By now you have heard about the side effects of this commonly used both over-the-counter and prescription medication to raise HDL and lower LDL. But I finally got the article in the July 17 New England Journal of Medicine and wanted to give you a little more scientific information.

I almost didn’t write this segment because I’ve been overwhelmed with what’s happening in Israel. The good news is that my daughter and her young children came to Los Angeles two days ago. They literally got out on the last flight before the 24-hour closure of the Ben-Gurion airport. I think it’s open now to flights on all airlines and hopefully some of this conflict will be resolved. I can’t stop watching the news and despair over the fighting in Gaza that has destroyed the homes and lives of civilian population that could not or would not find refuge and the hourly bombardments of missiles sent by Hamas to Israel, intended to cause widespread killing of anyone in range. (Thankfully, the iron dome works.) I like everyone, hope that a valid cease fire will be negotiated. But how does one negotiate with a terrorist organization whose goals are to hold on to power and eliminate the country of Israel and it’s citizens from the face of the earth? They show no regard for their civilian population (other than to allow them to shield weapon stores) and take every opportunity to run with cameras to record their suffering, and mourning…and yes, we all have to be appalled. As many of you know, I am on the board of Save the Children. We have programs in Gaza and have tried over the years to improve the health care, education and hope for a better future for the children there. Children are never to blame for conflict and are always the ones who suffer. Unfortunately, it would seem that much of the millions of dollars sent there by so many NGO’s has been used to building tunnels and purchasing weapons rather than for infrastructure and care of the population.

I”ll stop now…I know I am not supposed to wax political, but it’s hard to always be the evidenced based doc.)

So on to niacin… Ever since I went to medical school we’ve been taught that high density lipoprotein or HDL particles help decrease coronary heart disease. The higher the HDL the lower the disease in the general population. Likewise LDL or low density lipoprotein cholesterol increases plaque formation and enhances heart disease. The question is, are these two types of cholesterol risk factors or signs of heart disease or do they indeed have an impact in causing heart disease? The articles published in the July 17 New England Journal of Medicine may have changed our assumption of causation. In the heart protection study two- treatment of HDL to reduce the incidence of vascular events (HPS 2-THRIVE), 25,673 adults ages 50 to 80 with underlying cardiovascular disease were given either an extended release niacin combined with laropiprant (an agent that helps prevent flushing) or placebo and were followed for four years. Prior to the randomization, they had been put on statin based therapy. During the trial, the participants who received niacin raised their HDL 6 mg/dL and lowered the LDL cholesterol 10 mg/dL as well as their trygliceride level 33 mg/dL compared to those receiving placebo. Despite these favorable responses there was no significant reduction in major vascular events. Moreover, there were significant side effects which included an increase in gastrointestinal complications, infections, muscular skeletal pain, development of diabetes and a 9% increase in the risk of death. The American Heart Association now gives a very limited and cautious recommendation regarding the use of niacin…They state that niacin may still have a role in patients with very high risk for cardiovascular events who truly have contraindications for taking statins and who have a high LDL-cholesterol level. They also suggest that there may also be a use for those who have very high triglycerides and for whom it could be used to prevent pancreatitis. In an editorial in the same journal the author suggests that “it is time to face the fact that increasing the HDL cholesterol level in isolation seems unlikely to offer cardiovascular benefit”.

So before you take niacin as a so-called easier way to deal with cholesterol problems, please consult your physician. Next week, I hope I can write an article that doesn’t also deal with the middle east conflict.

This article is not based on a Colorado medical journal…it’s from a review article that was published in the New England Journal of Medicine on June 5. It was authored by the National Institute on Drug Abuse at The National Institutes of Health. They stated that, “In light of the rapidly shifting landscape regarding the legalization of marijuana for medical and recreational purposes, patients may be more likely to ask physicians about its potential adverse and beneficial effects on health.” So in case you ask me…here is a summary of what they said in seven and a half densely worded pages (with graphs).

Twelve percent of people over the age of 12 report using marijuana in the past year. In case you didn’t know, the most common route of intake is by smoking the shredded leaves, flowers, stems and seeds of cannabis sativa. Hashish is created from the resin of marijuana flowers and is also smoked. Marijuana can also be used to brew tea and it’s oil based extract can be mixed into food products. (I am trying to be serious here and will not discuss brownies.)

The article’s objective is to explain the potential adverse health effects of marijuana use. (Actually that’s it’s title.) It reports that evidence clearly shows that long-term use can lead to addiction and approximately 9% of those who experiment with marijuana will indeed become addicted. That number goes up to about 1 in 6 among those who start using marijuana as teenagers and to 25 to 50% among those who smoke marijuana daily. According to the 2012 National Survey on Drug Use and Health, an estimated 2.7 million people 12 years of age and older met the definition for dependence on marijuana, 5.1 million met criteria for dependence on any illicit drug and 8.6 million for dependence on alcohol. The NIH is particularly worried about adolescents…as compared to persons who begin to use marijuana in adulthood, those who begin in adolescence are approximately 2 to 4 times as likely to have symptoms of cannabis dependence within 2 years after first use.

The report states that in adolescents, certain brain regions are more vulnerable to THC, the primary ingredient in marijuana, than in adults. THC may impair the ability of neurons to connect in specific brain areas (functional connectivity). It goes on to state that regular marijuana use is associated with an increased risk of anxiety and depression… but that no one is sure that it causes this. (It might be used to self medicate anxiety and depression.) Heavy marijuana use has been linked to impairment in memory and attention that persist and worsen with increasing years of regular use and with initiation during adolescence. It has been linked to lower income, greater need for socioeconomic assistance, unemployment, criminal behavior and lower satisfaction with life. Just to add to this list of woes…they also report that the overall risk of involvement in an accident increases two fold when a person drives soon after using marijuana. (and 5 fold for drivers with a blood alcohol level above 0.08% and 27 for persons younger than 21 years if age!)

Another fact of interest: the THC content or potency of marijuana as detected in confiscated samples (I guess they did not buy and smoke joints to measure this) has been steadily increasing from 3% in the 1980s to 12% in 2012.

OK, now onto the positive…The Institute of Medicine has acknowledged the potential benefits of smoking marijuana by stimulating appetite, particularly in patients with AIDS, in combating chemotherapy induced nausea and vomiting, severe pain and some forms of spastic muscle disorders. It may also decrease eye pressure due to glaucoma. Recent reports have also shown that it can reduce epileptic seizures.

The article concludes that legal drugs such as alcohol and tobacco offer a sobering perspective of their potential harm, not because they are more dangerous than illegal drugs but because their legal status allows for more widespread use. And “as marijuana achieves a similar widespread use, so will the number of persons for whom there will be negative health consequences.”

Just thought I would share!

Seventy five percent of women who become menopausal will have hot flashes, night sweats and sleep problems which, although not life-threatening, can certainly impact quality of life. I have spent much of my career writing about this and indeed treating women with these symptoms. For those who have no contraindications, hormone therapy will usually be the “cure” they seek (as well as maintain bone density, vaginal integrity, skin collagen, perhaps impact cognition and focus, and at least initially, help prevent atherosclerosis and decrease abdominal fat distribution). There is, however, concern about the impact of oral estrogen and synthetic progestin on the risk of blood clots, breast cancer and even dementia. There are new ways to prescribe estrogen that maybe safer (transdermal) and alternatives to synthetic progestin. But a considerable number of women have clear contraindications and/or choose not to take hormone therapy. There is also a valid concern about long-term use; after three to five years of successful hormone therapy the question remains, “Is it safe to continue?” Some women will stop and have minimal symptoms but others will return to the same hot, bothered and sleepless condition that caused them to go on hormones in the first place! Until now, there been no FDA approved non hormonal medications to help treat these vasomotor symptoms.

So although I knew about this medication and have already started to prescribe it for appropriate patients, I wanted to mention the new article that was published in the May 8 issue of the New England Journal of Medicine, “FDA Approval of Paroxetine for Menopausal Hot Flashes” Paroxetine is also known as Paxil which is generally prescribed in doses of 10, 20 and up to 40 mg for several psychiatric conditions, including major depressive disorder. And as you may have noted as you watch or read the myriad direct to consumer ads, this type of antidepressant (as well as most others) has warnings about monitoring patients for suicidal thoughts and behaviors and the directive to discontinue treatment if there’s worsening depression or suicidality. The new medication, called Brisdelle contains a much much lower dose of Paroxetine, only 7.5 mg. It is a very mild selective serotonin reuptake inhibitor that causes a mild increase in that “feel good brain hormone”, serotonin.

The history of the FDA approval is interesting and was the subject of the article. The approval ran counter to the recommendation of the FDA reproductive health drugs advisory committee which had concluded, by a vote of 10 to 4 , that the overall benefit-risk profile of Brisdelle did not support approval. The FDA always carefully considers the advice from its advisory committees but it is not required to follow their recommendations… Here is what the committee considered: Among a total 1184 menopausal women who had a median of 10 moderate-to-severe hot flashes per day, Brisdelle was shown to provide modest relief in comparison to placebo. At week 12 (in one of the studies) there was a median reduction from baseline of 5.9 moderate-to-severe hot flashes per day with Brisdelle as compared with the median reduction of 5.0 per day with placebo. At week 12 (In a second study), there was a median reduction from baseline of 5.6 moderate-to-severe hot flashes per day with Brisdelle as compared with the median reduction of 3.9 per day with placebo. But even though this was a very modest effect, Brisdelle remained efficacious at six months, the latest time point assessed. Because of Brisdelle’s very modest efficacy and concerns about suicidal ideation the advisory committee’s 10 to 4 vote against approval occurred. But recognizing that no hormone-free drug product has been approved to treat vasomotor symptoms, the FDA concluded that Brisdelle still offers a clinically meaningful benefit for some menopausal women.

So yes, we have a new FDA approved medication for hot flashes and in many cases insurance will pay for it. I applaud the fact that we have this alternative; I’m not sure that it will work for every woman but for those of my patients who cannot take hormones and who have quality-of life-affecting symptoms, it’s worth a try.

Many of us do it, we take those pills that cost a fortune and we split them in half and then figure insurance will cover two month’s worth instead of one. The insurance company will save money, we have a lower co pay and fewer trips to the pharmacy, so why not? The editors at JAMA considered this “why not” and published an article about it in their Medical Letter on Drugs and Therapeutics.

A number of medications were tested and the amount of their active ingredient subsequent to cutting or breaking the tablet in half was measured. The studied medications included warfarin (an anticoagulant) and medications for hypertension, heart disease and depression (simvastin, metoprolol, lisinopril and citalopram). The good news was that the split pills were pretty much within the half dose range. The results with scored tablets were better than those with unscored tablets. The editors also cited a recent review that found that the use of split tablets did not seem to affect the clinical outcomes of patients with hypertension, hyperlipidemia (high cholesterol) or psychiatric disorders.

The article went on to state the obvious; that breaking the tablet in half is somewhat dependent on a patient’s visual acuity, strength, dexterity and cognitive ability. Clearly large, elongated tablets with deep score marks on both sides will be the easiest to split. (And just so you know…there is a tablet splitting device which you can buy at the pharmacy. I’ve actually used it, the only problem is taking a very small tablet and making sure it is cut exactly through the middle.) The article suggests that if patients want to split the tablets they do so one at a time so if one half is too small and under dosed, the next day the larger half will be taken and will compensate for the previous lower dose.

Obviously capsules should not be split, nor should tablets that are enteric-coated or extended- release. Also combination tablets in which the amount of one active ingredient changes from one size to the next, but the amount of the second does not, should not be split because that will impact the dosing. These include combination drugs that lower blood pressure and also control blood sugar (sitagliptin/simvastin also called Juvisync, linagliptin/metformin, codeine/acetaminophen, azilsartan/clorthalidone and amoxicillin/clavulanic acid) among others. (I sense that most of you reading this have looked away from this generic drug list…but I felt that in deference to the article and medical completeness I should include them.)

Bottom line: Tablet splitting probably does not have adverse clinical consequences and can reduce the cost to you and your insurance. (The pharmacy may not like this…but oh well.) This pill division is not appropriate for all drugs, nor for that matter all patients. If you do split the tablets, try to make sure that the halves are equal. And if the tablet is coated or comes with instructions not to chew or crush or if it contains a combination of medications, then take the whole tablet as prescribed.

Most of us have heard that men over 50 should consider taking daily aspirin in order to reduce their risk of a heart attack. This recommendation was primarily based on the Physicians Health Study which showed that in the healthy men that were followed, daily aspirin decreased the incidence of first heart attack by as much as 35%. This and other studies have shown, however that “preventative aspirin” has little effect on the risk of stroke in healthy men.

Do these studies apply to women. ..can we be considered “little men”? The answer of course is no… In order to make a gender appropriate recommendation, there must be gender appropriate studies! Only male physicians were included in the Physicians Health Study. But wait, we do have a large study that examined whether aspirin afforded heart attack prevention for healthy women: The Women’s Health Study (WHS) which was reported in 2005. A recent article in the North American Menopause Society Journal reminded physicians of the results of this study and was published under the headline “Practice Pearl”. I thought it would be helpful to review this “pearl” on this week’s website.

The WHS evaluated the benefits and risks of low-dose aspirin (100 mg on alternative days) for the prevention of heart attack, stroke and cardiovascular death among 39,876 initially healthy women age 45 and older who were followed for 10 years. The study demonstrated that aspirin significantly lowered the risk of stroke by 17% and the risk of ischemic stroke (caused by a clot in a cerebral artery which shuts off blood flow to a region of the brain) by 24% in these women. But aspirin DID NOT lower the risk of heart attack or cardiovascular death in healthy women under the age of 65. Moreover, aspirin increased bleeding risks. Gastrointestinal hemorrhage requiring transfusions were 40% more common with aspirin use and there was a 24% increase in the risk of hemorrhagic stroke. The study did show heart benefits for women, but only among those who were age 65 and older. Regular aspirin use was associated with a 26% reduction in the risk of major cardiovascular events, ischemic stroke (risk reduction, 30%) and heart attack (risk reduction, 34%).

These and other studies have definitely shown that aspirin prevents further adverse cardiac events in men and women who have coronary vascular disease, especially if they have had a heart attack. But for primary prevention of heart attack i.e. use of aspirin if you are heart healthy, the study we rely on indicates that women who are under 65 should not routinely take aspirin. Older women are likely to experience a net benefit from daily low dose aspirin unless they have bleeding or allergy contraindications. Most experts would recommended doses between 81-100 mg daily.

Bottom line: Do not routinely take aspirin if you are younger than 65 for coronary protection unless you have an elevated coronary risk, have been diagnosed with coronary artery disease, or have had a heart attack or ischemic stroke. Assess your risk with your physician…diabetes, a strong family history of heart disease, smoking, hypertension and obesity may all contribute to risk.

Last week, I had a somewhat animated discussion with an erudite friend who felt that science is so advanced that we don’t have to worry about resistant bacteria. I argued that we did. And although when it comes to bacterial attacks I really don’t want to be the one to say “I told you so”, an article in last week’s JAMA confirmed that I (and all of us) are right to be worried.

The article was titled “Report Reveals Scope of US Antibiotic Resistance Threat”. The author points out that although antibiotic resistance is well known to US clinicians, until now the true scope of the problem has been unclear and underestimated. A new report by the Centers for Disease Control and Prevention (CDC) provides clarity. They stated that more than 2 million people in the United States become infected every year with organisms that are resistant to antibiotics, and at least 23,000 die. They added that nearly 250,000 people acquire Clostridium difficile infections each year, a serious diarrheal illness that is not so much antibiotic resistant but rather is precipitated by antibiotic use.

The report listed at least eight different types of bacteria in the gut that have been found to be resistant to some or all of the most powerful antibiotics, as well as bacteria on the skin (Staphylococcus) and bacteria that inhabit the upper respiratory tract. The director of the CDC said in a recent press briefing that their report shows just the bare minimum and that they up to now that have only counted the infections that are resistant to antibiotics that occur in hospitals. They know however, that there are many more infections in nursing homes, dialysis units, long-term hospitals, assisted-living facilities and communities. The estimate is that hospital infections alone result in significant need for increased and prolonged care as well as loss of productivity and cost more than $50 billion a year! According to the FDA, more than 70% of the bacteria that cause hospital associated infections are now resistant to at least one type of antibiotic most commonly used to treat these infections.

One of the pathways that bacteria learn to become resistant is that genes jump from one organism to another. So, if one type of bacteria is resistant, it can teach others to have the same ability to shrug off antibiotic impact. Now that I’ve rung the bacteria alarm, I want to at least let you know that experts feel that we can try to do something about this. They have set a goal of at least preventing a worsening situation and perhaps improving the one that we currently have. They recommend developing and administering more immunizations, instituting infection prevention actions in healthcare settings, preparing and handling food more safely and being vigilant about hand washing. And to keep up with the natural process of antibiotic resistance that occurs as bacteria become resistant, researchers have to continue to develop new antibiotics. Despite this clear and present danger, the number of new FDA approved antibacterial drugs have been decreasing steadily since the 1980s. The federal government (which plays a very important role in our health) has passed “Generating Antibiotics Incentives Now Act” (GAIN) in 2012. It is (as usual) long and complicated but it essentially is trying to increase the commercial value of antibiotics by extending the length of time an approved drug is free from competition and simplifying the regulatory pathway for FDA approval of new antibiotics.

Perhaps one of the most important things we as physicians and you as patients need to realize is that antibiotics should be used appropriately and safely. Currently, up to half of antibiotic use in humans and much of antibiotic use in animals is absolutely unnecessary. So please remember this the next time you have a slight cough or sore throat and call your doctor to get an antibiotic prescription. There is a good chance that the antibiotic won’t help and moreover it can increase the chance of developing resistance to this and other “bugs” in your body and in the bodies of others.

Every once in a while you’ll see a “how awful” media story about a young woman who had a stroke or clot in her lungs that was ostensibly caused by oral contraceptive pills (OCPs). Lawyers are suing, OCP users are scared and I get lots of calls from concerned patients and parents. And then there are those ads that come on at night, often on non-network channels, that ask you to call a specific law firm if you have had “fill-in the blank” complications after taking Yaz or Yasmin or for that matter, any birth control pills. So although I have tried over the years to both reassure and address the pros and cons of birth-control pills to patients and concerned family members, unfounded and founded concerns remain. Hence I was delighted to see a new review in The Journal of Obstetrics and Gynecology titled ” Risk of Acute Thromboembolic Events With Oral Contraceptive Use”. The authors reviewed 6476 citations that reported on an association between exposure to oral contraception and outcomes of venous clots (thromboembolism), stroke and heart attack. They looked at every study’s design and quality as well the number of women who took OCPs and control women (who did not) and the number of years in which the women and controls were followed. In the end they found that 50 of the studies included the data that made them appropriate for their review.

Having given you ” the how they got to their conclusions”, I will skip the 7 dense pages of data and charts in the article… They found that there was a threefold increase in the odds of a venous thromboembolism diagnosis among current users of oral contraceptive pills compared to women who did not use OCPs. There was no evidence that the pills that had the progestin drosperinone ( found in Yaz, Yasmin and the generic equivalents) or other pills that had new second- generation progestins where associated with an increased risk of venous thromboembolism in many of the studies. Altogether, they did not find evidence for a difference in risk among the four types of progestins used in birth control pills. They also found a twofold increased risk of stroke from clot obstruction to cerebral vessels among current oral contraceptive pill users. But as they pointed out, the risk of a clot or stroke in pregnant and postpartum women is increased much more, threefold to eightfold that of non pregnant women. (In other words, a woman is far more likely to get a clot during pregnancy then she is using the pill to prevent pregnancy.) Additionally, there was no increase in heart attacks in women who took the pill when compared to women who did not.

The issue of whether OCPs that contain 20 ug of ethinyl estradiol or less (very low-dose pills) versus those that contain 35 ug (low dose pills) was not resolved because many of the studies did not distinguish between these two doses of birth control pills. The authors also pointed out that women who were high risk for clot formation because of heredity, obesity, previous clots or cardiovascular problems were less likely to get prescriptions for OCPs and hence the complication stats could be skewed.

So now when I’m asked, I can say yes, there is a slight increase in risk of clots with birth control pills but that risk of this complication is far greater during pregnancy. And I also want to remind women that birth control pills can regulate cycles, decrease cramps and heavy menstrual bleeding, treat acne, help overcome hormonal changes, reduce the risk of endometrial and ovarian cancer and of course prevent unwanted pregnancy. (But I should now add that there are other forms of contraception that are highly effective and for certain patients may be more appropriate, this is not an ad paid for by Ortho!)

The choice of OCP brand, amount of estrogen or type of progestin depends on a woman’s symptoms, side effects from previous use and her physician’s prescribing habits. This new analysis of multiple studies has shown that there is no difference between OCP types with regards to risk of thromboembolism. I hope the malpractice attorneys pay heed.

We’ve all been hearing more and more about HPV infections; that they cause cervical cancer, vaginal cancer, anal cancer, throat cancer, mouth cancer and venereal warts. I’ve written several articles about the need to immunize girls and boys with the HPV vaccine. The most common vaccine, Gardasil is given in 3 doses, it is a quadravalent vaccine, which means it gives immunity to 4 types of HPV (6,11,16 and 18). These are the ones that cause 70% of cervical cancers, many of the other above mentioned cancers as well as venereal warts. But alas, despite the multiple direct to consumer ads in the media, recommendations by most doctors and the studies in peer-reviewed journals, only one third of adolescents are currently being immunized.

We would certainly expect the prevalence of these infections to be significantly diminished in those whose parents had the clinical acumen to have their children immunized. But they represent just 30% of their peers. So it was pleasantly surprising to find that a study published online in the Journal of Infectious Diseases reported that the prevalence of infections with the human papilloma virus types included in the Gardasil vaccine dropped by almost 60% among females aged 14 to 19 years during the four-year period after the vaccine became available and was recommended. Dr. Thomas Frieden, the CDC director, said during a press conference held to announce the results of the study, that increasing the vaccination rate to 80% would prevent about 50,000 cases of cervical cancer among girls alive today. “We owe it to the next generation- our sisters, our daughters, our nieces and to protect them against cervical cancer.”

Just to remind you, a three dose series of the quarivalent HPV vaccine was recommended in 2006 by the CDC as a routine vaccination for females age 11 to 12 years and for females aged 13 to 26 years who had not been previously vaccinated. In 2011, the recommendation for the vaccine was expanded to include boys aged 11 and 12 years and for non vaccinated males up to 26 years. No data is yet available on the proportion of males who have been vaccinated and/or the impact of vaccination on their infection rates.

The nearly 60% drop in HPV infection is greater than expected but can be due to “herd immunity” from vaccination (nothing to do with animals, it means that those who got the vaccination were unable to infect those who did not).

Remember, HPV is the most common STD in United States. The estimate is that 14 million people becoming infected with HPV every year. According to the CDC, 79 million of the those who have become infected with HPV are in their late teens and early 20s. Every year, about 19,000 cancers in women are caused by HPV; most are cervical cancer. And of 8,000 cancers caused by HPV that occur in men in the United States, most of them are oropharyngeal (mouth and throat).

Wow, this vaccine can make a huge difference. It may be too late for many of us who are over the age of 26 but we certainly can make sure that the younger (and youngest) generation are vaccinated… Not to do so is malparenting!

I know this is the Fourth of July weekend and many of my patients and readers will be busy with family, barbecues and hopefully celebrating the independence of the fabulous country we live in. (And, of course, there are those wonderful sales!). But if you happen to be glancing at this website, I want to take this opportunity to indulge in a modicum of self-congratulation; a committee opinion from the American College of Obstetricians and Gynecologists was just released and it supports what I’ve been telling my patients for years; that hormone therapy does not increase coronary heart disease risk for healthy women who have recently become menopausal. What also makes this committee opinion novel is that it states that if a woman’s quality of life is diminished by menopausal symptoms past the age of 65, extended therapy may be considered. Let me repeat: The American College of Obstetricians and Gynecologists now recommends against routine discontinuation of systemic estrogen at age 65 for women who need HT to manage their vasomotor symptoms (hot flashes and night sweats).

So that’s the summary. And you can go back to your holiday celebrations. But if you want to read further here are some of the studies and facts that the committee used in its announcement:

Much of the controversy about the impact of hormone therapy (HT) on cardiovascular disease came out of the Women’ Health Initiative (WHI) and the Heart and Estrogen/progestin Study (HERS) which seemed to show an increase in heart attack and stroke in women who took hormone therapy. But more recent studies have cast doubt on some of the methodologies used. Many of the women who were in the those two studies were over the age of 63 when they started hormone therapy and already had underlying coronary heart disease, hence they had an underlying increased risk for developing heart attack and stroke, which perhaps was augmented by hormone therapy. But newer studies indicate that when hormone therapy is started at a younger age, in women aged 50 to 59, the opposite occurs. An important study used CT scans to examine the distribution of calcification (plaque) in the coronary arteries in 1064 women who were in that 50 to 59 year range. Those who took estrogen had calcium scores that were lower than women who took a placebo, moreover, those who stayed on estrogen for more than five years had a significant reduction of 40% in their calcification scores.

The committee also looked at other variables of hormone therapy that could affect cardiovascular disease. They stated that synthetic medroxyprogesterone acetate (Provera) causes constriction of blood vessels whereas natural progesterone causes the vessels to relax and therefore may have a positive effect on blood pressure. In addition, unlike synthetic progestins, natural progesterone causes little or no reduction in high density lipoprotein. (Remember, high density lipoprotein is the good cholesterol and works like a rotor router to protect vessels from plaque formation). The committee doesn’t go so far as to state that ET or HT improve cardiovascular outcomes, they simply state that the evidence is as yet insufficient. But they do say that recent evidence suggests that women in early menopause who are in good cardiovascular health are at low risk of adverse cardiovascular outcomes and should be considered candidates for estrogen therapy or combined estrogen and progesterone therapy for relief of their menopausal symptoms. And women over 65 should talk to their doctor. If their symptoms are persistent, it’s OK to consider continuing their hormone therapy.

My final summation: If you develop symptoms that make you miserable – start hormone therapy in the early years of menopause, there is no increased risk of CHD if you are healthy… and continuation beyond age 65 may be an appropriate option if your quality of life is significantly reduced by these symptoms. We still have to discuss risk- benefits (most specifically breast cancer risk…) There is no free lunch or hormone!

As women transition from their regular periods and reproductive stage of life to irregular periods, followed by their absence and menopause, we are likely to experience symptoms such as hot flashes and night sweats. And they are expected… But what we don’t expect is a decrease in our mental abilities or fine motor skills. (As I type this in my iPad, I am watching my fingers to see if they are doing the walking with diminished dexterity!). So I was somewhat alarmed by a recent article in the medical journal Menopause, which of course has a bright red cover. The authors come from the department of neurology at the University of Rochester and the department of psychiatry at The University of Illinois at Chicago. They followed 117 women between the ages of 40 and 60. The women were classified in 4 groups according to their menstrual histories:

  • Late reproductive stage; having subtle changes in menstrual flow, cycle length or both (34 women)
  • Early menopausal transition; persistent cycle irregularity, defined as a difference of 7 days or more at least twice during the previous 10 cycles (28 women).
  • Late menopausal stage; no period for 60 days or longer (41 women).
  • Early postmenopausal stage; the first 12 months after the final menstrual period. (This final menses is also given its own important initials… FMP. I do have to laugh at the acronyms we use in order to sound medical, by the way there were only 14 women in this group… Where have all the postmenopausal women gone?)

These women underwent a battery of psychophysiologic tests that assessed their working memory, verbal fluency, fine motor skills, visual spacial skills, and memory. They all answered questionnaires to help determine their degrees of depression, anxiety (and taking all these tests may have increased the latter), overall health and their menopausal symptoms (specifically hot flashes and sleep disturbances). The researchers then measures the blood levels of estrogen (estradiol) and FSH (Remember FSH is the hormone that is secreted by the pituitary to get the follicles in ovaries to develop and produce estrogen. If there is little or no estrogen, the pituitary works harder and puts out more FSH. The latter will always be high once we run out of follicles and can’t produce estrogen, i.e. menopause has occurred.)

Without going into excruciating detail, what the authors were trying to investigate is whether there was a direct correlation between levels of estradiol, FSH, depression, anxiety, hot flashes and sleep disturbances and cognitive function and whether this function got worse as women progressed through the stages of perimenopausal to menopause.

The results were as follows: Women in the first year of postmenopausal performed significantly worse than women in the late reproductive and late menopause transition on measures of verbal learning, verbal memory and motor function. And depression, anxiety, sleep disturbances as well as hot flashes did not predict cognitive performance.

Okay, this is all rather complicated, so let me come to the conclusion: according to this somewhat small study (and larger ones have not have been as thorough), cognitive function may vary across the menopausal transition, with early postmenopausal being a critical period during which subtle declines in attention/working memory, verbal learning, verbal memory, and fine motor speed and dexterity may occur. The authors (all women) postulated that this may be due to the fluctuating hormones during this transition rather than the total loss of estrogen production that will occur later.

Having brought your attention to this article, I would like to point out that women who were AFTER that first year of absent periods were not tested…they may have reestablished their cognitive ability. (I hope so, otherwise I and most of my friends are in trouble). And just one more comment.. women who took hormone therapy were not allowed in the study. It’s possible that the results would have been different had they been tested. Just a hormonal thought!

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