Women's Health Articles - General Medical Problems

By Date of Release Topic April 2, 2000 Controlling Hypertension Without Medicine October 31, 1999 Osteoporosis in Spite of Estrogen Replacement September 19, 1999 Idiopathic Cyclic Edema September 12, 1999 Facial Hair Growth After Menopause August 15, 1999 Cholesterol and Lipid Disorders August 8, 1999 Guidelines for Healthy Weight June 13, 1999 Cellulite - Is there hope? April 18, 1999 Malignant Melanoma Skin Cancers in Women March 7, 1999 Ulcer Symptoms and Helicobacter pylori January 24, 1999 Insulin Resistance Syndrome November 29, 1998 Involuntary Weight Loss Evaluation October 18, 1998 Low Back Pain -- When is Imaging Needed? September 20, 1998 Hormones and Hip Fractures in Older Women September 13, 1998 Heart Problems Caused by Diet Pills August 30, 1998 When is High Blood Pressure Hypertension? June 28, 1998 Diabetic Tendency in Polycystic Ovary Syndrome May 3, 1998 Menstrual Migraine Headache November 16, 1997 New Diabetes Diagnostic Categories October 27, 1997 Accuracy of Echocardiography in Women

Guidelines for Healthy Weight

Frederick R. Jelovsek MD

What should I weigh? The answer might be based on your age (older women will need to weigh less) , on your desire to be at low risk for death due to obesity-related diseases, or just according to how you wish your body to look. As far as your health goes, avoiding an excessive amount of body fat is the best way to lower your risk from heart disease, hypertension, diabetes and even from developing gall bladder disease. Sometimes, it is questionable as to what is ideal body weight. A recent journal supplement, Chez RA (ed.): Weighing the options on managing obesity. Contemporary Ob/Gyn 1999; June supplement:3-30, looks at the issues of weight and health and what is the best way to manage weight problems.

Is the body mass index (BMI) the b

est measure of how much fat is in my body?

Body mass index, BMI, is only an indirect measurement of body fat. For scientific research purposes there are more accurate methods of measuring what percent of a body's weight is composed of fat such as hydrodensitometry (underwater weighing) and dual-energy x-ray absorptiometry. Physical measurements such as waist and hip circumferences and skin fold thickness in the back of the elbow are also used.

The BMI happens to be the most commonly used measurement in epidemiologic studies and for middle-aged men and women, it correlates over 90% with fat mass densitometry. For older adults who tend to have less muscle mass proportionally, it loses some of its accuracy as an absolute measurement. The BMI is also called the Quetelet index and is calculated by the weight in kilograms divided by the square of the height in meters. While it does not distinguish fat mass from lean or muscle mass, it is a very useful approximation to what one should weigh depending on height.

What are the health complications of obesity?

In order to determine what people should weigh, researchers have looked at risk of death by different BMI categories in order to determine what would be ideal. Keep in mind that excess weight can have health-associated problems that do not result for quite a while. It can make arthritis or low back problems worse, cause diabetes and gall bladder disease. Risk of Type II diabetes (usually adult onset) rises in women at a BMI of over 22 even though the normal range for BMI is 19-25. Deaths from cardiovascular disease in non-smoking women rises slightly at a BMI of 22-25 but takes a dramatic jump at a BMI of over 30. Each kilogram (2.2 lbs) of weight loss will reduce systolic blood pressure (the first number) by .43 mm Hg and diastolic blood pressure (the second or bottom number) by .33 mm HG in women who have hypertension.

Certain cancers have also been associated with excess weight. Cancer of the gall bladder, breast, uterus and ovaries are more common in obese women and weight loss seems to significantly reduce these risks. Obesity is also a risk factor in for osteoarthritis which is the condition responsible for more than 70% of hip and knee replacements. In overweight individuals weight loss of an average of 11 lbs (5 kg) reduced the risk of developing osteoarthritis by more than 50%.

BMIs of 28-30 have a 2.4 times risk of infertility and ovulatory disorders compared to women with a BMI of 20-22. Excess hair growth and acne can also be associated with increased weight and disappear with weight loss.

What is the definition of overweight or obesity?

While BMI is not the perfect measurement for assessing increased body fat, it is the most easily obtained measurement that has a high correlation with percent of body fat so most of the standards are set using BMI. Even though there can be some increased health risks within the upper limits of the normal range, various groups such as the World Health Organization, the American Institute of Nutrition and the International Obesity task force, among others have given some guidelines.

Weight Category Definitions

Classification	BMI Body Mass Index
Underweight	less than 18.5
Normal	18.5 - 24.9
Overweight	25.0 - 29.9
Obesity	30.0 - 39.9
Extreme Obesity	40.0 and greater

You may calculate your body mass index in pounds or kilograms or look up on the table below where your current BMI puts you.

Normal							Overweight					Obesity										Extreme Obesity
BMI	18.5	19	20	21	22	23	24	25	26	27	28	29	30	31	32	33	34	35	36	37	38	39	40	41	42	43	44	45	46	47	48	49	50
Height							Weight (in pounds)
4'10"	88	91	96	100	105	110	115	119	124	129	134	138	143	148	153	158	162	167	172	177	181	186	191	196	201	205	210	215	220	224	229	234	239
4'11"	91	94	99	104	109	114	119	124	128	133	138	143	148	153	158	163	168	173	178	183	188	193	198	203	208	212	217	222	227	232	237	242	247
5'	95	97	102	107	112	118	123	128	133	138	143	148	153	158	163	169	173	179	184	189	194	199	204	209	215	220	225	230	235	240	245	250	255
5'1"	98	100	106	111	116	122	127	132	137	143	148	153	158	164	169	174	180	185	190	195	201	206	211	217	222	227	232	238	243	248	254	259	264
5'2"	101	104	109	115	120	126	131	136	142	147	153	158	164	169	174	180	185	191	196	202	207	213	218	224	229	235	240	246	251	256	262	267	273
5'3"	104	107	113	118	124	130	135	141	146	152	158	163	169	175	180	186	192	197	203	208	214	220	225	231	237	242	248	254	259	265	270	278	282
5'4"	108	110	116	122	128	134	140	145	151	157	163	169	174	180	186	192	197	204	209	215	221	227	232	238	244	250	256	262	267	273	279	285	291
5'5"	111	114	120	126	132	138	144	150	156	162	168	174	180	186	192	198	204	210	216	222	228	234	240	246	252	258	264	270	276	282	288	294	300
5'6"	114	118	124	130	136	142	148	155	161	167	173	179	186	192	198	204	210	216	223	229	235	241	247	253	260	266	272	278	284	291	297	303	309
5'7"	118	121	127	134	140	146	153	159	166	172	178	185	191	198	204	211	217	223	230	236	242	249	255	261	268	274	280	287	293	299	306	312	319
5'8"	121	125	131	138	144	151	158	164	171	177	184	190	197	203	210	216	223	230	236	242	249	256	262	269	276	282	289	295	302	308	315	322	328
5'9"	125	128	135	142	149	155	162	169	176	182	189	196	203	209	216	223	230	236	243	250	257	263	270	277	284	291	297	304	311	318	324	331	338
5'10"	129	132	139	146	153	160	167	174	181	188	195	202	209	216	222	229	236	243	250	257	264	271	278	285	292	299	306	313	320	327	334	341	348
5'11"	132	136	143	150	157	165	172	179	186	193	200	208	215	222	229	236	243	250	257	265	272	279	286	293	301	308	315	322	329	337	343	351	358
6'	136	140	147	154	162	169	177	184	191	199	206	213	221	228	235	243	250	258	265	272	279	287	294	302	309	316	324	331	338	346	353	361	368
6'1"	140	144	151	159	166	174	182	189	197	204	212	219	227	235	242	250	257	265	272	280	288	295	302	310	318	325	333	340	348	355	363	371	378
6'2"	144	148	155	163	171	179	186	194	202	210	218	225	233	241	249	256	264	272	280	287	295	303	311	319	326	334	342	350	358	365	373	381	389
BMI	18.5	19	20	21	22	23	24	25	26	27	28	29	30	31	32	33	34	35	36	37	38	39	40	41	42	43	44	45	46	47	48	49	50
Normal							Overweight					Obesity										Extreme Obesity

I will never get to my ideal weight -- why even try?

It can be extremely difficult for an obese person to lose weight down to an ideal level. Fortunately many studies show a huge reduction in mortality and weight related problems with even a modest reduction of 5-10% weight loss which is maintained for at least a year. In fact, losing large amounts of weight does not lower the mortality further than just a 10% weight loss does. Nurses who lost 11 kg (24 lbs) had a risk of type 2 diabetes that was 75% lower than nurses with unchanged weight. Thus the overall goal should be weight loss but not necessarily all the way to ideal body weight. A 10% loss occurring at a rate of 1-2 lbs per week is what most weight management specialists recommend.

When should diet pills be considered in the management of weight problems?

Various prescription medicines that aid in weight loss have come on and off the market over many years. Some have had dangerous side effects only discovered after years of use. Most have only a temporary effect on aiding weight loss. As each newer medicine comes available promising effortless weight loss, weight management experts still prefer non medication aided dieting and behavioral modification. There are circumstances in which the experts resort to medicines.

individuals with a BMI of over 30 and who have serious health complications
individuals with appetite problems to the extent that a women reports she is always thinking of food or has constant food cravings
more than one or two failures at weight loss or maintenance of weight loss using behavioral therapy

Surgical bypass therapy should be considered for women who have BMIs of 40 or over 35 with obesity health complications.

top of page

Cellulite - Is There Hope?

Frederick R. Jelovsek MD

Very frequently, women (and men) make requests to doctors to prescribe a medication or treatment that will smooth out the contours of the body - eliminate cellulite. It presents a problem for the doctors who are not dermatologists, plastic surgeons or obesity experts because they are somewhat removed from the latest concepts regarding adipose tissue distribution and problems. Medical literature is fairly thin on this subject while the lay literature describes numerous questionable treatments that promise to rid the body of irregular appearing fat deposits. It is apparent that this topic - cellulite - has not been studied by medical science very much. It is perhaps time to look at what evidence does exist is on this subject.

What is cellulite?

Dimpling of the skin of the buttocks and thighs, especially in women, is known as cellulite. Many people have heard stories about the existence of two types of fat - brown and white - in which the brown is the type in cellulite, but medical studies have failed to confirm that there are any different types of adipose tissue. One study, Rosenbaum M, Prieto V, Hellmer J, Boschmann M, Krueger J, Leibel RL, Ship AG :An exploratory investigation of the morphology and biochemistry of cellulite. Plast Reconstr Surg 1998 Jun;101(7):1934-9 looked at both the anatomical structure of cellulite as well as its physiologic function.

Ultrasound examination of the thigh showed a diffuse pattern of extrusion of underlying fat (adipose) tissue into the reticular dermis in individuals with cellulite, but not not in unaffected, individuals. Studies also demonstrated that women had a generalized pattern of irregular and discontinuous connective tissue immediately below the skin (dermis), but this same layer of connective tissue was smooth and continuous in men. They also found no significant differences in they way the fat tissue looked under the microscope, how it responded to fat deposition and resorption, or even regional blood flow between affected and unaffected sites within individuals. They did find there were structural characteristics of connective tissue below the skin that predispose women to develop the irregular extrusion of adipose tissue into the dermis, which characterizes cellulite. In other words, cellulite represents areas of a "break in the fence" where fat cells come into the skin area and the dimpling represents where the support structure of the skin (the original "fence") is still intact.

What causes cellulite deposits?

In spite of the above paper, most scientists really do not know what causes cellulite. They have studied fat metabolism and deposition and had many and varied findings. Most areas of fat deposits are the result of two factors

the number of fat cells - adipocytes
the amount of fat inside the adipocytes

Current evidence suggests that the original number of fat cells in any area of the body is controlled by one's original genetic make up. There are no factors or substances that increase the number of cells in a body region but rather they do not multiply unless the other fat cells get filled to capacity.

Occasionally there are reports that cellulite fat has more proteoglycans that lead to more water retention or that there are more or less receptors for various physiologic hormones or proteins, but it does not appear that these are the causative factors. Cellulite fat will respond to calorie restriction just as any other fat cell, but it is the stored fat that goes away; the cell is still present and can refill if calorie excess resumes. That is why most treatments of cellulite are directed at removal of the cells surgically.

Are women more likely to have problems with cellulite or are they just more concerned about it?

Yes, women are more predisposed to cellulite than men. The Rosenbaum study found that women have a much more irregular, discontinuous supporting skin matrix than men do so there is more opportunity for fat cells to extrude into the dermis area. To some extent this must be hormonally controlled through estrogens because most men are not as prone as women to cellulite but men who are given estrogens as treatment for medical problems are known to develop new areas of cellulite.

Fat distribution is different also in women and men. Women have more fat deposits under the skin but tend not to accumulate it inside the abdominal cavity; men seem to have less room for fat over their muscles and under the skin but they will accumulate much more excess fat inside the abdominal cavity. Regionally, women have a tendency for more fat deposition in the buttocks and thighs (gluteal/femoral areas) but that tendency only starts after a women's ovaries become hormonally active.

Are there any medical treatments known to actually get rid of cellulite?

The medical literature does not support evidence that I could find of any topical creams or ingested medicines or substances that get rid of cellulite unless those treatments result in significant loss of total body fat. In those cases, the dimpling from cellulite becomes less apparent but does not actually go away. This observation must be tempered by the realization that medical science does not seem to have studied this subject very rigorously, thus the room for many "claims of cure" that cannot be refuted as well as they should be.

Can cellulite be treated surgically?

Most physician-based treatments are surgical. Either fat cells are removed by various excision or suction techniques or/and the cells are redeposited in areas of dimpling so the contour looks more even. None of the surgical treatments are directed at fixing the underlying cause but merely fixing the result. Cellulite areas will recur as long as there is any excess fat deposition over the natural metabolic rate.

top of page

Malignant Melanoma Skin Cancers in Women

Frederick R. Jelovsek MD

Malignant melanoma is a potentially fatal skin cancer that is not very common, but it is the most frequent cancer in women ages 25-29 and the second most frequent cancer in those age 30-34. In these age groups, melanoma is more frequent in women than men. It is important to diagnose these dark, pigmented skin lesions early because late-stage, disseminated melanoma rarely responds to therapy.

A recent article, Guerry IV D: Melanoma in Women : Prevention, detection and treatment. The Female Patient 1999;24:33-42, outlines which women are at risk for this and what steps to take for early detection of skin melanomas.

Which women are at most risk for melanomas?

Melanomas occur most frequently in persons of Caucasian race, especially those with light colored hair or iris eye color. Their skin is more susceptible to ultraviolet light rays. Any woman that freckles and burns in the sun regularly without tanning has increased susceptibility. Living in the "sunbelt" has a two-fold risk. The use of tanning parlors makes a woman at higher risk but the most dangerous exposure is thought to occur with off-season recreation or exposure that produces a sunburn in skin that has not been exposed to the sun for awhile. In other words, a mid-winter trip to the Caribbean can sometimes be dangerous in the long run.

A personal or family history of melanoma or other common skin cancers increases the risk for melanoma. A woman who has a large number of common moles (i.e., greater than 25 lesions) is also melanoma-prone. Some families have an inherited increased risk of melanoma but fewer than 10% of melanoma cases are the result of strong genetic susceptibility. If a woman has had a mole biopsied and it turned out to be a "dysplastic nevi", then she has a two-fold risk of melanoma. If she has had 10 or more of those dysplastic nevi, the risk for melanoma is raised by a factor of 12.

How do you detect or screen for possible melanomas?

There is no special method to detect melanomas. A careful examination of the skin is the only method; no special equipment is needed. In women, melanomas occur many times on the arms and legs, but also on the back and upper chest. A partner or spouse can help look at all the freckles, moles and any pigmented (darkened) skin lesions.

What should you look for? The mnemonic used is "ABCDE":

Asymmetry: melanomas generally have an irregular border.
Border irregularity: the border is irregular and often notched.
Color variation: although melanomas are usually dark brown or black, they may sometimes have a range of colors including tan, brown, blue, pink or white.
Diameter: eventually melanomas become larger than ordinary moles. Any pigmented spot greater than 5 mm (1/5 inch) in diameter should be examined and followed carefully.
Elevation: some early melanomas are slightly elevated. A pigmented lesion that elevates quickly or develops a bump should be checked immediately. Ulceration, bleeding and oozing are generally late signs of a melanoma that is likely to already be advanced.

Do hormones, birth control pills or pregnancy increase the incidence or severity of melanoma?

One study noted a a six-fold increase in melanoma risk in women who noticed that their moles darkened and increased in diameter during pregnancy. Several other studies, however, have shown no convincing evidence that birth control pills, hormone replacement or pregnancy worsen the risk for melanoma. In spite of the lack of evidence of a hormonal effect, some physicians advocate deferring pregnancy after treatment for a melanoma until the highest risk of recurrence, the first 3 years, have passed. Estrogens in pills, hormones and pregnancy stimulate melanin production in the skin but do not appear to be a major stimulant for the cells containing the melanin such as moles or freckles.

What happens if a melanoma lesion is found?

Treatment for a melanoma is usually a wide local excision of the skin around and underneath the pigmented lesion. Generally a lesion that is confined to the most superficial layer of skin and is less than a millimeter (mm) thick is excised with a 5-10 mm margin of normal skin tissue and closed primarily with suture. Thicker lesions are removed with margins of 1.0 - 4.0 cm (10-40 mm). The nearby lymph nodes are also excised and if they are involved, all of the nearby lymph nodes are removed with "radical " surgery. Subsequent chemotherapy or immunotherapy treatments are often given to treat or prevent recurrence.

See You can be an expert at diagnosing melanoma.

top of page

Ulcer Symptoms and Helicobacter pylori

Frederick R. Jelovsek MD

Before 1982, we used to think that ulcers were caused by spicy food, acid, stress and the "Type A" personality. Then a bacterium called Helicobacter pylori was discovered. Now we know that up to 80% of stomach ulcers and 90% of duodenal ulcers are caused by the bacterium, H. pylori. As a result, ulcers are often cured now by medical therapy rather than surgical therapy.

The Center for Disease Control and Prevention now puts out a fact sheet for health care providers to make sure the message is out that this is often a curable problem. From this July 1998 Fact Sheet and the H. pylori web site that is maintained by the CDC, we can learn the answers to several questions about ulcer disease and the H. pylori infection.

What are the symptoms of ulcers?

The most frequent symptom noted with ulcers is a gnawing, burning pain in the mid stomach area just below the rib cage. Its onset is usually gradual over weeks or months rather than an acute beginning. The pain typically occurs when the stomach is empty between meals and in early morning hours. It can last from minutes to hours and is relieved by eating or taking antacids.

Less frequently occurring are symptoms such as nausea, vomiting, and loss of appetite. Bleeding from the ulcer may result in black, tar-like stools, vomiting of blood or even coughing up of blood.

Should I be tested for H. pylori?

Anyone who has been diagnosed with an ulcer or who has had a history of ulcers should be tested. Also, people who have a history of gastric (stomach) cancer or a mucosal-associated-lymphoid-type (MALT) lymphoma should also be tested. H pylori is strongly associated with these latter two malignancies. It is not currently clear whether persons with just stomach upset (dyspepsia) that do not have ulcers should be tested. Remember that over 2/3's of the world's population is infected with H.pylori and most do not have any symptoms or ulcers from it.

How is H. pylori infection diagnosed?

There are several methods currently available to diagnose H. pylori infection. There are antibody tests that can determine if a person has ever been exposed to the bacteria. They pick up about 80% of all people who have been or were infected. If the test is negative, it only misses about 5% of people who actually have been infected.

There also is a breath test in which patients are given radioisotope labelled liquids to drink and the H. pylori metabolizes the labelled compounds which can then be measured in a person's breath. These tests are more accurate than the antibody tests.

The gold standard diagnostic test is is at time of upper esophagogastroduodenal endoscopy (EGD) in which an endoscope is put into the stomach to look for ulcers and take a biopsy. The biopsy is then examined either by a urease test, a microscopic look at the tissue or a bacterial culture of the tissue.

What are the long term consequences of H. pylori infection?

Other than ulcer disease and its complications, gastric cancer is the biggest risk of long term infection. In places like Columbia and China where over half the population is infected in early childhood, there is a high incidence of gastric cancer. In the U.S., H. pylori is is less common in young people and the incidence of gastric cancer has been decreasing since the 1930's.

How would I have been infected with H. pylori?

It is not known how H. pylori is transmitted or why some people become symptomatic while others do not. It is thought most likely to be spread from person to person through the food or water supply.

What are the treatment regimens used to cure H. pylori?

There are several different treatment regimens used.

FDA-approved treatment options for H. pylori (1998)

Medication	Dose
Treatment
omeprazole (Prilosec®)	40 mg each day for two weeks
clarithromycin (Biaxin®)	500 mg three times a day for 2 weeks THEN
omeprazole (Prilosec®)	20 mg each day for 2 weeks
Treatment
ranitidine bismuth citrate (RBC) (Zantac®)	400 mg twice a day for 4 weeks
clarithromycin (Biaxin®)	500 mg three times a day for 2 weeks
Treatment
bismuth subsalicylate (Pepto Bismol®)	525 mg four times a day for 2 weeks
metronidazole (Flagyl®)	250 mg four times a day for 2 weeks
tetracycline	500 mg four times a day for 2 weeks
any H2; receptor antagonist	therapy as directed for 4 weeks
Treatment
lansoprazole (Prevacid®)	30 mg twice a day for 10 days
amoxicillin (Amoxil®)	1 gram twice a day for 10 days
clarithromycin (Biaxin®)	500 mg three times a day for 10 days
Treatment
lansoprazole (Prevacid®)	30 mg three times a day for 2 weeks
amoxicillin (Amoxil®)	1 gram three times a say for 2 weeks
Treatment
ranitidine bismuth citrate (RBC)(Zantac®)	400 mg twice a day for 4 weeks
clarithromycin (Biaxin®)	500 mg twice a day for 2 weeks
Treatment
omperazole (Prilosec®)	20 mg twice a day for 10 days
clarithromycin (Biaxin®)	500 mg twice a day for 10 days
amoxicillin (Amoxil®)	1 gram twice a day for 10 days
Treatment
lansoprazole (Prevacid®)	30 mg twice a day for 10 days
clarithromycin (Biaxin®)	500 mg twice a day for 10 days
amoxicillin (Amoxil®)	1 gram twice a day for 10 days