We all know that high cholesterol levels are a major risk factor for coronary artery disease (CHD). Once we’re menopausal, we face a double whammy: our cholesterol levels tend to go up (we produce more in the liver despite attempts at an appropriate diet) and as we get older, heavier and perhaps exercise less, plaque adheres to our blood vessels, they become restricted and stiff and our risk for CHD increases.

Some of this is probably due to the loss of circulating estrogen subsequent to menopause. Which then leads to the very complex question; does taking estrogen after menopause “fix” our cholesterol problem and help prevent CHD?  The prevailing opinion is that estrogen therapy can, to some extent, (I have to qualify statements like this) diminish the risk for CHD, but only if taken at the onset of menopause. Apparently hormone therapy won’t help and may actually do harm if given to a menopausal women who already has underlying CHD, nor will it necessarily help prevent CHD in a healthy women after many years of use or if started a decade after the onset of menopause.

But that is not what this article is about. The question that has been posed by many of my patients who do not want to take estrogen, have contra indications to estrogen or who simply want to follow the latest in nutritional health news is whether soy, as a food, will help lower their cholesterol levels and hence ward off CHD.

The aware consumers (hopefully those of you reading my newsletter) now know to look for a legitimate FDA health claim when a food (or supplement) is touted to prevent or treat disease. Well, in 1999 the FDA stated that “diets low in saturated fats and cholesterol that include 25 grams of soy protein a day may reduce the risk of heart disease”.

That statement may change…A recent article published in the journal Menopause tested the affects of soy ingestion in 87 postmenopausal women younger than 65 who were not using hormone therapy, prescription medications or herbal supplements, including soy, known to  influence cholesterol levels. Half the women were given a special snack bar, drink mix or cereal which contained 25 g of protein from soy, the other half were given similar looking (and tasting) products that were devoid of soy. The study was double blinded; neither the women tested nor the investigators following them knew what they were given until the study was completed after one year. Total cholesterol, high-density lipoprotein cholesterol HDL-C (the good kind), low-density lipoprotein or LDL-C (the kind that causes plaque) as well as triglycerides (also not good) were measured at the onset and completion of the study.

There was a slight weight advantage for the women who consumed the soy test foods; on average they gained 1.6% in body weight, whereas the control group of women gained 3.3%. But the cholesterol levels in the women who dutifully eat there soy foods did not improve. That 25 mg of soy just didn’t do it! Other similar studies have come to the same conclusion.  And the FDA is now reevaluating its previous claim about the cardiac benefits of soy protein.

Soy supplements and soy-rich foods may not be the answer to the rising levels of cholesterol that contribute to CHD us as we get older. But I still eat and enjoy my edamame; it has to be healthier than French fries!

It’s hard for a person who does not have a weight issue (yes I’ll admit I’m skinny) to proffer advice to those who do.  It’s rather like a non-smoker telling a smoker to just throw away the ashtrays and stop! And of course, it’s not fair. Obesity is both horribly complex and chronic; it has genetic, metabolic, endocrinological, psychological and behavioral components, many of which are very difficult to understand much less control. We all want to blame someone or some entity “out there” for the 72 million obese adults in the US. (Well, to be honest, at some point,  I do blame larger plates, our over abundance of cheap, highly advertised junk food, our obsession for getting more for our money and the lack or exercise that is pandemic in our society). Having made the last portion of this statement, I should now suggest that you get off your computer, iphone and/or blackberry and go take a brisk walk! But maybe you can wait until you finish reading this.

There are several definitions for the descriptive and medical terms overweight, obese or morbidly obese…however, the models in magazines and popular actresses make most women feel that they fit into the overweight category. But the World Health Organization (WHO) has made it clear that obesity is the abnormal or excessive fat accumulation that presents a risk to health. They use body mass index (BMI) as an estimate of obesity:  a BMI of 25 to 29.9 kg/meter squared is defined as overweight, a BMI of 30 to 39.9 obese, and a BMI 40 or over morbidly obese. To figure out your BMI, go to www.nhlbisupport.com/bmi/bminojs.htm.

I receive a publication for continuing medical education in my specialty. (The State requires a certain number of CME credits to renew a medical license, and answering questions attached to the article is one way to get those accredited hours). A recent Postgraduate Obstetrics and Gynecology article dealt with bariatric surgery among reproductive-age women and upon reading it, I thought that its information would be of interest to many women.

We all know the health consequences of obesity: hypertension, coronary vascular disease (heart attack and stroke), diabetes, osteoarthritis and cancer (among them, breast, ovarian, colon, uterine and pancreatic). In the reproductive years, obesity can affect ovulation, periods, fertility, result in complications of pregnancy, higher C Section rates and immediate and long term health for newborns. Between 2002 and 2006 health care costs for treating obese adults increased by more than 81%, rising from $166.7 to $303.1 billion. Obesity weighs heavily on our economy.

The NIH has recommended guidelines for surgery (bariatric) as a treatment for morbid obesity. Potential candidates include anyone with a BMI over 40 or those whose BMI is 35 or over if they have other “co-morbid” conditions such as cardiopulmonary disease, diabetes, difficult ambulation and severe joint disorders as a result of their weight. More and more patients in these categories are undergoing bariatric procedures ….there has been an 800% rise between 1995 and 2005 and that percent keeps leaping (as do some of the now thinner post-op patients as well as the surgeons and surgery centers performing these procedures).

Bariatric surgeries work via restriction (limiting the food that gets to the stomach) and/or malabsorption (limiting food absorbed by the stomach as well as the intestine). There are two common methods performed in the US: the first, the banding procedure, which is restrictive. An adjustable gastric band is positioned around the upper portion of the stomach so that food comes into and is absorbed or propelled downward though a small stomach pouch. The band is usually placed by means of a laparoscope, avoiding the need for a large abdominal incision. The band can be adjusted to widen or narrow the opening of the stomach pouch via a port that is placed under the skin. (Fluid is used to fill and expand the band or conversely fluid can be removed to narrow it.)

The second type of procedure that is available is both malabsorptive and restrictive. It’s called a Roux-en-Y gastric bypass (RYGB). It involves dissecting the stomach to create a small pouch that empties into a portion of the intestine called the jejunum. Most of the stomach and 100 to 150 cm of the bowel are bypassed so that they do not come into contact with food. This procedure can also be done through a laparoscope; but in some cases, if there are complications (it’s more technically difficult than the banding surgery), may have to be completed via an open abdominal incision.

Complications do occur. According to the review article, band slippage occurs in up to 15% of patients; they then can develop nausea, inability to tolerate food and problems swallowing. Others have no overt symptoms but simply start gaining weight. Sometimes it’s hard to get to the port opening or the tube that leads to the band kinks or leaks and this may require re-operation. Most of these problems can be fixed, the real issue is the mortality rates following the procedure; and they are low: between 0.02% and 0.1%. (Remember that many of these patients have medical problems that make anesthesia difficult and aside from their operative risk they could succumb to their weight-caused diseases without the surgery).

There are higher complication rates with the RYGB procedure. These include hernias in the area of incision (15% -24%), fluid or blood collection in the area of incision (8%), infection (7%) and need for re-operation (1.6%). There are also reports in the literature of pulmonary embolism, lung problems, breakdown of the area of the stomach that has been sewn (or stapled) and bleeding. The mortality rates for the RYGB can vary depending on the severity of obesity, the multiple conditions that could already have impacted the health of the patient as well as the experience of the surgeon. It ranges from 0.3% to 7%. (Scores that can predict these rates have been formulated by various agencies.). Then because this procedure promotes weight loss by decreasing nutrient absorption (think malabsorption), it can lead to a deficiency in vitamins and minerals, especially vitamin A,D.E and K as well as the B’s, C, thiamine and calcium. So vitamin supplementation and tests to see “what’s missing” are important subsequent to the surgery….and should be continued, basically, forever.

I should mention a few more potential side effects…the most common is dumping syndrome which can occur at least initially in 25 to 50% of patients who undergo gastric bypass. The dumping can occur 30 minutes after eating and results in nausea, vomiting, fullness, diarrhea and/or palpitations or it can occur hours after eating with symptoms of dizziness and confusion. But before I dump on the procedure, let me quickly state that most patients learn how to control this problem by abstaining from rich carbohydrate laden food, eating small meals and taking additional fiber.

I feel like one of those TV commercials where I list so many possible side effects that, in the end, make the product sound horrendous. Well in the right conditions and appropriate patients, bariatric surgery can be amazing. Maximum weight loss often continues for 2 years and can range from 40 to over a hundred pounds. The procedure can result in complete resolution or improvement of conditions such as chronic hypertension, type 2 diabetes, obstructive sleep apnea and abnormal cholesterol (hyperlipidemia) and of course, the size of waist bands and clothes.  In women of reproductive age, there is an improvement in menstrual cycles, fertility, and maternal complications during pregnancy. There have been studies that also have shown lower rates of preterm deliveries and abnormal birth weight of the newborn. (However, the nutrition of the pregnant mother has to be followed carefully so that she has no vitamin deficiencies.) There on ongoing studies to see if there are less C Sections in women who have had the surgery before getting pregnant.

I don’t want anyone to come away embracing the thought that “well I’m fat, but never mind any attempts to lose weight; I can always have the surgery.” This is a procedure that should be considered only when diet with caloric restriction and exercise just don’t work. The decision to undergo lap banding or RYGB can only be made after all the pros and potential side effects are weighed by the patient and her physician.

While I was in Tel Aviv visiting family, five new medical journals arrived on my desk. Despite a case of major jet lag, I forced myself to read through them the weekend I came back. Immersed among the many scholarly articles were a few facts and comments that I thought I would (as briefly as possible) share with you in this week’s newsletter.

The safety of tomography (CT scans) was discussed in a section called “Perspective” in the New England Journal of Medicine. The author (from the University of California at San Francisco) calculated that the risk of cancer from a single CT scan could be as high as 1 in 80!  She called for better standardization, monitoring and regulations as to how imaging equipment is used. In February 2010, the FDA did launch an initiative to reduce unnecessary medical imaging, but little has been done to implement their recommendations.

A second article in the same journal titled “The Uncritical Use of High -Tech Medical Imaging” continued an imaging critique. The authors pointed out that physicians often request imaging examinations in order to prevent future liability. We are sued if we don’t make a diagnosis but rarely are held accountable for overuse of testing. A recent survey of Massachusetts physicians showed that 28% of diagnostic imaging referrals were done as part of “defensive practice”. Moreover, the radiologists performing the imaging are often concerned about making a definitive interpretation with a single test and again, to avoid being sued, may suggest additional or follow-up CT scans. Patients expect an immediate and accurate diagnosis and often demand a scan; so excessive imaging is not entirely the fault of the physicians. The number of CT scans that are currently done is extraordinary high….we can’t all be that sick. Currently in the United States, approximately 10% of the population undergoes a CT scan every year adding up to a total of 75 million scans. (Obviously some patients receive multiple scans.) The authors also state that the use of CT continues to grow by more than 10% annually.

Everyone agrees that more has to be done to reduce the amount of radiation with each scan (it can be equal to 100 simple x-rays). Both physicians and patients should reconsider how often we have to look into our bodies to diagnose and treat a suspected or ongoing disease. The recommendations for getting a scan “just in case” or “to give the gift of good health” (the latter appears on ads for imaging centers) should be reevaluated. Non radiating tests such as ultrasound, MRI, as well as a good clinical examination and a thoughtful history can often be as helpful and less harmful to our health.

The same journal then had an article titled “Hunger and Socioeconomic Disparities in Chronic Disease.”  The number of US households whose members are at risk for hunger because of an inability to afford food (food insecurity) has risen. The rate was 32% in 2008 and is higher each year. In 2008, 21% of US households with children were classified as lacking food security. Because of their inability to afford healthy food, the members of these households had to resort to buying the cheapest calorie-dense products, i.e. food with added sugar, fats and sodium. The authors pointed out that $1 can purchase either 1200 calories of cookies or potato chips or 250 calories of carrots. As a result of these more affordable and abundantly advertised products, the parents and, of course, their children risk obesity, hypertension, diabetes and other diet–sensitive chronic diseases. Confronting food insecurity and making healthful food affordable will help prevent an enormous future burden of disease. The number of children and adults who may be destined to develop chronic disease in the US as a result of an inability to afford appropriate nutrition shames all of us!

Okay, I want to review just 2 more articles…

JAMA reported that proton pump inhibitors (PPI’s)  such as Prevasid, Nexium  and 6 other types that are currently on the market (and I have tried just about all of them) will carry revised labeling that warn that these stomach acid reducing medications can increase  patients’ risk of hip, wrist and spine fractures. The new warnings are based on 6 of 7 studies that showed a relationship between PPI use and an increase in fracture risk. Most of the patients in the studies were 50 years or older. The reason for this increase in risk is not known. Unfortunately, those of us who suffer from horrific “heartburn” (and let me take this opportunity to state that if it lasts for more than a few weeks and/or does not respond to a PPI you should have an endoscopy), there are no other terrific solutions. So if you need this type of medication, make sure you tell your physician, and she or he will probably order bone density tests.

Finally, the last article that I thought I should review dealt with the effect of glucosamine on chronic lower back pain caused by osteoarthritis (wear and thinning of the discs that separate the vertebrae). Glucosamine has been shown to help the body restore cartilage and seems to help knee and hip pain due to osteoarthritis. The current study on glucosamine’s affect on back pain was also published in JAMA. It was double blinded, randomized and placebo controlled (all the right things) and carried out in 250 Norwegian patients older than 25 who suffered from chronic back pain. (I can almost see a movies title here… “Back pain in Norway”). The patients were given 1500 mg of glucosamine or placebo for 6 months. And despite hopes that this over-the- counter product would help, there was no affect on their back pain. Twenty million individuals in the United States have chronic back pain from osteoarthritis, so this news was disappointing. I guess we’ll have to go back to Pilates and our orthopedists!

Although I haven’t kept an official count, probably 10% of patient visits to my office are for menstrual cramps and/or pelvic pain. The complaints range from “I’ve had cramps ever since I got my period” to “the cramps have become worse and now I have pelvic pain every time I have sex!”

Yes, up to 80% of women have some cramps during their period but if they are severe enough to compromise lifestyle (missing days from school, work or usual activities), the pain may be due to endometriosis. Briefly, this is a disease characterized by abnormal endometrial-like cells (the ones that line the uterus) which seed onto tissues and organs outside the uterus. The current theory is that these cells get there through retrograde menstruation (during period bleeding downwards some of the blood and sloughed cells from the uterine lining go upward through the Fallopian tubes and implant on the surface of the tubes, ovaries, uterus, peritoneum and nearby bowel). These ectopic or misdirected cells then react to estrogen and progesterone as if they were in their right place, i.e. in the uterine lining. The cells enlarge, multiply, bleed and secrete inflammatory substances. The endometriotic implants also cause blood vessels to grow around them; all in all creating havoc to the surrounding tissue. Adhesions (scar tissue) may form and in some cases cysts filled with blood grow within the ovary….the latter are called endometriomas. In addition to the pain that endometriosis causes, this condition frequently contributes to infertility as a result of scarring of the tubes as well as production of substances that interfere with fertilization.

Endometriosis is unfortunately all too common. It affects 6 to 10 % of women in reproductive age, 50 to 60% of women and teenage girls with pelvic pain and up to 50% of women with infertility.

Because many internists and general practitioners will see patients with complaints that may be due to endometriosis, the New England Journal of Medicine recently featured a summary of this disorder in the section devoted to clinical practice.

The author of the summary pointed out that risk factors for endometriosis include any situation in which there is an obstruction to menstrual flow, for example a tightly closed cervix or imperforate hymen, prenatal exposure to DES, prolonged exposure to high levels of estrogen, (early onset of periods, late menopause or obesity), short menstrual cycles, low birth weight and (here is where the environmentalists start to shout) exposure to endocrine-disrupting chemicals.

The diagnosis of endometriosis is not that easy to make. First, the physician has to rule out other pelvic causes of chronic pain such as ovarian cysts, uterine fibroids, infection and scar tissue from previous infection (pelvic inflammatory disease). And remember, that there are other organs “down there” that can hurt…including bowel (irritable bowel disease), the bladder (interstitial cystitis), muscles and abdominal tissues that can ache or burn. Women who have experienced sexual abuse may have pain with no anatomical cause.

Once all those other disorders have been ruled out, the next route that many physicians use to delineate the cause of the pain is via treatment. We try to make the ovaries “quiet” so that they don’t produce fluctuating levels of hormones that stimulate painful periods. First, most physicians try prescribing birth control pills on a monthly basis. If the withdrawal bleeding at the end of the pill pack “the period” still hurts, we will try to eliminate all bleeding by having the patient take the active pills continuously for months at a time. If this doesn’t work, it’s time to become more invasive in order to achieve a final diagnosis…This is when we suggest laparoscopy to see if there are endometriotic implants in the pelvis. If the diagnosis is confirmed, the surgeon will cauterize or excise the implants and any blood filled cysts on the ovary will be removed. Laparoscopy is the only way to make a final, definitive diagnosis and it also offers an important opportunity for treatment and pain relief. Unfortunately, the disease can recur and require additional surgery in the future.

Women who have infertility or recurrent disease may benefit from injections of GnRH agonists…the most common is a monthly or tri-monthly shot called Lupron. It fools the pituitary into “thinking” it doesn’t have to send messages to the ovaries to stimulate follicles and secrete hormones and thus prevents the care and feeding of the endometriotic implants (basically causing transient menopause). If menopausal symptoms become too severe, small amounts of hormone therapy can be prescribed to give back some progesterone or estrogen. The current recommendation for ongoing infertility in women who suffer from endometriosis is to then proceed with IVF (in vitro fertilization).

Sorry to give such a long and fairly complicated medical explanation about the recommendations for work up and treatment. Endometriosis is a very common disorder which is often ignored or misdiagnosed for years. I hope this information encourages you, your friends and family to seek help if your cramps are severe or “it really hurts down there”.

**We have changed the ‘from address’ on our newsletters so please be sure to add mail@reichmanmail.com to your safe senders list.  You can continue to contact us through info@judyreichman.com **

I am on vacation visiting family so there will not be a topic based newsletter this week. But, I wanted to take this opportunity to wish each of you a Happy Independence Day!

However, I’m already working on next week’s to be mailed July 9th.

You may want to take a moment to view the archives of my past articles. You can find them on my web site at: http://www.judithreichman.net See you next week,

Judith

**We have changed our mailing address so please be sure to add mail@reichmanmail.com to your safe senders list. You can continue to contact us through info@judyreichman.com**

Last week, I spent 2 days at a board meeting for Save the Children at our headquarters in Westport, Connecticut.

The efforts I make to treat my patients and, yes, to write this web site seem miniscule compared to what health care workers sponsored by Save the Children do for the children, women and their families in rural and virtually inaccessible areas around the world. The “good goes” campaign supported by the Ad Council has just been launched. I have been honored to be a part of the communications committee and I would like to share the following with you:

Every 4 seconds a child survives thanks to the basic health care provided by local health workers.
Front line local health workers help children all over the world survive threats like newborn complications, pneumonia, diarrhea, malaria, and malnutrition. But global estimates suggest we need 4.2 million more health workers in developing countries. Sadly, one child dies every 3 seconds largely from preventable and treatable causes due to the lack of basic health care.

Of the children under the age of 5 who die each year, almost two thirds could be saved with the simple, low-cost interventions delivered by health workers in clinics and in their communities. With attention from developing country governments and donor nations, we can help them bring lifesaving care to more hard-to-reach communities and make the survival of children a reality worldwide.

There are some amazing videos and pictures that tell their story. They will appear on television next month. You can get a first hand look and appreciate what Save is doing by going to www.GoodGoes.org.

Health care workers walk hundreds of miles to save children. I sit in my office in Westwood and my patients come to me. We are all very lucky….and spoiled. As you read this, 15 children who would have died from preventable diseases and complications have survived, but many more are not so fortunate.

As you know, I write my weekly newsletter to keep you informed on matters of health. This week I am making a request: Please consider what you can do to help provide lifesaving care by contributing to Save the Children and its campaign for newborn and child survival. It’s less than what we pay for valet parking!

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