A major concern for the majority of women in their late 40′s and early 50′s has been whether and when to start hormone therapy. (Note it used to be called hormone replacement therapy, but the experts now agree that this term suggests that the menopause transition is an endocrine deficiency disorder and not a natural change in our hormonal and reproductive status, so the word “replacement” is out.)  I concur with the current PC terminology, but should point out that 80% of women experience symptoms related to this menopause transition as their estrogen levels plummet. The most common symptoms are hot flashes and night sweats (called vasomotor symptoms or VMS).  Add vaginal dryness, sleep problems (either due to the hormonal transition or to the stresses we face in mid life), mood changes and even a sense of diminished focus and quality of life and it’s clear that for many women, lack of estrogen production in the menopause creates sufficient physiologic and psychological havoc that they want to do something about it. That most effective something has been hormone therapy; estrogen (as pills, patches, creams, sprays. vaginal tablets and rings) and if a uterus is present (i.e. no hysterectomy) some form of progesterone (again as pills, patches, creams, drops or vaginal gels).

Since the Women’s Health Initiative was publicized, women have been encouraged by the FDA and just about every other official agency that reviews the research on hormone therapy, that if they chose to take hormones, they take the smallest effective dose for the shortest duration, preferably no more than 5 years. That “magic|” 5 year mark has been suggested because it’s felt that menopausal symptoms resolve in most women after 5 years. (Much of the “this-won’t last” data comes from women who have chosen not to take HT and have been followed for years to see what happened to their symptoms.)

Many women don’t want to wait for symptoms to resolve, especially if they are not guaranteed a finish date. Indeed some research has shown that 15% of women continue to have symptoms in their 70′s. Twenty five to 50% of women who stopped hormone therapy after the Women’s Health Initiative resumed therapy. Those most likely to do so had severe symptoms before they started HT, were obese, younger at time of menopause, African American, smokers or physically inactive.

When it comes to “it’s time to stop your hormones” advice I generally suggest that quality of life vs. risk be considered: will you feel lousy enough without hormone therapy to counter the possibility of an increase in your risk for breast cancer with long term (probably more than those 5 years) use of HT?  I also explain that estrogen has positive effects on bone mass and in the first years of use is probably heart protective. |But as the years pass and other factors affect our cardiovascular system, estrogen may no longer afford the same cardiovascular protection.

So what is a woman (who has been happy on her hormone therapy) to do? Should she try to “wean off” or just stop after that arbitrary 5 years?  A new article in the Journal Menopause tried to address this in a scientific fashion.  A study was conducted in Sweden in which the researchers recruited women to stop their hormone therapy “cold turkey” or do so gradually by taking it every other day. They wanted 200 women for the study, but when faced with the idea of stopping their hormones, many refused and they could only find 87 volunteers!  At the end of 4 weeks there was no difference in the symptoms of the women who abruptly stopped and those who tapered and then discontinued.  And because vasomotor symptoms came back for many, within 4 months 30% of the participants resumed their hormone therapy and after 1 year that number had risen to 50%!

Now to my clinical experience… I try to lower the dose of HT for most of my patients after they have taken it for 5 years. (This necessitates a discussion of the possible risks associated with long term use). If a patient is amenable, I prescribe a dose that is lower than that which she has taken and suggest she try it for 4 to 6 weeks. Some of my patients can then keep lowering their dose until they successfully stop and have no symptoms. Others state that although their symptoms resumed “they were not that bad” and they try to stop HT for good. But I do have patients (about 30%) who feel pretty awful, either on a lower dose or once they stop. I then suggest that they continue at the very lowest dose that allows them to keep their symptoms under control.  (And in their next visit I will revisit the risks and benefits of long term hormone therapy. Basically we are agreeing to procrastinate.) As long as we have a frank discussion about the pros and cons of long term HT, the final decision should be made on an individual basis.  Unless there is a truly health threatening reason that dictates that she stop, issues regarding her quality of life (and life style) have to be considered.

We have all heard about the importance of breast feeding….for the baby. But less attention has been paid to what lactation can do for a Mom’s future risk of cardiovascular disease. So here are some breast-to-heart facts: Breast feeding increases caloric expenditure by approximately 480 calories a day, which of course means that pregnancy weight is more easily lost postpartum. Lactation improves glucose tolerance. (This means that when you do consume sugar or anything converted to glucose, your insulin levels won’t instantly surge; as you know surging insulin is not good, it can cause fat storage and increased “bad” triglycerides). Breast feeding also helps general fat metabolism and will lower the C-reactive protein profile. (C-reactive protein is a marker for inflammation and is correlated with the inflammatory process that increases development of plaque and cardiovascular disease). There are also a number of studies that have shown a long term benefit for lactation on midlife metabolic syndrome (high blood pressure, high triglycerides and obesity) and cardiovascular disease.

A new study published in the January Journal of Obstetrics and Gynecology gave additional credence to the “breast feeding is good for a Mom’s heart” theory. (Of course it’s good for emotional heart aspects, but that’s not what this article is about). In 1996 and 1997, The Study of Women’s Health Across the Nation (aptly acronymed SWAN) was established. Women between the ages of 42 and 52 were followed in seven sites. Two hundred and ninety seven of these women who reported at least one live birth on enrollment were enrolled in this aspect of the study; 121 women consistently breast fed all their children for at least 3 months, 84 inconsistently did so and 92 did not. Special electronic beam tomography scans were done on all the women to measure the amount of calcification in their coronary arteries and aorta. (Note calcification of these areas indicates the presence of atherosclerotic plaque and its presence has been show to increase the risk of heart attack or stroke.)

Those women who did not breast feed were more likely to be African American, more likely to smoke, consume fatty food, and ingest more calories. They were also less likely to be college graduates than the women who breast fed. But before we say voila, maybe these factors were more important than whether they breast fed, note that the statisticians adjusted for all of these factors. And they still found that mothers who had not breast fed were 3.82 more like to have aortic calcification and 2.78 more likely to have coronary artery calcification than those who had.

Bottom line: The decision to breast feed has implications not just for the health of the baby, but also for the heart of the Mom. Breast feeding may help her stay healthy longer and allow her to care for and cherish her children. Let’s make sure we, our daughters and any friends who plan to have a baby are aware of this!

I know we are all shocked and horrified about the events in Haiti this week.

With Haiti foremost in all our minds today and as a member of Save the Children’s Board of Trustees, I wanted to update you on Save the Children’s rapidly evolving response.

As of Thursday, our staff in Port-au-Prince continues to travel about the city on foot and by motorcycle to make assessments. Although our office was damaged, staff is able to work out of our compound. Our office has become an unofficial center for the injured as neighbors, children and other aid workers have come there as the office is relatively undamaged compared to other locations. We are making the injured and displaced as comfortable as we can. As of last night we still had not been able to make contact with 23 of our 59 staff in the city, as the communications systems are all still primarily down. We are hopeful we will locate about the situation of all our staff in the coming days. Save the Children’s sub-offices in Jacmel, Massaide and Gonaives were largely unaffected and all staff are accounted for there.

Given the extreme needs of children and families, we are focusing on distribution of basic items, The first kits of hygiene and household supplies are being assembled in our Dominican Republic office and have gone today and landed in Port-au-Prince with our initial response team. This additional team is focused on the distribution of these badly needed items. Hygiene kits contain such items as toothbrushes, towels and soap, and family kits include blankets, mosquito nets, and cans for water. But thousands more kits will be needed

We have identified these areas of immediate priority: addressing shelter, health, water, sanitation, and child protection needs and, as conditions allow, the restoration of education for children.

This may very well become one of the largest Save the Children relief efforts ever in this hemisphere. Given the extraordinary need, I would be grateful if you can consider a gift to Save the Children and forward this information to any of your contacts or colleagues who may be interested in making a gift. You can visit our web site at http://www.savethechildren.org to get the most updated information and to make a donation.

With over 20 years on the ground in Haiti and the strength of a global alliance behind us, Save the Children is one of the top international responders and will be a permanent presence in the lives of children who have endured unspeakable adversity. I hope we can have your help in this latest disaster for children.

To donate:
http://www.savethechildren.org

Save The Children – Haiti Relieve
54 Wilton Road
Westport, CT 06880

(Please mention Dr. Reichman when contributing)

We have all heard the weight gain formula: 3500 calories that are not burned off will add 1 pound of fat tissue. So if that’s the case 1 extra cookie that has 60 calories, when consumed daily, will add 0.5 pounds monthly or 6 lbs a year. Now let’s say you eat that cookie daily for a decade….does that mean you will gain 26 lbs, or if you eat it for 4 decades, you will gain more than a hundred pounds? Add to this the distressing fact that our basal body metabolism decreases by about 5% each decade…By now that cookie could make us look like sumo wrestlers before we get to take advantage of Medicare! (The last phrase is not meant to be an ad for Medicare Advantage.)

Well according to a very relevant commentary recently published in JAMA, this is not the cookie’s (nor you body’s) destiny. Weight gain does occur when your caloric intake increases above your energy expenditure, but it doesn’t continue indefinitely. The increased initial weight from that cookie requires more calories for maintenance. (It’s physics again, a heavier body needs more sustenance to stay heavy.) Eventually your weight will stabilize after several years of extra cookie consumption at approximately 6 lbs. But once you are in a steady weight state and you up your cookie consumption to 2 extra cookies, the process will begin over again.

The author of the JAMA commentary brought up some additional weighty information. If a young adult woman adds 1 oz of a sugar sweetened beverage and walks 1 minute less a day, she will have a temporary caloric excess of about 13 calories, leading to a weight gain of 1.4 lbs in one year. If she repeats nutritional and exercise changes of this nature on an annual basis for 28 years she will have a 370 calorie energy gap and a 35 lb weight gain. And she will not be alone in her caloric overage. The estimate is that the average per capita energy intake in the U.S.A since the 1970’s has increased by up to 500 calories. Our readily available food supply and mass encouragement to eat more and sweeter (for less money) has worked and contributed to our ever increasing girth. Obesity will overtake cancer as a cause of premature death! Future health care will have to start with food care, but now I digress.

Here come the “I am going on a diet or at least not eating that cookie” facts. As you loose some of that fat from your body, you also need less fuel to maintain that loss. Your weight recalibrates at a new steady state. Your body also “misses” some of that weight and strives to conserve whatever calories you do consume. So to continue to loose weight you have to further restrict your diet (much more than that cookie) and/ or really increase your energy output (i.e. exercise). Walking one mile a day expends just an additional 60 calories when compared to resting; the minimum to make up for that cookie. But to lose more you have to do more, and consume less. Unfortunately you can’t just rest on early weight loss laurels and resume your old diet and restricted physical routine. If you do the weight you lost will just come back. That New Year resolution has to be one that goes on and on and on…

The holidays are over…there are no more late night parties. As the New Year unfolds we need to approach our jobs and our lives with alert readiness. But we can’t if we’re exhausted. According to the National Sleep Foundation, adults need 7-9 hours of sleep a night; anything less will impact your body’s nightly renewal and its subsequent daytime capacity to handle your activities. So if you plan to get up at or before 7AM and your preparations for bed include flossing, brushing and moisturizing (my estimate is 15 minutes) you might want to forgo the 11 o’clock evening news. Moreover, the depiction of local murder, mayhem, infidelities and recession that you would view at this hour could impact your ability to fall asleep.

Approximately 29% of adults report sleeping less than 7 hours a night and 50 to 70 million have chronic sleep and wakefulness disorders. (I have to admit that I am a nervous driver and even a more nervous backseat driver…as I remember those 70 million sleepy motorists.) Indeed, The National Highway Traffic Safety Administration estimates that fatigue plays a role in over 100,000 car accidents a year. In addition to accident mortality and morbidity (a medical word meaning illness and in this case, injuries) sleep deprivation is associated with insulin resistance, weight gain, depression, diabetes, hypertension, stroke, heart disease and ultimately a shortened life span!

The CDC just reported on a new survey that was conducted to ascertain the number of individuals who were “sleepless in the USA”. The survey also examined whether gender, ethnicity, locality, work and socioeconomic status were factors. A state-based, random- digit telephone survey of individuals over 18 was conducted by state health departments in collaboration with the CDC. (I can just imagine my response if someone randomly dialed my phone number and asked me how I was sleeping, but never mind; 403,981 responsible individuals did respond to this survey.)

The survey takers asked “During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?” They then broke the number of days down to zero days (or blissful sleep), 1-13 days, 14-29 days and all 30 days.

Overall 11.1% of the respondents reported that they had insufficient sleep for the entire preceding 30 days whereas 30.7% reported no days of insufficient rest or sleep. Those in between may have had fewer than 30 days of poor sleep or simply refused to acknowledge that they weren’t getting enough and were tired.( I call this sleep denial….or that oft heard expression….”I don’t need much sleep”.)

Women were more likely to self report insufficient rest or sleep for 30 days than men (12.4% versus 9.9%). Non-Hispanic blacks (13.3%) were more likely to be sleep and rest deprived for that period than other ethnic groups. As individuals got older they seemed to get more rest and sleep…the cutoff age was 45. Finally retired persons (43.8%) slept better than individuals who were employed. Those with less than a high school diploma were also more likely to report 30 days of sleep and rest (33.8%) than those with a higher education (28.0%). Persons who were unemployed (13.9%) and those unable to work (25.8%) were more likely to report 30 days of insufficient rest or sleep than those who were employed (9.9%), retired (9.5%) or a student or homemaker (11.1%) The highest prevalence of insufficient rest or sleep was concentrated in the southeast United States. Interesting, this is also the area in which obesity, depression, hypertension, heart disease and stroke is concentrated!

What does all this mean? My first conclusion is that we are less sleepless in California (at least compared to the southeast). The survey indicates that lifestyle, occupation, family and economic stress (which apply to women and the under-employed) are factors that decrease sleep and sense of rest. The CDC editor also felt that preoccupation with technology (i.e. computers and the internet) was a factor. So, I hope you are not reading this on line after 11pm!

If you fit into this “not enough sleep or rest” scenario, please make sure you tell your physician (me, if you are my patient). All healthcare professionals will start by advising you to keep a regular sleep schedule (in other words go to bed 8 or 9 hours before you have to get up), avoid stimulating activities within 2 hours of bedtime (this usually means exercise, not sex), avoid caffeine, nicotine and alcohol in the evening; sleep in a dark, quiet, well ventilated space (my husband calls it a tomb, but hey I have science to back this up) and finally avoid going to bed hungry. (But don’t eat just before you plan to sleep.) If all this doesn’t help then we can talk about referrals for sleep labs, apnea tests and appropriate sleep specialists. And if necessary, consider pharmacologic interventions.

Sleep tight! (Actually, I never understood what that phrase meant so instead I’ll advise you to get your 8 hours.)

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