unfortunately it doesn’t always sell individual health care. The incidence of diabetes is rising to such an extent that it unfortunately warrants the term “epidemic”. Most concerning is the statistic that up to 40% of people with diabetes are not diagnosed! The principal reason (aside from the fact that they don’t go to a health care facility until they are really sick) is that screening usually requires a fasting blood test. If a visit is postprandial (a fancy medical way of saying after eating) a blood sugar test is often postponed for another don’t eat for 8 hours time, and subsequent noncompliance or busy schedules mean that there is a  good chance that it won’t be done at all.

Before I get to the “easier” test I must perform my public health duties and give you the scare the sugar out of us statistics from the American Diabetes Association:

  • 20.8 million Americans or 7.0% of the population had diabetes in 2005
  • 14.6 million were diagnosed
  • 6.2 million were undiagnosed
  • 51 million people aged 40 to 74 have impaired glucose tolerance (considered to be a pre-diabetic condition), impaired fasting glucose level ( it was high) or both.

Globally:

  • 5 to 10%, of those with diabetes have type 1 (insulin dependent)
  • 90 to 95% have type 2 (not insulin dependent, latter age onset, associated with obesity, heart disease and to sum it up…early onset of death)
  • Within the next 3 decades the number of people with diabetes is projected to double (to 366 million people); as the population ages, expands (literally and figuratively), eats more, exercises less and become obese.

Now, for the diagnostic good news: There is a blood test called hemoglobin A1c (HbA1c), also called glycelated hemoglobin, that reflects the status of your blood sugar in the previous 2 to 3 months. As you know hemoglobin carries the oxygen in your blood cells. It also links to excess sugar in a process called glycelation. The more your blood sugar levels rise, the more your hemoglobin becomes glycelated. The HbA1c test has become standard in “telling” whether glucose control has been adequate in individuals treated for diabetes. Now many experts feel that the test can be used in lieu of a fasting blood sugar to screen everyone. It “can see” if diabetes is developing in otherwise undiagnosed adults and children. (Unfortunately we have also seen an increase in Type 2 diabetes in adolescents and children over the last decade).  If HbA1c is higher than 6.0%, further testing should be done to check for diabetes. If it is 6.9 or higher, a diabetes diagnosis is highly likely and therapy warranted.

Bottom line…this is a simple blood test that would benefit all those with any risk factors for diabetes including:

  • Women who have had gestational diabetes
  • Women with a history or diagnosis of polycystic ovarian syndrome ( which may cause irregular periods, fertility problems, obesity, abnormal hair growth, acne and/or elevated blood triglycerides)
  • A family history of diabetes, obesity, hypertension and early heart disease
  • Obesity
  • Hypertension
  • Elevated lipids
  • Coronary heart disease

There are so many common and shared risks for diabetes that most of us might benefit from knowing our HbAIc level.

Data obtained from the well-known Nurses’ Health Study show that weight loss after menopause does indeed decrease the risk of breast cancer. This study began in 1976, at which time it enrolled over 120,000 female, married, registered nurses who were, at the time, between the ages of 30 and 55. These women have been followed ever since, receiving mailed questionnaires two times a year   requesting information on their lifestyle factors, including breast cancer risk factors. ( The majority of the nurses have responded,)

The breast cancer portion of the study, published in the Journal of the American Medical Association, included almost 50,000 of these women (some of who were followed for as long as 24 years) who noted their weight changes since menopause. It found that being overweight increased their risk of breast cancer. Specifically, women who gained 55 pounds or more since age 18 were 1.5 times more likely to get breast cancer compared to woman who did not gain weight from their late teens. (That means that their relative risk increased by 50% ) The women who stayed at the same weight from age 18 and then gained 22 pounds or more after menopause had an 18 percent increased risk of breast cancer when compared to the “never” weight gainers.

Now for the good news… Those women who lost 22 pounds or more after menopause (it didn’t matter if they had gained weight before or after menopause) had a 57 percent lower risk of breast cancer than the “weight gainers” who maintained their status quo. Loss of weight means less fat…and fat has its own hormone effect: it converts hormones produced by the adrenal glands into estrogens. The more fat…the more estrogen in a woman’s body. Is an “estrogenized environment” that’s associated with excess fat the culprit? We’re not sure; studies have also demonstrated that when estrogen is given as hormone therapy without concomitant progestin it does not appear to increase breast cancer risk. A simple hormonal explanation may not give us the answer. But the facts on weight remain empiric.

Losing as little as 10% of your body weight can decrease blood sugar (and risk of type 2 diabetes), improve the ratio of good and bad cholesterol and lessen hypertension (and risk of heart attack and stroke). You’ll certainly look better and feel better. You can add to these “thinning benefits” the fact that you will significantly decrease your risk of invasive breast cancer.

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A vaccination against 4 types of human papilloma virus or HPV (two that cause venereal warts and two associated with 70% of cervical cancers) has received FDA approval and has been marketed by Merck under the brand name of Gardasil. Pediatricians, internists and gynecologists have been giving the series of three shots to girls and women between the ages of 11 and 26. While many of my younger patients have received this inoculation there are still many who have not. They, their mothers and grandmothers want to know whether this vaccination causes reactions, and is indeed effective.

There has been some rather scary media coverage of adolescents who fainted or had severe reactions after receiving an injection. A recent study from Australia which provides free HPV vaccination to all females between the ages of 12-26  found that there were indeed very rare instances of severe allergic reaction or anaphylaxis (there were 7 cases out of 269,680 vaccines administered in schools: an incident rate of 2.6 per 100,000). The authors theorized that it was possible that a stabilizer in the vaccine solution caused a hypersensitive reaction. Moreover young females might be more likely to get a reaction than young men. (The vaccine is not generally used on boys who are, of course, the future propagators of this sexually transmitted virus). Since July 2007 the package inserts for Gardasil vaccine state that this side effect is a possibility.

The vaccine works best in young women who, in medical terms, are sexually naïve, i.e. they have not had prior sexual activity which could have led to an infection. But if a young woman is found to have HPV in her Pap smear, chances are that she has not been infected with all 4 types of HPV. It would probably still be worthwhile for her to be vaccinated. Gardasil won’t cure what she has, but may help prevent the 2 or 3 other HPV’s she has not contracted.

We don’t start Pap smears until a young woman has been sexually active for 3 years or after the age of 21. (This is based on data that cervical cancer has not been shown to appear for at least 3 years after infection.) And before every woman (or her mother) who has ever tested positive for HPV has an “OMG I will get cancer crisis”….know that at least 70% of young adult women are positive  for  HPV within 2 to 3 years of any unprotected  sexual activity and that in MOST instances the HPV disappears and never causes cervical pre-cancerous changes or cervical cancer. (This is one of the reasons we don’t biopsy or treat early changes associated with HPV in these women…the virus and changes are likely to subside on their own.) A final note….since the vaccine only protects against 4 types of HPV…and there are at least 100 types, Pap smear screening will still necessary, even after appropriately timed vaccination.

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The American College of Obstetricians and Gynecologists (or in short ACOG, the organization to which I belong) now recommends routine HIV screening for women aged 19-64 (or younger patients having sex). The CDC (Center for Disease Control) has actually made this recommendation since 2006. More than one million people in the United States are infected with HIV and a quarter of them don’t know it. That means the “unknowing” don’t receive medication that would allow them to live longer and they may not take appropriate steps to protect their partners, prevent unwanted pregnancies or take medications to impede mother-to- child transmission. In order to identify women who are HIV positive, ACOG suggests that screening be performed as a routine part of gynecologic and obstetrical care unless the patient declines testing (termed “opting-out”) .

So when you see me I may ask you about HIV testing. If you’ve never the test, or you  have but are now are at possible risk (you have a new partner, your partner may have had a new partner, one of you has used IV drugs etc.) it should be repeated. Please understand that this test is now as standard as checking your cholesterol, and yes, your Pap smear!

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This is a Stage 0 (not invasive) breast cancer. Today DCIS constitutes 20% of all diagnosed breast cancers. The in situ means that the cancer cells have not penetrated the basement membrane (think surrounding perimeter) of the breast ducts. This very early malignancy is now found much more frequently than in the past because of widespread mammography screening. There is probably no true increase in incidence (though we all seem to know someone who has been diagnosed of late).

DCIS usually arises in areas of ductal cells that were already somewhat abnormal and crowded together  (the official terminology is atypical ductal hyperplasia). Research has shown that in many, if not most women, DCIS does not become a life threatening, invasive cancer. But no one wants to take a chance, and therapy is geared to prevent further growth and/or invasion. Ninety to 95% of DCIS is detected through mammogram….the radiologist sees clusters or linear areas of micro (teensy) calcifications. Only 5 to 10% of women who have DCIS present with a lump or nipple discharge. So don’t skip that annual mammogram after 40 (and of course, don’t miss your physical exam).

In most cases a lumpectomy and radiation will suffice for treatment of DCIS.  Total mastectomy may be indicated if the tumor is large, occurs in several areas of the breast or if the margins show abnormal cells (despite attempts by the surgeon to try to “get it all out”).  Mastectomy cures 98% of patients with DCIS. Women who have had a lumpectomy and radiation may have a 5 to 9 % recurrence rate of DCIS. If it is estrogen receptor positive, adding tamoxifen therapy for 5 years (a SERM which acts as an anti-estrogen on breast tissue) will decrease this already low rate by 27% and will also decrease the chance of developing invasive cancer by 48%. Other medications which block estrogen receptors (aromatase inhibitors) are also being tested for patients who have had breast sparing surgery and subsequent radiation.

I am often asked if digital mammograms are superior to those done with film. Digital imaging may enable the radiologist to see a clearer image of the breast tissue in young women or in women with dense breasts. The images are also digitally stored for evaluation and future comparison…an obvious ecologic advantage to using and storing piles of film. But so far studies have not indicated that the new “digital” makes the old “film” inadequate. About 30% of radiology laboratory facilities have gone digital.

Breast ultrasound may also increase diagnosis of DCIS in women with dense breasts when added to mammogram. We now know that if your breasts are dense the risk of cancer is increased, not just because it’s “hard to see through them” but because there seems to be more activity in the glands.
Breast MRI may become the diagnostic tool of choice in the future. It is currently extremely expensive and time consuming (for the patient, technician and radiologist), moreover, there are simply not enough machines or trained personnel to use MRI as a routine screening procedure. But in order to give full disclosure (or should I say a better image), I have to report on a recent study published in Lancet in which MRI detected 92% of DCIS lesions while mammography found  only 56%.

Current indications for breast MRI imaging include women with strong family histories of breast cancer, women who are known to have a mutation in their BRCA genes, or women who have had chest radiation for Hodgkin’s disease before the age of 30.  Breast MRI is also used after diagnosis of breast cancer in order to determine if the cancer (or DCIS) is present elsewhere in the same breast or the other (contralateral) breast.

In the midst of this fairly technical and scary update let me point out the good news:  We are doing better than ever in our ability to diagnose DCIS. This allows us to treat and yes “cure” more women. The long term outcome is, in oncologic terms, excellent. Ten year survival with appropriate therapy is greater than 95%. So if you are due for your mammogram, breast check or have questions…let me know!

I know this isn’t a gynecologic subject, but it does allow us to tell our spouses, adult children, friends (and ourselves) to slow down, be alert and use a seat belt….and  for goodness sake stop talking on that handheld or even Bluetooth connected phone while driving. In 2005 (the most recent year for which data are available) 45,520 deaths in the United States were related to motor vehicle accidents. I wish I could  prominently display this number on my window every time I see a driver talking on their phone, turning to the back seat to talk to children or other passengers or (and this could be generically female) putting on make-up while driving!

Yaz is the relatively new birth control pill that contains a progestin called drosperinone. The estrogen and progestins in Yaz are the same as those in the older BCP called Yasmin.  However, Yas has a lower dose of estrogen and the active portion of the pill is present for more days in the pill cycle. Yaz was approved by the FDA in 2006. At that time studies were presented showing that Yaz helped with symptoms of a very severe form of PMS called PMDD (for those of you who want the full clinical name it’s premenstrual dysphoric dysfunction). This was the first time a birth control pill was approved to help treat PMDD…but not PMS. Apparently a line was crossed when it came to direct to consumer ads. Perhaps you noticed them; they are beguiling titled “Not Gonna Take It” and “Balloons”. The ads implied that if you bloat, are moody and have PMS symptoms, Yaz will help you feel better or better yet, become free (of symptoms, not political or social repression)! Drawing this conclusion just cost the pharmaceutical company Bayer 20 million dollars. The FDA has stated that the ads must be corrected; that no corroborating studies have been presented to indicate that “ordinary” symptoms of PMS constitute an indication for Yaz.

This makes a huge difference; probably more than 50% of women experience some PMS symptoms before their period.) PMDD, defined as a much  more severe condition that causes disruptive emotional and physical symptoms, including depression, anxiety, persistent anger, headaches and joint pain is rare affecting “only” 3 to 8 % of women. I know that I have, on occasion, drawn the conclusion that what is good for PMDD will be good for PMS. And some of my patients with PMS who took Yas did indeed feel better. But I don’t want to tout anecdotal medicine. If I prescribed this Pill for you or a friend and your doing well (it does help diminish acne and water retention) than stay with it.  But it’s possible that any birth control pill which prevents the hormonal fluctuations that occur with ovulation and post ovulation would have made a difference.

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