We’ve all had that concern…. Where is the rest room? Didn’t I just go? I just can’t get up from this bed again to pee!

Obviously, frequency and urgency (and usually pain with urination) may be due to a bout of cystitis or urinary tract infection which most women experience at least once in their lives. But there are lots of other times when a woman may feel these symptoms minus the pain: when pregnant, after multiple cups of coffee downed to stay alert, as a result of drinking too much water (yes there is such a thing) and unfortunately, with age.

Let’s just start with definitions:  We classify a bladder as being “overactive” if you void more than 8 times a day. (Some studies suggest that number is 13.) Urgency urinary incontinence is an involuntary loss of urine associated (you guessed it) with urgency … you feel you have to go but can’t make it to the bathroom and simply lose control and urinate, sometimes a lot. This accident may be instigated by the sound of running water, opening the bathroom door, turning the front door lock or just putting on layers of clothes (think skiing) and then realizing that getting them off and going to the bathroom has became an interminable task!

A “Clinical Practice” article that was just published in The New England Journal of Medicine  reviewed “idiopathic” urinary urge incontinence.  Idiopathic does not mean that you or your physicians are idiots … but it does mean that the actual cause is not well defined.

Having proclaimed that this type of incontinence is idiopathic, the article did list potential risks for overactive bladder and urge incontinence. These included increasing age, female sex (well we knew that!), obesity, diabetes, neurologic disorders, bladder symptoms in childhood, smoking and occasional excessive hydration. A total of 5 to 15% of women have urge urinary incontinence at least monthly. Overactive bladder is more common, affecting 10 to 15 % of women. From an anatomical point of view, it occurs as a result of hyperactivity of the bladder muscles (the detrussor muscles) or uninhibited contraction.

The author states that if a good history is obtained, the diagnosis can be made without major, invasive bladder testing. In order to get that history, doctors should ask patients to keep a voiding diary that helps answer simple questions: when do you void, how often, what factors precipitate the need to void, how much are you drinking (are you walking around and sipping designer bottles of water or drinking multiple cups of coffee or iced tea?) and when do accidents occur?

So what can be done? First, lifestyle changes…If you are overweight, try to lose those extra pounds. If you smoke, stop (for the latter there are a slew of other reasons…but don’t get me started). If you notice that caffeine or too many fluids instigate constant bathroom trips (and misfires), change your fluid consumption habits.

Then there are behavioral therapies also known as bladder training (not exactly what we did to potty train our toddlers, but similar). Try to learn ways to distract yourself when you feel the urge to void. (The article suggests you try mathematical calculations, deep breathing, or “freezing and squeezing” of the pelvic floor muscles.) Void every 2 hours so that you know your bladder can’t be that full. Slowly try to increase the interval between voids while you are awake. You can also try Kagel exercises.  In order to know which muscles you have to use to properly Kagel, insert a finger into your vaginal opening and try to constrict the muscles around your finger. (I know that certain candidates are against masturbation but this is not done for sexual stimulation and therefore does not have any political implications.) You should feel a tightening without using your abdominal or gluteal muscles. Do 3 sets of 15 contractions; hold for 10 second each, every day. There are also therapies or biofeedback in which a therapist uses a mild electric stimulation to the pelvic floor muscles with the aim of causing a passive contraction.

And of course, there are medical therapies…. many of which you have seen or heard about in direct to consumer ads in magazines and on television. These medications all basically work by blocking muscle receptors in the bladder (these receptors called muscarinic receptors are also found elsewhere in the body…. hence the side effects of dry mouth, dry eyes and constipation). Six medications are currently approved in the U.S. for urge urinary incontinence.  Randomized trials have not shown that one drug was definitively superior to anther although in 2 trials the decrease in the number if urgency incontinence episodes were greater with extended release forms. The generic names are: oxybutynin, tolteridine, fesoterodine, solifenacin, trospium, and darifenacin. In general, the older meds (and cheaper ones) may work…. It can take a month until an effect is apparent. If one doesn’t work then your doctor may suggest a higher dose or another.

Finally, systemic estrogen therapy does not seem to ward off this problem, indeed there are studies that show it can make it worse. However I and many of my urologist colleagues will have a patient who is not on estrogen therapy and who has atrophic vaginal changes together with overactive bladder symptoms try local estrogen vaginal therapy…it does seem to help.

Many women ignore their bladder problems, thinking that urgency is just a part of getting older.  Since it is often treatable make sure you tell your doctor and discuss your options. Our lives should not include immediately adjacent toilets!

My office is close to my home in Westwood but I have to drive through Beverly Hills to get to Cedars Sinai. On the way, I pass several tanning bed “salons” and as I slow down to peak into the reception area I see fit, attractive young women attending to the clients at the front desk. The receptionists invariably have that California hue of brown that makes one think of beach days, bikinis and youth. The idea I guess is that if you go in and use the tanning bed, you too will look young and fit. Nor do you then have to go to the trouble to find beach parking (most salons validate parking) or get sand out of your crotch; just use your credit card and sign up for a bunch of sessions.

Obviously, I am writing the above sarcastically and as you might have guessed strongly disparage and discourage this tanning bed “come-on”. A recent article in the New England Journal of Medicine analyzed the science, behavior and policy regarding use of tanning beds and gave credence to my medical negativity. (The article did not, however, deliver a joint condemnation of the sun; the assumption being that we have all been made aware of the warnings correlating sunburns and early childhood exposure with skin cancer.)

Here are some of the facts that were reported:

One million times a day, someone in the United States uses ultra violet (UV) radiation for skin tanning. According to the indoor tanning industry (I wonder where they have their annual conferences), tanning beds are used by 30 million Americans or about 10% of the U.S. population each year. And these users include large numbers of minors.

Recent data has shown that use of these beds is addictive, especially in college-age tanning bed users. (So I guess putting a tanning bed facility near UCLA was a good idea from a commercial point of view.)  UV rays stimulates an increased production of a hormone called melanocyte-stimulating hormone (MSH) which acts on a receptor to induce the production of pigment, but at the same time, the resultant increase of MSH also stimulates the release of beta-endorphins which are “feel good” brain hormones” . Over time, these endorphins want more and more stimulation and lack thereof causes a “down”. There may also be an evolutionary incentive to the seeking of UV radiation. Since UV rays increase the skin production of Vitamin D, “behavioral inclination toward sun exposure might have historically provided a survival advantage by averting lethal Vitamin D deficiency at pre-reproductive ages” Thousands of years ago, our ancestors were more likely to live and reproduce if they got some sun!

That doesn’t mean that women (or men) should use sun beds to get their vitamin D to reproduce or for their health. The amount of Vitamin D that is produced from UV exposure is dependent on skin pigmentation and age. Moreover there is now ample data that we should aim for fairly high blood levels of vitamin D (way more than that needed for successful reproduction by our ancestors) to help prevent osteoporosis, coronary heart disease and diminish the risk of many cancers. Most physicians agree that supplementation is better (and will be greater) than carcinogenic UV exposure.

Now let me get back to my condemnation of tanning beds. These emit UVA and UVB rays. The tanning industry has stated that indoor tanners avoid sunburn better than outdoor tanners because the UVA rays don’t burn the skin. But UVA radiation does damages the skin cells’ DNA and can induce mutations that lead to cancer. According to a 2006 meta-analysis by the International Agency for Research on Cancer (IARC), among people who first used tanning beds before 35 years of age, the relative risk of melanoma was 1.75 (or 75% greater than individuals who didn’t use these beds).. The risk of non melanoma cancers was found to be even higher. In the IARC study, the history of any indoor tanning was associated with a relative risk of 2.25 (225% greater) for squamous-cell cancer. Hence The World Health Organization has classified tanning beds as a carcinogen. I also want to emphasize that the DNA damage caused by both UVA and UVB radiation will cause photo aging of your skin….spots, irregular pigmentation, wrinkles and loss of tone. Unfortunately adolescents and teenagers rarely think of what can happen to their appearance (or health) as they age. I hope that as we get older we get wiser (or more worried).

Sometimes the Europeans are smarter than we are…France, Germany, Austria, Finland, and Britain ban indoor tanning for people under the age of 18.

I was amazed to learn that currently the FDA classifies tanning beds as medical devices but designates them as class 1, the same as tongue depressors and adhesive bandages, whereas tampons are class 2!

But they (the FDA) are reconsidering. Last March, they convened an advisory panel to review the safety of tanning beds and will in the near future announce a decision as to whether to reclassify tanning lamps and beds and possibly address minors’ access to them.

I do not plan to picket the tanning salons I pass near my home, office and hospital. But I will readily advise all my patients to avoid them. We just have to declare pale as the new California healthy. Or we can use safe skin sprays, creams and lotions to get that desired shade of brown.

I am writing this newsletter during the Labor Day weekend. It’s supposed to be labor free and shopping-full, but I have no intention of joining the crowds at the mall. Although writing is not really labor (more of a labor of love), I’ll keep it brief so I can spend time with my family and do the traditional barbecue of salt laden hot dogs. We also have Rosh Hashanah this week which celebrates the year to come….and this too should be as labor-free as possible (not the year but the actual holiday). I would like to wish all my patients and those who read my newsletters a “Shana Tova”…Happy New Year; may this next year be one of health for all of you (as well, of course, one of peace and prosperity ….here is where I could make some political comments, but won’t.)

On to a somewhat positive article: The latest Journal of Obstetrics and Gynecology featured a review on benign breast disease. One of the questions dealt with in the article (which many of my patients have also posed) is whether there is a correlation between breast cancer and use of the oral contraceptive pill (OCP). Basically, it would seem there is none. The authors pointed out that there are more than 50 epidemiologic studies which have evaluated this and most have NOT demonstrated an association even if birth control pills were used for a long time. They went on to state that “in a study of pooled data from 54 epidemiologic studies containing 150,000 women with and without breast cancer, no consistent association between oral contraceptive pill use and breast cancer was identified. This study did show an increase risk of breast cancer in women who were current or recent users but this affect disappeared within 10 years of discontinuing the pills.” They then hastened to point out that a separate study involving 10,000 women with and without breast cancer showed that there was no increase in risk of breast cancer in oral contraceptive pill users even among current or recent users, those who had a family history of breast cancer, or those who started OCP’s at a young age.

I think this analysis should be very reassuring to all of you who are currently using the Pill but worry that “those hormones” will cause breast cancer, or if you have pill remorse about having used OCP’s in the past.

Unfortunately, one in eight women will get breast cancer in their lifetime. There are known factors that increase risk….but they do no include oral contraceptives. Although I promised a positive article, this newsletter would not be complete without mentioning these risk factors. They are:

  • Early puberty and periods
  • Late menopause
  • Lack childbirth
  • First birth after 35 (as compared to having a baby before the age of 20)
  • Long term use of hormone therapy (menopausal hormone therapy, not birth control pills!)
  • A strong family history of breast cancer (especially known BRCA gene mutation)
  • Previous chest radiation, especially before the age of 21,
  • Obesity
  • Alcohol …which increases breast cancer risk in a dose dependent fashion (the more you drink, the higher the risk).

That “one in eight” statistic is terrifyingly high, but at least I can report that there has been an overall yearly decrease in mortality from breast cancer. The ability to diagnose this cancer with mammogram, ultrasound and, if necessary, MRI, appropriate biopsies and surgeries, the use of hormone receptor tests and genetic tests to evaluate which therapies will work as well as the recognition of risk allow all of us to get better breast care. It would seem that the one thing you don’t have to worry about when it comes to breast cancer risk is the contraceptive birth control pill.

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