Healthcare News and Research

[*Anya*]

Women at Midlife and Beyond Have Unique Health Needs

An Expert Interview With Ivy M. Alexander, PhD, APRN, ANP-BC, FAAN

"Hot Flashes and More: Midlife Women's Health and Beyond" was presented at the 14th Annual Nurse Practitioners in Women's Healthcare (NPWH) Premier Women's Healthcare Conference. We spoke with one of the presenters, Ivy M. Alexander, PhD, APRN, ANP-BC, FAAN.

Medscape: What percentage of women in midlife is living with symptoms related to menopause?

Dr. Alexander: Every single woman who lives long enough will experience menopause, and all of us will have some kind of symptoms; the biggest question is whether or not it is bothersome to them. All women experience vaginal atrophy over time. There are certain different symptoms that affect everybody; whether or not it is bothersome is a separate question.

Medscape: Do vasomotor symptoms associated with menopause consist only of hot flashes, or are there other symptoms as well?

Dr. Alexander: Some women get sweats and some women get chills. In Europe they call it 'hot flushes' instead of hot flashes, because their faces turn very red.

Medscape: What are some other consequences related to loss of estrogen?

Dr. Alexander: People can have psychosomatic symptoms, like mood swings, or they can have neurological symptoms like formication, where there's a sensation of bugs picking over the skin. Women sometimes have disbalance.

They can have genitourinary symptoms; they can have musculoskeletal symptoms; some women have gastrointestinal symptoms. The receptors for estrogen and progestogen are all over the body, and so symptoms can occur anyplace, in areas where those receptors become unbalanced, during and after menopause.

There are other physiologic changes that aren't so much symptoms as they are physiologic changes like loss of bone mass and increase of cardiovascular disease, although that's not really related directly to loss of estrogen — it's probably more related to estrogen-testosterone balance, or imbalance.

Medscape: What are some of the risks and benefits associated with use of hormone therapy, and which women would be considered the best candidates for it?

Dr. Alexander: We talked a lot during the session about the history of hormone therapy, and how it has swung like a pendulum over time: first it was in favor, then swung out of favor, then swung into favor, and then swung out of favor.

The most recent evidence-based (data) that we are working with include the HERS study and the WHI study. These studies have indicated that contrary to what was suggested in prior population-based observational studies, hormone therapy, estrogen therapy, or estrogen plus progesterone therapy do not confer cardiac protection, especially if taken a chunk of time after menopause.

We don't really have good data yet whether or not there might be any kind of benefit toward that if hormone therapy is started at the time of the woman transitioning towards menopause. It looks like there are a couple of theories that are evolving, if you look at one more data and start to analyze subgroups. That has suggested 2 different theories related to when one should initiate using hormone therapy; one of them was the "gap" theory, which looks at breast cancer risk, and there's some question about whether there might be a decrease in breast cancer risk if a woman holds off on starting hormone therapy for that 5 years post menopause.

The news is starting to suggest that if we start hormone therapy right at the time when a woman becomes postmenopausal, it helps to decrease, delay, or put off their risk of developing cardiovascular disease.

Now, it is very controversial; there's a lot of good data that's available. Some of the results from various different studies are rather controversial and confusing, and so it's important for people to really look hard to make sure they remain abreast of these developments.

The most immediate information that we have is what I've just described, and it's looking more and more like we really need to individualize care…if the greatest risk for her is related to heart disease, you might want to think about hormone care sooner than later if in fact she's a good candidate. If the risk factors are higher for breast cancer, you might want to wait.

Medscape: Are there any alternative therapies that you currently favor, and what are some of the risks and benefits of those, particularly when compared to hormone therapy?

Dr. Alexander: There are some alternative therapies, and nonhormonal prescription medications that can be used to try to allay symptoms related to menopause: selective serotonin reuptake inhibitors (SSRIs), selective neurotonin reuptake inhibitors (SNRIs), and the like.

The good thing is that we really have a lot of choices and we're learning a lot more about potential risks and benefits, and I think that's incredibly important. We do know that hormone therapy, estrogen therapy, or estrogen plus progesterone therapy are the single most effective for menopause-related symptoms, but it's not a good choice for every person, and it's not something that every woman feels comfortable taking because of some of the risk factors that we're learning about.

Some of the things that might be most beneficial [with hormone replacement therapy] are things like: A) when a hot flash is coming on, the woman can try to decrease its intensity, or B) possibly stop it from happening.

There are a couple of different products on the market that are available, and some of them suggest benefits that may not be borne out when we do larger head-to-head clinical trials. The other thing is that there are many different things that can trigger hot flashes, and it is really important for women to recognize that there are triggers, and if something is coming on, that they might be able to stop it…if they start to feel that hot flash, by using paced breathing.

The data [related to acupuncture] is kind of all over the place. I think the most recent meta-analysis suggested that it probably didn't have a very strong effect… The benefit of acupuncture is that it's a very well-known, well-proven, safe alternative therapy and it certainly increases relaxation and decreases pain, so if it helps lower someone's stress level and anxiety, it may help to decrease hot flashes — not so much because it's having an impact on the hot flashes directly, but more because it is decreasing some things that are possibly triggering the hot flashes to begin with.

Medscape: Which women would be considered good candidates for alternative therapies?

Dr. Alexander: Anybody.

Medscape: What screening tests should be done on all women at midlife and beyond, regardless of whether they are experiencing symptoms of menopause?

Dr. Alexander: We recommend colonoscopy for women starting at age 50 or younger if there's a family history of colon cancer that is identified before the age of 50; regular female Pap smears and annual internal exams; clinical breast exams and mammography; blood sugar and lipid screening at least every 5 years or more frequently in women at risk; PSA [prostate-specific antigen] sometime around age 40 or 50; hemoglobin around age 50; flu shots annually, pneumothorax depending on their health risk at 65, herpes zoster vaccine every 10 years; tetanus vaccine, and if there's any travel, they should have appropriate immunizations for that.

Osteoporosis is very important; some women need to be measured on a stadiometer every single year to be sure that you actually have an accurate height. Bone density screening should be done at the age of 65, unless experiencing other risk factors earlier.

For women who are experiencing menopause-related symptoms and for whom various different therapies might be being considered, there are some screenings that we do that are separate from that: clotting factor, blood cancer risk, heart disease risk, and so forth.

Medscape: Do you have any special tips for examining women at midlife and beyond?

Dr. Alexander: It's important that you maintain an open differential because even though a woman is 52 and hasn't had a menstrual period in 8 months, and has symptoms that sound like they are related to menopause, it doesn't behoove the patient or the clinic to just decide, "Those are menopause-related symptoms." You need to really make sure you go through an appropriate history and a complete physical exam and really maintain your open mind to a broad differential and potential basis for the symptoms.

Women who are at midlife are at higher risk for diabetes, just like men are, and the waxing and waning of blood sugar levels can sometimes mimic menopause-related symptoms such as hot flashes, and it's important to make sure that you screen for those other health conditions.

Dr. Alexander disclosed that she is on the speaker's bureau for Amgen.

National Association of Nurse Practitioners in Women's Healthcare (NPWH) 2011 Annual Meeting. October 12-15, 2011.

Medscape Medical News © 2012 WebMD, LLC

[Slowpurr]

Available at: http://www.medscape.com/viewarticle/408896.

Can Exercise Offset Impact of Estrogen Loss?

Physical activity, so vital to good health and well being, takes on even greater importance at menopause; as the ovaries shut down, a woman loses estrogen's protective effects against bone loss. The years surrounding the menopause, which occurs at an average age of 52, when a woman undergoes the transition from a reproductive to a postreproductive state, are termed the climacteric period. Regular exercise can prevent or lessen the impact of many of the changes women experience at this time. Exercise also can decrease morbidity and mortality after menopause by lowering a woman's risk of bone fracture.

Exercise can attenuate some of the effects of aging as well as the physical changes linked to a sedentary lifestyle. Regular physical activity can reduce the symptoms and risks of cardiovascular disease, osteoporosis, obesity, and other chronic diseases such as diabetes, which become more prevalent in the postmenopausal period.[1] There is some evidence that symptoms often associated with the hormonal changes of menopause, such as hot flashes, insomnia, and depression, can also be alleviated by exercise.[2] Despite the growing body of evidence for the benefits of exercise at any age, it is estimated that only 38% of females over the age of 19 exercise regularly.[3] The public health burden of inactivity, with its associations to coronary heart disease (CHD) and all-cause mortality, is high. All women should be encouraged to exercise regularly, and clinicians should reinforce the particular benefits of exercise to patients in their menopausal and postmenopausal years.


Authors and Disclosures

Margaret Burghardt is Staff Physician at the Fowler-Kennedy Sports Medicine Clinic, University of Western Ontario Faculty of Medicine, London, Ontario, Canada. She holds a diploma in sports medicine from the Canadian Academy of Sports Medicine (CASM).

Burghardt M. Exercise at Menopause: A Critical Difference. MedGenMed 1(3), 1999. [formerly published in Medscape Women's Health eJournal 4(1), 1999].

[*Anya*]

SAMHSA News Release
Date: 2/16/2012 12:05 AM
From: Substance Abuse and Mental Health Services Administration (SAMHSA)
Telephone: 240-276-2130

A new report shows 7.5 million children under age 18 (10.5 percent of this population) lived with a parent who has experienced an alcohol use disorder in the past year. According to the report by the Substance Abuse and Mental Health Services Administration (SAMHSA) 6.1 million of these children live with two parents—with either one or both parents experiencing an alcohol use disorder in the past year.
The remaining 1.4 million of these children live in a single-parent house with a parent who has experienced an alcohol use disorder in the past year. Of these children 1.1 million lived in a single mother household and 0.3 million lived in a single father household. This study is done in conjunction with Children of Alcoholics Week, February 12-18, 2012.

“The enormity of this public health problem goes well beyond these tragic numbers as studies have shown that the children of parents with untreated alcohol disorders are at far greater risk for developing alcohol and other problems later in their lives,” said SAMHSA Administrator Pamela S. Hyde. “SAMHSA and others are promoting programs that can help those with alcohol disorders find recovery – not only for themselves, but for the sake of their children. SAMHSA is also playing a key role in national efforts to prevent underage drinking and other forms of alcohol abuse.”

SAMHSA offers an on-line treatment locator service that can be accessed at www.samhsa.gov/treatment or by calling 1-800-662-HELP (4357).

There are many resources available to help children with a parent who has an alcohol problem. The National Association for Children of Alcoholics ( http://www.nacoa.org ) provides information and resources for professionals who may be in a position to help these children and their families. More resources are available at: http://www.samhsa.gov/prevention .

The report entitled, Data Spotlight: Over 7 Million Children Live with a Parent with Alcohol Problems, is based on data analyzed from SAMHSA’s 2005-2010 National Survey on Drug Use and Health (NSDUH). NSDUH is a scientifically conducted annual survey of approximately 67,500 people throughout the country, aged 12 and older. Because of its statistical power, it is the nation’s premier source of statistical information on the scope and nature of many substance abuse and behavioral health issues affecting the nation. http://www.samhsa.gov/data/spotlight...holics2012.pdf .

For more information about SAMHSA visit: http://www.samhsa.gov.


SAMHSA is a public health agency within the Department of Health and Human Services. Its mission is to reduce the impact of substance abuse and mental illness on America’s communities.


Last updated: 2/15/2012 4:16 PM

[*Anya*]

Joanna Broder
February 17, 2012 — Strong social support may help protect gay, lesbian, bisexual, and transgender (LGBT) youth against suicidal thoughts, new research suggests.

The first longitudinal prospective study to examine factors predictive of suicidal ideation and self-harm in this vulnerable, high-risk population indicates that support from friends and family may offer the greatest protection.

"Our research shows how critical it is for these young people to have social support and for schools to have programs to reduce bullying," senior author Brian Mustanski, PhD, a clinical psychologist and associate professor of medical social sciences at Northwestern University Feinberg School of Medicine in Chicago, Illinois, said in a release.

"I think it really informs us as to what sort of avenues we can take to help reduce suicide in gay youth," he told Medscape Medical News.

The study is published in the March issue of the American Journal of Preventive Medicine.

Suicide More Common in Gay Youth

Suicide is the third-leading cause of death among adolescents. However, LGBT youth are at least twice as likely to attempt suicide as their heterosexual counterparts. Contemplating suicide is a precursor of suicide attempts, prior research shows.

Understanding the risk factors for suicidal ideation is "crucial for improving prevention and treatment strategies," the authors write.

The investigators examined suicide risk factors such as depression and feelings of hopelessness in a general adolescent population along with a variety of LGBT-specific risk factors such as gay-specific victimization and gender nonconformity.

The study followed an ethnically diverse cohort of 246 Chicago-area LGBT youth aged 16 to 20 years at baseline for 2.5 years. The study population was not randomized. Participants self-identified their sexual orientation; they were recruited from a variety of sources, including flyers distributed in LGBT-identified neighborhoods and group listservs. Each participant completed a baseline interview, then 4 follow-up interviews were conducted 6 months apart.

Researchers chose to focus on suicidal ideation and self-harm as the main outcome measures, rather than suicide attempts, because different people mean different things by the phrase "suicide attempt," Dr. Mustanski said.

"By focusing specifically on these precursors that we can define much more clearly, it really gives us a much better window into what the risk and protective factors are," he said.

Self-Harm Risk

At baseline, participants were asked whether they had ever attempted suicide. They were also asked about their level of gender nonconformity, impulsivity, and sensation seeking.

During follow-up interviews, participants were asked about suicidal ideation, feelings of hopelessness, self-harm, bullying due to their sexual orientation, and level of support from family and friends.

Hierarchic linear modeling was used to examine between-person differences and within-person changes in suicidal ideation and self-harm over time.

Results showed that a history of attempted suicide (P = .05), impulsivity (P = .01), prospective LGBT victimization (P = .03), and low social support (P = .02) were all associated with an increased risk for suicidal ideation.

Prior suicide attempts (P < .01), sensation seeking (P = .04), female gender (P < .01), childhood gender nonconformity (P < .01), prospective hopelessness (P < .01), and victimization (P < .01) were all associated with greater self-harm.

On average, each experience of LGBT victimization was associated with a 2.5-fold increased risk for self-harm behavior.

"Well Done"

Commenting on the findings for Medscape Medical News, Anthony D’Augelli, PhD, a clinical and community psychologist and professor of human development and family studies at Pennsylvania State University in University Park, Pennsylvania, described the study as "extremely well done."

"There are a few longitudinal studies of this population, but none that have studied the issue of suicidality over time, so it makes it quite distinctive in that sense," said Dr. D'Augelli.

"Being LGBT as a young person is extremely stressful...the need for support is pretty intense," he added.

The other message for mental health professionals, said Dr. D'Augelli, is not to be judgmental and to use gender-neutral language when engaging with LGBT patients.

The authors and Dr. D'Augelli have disclosed no relevant financial relationships.

Am J Prev Med. 2012;42:221-228. Full article

Medscape Medical News © 2012 WebMD, LLC
Send comments and news tips to news@medscape.net.

[*Anya*]

Norgestimate and Ethinyl Estradiol Tablets: Recall - Packaging Error, Potential for Incorrect Dosing Regimen

AUDIENCE: OB/GYN, Pharmacy, Patient

ISSUE: Glenmark Generics Inc. issued a nationwide, consumer-level recall of seven (7) lots of Norgestimate and Ethinyl Estradiol Tablets USP (0.18 mg/0.035 mg, 0.215 mg/0.035 mg, 0.25 mg/0.035 mg), because of a packaging error where select blisters were rotated 180 degrees within the card, reversing the weekly tablet orientation and making the lot number and expiry date visible only on the outer pouch. As a result of this packaging error, the daily regimen for these oral contraceptives may be incorrect and could leave women without adequate contraception, and at risk for unintended pregnancy.

BACKGROUND: Norgestimate and Ethinyl Estradiol Tablets are used as an oral contraceptive, indicated for the prevention of pregnancy in women. The product was distributed to wholesalers and retail pharmacies nationwide between September 21, 2011 and December 30, 2011.

RECOMMENDATION: Consumers exposed to affected packaging should begin using a non-hormonal form of contraception immediately. Patients who have the affected product should notify their physician and return the product to the pharmacy. See the Press Release for a listing of affected lot numbers, expiration dates, and product photos.

Read the MedWatch safety alert, including a link to the Press Release, at:

http://www.fda.gov/Safety/MedWatch/S.../ucm293385.htm

You are encouraged to report all serious adverse events and product quality problems to FDA MedWatch at www.fda.gov/medwatch/report.ht

[*Anya*]

Diet is inextricably linked to conditions such as heart disease, obesity, and diabetes. However, what we consume also seems to have significant implications for the brain: Unhealthy diets may increase risk for psychiatric and neurologic conditions, such as depression and dementia, whereas healthy diets may be protective. Based primarily on recent Medscape News coverage, the following slideshow collects some of the more prominent investigations on nutrition and the brain into a single resource to aid in counseling your patients.

Make for Malta in Depression, Stroke, and Dementia

A 2009 study published in Archives of General Psychiatry found that people who follow Mediterranean dietary patterns -- that is, a diet high in fruits, vegetables, nuts, whole grains, fish, and unsaturated fat (common in olive and other plan oils) -- are up to 30% less likely to develop depression than those who typically consume meatier, dairy-heavy fare.[1]The olive oil-inclined also show a lower risk for ischemic stroke[2,3] and are less likely to develop mild cognitive impairment and Alzheimer disease, particularly when they engage in higher levels of physical activity.[4,5]

Fat: The Good and the Bad

A study conducted in Spain[6,7] reported that consumption of both polyunsaturated fatty acids (found in nuts, seeds, fish, and leafy green vegetables) and monounsaturated fatty acids (found in olive oil, avocados, and nuts) decreases the risk for depression over time. However, there were clear dose-response relationships between dietary intake of trans fats and depression risk, whereas other data support an association between trans fats and ischemic stroke risk.[8] Trans fats are found extensively in processed foods.

Fish Oil to Fend Off Psychosis?

Thanks to their high levels of polyunsaturated fatty acids, namely omega-3 fatty acids, fish can help fend off numerous diseases of the brain. A 2010 study correlated fish consumption with a lower risk for psychotic symptoms,[10] and concurrent work suggested that fish oil may help prevent psychosis in high-risk individuals.[11] Although data are conflicting, new research shows that the omega-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid are beneficial in depression and postpartum depression, respectively, and other research suggests that omega-3 deficiency may be a risk factor for suicide.[12-16] Oily, cold-water fish, such as salmon, herring, and mackerel, have the highest omega-3 levels.

Berries for Oxidative Stress

Polyphenols, namely anthocyanins, found in berries and other darkly pigmented fruits and vegetables may slow cognitive decline through antioxidant and anti-inflammatory properties. A study in rats from 2010 showed that a diet high in strawberry, blueberry, or blackberry extract leads to a "reversal of age-related deficits in nerve function and behavior involving learning and memory."[17] In vitro work by the same group found that strawberry, blueberry, and acai berry extracts -- albeit in very high concentrations -- can induce autophagy, a means by which cells clear debris, such as proteins linked to mental decline and memory loss.[18] Berry anthocyanins may also reduce cardiovascular disease risk by reducing oxidative stress and attenuating inflammatory gene expression.

What Not to Eat?

Saturated fats and refined carbohydrates have highly detrimental effects on the immune system, oxidative stress, and neurotrophins, all factors that are known to play a role in depression. The study by Akbaraly and colleagues cited previously[22] showed that a diet rich in high-fat dairy foods and fried, refined, and sugary foods significantly increases risk for depression. Similar findings were seen in another study from Spain,[7] showing that intake of such foods as pizza and hamburgers increased the risk for depression over time, and in another study, women with a diet higher in processed foods were more likely to have clinical major depression or dysthymia.[17] Research published last year[37] also showed for the first time that quality of adolescents' diets was linked to mental health: Healthier diets were associated with reduced mental health symptoms and unhealthy diets with increased mental health symptoms over time. Excess salt intake has been long known to increase blood pressure and stroke risk[38,39]; however, recent data also correlate high salt intake, as well as diets high in trans or saturated fats, with impaired cognition.[40,41]

PLEASE NOTE:

**Studies and references available if interested. Did not list as there are 41 separate citations!

[*Anya*]

From Pharmacotherapy

Comparison of Prescription Drug Costs in the United States and the United Kingdom: Statins

Hershel Jick, M.D.; Andrew Wilson, M.P.H.; Peter Wiggins, M.B.; Douglas P. Chamberlin, B.A.

Boston Collaborative Drug Surveillance Program, Boston University School of Medicine, Lexington, Massachusetts (Dr. Jick and Mr. Chamberlin); the Tufts Center for the Study of Drug Development, Boston, Massachusetts (Mr. Wilson); and Castlemilk Group Practice, Glasgow, UK (Dr. Wiggins).

Posted: 02/19/2012; Pharmacotherapy. 2012; 32(1):1-6. © 2012 Pharmacotherapy Publications

Abstract

Study Objective To compare the annual cost of statins in the United States and in the United Kingdom.

Design Matched-cohort cost analysis.

Data Sources U.K. General Practice Research Database (GPRD), and MarketScan Commercial Claims and Encounters Database, a large, U.S. self-insured medical claims database.

Study Population We initially identified 1.6 million people in the GPRD who were younger than 65 years of age in 2005. These people were then matched by year of birth and sex with 1.6 million people in the U.S. database. From this matched pool, we estimated that 280,000 people aged 55–64 years from each country in 2005 were prescribed at least one drug. Of these, 91,474 (33%) in the U.S. were prescribed a statin compared with 68,217 (24%) in the U.K. After excluding those who did not receive statins continuously or who switched statins during the year, there remained 61,470 in the U.S. and 45,788 in the U.K. who were prescribed a single statin preparation continuously during 2005 (annual statin users). We estimated and compared drug costs (presented in 2005 U.S. dollars) separately in the two countries.

Measurements and Main Results Estimated drug costs were determined by random sampling. Estimated annual costs/patient in the U.S. ranged from $313 for generic Lovastatin to $1428 for nongeneric simvastatin. In the U.K., annual costs/patient ranged from $164 for generic simvastatin to $509 for nongeneric Atorvastatin. The total annual cost of the continuous receipt of statins in the U.S. was $64.9 million compared with $15.7 million in the U.K. In June 2006, after our study results were analyzed, the U.S. Food and Drug Administration approved generic simvastatin. We thus derived cost estimates for simvastatin use during 2006 and found that more than 60% of simvastatin users switched to the generic product, which reduced the cost/pill by more than 50%.

Conclusion The cost paid for statins in the U.S. for people younger than 65 years, who were insured by private companies, was approximately 400% higher than comparable costs paid by the government in the U.K. Available generic statins were substantially less expensive than those that were still under patent in both countries.

For reprints, visit http://caesar.sheridan.com/reprints/...0089&acro=PHAR. For questions or comments, contact Hershel Jick, M.D., Boston Collaborative Drug Surveillance Program, Boston University School of Medicine, 11 Muzzey Street, Lexington, MA 02421; e-mail: hjick@bu.edu.