I’ve written several newsletters about potential side effects of bisphosphonates medications used to treat osteopenia and osteoporosis (Fosomax, Boniva, and Actonel….just to remind you of some brand names). This time I want to share some potentially good news about this bone density enhancing class of medications. And I am especially happy to share the report because it comes from a study conducted in Israel. (As many of you know, I have taught and worked there and indeed will be in Tel Aviv when this article appears.)

The Israeli researchers conducted a study entitled The Molecular Epidemiology of Colorectal Cancer. It was supported by the National Cancer Institute and published in the February issue of the American Journal of Clinical Oncology. (I hope I haven’t lost most of my readers by this point…just bear with me. So many of you or your relatives take bisphosphonates so that your skeletons can successfully bear your weight without an osteoporetic fracture)

They found that postmenopausal women who had taken an oral bisphosphonates longer than one year had a 59% reduced risk of colorectal cancer. Like the Scandinavian countries, pharmaceutical records in Israel are extremely well documented. (All the citizens have health insurance and most of their prescription medications are covered…I wish I could say the same for us!) The researchers used computerized pharmacy records and identified almost 2000 women who had colorectal cancer.

They found that in these women, compared to controls who were matched for age, weight, and religion, the use of bisphosphonates longer than 1 year, but not less than 1 year, reduced the risk of colorectal cancer by half, even when they adjusted for other factors that could perhaps lower colorectal cancer risk. (Here is where I list these factors to remind you that they too count in our “war on colorectal cancer”…as does screening. They include vegetable consumption, physical activity, and weight control, use of low-dose aspirin, statins, vitamin D and postmenopausal hormones.)

Ongoing research indicates that oral bisphosphonates may exert a cancer-protective effect (including breast and prostate cancer.)  Clearly this study is not large enough to persuade the FDA to approve any official indication that this class of medication will diminish colorectal cancer. So I’ll end with the phrase that is used in the conclusions of most medical articles: “Further studies are needed”. I felt , however, that a bit of good news about the medications that can lower the huge toll of osteoporotic fractures in women (and men) is welcome.

My husband (and anyone else I drive with) says I’m borderline hysterical when I sit in the front passenger seat. Perhaps this is due to the fact that as a resident I worked in the emergency room and treated victims of road injuries, or  because I now listen to the horror stories related to me by many of my patients as they hobble into my office weeks, months or years after back, neck or even internal injuries from road accidents. And then there was that time I managed to crack the front window of our Beetle when I was in high school after a 5-car pile up on the New Jersey turnpike. (The subsequent financial settlement did pay for a year of my college education and I had no on-going head problems, at least as far as I know, but there are those who would argue this conclusion…)

So it was with some degree of self-vindication that I read The Lancet journal editorial titled “Reducing Road Dangers”. The author reported that next week the first Decade of Action for Road Safety 2011-2020, established by the UN General Assembly, will be launched.  And a global plan has been issued by the World Health Organization to provide a framework for this worldwide action. What struck me the most in this editorial (perhaps the use of the word “struck” is unfortunate) were the statistics that were presented. I would like to share them with you…

3000 people die each DAY in accidents on the roads worldwide!  In case that number doesn’t say enough, that’s nearly 1.3 million people a year. And in addition 20-50 million people are injured each year, many of whom will then have lifelong disabilities. As more and more cars fill the roads throughout the world (personally, I am just envisioning the 405 Freeway in LA), road-traffic deaths are predicted to be the fifth leading cause of death by 2030. In case you are wondering what the first 4 will be; they are heart attack, stoke, chronic obstructive pulmonary disease and respiratory infections. This 5th ranking will have “progressed” since 2004 when it was a still an inexcusable 9th.  And although this number is horrific, it doesn’t even take into account the effects of air pollution and climate change from motor vehicles or the impact that driving everywhere (instead of foot propelled ambulation) has on our epidemic of obesity.

Usually I write newsletters that give you information that you can use to improve your health or the health of others. This time, I guess, this is more of an address to public policy and the need to maintain and improve our infrastructure.  I am not suggesting you trade in your car for a bicycle. But I do want to relate the 5 pillars of action outlined in the global plan, just so you are aware that they exist. They are certainly topics for dinner (or driving) conversation…  (1) Developing national road-safety strategies and funding for their implementation and monitoring. (2) Improving safety of roads for everyone (this includes motorists, pedestrians, bicyclists and motorcyclists). (3) Improving vehicle safety. (4) Changing road users’ behaviors through education and enforcement (this means seat belts, speed restrictions, no cell phone or texting distractions, helmets for motorcyclists and tackling road rage) and (5) Improving emergency medical response to crashes.

What each of us can do is to slow down and pay attention to the road while driving. This means we should try not to drive when we are sleep deprived.  (Fatigue and diminished concentration is a real problem…more than 37% of the population gets less than 7 hours of sleep and a recent survey of drivers in 12 states in the U.S. found that a sixth of all drivers have reported nodding off at some point while driving!)   We all know that drivers and passengers should use seat belts, and certainly wear helmets when on motorcycles and bicycles, but that admonition is not mandated in every state and certainly not in most countries.

Finally, we should support initiatives to improve road safety in our community, state and country. (And if necessary, we have to be willing to pay the taxes to do this.) And perhaps it would be helpful to listen to the directions and concerns of front seat passengers.

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As I read the current medical journals, I have to make use of a new “library” of terms that refer to our bodies’ genes, RNA messengers, proteins and enzymes, not to mention the generic names of the drugs meant to impact the molecular basis of disease. But as medical knowledge becomes more “micro,” we can’t discount the macro…the need for individuals to get basic screening, diagnosis and therapy of common disorders. There is no requirement for medical ten-dollar words to understand the recent “Vital Signs” article in JAMA. It was a report by the National Center for Health Statistics at the CDC, documenting the prevalence, treatment and control of hypertension in the United States.  Here are some of the stats that they reported, which could on their own make ones blood pressure go up by at least a few points. (I’m talking systolic here…)

  • Every year, hypertension contributes to one out of seven deaths in the U.S. and tonearly half of all cardiovascular disease-related deaths (heart attack and stroke).Hypertension affects an estimated 68 million U.S. adults.
  • If all individuals received adequate treatment for their hypertension, 46,000 deaths might be averted each year.
  • Direct and indirect costs of hypertension are more than $93.5 billion per year
  • Cardiovascular disease and stroke account for 17% of total health expenditures in the US annually
  • Overall U.S prevalence of hypertension among adults after the age of 18 between 2005 and 2008 was 30.9% (and highest among persons at or older than 65). This prevalence has remained unchanged during the past 10 years.
  • 30% of patients with hypertension are not being treated pharmacologically.
  • Only 45.8% of those with hypertension have their blood pressure adequately controlled.

There are, of course, recommendations as to what should be done to deal with this pervasive disorder and the resultant disease. Blood pressure readings should be taken seriously (and regularly). Anyone who has a blood pressure that is 140/90 needs to consider medication and lifestyle changes. Physicians now think that blood pressure reductions below the threshold for clinical hypertension (115/75) can have health benefits over time. An analysis of over 61 prospective observational studies of blood pressure and mortality (you know the ones that follow large groups of individuals for years) have shown that for each 20 mmHG increase in usual systolic blood pressure (This is the top number in blood pressure readings and represents the pressure that your heart is exerting to get the blood to flow through your arteries) or 10mmHG increase in usual diastolic blood pressure (which represents the pressure of the vessels between heart beats) above 115/75 mmHG was associated with a doubling in stroke mortality and death from heart attack at ages 40 to 69.

Before I sound the “get thee medicated” alarm, let’s go over the behavioral changes that can impact blood pressure. They should be adopted by all of us. (I’m sure we all know them, but since the American Heart Association has made them official here they are: (1) achieving and maintaining a healthy body weight; (2) participating in regular leisure-time physical activity (and I don’t think shopping counts, unless you have to walk rapidly for a total of 30 minutes from store to store to car.) (3) adoption of a healthy diet, including reducing salt intake and increasing potassium intake; (4) smoking cessation; and (5) stress management) Note, the AHA gave no indication in this report as to how to do this and I’m not going to begin to tackle stress reduction  in this “brief” newsletter. It would require a treatise in philosophy, psychology, economics and the 24-hour news cycle!

There are, of course, multiple pharmacologic therapies and frequently more than one is needed to achieve adequate blood pressure control. That’s where a physician’s knowledge and choices of medication are needed (as well as health insurance to help pay for access to the physician, appropriate follow-up and purchase of the medications… According to this CDC report, one of the groups with the lowest prevalence of blood pressure control consists of individuals without health insurance.)

Molecular biology may help us understand the whys, wherefores and potential treatments of disease. But unless we self-maintain our own health by eating right, moving our derrieres off the chair (I guess you should get off your computer, iPad or Blackberry where you are currently reading this admonition), adhere to prescribed medication and improve access to care, that “one in seven” (deaths due to hypertension) will continue.

Bottom line: Make sure your blood pressure is checked regularly and if elevated, even “a bit” (over 115/75) work on your lifestyle. If 140/90 or over, check with your physician as to your need for medication and adhere to whatever is prescribed. The pressures of life (and death) start with your own!

Let’s discuss several hormonal scenarios: (1) You’ve been on hormones for several years and now think you may try to stop. (2) You have just started having hot flashes and you haven’t quite made up your mind as to whether you will want to take hormones during the menopausal transition. (3) You are not yet menopausal but worry about what you will experience when it inevitably develops.

The defining question for most women (at least in regards to quality of daily life) is: “How long will I experience hot flashes?” One would think that since menopause has been around before and since the written word that we could estimate the average duration of this pesky and sweaty symptom. (Well maybe not, 120 years ago the average life expectancy for women was 47 and most did not outlive their ovaries.)

Hot flashes generally begin when estrogen levels plummet in menopausal or during the premenopausal transitions. The ovaries run out of follicles that are capable of responding to pituitary messages to develop and hence produce estrogen. In the absence of said estrogen, the pituitary works harder (it’s trying to get those damn follicles to work), hence it puts out more and more FSH (follicle stimulating hormone). The pituitary gets its signals from the part of the brain called the hypothalamus which produces GnRH or gonadotropic releasing hormone, the master hormone that instigates FSH production. In the absence of “usual” estrogen production, GnRH and FSH levels soar and there is a veritable hypothalamic storm. This then causes a state of confusion in the central thermostat in the brain which begins to “think” that the body’s core temperature is too hot. In order to correct this, the hypothalamus sends out directives to dilate the small blood vessels in the skin (the flush) and causes water to evaporate from the skin’s surface (as sweat, facial and body perspiration) in order to cool the body down. All of this may lower the core body temperature by as much as half a degree. Often subsequent to a hot flash, a woman may shiver as small muscles contract to re-elevate the core body temperature.

Hot flashes are associated with poor sleep, decreased quality of life, may worsen depressive symptoms and even signal the onset of a major depressive disorder. The flashes may also be a clinical sign for underlying cardio vascular disease as well as a risk factor for poor bone heath. Although “natural”, hot flashes are not great to experience and ultimately may correlate with poor overall health.
What we do know is that the peak incidence of hot flashes occurs approximately 1 year after menopause in 80% of women in the US, but (and this is what is so surprising) the overall duration of hot flushes is unclear.

(Sorry that this intro is so long, but now I’ll get to a recent attempt to answer the “how long will this last” question…) A study published in the May issue of Obstetrics and Gynecology tried to assess the duration of menopausal hot flashes and associated risk factors.

The “flushing and flashing” women that were followed were part of The Penn (Pennsylvania) Ovarian Aging Study of 435 women (half white and half African American) that were monitored for 13 years. Hot flushes (they use this term instead of “flash”) were evaluated at 9 -month and 12-month intervals though in-person interviews. At enrollment, the participants’ ages were 35 to 47 (mean age 42.2) and 91% were still premenopausal. The most common age at onset of moderate-to-severe hot flushes was 45-49(35%); 30% were between 40-44years, 21% were older than age 50and 14% were younger than 40 years. Age at the onset was inversely associated with duration of hot flashes. In other words, the younger the women were, the longer they suffered. This totaled 11.57 years for those whose onset of hot flushes occurred before the age of 40; and decreased with onset at older ages: 11.25 years for those whose flushes started at 40 to 44 years; 8.1 years with onset ages 45-59 and 3.8 years duration with onset at 50 years of age or older.

Other independent predictors of the duration of the flushes were race (African Americans had a longer duration) and body mass (thin women also had a longer duration.) It’s thought that obese women convert hormones produced by their adrenals to estrogen-like hormones in their abundant fat and hence have production of estrogen that “saves them” from many years of flushes. It’s interesting that in this study smoking, alcohol use and number of children the women bore had no association with the duration of their hot flushes. (Although in general, the data has shown that smokers enter the menopause at an earlier age than non smokers, simply because the toxins in cigarettes kill off the follicles in the ovaries….my comment in this article against smoking!).

In the discussion portion of the article, the author’s state that “the median duration of moderate-to-severe hot flushes was 10.2 years, well beyond the duration considered in clinical guidelines. When women who reported mild hot flushes were included, the median duration increased to 11.6 years.”

Before all you women who begin to have menopausal symptoms in your early 50′s freak that these will continue unabated into your 60′s, I have to point out that the majority of the women in this study were younger than 50 when they reported moderate-to-sever hot flushes. (Most were 45 to 49.) Hot flush duration was approximately 8 years for this group compared to less than 4 years when onset occurred at ages 50 years or older.

Bottom line: The earlier you begin to have hot flashes (even if you are still getting your period) the longer you can expect them to continue during menopause. Now that you have this information, discuss therapies with your doctor.

Several months ago, I wrote about the shingles shot and recommended (or at least the article I cited did) that just about everyone receive it at or after the age of 60. Quite a few of my patients called and told me they had followed up and were vaccinated. Others who were not yet 60 questioned why they should wait. The new news is that the FDA just lowered the age range for the shingles vaccine.

In this week’s JAMA, it was reported that the US Food and Drug Administration (FDA) announced its approval of expanding the age range for the vaccine (marketed as Zostavax) to adults aged 50 to 59 as well as those aged 60 years and older. The Center for Biologics Evaluation and Research (I won’t even bother to give an acronym for that one) stated “The availability of Zostavaz to a younger age group provides an additional opportunity to prevent this often painful and debilitating disease.”

A quick shingles review: (I discussed it fully in a previous newsletter titled “Out, Out, Damn Pox!” posted January 2011.) Shingles is caused by the varicella zoster virus, a herpes virus which triggers chicken pox. (Sorry, I seem to be fixated on herpes viruses lately….I promise to become non-viral next week.) After a bout of chicken pox (which we can assume we have had if we are now 50 or older), the virus remains dormant in certain nerve cells. Then one day, decades later, perhaps due to a combination of factors including age and a weakened immune system, the virus awakens (obviously without need of a sleeping beauty kiss), “climbs up” the nerve root to the skin where it erupts as a cluster of blisters that appear on the part of the body that is enervated but the inflamed nerve. The result is pain that can be excruciating. Though the lesions eventually heal, the pain can remain for months and in some cases, years.

The CDC based its expanded approval on a study carried out in 4 countries on 22,000 participants aged 50 to 59. Half received the vaccine and half received a placebo. After just a year of follow-up, the vaccine reduced the risk of developing shingles by 70% compared with placebo. In the US about 200,000 adults between 50 and 59 develop shingles annually; hence the use of this vaccine could have a significant impact for these not-so-young-any-more baby boomers.

Merck manufactures the vaccine. It’s not cheap. The cost is in the range of $200. You can check with your insurance to see if it’s covered. Many drug stores have it on supply and (like the flu shot) will have a nurse administer it. You can also get it through your physician’s office; just call to make sure it’s in stock.

Bottom line: If you or a family member (or someone you care about) is over 50, a one time (and timely) shingles vaccine is advisable.

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