Healthspanlife - the Official Life! Blog

Breast

                        · There is a wide variation across the world in the incidence of breast cancer and its risk factors.

                        · There are multiple risk factors for breast cancer, including life-style factors especially alcohol intake, obesity and lack of exercise. These need to be included during counseling to put the magnitude of risk of HRT into perspective [B]

                        · After 5 years’ use of combined estrogen and progestogen, there is a small increase in risk of breast cancer in North American women of about eight extra cases per 10,000 women per year. However, no significant increase was seen in women without prior use of HRT in the WHI study. [A]

                        · Estrogen-only use does not cause an increase in breast cancer for up to 7 years21. [A] In observational studies, a small increase in the risk with estrogen-alone therapy appears with long-term use22. [B]

                        · Women using combined HRT before a diagnosis of breast cancer have a reduced mortality23. [B]

                        · A decline in the incidence of breast cancer in the USA started before the WHI publication and can be partially related to fluctuation in screening. There has been no decline in breast cancer registration in the UK following the Million Women Study report, nor in Norway, Canada, the Netherlands and countries with stable screening programmes25. [B]

                        · Combined estrogen and progestogen therapy may cause increased breast density in up to 50% of postmenopausal women, dependent on the regimen (dosage, type of progestogen). The effect of estrogen alone is smaller26. [A]

                        · The effect on breast density is dose-related. Ultra-low-dose regimes do not cause perceptible change in density[A]

                        · The average increase in breast density under standard-dose HRT is only about 5–10%28. [A]

                        · Increased baseline breast density is a risk factor for breast cancer29. There are no data to support a direct association between HRT-induced breast density changes and the risk of developing breast cancer.

                        · Many women who develop breast cancer have no known risk factors other than growing older. most women with known risk factors do not develop breast cancer.

                        · Individual risk analysis for breast cancer is strongly recommended in clinical practice30.

Bone

 *Overall HRT is effective in preventing all osteoporosis-related fractures even in patients at low risk of fracture[A]

*Although no head-to-head studies have compared HRT to bisphosphonates in terms of fracture reduction, there is

                           no evidence to suggest that bisphosphonates or any other antiresorptive therapy are superior to HRT.

 * It is therefore suggested that, in 50–59-year-old postmenopausal women, HRT is a cost-effective first-line

                                  treatment in the prevention of osteoporotic fractures.

* Even below standard-dose preparations maintain positive influence on bone indices such as BMD[A]

                        · HRT has a positive effect on osteoarthritis and the integrity of intervertebral disks.

Cognition

*At present, there is no evidence of substantial cognitive decline across the menopausal transition[A] However, many women experience cognitive difficulties in association with vasomotor symptoms, sleep disturbances & mood changes.

*Verbal memory performance relates with the objective number of hot flushes women experience but not to the number of hot flushes they report.

*Clinical trials find no cognitive benefit among women initiating HRT late postmenopause (i.e. after age 65).

*Observational studies show a decreased risk of Alzheimer’s disease in hormone users and typically involve women who initiated estrogen therapy early in the menopausal transition. [B]

*Limited data exist on the effect of progestogen added to estrogen in the early postmenopause period. Clinical trial data suggest no cognitive benefit with MPA early in the menopause. [A]

   As it often does, the BBC health news item (CALL TO  RETHINK CHILDHOOD BMI TESTING  (Sunday, 29 June 200 misses the point.

         While anyone can see if someone is carrying excess fat by inspection of the unclad waist and ideally waist girth measurement, BMI is invaluable as an objective measure of weight-for-height - but how can weight or BMI ever  be a measure of fitness?
          
         Weight-for- height reflects the aggregate of lean mass and fat mass.
Except in body builders, athletes, the lean mass is as much a factor of hormone balance (anabolics- androgens, vitamin D, growth hormone) and water balance as it is of exercise.
Fat mass is far more a reflection of calorie intake than of calorie expenditure - physical excercise.

         So regular measurement of height, weight and waist girth is crucial at all ages  for monitoring both fat mass - the major marker of the risk of the obesity diseases from early puberty, infertility and type 2 diabetes to cardiovascular disease, cancer and weightbearing osteoarthritis - and lean mass. Low lean mass for height (the LMI- lean mass index) reflects reflects low  protein-exercise levels and thus risk of future frailty- fractures.

         Hence the increasing problem of fatness frailty in those who are pampered by abundance of food, transport and physical leisure - especially in postmenopausal women, especially those on oral estrogen-progestin hormone therapy- apparent “normal” BMI but increasing girth and fat mass while lean- muscle- mass declines inexorably. These are the patients we see in practice every day,  in whom weight and BMI is especially misused, in whom doctors dismiss a weight gain of say 1/2kg a year while this may mask a fat gain of 2.5kg a year while 2kg of lean mass a year is being lost.

       These are the patients in which doctors (who should know better)  negligently continue to ignore that the older patient often has  excess estrogenic:androgen balance if not frank androgen deficiency syndrome; and/or  negligently deny the patient metformin prescription until she has frank diabetes and obesity!

          There are thus two distinctly separate imperatives at all ages but especially in young schoolchildren, when habits are being set:  monitoring of fat mass- which must be regulated by prescription of  metformin supplement  (or equivalent natural weight-insulin resistance reducers) to tolerance long term if all else fails so as to halve the inexorable progession to overweight, metabolic syndrome and diabetes;  and enforcement of minimum exercise standards to promote both physical and mental health.

HIV/AIDS/TB SUPPORTIVE NUTRITION SUPPLEMENTS:

ACTIVE INFECTION eg AIDS, TB; and CANCER
are often a problem of defective NUTRITION among many important contributing factors.

Both infection; cancer; and chronic anti-infection/ anti-cancer drugs
promote poor nutrition, loss of other infection protection, and loss of muscle and bone.

Those with high risks of infections or cancer, and
those on anti-infection/ anticancer therapy, and
those in whom such therapy has failed,

should be offered both counselling;
measurement of lean mass, fat mass; and
risk of osteoporosis bone fracture; and
various regimes of complementary cancer/ infection NUTRITIONAL support.

Both with aging, illness, therapy, and with increasingly poorer food supplies, rising costs and pollution, the best diets cannot supply anywhere near optimal micronutrients - the effective doses of all ~15 vitamins, ~10 minerals, and the scores of biologicals- the dozens our own bodies make but run out of (including hormones), those from other species eg fish oil, glucosamine, and herbs.

For an appointment to have your body composition and bone fracture risk measured,
and to discuss and view the nutrition supports available with a relevant supplement counsellor,
make an appointment in Cape Town by phoning 021 6831465
or Bryanston Gauteng by phoning 011 4633604 during shop hours;
then discuss the results and options with your doctors.

In other countries, discuss them with your local Health Shops or Pharmacies.

MENOPAUSE SYMPTOM CONTROL and the HRT Sex Hormone Replacement vs PLANT REMEDIES DEBATE:

see http://www.imsociety.org/.

We are constantly exhorted to use commercial plant menopause/ andropause antiaging hormone alternatives like soy and black cohosh. The fight for a share of this billion-dollar patent market continues around bewildered aging men, women, healthcare professionals, and purveyors of supplements.

But -owing to the increasing shortage of fish, the overabundance of corn and decreasing grazing space, and the profit imperative - our western diet is now so stuffed with inflammatory omega6 (eg GLA gammalinoleic acid) that the average western diet omega6:omega3 ratio has risen from 6:1 to 20:1 - chickens are no longer fed fish-meal nor livestock on grass as they were when we were children; they are now fed on maize. And fast foods for gullible humans are now loaded with cornstarch.
so we should discourage any omega6 supplements ie plant oils except as salad dressing; but we all need at least 2g if not 4g fishoil a day.

West of Aden, we are not marketing to, caring for, long-lived small slim fish-and brown-rice eating Asians who till the fields all day- quite the opposite. So it is very relevant.
One sees few small Asian women in practice at the southern tip of Africa or north and west, as opposed to East or the Pacific rim. .

Most oil-bearing plants contain some plant estrogens. a patient brought this to my attention angrily after discovering that even flaxseed oil has them, they apparently grew her fibroid. Flax seed is better- only 40% oil, and balanced by the huge benefit of the fibre, lignans.

Soy is most certainly a major source of non-marine omega: per 100g soy - Linoleic Acid (LA-omega6) 9%. Alpha-Linolenic Acid (ALA Omega3) 1.6% ALA is not the marine eicosapentanoic acid EPA+DHA docosahexanoic acid required by human brains and membranes- in infants and sick/ aging humans, our conversion of omega6 GLA - and even ALA - to EPA+DHA -ie marine oil- is far too little for our needs.
So soy provides the opposite of the needed fish oil omega3 (which is 30% in good fish oil).

There is no apparent problem about soya (or eg pueraria) as part of a balanced diet – especially in small women who are largely vegetarians, and especially Asians. And soy is not the ideal fibre source!!!

We surely do not need plant oil extracts as a supplementary panacea when fish oil alone does far better, almost halves all disease and deaths without any adverse effects, and when appropriate HRT, metformin/galega officinalis, and appropriate combined other micronutrients, each reduce all disease and deaths by about 1/3.

Our audience and target is largely postmenopausal Afro/White women in a hugely polluted and stressed ie estrogenic -high cortisol-fat environment.

The problem is vigorous POSTMENOPAUSAL soy/other plant oil supplements- which provide excess phytoestrogens AND omega6 in overweight “westerners”- afro/hispanic/white.

The evidence is worrying that environmental estrogenics (including soya) long term in the West increase the problems of cancer let alone fattening.

It’s the usual story- as with black cohosh, for any commendation of a product,
1. there must be both evidence of benefit (which there is for soy, but not BC),
2. and evidence of need ie there must not be far cheaper safer products that do the job better;
3. and no evidence of harm.

So if there is no evidence of benefit, why recommend :
black cohosh - like red clover, it has no proven medicinal menopause benefit, but it (like kava) can unpredictably albeit rarely kill- black box warnings have been issued by most first world authorities,
or
soy or any plantoil supplement when these may stimulate breast , endometrial and prostate cancer, and aggravate omega6- mediated inflammation, and there is far better specific therapy in appropriate balanced HRT and fish oil? (palm oil MCT and sunflower oil supplement maybe better than soy, if not as good as fish oil.);
or
aspartamate when there are natural plant-derived insulin-sensitizing intense sweeteners like stevia ,
and when aspartamate is a slowly accumulating neuro-excitotoxin, carcinogen and cardiotoxin?

Surprisingly, search under Randomized Controlled Trials RCTs on Medline finds only 3 references for “Menopause symptom relief “, and 1 on “menopause herbs”- these favour estradiol plus androgen or lowdose estradiol + progestin over estrogen or placebo alone; .and estrogen over herbs including black cohosh. Under search for RCTs of black cohosh for menopause symptoms, the great majority of patients show no benefit of BC over placebo at any BC dose . We are all well aware that only drug companies can afford to pay for major drug trials- but only modern designer drugs are patentable, and only blockbuster patents are profitable- so drug companies (and therefore researchers that do research - clinicians, universities etc)- cannot afford to fund independent trials of natural alternatives, and especially not allow comparison of modern synthetics against obviously beneficial but unpatentable natural supplements.

The European, Uk , Canadian, Australian, New Zealand , Japan and Singapore authorities and now the US Pharmacopoeia- have all issued warnings against black cohosh BC. RSA remains the only (?ex-) “1st world” country where “authorities ” - MCC, HPCSA and Health24 - still ignore the issue of potential fatality. The University of Cape Town Medicines Information Centre issued a solitary warning in September 2006. The Health Products Association of South Africa still (January 200 refuses to withdraw its Endorsement of black cohosh on it’s website, despite the evidence against it.

So why promote BC or soya concentrates for any menopause therapy? Since the greatest common voluntary killers- sugar, alcohol, tobacco, motorcars, weapons, non-steroidal anti-inflammatory drugs- are freely available to adults, there is no reason to restrict sales of lesser potential hazards like xenohormones. But it is immoral to promote them (sugar, cigarettes, black cohosh, horse hormones, soya supplements), when there is no good evidence of need let alone benefit, and there is evidence of potential lethal harm in conventional usage.

The Wikipedia Menopause review puts it in perspective:
Treatment of symptoms (Appropriate conservative ) “hormone therapy provides the best relief.” While the prognosis from advanced memory or vascular deterioration or hip fracture is poor, appropriate physiological “hormone therapy from menopause is amongst the best prevention/ treatment for osteoporosis”; vascular disease; insulin resistance and type 2 diabetes; depression and memory loss.
“GABA” and 5HTP and their patent derivatives are ” second only to HRT in relief of menopause symptoms.”
“Complementary and alternative therapies Medical non-hormone treatments provide less than complete relief, and each has side effects. There are claims that soy isoflavones are beneficial concerning menopause. Other remedies that have proven no better than a placebo at treating hot flashes and other menopause symptoms include red clover isoflavone extracts and black cohosh. Black cohosh has potentially serious side-effects such as the stimulation of breast cancer, therefore prolonged administration is not recommended in any case.”
http://en.wikipedia.org/wiki/Soybean debunks many of the claimed benefits of soy supplements.

The 2007 Review of the world expert menopause body, the International Menopause Society, says it all on ALTERNATIVE TREATMENTS: at http://www.imsociety.org/pdf_files/ims_recommendations/ims_updated_recommendations_on_postmenopausal_hormone_therapy_27_02_07.pdf
“The efficacy and safety of complementary alternative medicines have not been demonstrated and further studies are required.”
Bodies promoting alternative therapies are not qualified to judge, let alone endorse products for treatment of symptoms that affect most older women, when well-proven remedies without any significant risks are well established. “
“There are no medical or scientific reasons to recommend unregistered bio-identical hormones.” The only proven and approved safe long-term treatment post menopause is appropriate registered HRT; and as alternative, GABApentin for hot flash relief.
Intensive post-menopause experience with appropriate HRT (even horse hormone HT) for almost 60 yrs has shown only benefit - and trials for up to 10 years (WHI; Oulu) the same.

The SAMS Review of Menopause therapy notes: No therapy for menopausal symptoms should be initiated without proper clinical assessment including breast and pelvic examination http://www.samenopausesociety.co.za/asp/pdf/SAMS%20Statement2006.pdf.;
and condemns black cohosh: http://www.samenopausesociety.co.za/asp/content.asp?ContentID=27

Thus, given the risks in middle-aged women, it is quite clear that no-one except a registered appropriately trained health professional may recommend therapy for menopause symptoms - which affect the majority of women at the most critical time of their lives, when they should if anything be starting (after appropriate clinical examination ) on appropriate HRT (for which there are rarely absolute permanent contra-indications), and when any menopause therapy requires that they be assessed clinically before any such therapy, and then regularly on it. Hot flashes are not always due to hormone imbalance- which is why placebo has such strong effect, and Gabapentin/5HTP more so..

Insulin resistance, overweight and obesity have become the greatest midlife risks in the affluent. So it is worth noting that while appropriate HRT, fish oil and hundreds of other natural supplements lower insulin resistance, fish oil is apparently better than olive oil, which is in turn better than sunflower and soy oils as regards insulin sensitization.

Finally, Professor Fred Naftolin of the IMS comments January 31, 2008 as follows
” This is an immensely complex area and cannot be disposed of with a few platitudes.
All agents that interact with ERs estrogen receptors - like phytoestrogens - are SERMS. This means that in isolation they have a specific profile of agonistic action, but have an antagonistic profile in the presence of other SERMS. Further, this may both tissue and subject-specific.
In short, the patient is on her own when she begins to experiment with these agents. This is true when using pharmaceutical compounds, but at least they will have been more widely tested using standardized paradigms.”

(Professor Fred Naftolin retired a few years ago from Chairmanship of Obs & Gyne at Yale, was then Prof of Biology there for a few years then “retired” to his present research position at New York University with the Nachtigalls.
He is a chairman of the scientific committee of the International Menopause Society. He has 444 citations on Pubmed since 1966, 55 papers as first author, and 10 books to his name.. He is a very modest man, arguably one of the greatest living authorities on women’s health, reproduction and biology, a born teacher, and a supreme diplomat in the chair under fire - as when colleagues raged around him over the Women’s Health Initiative debacle at the Vienna workshop in December 2003. Thus, to paraphrase Kipling, he could keep his head when all around us, the self-styled Regulators of Europe, UK and USA were losing theirs and damning gold-standard appropriate HRT.)

READ THE LITERATURE:

This April 2008 fulltext report in the latest MJAustralia is the latest published case of specific-type fatal iiver failure attributable solely to BC:
http://www.mja.com.au/public/issues/188_07_070408/cho11166_fm.html

Black cohosh: a cause of abnormal postmenopausal liver function tests The health scares restricting the use of hormone replacement therapy have made women tend to opt for ‘natural’ remedies that are generally perceived as safe. Unfortunately, there is lack of definite opinion on the safety of herbal remedies. Black cohosh is commonly used for postmenopausal symptoms. We present two cases of liver toxicity related to this and recommend close monitoring of women on this herbal preparation. D. Joy ea, UK. Climacteric, 2008:11: 84 - 88

Can the combination of flaxseed and its lignans with soy and its isoflavones reduce the growth stimulatory effect of soy and its isoflavones on established breast cancer? Consumption of phytoestrogen (PE)-rich foods (i. e., soy and flaxseed (FS)) is increasing because of their suggested health benefits. However, recent studies raise concern over the safety of soy and its isoflavones, particularly genistein (GEN), for postmenopausal breast cancer (BC), due to their potential stimulatory effects on human breast tissue and on the growth of existing tumors in rodents.(Power KA, Thompson LU. University of Toronto, Canada.Mol Nutr Food Res. 2007 J51:845-56. )

Endometrial effects of long-term treatment with phytoestrogens: a randomized, double-blind, placebo-controlled study. Long-term treatment (up to 5 years) with soy phytoestrogens was associated with an increased occurrence of endometrial hyperplasia. These findings call into question the long-term safety of phytoestrogens with regard to the endometrium. Unfer V et al, Obstetrics and Gynecology Centre, Rome, Italy. Fertil Steril. 2004;82:145-8,

Clinical characteristics and pharmacokinetics of purified soy isoflavones: multiple-dose administration to men with prostate neoplasia..In men with prostate cancer, relatively minor side effects of chronic soy isoflavone treatment were observed including some estrogenic effects (breast changes, increased frequency of hot flashes). Serum dehydroepiandrosterone was decreased by 31.7%. (Fischer L et al University of North Carolina Nutr Cancer. 2004;48:160-70)

Exposure to soy-based formula in infancy and endocrinological and reproductive outcomes in young adulthood.
women fed soy formula as infants reported slightly longer duration of menstrual bleeding with no difference in severity of menstrual flow. They also reported greater discomfort with menstruation. Infant exposure to soy formula does not appear to lead to different general health or reproductive outcomes than exposure to cow milk formula. (Strom BL et al University of Pennsylvania, JAMA. 2001;286:807-14).

Evaluation of soy phytoestrogens for the treatment of hot flashes in breast cancer survivors: A North Central Cancer Treatment. Group Trial. Although it has been shown that estrogen or progesterone replacement therapy can alleviate this problem, there are continued safety concerns regarding the use of hormonal therapies in these women. The soy product did not alleviate hot flashes in breast cancer survivors. Quella SK, et al: Mayo Clinic Rochester, USA. J Clin Oncol. 2000 ;18:1068-74.)

.Effect of the interaction between the fatty acid binding protein 2 gene Ala54Thr polymorphism and dietary fatty acids on peripheral insulin sensitivity: a cross-sectional study.Morcillo S, Rojo-Martínez G,ea, Hospital Universitario Carlos Haya , Málaga, Spain. Am J Clin Nutr. 2007 Oct;86(4):1232-7 : Anthropometric measurements were obtained for 1226 persons aged 18-65 y selected randomly from the municipal census of Pizarra, Spain. An oral-glucose-tolerance test was given to 1020 of these persons. Samples of the cooking oil being used were taken from the kitchens of a random subset of 538 persons. RESULTS: Persons who consumed sunflower oil and who also had the Thr54 variant had higher insulin resistance than did those who consumed olive oil (P = 0.01).

Soybean oil treatment impairs glucose-stimulated insulin secretion and changes fatty acid composition of normal and diabetic islets.Nunes E, ea . Institute of Physiology, Coimbra, Portugal. Acta Diabetol. 2007 ;44:121-30. We observed that soybean-treated Wistar rats present insulin resistance and defective islet insulin secretion when compared with untreated Wistar rats. The decrease in insulin secretion occurred at all concentrations of glucose and arginine tested. Concerning diabetic animals, we observed that soybean-treated diabetic rats, when compared with untreated GK rats, present an increase in plasma non-fasting free fatty acids, an exacerbation of islet insulin secretion impairment in all conditions tested and a significant decrease in the monounsaturated palmitoleic acid. Altogether our results show that SO treatment results in a decrease of insulin secretion and alterations on fatty acid composition in normal and diabetic islets. Furthermore, the impairment of insulin secretion, islet erucic acid and fasting plasma insulin levels are similar in treated normal and untreated diabetic rats, suggesting that SO could have a deleterious effect on beta-cell function and insulin sensitivity.

Oleic acid from cooking oils is associated with lower insulin resistance in the general population (Pizarra study).
Soriguer F, ea Hospital Universitario Carlos Haya, Malaga, Spain.
Eur J Endocrinol. 2004;150:33-9.
AIM: To evaluate the relation between type of dietary fatty acid and degree of insulin resistance. Anthropometrical data were measured in 538 subjects, aged 18-65 Years, selected randomly from the municipal census of Pizarra (Spain). An oral glucose tolerance test (OGTT) was given to all subjects and measurements were made of glycemia, insulinemia and the proportion of fatty acids in plasma phospholipids Samples of cooking oil being used were obtained from the kitchens. RESULTS: Insulin resistance was significantly less in people who used olive oil compared with those who used sunflower oil or a mixture. Statistical significance remained in the group of people with normal OGTT after adjusting for obesity. In the whole sample, IR correlated negatively with the concentration of oleic acid (r=-0.11; P=0.02) and positively with that of linoleic acid (r=0.10; P=0.02) from the cooking oil. In subjects with normal OGTT, IR correlated negatively with oleic acid from cooking oil (r=-0.17; P=0.004) and from plasma phospholipids (r=-0.11; P=0.01) and positively with the concentration of linoleic acid in cooking oil (r=0.18; P=0.004) and plasma phospholipids (r=0.12; P=0.005). The risk (OR) of having raised IR was significantly lower in people who consumed olive oil, either alone (OR=0.50) or mixed (OR=0.52) compared with those who consumed only sunflower oil.