September is Women’s Health Awareness & Gynecologic Cancer Awareness Month. The Methodist Hospital in Houston, Texas offers the following health tips for women regarding gynecological cancer, breast and ovarian cancer, heart health, and stroke risk.

Cervical cancer awareness tips
from Dr. Tri Dinh, gynecologic oncologist, The Methodist Hospital, Houston

• Cervical cancer is one of the most common cancers in women worldwide. Screening with the Pap smear has markedly decreased the incidence of cervical cancer in the United States over the past 40 years. Nationwide, though, about one-third of false negative Pap results are due to rare abnormal cells that were missed or misclassified. According to the National Cancer Institute, approximately 11,500 women in the United States are diagnosed with cervical cancer each year. The human papillomavirus (HPV) is the most common sexually transmitted virus, and more than 90 percent of women diagnosed with cervical cancer also have HPV.

The cancer is highly curable if detected early, and regular Pap screenings are key to help prevent cervical cancer.

• A breast-ovarian cancer gene test is a blood test that shows whether a woman has breast cancer or ovarian cancer gene mutations, known as BRCA 1 or 2, which increases a woman’s chance of having breast, ovarian or other cancers.

Every woman is born with the breast cancer gene 1 (BRCA 1) and breast cancer gene 2 (BRCA 2). For unknown reasons, these genes can mutate, putting women at increased risk for developing breast cancer compared with women who do not have these mutations. There is a 50-50 chance the mutated genes can be passed on to children, both girls and boys. Patients with multiple family members who have breast or ovarian cancer should be tested for BRCA 1 and 2. Most importantly, education and awareness about gynecologic cancers and family history, as well as annual well-woman exams, are keys to reducing the incidence of these diseases.

MRI/breast cancer test tip for women with implants
by Dr. Luz Venta, director of Breast Imaging, The Methodist Hospital, Houston

• Magnetic Resonance Imaging (MRI) can make it easier for doctors to detect breast cancer in its early stages in women with implants and dense breast tissue. An MRI gives a three-dimensional image of the breast, which allows a physician to see the detailed anatomy, down to the arteries and veins. The scan also provides a clearer picture for women with dense breast tissue, which is made up of less fat and more glands and ligaments, and shows up as a white area on a mammogram. Tumors also show up as white areas on the film, so the MRI technology can prevent a potentially devastating misdiagnosis.

A three-year research study, conducted at 17 different sites throughout the U.S., Canada and Germany, of more than 1,000 women, all with suspicious lesions on their mammograms, found that MRI was twice as effective as a regular mammogram in detecting tumors in these women.

Women’s heart health tips
by Dr. Karla Kurrelmeyer, cardiologist, Methodist DeBakey Heart & Vascular Center, Houston

• Heart disease is the nation’s number one killer of women. But, the well-known heart attack symptoms - acute pain, tightness, burning and a dull ache in the chest - describe what men typically experience during an attack. For many women the signs of a heart attack are completely different and can go unrecognized. Women tend to ignore signs of heart attack, thus increasing the likelihood of tragic consequences. With heightened attention to the facts about symptoms and treatments, much of this can be prevented.

Most people know to get to an emergency room immediately when they’ve identified that they’re having a heart attack. However, research shows that women go to the hospital on average one full hour later than men do after experiencing an attack. Most benefits of medical treatment occur in the first six hours after an attack, so delayed medical treatment reduces chances of full recovery.

Clot-buster drugs may be immediately given to break up the clot and allow blood to get through to the heart. If necessary a balloon or a stent can be placed in the clogged artery to open the artery and strengthen the artery wall. Sometimes surgery and other procedures are required.

Maintain low cholesterol levels, exercise and quit smoking. If you have diabetes, keep it under control. Monitor your blood pressure, and keep it in check. Know your family medical history. If there is a history of heart disease, start earlier and be even more diligent about prevention.

Stroke in women - awareness tips
by Jan Flewelling, Stroke Outreach Program Coordinator, Methodist Neurological Institute, Houston

• Although cardiovascular disease, including stroke, has generally been thought of as a man’s disease, more women suffer strokes than men, and their mortality rate is higher. Women account for more than 60 percent of stroke deaths. While these facts and statistics seem daunting, education and awareness are keys to helping reduce the incidence of stroke in women.

While women need to be aware of the common risk factors for stroke – high blood pressure, diabetes and high cholesterol - some gender specific risks can also alter a woman’s chances of suffering a stroke. Women who suffer from migraines with visual aura have a significantly higher risk of ischemic stroke. Brain aneurysms, one of the causes of hemorrhagic strokes, are more prevalent in women. Autoimmune diseases, including diabetes and lupus, are more prevalent in women and also contribute to the risk of stroke. Birth control pills are linked to increased blood clots, a contributing factor to stroke that can be worsened by cigarette smoking and increasing age. Hormonal changes during menopause also contribute to rising cholesterol levels in women. Finally, ethnicity also plays a role in a woman’s chances of suffering stroke. African-American and Latino women tend to be at higher risk of stroke (Newswise).

HBNS.org - Parents who have regular meals with their adolescent children - especially girls - might help lessen the chances they will start drinking or smoking later in their teen years, according to new research.

Past studies have shown that family meals provide many benefits, including offering a venue for parents to communicate with their adolescents about their daily activities, as well as monitor their moods and whereabouts.

In the new study, researchers noted benefits in families that ate five or more meals together each week, and found that about 60 percent of the participants did so.

“Sixty percent having regular family meals is about what we would expect for middle school students,” said lead author Marla Eisenberg of the Division of Adolescent Health and Medicine at the University of Minnesota. “The percentage is lower among high school students, who are more likely to have afterschool activities or more freedom to spend time away from home.”

The study appears in the August 2008 issue of the Journal of Adolescent Health .

Eisenberg and her colleagues examined data from 806 Minnesota adolescents (45.4 percent boys and 54.6 percent girls). They first surveyed the youth in school in 1998-1999 (at about age 13) and asked how often in the past week their family ate together and about their use of marijuana, cigarettes and alcohol. They followed up with a second survey by mail five years later.

In the second survey, girls who had reported five or more family meals per week had significantly less substance use than did the females who did not have regular family meals. The girls who had regular meals had about half the odds of substance use.

However, boys showed no significant difference in substance use between those who had regular family meals and those who did not.

“Unfortunately we don’t really know why we see this benefit for girls and not boys,” Eisenberg said. “There is some evidence that girls and boys communicate and interact differently with their families, so it’s possible that the conversations about behavioral expectations or the subtle ‘checking in’ that can happen during shared meals might be understood differently by girls and boys.”

Jeanie Alter is program manager and lead evaluator of the Indiana Prevention Resource Center at Indiana University’s School or Health, Physical Education, and Recreation. She agreed that regular family meals could benefit teens.

“Some of the factors related to substance use in teens are linked to family conflict,” Alter said. “So, if you have a kid that is sharing that much time with his or her family, it would suggest they have better family relationships, more protective factors and fewer risk factors.”

Eisenberg said that despite the “many challenges of bringing a family together every day, we would encourage parents to make family meals part of their routine as often as they can.”

Reference: Eisenberg M, et al. Family meals and substance use: is there a long-term protective association? Journal of Adolescent Health 43(2), 2008.

Reactivation of genital herpes is linked in some cases with the emergence of widespread chronic neuropathic pain , according to a Finnish study reported in The Journal of Pain .

In the clinic at the University of Helsinki, 17 patients were examined who presented widespread chronic pain with no visible lesions in brain magnetic imaging. Because the majority had herpes simplex virus (HSV) infections, the researchers studied a possible association between herpes and neuropathic pain. They hypothesized that in HSV-positive patients, the active virus may alter pain processing at different levels of the central nervous system (CNS).

Results of the study showed 80 percent of the patients reported at least moderate pain relief with anti-herpetic medication, and in more than half there was positive correlation between the activity of the HSV infection and pain.

The authors concluded that a CNS dysfunction is the most likely explanation for the widespread pain. Latency and possible activations of the herpes virus in brain areas involved in pain processing might cause functional changes in the pain matrix, even if there are no detectable lesions in anatomical MRI. Further, the strong inflammatory reactions in the CNS caused by activation of the virus may sensitize nerves at different levels (Newswise).

WPI.edu - For generations, people have consumed cranberry juice , convinced of its power to prevent urinary tract infections , though the exact mechanism of its action has not been well understood. A new study by researchers at Worcester Polytechnic Institute (WPI) reveals that cranberry juice changes the thermodynamic properties of bacteria in the urinary tract, creating an energy barrier that prevents the microorganisms from getting close enough to latch onto cells and initiate a bladder infection.

The study, published in the journal Colloids and Surfaces: B , was conducted by Terri Camesano, associate professor of chemical engineering at WPI, and a team of graduate students, including PhD candidate Yatao Liu. They exposed two varieties of E. coli bacteria, one with hair-like projections known as fimbriae and one without, to different concentrations of cranberry juice. Fimbriae are present on a number of virulent bacteria, including those that cause urinary tract infections, and are believed to be used by bacteria to form strong bonds with cells.

For the fimbriaed bacteria, they found that even at low concentrations, cranberry juice altered two properties that serve as indicators of the ability of bacteria to attach to cells. The first factor is called Gibbs free energy of attachment, which is a measure of the amount of energy that must be expended before a bacterium can attach to a cell. Without cranberry juice, this value was a negative number, indicating that energy would be released and attachment was highly likely. With cranberry juice the number was positive and it grew steadily as the concentration of juice increased, making attachment to urinary tract cells increasingly unlikely.

Surface free energy also rose, suggesting that the presence of cranberry juice creates an energy barrier that repels the bacteria. The researchers also placed the bacteria and urinary tract cells together in solution. Without cranberry juice, the fimbriaed bacteria attached readily to the cells. As increasing concentrations of cranberry juice were added to the solution, fewer and fewer attachments were observed.

Cranberry juice had no discernible effect on E. coli bacteria without fimbriae, suggesting that compounds in the juice may act directly on the molecular structure of the fimbriae themselves. This reinforces previous work by the WPI team that showed that exposure to cranberry juice alters the shape of the fimbriae, causing them to become compressed. Using an atomic force microscope as a minute strain gauge, the team also showed that the adhesive force exerted by bacteria on urinary tract cells declined in direct proportion to the concentration of cranberry juice in the solution.

"Our results show that, at least for urinary tract infections, cranberry juice targets the right bacteria - those that cause disease - but has no effect on non-pathogenic organisms, suggesting that cranberry juice will not disrupt bacteria that are part of the normal flora in the gut," Camesano says. "We have also shown that this effect occurs at concentrations of cranberry juice that are comparable to levels we would expect to find in the urinary tract."

Camesano notes that unpublished work has shown that while cranberry juice has potent effects on disease-causing bacteria, those effects are transitory. "When we takes E. coli. bacteria that have been treated with cranberry juice and place them in normal growth media, they regain the ability to adhere to urinary tract cells," she says. "This suggests that to realize the antibacterial benefits of cranberry, one must consume cranberry juice regularly - perhaps daily."

For those watching calories, Camesano says other recent work in her lab has shown that the effects of regular cranberry juice cocktail and diet (sugar-free) cranberry juice are identical. "That’s good news for people who do not like to consume a lot of sugary juice," she says.

Editorial note - Previous research from WPI on cranberry juice with E. coli bacteria showed that most if not all of the anti-bacterial benefit could be attributed to a group of tannins (called proanthocyanidins , which are bacically long-chain polyphenols ) found in cranberries, and which can be found now in over-the-counter dietary supplements. Read labels carefully, however, because some cranberry extract supplements are very weak (and thus a waste of money), while others are potent enough to mimic ingestion of "effective" amounts of cranberry juice. Blueberry polyphenols are also thought to have a similar benefit in preventing urinary tract infections - Dr. Z.

HBNS.org - For premenopausal women, the decision of whether to undergo a hysterectomy - removal of the uterus - is a challenging one. To make things more complex, added pressure to decide whether to remove the ovaries can arise - a decision that researchers say relies more on the preferences of the woman or her surgeon than on evidence-based medicine.

Prophylactic oophorectomy is the medical term for removal of healthy ovaries to prevent the potential risk of developing ovarian cancer later in life.

“Prophylactic oophorectomy is performed across the world on the basis of very limited evidence,” said lead review author Leonardo Orozco, M.D., an attending OB/GYN at Women’s Hospital San José in Costa Rica. “Questioning this practice is a crucial step in advancing our ability to make decisions that may ultimately improve the health and well-being of women.”

However, of the 119 studies that the researchers identified, only one controlled clinical trial met the review’s inclusion criteria - and it was not particularly strong.

“After our search, we were able to find only one clinical control trial of low-quality that has been used to justify such a high number of prophylactic oophorectomies every year,” Orozco said.

That single study included 362 women, who were ages 45 to 55 years when it began. Of those, 217 underwent hysterectomy alone and 106 underwent hysterectomy plus oophorectomy. The study looked at the average changes in psychological well-being and sexuality, both before and one year following the surgery.

Despite the study’s limitations, Orozco says the review’s results are worth noting. “For me, the most important result of this research was to raise the awareness that, as physicians, we must always question why we are performing a specific procedure. We cannot always rely on training, as there are ‘habitual’ procedures that we undertake, which may not be the best evidence-based decision.”

The review appears in the latest issue of The Cochrane Library , a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews like this one draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

“This is an almost impossible area to research insofar as a prospective, randomized, double-blind controlled trial is totally impossible,” said Mary Jane Minkin, M.D., a clinical professor of OB/GYN at Yale University School of Medicine. Therefore, she said, “This is one area where individualization of care is absolutely necessary.”

In the context of few studies to justify a choice either way, Minkin says she tells her patients “that it is their decision, as long as the ovaries are healthy.”

“But,” she adds, “it takes a lot of informed consent to help them make this decision and many docs do not take the time to go through this lengthy decision-making process.” With patients going from one HMO to another, doctors do not really get a chance to know these women really well, “and it becomes that much more difficult to make an informed decision,” she says.

The study analyzed in the review included premenopausal women who underwent hysterectomy for benign gynecological conditions. The reviewers excluded all studies where the women had gynecological cancer, were post-menopausal, or both - as defined by the original study authors.

Both Orozco and Minkin acknowledge that myriad factors go into the decision to remove the ovaries. For example, “We know that women who undergo early menopause, either medically, or particularly surgically [after removal of the ovaries], are at very high risk for cardiovascular disease and osteoporosis,” Minkin says. “If they are not given estrogen therapy, estimates in some papers are as high as a seven-fold risk of cardiovascular disease . There is a reduction in risk of breast cancer, to be sure, but the other diseases are substantially increased.”

Orozco adds that it is important to consider the long-term implications of ovary removal - some of which remain unclear. For example, even after menopause, the ovaries produce significant amounts of certain hormones that other tissues convert to estrogen. “Therefore,” he says, “there could be underlying advantages of ovarian function … that may mean that removal of the ovaries has clinically significant consequences.”

“The conclusions of this review are limited by the lack of data,” Orozco says. “However, it demonstrated that more research of higher methodological quality is needed in order to justify an intervention that we still don’t know is beneficial or harmful.”

Reference: Orozco LJ, et al. Hysterectomy versus hysterectomy plus oophorectomy for premenopausal women. The Cochrane Database of Systematic Reviews 2008, Issue 3.

UMaryland.edu - Consumers are facing a growing risk of getting counterfeit drugs because of rising Internet sales of medical drugs, projected to reach upwards of $75 billion by 2010, according to a report from the University of Maryland School of Pharmacy. Even more alarming is the infiltration of these counterfeit drugs into retail American pharmacies through the actions of unscrupulous "secondary distributors."

Counterfeit drugs get into the U.S. through different sources, but those through illegitimate Internet sites are of special concern, says report author Francis Palumbo, PhD, executive director of the School’s Center on Drugs and Public Policy at the University of Maryland.

“When consumers buy from those, it is definitely buyer beware. They are often not licensed anywhere we are aware of,” says Palumbo. He says the U.S. Food and Drug Administration (FDA) “has been pulling its hair out over the years trying to deal with rogue Internet sites, the terminology they [FDA] use.”

The report, “Policy Implications of Drug Importation,” published in the journal Clinical Therapeutics , tracks the growing “challenge” to U.S. drug regulators and pharmaceutical companies from the growth of imported drugs. The report also addresses the national debate over drug importation policies.

Personal drug importing used to be just a way for patients to continue therapy with medications that were not available in the U.S. and when all other options were exhausted, the report says. But the practice has changed because of pressure of high costs of branded drugs in this country and the desire of patients to find cheaper alternatives.

During the past 10 years, many people have been importing prescription drugs that were available for purchase in the United States and justifying the foreign purchases on the FDA’s policy of personal use exemption. “The policy was never intended to allow this practice to be institutionalized,” the report says. And it concludes that both FDA and U.S. Customs officials cannot handle the volume entering the country.

Blatantly ignoring historical policies on personal importing of drugs not sold in this country leaves the FDA “in a quandary,” the report states. The FDA, though, recognizes that there are many reputable Internet pharmacies, in the U.S. and licensed by states, that offer convenience, wide selections, and privacy, according to the agency’s Web site. Those pharmacies also provide easy access to medications for disabled patients “for whom a trip to the pharmacy can be difficult.”

The FDA also cooperates with other countries to try to stem the tide of illegal Internet sites that ship drugs to the United States (see: www.fda.gov/buyonline/). Ilisa Bernstein, PharmD, FDA’s director of pharmacy affairs, says, “When we do hear about an incident…,we follow up. But to stop it entirely would be difficult.”

Another concern, says Palumbo, is that unlicensed and unregulated drugs may find their way into pharmacies. “We are trying to keep the wolf away from the door and yet there are ways counterfeiters can inject their products into the drug distribution system in the U.S. and may end up in some pharmacies. These are often introduced through the conduit of some secondary wholesalers.” He adds that many secondary distributors are “very legitimate”; they buy products from other wholesalers.

More than 50 percent of Internet drug outlets, which conceal an actual address, have counterfeit drugs, according to the World Health Organization. Counterfeit drug sales are increasing at nearly twice the rate of legitimate drug sales and may expand to a $75 billion industry globally by 2010, according to the nonprofit Center for Medicine in the Public Interest.

Meanwhile some states have taken steps including legislation to “tighten up distribution,” Palumbo said. “There is still a long way to go with this wholesaler issue,” he continues. And because there are some 6,000 pharmaceutical wholesalers operating in the U.S., “there are places where there is vulnerability, where counterfeit products might move beyond the stream of commerce.”

Within the United States, counterfeiting of drugs is likely “quite low,” he says. Internet sales are generally from foreign pharmacies that may not primarily serve the citizens of their country - enabling them to avoid the standards their government requires for drug manufacturing and safety, concluded a 2004 report by the U.S. Department of Health and Human Services.

Also, some pharmacy chains have decided to work only through primary wholesalers and required them to have accreditation from organizations such as the National Association of Boards of Pharmacy (NABP), and other qualifications, to show that they have not purchased from questionable sources. Palumbo says, “This is a major step forward.”

Bernstein says recent FDA studies show is that 50 percent of people buying online get generic drugs "which tells us people are perhaps bypassing their doctors. That is very dangerous.”