Patient education & resources

Dr. Schroeder considers these links to be reliable and professional source of patient education materials



Hormone Replacement Therapy May Be Associated With Reduced Abdominal Fat Tissue In Postmenopausal Women, Research Suggests.

CNN (3/27/18, Lamotte) reports that research on “more than 1,000 postmenopausal women, ages 50 to 80, found that those who were currently taking hormones had significantly lower levels of tummy fat than women who had never used them.” The findings were published in the Journal of Clinical Endocrinology and Metabolism.

MedPage Today (3/27/18, Minerd) reports that “the mean percentage of body fat in women undergoing” hormone replacement “therapy was 34.6%, compared with 36.2% for women who had therapy in the past and 35.9% for women who never had hormone therapy.” The study indicated that “mean visceral fat mass, measured as the fat deep in the abdomen around the internal organs, not subcutaneous abdominal fat, was 0.42 kg for women undergoing therapy, compared with 0.48 kg both for women with past therapy and those who never received it.” Meanwhile, “the mean body-mass index (BMI) was 24.9 for current users of menopausal hormone therapy, versus 25.6 for past users and 25.8 for never users.”


The Biggest Loser: Physical Exertion Is Key to Keeping Weight Off

Miriam E Tucker


WASHINGTON, DC — Persistent increased physical activity is likely essential for long-term maintenance of weight loss, new research from participants in the US TV reality showThe Biggest Losersuggests.

The new data were presented October 31, 2017 here atObesity Week 2017andpublishedinObesityby Jennifer C Kerns, MD, of the Washington, DC Veterans Affairs Medical Center, and colleagues.

Using objective measures for both energy intake and physical activity in 14 formerBiggest Losercontestants 6 years after they participated in the competition, Dr Kerns and colleagues found that those who had regained the least weight were the most active, and vice versa.

Food intake, on the other hand, had very little effect on long-term weight-loss maintenance.

"TheBiggest Loserparticipants who were the most successful in maintaining lost weight had the greatest increase in physical activity after 6 years. Our results support previous recommendations that large, persistent increases in physical activity may be required for the long-term maintenance of lost weight," say Dr Kerns and coauthors.

Asked to comment, Eric Ravussin, PhD, Boyd Professor at Louisiana State University, Baton Rouge, and coeditor ofObesity, toldMedscape Medical Newsthat the data align with those of follow-ups to major trials — including theDiabetes Prevention Programand theAction for Health Diabetes(Look AHEAD) study as well as with theNational Weight Control Registry— of thousands of people who have lost at least 30 pounds and kept them off for at least a year.

"The successful losers…all report high levels of physical activity" for weight maintenance, in contrast to weight loss, for which caloric deficit plays a far greater role, Dr Ravussin noted.

"I think we have to distinguish the weight-loss phase vs the weight-loss maintenance. For the weight-loss phase, the best way is really calorie restriction," he said, but added that it's best to begin engaging in exercise at that time too, in order to become accustomed to it for the later maintenance phase.

The reason for the difference between what works for weight loss vs maintenance, he said, probably has a lot to do with metabolic adaptation.

This was the subject of anotherBiggest Loser paperpublished inObesityin 2016, in which aperson's metabolism slows down in response to a large drop in weight, making weight-loss maintenance difficult without an extra "push" from exercise, he explained.

35 Minutes of Intense Exercise/Day to Maintain Weight Loss

The subjects in the new study were 14 participants with class III obesity who participated in a single season ofThe Biggest Loser, during which they underwent an intensive 30-week diet and exercise program and lost an average of 60 kg. Most regained weight after the program ended, although the degree of regain was highly variable.



Vaginal Estrogens Appear Safe in Menopause


  • Vaginal estrogen use does not increase the risk for cardiovascular disease or cancer in menopausal women, researchers say.

An analysis of data from theWomen's Health Initiative Observational Study shows that in women with an intact uterus, the risks for stroke, invasive breast cancer, colorectal cancer, endometrial cancer, and pulmonary embolism/deep vein thrombosis were not significantly different between women using vaginal estrogen and nonusers, Carolyn J Crandall, MD, from the department of medicine at the University of California, Los Angeles, and colleagues write.

In fact, the risks for global index event (GIE) — defined as time to first occurrence of coronary heart disease, invasive breast cancer, stroke, pulmonary embolism, hip fracture, colorectal cancer, endometrial cancer, or death from any cause — were lower in users than in nonusers (GIE adjusted hazard ratio, 0.68; 95% CI, 0.55–0.86), the study authors report. The results werepublished onlineAugust 14inMenopause.

Among women who had undergone hysterectomy, the risks for individual and overall GIE were not significantly different in users compared with nonusers of vaginal estrogen (adjusted hazard ratio, 0.94; 95% CI, 0.70–1.26).

"We did not observe an increased risk of cardiovascular disease or cancer among women using vaginal estrogen compared with nonusers," the researchers write. "These findings should provide reassurance to women and their health providers regarding the safety of vaginal estrogen and will help to inform menopausal [hormone-therapy] clinical decision-making."

Warning labels on low-dose vaginal estrogen preparations approved by the US Food and Drug Administration (FDA) are not based on clinical-trial evidence of vaginal estrogen "and may discourage the use of a highly effective local treatment for a common condition with adverse effects on quality of life," the authors warn. "Currently, the US FDA is considering a proposal to modify package labeling so that it better reflects the safety profile of vaginal estrogen," they add.

"These findings should reassure women and their healthcare providers that low-dose vaginal estrogen, which keeps blood levels within the normal postmenopausal range, is effective and safe for postmenopausal women who need relief from only vaginal symptoms," JoAnn Pinkerton, MD, executive director, North American Menopause Society, said in a statement. "The boxed warnings about the risk of heart disease, stroke, blood clots, and cancer do not apply to these low-dose vaginal therapies. Instead, women who experience bleeding or those with breast cancer should include their healthcare providers and oncologists in deciding about this option."

The prospective observational cohort study looked at data from 45,663 women enrolled in the WHI-OS, a nationwide study of 93,676 postmenopausal women aged 50 to 79 years conducted from 1993 to 2005. During a median follow-up of 7 years, none of the participants used systemic estrogen therapy.

The American College of Obstetricians and Gynecologists (ACOG) released its updated breast cancer screening guidance for average-risk women… Washington, DC (7/10/17). ACOG’s revised guidelines continue to underscore the importance of screening mammography and its role in early detection of breast cancer and consequent reduction in mortality. Among the changes, however, is an emphasis on patient–provider shared decision making to help women make informed, individualized decisions about when to start screening, the frequency of screening and when to end screening.

“Our new guidance considers each individual patient and her values,” said Christopher M. Zahn, M.D., ACOG Vice President of Practice Activities. “Given the range of current recommendations, we have moved toward encouraging obstetrician–gynecologists to help their patients make personal screening choices from a range of reasonable options.”

Shared Decision-Making

ACOG’s updated breast cancer screening guidance promotes a focus on patient autonomy and shared decision making to help women and their ob-gyns decide on an appropriate breast cancer screening strategy from among the range of reasonable options encompassed within published major guidelines. ACOG recommends that women and their ob-gyns engage in a dialogue that includes discussion of the woman’s health history; the benefits and harms of screening; and the woman’s concerns, priorities, values and preferences about the potential benefits and harms of screening. This patient-centered, individualized approach empowers women to fully consider their breast cancer screening options and take an active and informed role in their health care.

Benefits and Harms of Screening

Breast cancer is the most commonly diagnosed cancer in women and the second leading cause of cancer death in American women. Regular screening mammography starting at age 40 years reduces breast cancer mortality in average-risk women. Screening, however, also exposes women to potential harms, such as callbacks, anxiety, false-positive results, overdiagnosis and overtreatment. Varying judgments about the appropriate balance of benefits and harms have led to differences among the major guidelines about what age to start, what age to stop and how frequently to recommend mammography screening in average-risk women. The variations between the current screening guidelines have created challenges for both patients and providers in choosing or recommending the most appropriate approach to screening in a particular patient.

Summary of ACOG’s Updated Recommendations for Screening Mammography

  • Women at average risk of breast cancer should be offered screening mammography starting at age 40 years. If they have not initiated screening in their 40s, they should begin screening mammography by no later than age 50 years. The decision about the age to begin mammography screening should be made through a shared decision-making process. This discussion should include information about the potential benefits and harms.
  • Women at average risk of breast cancer should have screening mammography every one or two years based on an informed, shared decision-making process that includes a discussion of the benefits and harms of annual and biennial screening and incorporates patient values and preferences.
  • Women at average risk of breast cancer should continue screening mammography until at least 75 years. Beyond age 75 years, the decision to discontinue screening mammography should be based on a shared decision making process informed by the woman's health status and longevity.

For more information, including online shared decision-making tools and resources, please visitACOG’s Breast Cancer Screening and Treatment Resource Overview.

The Practice Bulletin #179, “Breast Cancer Risk Assessment and Screening in Average-Risk Women,” is available in the July 2017 issue ofObstetrics & Gynecology.


Teenage Birth Rate In US Falls To New Record Low In 2015, CDC Finds.

The Los Angeles Times (9/28, Kaplan) reports the teenage birth rate in the US hit a new record low in 2015, according to a report from the Centers for Disease Control and Prevention’s National Center for Health Statistics. The rate fell to 22.3 births for every 1,000 women between the ages of 15 and 19, a one-year decline of 8%, according to the report.

Vox (9/28, Kliff) reports the teenage birth rate has declined 47% since 2009 and 64% since 1991.

HealthDay (9/28, Reinberg) reports that experts attribute the decline to teenagers having less sex, using more reliable contraception, and being more aware of the difficulty of having a child while a teenager.


The New York Times (8/29, Brody) “Well” blog reports some physicians are beginning to support the use of hormones “to control life-disrupting menopausal symptoms” when used at the start of or near menopause, contradicting a trend started by the Women’s Health Initiative study against hormone treatment due to an association with heart attacks, strokes, blood clots, and breast cancer. One of the WHI’s principal investigators, endocrinologist Dr. JoAnn E. Manson, said, “The W.H.I. findings have been seriously misunderstood and misinterpreted.” She pointed out that hormone therapy’s benefits still outweigh the risks for women experiencing menopause, as long as their family history does not suggest a high risk for breast cancer.

Study: 18 Million Americans Are Now Covered Because Of ACA.

The Hill (4/18, Sullivan) reports a study conducted by the Urban Institute found that some 18 million Americans have gained access to health coverage because of the Affordable Care Act. This finding is similar to HHS’ recent conclusion that the ACA has allowed about 20 million people to have health coverage. The article points out the study also revealed that “16.9 million people gained coverage from the health law’s main provisions: its marketplaces and expansion of Medicaid.” The remaining 1.2 million are young adults who are able to stay on their parents’ plans until age 26.



Tomosynthesis mammography now at Asante hospitals

Advanced breast cancer screening equipment installed this month at all three Asante hospitals is expected to increase early detection of invasive breast cancers by 41 percent while decreasing the number of false-positive results.


Digital breast tomosynthesis systems, known as 3-D mammography, have been installed at Asante Ashland Community Hospital and Asante Rogue Regional and Asante Three Rivers medical centers.

Studies have found that tomosynthesis can also improve the detection of all breast cancers by 29 percent and decrease recalls for additional imaging by 15 percent.[1]

3D Tomosynthesis Example - Hologic

The new system, manufactured by Hologic, uses both a two-dimensional scan and a three-dimensional scan (tomosynthesis). In a tomosynthesis scan, an X-ray arm sweeps in a slight arc over the breast and takes multiple images that are converted by a computer into a stack of thin layers. A radiologist can then review the breast tissue one layer at a time.

Tomosynthesis exams require no additional compression and take just slightly longer than a conventional two-dimensional breast screening. The tomosynthesis systems replace the mammography equipment currently in use at Asante’s hospitals.


Teen Abortion, Pregnancy Rates At All-Time Low, Study Shows.

The Hill reports that a Guttmacher Institute study released on Monday (4/11/16) showed that teen abortion and pregnancy rates have dropped to historic lows since the procedure became legal. The teen pregnancy rate in 2011 was 52.4 per 1,000, which is less than half of the peak rate in 1990, and nearly 25 percent lower than the rate in 2008.



Hormone Therapy For Menopause May Benefit Younger Women, Study Suggests.

NPR (11/9, Neighmond) reports in its “Shots” blog that a closer analysis of the 2002 Women’s Health Initiative findings, which previously suggested that women taking “estrogen plus progestin hormone replacement therapy” were at an increased risk “of heart disease and breast cancer,” revealed that age “really made a difference in heart disease risk.” The analysis revealed that women between the ages of 50 and 59 actually had a protective benefit to using HRT, while women over 60 did not have the same advantage. However, regardless of age, studies did confirm a small “increased risk of breast cancer among women taking hormones.” Lead investigator Dr. JoAnn Manson explained, “For every 1,000 women per year not using hormone therapy, about three would develop breast cancer,” compared to four out of “every 1,000 women using hormone therapy” who may “develop breast cancer.” This slight increase risk of breast cancer was not seen in women on estrogen only. Their risk was slightly decreased, but not statistically significant.


Asante Rogue Regional Medical Center named One of Nations's 100 Top Hospitals

Asante Rogue Regional Medical Center has been named one of the nation’s 100 Top Hospitals® by Truven Health AnalyticsTM. The winning hospitals were announced in March, 2014's edition of Modern Healthcare magazine. The study has been conducted annually since 1993. This is the second time Asante Rogue Regional has been recognized with this honor, with the other coming in 1994.

Truven is a leading provider of information and solutions to improve the cost and quality of healthcare. If you recall, last year Truven named Asante a 15 Top Health System (the 2014 list will be announced next month).

The Truven Health 100 Top Hospitals® study identifies hospitals and leadership teams that provide the highest level of value to their communities, based on a national balanced scorecard that looks at:

  • Mortality
  • Inpatient complications
  • Patient safety
  • Average patient stay
  • Expenses
  • Profitability
  • Patient satisfaction
  • Adherence to clinical standards of care
  • Post-discharge mortality and readmission rates for acute myocardial infarction (heart attack), heart failure, and pneumonia

Here’s what Truven had to say about its 100 Top Hospitals:

“This year’s 100 Top Hospitals represent the highest national standards in hospital care and management today. They set the benchmarks for peers around the country to follow — consistently delivering outstanding quality of care, satisfaction, and community value at a reasonable cost. The majority of the 2014 award winners have produced year-to-year performance improvement, as well. This speaks to the consistent focus on excellence by the entire organization and the men and women who serve patients.”

Jean Chenoweth, senior vice president

Truven Health Analytics

For the 100 Top Hospitals® study, Truven Health researchers analyzed public information — Medicare cost reports, Medicare Provider Analysis and Review data, and core measures and patient satisfaction data from the Centers for Medicare & Medicaid Services Hospital Compare website.

The study shows that if all hospitals in the U.S. performed at the level of this year's winners:

  • Nearly 165,000 additional lives could be saved
  • Nearly 90,000 additional patients could be complication-free
  • More than $5.4 billion could be saved
  • The average patient stay would decrease by half a day

More information on this study and other 100 Top Hospitals research is available at


Johnson & Johnson pulls surgical device

Johnson & Johnson said Wednesday that it plans to ask doctors to return its power morcellators, a controversial surgical device that may inadvertently spread cancer in women being treated for uterine growths called fibroids.

The company’s Ethicon unit in April suspended sales and distribution of the devices while their role in treating symptomatic fibroid disease is reviewed by the Food and Drug Administration and the medical community. The FDA had advised doctors not to use the devices, pending further review.

On Thursday, J&J will take the further step of reaching out to customers to ask them to return the devices they have already bought in what it is calling “a worldwide market withdrawal” of all Ethicon morcellation devices that remain on the market, an Ethicon spokesman said.

The morcellators are used to cut up the uterine growths so they can be more easily removed using noninvasive procedures. They are also used in hysterectomies. But the masses may sometimes be malignant, and the spinning blade of the morcellators could spread deadly cancer and worsen patient outcomes, the FDA had warned.

— Reuters

Dr. Schroeder hasn’t used the J&J power morcellator devise when he operates on his patients who have symptomatic leiomyomas (“fibroids”). He uses other minimally invasive methods to remove them. If you have fibroids that need to be removed either by laparoscopic myomectomy or hysterectomy he welcomes your questions regarding how he proposes to remove them more safely.


More mammograms, more problems for older women?

LOS ANGELES 01/06/2013- The American Cancer Society advises all women older than 40 to get a mammogram once a year to screen for signs of breast cancer. The U.S. Preventive Services Task Force, a panel of experts that advises the federal government on health matters, says most women need to get mammograms only once every two years, and only when they're between the ages of 50 and 74.


Who's right? A new study comes down on the side of the task force. Researchers examined records of about 140,000 women ages 66 to 89 who had mammograms between 1999 and 2006. Some of the women had mammograms every year, and some of them had them every other year.


It turned out that having annual mamograms did not reduce women's risk of being diagnosed with an aggressive breast cancer, as might have been expected. When all the numbers were crunched, "the proportion (of women) with adverse tumor characteristics was similar among annual and biennial screeners," the researchers wrote in a study published Tuesday by the Journal of the National Cancer Institute.


Consumer Reports- August 2013 - Cure or snake oil?

The Food and Drug Administration has a handy online resource to help educate consumers about health-related scams that can waste money, lead to delays in getting proper diagnosis and treatment, and even cause serious injuries. the consumer-friendly site, at, has a range of resources to evaluate products and treatments that claim to prevent, treat, or cure health conditions but have not been proved safe and effective for those uses.


The 2000-Year-Old Wonder Drug

Published: December 11, 2012

Opinion Twitter Logo.

THE inexorable rise in health care spending, as all of us know, is a problem. But what’s truly infuriating, as we watch America’s medical bill soar, is that our conversation has focused almost exclusively on how to pay for that care, not on reducing our need for it. In the endless debate about “health care reform,” few have zeroed in on the practical actions we should be taking now to make Americans healthier.

An exception is Mayor Michael R. Bloomberg of New York, who is setting new standards that we would do well to adopt as a nation. In the last several years, he’s changed the city’s health code to mandate restrictions on sodas and trans fats — products that, when consumed over the long term, harm people. These new rules will undoubtedly improve New Yorkers’ health in years to come.

Such bold moves prompt a provocative question: when does regulating a person’s habits in the name of good health become our moral and social duty? The answer, I suggest, is a two-parter: first, when the scientific data clearly and overwhelmingly demonstrate that one behavior or another can substantially reduce — or, conversely, raise — a person’s risk of disease; and second, when all of us are stuck paying for one another’s medical bills (which is what we do now, by way ofMedicare,Medicaidand other taxpayer-financed health care programs).

In such cases, encouraging a healthy behavior, or discouraging an unhealthy one, ought to be a matter of public policy — which is why, for instance, we insist on vaccinating children for themeasles,mumps,rubellaandpolio; we know these preventive strategies save lives.

Under that rationale, then, why not make it public policy to encourage middle-aged people to use aspirin?

Developed in 1897 by the German chemist Felix Hoffmann, aspirin, or acetylsalicylic acid, has long proved its value as an analgesic. Two millenniums before that, Hippocrates, the father of modern medicine, used its active ingredient — which he extracted from the bark and leaves of the willow tree — to help alleviate pain and fevers.

Since then, we’ve gained insight into both the biological mechanism and the effects of this chemical compound. Many high-quality research studies have confirmed that the use of aspirin substantially reduces the risk of cardiovascular disease. Indeed, the evidence for this is so abundant and clear that, in 2009, the United States Preventive Services Task Force strongly recommended that men ages 45 to 79, and women ages 55 to 79, take a low-dose aspirin pill daily, with the exception for those who are already at higher risk forgastrointestinal bleedingor who have certain other health issues. (As an anticoagulant, aspirin can increase the risk of bleeding — a serious and potentially deadly issue for some people.)

New reports about aspirin’s benefits incancerprevention are just as convincing. In 2011, British researchers, analyzing data from some 25,000 patients in eight long-term studies, found that a small, 75-milligram dose of aspirin taken daily for at least five years reduced the risk of dying from common cancers by 21 percent.

In March, The Lancet published two more papers bolstering the case for this ancient drug. The first, reviewing five long-term studies involving more than 17,000 patients, found that a daily low-dose aspirin lowered the risk of getting adenocarcinomas — common malignant cancers that develop in the lungs, colon and prostate — by an average of 46 percent.

In the second, researchers at Oxford and other centers compared patients who took aspirin with those who didn’t in 51 different studies. Investigators found that the risk of dying from cancer was 37 percent lower among those taking aspirin for at least five years. In a subsection of the study group, three years of daily aspirin use reduced the risk of developing cancer by almost 25 percent when compared with the aspirin-free control group.

The data are screaming out to us. Aspirin, one of the oldest remedies on the planet, helps prevent heart disease through what is likely to be a variety of mechanisms, including keeping blood clots from forming. And experts believe it helps prevent cancer, in part, by dampening animmune responsecalled inflammation.

So the question remains: given the evidence we have, why is it merely voluntary for physicians to inform their patients about a health care intervention that could not only help them, but also save untold billions in taxpayer dollars each year?

For some men over the age of 45 and women over 55, the risks of taking aspirin outweigh any benefits — and patients should talk with their doctors before taking any medication, including something as familiar as aspirin.

But with such caveats in place, it still ought to be possible to encourage aspirin’s use in those for whom the potential benefits would be obvious and the risks minimal. Just as we discouragesmokingthrough advertising campaigns, for example, shouldn’t we suggest that middle-aged Americans speak to their doctors about aspirin? Perhaps pharmacists or evenhealth insurancecompanies should be enlisted to help spread the word about this disease-prevention drug?

The right policy will have to be hammered out, of course. But if we’re going to address the country’s sky-high medical bill, we’re going to have to address the need for Americans to be active in protecting their own health.

Everyone may want the right to use tobacco products and engage in other behaviors that are unequivocally linked with disease — or have the right not to wear a seat belt and refrain from other actions that may protect their well-being. But, if so, should society have the obligation to cover the costs of the consequences?

As the former Supreme Court justice Potter Stewart once said, “There is a big difference between what we have the right to do and what is right to do.” Health care reform should, at long last, focus on the latter.

David B. Agusis a professor of medicine and engineering at the University of Southern California and the author of “The End of Illness.”


Flu Shot Myths, Busted

myths stopping you from getting a flu shot? We're in the thick of cold and flu season, and the U.S. Centers for Disease Control and Prevention estimates that seasonal flu shots prevented 5 million cases of influenza last year and helped keep 40,000 people out of the hospital in 2011. Still, more than half of the population of the United States avoids getting an influenza vaccine each year, usually because they're afraid that the flu shot itself will give them the flu.

It's one of the biggest myths about the flu shot out there. "It's impossible to get the flu, and it's impossible to spread the flu" from the injection, Dr. Dennis Cunningham, an infectious disease specialist at Nationwide Children's Hospital in Ohio, told

The confusion may come from the fact that some of the vaccine's side effects—low-grade fever, body aches, and soreness at the injection site—feel like flu-like symptoms. But, "the soreness is often caused by a person's immune system making protective antibodies to the killed viruses in the vaccine," the CDC says on its website. "You cannot get the flu from a flu shot."


Menopause - A Decade After the Women's Health Initiative - - The Experts Do Agree



Stuenkel, Cynthia A. MD, NCMP, Gass, Margery L.S. MD, NCMP, Manson, JoAnn E. MD, DrPH, NCMP, Lobo, Rogerio A. MD, Pal, Lubna MBBS, MRCOG, MSc, NCMP, Rebar, Robert W. MD, Hall, Janet E. MD

Aug 31, 2012Authors & Disclosures

Menopause. 2012;19(8):846-847. © 2012 The North American Menopause Society


This year marks the 10th anniversary of the 2002 presentation of the results of the Women’s Health Initiative hormone trials. Amidst the debate that ensued, the one consistent theme was that “even the experts don’t agree.” Much has been learned and is still being unraveled regarding the safety and efficacy of hormone therapy from previous and ongoing studies. In response to the many women and clinicians seeking answers, our goal is to reassure both symptomatic women and their providers that experts do indeed agree on key points regarding the safety and role of hormone therapy in menopause management based on the scientific evidence of the last 10 years. We believe that women deserve to know the facts that can inform their decision to use or not to use hormone therapy.


Symptom Relief Benefits

Systemic hormone therapy is the most effective treatment for most menopausal symptoms, including vasomotor symptoms and vaginal atrophy. Estrogen therapy as a single agent is sufficient in women who have undergone hysterectomy.

Progestogen therapy is required to prevent endometrial cancer when estrogen is used systemically in women with a uterus.

Local estrogen therapy is effective and preferred for women whose symptoms are limited to vaginal dryness or discomfort with intercourse; low-dose vaginal estrogen therapy is recommended in this setting.

Hormone Therapy Risks

Vascular Risks

Both estrogen therapy and estrogen with progestogen therapy increase the risk of venous thromboembolic events—deep vein thrombosis and pulmonary emboli. Although the risks of venous thromboembolic events and ischemic stroke increase with either estrogen therapy or estrogen and progestogen therapy, the risk is rare in the 50- to 59-year-old age group.

Breast Cancer

An increased risk of breast cancer is seen with 5 years or more of continuous estrogen with progestogen therapy, possibly earlier with continuous use since menopause. The risk is real but not great, and the risk decreases after hormone therapy is discontinued. Use of estrogen alone for a mean of 7 years in the Women’s Health Initiative did not increase the risk of breast cancer.

Duration of Therapy

The lowest dose of hormone therapy should be used for the shortest amount of time to manage menopausal symptoms. Although fewer than 5 years is recommended for estrogen with progestogen therapy, duration should be individualized.

For estrogen therapy alone, more flexibility in duration of therapy may be possible. There are reports of increased risk of breast cancer after 10 to 15 years of use in large observational studies with estrogen alone.

Additional Information

In observational studies, both transdermal estrogen therapy and low-dose oral estrogen therapy have been associated with lower risks of venous thromboembolic events and stroke than standard doses of oral estrogen, but comparison randomized clinical trials are not yet available.

Many options for Food and Drug Administration–approved bioidentical hormone therapy (estradiol and progesterone) are available. Evidence is lacking that custom compounded bioidentical hormone therapy is safe or effective. Many medical organizations and societies agree in recommending against the use of custom compounded hormone therapy for menopause management, particularly given concerns regarding content, purity, and labeling. There is a lack of safety data supporting the use of estrogen or estrogen with progestogen therapy in breast cancer survivors. Nonhormonal therapies should be the first approach in managing menopausal symptoms in breast cancer survivors.


Leading medical societies devoted to the care of menopausal women agree that the decision to initiate hormone therapy should be for the indication of treatment of menopause-related symptoms. Although research is ongoing and these recommendations may be modified over time, there is no question that hormone therapy has an important role in managing symptoms for women during the menopausal transition and in early menopause.

I agree…. Paul Schroeder, MD, FACOG



Up-date you on what’s new in my practice as of June, 2012…

  • RVMC purchased the most advanced da Vinci Robot in mid-April and we have developed an excellent program for minimally invasive gynecologic surgery.   I was initially trained and credentialed on the da Vinci robot at Providence in 2007 and am happy to be one of the two gynecologic surgeons initially credentialed and asked to help develop the program at RVMC.  With robotic assistance, hysterectomy can be done as an out-patient and open abdominal hysterectomy is rarely necessary.  It is shocking to me how much better women do post-op and how much quicker they get back to their usual activities!

  • For women who have heavy and painful periods, but who don’t need a hysterectomy… In-office NovaSure endometrial ablation is a very good option.  This is a brief 90 second procedure and with oral pre-medication and a paracervical block we can effectively minimize your discomfort.  

  • The “Gold Standard” for the treatment of genuine stress urinary incontinence is the transobturator sling.  And, the FDA and ACOG continue to support the sub-urethral sling as the “standard of care” for this indication.  The mesh controversy that the plaintive attorneys are litigating pertains to the “mesh kits” used to treat some forms of severe pelvic organ prolapse.  I don’t use these “mesh kits”.  And, if the transobturator sling is properly placed it will rarely create the erosion and pain problems that occasionally complicate the placement of “mesh kits”.  Since 2004 I have done hundreds of transobturator slings for stress incontinence and my patients have done very well.  If you desire more information about the mesh controversy, please see the “News” section of my web site (

  • I am working with Sunstone Medical Research and am the principal investigator in a phase 3 clinical trial for the treatment of dysmenorrhea, dyspareunia and pelvic pain caused by endometriosis.  Elagolix is a new, non-peptide, oral GnRH antagonist that is likely to become the first line non-surgical treatment for these patients.  In studies to date it has been shown to be safe and effective.  And, it doesn’t have the menopausal symptom side-effects of the other available injectable GnRH analogs.  If you or a friend are suffering from pain related to endometriosis please give us a call for more information.

Ovarian Cancer Screenings Are Not Effective, Panel Says

Published: September 10, 2012

Tests commonly recommended to screen healthy women for ovarian cancer do more harm than good and should not be performed, a panel of medical experts said on Monday.

Enlarge This Image


Michael Stravato for The New York Times

No existing method of ovarian cancer screening helps reduce deaths, Dr. Virginia A. Moyer said.

The screenings — blood tests for a substance linked to cancer and ultrasound scans to examine the ovaries — do not lower the death rate from the disease, and they yield many false-positive results that lead to unnecessary operations with high complication rates, the panel said.

“There is no existing method of screening for ovarian cancer that is effective in reducing deaths,” said Dr. Virginia A. Moyer, the chairwoman of the expert panel, the United States Preventive Services Task Force. “In fact, a high percentage of women who undergo screening experience false-positive test results and consequently may be subjected to unnecessary harms, such as major surgery.”

The advice against testing applies only to healthy women with an average risk of ovarian cancer, not to those with suspicious symptoms or those at high risk because they carry certain genetic mutations or have a family history of the disease.

The recommendations are just the latest in a series of challenges to cancer screenings issued by the panel, which has also rejected P.S.A. screening for prostate cancer in men and routine mammograms in women under 50. The task force is a group of 16 experts, appointed by the government but independent, that makes recommendations about screening tests and other efforts to prevent disease. Its advice is based on medical evidence, not cost.

The recommendations against screening for ovarian cancer were published on Monday in Annals of Internal Medicine. But the warning is not new; the panel is reaffirming its own earlier advice.

Although the task force has sometimes drawn fire in the past, particularly with its stand on mammograms, it has plenty of support in this case. Other medical groups, including the American Cancer Society and the American Congress of Obstetricians and Gynecologists, have for years been discouraging tests to screen for ovarian cancer.

But some doctors continue to recommend screening anyway, and patients request it, clinging to the mistaken belief that the tests can somehow find the disease early enough to save lives. A report published in February in Annals of Internal Medicine, based on a survey of 1,088 doctors, said that about a third of them believed the screening was effective and that many routinely offered it to patients.

“We are fueled by hope,” Dr. Moyer said. “It’s such a terrible disease. Almost everyone knows somebody’s who’s had it, and that means somebody who’s died of it. You get the feeling you should do anything possible to avoid that situation, but it’s easy to forget that what you do to avoid it can make matters worse.”

Ovarian cancer is among the more rapidly fatal forms of cancer. This year, 22,280 new cases and 15,500 deaths are expected in the United States, according to the American Cancer Society.

In most cases, ovarian cancer is already advanced by the time it is diagnosed. Doctors say the only advice they can give women is not to ignore symptoms that may be the first warning of the disease: persistent bloating, pelvic or abdominal pain, feeling full early while eating and needing to urinate frequently.

For its latest recommendations, the panel relied heavily on a large study published last year in The Journal of the American American Medical Association of 78,216 women ages 55 to 74. Half were screened and half were not, and they were followed for 11 to 13 years. The screening consisted of ultrasound exams and blood tests for elevated levels of a substance called CA-125, which can be a sign of ovarian cancer.

There was no advantage to screening: the death rate from ovarian cancer was the same in the two groups.

But among the women who were screened, nearly 10 percent — 3,285 women — had false-positive results. Of those women, 1,080 had surgery, usually to remove one or both ovaries. Only after the operations were done was it clear that they had been unnecessary. And at least 15 percent of the women who had surgery had at least one serious complication, like blood clots, infections or surgical injuries to other organs.

To find one case of ovarian cancer, 20 women had to undergo surgery.

The problem with the tests is that CA-125 can be elevated by conditions other than cancer, and ultrasound can reveal ovarian enlargement or cysts that are benign but that cannot be distinguished from cancer without surgery to take out the ovary.

Nan Gudgell, 70, of Bountiful, Utah, participated in the large study. She was hoping to be in the half that were screened, so she was a bit disappointed to find that she was not. “You hope you’re going to get it and your life is going to be saved,” she said.

But upon hearing the results, Mrs. Gudgell said, “Maybe I’m the lucky guy.”

Dr. Saundra S. Buys, an author of the study and a professor of medicine at the Huntsman Cancer Institute at the University of Utah, said that despite the bad news about screening, “I think it is still being done. I think some doctors and a lot of patients really do get enticed by the possibility that they’ll find a disease early, that it might save their lives.”

Dr. Barbara A. Goff, a gynecologic oncologist at the Fred Hutchinson Cancer Research Center in Seattle and an author of the study last year that found doctors still in favor of screening, said: “If patients request it, then I think a lot of times physicians feel it’s just easier to order the test, particularly if it’s covered by insurance, rather than taking the time to explain why it may not be good, that it could lead to inappropriate surgery, could lead to harm. I don’t think they think through the consequences.”

Dr. Edward E. Partridge, the director of the cancer center at the University of Alabama, Birmingham, and another author of the large study that found screening ineffective, said that even if the testing could be improved to reduce false-positive results, it still would not save women’s lives. Even if false positives could be eliminated, the death rate from the cancer would be the same whether women were screened or not, suggesting that the test simply cannot find the cancer early enough to make a difference.

“You can fine-tune it all you want to, and that still doesn’t change the bottom line,” Dr. Partridge said, adding that he also thought many doctors were still recommending the tests despite the data. “I think it’s really important that both the physician and the public really learn and assimilate that this test as it’s currently delivered is not effective at reducing death rates from ovarian cancer. We’ve got to find something else.”


Healthcare News that may affect you...


Two recent segments of The Oprah Winfrey Show highlighted the use of custom-compounded bioidentical hormone therapy for the treatment of menopause-related symptoms…. The North American Menopause Society (NAMS) issued a response consistent with their prior position on this matter.  NAMS confirmed their support of the Food and Drug administration (FDA) and other scientific organizations that have expressed concern regarding the potential harm these products pose to women.

The “custom-compounded” recipes create a product that can be inconsistent in dose and quality, facts that have been supported by post marketing surveys of such preparations.  Relying on unsubstantiated and misleading claims of improved safety and/or efficacy, these individually mixed recipes have not been tested to prove that they provide predictable levels in blood and tissue.  Accordingly, they lack the approval of the FDA or the recommendations of the major relevant medical societies.

Conversely, the process for obtaining FDA approval of branded and generic pharmaceutical products is extremely demanding, with data from extensive clinical, therapeutic and safety trials at the core the application.  Additionally, careful scrutiny of the production process insures that the highest level of consistency in dose and quality is achieved.  These standards are nonexistent for custom-compounded products.  As a reminder, for patient seeking relief for moderate to severe menopausal symptoms, the NAMS recommends the lowest effective dose of estrogen consistent with the treatment goals for the individual woman.  And, for women who have not had a hysterectomy, a corresponding low-dose of progestin should be added to counter the adverse effects of systemic estrogen therapy on the uterus.  Dr. Schroder encourages your questions on this matter and if hormone replacement is appropriated and indicated, he will recommend products that are manufactured, package and clinically tested to the exact standards the FDA demands, and that you deserve. 


Mesh Controversy:

Plaintiff attorney firms have been advertising on TV lately asking women to call if they have had problems with mesh used to treat pelvic organ prolapse or urinary incontinence.  Some background will be helpful in understanding this controversy…   Pelvic organ prolapse problems are very common and, like any other “hernia repairs”, recurrence is fairly common after surgical treatment.  Recurrence of these “hernias” is especially common in smokers and in obese patients.  About 10 years ago “mesh kits” were developed to reinforce the vaginal repairs in the hopes of decreasing recurrence risk.  Subsequently, some patients have had problems with mesh erosions and pain with intercourse following repairs with “mesh kits”.  Dr. Schroeder has not used these “mesh kits”.  His surgical approaches in the repair of pelvic organ prolapse (without mesh) have generally held up well.  And, if recurrence becomes an issue over time, then repeat repairs are much easier and less complicated if mesh has not been placed previously.

The two procedures in which Dr. Schroeder does use mesh are…

#1   Transobturator sling for treatment of severe stress urinary incontinence.

#2   Abdominal sacro-colpopexy for treatment of severe apical vaginal prolapse.

When these 2 procedures are done properly, mesh complications have been rare and the FDA and the American College of OB/GYN continue to support the use of mesh with these two procedures…  In fact, the transobturator sling with prolene mesh continues to be the “gold standard” for the treatment of severe stress urinary incontinence.  Dr. Schroeder prefers the Obtryx prolene mesh (Boston Scientific) for his transobturator slings.   And, abdominal sacro-colpopexy with prolene mesh continues to be the “gold standard” for severe apical vaginal prolapse. 

In Dr. Schroeder’s view, it has become increasingly evident that the “mesh kits” have had a higher rate of complications.  And, Dr. Schroeder remains skeptical about their continued use.  He does not find the “risk vs. benefit” equation acceptable for the use of “mesh kits” in his patients.  When the “mesh kits” first came out, Dr. Schroeder was on the Credentials Committee at RVMC & Providence Hospital here in Medford.  Because of the lack of peer reviewed literature supporting the use of “mesh kits” Dr. Schroeder, and the OB/GYN section, imposed a moratorium on the use of “mesh kits” in our hospitals.  Over the years since then many capable gynecologic surgeons across the country have used “mesh kit” with good success and most patients have done very well.  Even some local gynecologists continue to use “mesh kits” in selected patients with severe pelvic organ prolapse and they report good out-comes.  So, the “jury is still out”; but Dr. Schroeder is happy that he has not incorporated the “mesh kits” in his operative “tool kit” and will not offer these as an option for his patients. 

Dr. Schroeder is happy to visit with you further about these issues if you are afflicted with pelvic organ prolapse or urinary incontinence.  


New report from the women's Health Initiative (WHI) regarding estrogen plus progestin hormone therapy and breast cancer published in jama on 10/20/10 (Chlebowski RT, et al)



·        "Estrogen Plus Progestin and Breast Cancer Incidence and Mortality in Postmenopausal Women" is a further analysis of the Women's Health Initiative randomized study of postmenopausal women taking conjugated equine estrogen plus medroxyprogesterone acetate, conjugated equine estrogen alone or placebo.



·        After a total mean follow-up of 11 years, there was an increased finding of invasive breast cancer in women taking estrogen plus progestin compared with placebo (385 cases [0.42% per year] vs 293 cases [0.34% per year], respectively; Hazard Ratio (HR), 1.25; 95% confidence interval [CI], 1.07-1.46; P = .004). Frequency of mammography was the same in both groups, the combined hormone and placebo groups (86%).

·        A significantly larger proportion of women with breast cancers had positive lymph nodes in the combined hormone therapy group compared with the placebo group (81 [23.7%] vs 43 [16.2%], respectively, with a HR of 1.78; 95% CI, 1.23-2.58; P=.03).   The breast cancers detected were similar in histology and grade to breast cancers in the placebo group. The increased incidence of invasive breast cancer with estrogen plus progestin compared with placebo was 385 cases [0.42% per year] vs 293 cases [0.34% per year], respectively; HR, 1.25; 95% CI, 1.07-1.46; P = .004.

·        Breast cancer mortality was increased in women taking combined estrogen plus progestin compared with women takBying placebo.  The study reported 25 deaths [0.03% per year] vs 12 deaths [0.01% per year], with a Hazard ratio of 1.96; 95% CI, 1.00-4.04; P=.049). This represents an absolute risk of 2.6 deaths from breast cancer (in the combined hormone group) vs 1.3 deaths (in the placebo group) per 10,000 women per year.

·        There were more deaths from all causes occurring after a breast cancer diagnosis (51 deaths [0.05% per year] vs 31 deaths [0.03% per year]; HR, 1.57; 95% CI, 1.01-2.48; P=.045) in women taking combined estrogen and progestin compared with placebo.  This represents 5.3 vs 3.4 deaths per 10,000 women per year, respectively.


·        The recent report from follow-up to the WHI study demonstrates the risk of breast cancer for women taking combined estrogen plus progestin.  There is an increased risk of invasive breast cancer, breast cancers presenting with positive lymph nodes, and breast cancer mortality.  While the absolute risk of breast cancer mortality is small, it is significantly increased for women taking combined estrogen plus daily progestin.

·        A 2004 report published in JAMA on the estrogen-alone component of the WHI found no increase in breast cancer risk among women with hysterectomy over an average of 7 years of randomized treatment.  

·        Women considering hormone therapy for relief of menopausal symptoms should continue to be counseled that they should use the lowest effective dose, for the shortest period of time.  Also, there is no level 1 data to support the assertion that “Bio-identical” hormones would be safer than the branded hormones used in the WHI study summarized above.


IUDs May Protect Against Cervical Cancer

By Nicholas Bakalar

Published: September 19, 2011

Intrauterine devices may offer some protection against cervical cancer, a large review of studies has found.


Health Guide:Cervical Cancer
More Vital Signs Columns

The studies were conducted from 1985 to 2007 in Europe, Asia and South America and involved nearly 20,000 women. After controlling for many health and behavioral factors, the researchers found that using an IUD reduced the risk of cervical cancer by 45 percent, compared with never using one. The review, published online last week in Lancet Oncology, said the protective effect was apparent in the first year of use and continued for as many as 10 years.

Women who choose to have IUDs inserted are more likely to have been screened for cervical cancer, but the researchers found that screening was not a factor in the reduced risk. And women with IUDs were no more or less likely than women without them to be infected with human papillomavirus, the main cause of cervical cancer. Rather, the researchers suggest, the insertion of an IUD might provoke a immune response

to HPV.

The data underscore two important points, according to the lead author, Dr. Xavier Castellsagué, an epidemiologist at the Catalan Institute of Oncology in Barcelona, Spain. First, having an IUD does not change the risk for HPV infection. And second, IUD use is associated with a reduction of almost 50 percent in the risk for cervical cancer.


Changes in Diet and Lifestyle and Long-Term Weight Gain in Women and Men

Authors: Mozaffarian D, Hao T, Rimm EB, Willett WC, Hu FB.

Citation: N Engl J Med 2011;364:2392-2404. [PubMed® abstract]

Study Question:
Do specific dietary and lifestyle behaviors promote or prevent long-term weight gain?

Three separate cohorts, which included men and women residing in the United States who were free of chronic diseases and were not obese at baseline, were used for the present analysis. The cohorts included the Nurses’ Health Study (n = 50,422), the Nurses’ Health Study II (n = 47,898), and the Health Professionals Follow-up Study (n = 22,557). The follow-up periods included years 1986 to 2006, 1991 to 2003, and 1986 to 2006. Relationships between changes in lifestyle factors and weight change were evaluated at 4-year intervals, with multivariable adjustments made for age, baseline body mass index for each period, and all lifestyle factors simultaneously.

A total of 120,877 men and women (1,570,808 person-years of follow-up) were included in this prospective study. The average weight gain across the cohorts was 3.35 lb (5th to 95th percentile, −4.1 to 12.4), or 2.4% of body weight (5th to 95th percentile, −3.0 to 8.4), during each 4-year period. This change corresponded to a weight gain of 16.8 lb over a period of 20 years. Weight change during a 4-year period was most strongly associated with the intake of potato chips (1.69 lb), potatoes (1.28 lb), sugar-sweetened beverages (1.00 lb), unprocessed red meats (0.95 lb), and processed meats (0.93 lb). Weight gain was inversely associated with the intake of vegetables (−0.22 lb), whole grains (−0.37 lb), fruits (−0.49 lb), nuts (−0.57 lb), and yogurt (−0.82 lb) (p ≤ 0.005 for each comparison). Additional lifestyle factors, which were independently associated with weight change (p < 0.001), included physical activity (−1.76 lb across quintiles), alcohol use (0.41 lb per drink per day), smoking (new quitters, 5.17 lb; former smokers, 0.14 lb), sleep (more weight gain with <6 or >8 hours of sleep), and television watching (0.31 lb per hour per day).

The investigators concluded that specific dietary and lifestyle factors are independently associated with long-term weight gain. Substantial aggregate effect exists, which is associated with significant weight gain.


Prognosis: Slight Rise in Blood Pressure Carries Risk

Published: October 10, 2011

A review of studies suggests that young and middle-aged people with slightly elevatedblood pressure, or prehypertension, are nonetheless at much greater risk forstrokethan those in the normal range.

The National Institutes of Health define prehypertension as a systolic pressure (the top number) of 120 to 139 millimeters of mercury or a diastolic pressure (the bottom number) of 80 to 89 millimeters of mercury. Readings greater than or equal to 140/90 are consideredhypertension.

Scientists at the University of California, San Diego, reviewed 12 prospective cohort studies of prehypertension and stroke incidence covering more than 500,000 participants with follow-up periods as long as 32 years. The report appeared last week in the journal Neurology.

The researchers found thatpeople under age 65 with prehypertension had a 68 percent increased risk of stroke compared with those with normal readings, independent of other risk factors. There was no increased risk among people over age 65.

Dr. Bruce Ovbiagele, lead author of the study and a professor of neurosciences at U.C.S.D., said this does not mean that people with prehypertension should start taking anti-hypertensive drugs.

Instead, he said, they should “modify their lifestyle, maintain an ideal weight, lower their sodium intake. You shouldn’t be deceived because nothing seems to be going on.”


Study flags risk of daily vitamin use among older women

ByJanice Lloyd, USA TODAY

Women who took a daily vitamin supplement — even just a multivitamin — had an increased risk of dying of cardiovascular disease and cancer, according to a study published Monday in the journalArchives of Internal Medicine.

The study highlights concerns about the long-term use of supplements and vitamins in people who do not have severe nutritional deficiencies, the authors say. An accompanying editorial notes that findings "add to the growing evidence demonstrating that certain supplements can be harmful."

Previous studies have raised questions about the value of supplements and vitamins, but researchers and nutrition experts call these new findings "puzzling" and say more research is needed.

About half of adults in theUSAtake multivitamins. Annual vitamin and supplement sales total more than $20 billion.

"I think the main message is researchers are finding very little benefit from these substances," says lead author Jaakko Murso, a nutritional epidemiologist at the University of Minnesota in Minneapolis. "Other studies have not shown the mortality risk our study shows, but those studies have not seen any positive effect either."

Researchers used data from the Iowa Women's Health Study to examine the link between vitamin and mineral supplements and death rates among 38,772 women, average age 61.6. Women filled out questionnaires about supplement use in 1986, 1997 and 2004. "Out of 15 studied supplements, seven are associated with increased total mortality risk," Murso says.

Among the findings:

•Use of multivitamins, vitamin B6, folic acid, iron, magnesium, zinc and copper were associated with increased risk of death.

•The link between supplement intake and death risk was strongest with iron.

•Calcium supplements were associated with reduced risk.

The study's authors advise that vitamins "be used with a strong medically based cause," not for prevention alone. Murso says the findings focus on the higher risk of death from cardiovascular disease, cancer and "other causes," but the study didn't examine how supplements and vitamins might affect health. "There is much more research needed to begin to understand that," he says.

"This study is very puzzling and calls for more research," says Miriam Pappo, director of clinical nutrition at Montefiore Medical Center in New York. "I wouldn't conclude from this that you stop taking a standard multivitamin. Very few people eat the required amount of fruits and vegetables a day. It's best to get your daily needs from food, but few people do that."

A spokesman for the vitamin industry was skeptical. "The study may make for interesting scientific water cooler discussion, but certainly does not warrant sweeping, overstated concerns for elderly women," said a statement from Duffy MacKay of the Council for Responsible Nutrition.

Among the 38,772 women who started the study in 1986, 15,594 died within 19 years. Self-reported supplement use increased substantially from 1986 to 2004: 62.7% of women reported using at least one supplement daily in 1986, 75.1% in 1997 and 85.1% in 2004.


New Views Of Hormone Therapy in Menopause

  • As the 25 million American women turning 50 in the next decade face a vexing question -- whether to go on hormone-replacement therapy or not. Melinda Beck on Lunch Break looks at new thinking in the great hormone debate.
  • The 25 million American women turning 50 in the next decade face a vexing decision: Hormone replacement therapy? Or not.

There's still no simple answer. For years, estrogen was seen as a fountain of youth that would keep women healthy and sexy long after menopause.

Then in 2002, the Women's Health Initiative (WHI), the big health study, found hormone-replacement therapy could raise the risk of heart disease, stroke and breast cancer. And millions of women put their pills on the shelf.

Now, after examining the data in more detail, some experts are reaching a more nuanced view of the risks and benefits and concluding that hormone therapy may still be a good option for healthy women in their 50s, depending on their symptoms, family history and worst fears.

"Every patient is like a Rubik's cube, and you have to find the right solution for her," says Maude Guerin, an obstetrician and gynecologist from East Lansing, Mich., one of 1,500 practitioners at a meeting of the North American Menopause Society (NAMS) in Washington D.C. last week. "Hormones are not a panacea or a weapon of mass destruction," she says.

There are also more treatment options today, with different hormone formulas and combinations in patches, gels, rings, creams, sprays and suppositories, allowing doctors to fine-tune dosages.

The WHI was halted in 2002, three years early, after researchers noticed a surprisingly high rate of stroke and heart disease among subjects taking estrogen and progestin—the opposite of what they expected.

Recent analysis shows most of those ill effects were in women in their 60s and 70s, who made up the bulk of the study and were on average 12 years past menopause when they began taking hormones. But among women aged 50 to 59, those who took hormones had less heart disease and were less likely to die for any reason than those getting a placebo.

Estrogen Equation

Once seen as a way for postmenopausal women to stay young and sexy, hormone therapy fell out of favor after a major health study linked it with an elevated risk of heart disease, stroke and breast cancer. Now, experts are rethinking the risks and benefits for women in their 50s.


• Lowers risk of osteoporosis and fractures

• Lowers risk of diabetes

• Lowers risk of colon cancer

• Reduces hot flashes and night sweats

• Reduces mood swings

• Prevents vaginal atrophy

• May lower cardiovascular risks in healthy women


• Increases risk of stroke

• Increases risk of pulmonary embolism

• Increases risk of heart disease in older women

• Increases risk of breast cancer, with progestin

• Increases risk of dementia after age 65

• May increase breast tenderness

The very latest research suggests that while estrogen makes atherosclerosis worse in women who already have it, it can actually help stave off atherosclerosis, inflammation and other precursors of cardiovascular disease in younger, healthier women.

Another big concern is the increased risk of breast cancer, although the absolute numbers were small. Women in the WHI who took combined estrogen and progestin had 38 cases of breast cancer per 10,000 per year, compared with 30 per 10,000 in the placebo group. Among women who took estrogen alone, however, there were 10 fewer breast cancers per 10,000 women, according to an analysis published in April in the Journal of the American Medical Association.

Some experts surmise the extra risk was due to the type of progesterone used in the trial, a synthetic form called medroxyprogesterone acetate (MPA). Women taking estrogen who haven't had a hysterectomy do need some form of progesterone to reduce the risk of uterine cancer. But other studies suggest using natural progesterone in lower doses or for fewer days may minimize the breast-cancer risk.

Some studies also suggest that a form of estrogen called estradiol, delivered in transdermal patches or gels, may avoid some cardiovascular issues that oral forms have. Two new clinical trials, called KEEPs and ELITE, which are testing transdermal estradiol and natural progesterone gel in women in their 50s, are expected to begin reporting data next year.

Considering all the current data, Wulf Utian, founder and former president of NAMS, says, "It's actually quite safe to take hormones for five to 10 years after menopause. If you minimize a woman's exposure to progesterone, you minimize her slight risk of breast cancer. Meanwhile, the estrogen will have a beneficial effect on her brain, her skin, her bones and her heart."

Some of those benefits could help millions of women. Estrogen and progestin cut hip fractures by 34% in the WHI. Half of all U.S. women over age 50 will break at least one bone as a result of osteoporosis.

"Breaking a hip will kill you a lot faster than breast cancer," says Patricia Sulak, professor of obstetrics and gynecology at Texas A & M College of Medicine. "Most women with breast cancer die of old age."

Women who took estrogen and progestin in the WHI also had a 34% lower risk of colon cancer and a 21% lower risk of developing diabetes than those who got placebos.

Estrogen therapy is also highly effective against hot flashes, which 80% of menopausal women experience, sometimes for years, according to a Gallup survey. They can be severe enough to disrupt sleep, which in turn affects energy, mood and cognitive function.

"If you have a patient who hasn't slept in three nights due to hot flashes and she's the neurosurgeon operating on your son in the morning, would you tell her not to take hormones?" asks Martha Stassinos, a doctor of pharmacy with VA Northern California Health Care System, in Oakland, Calif. "Women have been living in fear of hormones far too long."

Fluctuating hormone levels before and during menopause can affect memory, cognition and vulnerability to depression, particularly in women who have had depression in the past, according to a growing body of research.

Even a little estrogen can help stave off pain that many postmenopausal women experience during sex and even during pelvic exams because of vaginal thinning, shrinking and dryness. Creams and other local products are an option for women who can't or won't take estrogen in pill or patch form because of risk factors.

Critics of hormone therapy note that other medications can address many of these symptoms. Most, though, have their own side effects. Bisphosphonates can help halt bone loss but have been linked to severe muscle pain and sudden fractures of the thigh bone.

Some doctors prescribe antidepressants off-label for menopausal symptoms. Earlier this month, the Food and Drug Administration denied Pfizer Inc.'s application to have its antidepressant Pristiq approved as the first nonhormonal therapy for hot flashes.

Some women say natural remedies like black cohosh, red clover, soy and omega-3 fish oil also help relieve hot flashes and other symptoms. The few clinical trials to study them have yielded mixed results.

Experts stress that, although many patients don't listen, maintaining a healthy weight, eating a balanced diet, quitting smoking and regular exercise can do more for long-term health than any medication can.


Taking vitamins and minerals may be linked to a shorter, not longer, life

THE QUESTION For those who are not malnourished or vitamin-deficient, does taking vitamin and mineral supplements lead to a longer life?

THIS STUDYanalyzed data on 38,772 generally healthy women who averaged 62 years old when the study began. Their use of 15 dietary supplements was assessed periodically. By the end of the study, 85 percent of the women were taking at least one supplement daily, the most common being calcium, a multivitamin, Vitamin C and Vitamin E. During a 19-year span, 15,594 of the women died. Overall, the odds of dying in that time were higher for women who took supplements than for those who did not. Looking at supplements individually, risk increased by 2 to 6 percent for multivitamins, folic acid, Vitamin B6, magnesium and zinc. Risk fell by about 4 percent for calcium. Iron was described as being “of particular concern” because the chances of dying increased as women who took iron aged, even though they took lower doses of the supplement.

WHO MAY BE AFFECTED?Older women. More than half of U.S. adults are thought to take supplements daily. Health experts generally urge people to try to get needed nutrients from food, especially fruits and vegetables.

CAVEATSData on supplement use came from the women’s responses on questionnaires. Almost all participants were white; whether the findings apply to men and to other races was not determined. Some women may have taken particular supplements to combat health problems that may have contributed to their death (taking iron for a disease or surgery that caused anemia, for instance).

FIND THIS STUDYOct. 10 issue of Archives of Internal Medicine(

LEARN MORE ABOUTdietary supplements atwww.ods.od. for “supplement”).


Information sourced from British Medical Journal: Chocolate consumption and cardiometabolic disorders: systematic review and meta-analysis


BMJ 2011; 343:d4488 doi: 10.1136/bmj.d4488 (Published 29 August 2011)
Cite this as: BMJ 2011; 343:d4488
[Link to free full-text BMJ Research article PDF][PubMed® abstract]

Buitrago-Lopez, A et al.


Objective To evaluate the association of chocolate consumption with the risk of developing cardiometabolic disorders.

Design Systematic review and meta-analysis of randomized controlled trials and observational studies.

Data sources Medline, Embase, Cochrane Library, PubMed, CINAHL, IPA, Web of Science, Scopus, Pascal, reference lists of relevant studies to October 2010, and email contact with authors.

Study selection Randomized trials and cohort, case-control, and cross sectional studies carried out in human adults, in which the association between chocolate consumption and the risk of outcomes related to cardiometabolic disorders were reported.

Data extraction Data were extracted by two independent investigators, and a consensus was reached with the involvement of a third. The primary outcome was cardiometabolic disorders, including cardiovascular disease (coronary heart disease and stroke), diabetes, and metabolic syndrome. A meta-analysis assessed the risk of developing cardiometabolic disorders by comparing the highest and lowest level of chocolate consumption.

Results From 4576 references seven studies met the inclusion criteria (including 114 009 participants). None of the studies was a randomised trial, six were cohort studies, and one a cross sectional study. Large variation was observed between these seven studies for measurement of chocolate consumption, methods, and outcomes evaluated. Five of the seven studies reported a beneficial association between higher levels of chocolate consumption and the risk of cardiometabolic disorders. The highest levels of chocolate consumption were associated with a 37% reduction in cardiovascular disease (relative risk 0.63 (95% confidence interval 0.44 to 0.90)) and a 29% reduction in stroke compared with the lowest levels.

Conclusions Based on observational evidence, levels of chocolate consumption seem to be associated with a substantial reduction in the risk of cardiometabolic disorders. Further experimental studies are required to confirm a potentially beneficial effect of chocolate consumption.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See:

© 2011 BMJ Publishing Group Ltd.

The above message comes from "BMJ", who is solely responsible for its content.









Short-term estrogen treatments increase the brain’s gray matter among women who have gone through menopause, a time when the brain works measurably harder to focus on simple memory tasks, researchers reported Sunday.

To assess the cognitive benefits of the estrogen replacement therapy, researchers at Vanderbilt University and the University of Vermont studied two dozen healthy, post-menopausal women by giving 12 of them a standard daily dose of estrogen for three months and giving the other 12 a placebo.

Using magnetic resonance brain scanning, the scientists found that the hormone treatment had a significant effect on brain anatomy, by increasing the volume of gray matter in the brain’s cortex, where attention, decision-making and memory are centered.

“We are seeing actual differences in gray matter density,” saidPaul Newhouse, director of Vanderbilt’s Center for Cognitive Medicine, who reported the group’s findings Sunday at theannual meeting of the Society for Neurosciencein Washington, D.C.

The researchers said that the structural brain changes are evidence that women might only have to take estrogen for a relatively short time to prevent the mental lapses that often accompany menopause, avoiding the risk of serious adverse side effects associated with long-term hormone therapy.

“It’s going out on a limb, but this change in gray matter density might be important in helping to preserve cognitive function,” Newhouse said. “That could be good news.”


The truth about 'early detection' for cancer.

Go to and search for "catch me if you can" in the 2/6/12 edition


Pregnancy Rates Sank Over Last 20 Years

Published: July 2, 2012

Pregnancy rates have decreased over the past two decades among all races, ethnicities and age groups — except for women in their 30s and early 40s.

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A report issued in June by the National Center for Health Statistics says there were 4,248,000 live births in 2008, a rate of 68.1 per 1,000 women of childbearing age, down from 70.9 in 1990.

Pregnancy rates for teenagers (ages 15 to 19) fell 40 percent from 1990 to 2008, and rates for black and Hispanic adolescents also fell substantially, even though their rates are still two to three times that of white teenagers. Rates among 18- and 19-year-olds were 19 percent lower than among the 30-34 age group in 2008; in 1990 they were 41 percent higher.

Over the 19 years, pregnancy rates for women in their early 20s declined 18 percent, while the rates for women 35 to 39 rose 38 percent, and rates among women 40 to 44 went up 65 percent.

Abortions declined sharply, to 19.4 per 1,000 in 2008 from 27.4 in 1990 — about 400,000 fewer abortions. There were declines in abortions in all age groups except the oldest women, with the sharpest reductions in teenagers. Abortion rates among African-Americans were almost five times the rate of whites and more than twice that of Hispanics.

The overall pregnancy rate for black and Hispanic women was about 60 percent higher than for whites, but the disparity decreased with advancing age.

The report’s lead author, Stephanie J. Ventura, a demographer with the health statistics center, said the declining numbers were largely a result of birth control. “It’s not that the birthrate is going up and the abortion rate down, which has happened in the past,” she said. “Now everything is changing in the same direction, suggesting that more effective birth control is at work here.”

In 2008, 65 percent of pregnancies ended in a live birth, 18 percent in an induced abortion, and the rest in fetal loss. In 1990, 61 percent of pregnancies ended in a live birth, and 24 percent in an abortion.