I didn’t have a chance to discuss this in my last website and even though I’m a week late I wanted to belatedly acknowledge the International Day of the Girl which was celebrated on October 11. In honor of that day, the CDC sent an email with information that they hoped would raise awareness about the health issues that impact young girls worldwide. They chose seven topics (none, thank goodness about Ebola) that should be addressed in order to promote the health and safety of girls. I thought I would outline them this week:

Binge Drinking
The CDC noted that “alcohol is the most commonly used and abused drug among youth in the United States.” According to their statistics one in five high school girls binge drink and half of high school girls who drink alcohol report binge drinking. That means that they’re consuming four or more drinks on a single occasion. This increases their risk of behavior problems, injuries, sexually transmitted infections, unintended pregnancy and also impacts their risk of becoming addicted to alcohol and future health problems.

Human Papilloma Virus (HPV)
This type of virus causes most cases of cervical cancer as well as vaginal and anal cancer. It’s now calculated that 14 million people including teens become infected with HPV every year! But here’s the good news… We now have an HPV vaccine that protects against the HPV types that most often cause anal, cervical, vaginal, vulvar and mouth/throat cancers in women. I’ve talked to most of my patients who are mothers, as well as my younger patients, about the importance of getting this vaccine and indeed have written several articles on my website. Here is a reminder: The HPV vaccine is recommended for girls and boys when they are 11 or 12 years old. It can lower HPV infection rate for teen girls by half. Unfortunately, only 57% of girls and 35% the boys have started the HPV vaccine series. We have to do better…

Indoor Tanning
As I hope we all know, this significantly increases skin cancer risk. The risk is highest among those who start tanning at a younger age. Nearly 33% of white high school girls have tanned indoors and some start doing this as early as age 14 or younger. Indoor tanning causes melanoma which is the deadliest type of cancer. It also contributes to premature aging. We do have laws that prevent young teens from using indoor tanning salons in California but I’m not sure that they are well followed. Somehow we have to promote the slogan that untanned skin is beautiful (and will stay beautiful longer). So many of us wish we had known this years ago.

Sexually Transmitted Infections (STI’s)
Teens and young adults between the ages of 15 and 24 account for half of all new STI’s. Clearly this is where choice of partner and condoms come into play or should I say foreplay…

Sexual Violence
The CDC reports that studies indicate that 36% to 62% of reported sexual assaults are committed against girls age 15 and younger around the world. In the United States, 40.4% of female rape victims where first raped before age 18.

Among 15 to 24-year-olds, suicide accounts for 11% of all deaths annually!

Teen Pregnancy
In 2012, more than 86,000 teens in The United States ages 15 to 17 gave birth. As the CDC points out, this increases their medical risks and results in huge emotional, social and financial costs to the mother and her children. Becoming a teen mom affects whether the mother finishes high school, goes to college, and the type of job she will get.

I listed these alarming stats because I (and the CDC) think we should be aware of the major issues that impact the teen girls in our lives. Ignoring them will not help us address their problems. Yes, we should be celebrating the day of the young girl, but to do so, we need to make sure she stays safe and healthy.

In a week in which we’re supposed to get ready to ask to be written during Yom Kippur “in the book of life” there’s been a lot of news about death, especially Ebola….All the medical journals are now publishing articles about this devastating disease. As a trustee on the board of Save The Children, I’ve been appraised almost daily about the epidemic in the three countries in West Africa where we already have significant programs. Caroline Miles, our CEO has traveled to Liberia where Save the Children and other NGOs are establishing Ebola diagnostic centers, isolation centers and Ebola treatment centers. The consequences of not becoming involved in attempts to treat, contain and hopefully prevent further spread of this disease will have devastating country-wide and global consequences.

But I’m not going to report on Ebola or other diseases in this week’s website. The media is finally doing a good job (especially the New York Times) and so I looked for some novel, not completely medical news to report. I found it in good old JAMA.

In the past, physicians have tended to be Republican. I assume this was for mostly for monetary reasons. (I would try to avoid political discussions with many of my colleagues because I knew we disagreed, especially about their economic woes, which are perhaps currently more valid.) My good news is that the growing ranks of women in the medical profession are shifting political allegiances toward the left.

Women now account for roughly 1/3 of the US physician workforce and happily that proportion is growing. A new study analyzed donations from physicians to national political campaigns between the 1991-1992 election cycle through the 2011-2013 election cycle. Physician campaign contributions increased during this time. But those made to Republicans declined between the mid-1990s and 2012. It was reported that the majority of male physician contributors still backed Republicans but only 31% of female physician contributors supported that party. My take is that this is due to the lack of the official Republican Party’s support of women’s reproductive rights, immigration reform, and funding for causes so many women, especially those involved in health care, care about.

Finally some news that made me smile…May the Jewish New Year bring improved health, governance and stability to all of us.

I’ve been back from vacation this week and have diligently looked at the articles in most of the usual journals. Initially, I didn’t find one that I wanted to report.(Note one article, in the New England Journal of Medicine, dealt with a mutation in a gene in 154 families in Europe and their risk for breast cancer… but I think it was a bit too esoteric to cover in the website.)

I did download an article that appeared in Contemporary OB/GYN which I get online. Under the heading “expert advice” they reviewed an article published in the Journal Radiology (which I don’t read) and that I thought was interesting. This was a study of 1162 women who had primary breast cancer and were 75 or older. Information in their charts from the time of diagnosis was reviewed and accessed for stage, treatment, outcomes, and whether the disease was detected by the patient, her physician or with mammography. The women’s survival rates were then compared. During the study (between 1990 and 2011) mammography detection of cancer over time increased from 49% to 70% and was most common for early stage 1. Detection by a patient or her physician was more common when the disease was more advanced at stage II or stage III. The investigators found that lumpectomy and radiation were common and mastectomy and chemotherapy less common in women who had mammography-detected disease than those with cancers found by the patient or her physician. Additionally, five-year disease specific survival was better in women with invasive breast cancer detected by mammogram (97% versus 87%). The investigators concluded that women who have mammogram-detected cancer were diagnosed at earlier stages, required less overall treatment and had better survival rates than women with cancer detected by themselves or physicians.

Bottom line: Women older than 75 may still derive benefits from mammography screening. I will keep ordering them…

I know most of you may not be reading this email on Friday because it’s the Fourth of July. I’ll try to send it out earlier or you might pick it up after the holiday. So Happy 4th and enjoy the barbecue, parades and fireworks.

I couldn’t let the week go by without reporting on an article in the June 25 issue of JAMA that reports on a study of breast cancer screening using a method called tomosynthesis. The efficacy of tomosynthesis combined with digital mammogram was compared to digital mammogram only for breast cancer screening. A debate about the utility of digital mammogram has once more been brought up by the recent publication of the 25 year follow-up results from the Canadian National Breast Screening Study. It showed that there was no difference in breast cancer-related mortality in screened women versus controls. Many physicians and organizations have however, countered that these results were not valid for current U.S.policy; that the study was based on mammograms that were of poor image quality and that there were significant problems in randomization. Indeed, 14 more recent studies published between 2001 and 2010 have indeed shown a 25 to 50% reduction in breast cancer related mortality for women aged 42 to 74 years who had modern (and presumably better) types of digital mammogram screening. The American Cancer Society, the American Congress of Obstetricians and Gynecologists and other organizations still recommend screening mammography annually for women older than 40 years. The American Cancer Society also recommends annual MRI for women with a 20 to 25% or higher lifetime risk of breast cancer.

The article in JAMA is a retrospective analysis of screening in 13 centers over two time periods. During the initial period more than 281,000 examinations were done with digital mammogram alone. The second period included more than 173,000 examinations during which patients underwent combined digital mammogram and tomosynthesis screening. I know the word “tomosynthesis” sounds very synthetic biology. It is high tech but but not a biological creation. Basically, it is composed of a set of low-dose images produced by x-rays as they moves across the breast. The images are then put together to form a picture by a computer algorithm (of course) that reconstructs the images as slices of the breast. The advantage is in the resolution and clarity of the final image. An area may look suspicious because tissue overlaps from the pressure of a simple mammogram procedure; tomosynthesis is meant to prevent this effect and hence reduce false densities while making a cancer appear more conspicuous.

So does adding tomosynthesis to usual breast screening make a clinical difference? In this study the authors found that the introduction of tomosynthesis was associated with a significant decrease in recall rate (i.e the. need to get additional films, ultrasound, MRI or even biopsy) of 1.6%. There was however, a significant increase in the biopsy rate (1.3%), but perhaps the biopsies were more likely to confirm a cancer. There was an increase in the cancer detection rate of 0.12%. The latter doesn’t sound like much, but it made a difference for the 1.2 women whose cancer was found per 1000 screenings… They might not have had that early diagnosis with standard mammograms. There is however, as always, a drawback in medical innovation and the one here is that tomosynthesis requires twice as much radiation as a regular digital mammogram. And it is too early to know if adding this procedure will impact mortality rates from breast cancer.

In an editorial in the same journal the authors state that “Recent work has suggested that tomosynthesis is likely to outperform mammogram in finding small invasive cancers and lobular cancers, the ones that are most likely to be lethal.”

This and other studies raise some major questions for both physicians and women. Should we seek screening with tomosynthesis over digital mammogram? Should breast cancer screening centers convert to tomosynthesis and abandoned digital mammography? (Which will be costly.) Right now there doesn’t seem to be enough data or financial incentive to do so. But, tomosynthesis may indeed be an advance over digital mammogram for breast cancer screening and one day may become the norm in breast screening. As usual, I’ll end with the off-stated refrain…More studies are needed.

As we read, hear and see the news of the violent onslaughts in Iraq, the ongoing civil war in Syria and learn about the horrific impact of these events on the women and children in these areas as well as in conflict zones in Africa, most of us are appalled and don’t know how to begin to become personally involved. And to add the bad news about these distant emergencies, we now have headlines about the one that is occurring in our own country, namely the wave of young migrants that are crossing the border of Mexico in an attempt to escape violence and severe economic deprivation. I just returned from a board meeting of the Save the Children trustees that was held in Washington, DC. We were updated on these emergencies and what Save is doing to help. If you would like to see some of our programs and our messages, please download from Save the Children’s website. I also suggest that you watch two amazing YouTube videos. The first is titled “Save the Children Most Shocking Second a Day Video”. The link is HERE and the second is “The Most Important “Sexy” Model Video Ever”, watch HERE. I think they will help you (and anyone you want to send these to) understand what this organization is doing and why we all should care, get involved and yes, if possible donate.

Okay, that’s my on-line solicitation, now on to my usual medical website article… JAMA this week had two short stories that I thought would be of interest. One was based on an article that demonstrated that stroke risk increased after shingles infection: When researchers looked at the time at which strokes occurred in relation to shingles episodes, they found that the rate of stroke with significantly higher during the first six months following a shingles episode compared with before an episode. The risk was approximately 63% higher during the first month, 42% higher during the second and third months, and 23% higher during the fourth through sixth months. I have pointed out in previous articles that the CDC now feels that we should all get our shingles shots by the time we reach 50. Without immunization, one in three adults are destined to have shingles as they age. I am sure you have seen those direct to consumer ads that have someone say how horrible their shingles episode was. Indeed it can result in significant pain which lasts for months or even years. So if you have not had your shingle shot you now have another reason (i.e. stroke) to get it.

The second short article had to do with physical activity and the fact that it can stave off diabetes for women who are at-risk for this disease. (This week, the entire Journal was dedicated to diabetes.) Women who develop gestational diabetes are at increased risk of developing type 2 diabetes later in life. About 35% to 60% of women who had gestational diabetes will develop type 2 diabetes within the subsequent 20 years. Studies have shown that a combination of a healthy diet, weight maintenance and physical activity may protect against diabetes in this at-risk group. A new study published in May suggests that even a small increase in physical activity, about 2.5 hours a week of moderate activity like walking, reduces the risk of developing type 2 diabetes. What fascinated me was the additional data… In this study the number of hours per week that participants spent watching television was associated with an increased risk of diabetes. Women who watched 10 or more hours of television each week had a greater risk of developing diabetes than those who watched less, regardless of weight. Perhaps it was their inactivity, their snacking while watching or their exposure to the ads for on unhealthy foods between the shows; but there was a very real association between television viewing and diabetes risk.

Bottom line: Don’t snack while watching television. DVR the shows you want to see so you don’t have to watch all of those ads for unhealthy foods. Get out and walk 30 minutes a day. This advice is appropriate for both at-risk and normal-risk individuals as well as our kids. And don’t put off that Shingles shot. You can get it without a prescription at most pharmacies.

I spent the last week in Berlin at the International Women’s Forum (IWF) conference in Berlin. It was a thrill to be among 700 women from all over the world who have been elected to their respective leadership forums. The panel discussions centered on innovation in areas of education, finance, the internet, human rights and career women in Germany. The most rewarding aspect of the conference was the opportunity to become acquainted with women in leadership roles from all over the world. At this conference, there were very few women from clinical medicine, however there were a significant number of women who had major positions with pharmaceutical and biotech companies. We were all surprised by the fact that in Germany only 6% of women who have two children continue with full-time careers. There seems to be a significant prejudice against working moms. Hopefully this will change…

Now on to medical news… This week’s JAMA reported on the FDA warning against a common procedure used in removing fibroids. The US Food and Drug Administration (FDA) is discouraging the use of a surgical technique that is often used during minimally invasive surgery to treat uterine fibroids. They feel it poses a risk for inadvertently spreading cancer cells from an undetected cancerous tumor. In the past, when there were large fibroids that were clinically bothersome and of concern because of their size, rapid growth, impact on pregnancy, pain, bleeding or pressure, surgery with removal of the fibroids (myomectomy) or hysterectomy would be performed through a large horizontal or vertical abdominal incision (laparotomy). But with the development of power morcellators which basically “chew off” the fibroids so that fragments can be removed separately through laparoscopy, surgeons could switch from a large incisions too much smaller ones. The first power morcellator was cleared for marketing in 1995 and 24 devices are currently marketed for laparoscopic use. In a safety communication released in April, the FDA states that current data has shown that one in 350 women treated for fibroids with a hysterectomy or myomectomy have been found to have an unsuspected uterine sarcoma (cancer of the wall of the uterus). They stated that “if power morcellation is performed in women with unsuspected uterine sarcoma, there is a risk that the procedure will spread the cancerous tissue within the abdomen and pelvis, significantly worsening the patient’s likelihood of long-term survival. For this reason, and because there is no reliable method for predicting whether a woman with fibroids may have a uterine sarcoma, the FDA discourages the use of laparoscopic power morcellation during hysterectomy or myomectomy for uterine fibroids.” The major medical centers have now issued statements about the importance of counseling patients about the procedure and potential risks of morcellaton. Although this warning has received a lot of attention, in many ways it simply points out that a decision about the type of surgery a patient will need and how it is performed will always warrant a discussion about risks and benefits. The minimal procedure of laparoscopy does allow for early discharge and a much faster healing process than the more invasive laparotomy, but consideration about a rare, albeit real risk of having an unknown cancer inadvertently spread should be considered.

Many of my website articles cover medical tests, services and therapies that can significantly impact and increase women’s health spans and lifespans. And I have deplored in some of these reports the fact that so many women have neither access nor insurance coverage to “do the right thing”. Despite all the brouhaha about Obama Care (correctly termed The Affordable Care Act or ACA), it is here, despite partisan controversy, it will stay and it should make a positive difference in the health of millions of women. A single page overview of what we can now expect from the ACA was published by The Kaiser Family Foundation in the May 14 issue of JAMA. Some of the stats of the” before-and-what-will-be after” ACA are important for women to know:

82% of women did have a general checkup in the past 2 years. But in the past 3 years:

  • Only 44% discussed smoking
  • 31% discussed alcohol or drug use
  • 41% discussed mental health issues such as anxiety and depression (at this point I am getting depressed)
  • 70% discussed diet, exercise and nutrition.

Counseling on sexual health issues among reproductive- age women in the past 3 years was inconsistent:

  • 61% were counseled on contraception or birth control
  • 50% on sexual history/ relationships
  • 34% were counseled about HIV
  • 30% counseled about other STDs
  • 23% Discussed domestic or dating violence

Most women thought STD testing is routine, but it was not:

  • 56% did not receive a test
  • Only 14% of doctors or providers recommended a test

Uninsured women have much lower screening rates than insured women

  • Over 70% of insured women were tested for blood cholesterol, mammogram and Pap test in the past 2 years.
  • Less than 44% of uninsured women had cholesterol testing or mammogram
  • 52% had a Pap test

Cost is a barrier

  • More than 50% of uninsured women put off or postponed preventive medical service or a recommended test because of cost
  • 13% of insured women put off these tests

The good (or great?) news is that the ACA requires plans to cover these preventive services with no cost sharing; this means:

  • Cancer screening
  • Chronic condition screening
  • Healthy behaviors counseling
  • Vaccinations
  • Reproductive and sexual health services
  • Pregnancy – related services

According to the Kaiser Family Foundation Survey 4 in 10 women are unaware of this new preventive coverage! So when you your physicians and we ask you about your exercise, diet, smoking, drinking, drug use, contraception, partner history, mental health issues and go over previous medical tests and conditions…we are not being intrusive, but need this information so that we can appropriately go on to discuss, council and screen your health and behavioral issues. And discussion of these health parameters and tests should be covered by your health insurance.

I know all this may be initially cumbersome for the physician and patient (especially since all this has to be entered on an electronic medical record), but let’s all be patient…the ACA should improve our health care and who knows…maybe our health behaviors!

Firm is good, dense may not be… I’ve written articles on the current California law that requires imaging centers to send you a letter if, at time of mammogram, it’s noted that your breasts are dense. And as I expected, I’ve received quite a few phone calls with queries as to what sort of follow up “dense” mandates. The official committee opinion from the American College of Obstetricians and Gynecologists on this subject was published in April 2014 in (you guessed it) the Journal of Obstetrics and Gynecology.

Perky, firm and dense (breasts) are not always synonymous. Dense breast tissue is usually found in younger women. When we are (were) young, our breasts lack abundant fat separating the glands. And some of us stay that way breast-wise… Dense glands in breast tissue absorb more radiation during mammography than fat and look radiographically white whereas fatty tissue allows the radiation to pass through and appears more translucent in the image. A small tumor or calcification that could be the hallmark of a very early cancer or DCIS will also appear white on mammogram. White on white does not allow for good differentiation. And to somewhat complicate the matter it turns out that women with dense breasts i.e. glands that are close together with less surrounding fat, have a modestly increased risk of breast cancer in addition to a reduced sensitivity of mammography to detect cancer.

Just so you know how we categorize breast density by mammogram, the percent of the women within each category and what that means, here is a chart:




(compared to average density)

Almost entirely fat:

10 %



Scattered densities:




Heterogeneously dense



Relative risk 1.2

Extremely dense



Relative risk 1.4

Once the imaging center lets you know that your mammogram demonstrated that your breasts are dense, their letter then states that this increased density limits their ability to diagnose cancer (which also covers their tuches) and they usually go on to suggest that you discuss this with your physician. In turn, we then may recommend that you get additional ultrasound tests and perhaps even an MRI to address your newly induced concerns. Offering these exams also diminishes potential physician neglect and culpability and, of course, also gives reassurance that a diagnosis of early breast cancer is not missed.

I wish I could leave it at that, but the committee opinion does not agree with this line of action. They negate the need for these extra tests stating they are not appropriate in women with dense breasts who do not have additional risk factors. They state that “current published evidence does not demonstrate meaningful outcome benefits (eg, reduction in breast cancer mortality) with supplemental test (eg, ultrasonography and magnetic resonance imaging) to screening mammography or with alternative screening modalities (eg, breast tomosynthesis or thermography).” They go on to say “evidence is lacking to advocate for additional testing until there are clinically validated data that indicates improved screening outcomes.”

But before we all feel frustrated, please note that the committee did bless mammogram, especially digital mammogram as the best diagnostic screening tool that has consistently demonstrated a reduction in breast cancer mortality. The College does not, however, recommend routine use of alternative or adjunctive test to screening mammogram in women with dense breasts who have no symptoms and no additional risk factors.

I still urge you to call your physician if you get that “density” letter. We can then discuss your risk factors such as family history, previous biopsies, excessive alcohol consumption, obesity, even hormone therapy and try to figure out how to best to assess and reassure you.

Baby boomers are overwhelmed with studies and concerns about future risk of Alzheimer’s and dementia. There is a book or article that appears weekly telling us what we can do to keep our cognitive function functioning. (I am hoping that reading medical journals and writing about them will help mine! I would also like to point out another mind issue that should not be dismissed with a “never mind”, which is stroke. Of the estimated three quarters of a million new or recurrence strokes in the United States each year, 53.5% occur in women. And according to a new article that came out in the March 12 JAMA women account for about 60% of stroke related deaths. An estimated 3.8 million women and 3 million men are living in the United States after having a stroke. Yes, let’s mind…

So I thought it appropriate to review the new guidelines that have recently been issued by the American Heart Association/American Stroke Association for prevention of stroke in women. Many of their guidelines pertain to both women and men and these include the need to control blood pressure, avoiding or quitting smoking, maintaining a healthy weight and exercising. The recommendations unique to women are centered on reproductive health. Here they are:

  • Women with a history of high blood pressure should consider taking low-dose aspirin and calcium supplement therapy when they become pregnant. Since women who have developed preeclampsia will have twice the stroke risk and four times the risk of high blood pressure later in life they should be evaluated frequently, beginning six months after delivery. If they have additional risk factors such as smoking, high cholesterol and obesity, they should be counseled and treated.
  • Pregnant women with moderately high blood pressure (150-159/100-109 mmHg) may need medication and if blood pressure is even higher (more than 160/110) they should definitely be treated with anti-hypertensive medication.
  • Before taking oral contraceptives, all women should be screened for high blood pressure. The combination of hypertension and birth control pills can increase the risk of stroke.

I know these recommendations are specifically geared to younger women but the medical societies (and the rest of us) now acknowledge that what we do at every stage of our lives impacts our future health and brain span. Blood pressure should be checked regularly from childhood and it turns out that elevation in pregnancy can be especially ominous. Appropriate therapy together with healthy lifestyle maintenance throughout our lives will impact our risk of a catastrophic brain event at every age.


I spent part of last weekend volunteering for the Care Harbor/LA Free Clinic. This once-a-year event has received extensive media coverage so you may have heard or read about it. But for those who did not, I thought I would share what I saw on this week’s website. (And it will give me a chance to express my amazement that it was (a) so well organized and (b) there is such a need for free health services.)

Thousands of individuals lined up before the weekend to get wristbands that allowed them to access the three day event. Four thousand succeeded but demand was much higher and many of those who waited in line did not. The clinic was held at the LA Sports Arena and offered free dental care, vision care, general health care and women’s health care. Women of all ages (including teens) could get Pap smears, STD testing, pregnancy tests, blood tests and if 40 or older, mammograms. When necessary, pelvic ultrasound was available. All the health care providers, assistants, organizers and translators were volunteers and all supplies, instruments and lab tests were donated. Each patient signed in, gave an address and was directed to the medical area that she or he requested or needed. There was food, hairdressers for the women and areas that could help patients sign up for needed referrals, Medicare, Medicaid and government insurance. I was overwhelmed by the number of volunteers who cared enough to come down and spend their weekend donating their services.

I know I don’t usually wax political on my website emails (well not that usually) but this time I will… When you see how this very basic offering of healthcare was so welcomed to the thousands of people who stood in line for hours to get their wristband, and then returned and waited to be seen; you have to acknowledge that our lack of universal health care is wrong! As many of my readers know, my family lives in Israel and I go there frequently. Healthcare in Israel is available and covered for everyone, no matter age, work status, ethnicity or religion. A comparison (indeed comparison to just about every other developed nation) is embarrassing and depressing. Many of the people that were seen at this three day clinic LA clinic had received no other health care. And although on-going care referrals to community and public health clinics were offered, few would get vision or dental care after this event.

I hope that the Affordable Care Act (Obama Care) will help rectify some of these inequities. It will (or should) happen. But there will continue to be a need for events such as the Care Harbor/ LA Free Clinic in the future… especially for those women, men and children who are currently undocumented or remain uninsured. Events such as the one last week show that the community cares, and hopefully will continue to do so.