I am writing this while away in Colorado during the holidays. The snow-covered mountains are truly gorgeous and instill a peace that I needed as the New Year approaches. Although I am not skiing, I watch those who are come down from the mountain. They are covered from head to toe (so am I, to keep warm) and although they are in the sun, most are slathered in sun block. So being the negative thinking doctor that I am, I wonder what their vitamin D levels are? And then as I read the publication “Postgraduate Obstetrics and Gynecology (it’s a biweekly publication for continuing medical education), I came across an article titled “The New Face of Vitamin D”. I’ve written several articles about “D” but I thought the authors summed up the data very well and so I would like to share this year’s “D” facts with you.

Vitamin D has always been considered a bone-necessary vitamin. Without it children developed rickets and adults were likely to lose bone density and risk osteoporotic fracture. “D” is needed to facilitate the absorption of calcium and phosphate from the intestine; and if there is not enough calcium “on board” (hypocalemia), the parathyroid (glands on both sides of the thyroid that regulate calcium) goes into overdrive to get calcium into the circulatory system from the body’s calcium depository (the bones), causing bone demineralization.

We now know that nearly every tissue in our body has Vitamin D receptors; and if they are insufficiently “fed”, the systems that are made up of these tissues can go awry. Here are some of the systems that are affected and disorders that are more likely to occur with inadequate vitamin D:

The Immune System

Vitamin D is an immunosuppressant. That means it may be helpful in protecting us from autoimmune disease in which antibodies attack our cells. A study published in 2006 showed that Vitamin D either helped prevent or reduce the severity of multi[le sclerosis.

Diabetes

Vitamin D may impact glucose metabolism. The Nurse’s Health Study which followed more than 83,000 women fund that those who took at least 800 IU (international units) of Vitamin D has a 33% lower risk of developing type II diabetes. And a study of 10,000 children demonstrated a 50 to 80 % decrease in the risk of type I diabetes in children who received the recommended dose of Vitamin D.

Cancer

High doses of Vitamin D have been shown in multiple studies to have a protective effect against colon cancer especially in women older than 60. There are ongoing investigations to ascertain whether this holds true for other cancers especially breast cancer.

Cardiovascular Health

Low Vitamin D levels have been shown to be associated with a higher rate of heart attack and increased cardiovascular mortality. An ongoing 5-year study of 20,000 subjects (called VITAL, don’t you just love these acronyms that researchers make up…) will help determine if Vitamin D supplementation can help prevent cardiovascular disease.

Pregnancy

Women who have the lowest levels of Vitamin D have been shown to have higher rates of preeclampsia compared to those who take Vitamin D. They may also have more vaginal infections with bacteria that don’t like oxygen (anaerobes) and this type of vaginitis has been accepted as a risk factor for preterm birth. Low maternal Vitamin D levels also means low levels in the fetus and (at least in rats) may affect brain development.

Osteoporosis

An overall review of the literature points to the fact that there is an approximate 26% reduction in hip and nonvertebral fractures in adults with supplementation of 800 IU of Vitamin D daily. This benefit was not seen with supplementation of only 400 IU of Vitamin D daily.
So now that I have given a quick overview, it’s quite clear that we need our “D”… I’ll give you some statistics as to how many of us are D deficient. Let’s start with the number 1 billion. (No, it has nothing to do with our national deficit.) That’s how many people worldwide are thought to be “D” deficient. In the US, depending on the data that is published, 25 to 57 % of us lack enough “D”.. The percentage is generally thought to be higher at 68%. In postmenopausal women its 50%

Our primary source of Vitamin D is the sun. It radiates ultraviolet rays that, when absorbed in our skin, produce pre-vitamin D. This is converted to (sorry think this is a bit scientific) to 25-hydroxyvitamin D in the liver, which then releases it in two forms, Vitamin D3 and Vitamin D2. The majority of “D” is stored in our body as Vitamin D3. Your Vitamin D level can be determined though a blood test that measures total 25- hydroxy D.

Skin can produce 20,00 to 50,000 units of vitamin D with 30 minutes of midday exposure. But most of us inhibit this source of “D” because we use sunscreen, cover our bodies with outdoor clothes, or dress in a way that is deemed socially acceptable. We obviously get less sun exposure in northern latitudes or during winter months. The darker our skin from the pigment melanin, the less we absorb those ray. (This causes Black and other dark skinned individuals to be particularly susceptible to “D” deficiencies.) Obesity will promote sequestering of “D” in fat cells so that the vitamin is not available for the body’s utilization. And finally vitamin D production slows down with age.

Unlike other vitamins it’s hard to get enough “D” though diet. Unless you consume herring (3 oz. have 1383 IU), cod liver oil (1 tablespoon has 1360 IU) or salmon (3 oz. have about 500 IU) your food may not suffice. (Other fish average less than 150 IU for a 3-ounce serving, and 8oz. of fortified cow’s milk has only 120 IU).

Hence, it would seem that most of us should supplement, but how much? Well that remains controversial.. There are many researchers and health organizations that proclaim that as long as our “D” level is above 30 ng/mL or even 40 ng/mL we will achieve the beneficial effects of vitamin D. Levels below 20ng/mL lead to bone density problems so the goal is to stay at least above that. . (My lab considers the above 30 to 100 to be normal range.) The Institute of Medicine (IOM) states that for women age 18 to 70 the daily recommended intake is 400 to 600 IU. For women over 70, it should be 800 IU. They increased the safe upper limit to a range of 2000 to 4000 IU. Having said that, ACOG and other organizations as well as many doctors are considering recommending higher doses. Too much “D” can be toxic, but toxicity has not been found with doses of up to 10,000 IU daily. Moreover since Vitamin D is fat-soluble it can be given daily, weekly or monthly.

I now suggest that my patients get at least 1,000 IU a day. In women who may be high risk for “D” deficiency, I measure their Vitamin D level. If it is low, I might increase their dose or prescribe 50,000 IU of vitamin D to be taken by mouth weekly for 12 weeks and then retest their level. I, personally, take 2,000 IU of vitamin D a day…to hedge my bets. No, I did not stand at the bottom of the ski run and proffer “D” supplements to the skiers.

There have always been expectations associated with the holidays. And may you achieve them! Unfortunately (I am being very scrooge-like here) some of these expectations may also lead to disappointment and depression. Many women (and men) find that the rush to finish buying presents, keeping lists and being nice is overwhelming. And for some of us the memory of family get-togethers that perhaps can no longer be relived brings aching sadness.

As you prepare to be joyful and loving, the intimate part of the latter may present problems. This constitutes my lead-in to a short discussion of sex and mistletoe: Just to clarify there is no medical evidence that standing under that botanical entity increases libido and/or sexual function

An abstract from the 2011 Annual meeting of the North American Menopause Society (NAMS) dealt with the pros and cons of using testosterone (not mistletoe) as a therapy for female sexual dysfunction. It was helpfully titled “Androgen Treatment of Female Sexual Dysfunction: Risks, Benefits and Available Therapies”. Frankly I chose to report on this abstract because it reinforces what I tell my patients who consult with me regarding hormonal therapy. And of course I wrote a book that dealt with testosterone. (“I’m Not in the Mood “…I thought it was a rather funny but relevant title at the time.)

A quick reminder…. our ovaries produce female and male hormones ; the latter are termed androgens. The adrenals also produce weak androgens. These androgens play an important role in our physiology and well-being: they are the precursor hormones of estrogen synthesis in the ovaries as wells as other tissues. Androgens also act directly on receptors through out our bodies and may have many functions in women even though we clearly have lower levels then men and hence have a very different body build and physiology. The level of our androgens, especially those produced by our adrenal glands decline with age and the greatest change actually occurs before menopause.

There have been many studies that have shown that testosterone therapy can be beneficial for the treatment of hypoactive sexual desire disorder (HSDD) with and without concurrent estrogen therapy in woman who had undergone natural or surgical menopause.. Recent studies have also shown that testosterone therapy can improve sexual well being in women with HSDD who are premenopausal. Testosterone may also help improve bone density, muscle mass and even cognitive function in women who have very low levels of free testosterone (not bound up by a protein). The FDA did not approve testosterone patches that were developed for women years ago because they were concerned that the data that was needed to demonstrate that testosterone therapy did not increase the risk of (CVD) coronary artery disease (heart attacks and strokes) was insufficient. But recent published randomized control trials seem to indicate that non-oral testosterone (creams, ointments, patches or sublingual drops or lozenges) do not affect lipids or blood markers for CVD.

Although there are no direct studies that show that testosterone therapy increases risk for breast cancer…no one can make a definitive statement about its breast safety. All this has to be considered in any form of testosterone therapy that might be used in women. Of course, if too much testosterone (in any form) is prescribed, it can result in virilization effects such as acne, abnormal hair growth, enlargement of the clitoris and even voice changes. The authors of the abstract point out that despite the fact that there is no FDA approved product for the treatment of libido in women, the use of testosterone by women is widespread. Some women use products that are approved for men (and they are way to strong, the product, not the men…) or they are given testosterone preparations compounded in individual prescriptions. They go on to state that there is “a clear need for a testosterone therapy delivering an appropriate female dose to be approved, so that women have the option of using a product formulated for women”. I agree, but until then, if mistletoe, the light of the Chanukah candles or everyday circumstances are accompanied by significant lack of libido and sexual dysfunction…talk to me or your gynecologist. After a complete history (to rule out other libido dampening causes) and physical, you may be a candidate for the compounded testosterone therapies that are available. But dosing and administration have to be followed closely.

I like many physicians who specialize in women’s health await an FDA approved testosterone patch. Until then we have to “makeup” the equivalent. Sexual function is a part of a woman’s health, during and after the holidays!

As I was salting my breakfast eggs (I scramble them with one yolk) and reading JAMA this week, I found an interesting article from the Centers for Disease Control and Prevention.. A new survey done by the CDC and the National Health and Nutrition Examination survey (NHAMES) showed that most of us are sodium failures!

The “Dietary Guidelines for Americans” put out in 2010 recommends that everyone over the age of 2 years limit their sodium intake to less than 2,300 mg daily and that persons aged greater than 51, blacks and persons with hypertension, diabetes, or chronic kidney disease should limit sodium to 1,500 mg daily to reduce their risk for hypertension, heart disease and stroke.

The NHANES survey is extraordinarily between 2005 and 2008; it includes 18,823 participants over the age of 2 who were interviewed and examined. Their blood pressure was measured, blood and urine collected for testing and a 24 hour dietary recall was administered.  In order to make sure that the dietary recall was representative of “usual and customary food intake,” a second survey on diet was conducted for each participant by telephone 3-10 days after the first. If the chosen participant was young, the parents reported on their diet.

And these are the unsettling ” you got an F” results:

47.6% of the general population should have a restricted sodium diet. But 98.5% of these individuals consumed more sodium (usually way more) than the recommended amounts.

Among those who were not felt to be restricted and were OK’d to consume 2,300 mg of sodium, 88.25% failed even that amount and indeed consumed more.

Some individuals (very few) can probably go into the category of “I need more than that amount of sodium”. We lose our body’s sodium when we sweat. So if you live in a very hot climate, are exposed to heat during your work (this probably applies to foundry workers or firefighters); you need more salt. The more salt dictum also applies to competitive athletes. But all these exempted individuals consist of less than 0.2% of the population. (Way less than the “one-percenters”, so I guess they don’t require protest demonstrations!)

Where is all this excessive sodium coming from? Approximately 75% of sodium we consume is added to commercial foods during processing and baking or to restaurant foods during preparation. Only 29% occurs naturally or is added at the table or through cooking by the consumer. ( So I guess I can feel a bit less guilty about slating my eggs.)

I know we are all tired of reading food labels, but in order to get to that less than 1,500 mg, it’s a must. Canned soups (unless labeled “no sodium added’, breads, cereals, snack foods, even veggie drinks are often full with sodium.) And if we eat out, we have to ask how the food is prepared…. Many restaurants are used to hearing “I can’t eat salt” and the chefs will make appropriate changes. Our US Department of Agriculture has begun to work to establish low salt provisions such as a less than 140 mg sodium per serving for all canned beans and vegetables in the National School Lunch Program. (It’s a weak start but it’s a start.)

It takes about 2 weeks until you can get used to a lower sodium diet and taste the other flavors in your food. Some countries have worked with manufactures of food products to lower sodium content. They did it in The United Kingdom where there has been an estimated 9.5% reduction in salt intake over 7-8 years. According to the JAMA article similar reductions, if achieved in the United States, would save $4 billion in health care costs per year and $32.1 billion over the lifetime of adults aged 40-85 years today. I am going to go have a banana after I write this, that’s probably safe.

And to my patients….As you know I am back in the office seeing patients and keeping busy.  This has helped me tremendously over the last 2 weeks. You are my therapy. Thank you!

I am back to scanning the literature… I know some of you love to read magazines as a respite from daily activities, I hope most of us are still consumed by good books; my “escape” is the perusal of medical journals. This month’s Journal of Obstetrics and Gynecology had an interesting (at least for me) article titled “Effect of Hysterectomy With Ovarian Preservation on Ovarian Function”. The research for this article was carried out at Duke University.

Hysterectomy is still one of the most common nonobstetrical surgical procedures performed in the United States. Estimates of the number  of these procedures range from 460,000 to 600,000 annually. (This number is however decreasing with the prevalence of myomectomies, endometrial ablations for uterine bleeding, various medical therapies and embolization procedures in which vessels leading into the uterus are catheterized and then blocked). The majority of hysterectomies that are performed are in women under the age of 44, and indeed the highest rates are in women aged 40 to 44. As you know, the average age of menopause is 51.
The question that this article tried to answer was: Are women who undergo removal of their uterus at risk for an earlier than expected menopause even if their ovaries (or at least one ovary) remain intact? Remember that early menopause can lead to the development of osteoporosis, coronary vascular disease,  perhaps early onset of dementia, not to mention significant menopausal symptoms such as hot flashes, sleep disturbances, vaginal atrophy and mood swings. So the function, or lack thereof, of those ovaries once devoid of an adjoining uterus has significant health implications.

The study was called the Prospective Research on Ovarian Function (PROOF); I love these acronyms! It was  a prospective study in which  406 women between the ages of 30 and 47 who were undergoing hysterectomy without removal of their ovaries were followed and matched to a control group of 465 women who did not have the surgery and had intact uteri and ovaries. Blood samples for hormones were taken at baseline and annually for 5 years.  And, the researchers found that the women undergoing hysterectomy were nearly twofold more likely to develop ovarian failure compared to women who did not have the surgery. 14.8% of the women who had a hysterectomy became menopausal after 4 years compared to 8% of the women in the control group.

It’s not clear why ovaries stop working before their expected demise date subsequent to hysterectomy. It’s possible that the blood vessels feeding the ovaries are compromised during the surgery. Another hypothesis is that the uterus has an inhibitory influence on secretion of FSH (follicular stimulating hormone).  If too much FSH is produced, it can accelerate follicular development, causing untimely atresia (a medical word for death) of said follicles, and hence could lead to early menopause.

Knowing all this will not stop surgeons from performing needed hysterectomies. But both physicians and their patients who undergo this procedure should not dismiss the early development of menopausal symptoms just because they are “too young”. It also alerts us to the need to check hormone levels in the follow-up subsequent to hysterectomy, especially if the procedure was performed at a young age,. And it warrants a close look at cardiovascular factors and bone loss in post hysterectomy patients. Many  physicians would suggest considering estrogen therapy for  women who experience ovarian failure in their early 40′s if there are no contraindications.

I have received hundreds of condolence cards and messages from you. Your tributes to my late husband Gil Cates and your words of sympathy have been overwhelmingly thoughtful and kind. I can’t begin to thank each of you individually… Please know that I read every letter, card and email and am truly grateful.

Gil was an exceptional man, with a love of theater, film and television. He sought to educate and mentor students in these fields and worked with The Directors Guild of America to guarantee creative rights. He helped all of us celebrate the movies at The Academy Awards. The media has portrayed his passion, work and abilities in all of  his endeavors. My family and I want to celebrate his love and incredible devotion to us and his many friends. I miss him terribly. I am grateful for the incredible years I had with the love of my life.

Once more, please accept my sincere thanks for your support. This is the last time I will write such a personal message in my newsletter…

I am now back in the office seeing patients. I still love practicing medicine! And yes, I will continue to write my weekly newsletters about the latest studies and articles that pertain to health. And every once in a while, I’ll tell you about my travels and projects for Save the Children.

Judith Reichman

Links

-->