This week I’m going to diverge from my usual review and commentary of articles published in peer-reviewed journals and write about one that I read in the New York Times. The headline read “Younger Skin Through Exercise” and after I dutifully read the pages devoted to the conflicts in the Ukraine and Syria, I was delighted to find a good-news health article which pertained to aging skin.

The author cited a study which was presented this month at the American Medical Society for Sports Medicine. Having just returned from The Golden Door where, for a week, I exercised up to six hours a day with hikes, tai chi, yoga, dance, stretching, toning and Pilates I thought “wow not only did I get my body and mind in better shape, but I may have helped my skin!” So obviously I was intrigued, and unless you read the article in The New York Times, here is a summary:

The first part of the study was conducted on 29 male and female volunteers between the ages of 20 and 84. Half of the participants were active and exercised moderately or vigorously for at least three hours every week. The other half were sedentary, doing nothing or exercised for less than an hour per week. The scientists did skin biopsies from the volunteers buttocks. (They chose the tush area in order to examine skin that had not been exposed to sun… I assume the participants were not nudists.) The older volunteers had thicker outer layers of the skin and significantly thinner inner layers. But when they compared those who exercised and those who did not, they found that after age 40 the men and women who exercised frequently had markedly thinner, healthier outer layers and thicker inner layers in their skin. (Note, if for the top layer is thick it is also dryer, flakier and crocodile-like and when the underlying layer begins to thin it loses elasticity giving it a saggier appearance.)

The researchers understood that other factors, including diet, genes and lifestyles might have influenced the difference in the skin condition between the exercising and sedentary group. So they took a group of sedentary volunteers who were age 65 or older and who had normal skin for their age and had them begin an endurance training program. The volunteers worked out twice a week by jogging or cycling for 30 minutes for a period of three months. At the end of the three months, the researchers again biopsied the volunteers skin. (They were certainly brave volunteers.) Lo and behold, when viewed under the microscope, the volunteers’ skin looked like that of younger persons!

The researchers then analyzed the skin of those who had exercised and found elevated levels of a substance produced in working muscles, a myokin called IL-15. The skin samples contained almost 50% more IL-15 after exercising then at the start of the study. But before we start thinking we can just rub on some IL 15 or take a pill containing this myokin, the chief investigator specifically stated that it was unlikely that this would replicate the skin benefits of a work out.

This is a small study but I found it fascinating and felt it adds to our knowledge about the importance of exercise. Remember, the one intervention that has been found to prolong our lifespan and health span is exercise. Of course it helps to be in fabulous surroundings, focus one’s mind with meditation, get daily massages and eat great and nutritious foods… Last week was health week at The Golden Door and I was asked to give a talk on women’s health each day. I hope this was helpful to the other women there. But I have to admit that my personal health and well being significantly benefitted and perhaps it was also good for the layers of my skin! I’ll notify my dermatologist…

Oy! (Probably not the best word to start my website this week, but I couldn’t come up with a different one.) Right after I wrote about the recommendations for women who were found to have dense breasts during their screening mammogram, I, and everyone in the media, read the article published in last week’s JAMA titled ” A Systemic Assessment of Benefits and Risks to Guide Breast Cancer Screening Decisions”.

The authors, who are on the faculties of Brigham and Women’s Hospital and Harvard Medical School, reviewed articles that were published between 1960 and 2014. They searched for information on the benefits of mammogram, harms of mammogram and modes of individualized mammography screening decisions including communication of risks and benefits. The article is long and the citations many, but basically, the conclusion is that there was an overall 15 to 20% decrease in the relative risk of breast cancer-specific mortality as a result of mammography screening. Broken down by age groups, mammography screening was associated with a 15% decrease in breast cancer mortality for women in their 40s and 32% for women in their 60s.

So that’s the good news. The bad news is (according to the article) that the risk of a false positive diagnosis was high… For a 40- or 50- year old woman undergoing 10 years of annual mammograms, the risk of false positive results over that period of time was about 61% and for women aged 66 to 74 who had annual mammograms over 10 years, the false-positive rate was 49.7%. (A false positive result raises suspicion for breast cancer and leads to further testing, additional imaging and/or biopsy but does not result in a cancer diagnosis.) The authors also considered the statistics from published trials on overdiagnosis. (I know this term is difficult to understand when we are discussing breast cancer but basically it means that the type of tumor that was detected, such as DCIS, will not eventually lead to invasive or life-threatening disease and/or the patient will die of something else and not from her breast tumor.)

In order to better convey the context of these statistics, the authors discuss lifetime risk of breast cancer as well as risk at any age. For a woman in United States, the average lifetime risk of breast cancer is 12.3%. However, the 10 year risk of invasive breast cancer at age 40 is “only” 1.5%, at age 50, it’s 2.2% and at age 60 it is 3.5%. (These numbers may somewhat decrease the concerns for many of us who worry about our breast health risk in the decade to come.) The high 12.3% number represents a risk over an entire lifetime… well into our late 80s or even early 90s.

So how do we look at risk-benefit when it comes to screening mammogram? If dollar cost is the issue, it accounts for almost $8 billion in annual health care expenditures in United States. But for those women whose lives have been saved or who had to undergo lesser procedures in order to treat their breast cancer, national cost is probably not an issue. Therapies have improved and most women diagnosed with breast cancer do not die from the disease, even if their tumors were detected without mammography. However, as pointed out in an editorial in the same JAMA issue “many women diagnosed with late stage disease who were not screened recently wrongly blame themselves, encouraging others not to make the same “mistake”. Others attribute their survival to screening mammogram received even when this is unlikely to be the case.”I hope this doesn’t sound too cavalier. These were statements in the articles and I, like many women and physicians, feel that any deaths from breast cancer are tragic.

So how do you decide if and how often you should get screened? The authors give a a list of pointers that should be considered by each woman when she considers making her mammogram appointment and by her physicians who suggest she get screened, especially at an early, under 50 age.

* Many cancers will be found, but most women diagnosed with breast cancer will survive regardless of whether the cancer was found by a mammogram.

* Some cancers that are found would have never caused problems.

* Often, women are called back for further testing because of an abnormality that is not cancer.

* Mammography decreases the number of women who will die from breast cancer. This benefit is greater for women who are at higher risk for breast cancer based on older age or other risk factors such as family history.

* The number of women whose lives are saved because of mammography varies by age. For every 10,000 women who get regular mammograms for the next 10 years, the number whose lives will be saved because of the mammograms over each age group is approximately

- 5 of 10,000 women aged 40 to 49 years
- 10 of 10,000 women aged 50 to 59 years
- 42 of 10,000 women age 60 to 69 years

* If your breast cancer risk is higher than average, you may benefit more from a mammogram than someone with average risk.

* About half or more of women who have a mammogram yearly for 10 years will have a false positive mammogram and need additional studies. Up to 20% of these women will need a biopsy.

* In some women the mammogram will find an invasive cancer or noninvasive conditions such as DCIS that would never have caused problems. We cannot tell which these are so they will be treated just like other cancers. There is about a 19% chance that the cancer is overdiagnosed and treatment may be unnecessary.

I know this all sounds complicated and makes decisions about screening more difficult. But in the end it really has to do with your values and your personal philosophies regarding healthcare. Do you prefer to do more to insure that a diagnosis of this malignancy be made or do you think less is more and want minimize the risk of a false positive result that could cause anxiety, procedures and cost? I prefer the former but realize that many women don’t.

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:

DENSITY

PERCENT

MAMMOGRAM
SENSITIVITY

RELATIVE RISK CANCER
(compared to average density)

Almost entirely fat:

10 %

88%

-

Scattered densities:

43%

82%

-

Heterogeneously dense

39%

69%

Relative risk 1.2

Extremely dense

8%

62%

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.

This is not just a story about pregnancy woes….it really has to do with the way the American court of opinion can influence the regulation of medication. Many of you will remember the medication Bendectin, which was prescribed years ago to help control gestational nausea and pregnancy. (I took it along with 25 percent of all pregnant women! )

Bendectin was voluntarily withdrawn from the US market by the manufacturer 30 years ago. Nausea and vomiting occurs in 80% of all pregnant women between 6 and12 weeks of gestation. Roughly 1/3 of women who have nausea and vomiting of pregnancy have symptoms that are so severe that the quality of their lives and their pregnancy suffers tremendously. And 1% of pregnant women progress to a condition called hyperemesis gravidrum. Their persistent vomiting causes them to lose more than 5% of their body weight, develop an electrolyte imbalance and severe dehydration. The condition requires hospitalization, IV fluids and significant medication to stop the vomiting.

Bendectin was a medication that combined doxalamine succinate (an antihistamine) and peridoxine hydrochloride (vitamin B6) in one tablet. Between the late 1960s into the 1970s the medical journals began publishing letters reporting an association between Benedictin use and birth defects. (Well actually, at that time a general increase in reports of birth defects appeared as researches published the data that hospitals and medical organizations were releasing as they paid more attention to and recorded birth defects.) Lawsuits claiming that this product was a teratogen causing birth defects first appeared in 1980. And by the time the product was withdrawn in 1983 there were more than 300 pending lawsuits. However, as pointed out in an article in the section ” Prospective” in this week’s New England Journal of Medicine, “Courtroom testimony claiming that Bendectin was a human teratogen was markedly devoid of evidence-based corroboration”. As a result of all these lawsuits, Merrill Dow, the company that made Bendectin, withdrew the product … not because of safety issues, but because of financial concerns. The company’s insurance premiums had risen to $10 million per year which was only 3 million less than their total income from Bendectin sales.

So was Bendectin really a teratogen? In 1979 the FDA issued a talk paper stating that studies in animals as well as several large epidemiologic studies had provided no adequate evidence linking Bendectin to an increase risk of birth defects. Another review of 13 epidemiological studies found no association between Bendectin and elevated risk of birth defects. Data maintained by the birth defect monitoring programs of the CDC found that during the period from 1985 to 1987, (which was after the product was withdrawn) the incidence of birth defects was the same as that seen during the peak time of Bendectin use. There was actually an increase in the number of hospitalizations in the United States for nausea and vomiting of pregnancy in those years. It rose from 7 per 1000 live births to 16 per 1000 live births during the period from 1981 to 1987. So to make a long story short, pregnant women suffered and were more likely to be hospitalized once they did not have access to this drug.

So here’s the good news… Recently, the FDA approved Diclegis. Aside from the fact that it’s very difficult to pronounce or spell, this is a product that has the same combination of doxylamine and pyridoxine that had been marketed as Bendectin. I’m not writing this website as an advertisement for the new drug; I’m simply intrigued by the fact that the story of Bendectin demonstrates how important it is to make clinical decisions on the basis of scientific evidence and not on lawsuits. The FDA’s approval of the “new Bendectin” was based on efficacy and safety data from randomized, placebo-controlled clinical trials and took into account extensive data showing that this product is not teratogenic. Attorney-instigated lawsuits and the fear that they generate for manufacturers, physicians and patients was, in this case, finally superseded.

There are appropriate avenues to assess drugs and then there are litigious-inspired negative headlines. As physicians and patients we should prefer the former.

There are a slew of over-the-counter products in the pharmacy (and supermarket!) isles that are supposed to help or cure itching, irritation and discharge “down there”, and/or make you feel fresh, smell like a garden and keep you dry. So when an article appeared in the Journal Menopause titled, “Over-the-counter treatments and perineal hygiene in postmenopausal women” I both read it and thought I should summarize it on this week’s website.

The authors who are physicians in the Department of Obstetrics and Gynecology at Brown University questioned 114 postmenopausal women, who were seen for routine gynecological care, on their use of over-the-counter (OTC) products. They grouped the products into five major categories: barrier treatments, powders, topical anesthetics, antifungal (yeast) treatments and topical steroids (hydrocortisone). The women were also asked if they douched, took sitz baths, used soaps with perfumes and/or waxed. (I know this is getting somewhat embarrassingly technical but the percentage of women who used the products or did this was surprising.)

Over 50% of the women reported using at least one OTC vulvovaginal treatment in the last three months, including barrier treatments, topical anesthetics, powders and an antifungals. Women often used more than one OTC product during that time. Eight percent reported douching in the last three months. More than 50% of women used pantiliners, pads or some sort of diaper for garment protection. Half of the women were sexually active and of those almost 50% reported using a product for lubrication with intercourse. (Remember these were post menopausal women.)

The authors then emphasized that some OTC products can cause adverse reactions. For example, topical benzocaine, a common ingredient in OTC products marketed for itch relief has been shown to cause severe contact dermatitis (an allergic skin reaction) of the vulva. Likewise absorbent products for garment protection can have ingredients such as rosins, colophony and methydibromoglutsronitril (I have no idea what these are!) which can also cause severe contact vulvitis.

Besides products that cause allergic reactions other products have been shown to cause harm. The use of talcum powder is associated with an increased risk of gynecologic malignancies. Talcum powder is widely available in United States and they found that 22.8% of postmenopausal women reported talcum powder use within the last three months. Another practice that has been shown to cause harm is douching. Douching leads to a disturbance of the normal vaginal flora and an increase in bacteria that don’t like oxygen (anaerobes). When they multiply, a condition called bacterial vaginosis occurs, which can then cause irritation, discharge and odor. This is the opposite of the freshness that douching advertisements promote…. The authors found that 8% of post menopausal women reporting douching within the last three months. Other medical literature has shown that 25 to 70% of reproductive age women report douching on a regular basis.

So what does this all mean? If you are using any of these products and start to feel irritated the first thing to do is stop. And certainly don’t douche or use talcum powder to ” freshen up”. If irritation or discharge continues make sure you tell your physician about your OTC perineal habits. Contact dermatitis is the most common cause of chronic vaginitis. The products you use to help you feel that all is right ” down there” may be making it wrong.

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.

Most of you know about amniocentesis and chorionic villus sampling (CVS…not the drugstore!). A quick review: Since the 1960s women over 35 were told that they had an increased risk of having a child with the extra chromosomal that caused Down’s syndrome and that once pregnant this could be detected with amniocentesis. (A procedure in which amniotic fluid is withdrawn with a long needle inserted through the abdominal wall into the uterus at around 16 week’s gestation. Cells from the fluid are then cultured for 10 to 14 days and stained so that the chromosomes can be counted.) CVS procedure was developed in the 80s. (Cells obtained from the edge of the placenta are identical to those of the fetus. They can be obtained with an instrument inserted through the cervix under ultrasound guidance as early as 10 week’s gestation.They are then immediately stained and their chromosomes are counted and analyzed and in most cases allow for an early diagnosis.)

Noninvasive prenatal testing was developed in the 1970s when the first ultrasounds produced two dimensional images of the fetus in the uterus. Initially ultrasound was used for measurements to determine gestational age and later to view anatomy. And as ultrasound developed, a maternal blood test of a protein called alpha-fetoprotein was found to be associated with open neural- tube defects (spina bifida) and other fetal abnormalities if high and if low, Down’s syndrome. As these noninvasive ultrasounds and blood tests became more less expensive, “blessed” and backed by the major medical organizations, they were offered to pregnant women of all ages. Meanwhile, back at the ultrasound, engineers and radiologists improved the imaging devices, went to real time and three dimensions. This allowed physicians and their patients to view fetal cardiac, neural and skeletal development. The perinatologists also found that ultrasound in early pregnancy allowed them to measure the thickness of the tissue at the nape of the neck (nuchal fold) which could then help foretell fetal chromosomal abnormalities. This was added to the armamentarium of noninvasive prenatal testing.

This long introduction to prenatal diagnosis is my way of getting to an article in the New England Journal of Medicine that appeared in the February 27 issue. It basically is a “We have come a long way baby” introduction to a new noninvasive test using maternal blood to access fetal chromosomes. The actual fetal DNA is analyzed from small fragments of cell-freeDNA (cfDNA) that are shed from the placenta into the maternal circulation. The amount of fetal cfDNA in maternal blood increases rapidly at the onset of embryo development so that it represents about 10% of free DNA in maternal blood during the first and second trimesters. Currently a method called massive parallel sequencing (or if you care to know, next generation sequencing) which reads millions of sequences along the length of each chromosome can be used to determine abnormal fetal chromosome number (termed aneuploidy) in maternal blood.

The current study was carried out at 21 centers in the United States. Blood was collected from women with single pregnancies who were undergoing the standard screening of blood biochemical methods (which included a few more than outlined above) with or without ultrasound measurement of the nuchal fold in the fetus. The researchers compared rates of detection of certain extra chromosomes (that is three instead of two) in trisomy 21 or Down syndrome and trisomy 18 between the fetal cfDNA test and traditional tests. They then examined birth outcomes or chromosomal counts on terminated pregnancies. The series included 1914 women. Fetal cfDNA testing detected all cases of aneuploidy and the false positive rate was significantly lower than detection with standard screening.

A separate editorial in the journal predicts that a negative result in this type of maternal blood screening will help prevent the need for invasive testing. They also state that a positive test is not enough for a final prediction that the pregnancy is abnormal. Women who have a positive fetal cfDNA test will need amniocentesis or CVS to ascertain if the fetus has a triple chromosome 18 or 21. But once this test becomes less expensive, is studied in a larger group of “low risk” women and goes mainstream, the majority of pregnant women may be assured with just this blood test that, if negative, they will not have to undergo further invasive testing.

I know this was a long (and for many uninteresting) analysis of advances in prenatal testing. But for those obstetricians who spent most of their careers helping women ensure the chromosomal health of their pregnancies, and for their future patients, this is an exciting advance.

As physicians who treat women over 40, we’ve always assumed that estrogen is great for our bones. Studies have shown that there is rapid bone loss (as much as 10% in the first three years) after menopause! And even if estrogen is given initially, once it is discontinued, rapid bone loss occurs, again as much as 5 to 6% after one year. But it is not the loss seen on bone mineral density scans that worries us, it’s the increase in fracture rates. In the Million Woman Study in England (Guess how many women participated?), those on estrogen or estrogen and progestin had a 30% reduction in fractures; among those who discontinued their hormones, the fracture rate was similar to that of the untreated population within one year. In a study of a large group in California, the number of women taking estrogen declined from 85% to 18% between 2002 and 2007 as a result of the publication of the initial data from the Women’s Health Initiative (WHI) which scared women and their physicians with evidence that in older women Premarin and Provera increased breast cancer risk. And lo and behold, fracture rates in this population increased by 50%. With all this in mind I was somewhat surprised by a recent article in the journal Menopause published by the North American Menopause Society.

The authors again used the WHI study to look at the impact of hormones as well as calcium and vitamin D on osteoporosis. Several years after starting hormone therapy, half the women in the study who were on Premarin alone or Premarin and Provera were randomized to either a group that took 1200 mg of elemental calcium and 400 units of vitamin D daily or a group that did not. Bone status was then followed for the women on hormones taking no supplements, women taking supplements but no hormones and women in the control group who took neither. A total of 16,089 women participated in this arm of the study.

The researchers looked at the fracture rates and bone density in all of the groups. They found that the effect of hormone therapy on hip fracture was significantly stronger among women who were assigned to also take calcium and vitamin D. In short, calcium and vitamin D supplementation significantly reduced the incidence of hip fractures beyond hormone therapy alone. The beneficial effect of hormone therapy on the bones was evident at a level of 1200 mg of calcium use and continued to increase at even higher doses. Similarly, the benefit of hormone therapy continued to increase at levels higher than 400 units of vitamin D. But the supplements alone were not effective…this study and others that were published based on WHI data have shown no overall significant fracture prevention when calcium and vitamin D supplements were taken alone. The conclusion: although taking calcium and vitamin D may not be statistically effective for fracture prevention but they may have a significant effect when used with hormone therapy. And for hormone therapy to “work” to prevent fracture, these supplements should be added.

In an accompanying editorial, the authors suggest that 1200 mg calcium (by diet and/or supplements) and 600 to 800 units of vitamin D be taken with hormone therapy in order to achieve the hormonal benefit of reduction in risk of osteoporotic fractures.

Bottom line: Hormone therapy alone is not enough for osteoporosis prevention, nor are supplements… But together they are effective. So if you use hormone therapy make sure to add calcium and vitamin D.

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.

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