Women's Health Annual 2012

Menopause: Handle with Care

Thu, 06 Sep 2012 13:40:00 -0700

Do I need to take hormones?

Doctors used to give every postmenopausal woman hormones, but these days they are only prescribed for symptom management. If a woman is troubled by hot flashes that greatly affect her quality of life, they will dissipate after about two weeks of supplemental estrogen, Dr. Adams says. Also, the lower estrogen levels in women who are around 60–65 may manifest themselves in vaginal dryness or burning. This can be remedied topically, Dr. Adams says, with a vaginal estrogen cream, tablet, or ring.

But aren’t hormones dangerous?

It’s definitely not a one-size-fits-all kind of therapy. “Research has shown that women who are on combined estrogen and progesterone have higher rates of breast cancer and blood clots, though lower risk of bone fractures,” Dr. Adams says. “There is also data that shows women who begin hormone therapy at the start of menopause and continue it regularly have lower rates of dementia. But ultimately it’s all about your priorities, medical history, and family history.”

Is my sex life going to change?

Many women find that they’re not quite as into it as they used to be. Dr. Adams urges that this is something to be discussed with your health care provider. “If you have pain during intercourse, something is wrong,” she says. “There’s a lot we can do to help women have a satisfying sexual relationship with their partners.”

Will I gain weight?

Managing and maintaining a healthy weight before menopause should be your priority, Dr. Adams says: “In a large study of US nurses, weight gain between ages 30 and 50 was more important than any other factor in your risk of developing breast cancer.”

Will my bones get brittle?

Not only will regular exercise at any age help keep the pounds off, but it will also benefit your heart through aerobic exercise. Strength training is also important to maintain bone density and boost metabolism.

What about vitamin supplements?

Postmenopausal women should take 1,000–2,000 iu of vitamin D and 1,200 mg of calcium a day. Since the body can only absorb 500 mg of calcium at a time, though, space out your dosage. Dr. Adams also recommends a women’s formula multivitamin.

Do I need any more health screenings?

Women should get age-appropriate regular screening for mammography, colonoscopy, and bone density checks, as well as regular blood testing for chronic conditions like high cholesterol and diabetes. They should also work with their doctors to help identify risk factors or issues to pay attention to for health in the 70s and beyond. “Seven out of 10 leading causes of death are lifestyle-related,” Dr. Adams says. “We don’t have control over our genes, but we can control how healthy we are.”

Menopause: Flash Forward

Thu, 06 Sep 2012 13:39:00 -0700

Menopause has been misunderstood, maligned, and made into musicals. But the cessation of menstruation and the bodily changes that accompany it shouldn’t be something to grieve. Rather, they’re something to understand—and maybe even welcome.

The average age of menopause is 51 years old, says Karen Adams, ob-gyn and the director of the Over-40 Clinic at the OHSU Center for Women’s Health. However, other medical issues, including chemotherapy, premature ovarian failure, and surgeries can cause women to experience menopause earlier.

The textbook definition of menopause is not getting your period for a year. But women can anticipate about four years of perimenopause as the body prepares itself to stop ovulating; the transition time can last anywhere from one to 10 years. While it’s rare to still have your period at age 55, genes do play a part. “You can expect something similar to the experience of other women in your family,” Dr. Adams says.

During perimenopause, Dr. Adams says, many women find that their cycle is lengthening; for example, if you used to get your period every 28 days, by your late 40s you might find the time between periods is more like 36 to 40 days. “Some women get periods that are closer together and with erratic or heavy bleeding, but more commonly they stretch out,” Dr. Adams says. Another very common perimenopause symptom is hot flashes or night sweats, which are triggered by shifting estrogen levels. Dr. Adams advises women to dress in layers, and if hot flashes are taking over your life, hormonal supplements can help.

This drop in estrogen is often accompanied by moodiness or irritability. “When a woman has a period every month, it shows that the hormones estrogen and progesterone are cycling very predictably,” Dr. Adams explains. “But during perimenopause, she’s not ovulating regularly and can feel not quite herself.” She also cautions that while menopause doesn’t cause depression, it may trigger depression in someone who has previously suffered from it. Women should talk to their health care providers about their concerns.

Overall, menopause gets a bad rap, Dr. Adams believes; the disappearing of periods can be a wonderful and freeing thing. “This is a time in a woman’s life when she knows who she is and is creating the kind of life she wants to live,” she says. “You know what you want your life to look like and can focus on that.”

Contraception: Not Your Mother's Birth Control

Thu, 06 Sep 2012 13:38:00 -0700

Call them what you will—generation Y, generation next, echo boomers, millennials. They probably won’t answer you anyway. Generational identity isn’t a big thing for the young women who are now in their 20s and early 30s—they’re too busy piecing their lives and careers together in a new economic landscape. For many, kids don’t fit into that puzzle quite yet.

“Women are, overall, tending to delay childbearing,” says OHSU assistant professor Dr. Kathleen Wilder, whose professional focus is on contraception and adolescent reproductive health care. “They’re wanting a method that is very reliable, that lasts longer, that they don’t have to think about every day.”

Nationally, the combination-hormone birth control pill is the most popular contraceptive choice for women under 30, as it has been for much of the half-century since “the pill” was introduced in the United States. Dr. Wilder, who sees many millennials in her obstetrics and gynecology practice, confirms the trend—for now.

“The pill has been the most popular choice for many years, and it is by far the most commonly used among women of that age group,” she says. “But we definitely are seeing a bit more of a shift toward what we call the long-acting reversible contraceptive methods—implants and IUDs.”

Intrauterine devices, or IUDs, are now one of the most commonly used contraceptive methods in the world. In this country, however, the IUD has only recently begun to shake the stigma that has clung to it since the Dalkon Shield was taken off the market in 1974 amid thousands of lawsuits over severe injuries, infertility, and even deaths caused by the poorly designed device. Dr. Wilder thinks it’s about time.

“We now have two very safe, extremely reliable IUD options that are bringing it back,” she says. “The two available in the US right now, the Mirena and the Paragard, are designed differently. They’re easy to remove safely. We have so much research on them showing how safe they are and how effective they are that a lot of women are shifting toward them.”

A shift in birth control preferences over the years is common. “A lot of young women end up starting out on birth control for a medical reason—to regulate their periods and to limit blood loss,” Dr. Wilder says. “Then, as they become sexually active, they can transition to a longer-acting method or just continue on the pill. The pill also assists with preventing ovarian cancer and endometrial cancer, so you’re getting other benefits at the same time.”

And there’s another reason women are drawn to the pill.

“On the pill, you don’t really have a period—it’s technically a withdrawal bleed,” Dr. Wilder explains. “The cycle was designed that way back in the day to mimic a woman’s regular cycle and have her period be conveniently timed. But we know that you don’t actually have to have a period. So nowadays, when women are so active and it’s expensive to have a period, a lot of women are choosing to just skip it.”

Still, as millennials and other women are choosing to have children later, they need flexibility with their birth control options, too.

“Sterilization used to be common when you had women who were completing their families earlier, but now that women are delaying childbearing, they need a really effective method that’s both long-acting and reversible, such as the IUD or implant,” Dr. Wilder says. “Also, there are plenty of women who in the past would have considered sterilization, but now that they know they have an option that doesn’t require surgery but has the same effectiveness as getting their tubes tied, they’re jumping at that opportunity.”

Of course, IUDs and the pill aren’t for everyone. Women today have more contraceptive choices than ever before: not only familiar barrier methods such as condoms and the diaphragm, but also hormonal birth control options such as skin patches, injections, vaginal rings, and implants (Dr. Wilder advises her patients to use condoms in conjunction with any other options, in order to prevent the spread of sexually transmitted diseases.)

At the OHSU Center for Women’s Health, researchers are conducting clinical trials of potentially promising contraceptives, including a vaginal ring that’s effective for six months and an IUD that could be placed only three weeks after a woman gives birth.

In Dr. Wilder’s view, the more choices, the better. “That’s one of the great things about having so many options,” she says. “Some women hear about an IUD and say, ‘I don’t want anything inside me.’ They would rather do a ring, a patch, a pill, a shot. Other women want to avoid hormones, so the Paragard IUD is perfect. It’s ultimately a very individual thing.”

Oncology: Magic Markers

Thu, 06 Sep 2012 13:36:00 -0700

For many of us, it's fun to watch celebrities discover family-tree secrets on TV. But DNA research helps people in far more ways than simply entertainment. The Knight Diagnostic Laboratories, part of the OHSU Knight Cancer Institute, conduct pioneering research on cancer and the genetic alterations the disease may contain.

“The diagnoses we’ve been making at the microscope for the past 150 years or so have told us what kinds of cancer we’re looking at, but that doesn’t give a sense of their true complexity,” says Christopher Corless, MD, PhD, medical director of the Knight Diagnostic Laboratories. In other words, each cancer is different, and the most effective treatment targets each cancer individually.

We are moving toward such tailored treatments, according to Dr. Corless. “Mutations in the DNA are what make tumors grow, but most new cancer drugs are only targeted to a few of them,” he explains. “By identifying the exact mutations in a patient’s tumor, we can match up the drug to get the correct treatment.”

These mutations are uncovered by the Knight Diagnostic Laboratories’ cancer panels, DNA tests that focus on cancer and hereditary disorders. Advances in DNA technology are allowing OHSU to screen up to 50 genes in the amount of time it used to take to screen just one. These panels can be ordered by physicians, and Dr. Corless has been reaching out to area oncologists to educate them on the panels’ potential.

Not all cancers require extensive genetic testing, Dr. Corless emphasizes. While a person with leukemia should be tested right away, someone else with a superficial melanoma that can be removed entirely via surgery needn’t be tested. “Right now our cancer panels are more for an advanced type of cancer in which drug therapy is needed,” he says, adding that patients with cancer should talk to their doctors about what might be right for their situation.

Though there are some exceptions, diagnostic tests are becoming increasingly important in treating cancer and advancing cancer research. “This is an area that’s completely exploding in growth,” Dr. Corless says.

Oncology: A Parting Shot

Thu, 06 Sep 2012 13:35:00 -0700

Each year in Oregon, about 300 women are diagnosed with ovarian cancer. Most of them, according to Tanja Pejovic, MD, PhD, are diagnosed when the disease is advanced; they are treated by surgery, followed by chemotherapy. The majority of these women, Dr. Pejovic says, do well initially, and about 75 percent go into remission. But of those who go into remission, three-quarters will experience a cancer recurrence within the first two years—and at that point, she says, the cancer becomes difficult to cure.

Dr. Pejovic, a gynecologic oncologist at the OHSU Knight Cancer Institute.

OHSU is the only cancer center on the West Coast participating in the Phase 1/Phase 2 clinical research trial with a new vaccine, called Survivac-DPX, for the prevention of relapse in ovarian cancer. In this clinical trial, patients with ovarian cancer will be treated with the vaccine after completing their standard treatment in an effort to safely prolong the period of remission.

Heart Health: Jumping For Joy

Thu, 06 Sep 2012 13:32:00 -0700

The American Heart Association recommends 150 minutes a week of moderate aerobic exercise—that’s 30 minutes a day, five times a week. But Tina M. Kaufman, PhD, assistant professor in preventive cardiology and clinical supervisor of cardiac rehabilitation at OHSU, likes to break it down even further.

“People already feel like they don’t have time to go to the supermarket,” she says. “But when you divide a half-hour into smaller bits—10-minute walks in the morning, at lunchtime, and in the evening—it’s easier and just as beneficial.”

So how hard should you exercise? Kaufman recommends the “talk test” to gauge how hard you’re pushing yourself. In a relaxed, low-intensity effort, you should be able to talk and sing. In vigorous, high-intensity exercise, singing is impossible and talking is difficult. Moderate exercise, she explains, is that sweet spot where you should be able to talk but couldn’t sing a song.

Whether it’s cycling outside or on a stationary bike, jumping on a mini-trampoline, taking water aerobics classes, using an arm pedal machine, hiking, swimming, walking, dancing, or running, the best exercise is the exercise you enjoy, Kaufman says. She adds that even though aerobic exercise gives your heart the most benefit, women should also make time for strength training.

“The more muscle mass you have, the higher your metabolism: that’s why men generally lose weight faster than women,” Kaufman explains. “As you age, you tend to lose muscle mass unless you do something to maintain it.” That might include working with free weights, machines, or functional exercises that use your own weight such as sit-ups or push-ups. Flexibility training, through activities like stretching and yoga, helps keep women agile and prevent falls.

While making changes to boost your heart health isn’t easy, Kaufman emphasizes that the divide-and-conquer approach works for more than just exercise habits. “Do the easiest things first: if you change your diet, for example, try reducing some of the fats you eat,” she says. “You can make life changes through baby steps.”

Heart Health: Can I Get Your Number?

Thu, 06 Sep 2012 13:30:00 -0700

While many women receive regular mammograms and Pap smears, they often overlook the tests that monitor heart health. Cancer remains a large concern, to be sure, but the discrepancy is striking when you consider that heart disease is actually the leading killer of women—of all ages.

“One in 30 women will die of breast cancer, but 1 in 3 will die of stroke or heart disease,” says Diana Rinkevich, director of the Heart Disease in Women program and director of the Cardiology Outreach CMH-OHSU program.

The lack of heart health monitoring owes to a variety of factors, she explains. First, women are less likely to be aware that they have heart disease: although chest pain can be a common sign, other symptoms occur more often in women than in men. They include upper abdominal pain; heartburn; shortness of breath; neck, back, or jaw pain; nausea; dizziness; and fatigue. Women don’t often attribute symptoms like these to heart disease, Dr. Rinkevich says.

Second, women may differ from men in the type of heart disease they experience. For example, coronary microvascular disease (MVD), a condition that affects the heart’s smallest arteries, afflicts women’s hearts more than men’s. In coronary MVD, the walls of the heart’s tiny arteries don’t relax properly and can spasm. Even though women with this condition have insufficient blood and oxygen flow to the heart, a standard angiogram (which is designed to show blockages in large arteries) is likely to show their arteries to be normal. Many researchers attribute coronary MVD to traditional risk factors for heart disease—along with the drop in estrogen levels during menopause.

“Once a woman reaches menopause, her risks of heart disease and heart attack jump dramatically,” Dr. Rinkevich says. “One in eight women between the ages of 45 and 64 has some form of heart disease, and this increases to one in four women over 65.”

But heart disease can be a factor at any age, she cautions. That’s why you need to know your own risk factors for heart disease (e.g., smoking, cholesterol, eating habits, family history). Screening tests are different for each woman; for example, an EKG or stress test for everyone isn’t cost effective. It’s also important not to be complacent: Not having diabetes or hypertension doesn’t equate to good heart health, Dr. Rinkevich says. You need to know your numbers:

Blood pressure: Should be less than or equal to 120/80.

Body Mass Index (BMI): Should be in the range of 18.5–25. 25–30 is overweight, and over 30 is obese.

HDL: Otherwise known as your “good” cholesterol, this should be 50 milligrams/deciliter (mg/DL) or above.

LDL: The “bad” cholesterol—this should be less than 100 mg/dL.

Triglycerides: Less than 150.

Fasting blood sugar: Less than 100.

Exercise: 150 minutes a week minimum of moderate exercise (for example, 30 minutes of walking over five days).

Several risk factors appear to be more aggressive in women, Dr. Rinkevich says. For example, stress and depression affect women’s hearts more than men’s. Depression also makes it difficult to maintain a healthy lifestyle. Smoking is a risk factor for both women and men, but it appears that the risk is even greater for women smokers. Also, a condition called metabolic syndrome—a combination of fat around the abdomen, high blood pressure, high blood sugar, and high triglycerides—has a greater impact on women than on men.

Women are also less likely to seek help; recent research shows that women may have symptoms for a month or longer before seeing a health care provider, and by that time, their hearts are already damaged.

“Some women think heart disease can be ‘cured’ by surgery—that’s a myth,” Dr. Rinkevich says. “Heart disease is a lifelong condition: once you get it, you’ll always have it. True, procedures such as bypass surgery and angioplasty can help blood and oxygen flow to the heart more easily, but the arteries remain damaged, which means you are more likely to have a heart attack. What’s more, the condition of your blood vessels will steadily worsen unless you make changes in your daily habits. That’s why it is so vital to take action to prevent and control this disease.”

The good news, according to Dr. Rinkevich, is that heart disease is preventable. “It’s never too early to get regular checkups and talk to your health care provider about heart disease,” she says. “Women need to be proactive in asking questions, sharing their risk factors, and making healthy choices.”

In addition, while for years heart disease studies primarily involved men, women’s heart research is showing signs of progress. At OHSU, the Women’s Heart Program offers research and technology including myocardial contrast echocardiography to test for coronary MVD.

The Waiting Game

Thu, 06 Sep 2012 13:28:00 -0700

For patients of Paula Amato, there are no gray areas, no charts with lines that curve up or down to indicate improvement or decline. There’s only positive or negative—one or the other.

“In other areas of medicine, there can be incremental progress,” Dr. Amato says. “But pregnancy is black and white. You either are, or you’re not.” For women working with Dr. Amato and other ob-gyns at the Oregon Health & Science University Fertility Center, though, the experience adds up to much more than a simple either-or.

A Doctor

“Typically when I see patients, they’ve already been trying for years,” says Dr. Amato, a subspecialist in reproductive endocrinology and infertility. “I empathize with them. I want it to work. But the overall pregnancy success rate is still around 50 percent per cycle, so half the time I’m the bearer of bad news.”

Dr. Amato believes that for her patients, knowing that rate of success is crucial to making an informed decision.

“Infertility is emotionally charged and physically taxing for most patients,” she says. “And we can never guarantee success.”

New advances in infertility care—“infertility” is defined by the Centers for Disease Control and Prevention (CDC) as no pregnancy after one year of trying—encourage Dr. Amato and her team. Part of the OHSU Center for Women’s Health, their clinic addresses reproductive health from evaluation and treatment to egg donation, fertility preservation, and preimplantation genetic diagnosis. Nationwide, success rates are up for assisted reproductive technologies like in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). Technical improvements have allowed for transfer of fewer embryos. Egg donation is on the rise, as is interest in egg
preservation.

“Awareness of the decline in fertility that occurs with age is growing,” Dr. Amato says. “But I still see women surprised—they may feel young, exercise, and eat well, but their eggs may be acting older than they otherwise feel.”

As the demographics of modern parenthood evolve, new techniques compete with this truth. While fertility declines with age for both men and women—though much less so for men—women’s fertility drops sharply after age 37. Of the 20 percent of women in the United States now having their first child after the age of 35, the CDC estimates one-third will experience infertility.

During an initial consultation, Dr. Amato will review a new patient’s full medical history and may perform testing before arriving at a treatment recommendation. She tends to start with the least invasive and lowest-cost therapies. Ovulation-induction medications like clomiphene citrate, in combination with intrauterine insemination, are often prescribed for three to six cycles.

At the other end of the spectrum is IVF, the most successful fertility therapy, but also the most invasive and costly.

“IVF doesn’t happen without a team,” says Dr. Amato. Working closely with the clinic’s other physicians (Drs. Lee, Patton, and Wu), nurses, laboratory embryologists, and often other medical specialists—including urologists, perinatalogists, and mental health counselors—Dr. Amato

and her team provide 24/7 care to coordinate the complex interplay of ovarian-stimulating medications, ultrasound and hormone monitoring, egg retrieval, and embryo transfer.

Given the OHSU Fertility Center’s reputation for quality medical care and a supportive, patient-centered environment, Dr. Amato concedes frustration that in Oregon, few insurance plans cover infertility treatments like IVF. From expanding insurance coverage for fertility services to pioneering new research, she sees room for improvement. But, she cautions, there will never be a guarantee, which can be difficult for patients as well as their care providers.

“As a physician, it’s difficult not to feel personally responsible for the outcome, despite the many factors that are out of our control,” she says. “I share in the miracle, but I also share in the disappointment.”

A Miracle

Two black labs are barking in the Salem house that Zoe Ann Jundt, 31, shares with her husband, Chris.

“They are our kids for the time being,” says Zoe, who works in customer service for First American Title.

When Zoe and Chris first started trying to conceive in August 2009, they were newly married and eager to start a family. After one year of no pregnancy, Zoe got tested. Her ob-gyn in Salem prescribed Clomid, a brand name for clomiphene citrate.

“I was on Clomid for six months before we tested my husband,” Zoe says. “I was convinced that it was me, and was shocked that it wasn’t.”

Over the next year, Zoe and Chris each tried sequential rounds of taking Clomid and then tried taking it simultaneously, but Chris’s sperm levels didn’t rise. Zoe’s ob-gyn proposed intrauterine insemination, as well as a shot of the hormone hCG to trigger ovulation. Nothing worked.

That’s when Zoe’s sister-in-law, newly pregnant, suggested her doctors at the OHSU Fertility Center. “With her recommendation,” Zoe says,

Following an initial consultation with Dr. Amato in January 2012, Zoe and Chris realized that IVF was their best option.

“It was ... well, easy isn’t the right word,” Zoe says. “At the clinic, you get poked a lot. It’s a lot to go through for your poor body, but it’s for a greater good. From the beginning they took such good care of me. They kept me in the know.”

Soon after her January consultation, Zoe took birth control pills to help optimize follicle growth for later egg recovery. A few weeks later, in February, she began shots for ovarian stimulation. Following a week of injections, she returned to the clinic every few days for ultrasound monitoring and hormone measurements.

During Zoe’s egg retrieval process, 12 eggs were retrieved and 9 successfully fertilized in vitro by clinic specialists. Of the four fertilized embryos that proved viable, two were frozen and two were transferred into her uterus. On March 17, Zoe began a nearly two-week wait before blood work could conclusively determine the outcome.

“When we knew in vitro is what we had to do, I didn’t think I could do it,” Zoe says. “I was afraid of the egg retrieval process, of the emotions involved. Now, I’d tell people not to be afraid—the process was not as bad as I thought.”

On March 27, Zoe’s pregnancy test came back positive. Following an ultrasound, the results were confirmed: a single pregnancy, due November 3.

“It’s a miracle,” Zoe says. “Now that it’s here, it’s hard to remember the process. It was all worth it.”

After three years of infertility, Zoe and Chris are celebrating, but quietly.

“I don’t share it with everybody. Not everyone who knows I’m pregnant knows that it was IVF,” she says. “You don’t know how they’ll take it. And though I was successful the first time with in vitro, I know a lot of women aren’t.”

A Journey

From Medford, Crystal Pump, 29, has centered her life on children. A fourth-grade schoolteacher in nearby Rogue River, Crystal married her husband, Michael, a school psychologist, in 2008. With plans for a big family, the couple immediately started trying to conceive.

“We felt that we’d be one of those couples that calls everyone within a month with the news [that we were expecting],” Crystal says. “But the further we got from our wedding, the more heartsick we got. My husband’s older than I am. I felt that I couldn’t wait.”

Crystal and Michael consulted a doctor in Medford, who suggested intrauterine insemination and Clomid. After four costly attempts, their ob-gyn pointed them to the OHSU Fertility Center. Their first consultation took place in fall despite the onslaught of procedures, Crystal describes the clinic atmosphere as “phenomenal.”

“One thing that really attracted me to OHSU was that the people at the front desk were as helpful and friendly as the doctors and nurses,” she says. “I felt that everyone was in my corner.”

Crystal’s first IVF treatment did not result in a pregnancy, so Dr. Amato tweaked the medication protocol, and the couple tried again.

“We thought, now my body would know what to do,” Crystal says.

After a second round of IVF, clinic staff tested Crystal’s blood for pregnancy hormone levels.

“My number was seven,” Crystal says. “Technically that’s pregnant, but still very low. If it’s healthy, my number should double.”

Instead, her number dropped—suggesting an early miscarriage sometimes called a “biochemical pregnancy.” Still hopeful, the couple took time to save up for one more round of IVF. Crystal and Michael returned to the clinic in January 2012, but like their previous two experiences, their third attempt at IVF did not result in pregnancy.

“The hard part, the part that people might not get, is the hope—what I call the hope-a-coaster,” Crystal says. “You feel you have every sign of pregnancy, and then the negative. It’s a feeling of getting slapped down.”

Crystal says that one way or another, she and Michael know they will be parents. Right now, they’re stepping back to relax, reflect, and evaluate next steps.

“I’ve gone through this to share our story with others,” she says. “Infertility’s not something like getting your arm cut off. It’s internal, and so hard to find other people to relate to. But once we started talking to people, it became more common than we had thought.”

Crystal concedes that the process of IVF was emotionally challenging—“the hardest journey I’ve ever taken.” Though IVF did not result in a pregnancy for her and Michael, Crystal says the bond they developed with their clinic doctors—in addition to Dr. Amato, they worked with Drs. David Lee and Phillip Patton—was phenomenal.

“I wouldn’t take back this experience, having met such fabulous people, having them become a part of our lives,” she says. “I’m a firm believer that everything happens for a reason.

“If I could say one thing, it would be to have hope. We know there’s a journey for us to be parents.”

Beyond IVF

Two advances expand the promise of treatment.

Paula Amato is one of several medical professionals at the OHSU Fertility Center who double as clinical researchers. The following two genetic advances—one now in practice at OHSU and the other still preclinical—hint at exciting new frontiers in reproductive medicine.

Preimplantation Genetic Diagnosis (PGD)

Through PGD, embryos can be analyzed for specific genetic disorders. In the event that both partners are carriers of serious disorders—cystic fibrosis, for example—PGD ensures that only unaffected embryos are transferred through IVF.

Mitochondrial DNA Replacement

In collaboration with the Oregon National Primate Research Center, the OHSU Fertility Center is conducting a preclinical study in humans involving the replacement of mitochondrial gene mutations in a mother’s oocyte (egg)—mutations that are often fatal to a fetus—with donor DNA. According to Dr. Amato, this gene therapy, if proved feasible, could have other applications in infertility.

Health Watch: I Screen, You Screen

Thu, 06 Sep 2012 13:27:00 -0700

Christmas comes but once a year. So, traditionally, did a woman’s Pap test. But the most recent guidelines from the American Cancer Society and the US Preventive Services Task Force actually recommend that women be screened less often. Though it may seem counterintuitive to advise fewer screenings, numerous tests aren’t always the right choice, says Michelle Berlin, MD, MPH, vice chair of the OHSU department of obstetrics and gynecology and associate director of the OHSU Center for Women’s Health.

“A Pap test is a screening test,” Dr. Berlin says. “Just like all screening tests, it may not pick up everything, or it may show that something is there when it isn’t. This second case is called a ‘false positive’ test; the possible harm in that is that as we try to determine why the test was positive, we may end up performing procedures women may not need.”

Those procedures may include a colposcopy to take a small biopsy (about the size of a match head) or a loop electrosurgical excision procedure (LEEP) to remove a lesion from the cervix. Risks might be bleeding or damage to the cervix, which could affect a later pregnancy. “The risks aren’t high, but they’re ones you don’t want to incur if you don’t need to,” Dr. Berlin adds. “That said, there are plenty of times we do need to do a colposcopy and/or a LEEP.”

The new guidelines recommend that women 21 to 65 have a Pap test every three years. If they prefer, women from 30 to 65 years old can go every five years if they have a Pap test and a test for human papillomavirus (HPV) at the same time and both are negative. Women under 21 don’t need a Pap test. HPV is very common—80 percent of women have the virus by age 50, and for most of them, it’s not a problem. However, HPV has also been shown to cause cervical cancer, so regular Pap tests still remain essential.

But every woman is different, Dr. Berlin cautions. Ultimately, it’s up to each woman to ask her health care provider what tests she should get done, and when. “Women tend to think an annual exam is just for a Pap and breast exam,” she says. “But women—and men—need to see their health care provider on a periodic basis regardless.”

Health Watch: Alphabet Soup

Thu, 06 Sep 2012 13:25:00 -0700

If you’re someone who tries to stay on top of the latest recommendations about your health, you may have found the news about vitamins and supplements more confusing than helpful in recent years. Where’s a concerned, health-conscious person to turn?

To your doctor, of course. Practitioners like Amy Cantor, assistant professor of ob-gyn and family medicine at the OHSU Center for Women’s Health, base their recommendations on the same research that the media reports on. But while a news outlet may sensationalize a headline in an effort to draw in readers (“Supplemental calcium leads to heart attacks!”), doctors have the expertise and the resources to explain research findings to patients (supplemental calcium may be associated with heart attacks in some people; more research is needed).

When reviewing scientific research, Dr. Cantor notes, it is important to understand how the research was conducted: Was it a self-reported survey? Was there a control group? “If you just happen to be Googling for health news, you can be overwhelmed,” she says. “Go to the source.” She recommends reading the study itself and looking for dot-gov sites like the US Preventive Services Task Force to find reliable information.

One supplement with enough proven effectiveness to earn Dr. Cantor’s wholehearted recommendation is folic acid for pregnant women. She recommends this B vitamin to all of her patients who have the potential to get pregnant. Half of all pregnancies in the US are unplanned, and to reduce the risk of neural tube damage from folic acid deficiency, supplements should be started at least one month before getting pregnant. Besides food sources like leafy greens, any prenatal vitamin and some multivitamins will provide an adequate dose (0.4 to 0.8 mg).

What about women in other stages of life? Generally, Dr. Cantor says, healthy, premenopausal women eating a balanced diet will not need to supplement, although she won’t keep anyone from taking a multivitamin, which has not been shown to cause any harm and may be helpful.

Some older female patients have been advised to take low-dose calcium supplements to prevent bone fractures, but in June the Preventive Services Task Force released a recommendation against the practice, based on a lack of evidence that it does any good and citing an increased risk of kidney stones. Calcium can also come from a good diet.

Some supplements Dr. Cantor would consider recommending to patients with specific conditions, but not to the general population. Fish oil, in conjunction with dietary changes supervised by a doctor, can help with high cholesterol, and menopausal women struggling with hot flashes may find relief through black cohosh. Women with an iron deficiency, which can develop from heavy periods or pregnancy, may need extra iron.

The risk of overdosing on vitamins is low, but people do need to be careful about drug interactions. Dr. Cantor cautions against taking any supplements without talking to your doctor about the other medications you’re taking.

Like those of us looking for the latest in health care news, Dr. Cantor keeps an eye out for health reports. “There’s a lot of information out there, and it’s hard to know what’s accurate,” she says. “Helping patients navigate that is part of my job.”