Women's Health Newsletters 6/17/01- 7/22/01
****** Woman's Diagnostic Cyber Newsletter ******* June 17, 2001 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ This week from Woman's Diagnostic Cyber ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1. What is obesity? 2. Recurrent yeast infections - A theory of cause 3. Reader submitted Q&A - HRT and breast cancer 4. Migraines and hormones - What you should know 5. Seniors are also at risk for HIV 6. Health tip to share - Wolff-Parkinson-White Syndrome 7. Humor is healthy Spread the word! Send a copy of this newsletter to someone you know. Note: Some of the long URLs may not wrap as a hyperlink and you may need to cut and paste. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1. What is obesity? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ The term 'obesity' hits us right in the midsection -- or elsewhere. It is defined as a body mass index (BMI) of 30 or higher. In other words, at various heights for women, the following weights or higher would be classified as obesity: height weight lbs 5'0" 153 5'1" 158 5'2" 164 5'3" 169 5'4" 174 5'5" 180 5'6" 186 5'7" 191 5'8" 197 5'9" 203 5'10" 209 5'11" 215 6'0" 221 Unfortunately no other recipe than 'more calories in than calories out' leads to obesity. Therefore the primary treatment is a long term 'more calories spent than are taken in'. The main conditions known to promote obesity are: genetics - with one or both obese parents, your chances increase to 25-30% medications - tricyclic antidepressants, steroids including DepoProvera aging - we all lose muscle mass as we age and our calorie requirement goes down hypothyroidism - about 2% of obesity is explained by low thyroid function. Inactivity - It is easy with sedentary activity to expend 500 less calories a day. If eating goes on the same rate as before this decreased activity, a weight gain of almost 50 pounds a year is possible. For a list of suggestions as to how you might take off some weight, see this article below at Mayoclinic.com. Also see our past article on the health consequences of an elevated BMI. Guidelines for Healthy Weight ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 2. Recurrent yeast infections - A theory of cause ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Recurrent yeast infections can be difficult to treat. One of the big questions that faces physicians is whether a recurrent yeast infection represents reinfection after successful treatment or whether it represents reemergence of the yeast overgrowth from an infection that was not completely treated. The following study tries to answer that question by looking at the specific strains of yeast that could be cultured after an infection. Yeast have many different strains that can be measured by their DNA configurations and other properties. In a series of 22 women who had recurrent vaginal yeast infections the investigators looked at whether the recurrent infection had a different strain of yeast than the previously treated one. They found that the same strain of yeast was responsible for the initial and recurrent episode in 17 out of 22 women (77%). The other 5 women had different strains or a different species of yeast growing. This implies that in about 3/4's of the cases, perhaps we need to have longer courses of treatment because the yeast does not seem to be fully eradicated. The other 25 percent of cases represent a vaginal environment that is simply just too conductive to growing yeast and the environment needs to be changed. For those of you who have recurrent yeast infections, you might ask you doctor about a regimen of 100-150 mg of Diflucan once a week. That has worked well in our practice although it is not a common way to prescribe for recurrent yeast. Remember also to change the environment by taking lactobacillus acidophilus as a separate or a food supplement. Recurrent yeast infections ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 3. Reader submitted Q&A - HRT and breast cancer ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ "What are the risks of cancer when taking Fem-HRT? I am 48 and my Dr. put me on it a year ago. I go on it for awhile then read about HRT and quit taking it for fear of cancer. But it does help with severe hot flashes." "My mother and grandmother never took HRT. They both had strokes. My mom had throat cancer. I worry about how safe Fem-HRT is." - T J. This is a question the doctor cannot answer for you; you have to answer it for yourself. Hormone replacement therapy (HRT) has been used for decades and there is a good body of knowledge about the risks and benefits of it. Fem-HRT(R) is a fairly new combination of estrogen and progestin but both components have been used extensively and there is no reason to think that it will react or produce differently than other more extensively studied HRT. Estrogens have benefits and risks. You know the short term benefits of the hot flash reduction and counteraction of vaginal dryness. The long term benefits are the protection of the new occurrence of heart disease and osteoporosis. There also appears to be a 50% reduction of colon cancer and Alzheimer's disease in women who are on long term HRT. Menopause The main concern most women have is the possibility of a slightly higher incidence of a well-differentiated breast cancer. The risk ratio for developing breast cancer may be 1.3-1.4 to 1. There are other factors that are more important for breast cancer risk than taking HRT. The Gail model is the most commonly associated risk assessment tool to predict breast cancer risk and the factors it uses are: age race number of 1st degree relatives with breast cancer age at first menstrual period age at first delivery of a child number of previous breast biopsies previous history of atypical ductal hyperplasia on breast biopsy past history of ductal carcinoma in situ or lobular carcinoma in situ These above factors are much more important than whether you take HRT. If you do have some of these risk factors, use the Gail model to calculate your risk. If you are at least 35 yrs of age with a 5- year predicted breast cancer risk of 1.67% or more, as calculated by the Gail model, then you would be considered at high risk and I would not suggest taking HRT. Am I at risk for breast cancer? Risk model software If you are at high risk or are just concerned enough that you do not wish to take HRT, then you might want to consider taking phytoestrogens such as that found in soy or red clover. It is only about 50% as effective in preventing hot flashes and preventing osteoporosis as estrogens but it is better than not taking anything. Promensil(R) which is available at health food stores and many pharmacies is my choice (taking 40 mg of isoflavones a day). If you still have hot flashes, you may just need to manage them conservatively. The Non Hormonal Treatment of Hot Flashes To summarize, this is an agonizing question for all women. Try to read as much as you can and keep an open mind. Discuss your specific concerns with your doctor and when your questions seem to be answered as best they can be, make your choice. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 4. Migraines and hormones - What you should know ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ In women who have migraine headaches, the question arises as to whether hormones will make the headaches worse or if a woman who has migraines is at risk for strokes from hormones. Traditionally all types or forms of migraine headaches have been lumped together when assessing for the risk of ischemic stroke. This article below represents a current neurological opinion about the risk of stroke in women with migraines and whether or not they take hormones including oral contraceptives (OCs) or postmenopausal estrogen replacement (HRT) therapy. The opinion is based on how the International Headache Society Task Force assessed the efficacy of treatment of women with OCs or HRT. It concludes that women who do not have an aura with their migraines can take oral contraceptives safely. If they do have migraines with aura or have other risk factors for stroke (e.g., previous stroke or ischemic heart disease) then they are at risk if they take OCs. They also conclude that postmenopausal hormone replacement therapy neither increases nor decreases stroke risk in women with migraines whether or not they have auras associated with the headache. An aura with a migraine is an unusual visual episode of "seeing stars" or spots in the eyes, seeing wavy or jagged lines or color patterns. The visual disturbance usually precedes or coincides with the headache; rarely it can take place even without the headache. Migraines and hormones - What you should know ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 5. Seniors are also at risk for HIV ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ "`When we were going together, I always used condoms,' she said of her second husband, ... who died seven years ago. `But when we got married I felt, well, husband and wife, I didn't think he could've had the (HIV) virus.'" Doctors forget to counsel seniors about safe sex. The Center for Disease Control (CDC) says that AIDs is growing twice as fast among individuals over 50 years of age as among those under 50 years old. The suspected reason for this is basically because those under 50 are probably using more precautions in sexual relationships than are those older individuals. There also seems to be a delay in diagnosis of AIDs in more elderly individuals. This may be because seniors have more medical conditions that are difficult to differentiate from the early symptoms of AIDs. Symptoms such as chronic fever, sore throat or rashes may not trigger the investigation for AIDs in seniors as it does in younger individuals. With the more frequent use of Viagra and a refractoriness to using condoms by elderly men, AIDs may continue to rise in frequency unless physicians start to remind seniors about using precautions and seniors themselves begin to realize it can happen to them. Seniors are also at risk for HIV ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 6. Health tip to share - Wolff-Parkinson-White Syndrome ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ "I have Wolff-Parkinson-White syndrome and my tip on how to live with this is by taking my meds and saying to myself 'it could always be a lot worse'" :) Deborah (editor note - Wolff-Parkinson-White syndrome is a condition in which a rapid heart rate is caused by abnormal electrical pathways in the heart.) If you have discovered ways of coping with a disease or condition and it works for you, please share it with us: Health tip suggestion form ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 7. Humor is healthy ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Unity Candles I was escorted to a wedding by my twenty-four-year-old bachelor son. He appeared unaffected by the ceremony until the bride and groom lighted a single candle with their candles and then blew out their own. With that he brightened and whispered, "I've never seen that done before." I whispered back, "You know what it means, don't you?" His response: "No more old flames?" ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ That's it for this time. Your BACKUPMD on the Net. Rick Frederick R. Jelovsek MD ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
****** Woman's Diagnostic Cyber Newsletter ******* June 24, 2001 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ This week from Woman's Diagnostic Cyber ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1. Bone density testing 2. Weight loss obsession 3. Reader submitted Q&A - Rectocele after hysterectomy 4. Laparoscopic surgery for uterine prolapse 5. Cancer in patients with hidradenitis suppurativa 6. Health tip to share - Breathing for relaxation 7. Humor is healthy Spread the word! Send a copy of this newsletter to someone you know. Note: Some of the long URLs may not wrap as a hyperlink and you may need to cut and paste. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1. Bone density testing ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Unfortunately many insurance plans do not pay for bone mineral density testing unless you already have a diagnosis of osteoporosis. This makes it very difficult to get an initial test to diagnose whether you are at risk or not. The 'gold standard' test for osteoporosis is dual energy X-ray absorptiometry (DEXA) scan. It measures the bone mass in the spine and hips which are very important for predicting hip fractures and spinal vertebrae compression fractures. It also estimates total body bone mass. Unfortunately a DEXA scan is expensive so other less costly devices have been developed in order to estimate bone loss. These devices are explained in the article at mayoclinic.com. They are made to measure the heel, finger or wrist bone density. Those joints or bones may or may not reflect the bone density in the critical areas of the hip or the spine, so if they are used for screening and the results are abnormal, then the DEXA scan must be performed for confirmation as to whether there is a problem at the hips or in the spine. Results are given in T-scores. Those T-scores measure how far your measurements are away from the average measurements of other women your age. If you have a score of -2.5 or more (eg., -2.6, - 3.0) then that joint is at fracture risk. If the score is -1.0 or less (eg., -0.5 or +1.5) then you do not have osteoporosis in that joint. There is a quite a variability among joints so while one hip could be bad, the other may be better than the average woman's. The scan is repeated after a year's treatment to make sure bone loss is arrested or even some bone is restored. Medicare now pays for screening scans even if you do not yet have osteoporosis but if you meet the following conditions: If you are postmenopausal and at risk of osteoporosis If you have a condition called primary hyperparathyroidism If you have certain spinal abnormalities that might indicate a fracture If you are on long-term corticosteroid therapy, such as prednisone ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 2. Weight loss obsession ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ We have written about obesity before as a health risk and it certainly is. Even when women are not significantly overweight, many are still obsessive about dieting to the extent of being willing to submit their bodies at any cost to the latest and greatest weight loss plan. The article below at personalmd.com points out a survey where, if given a choice between losing 20 lbs permanently or living to 90 years of age, over half of the women chose the weight loss. Thus it is not for health reasons that most women desperately want to lose weight. This trait has made women very susceptible to the marketing efforts of any company trying to sell a painless weight loss solution. With the last fen-phen diet debacle, women literally lost their lives trying to diet. It is this obsession with weight loss that makes women especially prone to unproven or poorly tested diet regimens. A woman needs to know the extent to which she is targeted by companies trying to make money. The companies hype the need for weight loss and quickly offer to sell you the solution. The moral of the story is not to be so gullible for every new diet pill. To lose that gullibility, a woman has to give up the obsession for weight loss and just focus on lifelong healthy eating habits. Don't let the marketers con you. Women's weight loss obsession ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 3. Reader submitted Q&A - Rectocele after hysterectomy ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ "Is it normal or usual to develop a rectocele after a vaginal hysterectomy? Is surgery the only way to repair/reverse the condition?" "I am 56 and have had 4 children delivered vaginally; menopause 2 years prior to surgery; otherwise healthy." - J.A.E. It is not normal to develop a rectocele right after hysterectomy but it also is not unusual. The most common reason for it to occur within a few months is that the rectocele was not recognized prior to surgery and thus was not repaired at the time of the vaginal hysterectomy. It may not have been symptomatic (difficulty with defecation) for you before the hysterectomy because the uterus and cervix which had dropped down somewhat could have been preventing the rectum from protruding very much and causing symptoms. Another reason for rectocele occurrence closely related to vaginal hysterectomy is lack of support of the vaginal vault from the surgery itself. If the ligaments from the sacral bone that are primary support of the uterus and vagina are not well attached to end of the vagina, or if with coughing or straining after surgery those sutures are broken or pull out of the tissue, then the end of the vagina becomes unsupported. The vaginal end (like the end of a sock), which is now the superior portion of support of the rectovaginal wall, will drop down with straining and allow the posterior vaginal wall (rectocele) to protrude from the vagina. Finally, with any vaginal surgery and repair, the weak points are reinforced and made stronger. Any subsequent intraabdominal straining attacks the weakest areas which then may quickly develop herniation. Water behind a storm dyke will always find the weakest area to break through and that can happen in the pelvis. There may not have been any recognizable weakness at the time of surgery but as soon as the weakest areas were supported, the rectocele quickly developed in an unrepaired weak spot. This can happen especially where you had an episiotomy or vaginal tearing with any of your 4 vaginal deliveries. That weakness was never evident until you became menopausal and the mesh of blood vessels around the vagina (which gave additional support) has shrunk and gone away. If you have a rectocele now (you did not mention if you did and how soon it developed), then the main consideration is what other pelvic support defects are still present. You do not want to have a rectocele surgically repaired and then a few years later find out you need bladder support surgery and or vaginal vault suspension. Be sure that your doctor is well versed with these different support defects. Remember that the main reason gynecologic surgeons are able to remove the uterus vaginally is because of pelvic support weakness. A woman who has not delivered children vaginally will usually have to have an abdominal hysterectomy or a laparoscopic assisted hysterectomy and is much less likely to develop these support problems because they did not have weakening of the tissue in the first place. Muscle exercises such as Kegel's do not usually help a rectocele. They can help stress incontinence and anterior wall bladder support but not posterior wall rectal support. A pessary, a silicone object placed in the vagina, can give support to the rectal wall and can be effective in relieving some symptoms, but most women of your age do not choose to use them for long term treatment. Unless your health is bad, you will probably want to have surgical repair so you can remain physically active for several decades. Cystocele, rectocele and pelvic support surgery ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 4. Laparoscopic surgery for uterine prolapse ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Many women ask if uterine prolapse can be fixed without having a hysterectomy. While vaginal hysterectomy has been the most common treatment, uterine prolapse can be treated with a hysteropexy, or a suspension of the uterus. In recent years, suspension of the uterus (hysteropexy) has been performed via laparoscopy so it can be done with only several small incisions. It is not as effective as removing the uterus but up until now we have not had good statistics to know how successful it is. The article below followed 43 women prospectively for a year after a laparoscopic hysteropexy. They found that approximately 80% of the procedures were successful at preventing symptoms. Two women even conceived after hysteropexy and delivered by Cesarean section. As long as a woman understands that this surgery is not always successful, it is a very good procedure to fix uterine prolapse. Symptoms of early uterine prolapse, before the uterus/cervix is actually protruding out of the vagina at rest, are pelvic pressure, sometimes low back pain and pain or discomfort with sexual intercourse when the uterus is hit during the thrusting of sex. If you think you may be having symptoms of prolapse, discuss this with your doctor. Laparoscopic surgery for uterine prolapse ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 5. Cancer in patients with hidradenitis suppurativa ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Hidradenitis suppurativa is an infectious condition of the sweat glands of the skin that causes lumps and bacterial abscesses which may drain pus. It is like having several to quite a few boils on the skin very close together. It is very difficult to treat. The most common areas affected are the armpits (axillae) and the vulva although anywhere with sweat glands can be affected. A big question when it affects the vulva is whether or not there is a higher incidence of vulvar cancer in women with hidradenitis of the vulva. The following Swedish study looked at over 2100 people with hidradenitis of all skin locations and determined how many of them had non melanoma skin cancer. They did not just look at cancer of the vulva but rather all skin cancers except the malignant melanomas. They found that those with hidradenitis had a 50% increased risk for any type of cancer and had 4 times increased incidence of skin cancer. Women with hidradenitis of the vulva (or any skin location) need to be examined frequently for possible cancer. Cancer Among Patients With Hidradenitis Suppurativa ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 6. Health tip to share - Breathing for relaxation ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ A helpful technique for relaxing from the stress of everyday life when you only have 5 minutes is "tummy breathing". To do it, let your stomach just below your ribs move out a little as you breathe in, and then go back down when you breathe out. Don't let your chest move when you breathe. Do this softly and gently until it feels like you are breathing into your stomach a little, maybe 5-10 breaths. Once you get used to it. Use this technique to relax for about 5 minutes at a time. (From respire.net) Relax with tummy breathing If you have discovered ways of coping with a disease or condition and it works for you, please share it with us: Health tip suggestion form ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 7. Humor is healthy ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ "Vacation Term Translation" In case any of you are still thinking about picking a vacation spot, be aware of the following advertising lingo... Old world charm .................... No bath Tropical ........................... Rainy Majestic setting ................... A long way from town Options galore ..................... Nothing is included in the itinerary Secluded hideaway .................. Impossible to find or get to Pre-registered rooms ............... Already occupied Explore on your own ................ Pay for it yourself Knowledgeable trip hosts ........... They've flown in an airplane before No extra fees ...................... No extras Nominal fee ........................ Outrageous charge Standard............................ Sub-standard Deluxe ............................. Standard Superior ........................... One free shower cap All the amenities .................. Two free shower caps Plush .............................. Top and bottom sheets Gentle breezes ..................... Occasional Gale-force winds Light and airy ..................... No air conditioning Picturesque ........................ Theme park nearby Open bar ........................... Free ice cubes ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ That's it for this time. Your BACKUPMD on the Net. Rick Frederick R. Jelovsek MD ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
****** Woman's Diagnostic Cyber Newsletter ******* July 1, 2001 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ This week from Woman's Diagnostic Cyber ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1. Knee injury to anterior cruciate ligament 2. What is dysplasia? 3. Reader submitted Q&A-Constant menstrual bleeding 4. Endometrial hyperplasia rate of progression 5. Condom effectiveness in preventing herpes 6. Health tip to share - No BHT for herpes 7. Humor is healthy Spread the word! Send a copy of this newsletter to someone you know. Note: Some of the long URLs may not wrap as a hyperlink and you may need to cut and paste. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1. Knee injury to anterior cruciate ligament ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Injury to the anterior cruciate ligament (ACL) of the knee is a somewhat frequent sports injury. You do not need to be a competitive athlete to injure it, however. It can be injured from a slip-and- fall, a sudden twisting motion, a hyper extension injury in which the foot slips forward and the knee goes backward or even the opposite in which the knee goes suddenly forward while the foot goes backward. Characteristically one hears a loud "pop" sound when the ligament tears. Women get torn ACL ligaments much more frequently than men. In fact a recent study suggests that women may tear the ligament more often at mid menstrual cycle during ovulation than at other times. No one is sure of why there is a gender difference in frequency of a torn ACL. The ligament is does not heal after it is torn. All that can be done is to strengthen the muscles surrounding the knee to keep the joint stable so the main calf/shin bone (tibia) does not move excessively across the main thigh bone (femur). You can wear a knee brace to aid in stability of the joint during any fitness activities. You may need to alter your usual sports and leisure or daily living activities so that the joint is not reinjured. It may take years before the pain finally leaves completely if you do not keep reinjuring the knee. Non surgical treatment with physical therapy, a brace and altering daily activity is usually the first choice of treatment but surgery can also be an option. The ligament cannot be repaired but it can be replaced. Since surgery can have complications of permanent pain or continued joint instability, it should not be undertaken lightly. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 2. What is dysplasia? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Dysplasia is an abnormal growth of the skin cells of the cervix, vagina or vulva. The nucleus of the cell enlarges and the whole cell becomes more active. Dysplasia is not cancer but it is felt that dysplasia cells are on a growth pattern in which they can turn into a cancer over time. When the cells get to a point where they are so active they are reproducing faster than they are dying off, the extra cells grow into normal tissue and become an invasive cancer. No one knows for sure what causes these cells to become so actively growing but it is strongly suspected that certain strains of human papilloma virus (HPV) cause or promote these changes. The Pap smear picks up these nuclear activity changes but in early phases it can not always distinguish between inflammatory or irritation changes. These Paps are classified as atypical squamous cells of undetermined significance (ASCUS) or mild dysplasia. Much work is going on with HPV typing of abnormal Pap smears (The Digene Hybrid Capture(R) HPV test) to try to tell if the particular strain of HPV that is associated with the abnormal Pap is one of the "high risk" strains of HPV known to be associated with cancer. In theory if the HPV is a high risk type, doctors might need to be more aggressive in treating the tissue involved rather than waiting for the Pap smear to get worse before treating. Conversely, if the virus associated with an abnormal Pap is a low risk (for cancer) type, then screening with repeat smears can be put off longer. In practice, it becomes very expensive to do both tests and the long term outcome is not much different. Some studies have even suggested that HPV typing smears may be cost effective in replacing Pap smears for the detection of moderate and severe dysplasia to prevent cancers of the cervix. We are not at that point yet but this test bears watching. Dysplasia 101 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 3. Reader submitted Q&A - Constant menstrual bleeding ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ "I have had nearly constant menstrual-type bleeding for the last two years. I have been diagnosed in the past with uterine cysts and cervical dysplasia. Even though I am very concerned about the bleeding, my gynecologist is not. Should I get a second opinion?" "I am 39, and have had regular periods from age 14 through 36. After the birth of my child (at 36), periods have been very long (15-20 days) or I have intermittent bleeding all month. I had one laparoscopy after a "mass" was found, but nothing was removed (it had disappeared)." - Gyl Two years of constant bleeding is about 22 months too long. If your doctor has not performed any investigation into the cause of the bleeding then you should definitely seek a second opinion. You did not mention being on any hormone therapy so at age 39, the most likely cause of this type of bleeding is either polyps in the uterus or fibroids. Some type of diagnostic testing needs to be performed such as an ultrasound or saline sonohysterogram or even going straight to a hysteroscopy and D&C. See our article below for an explanation of what is involved in diagnosing and treating this prolonged bleeding: Constant Menstrual Bleeding at Age 39 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 4. Endometrial hyperplasia rate of progression ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Hyperplasia of the lining of the uterus (endometrium) is not the same as dysplasia of the cervix. It is not associated with HPV or any other virus as far as we know. However, it sometimes can be considered a premalignant lesion just like dysplasia. This is especially true if the hyperplasia has areas in it microscopically that the pathologist considers "atypical". Then there is chance that this tissue, if left alone for a time, could go on to form an invasive cancer of the uterus (endometrium). When a woman has abnormal uterine bleeding, especially after the age of 35 or 40, and the doctor performs and endometrial biopsy or D&C and the tissue returns with hyperplasia, then there may be a concern about this being a premalignant lesion. One question we are commonly asked is "what is the rate that these hyperplasias can go on to turn into a cancer of the uterus?". There is not good data to say precisely how worrisome this is. A recent Japanese study looked at 77 women with endometrial hyperplasia and followed them 3 years without any surgery other than doing a total curettage every 12 months for 3 years. They looked at how often the lesion progressed to cancer and how often it just regressed to normal on its own. They classified the hyperplasias into 4 grades: simple hyperplasia without atypia (SH) complex hyperplasia without atypia (CH) simple hyperplasia with atypia (SHA) complex hyperplasia with atypia (CHA) They had the following findings for progression to cancer and regression to normal: Progression Regression to Cancer to normal SH 0% 79% CH 0% 94% SHA 0% 100% CHA 9% 55% Older studies indicate that any hyperplasia with atypia can progress to cancer although complex hyperplasia with atypia does so more often (up to 20%). The bottom line is that any endometrial hyperplasia with atypia can go on to become cancerous and should be monitored closely, but the others can be followed with just periodic D&C (not just endometrial biopsy) rather than having to have a hysterectomy. Endometrial hyperplasia progression ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 5. Condom effectiveness in preventing herpes ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Herpes virus, type 2 (HSV-2), that infects the vulva in women and penile skin in men, is for the most part a sexually transmitted disease (STD). It is estimated that over 22% of the adult population has been infected with HSV-2. While condom use is recommended to prevent transmission of any STD, we are not sure how well condoms work to prevent this. Women may get the active lesions on the vulvar area where a condom will not be protective. This study below in the Journal of the American Medical Association (JAMA) looked at couples in which one person was infected with HSV-2 while the other one was not, as measured by blood antibodies. They followed 528 couples over about 30 months and measured whether the HSV-2 free partner contracted herpes or not. The methods they used to try to reduce transmission were encouragement of everytime condom use and decreasing the frequency of sexual intercourse when one's partner had an active herpes lesion. They found: Only 10% of the women and 2% of the men newly contracted HSV-2 The rate of infection transmission with these methods was approximately 1/1000 sex acts. Younger partners and partners that were positive for both HSV-1 (cold sore herpes) and HSV-2 had slightly higher transmission rates. Condom use less than 25% of sexual acts was not protective for women at all. Therefore, while not perfect, condom use can significantly reduce the transmission of HSV-2. Condom effectiveness in preventing herpes transmission ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 6. Health tip to share - No BHT for herpes ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ There has been a resurgence in interest in using butylated hydroxytoluene (BHT) as a treatment for genital herpes ulcers due to the resurrection of some old articles in the Web. This is based on studies about 15 years ago and topical BHT was shown not to be significantly effective. Oral BHT has also been used but it has liver toxicity and a small margin of safety in comparison with lethal doses in animals. For that reason it is NOT recommended. You would be better off using L-lysine (1000 mg three times a day) which has been shown to reduce herpes outbreaks. - FRJ Herpes and topical BHT L-Lysine for recurrent herpes If you have discovered ways of coping with a disease or condition and it works for you, please share it with us: /healthtip.htm Health tip suggestion form ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 7. Humor is healthy ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Mother was having a hard time getting her son to go to school in the morning. "Nobody in school likes me," he complained. "The teachers don't like me, the kids don't like me, the superintendent wants to transfer me, the bus drivers hate me, the school board wants me to drop out, and the custodians have it in for me. I don't want to go to school." "But you have to go to school," said his mother sternly. "You're healthy, you have a lot to learn, you have something to offer others, you are a leader. And besides, you are 45 years old and you are the 'Principal'." ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ That's it for this time. Your BACKUPMD on the Net. Rick Frederick R. Jelovsek MD ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
****** Woman's Diagnostic Cyber Newsletter ******* July 8, 2001 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ This week from Woman's Diagnostic Cyber ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1. Postmenopausal ERT use reduces cataracts 2. Marijuana chemicals for chemotherapy nausea 3. Reader submitted Q&A - It hurts during sex 4. How risky is vaginal birth after Caesarean (VBAC) 5. Cholesterol Challenge - low cost testing 6. Health tip to share - Diet and blood pressure 7. Humor is healthy Spread the word! Send a copy of this newsletter to someone you know. Note: Some of the long URLs may not wrap as a hyperlink and you may need to cut and paste. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1. Postmenopausal ERT use reduces cataracts ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Estrogen replacement (ERT) during menopause has previously been associated with a reduced incidence of an eye disease called macular degeneration that can lead to blindness, However, there have not been consistent findings on whether ERT reduces clouding of the lens of the eye which results in cataracts and extremely poor vision if not blindness. This study in the Archives of Internal Medicine looked at surviving members of the original subjects of the Framingham Heart Study who also participated in the Framingham Eye Study (1986- 1989). It included 529 women aged 66 to 93 years and looked at their estrogen use versus how much clouding of the eye lens they experienced. It also looked at whether they had undergone surgical versus natural menopause. Basically the study found that estrogen use of 10 years or more resulted in a 60% reduction of nuclear lens opacities. Also, women who underwent natural menopause had a lower incidence of opacities than women who had surgical menopause. Their main conclusion was that "reduction in the risk of lens opacities may be an additional benefit of postmenopausal estrogen use." ERT Use, Type of Menopause, and Lens Opacities ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 2. Marijuana chemicals for chemotherapy nausea ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ You may or may not have been following the recent push to have marijuana or its chemical components legalized for certain medical uses. The main indication cited is to treat the severe nausea and vomiting that some cancer chemotherapy treatments cause. A review article in the British Medical Journal looked at all of the high quality scientific studies that investigated how effective the chemical components of marijuana, called cannabinoids, are at reducing nausea and vomiting from chemotherapy compared to traditional prescription medications. Non of the studies looked at just smoking marijuana but rather all of them looked at either natural or synthetic extracts of the chemicals in marijuana that are know to be the active agents for nausea. Those extracts were given either orally or by intramuscular injection. The summation of the 30 randomized studies was that these components of marijuana were slightly more effective than traditional medications, patients more often preferred the cannabinoids as treatment, but they also had a higher discontinuance rate because of adverse effects. The cannabinoids produced more beneficial side effects such as a "high", sedation, and /or euphoria, but they also produced more harmful side effects such as dizziness, feeling awful or depression, hallucinations, paranoia and hypotension. The authors felt that despite some advantages of the cannabinoids for treatment of cancer chemotherapy induced nausea and vomiting, the potentially serious side effects were likely to limit their widespread use if such treatments were made legal and widespread. Cannabinoids for chemotherapy induced nausea and vomiting ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 3. Reader submitted Q&A - It hurts during sex ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ "I feel pain when having intercourse, I also feel pain, just before and during orgasm, can you please tell me what is causing this. Sometimes it is so sore that I lose the desire to have sex. Sometimes it is also difficult for me to reach orgasm, please let me know if you can help me." "I am 21 years old, and I also suffer from constant bleeding, I've been on the Depo for nearly 5 or 6 years and I still have spotting all the time, the doctors can't help me". C. In order to help you, we first need to determine the original cause of the pain and to what degree you are having an involuntary reaction to fear of having pain each time you have sex. If we can then make sure the original cause of the pain is treated as best as possible, what remains is the body's reaction to the fear of pain which in turn causes vaginal muscle spasms that cause a secondary pain. This fear of pain may be conscious or subconscious but is also decreases the ability to have orgasm. It is important to know if the pain started originally at the opening of the vagina (vulva, introitus), the inside of the vagina or only deep inside the pelvis when thrusting moves the pelvic contents such as the cervix, uterus or ovaries. It should be easy for you to tell if the entrance to the vagina (introitus) was the original painful part. It would have hurt just with touching the area with your fingers or a pad rubbing against it. Vaginal pain is a little harder to tell. The pain would be present mostly upon your partner entering the vagina and with the movement back and forth without deep penetration. You probably have some degree of this pain now even though you may not have had it originally. This is because the vaginal muscles now involuntarily contract because of fear of being hurt and the contraction makes the vagina and opening smaller instead of larger which is the normal response. Since you are on DepoProvera (R) which is known to cause vaginal dryness, this could have been or can still be your main problem. Deep pelvic pain is much worse when you are having intercourse and you are on the "top" position. This results in the deepest penile penetration and often moves the pelvic organs. Any pathology such as endometriosis, an ovarian cyst or uterine abnormalities can be painful with deep penetration. If that is your original pain problem then a pelvic exam and possibly a pelvic ultrasound will help clarify the cause. Possible causes of painful sex (dyspareunia) Vulvar entrance congenital abnormalities of the hymen post traumatic scarring of the entrance episiotomy scarring or delivery lacerations post laser treatment of condyloma vulvar hypersensitivity or allergic reactions periorificial (irritant) dermatitis cyclic/recurrent yeast vulvovaginitis cyclic/recurrent bacterial vulvovaginitis vulvar vestibulitis dysesthetic vulvodynia vulvar dermatoses Vaginal lack of estrogen breast feeding menopausal estrogen deficiency use of DepoProvera (R) use of progestin only birth control or ovarian suppression vaginismus (involuntary pelvic muscle contraction) vaginal foreign body Deep endometriosis adenomyosis interstitial cystitis ovarian neoplasm ovary adhered to uterus/vaginal apex prolapse of fallopian tube pelvic adhesions uterine prolapse/descensus uterine retroversion posterior uterine fibroid other uterine neoplasms As you can see the list of possibilities is extensive and treatment must be directed toward the initial cause. Once the initial cause of pain has been treated, any secondary vaginismus due to a learned fear of pain must be treated. This is a slow process and will involve your partner's help in getting the pelvic muscles to relax rather than contract. You will need you doctor's help or that of a professional sex therapist for instructions on manual massage of the vaginal muscles to induce relaxation. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 4. How risky is vaginal birth after Cesarean (VBAC) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Prior to the decade of the 1990's, doctors felt that once a woman had a Cesarean section for delivery of her child, she should always have a Cesarean section for subsequent deliveries. The main concern was that surgery on a uterus can weaken it and with the high intrauterine pressures of labor, the old surgical scar might rupture where it previously had been sewn back up. Uterine rupture carries not only the increased risk of hemorrhage, infection, injury to bladder and possible need for hysterectomy, but also the baby can die if the placental blood supply is disrupted by the rupture before an emergency C-section can be performed. Data in the 70's and 80's seemed to indicate that the rate of uterine rupture for a normal C-section incision (called low transverse) was about 1% or less. It was shown through prospective experimental studies that about 2/3's to 3/4 of women who had a previous C-section could successfully deliver vaginally even after they had had a previous C-section birth. This is called vaginal birth after Cesarean or VBAC. The 1% risk of rupture was felt to be acceptable risk in order to reduce the surgical morbidity of the 65-75% of women who were saved a repeat C-section. Recently some physicians have questioned whether this uterine rupture rate is acceptable at all so studies are trying to look at the comparisons in women who have routine, scheduled repeat Cesarean sections versus those who attempt VBAC. VBAC has a generally lower chance of maternal complications but the one serious complication of uterine rupture is potentially catastrophic for baby and very serious for mother. This study recently reported in the New England Journal of Medicine is not the first such study to look at large numbers of deliveries to determine how often uterine rupture occurs but it also includes different complication rates in the subgroups of women. They found: Group Rate of uterine rupture Repeat C/S, no labor .16% (1.6/1000) Previous C/S spontaneous .52% (5.2/1000) labor Previous C/S induced .77% (7.7/1000) labor (not using prostaglandin) Previous C/S induced 2.45% (24.5/1000) labor using prostaglandin An obvious conclusion is not to induce labor using prostaglandin for women who wish to attempt VBAC. Also, the study shows if the uterus ruptures, there is a 5.5% chance that the baby would die. When you use these numbers to calculate the difference for a mom between choosing repeat C- section versus choosing VBAC, we see that with VBAC there will be a 3.6/1000 (.36%) higher rate of uterine rupture and the chance of the baby dying is about .2/1000 or 1/5000 women who choose VBAC. This is a very small number but it does represent an increase in risk. These are numbers that a woman needs to know when deciding about attempting a vaginal delivery versus a scheduled repeat C-section. Risk of uterine rupture with VBAC ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 5. Cholesterol Challenge - low cost testing ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Occasionally we receive press release announcements that we think are worth passing along: BIOSAFE Medical Technologies, Inc. announced that it will use its new Cholesterol Test System to make FREE cholesterol testing available to all Americans. The BIOSAFE test utilizes a small blood sample (three drops) placed on a special card and collected through a simple nick of a finger. The card is then mailed to BIOSAFE's CLIA Certified Laboratory for testing. The quantitative results, which meet the College of American Pathologists (CAP) guidelines, are then mailed back to you. The BIOSAFE system eliminates the need for a trip to the doctor for a standard blood draw from the arm. The collection kit will be sent free of charge directly to the home without the need for a visit to a doctor or clinic. Recipients of free kits will be asked to pay shipping and handling of $6.95 and will be given the opportunity to upgrade the free test to a full Cholesterol Panel, which includes Total Cholesterol, HDL (good cholesterol), LDL (bad cholesterol), and Triglycerides for an additional $9.95 - a $39.95 value. This FREE Cholesterol Test offer is limited to one test per person, is subject to change without notice, and is NOT available in New York or where prohibited by law. Participants should allow 4-6 weeks for delivery. For more information or to get your free kit, call 1-800-200-TEST (8378). eBioSafe.com ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 6. Health tip to share - Diet and blood pressure ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ "I am 53 yrs old and have had my blood pressure monitored since I was 20, because it fluctuates around 140/90, being lower most of the time. Six months ago I was introduced to hacres.com where I learned about the Hallelujah Diet. I began eating 85% raw fruits and veggies and 15% cooked food, limiting or eliminating white flour, sugar, salt, dairy and meat except for cold water fish. This week my physician announced that my blood pressure was 118/82 and asked me where I learned how to eat this way. I shared the web site with her. She said she would look it up and share the info with other patients." "I also am losing the extra weight I have carried all of my adult life and most of my childhood. It's so simple, but effective!! - Rebecca R. The Hallelujah Diet If you have discovered ways of coping with a disease or condition and it works for you, please share it with us: Health tip suggestion form ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 7. Humor is healthy ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If Men Got Pregnant... Maternity leave would last for two years...with full pay. There'd be a cure for stretch marks. Natural childbirth would become obsolete. Morning sickness would rank as the nation's number one health problem. All methods of birth control would be improved 100 percent effectiveness. Children would be kept in the hospital until they were toilet trained. Men would be EAGER to talk about commitment. They wouldn't think twins were quite so cute. Fathers would demand that their SONS be home from dates by 10:00pm. Men could use THEIR briefcases as diaper bags. They'd have to stop saying, "I'm afraid I'll drop him." Paternity suits would be a line of clothes. They'd stay in bed for the entire nine months. Menus at most restaurants would list ice cream and pickles as an entree. Women would rule the world! ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ That's it for this time. Your BACKUPMD on the Net. Rick Frederick R. Jelovsek MD ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
****** Woman's Diagnostic Cyber Newsletter ******* July 15, 2001 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ This week from Woman's Diagnostic Cyber ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1. Overweight, diabetes and exercise 2. Vestibular pain versus generalized vulvar pain 3. Reader submitted Q&A - Endometrial stripe 4. Calcium robbers 5. Insect bites this summer 6. Health tip to share - Hyland's for bladder 7. Humor is healthy Spread the word! Send a copy of this newsletter to someone you know. Note: Some of the long URLs may not wrap as a hyperlink and you may need to cut and paste. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1. Overweight, diabetes and exercise ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Which comes first, becoming overweight or the adult onset diabetes? Papers from the Nurses Health Study suggest that the weight gain, lack of exercise, and eating of high glycemic foods (simple sugars,carbohydrates) come first and cause the adult onset diabetes. Women who are at low risk for adult onset diabetes (type 2) had a body mass index under 25; performed moderate physical activity for at least a half hour daily; were non smokers, ate foods "high in cereal fiber and polyunsaturated fat and low in transfat and glycemic load; and consumed an average of at least a half a drink of an alcoholic beverage daily." Another interesting characteristic studied is people's inability to accurately recall what they have eaten. Its not that a person consciously lies about their food intake, rather they just do not register all of the unscheduled food (snacks, stress eating) or perhaps report what they think the interviewer wants to hear. The more obese a woman was, the greater chance of under- reporting of caloric intake. Overweight Pivotal Cause of Most Diabetes ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 2. Vestibular pain versus generalized vulvar pain ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Vulvodynia, vulvar burning, vulvar vestibulitis, and vulvar dysesthesia are all confusing terms even for physicians. Pain and the word component, "dynia", mean the same thing. Therefore vulvodynia and vulvar pain are identical terms. The entire vulva is different than the vestibule of the vulva. The vestibule is a small area of the vulva just in front of the hymen but not extending to the dry skin of the labial lips. So if someone labels pain as vestibulodynia, that would mean the pain is confined to the vestibule. The condition called vulvar vestibulitis is confined to the vestibule area and produces pain or burning. Therefore it would labeled as producing vestibulodynia. The doctor checks with a Q-tip on pelvic exam touching the area of the vestibule and then other areas of the vulva. If the pain in only in the vestibule, that makes the diagnosis of vulvar vestibulitis. If the pain is anywhere else on the vulva, some other condition is causing it. Vulvar dysesthesia is a term also used to describe vulvar pain that is beyond the vestibule and for which no obvious cause such as recurrent vaginitis, irritant vulvitis, or vulvar skin conditions are known. For a review of vuvlar pain, see this article at OBGManagement.com: Vestibulodynia: tracing and treating vulvar pain ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 3. Reader submitted Q&A - Endometrial stripe ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ "What does endometrial stripe mean? My doctor ordered a pelvic ultrasound. The nurse called and said it showed an endometrial stripe but she didn't know what that meant and I needed to see a obgyn?" - Anonymous On pelvic ultrasound, one of the views is of the uterus showing it as if it were cut down the middle. This shows the anterior (toward the abdominal wall) and posterior (toward the back) thickness of the uterine cavity. In this view it just looks like a double line. Doctors measure the thickness of that double line to get an idea of how much skin lining (endometrium) there is in the uterus. Normally a woman who is in the first week of her menses will have a thin lining. A post menopausal woman will also have a thin stripe. In the second two weeks of a normal menstrual cycle, the stripe will become thicker until just before menses starts. After menopause, a thickened endometrium can mean a cancer of the endometrium or a hyperplasia that can become cancerous. If the endometrial stripe is not straight but rather like a wavy or indented line, that may indicate endometrial polyps or a fibroid of the uterus impinging upon the uterine cavity. If the line is straight and you are premenopausal, endometrial thickness has no meaning at all. Many radiologists have been confused about this and report linings at the upper range of normal as thickened. Your doctor has no choice but to refer you to an ObGyn for follow-up but it may be unnecessary. If you are postmenopausal, the thickness of the lining may be significant. Originally, the stripe was looked at in women with postmenopausal bleeding and if the stripe was thin (less than 5 mm) an endometrial biopsy could be avoided. The converse, a thickened stripe does not indicate any concern if there is no abnormal bleeding. You did not give us enough information about the circumstances surrounding why you had an ultrasound in the first place or age or menopausal status so it is difficult to precisely say whether this ultrasound finding is of significance or not. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 4. Calcium robbers ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Experts recommend 1000-1200 mg/day of calcium but most women only ingest about half of that. If you do not ingest enough calcium, your body takes it from your bones. Even if you are getting enough dietary calcium, you do not want to do anything that will rob it from your body. There are some commonly known calcium robbers. They are: low levels of vitamin D - needed for absorption from the GI tract. salt - too much lets calcium be lost through the kidneys certain medications - water pills (diuretics), steroids, anti-seizure medications, immuno- suppressive medications, non-steroidal anti- inflammatory drugs (NSAIDs like ibuprofen, naproxen), asthma medications with steroids excessive lifestyles - cigarette use, too much alcohol (more than 2 drinks a day) sedentary lifestyle - lack of weight bearing exercise such as walking, running, weight lifting, fitness workouts Too much caffeine or too many sodas can also inhibit calcium absorption. So in general, it is a good idea to take some additional calcium in the form of pill supplements or food supplements where calcium and vitamin D have been added. Are You Bad to Your Bones? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 5. Insect bites this summer ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Bug bites are a fact of summer. Most are not serious but some can be. Do you know how to take care of insect bites when they happen to you? For most bites, you need to gently scrape off the stinger if there is one, using a edge such as a credit card. Wash with a disinfectant and then apply a baking soda paste. If you tend to react with a large reddened skin area to a bite or swell in reaction to a bite, be sure to take an antihistamine such as Benedryl(R), Tylenol Severe Allergy (R) or chlorpheniramine maleate (Chlor- Trimeton (R), Teldrin (R). Most women who have serious reactions to bug bites know the emergency measures they must take to avoid shock but if you have a severe reaction such as difficulty breathing or swelling of the throat, contact emergency services or 911. Two potentially serious bites to the non allergic are ticks which may carry Lyme disease and the brown recluse spider and the black widow spider. Lyme disease is carried by deer ticks and is spread to humans after a tick has been attached tot he skin for 24-48 hours. If you are in a tick infested area and routinely check your skin each day for ticks, you can prevent Lyme disease which causes joint pains, a rash and fever. If you find a tick, gently remove it with tweezers without squeezing it and save it in a plastic bag in case you develop any symptoms. Spider bites can be quite serious if they are due to a black widow or a brown recluse spider. They only rarely can cause death but they can make you very sick with severe pain in the bite area and nausea and vomiting. The important part is to try to identify the spider so if symptoms worsen you can be treated.