The Medical New Report

August, 2016, #55

Samuel J LaMonte,MD, FACS

www.themedicalnewsreport.com

Subjects for August:

1. The Mental Healthcare Crisis

2. Personality Disorders-- Borderline Personality Disorder and Antisocial Behavior Disorder

3. A look at the Insured and Uninsured in Healthcare—is there an alternative to Obamacare? The GOP’s alternative!

4. The Placebo Effect—the Mind/Body Connection

5. Menopause—all you need to know!

6. Management of High Cholesterol; Statin intolerance; Alternative therapy! Combination therapy!

Did you know?

Death rates increased in 2014 for the first time in a decade according to the CDC’s National Health Center on Health Statistics. The increase comes from more deaths from Alzheimer’s disease, COPD, homicides, drug overdoses, hypertension, suicide, Parkinson’s disease, liver disease, strokes, and septicemia (infection in the blood). It is certainly not a trend we want to see continue.

New Information on the U.S. diet—JAMA reports that the percentage of Americans with a poor diet dropped from 56% to 46%. Those who are eating the ideal recommended diet increased from 0.7% to 1.5% in the U.S.!

Cool off!!

IMPORTANT REMINDER!!!! PLEASE READ!!!

  Remember that any medical information provided in these reports is just that…information only!! Not medical advice!! I am not your doctor, and decisions about your health require consultation with your trusted personal physicians and consultants.

  The information I provide you is to empower you with knowledge, and I have repeatedly asked you to be the team leader for your OWN healthcare concerns.  You should never act on anything you read in these reports. I have encouraged you to seek the advice of your physicians regarding any health issue. Feel free to share these reports with family and friends, but remind them about this being informational only. We must be proactive in our current medical environment, but in conjunction with out trusted physicians.

  Now, on with the information!! Thanks!! Dr. Sam

1. The Mental Healthcare Crisis

Types of Mental Illness

A. There are several factors to consider when discussing the current status of mental healthcare in the U.S.:

  1- The number of psychiatrists is diminishing. The Department of Health and Human Services estimates we currently have 4000 fewer mental health providers in the U.S. than is needed.

  2- There are fewer psychiatrists today than there are patients who need help. Half of all psychiatrists are 60 years of age or older. Doctors are not choosing psychiatry as a specialty; one factor is the income is very low compared to many of the specialties.

  3- More patients are being treated by primary care doctors for their mental disorders, many of whom are not trained to treat many psychological disorders. A correct diagnosis is critical to initiate the proper treatment.

  4- Reimbursement is provided for mental health services, but the insurers are creating major blocks in the implementation of treatment. Last year, more than half of those with mental health issues did not receive adequate care even with insurance. Insurers have come up with a “medical necessity” review, which creates barriers by limiting care or requiring inferior treatments be tried first.

  5- Prescribing a pill to treat a psychological disorder is only part of the treatment. It requires psychotherapy. To them to personally survive, many psychiatrists have become psycho-pharmacologists seeing patients in as little as 15-20 minutes, rather than the traditional hour session for psychotherapy. Adjusting dosage or changing medications has replaced the traditional psychotherapy session.

  6- Thanks to a continued reduction in physician reimbursement, many psychiatrists stopped accepting insurance (especially Medicare and Medicaid), which has greatly aggravated the crisis for those who are unable to pay cash for sessions. This has placed a bigger burden on less trained professionals and has shifted care to primary care physicians, nurse practitioners and PAs, when there is already a shortage in primary care.

  7- Since Obamacare began, the number of uninsured in the U.S. has dropped from 28% to 19%, but the CDC reports that there has been no increase in the use of psychological services in the U.S. due to the lack of access by those in the lower socioeconomic levels. High deductibles and unwillingness to admit the need for help are just two factors.

  8- The mental health crisis continues. Over half of the Americans today report mental health issues!

B. Some possible solutions to this crisis are:

  1- Honestly address the shortages in mental healthcare by increasing specialty training for nurse practitioners and PAs; integrate the fields of psychology with psychiatry.

  2- Strengthen enforcement of mental healthcare parity laws (the laws are there, but insurance companies are abusing them and not being punished).

  3- Invest in early intervention programs.

  4- Promote integration of primary care and mental healthcare.

  5- Improve reimbursement for the psychiatric community and find incentives for young medical students to choose psychiatry as their specialty.

  6- Until this crisis is stopped, mental health and addiction care will greatly suffer, because the current system is failing!

2. Personality Disorders—Borderline and Antisocial Personality Disorders

I. General discussion on these two Personality Disorders 

  Aggressive behavior in young men is at an all-time high. Prisons are full of these individuals without access to therapy. Personality disorders are frequently influenced by environmental factors. Recently genetic markers have been discovered that increase the risk of these disorders, which lead to problems with the family, workplace, friends and eventually the police.  

  These individuals are classic trouble makers. Growing up in a poor, high crime neighborhood is a rich environment for developing these disorders. And yet there are plenty of “rich kids” that are spoiled rotten by their parents, who come from broken homes, and or abuse drugs who are also diagnosed with these disorders. Many of these young people are never diagnosed and treated.

  A. Borderline Personality Disorder

  1.6% of the American population suffers from this disorder, and this disorder frequently goes underdiagnosed or misdiagnosed, which frequently begins as early as adolescence or early adulthood.

  Borderline is a very serious mental illness and 85% of these patients suffer with other mental problems including anxiety, depression, substance abuse, antisocial personality, and eating disorders. Unfortunately, the name of this disorder does not describe it well at all.  

  B. Borderline personality disorder should be suspected if several of the following abnormal traits are present:

  a) Unstable moods, bad behavior, and unstable relationship issues

  b) Problems regulating emotions and thoughts, impulsive and reckless behavior; anger issues

  c) “Hard to get along with”; labeled rebels and hotheads

  d) More prone to self-harm and may have suicidal thoughts  

  e) A strong genetic tendency with unstable families

  f) Aggression, impulsiveness, and poor judgment lead to trouble with law enforcement

  g) A distorted sense of self leading to difficulty staying in school or in a job

  h) Reckless behavior may lead to car accidents and dangerous hobbies

  i) Self- mutilation including cutting, hair pulling, burning, or head banging

  j) Complain of feeling empty and bored frequently

  k) Losing touch with reality including paranoid ideation can occur if the disorder worsens

  l) These patients are not adaptable to situations or change.

   C. Treatment of borderline disorder

  Borderline personality disorder is extremely difficult to treat. Psychotherapy includes cognitive behavioral therapy used to identify the core issues to work on, dealing with the patient’s misperception of themselves, anger management, enhancing self-esteem, and relationship development. Group therapy is sometimes helpful.  Therapy for the families coping with the patient is recommended.

  There is no medication specifically recommended for borderline personality disorder. However, since 85% of patients have other underlying psychological diagnoses, treatment of those associated conditions such as anxiety or depression, etc.

  Omega-3 supplements are cited as possible help. In fact, this supplement at 4 grams a day has shown promise in depression, and this may be the reason for some success in borderline personality disorder.  

II. Antisocial (Behavior) Personality Disorder

  A.  Definition 

  Antisocial personality disorder is defined as a mental condition in which a person has a long term pattern of manipulating, exploiting, and violating the rights of others. Being abused as a child, a family history of a parent having this diagnosis, or an alcoholic parent is common in these patients. Most will have conduct disorders as children. Fire setting and animal abuse is not uncommon. Some experts consider this to be the same as a psychopathic personality disorder.

  B. Symptoms of antisocial behavior

-     Being able to act witty and charming

-     Good at flattery and able to manipulate other people’s emotions

-     Break the law frequently

-     Disregard for safety of self and others

-     Substance abuse

-     Lie, steal, and fight

-     No guilt or remorse

-     Angry and arrogant

  A recent report by the British Journal of Psychiatry stated that a gene variant has been discovered (monoamine oxidase A gene) that combined with negative environmental influences (violence and or mistreatment) during childhood will predispose to this personality disorder. This genetic vulnerability continues to link genetics with the environment and aberrant behavior personalities. This link has been taught in departments of psychology and criminology for a long time, but now we have the research to prove this link between behavior and environment.

  C. Treatment

  This disorder is also very difficult to treat, but attempts in therapy to deal with rewarding good behavior have value. Anger management and addressing specific defects in a patient’s profile of signs and symptoms will help these patients.

Reference—American Psychiatric Association; Medline Plus

3. The insured and uninsured in healthcare—President Obama promotes a single payer option again!  Alternatives to Obamacare

I. Late breaking news!

  The VA has proposed that nurse practitioners be allowed to practice without supervision by physicians, since the environment at the VA is not attracting enough physicians.

  This is the government’s solution is to provide care from nurses rather than doctors. There is no question about their value. I have always been in favor of nurse practitioners and PAs to take up the void of fewer physicians, but to allow these nurses to work without a physician’s guidance, I am concerned the country is settling for less. Once this is approved, it will be years before research will tell us it was wise.  Reference: The Federal Register, the daily journal of the federal government.

II. Uninsured and insured Americans—an update!

1- When you compare the uninsured in 2010 (50 million) with the number in 2015 (30-34 million), Obamacare has done a good job of decreasing the uninsured numbers. The exchanges to purchase Obamacare policies have insured 14-16 million people in the U.S. and 15-17 million more are eligible for subsidized coverage.

2- 5-7 million make too much money to qualify for this insurance and have not bought private insurance. 5-6 million illegals are uninsured as well. There are also 3-4 million poor working Americans that don’t qualify in the states that did not expand Medicaid (20 states). See the chart for the breakdown:

3- There are still over 32 million children and adults uninsured in this country and many are illegal.  

4- This week President Obama openly endorsed a single payer option once again, which he promoted before Congress refused Obamacare. Senator Bernie Sanders promoted this system, and has influenced Secretary Clinton to come out with this option and has promised illegals will be eligible if she becomes president, which would add over 30 million to Medicaid. Donald Trump has promoted repealing Obamacare, and I expect him to negotiate for a single payer plan as well, although that option is not on his website. 

5- Several insurers including the biggest, United Health Care, have pulled out of the Obamacare exchanges, since they are losing money trying to insure these patients. Although, we all want Americans to have access to care, but as a nation have to decide how we can pay for it.  

6- There are still major barriers to many that are insured under Obamacare because of high deductibles and co-pays, many of whom folks can’t afford. 20 of the states did not expand Medicaid and is another major barrier. In those states, finding a doctor in a good network is becoming quite difficult. Narrow networks limit choice greatly.   

7- After 2016, the percentage of cost to states starts to rise, since the feds paid for it for 3 years alone. It will require increase in taxes, which over half of the country is against. Keep in mind less than half of the country pays the majority of taxes.  

8- Tax credits are given to those with incomes from 138%-400% of the Federal poverty level (single-$11,770; family of four-$24,250). Americans do not qualify above 400%.

9- The average deductible cost of the bronze plan (lowest level) for Obamacare (ACA-Affordable Care Act) is $5,200 and $3,000 for the silver plan. These are very inexpensive plans and are subsidized totally for families within 0-138% of poverty level, but they still can’t afford the deductibles and the co-pays. They are not seeking routine care and still overusing the emergency rooms as their primary source of care.

 10- The silver plan’s premiums are going up 7.5% this year. Many of them choose not to use their insurance unless it is a catastrophic problem. Many of these are poor working families.

11- Subsidy for Obamacare was based on all Americans buying insurance

  The financial penalty for not buying insurance is too low, and if the government wants these people to buy insurance, they need to penalize them accordingly. Most of these are young healthy self-employed people have to seek private insurance. The government expected 10 million Americans would buy insurance, and they have not. This is the main reason rates continue to rise for those on Obamacare, and the insurance industry raised the premium rates on everyone else, because they were losing so much money with Obamacare recipients.   

12- Breakdown of types of insurance coverage in Georgia and Florida

  In Florida, 39% of the population has employer-based insurance, 8% private pay, 19% Medicaid, 17% Medicare, and 15% are uninsured.

  In Georgia, 47% of the population has employer-based insurance, 6% private pay, Medicaid 16%, and Medicare 12%. 18% are uninsured.

13- Medicare Part D—prescription plan

  The average premium for Medicare Part D (prescription plan) individuals in 2015 was $466, and in 2016 it will go up to $496. The average Medicare cost for medications is $1926 for those ages 65-74, and $5962 for those over 85.  If a Medicare recipient has significant health issues, the cost for their drugs is two and half times these figures. You can see this is really straining Americans.  It is time the government negotiate these Medicare drug prices with Big Pharma, and the candidates promise to do so. 

14- The breakdown of cost by chronic diseases

The figures are in billions!

15- Cost of a single payer system

  It is estimated that to provide “free” healthcare, it will cost over $12 trillion dollars a year (Bernie Sanders). With the number of poor people already in the country and the borders flooding with more, this is coming to a head, and is obviously a huge political issue.

16- The cost of an employer-sponsored family health coverage premium is currently $16,834, up 3% from 2014, with the average cost to the employee of $4,823 according to the Kaiser Family Foundation.  Can employers continue to pay for their employee’s healthcare?

17- Other Alternatives to Obamacare

   We need to listen to alternative plans, because Obamacare is not working, at least financially. Nothing is going to come easy. Before we consider the option of a single payer healthcare system, consider that the management by the federal government of the VA, Medicare, and Medicaid, that are stressed to the seams and very inefficient. Americans may not like the necessary reform to sustain these programs. BUT IT IS REALITY!

   The Medicare fund will run out of money in 2028, 2 years earlier than predicted, it was just announced. Social security and disabilities programs will run out of funds in 2034.  

   Socialized systems have significant restraints on recipients (chronic, non-emergency care, and joint replacement care will immediately be affected. In other countries, the dissatisfaction with the system has led to a 2-tiered system (those who can afford private care will pay for additional private insurance for care above what is provided for by the single-payer system). DO NOT THINK A SINGLE PAYER SYSTEM WILL GIVE YOU WHAT YOU ARE USED TO IN THE CURRENT MEDICARE SYSTEM.

4. The Placebo Effect/ Mind-Body Connection

The placebo effect is defined as a fake treatment which can give a patient a positive response even though the   h the treatment is fake, because a person has the expectation that the so-called treatment will help. It is all about a person believing in the effects. The response is directly proportional to the strength of the belief.

  Multiple studies show that 25-32% of patients taking a placebo will be at least partially be relieved of their symptoms. No treatment, however, will give 100% results. Side effects of placebos occur as often as taking a real treatment. Placebos have measurable physiologic effects. Reference-medicinenet.com  

The placebo effect is attributable to a complex number of factors including:

1. The therapeutic intervention by healthcare professionals (doctors, nurses, PAs, and even the office staff) with its rituals, symbols, and interactions. In other words, if your doctor hands you a prescription, there is an endorsement of a benefit. Patients buy into that from a respected healthcare professional.

2. The clinical setting with the cues, and behavior of the professional influence a patient’s response.

3. The “hands on” advantage! When a doctor does not put his or her hands on you, the visit is considered less valuable. I hear this all the time from friends. The human touch has value.  .

4. There are well-known neurobiologic mechanisms  involving neurotransmitters (endorphins, cannabinoids, and dopamine) with activation of specific brain centers (prefrontal cortex, amygdala, and cingulate gyrus). Many medications act through these portions of the brain.

6. There are genetically determined placebo responders that are more likely to experience a more positive reaction, just like there are certain people who more easily respond to hypnosis. “The power of suggestion”!

7. The response is a proven biopsychosocial response.

8. Placebo effect may improve but rarely cures. However, actual therapeutic medications will have a much greater effect when properly labeled. Knowing you are taking the proper medication also has benefit.

9. There is a psychosocial effect from a therapeutic medication called “the nocebo effect”. For instance, if the side effects are known, there is a greater likelihood they will be experienced by anticipating their appearance, or the patient may become super sensitive to the possibility of certain symptoms. One study found that if a person is told the medication may cause sexual side effects, the patient was three times more likely to experience them. Various studies have reported 4-26% of patients will stop their medication because of perceived side effects.

10. Many view the placebo effect to be unscientific because of bias and prejudice. Some just aren’t believers.

11. Consider prayer, very supportive caregivers, and a strong positive attitude! There are studies to prove a boost in the immune system from supportive methods that could play a role in improving one’s outcome.  

12. Clearly, there are examples of “cures” that can’t be explained by medicine or placebo alone. That is why medicine is a science but also an art! We know that spontaneous regression of cancers can occur. There are genetic markers that can predict responders to certain chemotherapies. This is a classic mind/ body connection.

Quack medicine is based on the placebo effect!

   The placebo effect is taken advantage of by charlatans, quack medicine doctors, and those out to deceive people at their expense. When patients are desperate, they will spend every dime they have trying unproven methods. Consider Steve Jobs, Steve McQueen, and tens of thousands more that turned their backs on traditional medicine to try quack methods and died trying. If a person wants an experimental treatment, chose a legitimate clinical trial from a certified licensed medical center.

5. Menopause- diagnosis and treatment options

1.3 million American women reach menopause annually in the U.S. Going through the “change” is a normal biological activity as women’s reproductive years start coming to an end. Menopause has phases.

I. Phases of menopause:

  A. Menopause is defined as 12 months after the last menstrual period with the average age of 51.

  B. Pre-menopause can begin several years before actual menopause (47.5 years is the average age of actual menopause). It is defined as the period 4 years prior to the last menstrual period.

  C. Peri-menopause is defined as the time surrounding inevitable menopause. It is marked by a woman’s body starting to transition from ovarian hormonal stability to erratic production of hormones as the ovaries begin to involute (shrink) and stop making estrogen and progesterone.

  However, the ovary still produces a small amount of testosterone even after female hormones stop being produced. It may be marked by irregular periods, psychological and other physical symptoms from mood swings, less interest in sex, sleep problems, night sweats, hot flashes, and vaginal dryness with painful intercourse. Although most women experience some changes in their 40s, some will note changes in their 30s.

  One thing must be kept in mind….pregnancy can occur until a woman is no longer having menstrual periods. If you don’t want a surprise later in life, take BCPs.

  This transition is a normal process indicating the woman’s fertility phase is beginning to end. It affects some women in a dramatic way and others are blessed to have minimal symptoms. There is no clinical explanation regarding such a wide variability.  When estrogen and progesterone are not produced in normal amounts each day, these symptoms occur as the body senses these changes in levels of hormones.

  D. Early menopause

  There are factors which can influence the timing of menopause—smoking, family history of early menopause, having had a hysterectomy even though the ovaries were left intact (new study—menopause will occur on an average of 1.9 years earlier), or cancer treatment with chemotherapy or pelvic radiation.

  E. Surgical Menopause

   Forcing a woman’s body into menopause creates many challenges. Removing a uterus and one ovary will not create menopause in most women, but there are indications for removal of both (about half of all hysterectomies) in patients, for example, with cancer, severe endometriosis, and fibroids.

   Hysterectomy is the second most common surgical procedure women undergo, so this is major issue. With surgical menopause, estrogen levels plummet without HRT (hormone replacement therapy). These women need HRT until the average time for normal menopause (average 51). Early menopause will increase cardiovascular disease without HRT. The emotional consequences, and other health risks can be magnified in women with early menopause. 

   In the past, most menopausal women were given estrogen, however, this practice has changed dramatically now that the risks of continued estrogen are known. Women who have only the ovaries removed need both estrogen and progesterone, because estrogen alone increases the risk of uterine cancer.

Reference: The North American Menopause Society

For more information on menopause, click on:

www.menopause.org/for-women

II. Physiologic effects of estrogen insufficiency:

  1. Weight gain is particularly distressing and seems to enhance the anxiety of all peri-menopausal symptoms. The metabolism changes may create weight gain even in the face of taking in the same number of calories.  Redistribution of weight can also occur.

  2. The skin and hair become drier and thinner. This occurs because of the drop in oil gland production in the skin and some loss of small blood vessels in the skin. The loss of the fat and structural support (elasticity) of the skin lends itself to sagging and fine wrinkling of the skin. Added facial and body lotions will help.

  Thyroid hormone levels need to be checked as these symptoms can occur from low thyroid levels. Smoking creates wrinkled skin also. Because women still secrete testosterone, now that the estrogen is not present to counter the effects, facial hair growth can occur. Acne can begin and add to the stress. Fluctuating hormones are the culprit, just like in puberty.

  3. Brain effects are hard to prove, but vascular changes (increasing atherosclerosis) appear to be the most likely cause of subtle changes in brain function. Also the direct effect of hormonal insufficiency causes brain cellular changes. The stress of “the change” can play a role.  Headaches can worsen during the peri-menopausal time in a woman’s life.

  4. Vascular—heart disease occurs in more than 1 in 3 women and is the leading cause of death. Stroke is also increased after menopause. There is an average of a 10-15% increase in lipids as menopause approaches and contributes to an increase of heart disease by age 50.  The effects of menopause appear to begin about 10 years after the onset of menopause. Estrogen has an effect on the elasticity of blood vessels which affects the inner wall of vessels and also increases blood pressure.

  The LDL-cholesterol tends to increase. Even in the face of these effects, the American Heart Association does not recommend HRT for the average healthy menopausal female to prevent heart and vascular disease.   

  5. Hot flashes are caused by the sympathetic nervous system’s effect on the skin’s blood vessels, causing dilation of the vessels creating hot flash with sweating and flushing. Triggers include spicy foods, alcohol, nicotine, caffeine, and stress. It occurs in 80% of women peaking one year after periods cease. 50% still report these symptoms 4 years later, and 10% 12 years later.

  Risk factors to trigger hot flashes include elevated blood pressure, stress, tight clothes, spicy foods, alcohol, caffeine, heat, and cigarette smoke. Assistance may come from fans by the bedside, a cool temperature in the bedroom (68 degrees is optimum), deep breathing (yoga) techniques, very light bed clothes, exercise, a cooling pillow (foam instead of feather) or topper for the mattress. Regular exercise is highly recommended.

  If symptoms are severe enough, HRT will relieve these symptoms. Vitamin B, E, and ibuprofen may help hot flashes. Clonidine (a blood pressure medication), Gabapentin (an anti-seizure medication), Duavee, an estrogen medication plus an anti-depressant for hot flashes, have all been listed as therapeutic options.

  The only effective treatment for hot flashes is estrogen replacement, however, it should be used only in more resistant cases and monitoring of female organs for cancer is necessary. Many doctors recommend no more than 5 years of continuous therapy.

  A form of Prozac (Brisdelle) is now approved for hot flashes, which is an older antidepressant.  

  Herbal treatments have no scientific basis and the placebo effect may be playing a role. Black cohosh, red clover, Dong Quai, evening Primrose oil, and soy are mentioned as common supplements taken. Some of these can “thin” the blood, so be sure you check with your doctor before consuming these over-the-counter treatments.  Acupuncture may also be effective.

  6. Mucosal atrophy of the vagina and bladder lining is very common. In fact, the pelvic muscles lose elasticity creating many physiologic changes. Prolapse of pelvic organs can occur. Symptoms of irritation, itching, and painful intercourse are very common (40%). Symptoms of bladder irritation mimicking a bladder infection can occur. Vaginal suppositories, creams, gels containing estrogen are effective. DHEA (dehydroepiandesterone), an adrenal gland hormone, has been proven effective.

  7. Osteoporosis is a real concern with menopause.

  The first 3 years of menopause have the greatest effect on bones. Without estrogen, bone absorption occurs more rapidly than bone cell growth resulting in more brittle bones and potentially painful fractures.

   a) Osteopenia is defined as a low score (low bone mass) on a DXA scan (recommended in all women at age 65).  Osteoporosis is a silent disease until the weakness of the bone increases the risk of fractures from trauma, a fall, stress from exercise, or even just a cough or bending over.

   b) Risk factors for osteoporosis:

  Over 50 years of age, Caucasian or Asian (hip fracture twice as common in whites), thin or petite women, and those with a family history of fracture or known osteoporosis increase the risk.

   c) Testing for osteoporosis (DEXA scan)

  Bone mineral density is an indirect test that measures the strength of bones. DEXA stands for-- Dual Energy X-ray Absorpitometry.

   d) Indications for a DEXA scan:

    1- postmenopausal women under 65 with risk factors,

    2- all women over the age of 65

    3- those women who have had a fracture.

e) Treatment for menopausal osteoporosis/osteopenia

      1- Osteopenia should be considered pre-osteoporosis and can be determined with the measurements from the scanner. Calcium and Vitamin D3 supplements are recommended.

      2-Osteoporosis can be treated with HRT—estrogen replacement to reverse the bone loss plus calcium and D3.

  Below is the suggestion for dosage of calcium and Vitamin D3:

Fracture with spinal compression from osteoporosis

3- Additional treatment for osteoporosis also includes weight bearing exercises and a wide choice of prescription medications:

        --Bisphosphonates (Actonel, Boniva, Fosamax, and Skelid, Aredia, and Reclast). Fosamax and Reclast have time limits on how long they can safely be taken. These are the most common group of medications prescribed. These medications slow down the resorption of bone.   

        --Fortical-This is calcitonin--a hormone secreted by the thyroid, which lowers the blood calcium when it has risen above a normal level. It is the antagonist to parathyroid hormone, which regulates the blood calcium by suppressing the osteoclast cell. (There are osteoclasts and osteoblasts that increase or decrease the laying down of more or less calcium in the bone. Fortical, is available as an injectable medication or a nasal spray. 

        --Evista (an estrogen modulator) can also interfere with bone calcium being lost and treats osteoporosis. It is also used to prevent breast cancer from spreading into bones. Side effects include an increased risk of blood clots.

        --Prolia is a biologic agent, 2 injections (given subcutaneously) per year. It is used in men who have osteoporosis.

        --Forteo, an injectible anabolic agent, created from a bacteria (E.coli) and DNA technology. It is similar to parathyroid hormone, and is the only medication that forms new bone.

        --Viviant , another estrogen receptor modulator option, can protect the breast and uterine tissues while protecting a woman from osteoporosis.    

 Navigating which choice of medication will be your doctor’s decision!!

  8. Psychological side effects of menopause

  Although most women transition through menopause without major emotional trouble, 20% suffer from clinical depression in the peri-menopausal phase with a decreased risk after menopause occurs. Prior depression is the greatest risk factor. Higher testosterone levels during this period increase the risk as well.

  Insomnia occurs in 50-60% of women, especially if they suffer from stress, anxiety, or depression. Panic disorders also increase during the peri-menopausal period. Obsessive-compulsive and bipolar disorders may also worsen during this time. Memory loss can be stressful in some women.

III. Tests needed at the time of menopause?

  Estrogen is secreted by the ovaries, and is regulated by the pituitary gland. The pituitary is governed by the brain (hypothalamus). Stimulating hormones (gonadotropins) in turn stimulate the endocrine glands to secrete hormones. Testing the levels of the pituitary follicular stimulating hormone (FSH) can determine the extent of menopause.  To review this mechanism, please click a previous report: www.themedicalnewsreport.com (Report #31)

  To determine the extent of menopause, in addition to FSH, levels of estrogen, the pituitary thyroid stimulating hormone (TSH) level, bone density, and certain antibody tests need to be tested.  

IV. Treatment of Menopausal symptoms

  Treating specific symptoms with your doctor may help. The only actual treatment for menopause is estrogen replacement. Melatonin for sleep, antidepressants for mood swings, black cohosh for hot flashes, vaginal estrogen creams for dryness and bladder issues, vitamin D and calcium for osteoporosis prevention, statins for increasing cholesterol, a healthy diet, physical exercise, yoga, and meditation may help.

Specific treatments:

 a) Antidepressants

  Since estrogen increases serotonin and other neurotransmitters, it would follow that drops in those brain hormones from loss of estrogen would cause mood issues. Antidepressants (SSRIs-serotonin selective reuptake inhibitors) would help in many of these cases. Brisdelle, a SSRI is specifically recommended for hot flashes, although other anti-depressants are probably just as effective (Paxil, Effexor, and Prozac). Groups at increased risk include those that are unemployed, have health issues, lack social support, and those who have surgical menopause.

  b) Vaginal creams

  Painful intercourse is the most common reason for using estrogen in vaginal preparations. Very little estrogen is absorbed, but if in a high risk category, you and your doctor will have to weigh the risk and benefits.

  An alternative to topical estrogens is Osphene, a pill similar to estrogen (estrogen modulator), which will help only genital issues. The downside is it does increase the risk of uterine cancer and blood clots, as does HRT. Your doctor will need to monitor these issues. It can harm unborn babies so do not let a pregnant woman touch the pill.

   Another vaginal suppository (DHEA) should be available this year, an adrenal hormone. This is another alternative to estrogen preparations.

  c) Herbal and alternative methods were discussed under hot flashes. 

  d) Lifestyle changes--Tips to cope with menopause: exercise, limit alcohol, stop smoking, do yoga or tai chi, drink lots of water, skip hot showers, increase antioxidants, and keep busy. Ask for support from your significant other….it will help.

  e) Female Replacement--Taking estrogen and progesterone will limit the risk of uterine cancer, but progesterone increases the risk of breast cancer even more than estrogen replacement by itself. Certain risk factors for developing breast/ovary/colon cancer will play a role.

  f) Risk of estrogen replacement

   If on HRT, closer surveillance for breast, ovarian, and uterine cancer are indicated.  A strong history of osteoporosis and heart disease or stroke also should be included in the decision making. Family history, BRCA gene mutation presence, severity of symptoms, etc. are all issues to be considered. Gall bladder disease and blood clots can occur at an increased rate.

  g) EPT-Estrogen and Progesterone combination therapy versus Estrogen alone--If a woman and her doctor decide to take a combination of estrogen and progesterone replacement, consider taking the smallest dose possible to minimize the risks.

  There is no increased risk of breast cancer with estrogen alone, in fact, if a woman has no family history of breast cancer, there is a slight decreased risk. Taking both estrogen and a progestin increases the risk. The treatment also should be taken for less than 5 years. After 3 years of not taking HRT, the risk for breast cancer returns to that of the general population.  

  If a woman has not had a hysterectomy, consideration for both progesterone and estrogen can be discussed. The reason is to prevent the increased (2-3 fold) risk of uterine cancer with estrogen alone.

  Even though combination therapy does not increase the risk of lung cancer, it does increase the risk of dying from it.

  Taking hormone replacement is known to decrease the risk of colorectal cancer by as much as 50%.  

  Estrogen-Progestin-EPT:

  a) There is a continuous daily dose of both estrogen and a progestin. It is preferred by many women because it causes less menstrual bleeding.

  b) Sequential EPT—implies giving estrogen and a progestin at different doses during the month.

  c) Bio-identical hormones imply taking both estrogen and a progestin, the dose of which is determined by the level of hormone monitored by blood tests.

  d) ET-Estrogen therapy alone—should be reserved for those women who have had a hysterectomy.

  e) Preparations:

     --Systemic therapy--The preparations that provide blood (systemic) levels of hormone replacement can be given as 1) a pill 2) a patch 3) a high dose vaginal ring or 4) an injection.  These preparations will help hot flashes, night sweats, vaginal dryness, and prevent and or treat osteoporosis.

     --Topical hormones can be used to treat localized vaginal symptoms in the form of creams, low dose vaginal ring, or vaginal tablets. If the dose is low, very little of the hormone is absorbed in the blood stream.    

 Caution:

Estrogen replacement is not recommended for a woman who has had breast, uterine or ovarian cancer, a family history, genetic markers such as BRCA, vaginal bleeding, a history of blood clots, a heavy smoker, or liver disease (gall bladder disease may be worsened).

  This is a complicated issue and needs to be carefully discussed with your doctor (and a second opinion) and consider the risks and benefits depending on the severity of post-menopausal symptoms.

The North American Menopause Society is good resource:

6. Management for high Cholesterol; Intolerance to statins! Alternatives to statins; Combination therapy

Background

  Only 50% of patients that need statins to lower LDL-cholesterol are taking these medications. This is sad since these medications are proven to reduce cardiovascular events from high cholesterol. Statins have more benefits than previously known, which will be discussed.  

  I have discussed cholesterol and the statins are numerous occasions. For a review, click on these reports:

www.themedicalnewsreport (#4) (#5) (#8) (#13) (#27) (#43)

A. What are the benefits of taking statins?

  With a low fat diet, statins are very successful in reducing LDL-cholesterol. They also can actually reduce cholesterol plaques in arteries directly. Even if the patient did not have a reduction of cholesterol, they still had measurable reduction of plaque in arteries.

B. What are the barriers to taking statins?

  1) cost 2) ignorance about value 3) don’t have insurance 4) fear of side effects (60% stop by 2 years because of the fear) 5) some physicians do not explain the importance of statins and 5) indifference to taking a medication for life.

C. Importance of diet

  Reducing cholesterol always begins with a proper diet. Medications to reduce the LDL should be considered as an adjunct to a proper low fat diet. If a person needs help with this, ask your doctor to see a dietician.  

  More recent studies indicate that taking a statin works directly on blood vessel lining, thus reducing the risk of obstruction from plaques.

 D. The 2013 guidelines for taking statins (American Heart Association/American College of Cardiology) include:

1) Start statins at 21 years of age if the patient has clinical heart disease 2) 21 years of age if the LDL-cholesterol is 190mg/dl or greater 3) age 40-75 without an elevated cholesterol but type 2 diabetes with a LDL of 70-189mg/dl 4) 40-75 with an elevated risk for heart disease and LDL of 70-189mg/dl. 

E. Intolerance to statins

  20% of those prescribed statin medication for the treatment of high cholesterol are reported to not tolerate them for one reason or another (gastrointestinal, increase blood sugar, etc.). There are those patients that statins do not work on probably on a genetic basis. In studies even the placebo group claim muscle pain and cramps in 35%!

   Although there are the usual side effects, muscle pain from actual muscle cell damage (myopathy, myositis, rhabdomyolysis) is a known side effect of all statin medications (some more than others). Muscle cramps, tightness, and pain are all symptoms described. 40% stated that heavy exercise preceded the symptoms.

  If associated shortness of breath and fatigue is present, it is thought to be even more likely to occur from statins.  It should be noted there is a big difference between true myopathy and simple muscle pain. Your doctor needs to diagnose the difference before taking you off statins. The recognized true myopathy side effect of statins is only 0.1% in double-blind studies (very controlled and much better than any observational study).

 F. How statins actually work!

  For those who would like to know how statins cause muscle damage, here is the theory—statins inhibit the release of mevalonate, a biologic compound necessary to form cholesterol and other compounds. Blocking an enzyme (HMG reductase CoA) in the pathway leads to depletion of certain metabolites (cholesterol, isoprenoids, and Co-Q-10). Depletion of these intracellular metabolites causes damage creating the release of an enzyme creatine kinase, which can be measured in the blood. It should be noted that about 25% of these injuries have underlying muscle disorders.

Here are some common statins:

Big Pharma continues to abuse the public:

The fact that co-enzyme Q-10 is theoretically depleted in the muscle cell, has led to the supplement industry to recommend replacing it by taking a supplement of Co-Q10. There is no solid research to prove that taking this supplement is valuable.  

  There is an increased risk of myopathy from statins in patients with liver or kidney disease, diabetes, hypothyroidism, female, and older (>65), heavy exercise, excess alcohol intake, and intake of certain foods and medications-grapefruit daily, digoxin, calcium channel blockers such as Cardiazem, niacin, fibrates, antifungals, Coumadin, etc.).

 G. Consideration for stopping a statin

  If muscle tenderness, cramps, or pain occurs for over 2 weeks, you should report this to your doctor immediately and discuss whether you should stop the medication, consider a lower dose, add additional medications, or rely on alternative therapy.  Reference: Cleveland Clinic

  It is now recommended that if statin intolerance is assessed, the dose should be lowered, taken every other day, or discontinued. 

 H. Adding an additional medication

  If the LDL is greater than 190mg/dl, adding a non-statin can be considered, if the statin did not lower the LDL by 50%, an additional medication mat be considered.  Xetia is the best additive therapy. Reference- J. Amer. College of Cardiology, 2016

  Statins can decrease complications from cardiovascular disease, but there are alternatives.

 I. Alternative or added therapy

  --Ezetimibe (Xetia) (pronounced with a “z”) is a fat blocker, in that it prevents fat from being absorbed into the blood stream from the bowel (10mg dose daily).  Although proof of its value in reducing cardiovascular disease as a substitute is under study, Xetia has value if statins are not tolerated. This, of course, is a decision for you and your doctor.   

  Xetia, in addition to a statin, can drive the cholesterol even lower (the latest level is 70mg/dl which is 30 points below normal levels). This level is the goal for people who have elevated cholesterol and known cardiovascular disease. Whether the combo reduces cardiovascular events above the value of a statin alone is still being evaluated. It is hypothesized that if the cholesterol is lower, that correlates with a reduction in cardiovascular events.

  Since a significant percentage of patients have to be taken off statins, I suspect the interest in Xetia has been rekindled.

  --Evolocumab (Repatha) or Alirocumab (Praluent)

  The new injectable medication evolocumab (Repatha) or alirocumab (Praluent) are two of the new class of drugs called PCSK9 inhibitors, which are antibodies that interfere with the liver being able to release cholesterol into the blood stream.  The FDA approved it for families with hereditary cholesterol cases. Studies have shown that after taking it for 12 weeks, there was a 60% reduction in LDL cholesterol.

   As many as 11 million patients could qualify for this medication and bring $2.5 billion annual profit to Amgen, the drug company. It is injected subcutaneously every 2 weeks at home. Cost to the patient starts at $14,500 yearly. Not all insurance plans cover these drugs.

  This medication is recommended for only the highest risk patients.

  It should be noted that all these medications can cause muscle symptoms (about the same as Xetia).   

  --Fenofibrate

  This medication can lower cholesterol and triglycerides, but there is no proof that it lowers cardiovascular disease.

  The FDA just pulled approval using the extended release niacin (Niaspan) and a fibrate called fenofibric acid (Trilipix) in addition to a statin (the additional drugs  increase HDL-cholesterol and lowers triglycerides) do not reduce the risk of cardiovascular events. There are two preparations that combine these drugs with a statin in one pill (Advicor and Simcor). If you are on these meds, contact your doctor. Medscape

  --Niacin-Vitamin B3

  Although the vitamin niacin amide, 2000mg a day, causes burning of the skin and a sensation of “needles and pins”, a very uncomfortable feeling, it can lower cholesterol, if you can tolerate it.

 J. General comments about these alternatives

  About 20% of patients prescribed these alternative meds will experience muscle pain as well, so it is very important to carefully assess the cause of muscle complaints. In studies, placebos cause the same symptoms about 20% of the time. Muscle enzymes can be tested, which are elevated if there is actual damage to the muscle, but extreme exercise can elevate it as well.  

  Talk to your doctor and discuss with them the best methods for lowering the risk of cardiovascular disease. All of these meds must be added to a low fat diet, regular exercise, and a balanced diet to really be effective. If you can’t take statins because of side effects, these alternatives have to be considered.

Reference-

www.medlineplus.gov/statins.html

  This concludes the August, 2016, Medical News Report. Next month, I will present information on:

1) New information on insomnia 2) Concierge Medicine 3) Genitourinary Series-function of the kidneys and bladder 4) GI series-function of the large bowel and diseases of the colon 5) The controversy of bilateral mastectomy for one sided breast cancer 6) new guidelines for atrial fibrillation treatment.

  As always, Stay healthy and well, my friends. Dr. Sam

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