Saturday, November 29, 2014

Dental Probiotics: Bacterial Dental Insurance?

Our microscopic fellow travelers are all the rage today, rating their own study group known as the Human Microbiome Project.  I’ve long recommended intestinal probiotics for years to my patients as they’re treated for infections in an effort to avoid some of the intestinal upset associated with antibiotics.  I never gave a thought to probiotics for oral and dental health until I was invited to try this Pro-Dental for review.

Tuesday, November 25, 2014

How Do I Make a Medical Decision? Part II

When last I wrote about making a medical decision (Part I), I focused on the importance of identifying a trusted source to assist you in the process.  While there are inanimate sources such as Internet sites of more or less trustworthiness, printed or pixelated matter informants are one-way interactions.  You  match your situation with the closest approximation available which cannot in turn adjust its wisdom to the unique details of your past or present history.

So let's say your matter involves a consultation with a medical professional.  You've doubtless arrived with thoughts on your subject. What's going through your doc's mind as you meet face-to-face?  

From the first moment that I greet a patient, I am already forming hypotheses or educated guesses. Back in the good old days, I'd walk to the waiting room to call a patient in; we'd shake hands in greeting ( fingers dry? cold? clammy? weak?)(1), then I'd watch them walk--or limp--down the hall.   Armed with the 'reason for visit' from my day's schedule, I'm looking for pattern recognition from moment one of our visit, and 33 years into practice, I've seen a lot of patterns go by(2).  In for foot pain?  Teenaged boy limping with skateboard in hand maybe has broken his toe; older, stout man in a suit, well perhaps he's got gout.

My thoughts are forming as I call on experience (Have I seen this before?) and/or evidence (Have I read about this before?).  If I jump to a conclusion too fast, a diagnostic error called 'premature closure', I'm risking a missed diagnosis which could be inconsequential or a downright disaster.  If I narrow the diagnostic field not at all (which, unfortunately, seems to be an ER predisposition), I may be heading for an unguided work-up of unbridled costs in money and time.  What if I don't let go of my initial impression as contradictory test results come in--an 'anchoring bias'--or fall into a 'confirmation bias' in which I highlight data that supports my anchored diagnosis, ignoring the results that just don't fit in. 

No wonder patients prefer doctors with whom they have a history, seek information on the Internet, and request second opinions.  Now more than ever, get informed and ask questions. Be an advocate for yourself and your family; you're half of the diagnostic partnership.
(1) There's a serious debate now over whether or not patients and docs should shake hands.

(2) Which raises an interesting question:  Would you rather be seen by a doc out in practice for years with a lot of hands-on experience or one just out of training who's up to date on the latest medical studies, clinical tests, and procedures?

Monday, November 24, 2014

Duavee: Finally! A new approach to menopause

A decade into menopause, and I'm still hot (no, not that kind of hot, just middle-of-the-night way too warm hot).  For ten years I weighed estrogen pluses, namely good for the bones, brain, and heart, with estrogen negatives, that nagging worry regarding breast health, and I revisited that analysis annually.  Just this past year, estrogen yikes overtook estrogen yay, and I dropped my weekly dose to just a tick over negligible.  And subsequently lost two checks, a zillion pens, one notebook, my pedometer, my keys again and again, 5 pounds of muscle, and 1/2 inch of height. 

Enter a new kid on the menopausal treatment list, a so-called TSEC or tissue selective estrogen complex, also known by the not-so-catchy name of Duavee.  It was approved in October, 2013, but I only found out about it in the March issue of the journal "Menopause" which featured a long article and accompanying editorial about this drug.

Duavee is a combo drug, a pharmaceutical 'two-fer'.  It contains Premarin (no, I don't love that about it either, but more on that later) and bazedoxifene which is not approved as a stand-alone drug in the U.S. although it is available in Europe.  Each of these drugs interact with estrogen receptors in the body, but while Premarin stimulates the 'on switch' when it couples with cellular receptors, bazedoxifene turns some estrogen receptors on and some of them off depending on the specific tissue involved.  It is one of a class of drugs called selective estrogen receptor modulators (SERMs). 

Tamoxifen is also a SERM long-used to decrease risk of estrogen-receptor positive breast cancer or to prevent its recurrence. Tamoxifen, unfortunately, stimulates estrogen receptors in the uterus, thus increasing risk of uterine cancer, and some women do not like the way they feel when they're on it.  Another SERM that's been around for awhile is raloxifene or Evista which is prescribed for the prevention and treatment of osteoporosis.    Evista works well on preserving bone density, protects the breast against estrogen stimulation, but aggravates hot flashes.

The ideal treatment for the health challenges of menopause would turn on all the right estrogen receptors (bone, brain, vascular tissue, genitalia) and would turn off those better left quiescent in aging ladies (breast and uterus).  Estrogen works wonders on hot flashes also known as vasomotor symptoms; in fact, it's the very thing.  It supports bone density and has a number of favorable effects on brain and cardiovascular health.  Unfortunately for women no longer in their reproductive years, it stimulates breast and uterine tissue in an unwanted sort of proliferative way that, over many years, increases risk of cancer and fibroids.  As a result, progesterone is added to hormone regimens to offset the estrogenic stimulation to the uterus, but this addition only increases the breast cancer risk.  In addition, the effect of oral estrogen, particularly non-human oral estrogen such as Premarin, has undesirable effects on inflammation and clotting in the body.  While many women did well for many years on the combo drug known as Prempro (Premarin plus a synthetic progesterone called Provera), the results of the Women's Health Initiative released in 2002 included significant increases in incidence of stroke, heart attacks, breast cancer, and dementia in women on the Premarin/Provera combination.  Of note, however, is that women taking only Premarin did not experience an increased risk of breast cancer.  Nevertheless, this study drastically changed prevailing opinion on the benefits of post-menopausal hormone therapy, and its use has since dramatically dropped.

The combination of bazedoxifene and estrogen is just short of perfect.  The estrogen component decreases hot flashes although the dose is lower than ideal to completely beat not only the heat but also genital atrophy (as in painful intercourse).  Better yet would be bazedoxifene all by itself to be used along with an estrogen skin patch.  For now, however, as I work on my personal equation of health goals vs. personal fears, Duavee gets a tentative one to two thumbs up.

Interested in more insider scoops on good health choices for the rest of your life?  Stay tuned for September announcements on small group seminars on menopause, osteoporosis, and cardiovascular health.
Check out Duavee review and Duavee and sleep for an update on my Duavee journey.

Duavee and sleep

...or how I gave up formication and got enough sleep
I'm now entering month five of Duavee use, and updating my previous review with a bit more good news.  If you're reading this post, you must be dissatisfied with the state of your sleep.  More than one scholarly review of the downside of menopause--the upside, I suppose, being the state of maturity and wisdom to which we've arrived--states that associated poor sleep  is not just about heat.  As my night's rest improves post-Duavee, I realize that it is more, in fact, than the end of the sweats. 

Yes, hot woke me wondering what on earth I was thinking when I turned off the light and settled to sleep beneath a mountain of quilts. But what kept me awake once I'd doffed the duvets was a maddening case of formication.  Look carefully, that's an 'm' not an 'n', as in formication from the latin word formica meaning ant.  A known side effect of menopause, formication is the itchy, maddening sensation that ants or some other insects are crawling on your skin.  If you're a woman of a certain age and you know it's an illusion, it's formication.  If you are convinced there's really insects on or in your skin, it's called delusional parasitosis which is a nightmare syndrome and no laughing matter.

I still wake up in the middle of the night, but, if I do, I'm not sensing an army of ants on the march up my limbs. As a result, after a trip to the bathroom, I'm right back to sleep. One can never be sure if improvements with meds are coincidental or causative, but perhaps due to Duavee, my sleep is creep-free.

Duavee review

Since last I wrote about Duavee, I have had several e-mails from a scientist heavily involved with hormone research, specifically the development of an ideal selective estrogen receptor modulator (aka SERM) for post-menopausal use. Our communications have convinced me that this medication is the best solution currently available for those of us aging ladies unhappy with the physical effects of no estrogen on the quality of our lives yet worried about the downside of hormone therapy.

SERMs are, as I mentioned, synthetic molecules that act like estrogen insofar as they can occupy estrogen receptor sites on cell membranes.  However, unlike estrogen which activates cellular machinery in a stimulatory sort of way, these compounds can activate or turn-off estrogen effects depending on the specific tissue involved.  For instance, the SERM tamoxifen is used to prevent the development or recurrence of estrogen-receptor positive breast cancer (a tumor whose growth and spread is spurred on by its interaction with estrogen) through a blockade of estrogen receptors in the breasts. Raloxifene (brand name Evista) is prescribed for the prevention and treatment of post-menopausal bone loss because it stimulates bone in an estrogen sort of way but has tamoxifen-like effects on breast estrogen receptors.  Due to this latter property of the drug, it has the possible beneficial side effect of decreasing risk of estrogen-driven breast cancer but is not FDA approved for this purpose.

Duavee contains bazedoxifene, the newest addition to available SERMs. This compound turns on estrogen receptors in bone while turning off those in breast and uterine tissue.  When paired with a touch of conjugated estrogens (Premarin), it promotes bone health while blocking detrimental effects of its estrogen partner on breasts and uterus. Meanwhile, the estrogen squashes hot flashes and favorably affects vaginal dryness although the dose is low enough that it may not completely eliminate these problems. This is exactly what I was looking for in menopause support as my bone density is going downhill along with my height, and my sleep continues disturbed by hot flashes.

If you've been researching menopausal remedies, you are aware that the ongoing use of hormones after menopause can stimulate unwanted cell proliferation in both the breasts and the uterus and, over time, can induce a malignant transformation in either of these tissues.  For those of us who have never had a hysterectomy, hormone replacement therapy has routinely included progesterone in order to protect the uterus from estrogenic stimulation.  Progesterone, however, is fraught with side effects including breast swelling and tenderness, bleeding, drowsiness (especially from natural progesterone), and depression.  Worst of all, the estrogen/progesterone combo, whether 'natural' (molecules produced synthetically but just like those you had through your reproductive years) or 'unnatural', is the actual culprit behind the very small but real increase in breast cancer risk associated with HRT.

I'm just like you, who wants breast cancer, uterine cancer, drowsiness, underwear-ruining spotting, or just big old breasts that hurt every time you bounce downstairs?  I have loved and used transdermal estrogen patches through the years.  I have tried natural progesterone but it makes me so goofy the day after that I can't get a sentence out without fumbling word choice or pronunciation.  I have taken norethindrone rarely to counteract the estrogen, but honestly I can only say that it creeps me out when my breasts get sore.

Three months into Duavee, I feel great.  I pretty much felt great before I started Duavee but my sleep was disturbed by middle-of-the-night hot flashes which now are gone. While backaches and fretting can still plague me in the wee hours, I mostly awaken now refreshed instead of grumpy and reluctant to rise. My breasts do not feel altered in any big or sore sort of way.  I think I'm less scatter-brained, but only time--and my husband!--will tell on that one.  And finally, another time-telling sort of thing, I am hopeful based on the well-researched science of Duavee and its carefully formulated blend of estrogen and SERM (9 different combinations were tested) that my bone density, decreasing over the last two years along with my dose of estrogen, will stabilize when I check it next year.

If your 'change' is not for the better, and you're trying to make a decision about what to do about it, talk to your doc about Duavee.  I went through menopause a decade ago so I can't be sure how well it works for those just starting on journey, but I am pleased with this choice for residual flashing, bone density support, and less worry about breast cancer.

Saturday, November 15, 2014

How do I make a medical decision? Part I

Be sure to visit Medical Decision Making Part II at Medical Decision Making Part II

A weekday supplement to the Denver Post featured Bob Moore of Bob's Red Mill on its cover this past spring.  If you don't know who Bob is, you must not be into the rising nuts, seeds, and stone-ground, gluten-free flour scene.  Bob's Red Mill is an Oregon-based company which has been stone milling whole grains, seeds, and nuts for nearly 50 years.  After just one look at his picture on every Red Mill product, you'll agree with me this octogenarian not only looks a decade or more younger than he really is, but he could easily be dubbed the "Gerber Baby" equivalent for the geriatric set so round-cheeked, pink, and glowing is he.

So when Bob extols the virtues of flaxseed in this article--"One of the healthiest foods on Earth! You should have a tablespoon of that every single morning of your life. I do."--no surprise that I pulled the sack of unused flaxseed off my shelf and started doing just that, ground up a tablespoonful that very day and every day since into my morning bowl of nuts and seeds. A no-brainer decision this one; flaxseed is cheap, and a search on for 'flaxseed and health' yields 407 results, whereas 'flaxseed and dangers' returns none. Be sure to grind it before you eat it, warns Andrew Weil, or it will come out the other end unchanged and undigested.  But I digress, the health benefits of flaxseed can wait for another day, another post.

I wish all medical decisions were so simple and straight forward.  Alas, more often than not, they are complicated by emotions, belief systems, current medical evidence, conventional wisdom, Wikipedia, your doctor's latest patient, and your sister-in-law's cousin's experience last fall.  Since I semi-retired last fall, I have been particularly impressed by the power of an established partnership between patient and physician.  When I fill-in for clinics short on docs, all patients I see are as new to me as I am to them. Whether I am talking them out of an antibiotic prescription ("...but Dr. M. always gives me antibiotics, I will get terribly sick if I don't start them now") or urging them to change their usual meds ("Your blood pressure is not at goal, and has been unacceptably high for months"), when they fold their arms across their chests and regard me through lowered brows, I know we're going nowhere without that element of trust.

Fortunately, most decisions are not urgent, and most can wait for another day, another doc, an Internet search.  Those that are have an element of duress where haste trumps trust as the deciding factor. The young man doubled over in pain whom I bundled into an ambulance last week for a quick ride to the nearest hospital for an emergency appendectomy will probably neither remember my face much less my name.  Other times, finances over relationships determine decisions as in the day I told a man, thin as a rail with anemia and an enlarged spleen, that he needed evaluation for cancer. My inability to speak his language did not influence his decision-making process but a lack of insurance delayed follow-up by nearly two months.

So far, we're only talking information-gathering here--who or what is your trusted source. Are you fortunate enough to be partnered with a doc you've known for years? Perhaps it's a Santa-Claus-look-alike grist mill operator, or a vascular surgeon young enough to be your grandson who's just out of one of the nation's top fellowship programs.  Are you having trouble even defining your problem prior to researching solutions? 

What are your go-to sources for medical facts?  I'd love to hear from you.