Hormones- Should We Take Them or Not?

Hormone replacement therapy (HRT) for menopausal women has been back in the news. In medicine, we've swung from placing virtually every post-menopausal woman on estrogen to barely allowing even the most miserable, hot-flashing, night-sweating woman to have any (after the Women's Health Initiative- WHI). What's the answer? Is estrogen safe or not?

As always, the devil is in the details. The WHI never said that we shouldn't be using estrogen (and progesterone) for women who had menopausal symptoms (such as hot flashes and night sweats). In fact, this is an excellent use of estrogen, and physicians and patients need not fear the short term (around five years) use of hormones to reduce symptoms as a woman's body adjusts to menopause.

The larger questions are those involving taking hormones as prevention for other issues, such as thinning bones (osteoporosis), heart disease, or dementia. Although earlier studies suggested estrogen helped protect against Alzheimers, there is not enough evidence to support taking HRT for this reason. Estrogen is one of the strongest protective factors for thinning bones, however, so for women at high risk for osteoporosis and bone fracture, there is data to support starting hormones around menopause in this group. Heart disease, however, is another story. The old thinking was that it was estrogen in women that allowed women to have lower rates of heart attacks than men, and therefore HRT might continue that benefit for menopausal women. The WHI study raised the alarm that women on HRT had a higher incidence of cardiovascular events (heart attack and stroke), and therefore confirmed other studies that suggested HRT is not appropriate if given only for prevention of heart disease. This was not new information, but it was magnified in the media and popular interpretation was that HRT is BAD and causes heart disease.

What do we know today? We shouldn't be starting hormone therapy on women who have gone through menopause many years ago. Hormone therapy is best used at the beginning of menopause, and is fully indicated for those women who are complaining of hot flashes, insomnia, night sweats, etc., during this transition time. How long should we use it? About five years. If symptoms flare as the woman tries to go off HRT, go back on for awhile longer and try to taper next year. There are many subtleties that need to be addressed (such as adding progesterone if the woman still has a uterus) but the take home message should be that women need not suffer through menopausal symptoms.

BOTTOM LINE: Estrogen is still the best medication to address menopausal symptoms such as hot flashes, insomnia, and night sweats- talk to your doctor about HRT if you are suffering!

Gardasil- Not for the FAINT,,,

Continuing my discussion this week about the HPV vaccine, Gardasil, I'd like to address side effects. At this point in the United States, there have been over 46 million doses of HPV vaccine administered (the vast majority Gardasil), which implies over 15 million people (since a series includes three shots.)
Unfortunately, when you start involving a population this large, within that group there will be uncommon diseases that occur in the general population. For example, a disease that occurs in only one out of 500,000 will have 30 cases in this group. Sorting out which of these rare occurrences are random and which are linked to a cause such as a vaccine can be challenging.

We have multiple organizations that closely follow adverse reactions to vaccines. The VAERS (Vaccine Adverse Event Reporting System) accepts reports from anyone- patients, family members, clinicians, etc. The Vaccine Safety Datalink coordinates the CDC- Center for Disease Control and Prevention- with managed care systems through electronic medical records. The Clinical Immunization Safety Assessment (CISA) network hooks up the CDC with our academic medical centers. All of these organizations collect and analyze adverse reactions to vaccines, from minor issues like transient pain, redness, swelling or headache, to fainting, blood clots and even death. What have they discovered from Gardasil?

Let's address what was not found first. Although there have been over forty deaths reported, there is no common pattern in these tragic events to link the cause to this vaccine. Some causes of death included diabetes, illicit drug use, heart failure and viral infections (not HPV).

There is an increased incidence of serious blood clots in this group, but only 10% did not have other obvious identifiable risk factors for clotting (such as obesity, smoking, or oral contraceptive use.)

FAINTING (medical term, syncope) IS a real possible side effect of this drug. The numbers are not staggering, but they are significant. Although fainting after vaccination is reported in significantly less than 1% of Gardasil recipients, Gardasil is the most frequently reported vaccine to cause fainting (as a single vaccine), accounting for over half of vaccine-related fainting episodes reported. The good news is that half of the fainting episodes occur within 5 minutes of receiving the shot, and 80% occur within 15 minutes.

BOTTOM LINE: Make sure to wait the full recommended 15 minutes after injection to minimize the risk of fainting, but be assured that Gardasil is a safe vaccine.

Gardasil- What's IN it?

Continuing the discussion about the HPV (Human Papillomavirus) Vaccine Gardasil...I'd like to step back and talk about exactly what is IN this vaccine. Much of the fear about immunizations surrounds concerns about the makeup of the vaccine, and what peripheral damage could potentially be caused from the content.

First of all, can you "catch" HPV from the vaccine? NO. Absolutely NOT. There are vaccines (like chicken pox or measles) that contain essentially watered-down versions of live virus, and as such, can in the course of an appropriate response cause a mild version of the disease as the body reacts to the vaccine, causing long-term immunity. However, the HPV vaccine does not work this way. There is only a tiny portion of the virus  (a surface protein called L1), that scientists extract, multiply and wad up into a ball. Our immune systems "see" this balled-up material as the whole HPV, and make very effective antibodies to fight it off.

What else is in the vaccine as a by-product? Is there thimerosol? NO. Is there Mercury? NO. Is there a tiny bit of aluminum? Yes. 225 micrograms of alum, to be exact, which is the same tiny amount that is allowed in infant formula (and yes, there is even aluminum in breast milk, though less than formula.) Why is there any aluminum in there at all? Well, aluminum is the most common metal found in nature- present in our water and much of our food. In vaccines, aluminum is an "adjuvant"- something added to improve the immune response.

BOTTOM LINE: The HPV vaccine Gardasil creates very effective immunity against the strains of HPV that cause 90% of genital warts and 70% of cervical cancers, and does NOT contain other byproducts that have raised concern in other immunizations.

PS Full disclosure: I am not on Merck's payroll in any fashion. I am a family physician with a special interest in STDs & I believe this vaccine will help prevent much disease & heartache.

Gardasil & Increased Promiscuity? NOT an Issue

The Gardasil vaccine is back in the news. Gardasil is the vaccine recommended for both boys and girls to protect them against the Human Papillomavirus (HPV), which causes genital warts and cervical cancer) Yesterday, an article published in Pediatrics confirmed that girls who had received this vaccine did not, in fact, have any increased sexual promiscuity compared with their peers who did not receive the vaccine. Why was this study done? One reason for lower vaccination rates with this recommended vaccine (compared to other vaccines recommended in this age group) was parental concern that giving their preteen and teenage daughters this shot would appear to be giving "permission" to be more sexually active since they would be protected.

This study looked back at roughly 1400 girls over three and a half years. Almost one third of these girls received the Gardasil vaccine, while the other 2/3 did not. After the immunization, medical issues that can result from increased sexual activity- pregnancy and sexually transmitted diseases- were measured and compared between groups. Results? No significant difference in the two groups.

The results are not surprising, but I am happy to have this data to help reassure any parents who may have this concern. I have not yet found a teen who believes that the Gardasil vaccine somehow makes them bullet-proof in the sexual arena, although I have seen many who falsely believe condoms will do so- but that is a different discussion. If teens are aware of Gardasil, they know it is "for cancer". Only the rare teen (and parent, frankly) seems to realize that this vaccine also protects against genital warts- a disease that affects over a MILLION sexually active people each year in the United States; a disease that often destroys the self-image of young people just as they are trying to make critical life decisions. Genital warts make people feel "dirty" and "gross", and although we can treat warts to make new outbreaks resolve more quickly, we do not have a cure. And if you've ever had a wart frozen off your knee or finger, you know it hurts, so add painful plus embarrassing when that wart is in the genital area.

BOTTOM LINE: Gardasil is recommended as part of our routine vaccinations for both girls and boys to protect them from HPV-related cancers and genital warts. If your child is not yet vaccinated, talk with his or her doctor at the next visit.

Teen Sexting & Risky Behavior

In 2009, headlines already noted that one in five teens "sext" despite knowing the risks. Teens sexting may be old news, but as the percentage of teens involved in cell phone based sending and receiving of sexually explicit pictures and texts increase, the links from this behavior to end points such as sexually transmitted infections and/or pregnancy need to be assessed. Last month in Pediatrics, a new study focused on teens & sexting: "Sexually Explicit Cell Phone Messaging Associated with Sexual Risk Among Adolescents". Nearly 2000 students from Los Angeles high schools were surveyed to try and determine if sexting was merely a safe alternative to the real thing or part of a pattern of risky behaviors.
Not surprisingly, sexting does indeed seem to be "part of a cluster of risky sexual behaviors" including not only sexual activity but specifically unprotected sex at last sexual encounter.

Who is doing all this sexting? Another large study from this year took place here in Texas, including 964 public high school students in Houston. (Teen Sexting and Its Association with Sexual Behaviors, from Archives of Pediatrics & Adolescent Medicine, Sept 2012).  Interestingly, although the make up of the study participants was racially split fairly evenly, "whites/non-Hispanic" had by far the highest percentage sending and requesting texts, with ~34%.  Over a quarter of these teens (28%)  reported having sent a naked picture of themselves, with equal numbers of males and females, although the girls were more likely to have been asked to send a sext. (68% girls vs. 42% of boys were asked to send one.) Of note, this request (to send a naked picture) bothered  27% of the girls "a great deal" versus only 3% of the boys.

Sexting is bringing with it a whole new set of challenges for our teens. What starts off as a joke or simple flirting can rapidly progress to pictures that would not only give their parents a heart attack, but can label the sender or recipient as a sex offender or pornographer. Behind closed doors  in the comfort of their own bedroom, teens feel safe and private flirtatiously sexting, but these exchanges rarely remain private. Additionally, these couples are at a whole new level of intimacy the next time they are together in "real life", which leads to more advanced physical intimacy at a quicker pace.

Personally, I think the vast number of non-sexting photos that young people are posting is escalating the sexting. When a guy can look and see a hundred pics of his girlfriend (& all her friends) in bikinis at the lake,  there isn't much left that wont cross the line if she wants to send something more intimate. Just my  "insta-opinion".

BOTTOM LINE: Parents, if your kids have a cell phone, please open the discussion about sexting- perhaps leading with asking if they are being sent (or asked to send) any "inappropriate" photos. 

What's This Little White Pill?

I'm guessing that I am not the first person to stumble across a stray pill- whether it's in the bottom of the purse, on the bathroom floor, or maybe in a pill bottle where you tossed together all your meds for a trip.  Certainly it can be alarming if you find a stray pill in your house- whether you are worried about your pet accidentally eating it or wondering if your teen/spouse/roommate is using a new medication. Today I simply want to share that if YOU find one of these strays somewhere and want to know what it is, thanks to technology there is a much easier answer than flipping through the picture pages of a PDR (the Physicians Desk Reference for drugs).

Online pill identifiers have you enter the pill color and shape, and then any imprint on the pill. Most pills have numbers and letters imprinted on the surface of one or both sides if you look closely. If you are still in doubt, head to your favorite pharmacy and the professionals there can use their additional resources to help identify the pill.

BOTTOM LINE: If you find a "stray" pill, start with an online pill identifier to determine what you've got. I've linked to the WebMD identifier, but there are many available. 

PS. Happy new month! You know what to do- change those air filters!