Most of us watched with amazement (at least I did) during the World Cup as the soccer players used their heads and feet to make goals. (I will not discuss the Brazil team.). We have also been bombarded with information about concussions, especially in male football players. I suppose that butting the ball with one’s head in soccer is not brain protective. An article in the clinical review of JAMA at the end of August caught my attention. It was titled “Concussion and Female Middle School Athletes”. There were definitions of concussion, a list of health implications of concussion and statistics that I thought were highly informative for many of us as we watch our daughters and the daughters of our friends and family engage in this “getting more popular” sport.

A concussion in sport is defined as a process that affects the brain as a result of traumatic forces. (Well that part is clear.)

There are five features that characterize a concussion:
1. A direct blow to the head a blow to the body that transmits and “impulsive” force to the head.
2. This results in a rapid onset of short lived neurologic impairment that resolves spontaneously.
3. The clinical symptoms may or may not include loss of consciousness.
4. No abnormalities are seen on imaging studies.
5. The symptoms may be prolonged in a small percentage of cases.

Among high school athletes, concussion rates are highest in boys football and girls soccer. And in similar sports girls have higher rates of concussions then boys. Apparently female sex is a risk factor, so is prior concussion, young age and a history of migraine headaches. Symptoms include headache, dizziness, mental fogginess, difficulty concentrating and remembering and fatigue. Loss of consciousness occurs in less than 10% of concussions and the typical recovery time for an adolescent athlete is 7 to 10 days. (But the article noted that for some individuals, recovery may take weeks or months.)

In a report that was published in JAMA Pediatric a study, was done between 2008 and 2012 for soccer clubs in Washington state that involved 351 elite female soccer players from 33 youth soccer teams age 11 to 14. Among these girls 59 concussions occurred within over 43,000 athletic exposure hours. This meant that the cumulative concussion incident was 13% per season and the incidence was 1.2 per 1000 athletic exposure hours. “Heading” the ball counted for 30.5% of the concussions and most players continued to play with symptoms!

Perhaps the most concerning part of the report pertained to potential long-term effects of concussion. These include persistent deficits in memory and visual processing, decline in academic performance, depression, dementia and postconcussion syndrome (the symptoms last longer than three months) as well as second impact syndrome. That means that if another concussion occurs it can cause rapid brain swelling and this can be fatal!

The good news is that there is now legislation in all 50 states requiring schools to have protocols in place for concussions. They are supposed to have educational materials and guidelines for athletes, coaches and parents and the parents and athletes have to sign informed consent acknowledging the dangers of concussion before participation in sports. Any student who shows signs of concussion must be evaluated and cleared by a healthcare professional before being allowed to return to practice. However, unlike many high schools where athletic trainers are trained (we hope) to evaluate and manage injuries, youth sports leagues rarely have any type of medical coverage on site.

Since I knew so little of this information, I thought it was worthy of being shared…my conclusion is that parents need to be aware of concussion risk and engage in discussions with their daughters’ coaches. And just perhaps, encouragement to play tennis, swim, dance or go out for track is in order…

I have to admit that I’m writing this in the midst of feeling wide-awake, rested and in fabulous mountain air while vacationing with my family at Mammoth Lake. Amidst the hiking and biking, I relaxed by checking out recent medical articles on my iPad. (Yes, I know this is not a sign of great mental health.) And what I found were the new clinical guidelines from the American College of Physicians based on their review of the medical literature on obstructive sleep apnea (OSA). No, this did not cause a diminution of family worries, but I thought the guidelines were worth sharing…

A quick review of the subject: In individuals with obstructive sleep apnea, breathing slows or briefly stops because the airway becomes blocked during sleep. This is usually accompanied by snoring (which annoys or disrupts the sleep of anyone within 20 feet and certainly a bedmate). The clinical symptoms of sleep apnea include unintentionally falling asleep, daytime sleepiness, waking from sleep without feeling refreshed, fatigue, and cognitive impairment. OSA affects 10 to 17% of the US population! It’s not just an annoyance; it is a serious health condition and is associated with cardiovascular disease, hypertension, difficulty with cognition and type two diabetes. It is not gender specific and the most common risk factor is obesity. As women get older, go through the menopause transition and often gain weight they begin to equal men in their incidence of obstructive sleep apnea.

Clearly there are are other causes for day time sleepiness and fatigue. Too few hours devoted to sleep and chronic insomnia are, unfortunately, extremely common…. The National Sleep Foundation states that as many as 40% of the population may be sleep deprived! Other disorders that can cause these symptoms include thyroid disease, GERD (reflux), and respiratory conditions. Until they are ruled out, the ACP states that it’s important to diagnose excessive daytime sleepiness with a sleep study, preferably done overnight in a sleep lab. A special monitor called a polysomnograph is used to monitor breathing, airflow, brain activity, oxygen levels and certain muscle movements during sleep. The study is fairly expensive and not always available…the alternative is to have a physician prescribe testing with a portable sleep monitor that can be used at home or in the hospital.

The most common form of treatment for obstructive sleep apnea is with a CPAP or continuous airway pressure device which keeps the airway open while asleep. It consists of a mask or other device that fits over the nose or the mouth and nose. This is connected to a motor that blows air into a tube connected to the mask. Most CPAP machines are small, lightweight and fairly quiet. The noise they make is soft and rhythmic (sort of white noise) and often does not impede relaxation and sleep. According to the NIH most people who use a CPAP report feeling better almost immediately once they begin treatment; they feel more attentive and better able to work during the day. So do their partners. There are surgical therapies, but they’re usually not used unless the CPAP has failed. And because obesity is the most weighty factor for obstructive sleep apnea, weight loss is vitally important. Every expert will tell patients that the first thing they should do is to lose weight. That alone may suffice to treat OSA.

So instead of using the expression “good night, sleep tight” when we send loved ones off to bed, we should probably say “sleep silently and continuously”. Those eight hours (the ideal) mean as much to our health and well-being as our daytime behavior.

Autism spectrum disorder (ASD) affects almost one percent of all children born in the United States. It can vary in severity from a complete inability to communicate and interact socially to a minimal lack of social and communicative skills, restricted interests (and even intellectual brilliance in the interest) and repetitive behaviors. How much of this is genetic and how worried about heredity do families have to be if one child is already affected by ASD?

A recent study in Sweden of all children born between 1982 through 2006 assessed this genetic concern and the findings were reported in the May 7 issue of JAMA. In Sweden, all infants and preschool children regularly undergo medical and development examinations. And at age 4, every child goes through a mandatory development assessment of his or her motor, language, cognitive and social development. Any child with suspected developmental disorders is referred for further assessment by a specialized team in a child psychiatry unit or habilitation service. (Ideally, this should be done here in the US; alas it is not…so much depends on parents’ recognizing and reporting initial symptoms and follow up by pediatricians. A similar comprehensive study will not be forthcoming nationally, unless, of course, we embrace universal health care…but I am supposed to leave that subject alone for a while.)

The investigators followed the records of a total of 2,049,973 children; 37,570 were twins, 2,642,064 were full siblings (sisters and brothers with the same parents), 432,281 were maternal half siblings (with the same mother) and 445,531 were paternal half siblings (with the same father). Please don’t try to remember these numbers, I just thought they were meticulously fabulous and had to include them!…To continue, they found that 14,516 children had ASD. The male to female ratio was 2.74.

What this means is that for children with a full sibling who has ASD, the probability of an ASD diagnosis by age 20 is estimated to be 12.9% compared with 1.2% for individuals without am affected sibling. The probability of an ASD diagnosis at age 20 is 59.2% for identical twins, 12.9% for non-identical twins, 8.6% for maternal half siblings, 6.8% and for paternal half siblings, 2.6%.

This was a study of more than 2 million families and indeed is the largest population-based study evaluating familial risk of ASD. After the epidemiologists and statisticians did their analyses they came to the conclusion that heritability of ASD is 50%, and that genetic factors explain half of the risk of autism-spectrum disorder. An individual’s risk increases with the degree of relatedness to the person who has ASD. In statistical terms: the relative risk is 10.3 for full siblings (versus 1 for non relatives… i.e.. more than 10 times more likely to occur), 3.3 for maternal half siblings, 2.9 for paternal siblings, and 2.0 for cousins. (My take on the difference between maternal and paternal half siblings may have to do with the fact that the stats may not always represent the true father!)

The authors concluded with the statement that “These findings may help inform the counseling of families with affected children.” I’m not sure it helps to know that heritability of ASD is 50% but I guess it’s a lot better than being told it’s 100%… we definitely need more research and methods for predicting ASD at or before the onset of a pregnancy. The good news is that we’re getting better at early diagnosis and cognitive therapies.

Having traveled for 20 hours to reach Addis Ababa in Ethiopia at 3 AM on January 17th…I did not know if I could gather up the energy to get in a jeep and travel 130 kilometers that same morning to see the school that our group of LA Associates of Save the Children had funded. But when I and the three women who went on this trip arrived, we forgot our fatigue as we were met by hundreds of children, parents, village elders and horse back riders(!) who sang and cheered as we traversed the dirt road leading to the village and school.

Until this year, in order to get to a school for primary education the children had to walk two hours each way from their village! The little ones could not do it, and the older girls were not allowed to attend school unless they had separate latrines. These children and their parents dreamed of their chance to acquire an education; they knew it was the only way they could break their existing bonds of poverty. Save the Children has worked for decades with the government of Ethiopia to help establish schools throughout the country. Once those schools are built and supplied the government then provides the teachers and together with the community continues to run them. The local school often becomes the center for democratic participation in governance, child health, child rights and community welfare. It was with this in mind that the LA Associates of Save the Children raised the funds to establish the school in this village. The opportunity our journey afforded us to experience the joy and gratitude of the children and their community was extraordinary. Save the Children is an amazing global organization and we now have a West Coast presence here on LA. I feel honored to be a part of it…

Rather than go on with words, I thought I would share some of the pictures we took during our visit. Yes, I usually share medical information on this website… This time I hope you agree; giving children a future is medicine for all of us!

I just returned from Ethiopia where there is a very high level of premature birth, infant death and mortality in the first five years of life. I plan to delve into this in detail and show you pictures of the school that the LA associates of ‘Save the Children’ and I built in a small community about 50 miles outside of Addis Ababa. However, I need time to collate our pictures and write a full story to share with you. Quite frankly, I’ve been jet lagged this week and coming back to the practice has kept me busy. But I did come across an article in the New England Journal of Medicine about prevention of preterm parturition (delivery) which I would like to share with you.

The author states that in the United States, the annual rate of preterm births (before 37 weeks of gestation) was 11.7% in 2011. Unfortunately, the rate in the United States remains nearly twice the rate of that in European developed nations. Premature birth in the United States accounts for 35% of deaths in the first year of life and an estimated annual cost exceeding $26 billion. Babies born before 24 weeks of gestation rarely survive without serious handicaps and even after 24 weeks their mortality and morbidity can be significant. Before gestation of 32 weeks, we see serious neurodevelopment complications and even in babies born before 36 weeks gestation there are often difficulties with respiration, their ability to maintain their body heat, feeding, as well as an increased risk of health problems and death in childhood.

And here are some of the risk factors that were listed in this article: black maternal race, previous pregnancy with an adverse outcome, infection in the bladder or pelvic area, smoking, extremes of bodyweight and social disadvantage. Premature delivery may also be impacted by maternal depression, prepregnancy stress, poor diet, assisted fertility and periodontic disease. A previous preterm birth is a strong risk factor for future preterm birth; a preterm birth increases the risk of future preterm births by a factor of 1.5 to 2. The author also points out that short cervical length as measured with the use of transvaginal ultrasound at 18 to 24 weeks of gestation is a consistent predictor of an increased risk of preterm delivery regardless of all the other factors. Hence many obstetricians do look at cervical length with ultrasound at around this time of conception.

The article becomes very medical with terms that are basically written for the obstetricians or other medical practitioners, so I won’t get into too much detail. But the author did make a very nice summary of the current measures that may prevent preterm labor. Here it is:

  • Change reproductive health care to reduce the incidence of multiple pregnancies and scheduling births after 39 weeks unless there is a medical indication.
  • Identify and treat medical risk factors in early pregnancies (e.g. genital urinary infection and poor nutrition) may help (but so far there is no data that this is truly effective in reducing preterm birth rates).
  • Knowing that previous preterm birth and a short cervix as measured by transvaginal ultrasonography are major risk factors for preterm birth.
  • Using progesterone supplementation in women with the previous preterm birth, a short cervix or both is recommended for women with these risk factors.
  • Cervical cerclage (putting a special stitch on the cervix to help keep it closed) reduces the risk of recurrent preterm birth among women with a short cervix.

Obviously these prevention tactics have been issued for physicians who are treating pregnant women. I know that many of my readers will not have to deal with obstetrical problems. But as we increase our knowledge about women’s health and the medical issues that impact our future generations, I felt that this data was important … if not for each of us, certainly for our daughters and perhaps granddaughters. I will get back to you about my Ethiopia trip next week.

As I sat down to write this website, my iPhone and iPad both beeped with a new message. It was from the CDC with a flu alert. So I thought it was appropriate to pass this on to you. (I was going to write about an article in JAMA about the “Ingredients for successful and interventions to improve medication adherence.” Just briefly…I have to relate some of what was written!… on average, 50% of CDC is alerting clinicians nationwide medications for chronic diseases are not taken as prescribed. There are new options to deliver patient education. These include mobile health technologies in which text messaging is used to remind patients to take their medication on time. Electronic monitors could help them check their blood pressure, glucose, physical activity and weight. There are new pill monitoring technologies that include electronic pill caps, smart blister packaging and digital pills. And finally there are now online resources and social media outlets that help support individuals with specific chronic diseases and build support communities. Okay… I did it; now on to flu.)

The CDC is a alerting clinicians nationwide about cases of severe influenza. Apparently from November through December 2013, the CDC has received numerous reports from several states of severe respiratory illnesses among young and middle-aged adults, many of whom are infected with a specific virus called the influenza A (pdm09) (pH1H1) virus. Data indicate that for the 2013/14 season, if this virus continues to circulate widely, the illness that occurs will disproportionately affect young and middle-aged adults. Hence, they are recommending that all individuals who are six months and older would have not yet received an influenza vaccine this season be vaccinated. All the available vaccine formulations this season contain aPH1N1 component and the CDC does not recommend one flu vaccine formulation over another.

Many of you know that as soon as you enter my office, we offer a flu vaccine but you can also get it at most pharmacies and health care facilities. I know that some of you feel that because you never had the flu and you are otherwise healthy, that you don’t have to worry. In the past, we all thought high-risk individuals were those who were elderly, very young or were immune compromised. But now it appears that it’s healthy young and middle aged adults who are at risk.

The CDC’s nationwide notice also encourages all persons of all ages with influenza like illness to seek care promptly in order to determine if treatment with influenza antiviral medication is warranted.

I wanted my last newsletter of the year to be somewhat positive. So I will positively try to ward off potential evils and continue to champion an agenda of appropriate prevention. Unless you plan to spend the next few months around people wearing masks or you are going to wear one yourself (and not touch anything), it would be very good idea for you to get the flu shot.

Aside from my proclamation of potential flu emergency I do want to offer the traditional “Have a happy and healthy New Year! ” And I will try to help keep my patients and readers healthy and up to date on medical articles and news in the year come.

As many of us try to consider and perhaps atone for past bad behavior (sins?) this Yom Kippur I want to point out a review that appeared in the September 5 issue of The New England Medical Journal. It was an article titled “The behavioral and dietary risk factors for noncommunicable diseases”. In other words, what are the worldwide behavioral misdemeanors that cause disease and death from noninfectious causes. There were a lot of graphs and statistics about the “death burden” of disease in men and women and the behavioral factors that caused them. I just want to give you some of the more startling statistics.

Let’s start with smoking… We all know that smoking impacts mortality from cancers, cardiovascular and respiratory diseases. It also effects diabetes and tuberculosis. Exposure of pregnant women and children and nonpregnant adults to second hand has also been found to be associated with infertility, miscarriage, premature delivery, fetal malformation, childhood respiratory diseases and many of the same diseases that are associated with active smoking. There are now more than 1 billion (that’s billion with a B) smokers worldwide and a rising number live in low and middle income countries. The prevalence of smoking has fallen below 20% in Australia and Canada and in areas of the US but has risen among men and women in Central and Eastern Europe, among women in some Western and Southern European countries, and among men in East Asia. An estimated 60% of men in some countries in Eastern Europe and East Asia smoke. Tobacco smoking and exposure to secondhand smoke together are responsible for about 6.3 million annual deaths worldwide and 6.3% of the global burden of disease. (In other words, we should consider that tobacco is one of the most deadly weapons that mankind has developed).

The next deadly sin that was listed in the article was alcohol. Alcohol consumption is responsible for about 2.7 million annual deaths and 3.9% of the global burden of disease. Alcohol is a major contributor to cancers, chronic liver disease, unintentional injuries, alcohol-related violence, neuropsychiatric conditions, and in regions such as Eastern Europe where there is a high prevalence of binge and harmful drinking, cardiovascular diseases. As a matter of fact, alcohol consumption is the leading single because of disease burden in Eastern Europe and is one of the top three risk factors along with high blood pressure and obesity in much of Latin America where it ranks ahead of smoking. In Russia and neighboring countries, men (especially those of low socioeconomic status) consume very large amounts of spirits either regularly or though binge drinking. Alcohol consumption may be responsible for 1/3 to 1/2 of death among young and middle-aged men in Russia!

Sin number three is excess weight and obesity. We know it increases the risk of disease or death from diabetes, heart disease, stroke, cancers, chronic kidney disease and osteoarthritis. It’s estimated that currently, excess weight is responsible for about 3.4 million annual deaths and 3.8% of the global burden of disease. According to the article, the global prevalence of obesity which is defined as a BMI greater than 30, doubled between 1980 and 2008 and is 29.8% among men and 13.8% among women. This is equivalent to more than half a billion obese people worldwide. The United States has had the largest absolute increase in the number of obese people since 1980, followed by China, Brazil, and Mexico. (Please don’t read this while you eat dessert…other than fruit!)

Next let’s go to diet and nutrition. The authors calculated that low dietary intakes of fruits, vegetables, whole grains or nuts and seeds or a high dietary intake of salt are responsible for 1.5% to more than 4% of the global disease burden. We know that Mediterranean diets are healthy, but recent data show that the consumption of animal fats and high calorie foods is increasing in Mediterranean countries such as Greece. There are even more drastic dietary changes in Asia; China is rapidly adopting a western, animal-based diet and has one of the largest worldwide increases in serum cholesterol levels.

I don’t want to leave the reader with the thought of “woe is the world and there’s nothing that can be done.” There are major successes and tobacco control in many high and middle-income countries and the hope is that these can be shifted to lower income nations. Harmful alcohol consumption and cigarette smoking has been curtailed by public policies including taxes as well as limits to age and place of use in many western countries. The governments in Eastern Europe and Latin America have to be pay attention to these successes and follow some of the same policies. There has also been progress in lowering blood pressure and cholesterol levels in high income countries and parts of Latin America. There is obviously much to be done as regarding weight gain and exercise. But once more on the plus side (a non weight comment), we have seen successful efforts in limiting trans fat and salt consumption. World-wide public health policies seem almost philosophical to most of us but each of us can start our own health policy with individual social and political decision-making and better health habits.

On this evening of Yom Kippur, I want to repeat the age old blessing: “May you be inscribed (next year and for many years to come) in the book of life”.

Let me start this week’s website article with a blessing: Shana Tova. As many of you know this is the beginning of the Jewish New Year and I did not want to commemorate the holiday by writing this article on the actual Rosh Hashana holiday. In the spirit of holiday planning, I am writing this on the preceding Monday, September 2. Yes, this is Labor Day, a time to reflect and celebrate the labors of others as well as my own. But reading medical journals and reporting on them is not, in my view, labor. I actually enjoy it! Moreover I suspect that many of my readers, friends and relatives are out shopping the sales, so I don’t feel guilty.

This week’s JAMA included an article titled “Acute Abdominal Pain and Abnormal CT Findings”. It’s meant to show physicians and ultimately their patients why CT scans should he performed when appendicitis is suspected. CT results have saved as many as 40% of patients with suspected appendicitis from unnecessary surgery. Interestingly, women are more likely to undergo unnecessary appendectomy than men.

Appendectomy is the most common emergency operation United States. The usual symptoms include pain around the umbilicus (belly button) which increases over time, a mild fever and less routinely, loss of appetite, nausea, vomiting and constipation. The exam by a physician usually shows that the abdominal is rigid, that there is pain with flexion of the right leg and exquisite tenderness in the lower right abdomen, whereas deep palpation on the left lower abdominal area does not cause the same distress. The white cell count may be elevated but is not specific for the diagnosis of appendicitis and, frankly, there are no other diagnostic blood tests for acute appendicitis.

Since CT scans have greatly reduced the misdiagnosis of appendicitis, especially in women, they are now used in most emergency rooms. In a 10-year, single-institution review that was published in the New England Journal of Medicine, the use of CT for suspected acute appendicitis increased from 19%, in 1998, to 93% in 2007 and was associated with a decrease in the negative (unnecessary) appendectomy rate, which fell from 17% to 8.7%. CT was even more impressive in reducing misdiagnosis for women younger than 45, decreasing negative appendectomy rates from 43% to just 7%. The authors of the article conclude that “Because of high misdiagnosis rates, women presenting with lower abdominal pain or any atypical presentation for appendicitis may benefit from CT imaging.”

Bottom line: If you experience the sudden onset of mid abdominal pain that subsequently radiates to the right, your abdomen becomes rigid, you develop a fever with or without nausea or vomiting; don’t wait…see your health care provider or go directly to the emergency room. A doctor should examine you, do a blood test to see if your white count is elevated and in most instances order a low-dose CT scan. This is the most reliable method to establish the need for emergency appendectomy. The goal is to diagnose appendicitis before the appendix ruptures. A laparoscopic procedure can then be done and in most instances you can go home the next day.

Hopefully none of this will happen on a holiday.

Patients often ask me whether I can predict if they will have severe hot flashes, night sweats and other symptoms of menopause when they go through this transition. My crystal ball has always been rather cloudy regarding the severity of future menopausal symptoms. What I can forecast with certainty is that we will all become menopausal by our mid 50′s or (often) even earlier. But perhaps this will help… there are studies that have looked at the correlation between PMS symptoms and menopause and have found that indeed the former may be predictive of severity of symptoms in the latter.

A new study was published in the journal Menopause briefly (!) titled “Past reproductive events as predictors of physical symptom severity during the menopause transition”. Initially, the author summarized past studies which have shown that there is a correlation between PMS and menopausal woes; one of which found that women who experienced premenstrual syndrome were five times more likely to report hot flashes during the menopause transition and were significantly more likely to report decreased libido, depressed mood, and/or poor sleep.

The article then went on to report on a recent study conducted in Canada in which 270 participants who had started the menopause transition were followed. The mean age at which menopause began in these women was 46.5 years. The women filled out a lot of forms: a menopause specific quality of life questionnaire, a menstrual distress questionnaire, a pregnancy experience questionnaire, a postpartum physical symptoms questionnaire, and an oral contraceptives side effects questionnaire. (My comment at this point is that having to fill out all these questionnaires could provoke anxiety and subsequent symptoms, but hey I am trying to be a non opinionated reporter.) I won’t go into the complicated statistical analyses, which took up pages… But in the end the present study did demonstrate that a history of premenstrual symptoms (i.e., pain, concentration difficulties, and water retention) as well as physical symptoms experienced during pregnancy were excellent predictors of menopausal symptoms.

Their association may be due to similarities in hormonal changes during the premenstrual phase and those of the menopausal transition. Remember, PMS symptoms are experienced late in the second half of the menstrual cycle before the period occurs. This is when both estrogen and progesterone levels are declining or low. The link between PMS symptoms and menopausal symptoms suggests that those of us who are or are “destined” to have hot flashes, night sweats and sleep disorders in menopause may be more susceptible to physical symptoms when hormone levels decline.

The bottom line doesn’t seem fair…that if you suffered from PMS you are more likely to have significant menopausal symptoms. Sorry, as I said before, I am just reporting. But I and other doctors are here to help you get through both!

Most of you know that I try to be very thorough (with a slight bias) when discussing hormone therapy and indeed, many of my previous website articles have dealt with the pros and cons of hormone therapy in menopause. So I certainly want to make sure to report on a study that recently came out in the American Journal of Public Health. Its title is “The Mortality Toll of Estrogen Avoidance”. The authors created a formula based on data that came out in the Women’s Health Initiative Estrogen Alone Trial. (Like so many studies this has an acronym: WHI -ET.) I’ll start with their conclusion; that at least 18,600 and possibly as many as 91,600 excess deaths occurred between 2002 and 2011 among women who had a hysterectomy and were between the ages of 50 and 59 years, as a result of their estrogen therapy (ET) avoidance.

ET protects the heart and bones and, of course, relieves menopausal symptoms. In the 1990s, more than 90% of women in their 50s who had a hysterectomy used estrogen therapy. But in July 2002, the investigators of the Women’s Health Initiative (WHI) published the results of the estrogen plus progestin trial and terminated the study because of adverse effects. There was a mass media rush to characterize hormone replacement as all bad. In less than two years, half of the women who are using systemic hormone therapy stopped. Compared with 2001, use of oral estrogen only among women aged 50 to 59 years with no uterus declined by almost 60% in 2004, 71% by 2006, and 79% in 2010 and 2011.

This decline continued despite the positive results that were later found in the WHI estrogen only trial which was published in 2004 and then again in 2011. It showed that the absolute total risk of death was reduced by 13 per 10,000 women per year among hysterectomized women aged 50 to 59 years who were using estrogen during 10 years of follow up. The researchers used this 13 per 10,000 women per year to calculate mortality associated with not using estrogen among women who had a hysterectomy. They then looked at the numbers of women who had hysterectomies since 2002 and with these numbers got to their estimate of close to 49,000 excess deaths. And that number may be low. The authors calculated the decline in use of oral estrogen only for their estimates. They did not include transdermal estrogen which has been found to be more effective than oral estrogen in preventing cardiovascular events such as heart attack and stroke. So if many of these women had used transdermal estrogen, their longevity might have been protected to a greater extent.

Poor estrogen, its had very negative press, and even when good results are published they do not receive the attention given the negative ones…Well that’s what makes news all the news that’s fit to get attention!

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