Research Shows During Menopause Prolonged And Heavy Bleeding Is Common

Dr. Enrique Jacome

Women going through menopause most likely think of it as the time for an end to predictable monthly periods. Researchers at the University of Michigan say it's normal, however, for the majority of them to experience an increase in the amount and duration of bleeding episodes, which may occur at various times throughout the menopausal transition.

The researchers from the U-M School of Public Health and U-M Health System offer the first long-term study of bleeding patterns in women of multiple race/ethnicities who were going through menopause. They say the results could impact patient care and alleviate undue concern about what to expect during this life stage that can last anywhere from 2-to-10 years.

"For most women in their 30s, menstrual periods are highly predictable. With the onset of the menopausal transition in their 40s, women's menstrual periods can change dramatically. These dramatic changes can be disconcerting and often provoke questions about whether something is wrong," said Sioban Harlow, U-M professor of epidemiology.

"Women need more descriptive information about the bleeding changes they can expect. We need clear guidance to help women understand what changes in bleeding patterns do and do not require medical attention."

The study, "Menstruation and the Menopausal Transition," is reported in the current issue of BJOG: An International Journal of Obstetrics and Gynecology.

Specifically, the research found that it is not uncommon for women to have prolonged bleeding of 10 or more days, spotting for six or more days and/or heavy bleeding for three or more days during the transition. In fact, of the more than 1,300 women ages 42-52 in the study, 91 percent recorded 1-3 occurrences in a three-year period of bleeding that lasted 10 or more days, nearly 88 percent reported six or more days of spotting, and close to 78 percent recorded three or more days of heavy flow. More than a quarter of the women had as many as three episodes of the 10+ days of bleeding in a six-month period.

The data from the Study of Women's Health Across the Nation involved participants recording their experiences over a period from 1996 to 2006. The women were identified as African-American, Japanese, Chinese and white, and were from southeast Michigan, Los Angeles and northern California. Previous studies have been short and mostly limited to white women.

A few differences were noted between race/ethnicities, but most women from all groups reported instances of bleeding following one or more of the three patterns. Other health factors impacted the experience as well, including reported uterine fibroids, use of hormones and body mass index.

The authors say more research is needed before determining if the information about what is normal in the menopausal transition should impact diagnostic or therapeutic interventions.

"We think this paper will be helpful to professionals, both clinical and investigational, as it describes in much more quantitative terms the range of bleeding patterns women may normally experience through the menopausal transition," said Dr. John Randolph Jr., U-M professor of obstetrics and gynecology.

"This finding calls for further clinical research to determine the optimal diagnostic and therapeutic approaches for evaluating alterations in bleeding during the midlife. It forms the basis from which appropriate clinical trials can be designed, and may be reassuring to some clinicians at the initial presentation of any of these patterns that watchful waiting is an acceptable option."

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Study Shows HPV Vaccine Benefits HIV-Positive Women

Dr. Enrique Jacome

HIV-positive women respond well to a vaccine against the human papillomavirus (HPV), even when their immune system is struggling, according to newly published results of an international clinical trial. The study's findings counter doubts about whether the vaccine would be helpful, said the Brown University medical professor who led the study. Instead, the data support the World Health Organization's recommendation to vaccinate women with HIV.

HPV causes cervical and other cancers. The commonly used HPV vaccine Gardasil had not been tested in seriously immune-suppressed women with HIV, said Dr. Erna Milunka Kojic, associate professor of medicine at the Warren Alpert Medical School of Brown University and The Miriam Hospital. Despite the WHO recommendation, she said, skeptics have wondered whether the vaccine would be safe and helpful for women with weakened immune systems who were already likely to have been exposed to HPV through sex. Vaccines are often less effective in HIV-positive people.

To address that debate, Kojic's study, dubbed "AIDS Clinical Trials Group Protocol 5240," measured the safety and immune system response of the vaccine in HIV-positive women aged 13 to 45 with a wide range of immune statuses. In the vast majority of the 315 volunteers who were vaccinated at sites in the United States, Brazil, and South Africa, the vaccine built up antibodies against HPV and posed no unusual safety issues during the 28 weeks they were each involved.

"The vaccine works for HIV-infected women in terms of developing antibodies," Kojic said.

Co-author Dr. Susan Cu-Uvin, professor of public health and of obstetrics and gynecology at Brown, said women with HIV are especially susceptible to cervical cancer from HPV because their weakened immune systems are less able to clear the virus. That makes vaccinating HIV-positive women especially important, so long as it's safe and they respond.

Response across the board

To investigate that response in the context of HIV, the study grouped women by their CD4 cell count, a measure of immune system health. Group A had CD4 counts above 350, group B rested between 200 and 350. Group C was composed of women with counts below 200, the defining level of AIDS for which response to an HPV vaccine had not yet been studied.

Gardasil is a "quadrivalent" vaccine, in that it protects against four types of HPV (6, 11, 16, and 18). Each group in the study, therefore, had four measures of "seroconversion," or the buildup of a significant army of antibodies against each type of HPV. The researchers determined that seroconversion in at least 70 percent of patients for each HPV type would define success.

They exceeded that mark in every group for every type, according to the data published in advance online in the journal Clinical Infectious Diseases.

"Seroconversion proportions at week 28 among women in CD4 stratum A were 96 percent, 98 percent, 99 percent, and 91 percent for HPV types 6, 11, 16, and 18 respectively; in stratum B, 100 percent, 98 percent, 98 percent, and 85 percent; and in stratum C, 84 percent, 92 percent, 93 percent and 75 percent for each type respectively," the authors wrote.

Seroconversion rates were clearly lower for women with the weakest immune systems, but still high enough to be worthwhile, Kojic said. And although some of the women in the study had already been exposed to at least one type of HPV, only 1 in 25 had been exposed to all four, suggesting that even older, sexually active women can benefit from vaccination.

The extent of the benefit, she acknowledged, is not yet clear because the trial did not measure the vaccine's efficacy in preventing cancers. It only measured safety and the number of patients who had the desired immune system response. But that response has been shown to be effective in other studies of other populations of women.

What is clear from the study is that the vaccine produced no more side effects or problems than any vaccine typically does.

"Comparing vaccine reactions, this is a very safe vaccine," Kojic said. "It doesn't have any systemic side effects among these women who are already taking medicine for other conditions."

Kojic said she hopes that by confirming that women with HIV are responsive to the vaccine without unusual adverse effects, more doctors will vaccinate HIV-positive patients.

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The Hunt For A Healthier Easter Basket

Dr. Enrique Jacome

The Easter Bunny is the bearer of all things sweet, delicious, and right with the world. But this holiday doesn’t have to induce the same sugar high as Halloween. Instead, fill those Easter baskets with some healthy alternatives. Yes, I’ve included veggies and fruit, but I promise chocolate still has a strong presence in the list of healthy Easter basket items.

1. Chocolate Covered Fruit
For a chocolate fix with a healthy dose of fruit, dip whole strawberries, grapes, or banana slices in melted chocolate. Microwave the chocolate on 50-percent power in 30-second increments, stirring between spurts, until smooth (or use a double boiler). Place the chocolate-ized fruit in mini muffin papers so the chocolate doesn’t smear all over the rest of the basket’s contents. To scale back on the chocolate, drizzle the melted stuff over fruit with the tines of a fork. For an added crunch, roll the fruit in chopped nuts (we like almonds, walnuts, pecans, and pistachios).

2. Fruit Snacks
Standard fruit snacks often contain a host of artificial flavors, synthetic colors, and preservatives. While it takes some time, it may be worthwhile to make your own fruit snacks using real fruit (this version uses just four ingredients—strawberries, lemon juice, honey, and gelatin). Pour the mixture into a shallow baking pan or cookie sheet and cut into cubes, or use bunny-shaped molds to get extra festive!

3. Individually-Wrapped Treats
Now that you know how to choose the good stuff, it’s time to healthify that Easter basket in another less obvious way. Chocolate bars are exciting and all, but individually wrapped spheres and squares of chocolate offer built-in portion control. Instead of ripping open a bar, grab one or two pieces at a time to enjoy.

4. Dark Chocolate
This time of year, drug stores and grocery stores stock their shelves with bunny- and egg- shaped treats… which are loaded with sugar, syrups, and hard-to-pronounce stuff. While we wouldn't tell you to forego candy completely (that's just cruel), youcan choose a healthier chocolate bar by keeping a few things in mind. To reap the benefits of dark chocolate, choose a bar with 70 percent or more cacao. Healthy bonus points: Cacao has been shown to help lower blood pressure and reduce the risk for coronary heart disease. Make sure the first ingredient on the label reads “cocoa butter” or “cocoa liquor.” When sugar is the first ingredient, it may taste sweeter, but it has far fewer health benefits. Organic chocolate bars, while generally a little pricier, are more bang for your buck. Why? They’ve got fewer ingredients (usually just cocoa, sugar, and sometimes an emulsifier, vanilla, and milk) while other bars feature artificial flavors and cocoa processed with alkali (which knocks out some of the flavanol antioxidants).

5. Peanut Butter Eggs
Name one person that doesn’t like peanut butter eggs. (Thought so.) Though store-bought eggs taste like the nectar of the Easter Gods, they’re often oversized and full of not-so-healthy ingredients. The filling, for instance, often contains more sugar than actual peanuts. Make your own PB eggs with recognizable ingredients and switch things up with almond butter for more fiber, iron, and vitamin E.

6. Gold Fish (or Bunnies)
Cheesy snacks make an Easter-appropriate basket filler when they’re shaped like bunnies! We like Annie’s cheddar bunnies—which come in a whole-wheat variety—but it doesn’t take much to make your own. Grab a set of Easter-themed cookie cutters for festivity’s sake. While moderation is key with these cheesy little guys, the obvious benefit of homemade versions is that they actually use real cheese.

7. Carrots
You don’t have to tell us carrots aren’t as cool as chocolate; we know. But the Easter Bunny loves ‘em, right? Wrap a few carrot sticks with green ribbon, or fill small cellophane bags with baby carrots to jazz the veggie up. Toss a few individual hummus containers in the basket as well for a healthy dipper.

8. Homemade Peeps
Easter without peeps is like Christmas without milk and cookies, Chanukah without gelt, and St. Patty’s day without green beer (the shame). For a healthier marshmallow chick remix, ditch the corn syrup and white sugar in favor of honey. We’re not saying these peeps are as healthy as a floret of broccoli, but at least they’re free of preservatives, artificial dyes, and carnauba wax (the main ingredient in car wax, which also makes an appearance in Peeps).

9. Graham Bunnies
Just like gold fish, feel free to make your own graham snacks without hydrogenated oils and high fructose corn syrup. Annie’s bunny grahams are a great choice for a pre-made version, which comes in a handful of varieties (such as vanilla, chocolate, and gluten-free snicker doodle). They’re still cookies, so eat the bunnies in moderation.

10. Tea
For a soothing sipper for after your giftee has reached a sugar high, include some canisters or boxes of tea. We really like the fun flavors from Republic of Tea and the pretty tea bags from Tea Forte.

11. Hard-Boiled Eggs
While creme eggs and peanut butter-filled chocolate eggs may take center stage on Easter, why not eat real eggs? This superfood-in-a-shell is just about 70 calories per egg and provides 6 grams of protein. Plus, they’re full of omega-3 fatty acids (important for heart health). And good news is that it’s OK to eat the whole egg! For perfect hard-boiled eggs, gently place them in a large saucepan, cover with about an inch of water, bring to a boil, remove from heat, and let sit for 12 minutes. Skip the artificial dye and try homemade versions using ingredients like saffron (yellow), cabbage (blue), and raspberries (red).

12. Nut Butter and Fruit
To keep the carrots company, chuck a few apples and bananas in that Easter basket. We like pairing them with Justin’s Almond Butter packets for a healthy fiber- and protein- filled snack.

13. Filled Plastic Eggs
Those classic plastic Easter eggs are a genius way to pre-portion treats. Fill ‘em up with dried or dehydrated fruits—we’re big fans of Peeled snacks—or nuts (we like them cocoa dusted, seeds, healthy trailmix, granola, or cocoa nibs. Surprise!

NON-EDIBLE OPTIONS

14. Sidewalk Chalk
Whether this Easter basket is for a kiddo or not, sidewalk chalk is undeniably messy—and fun. Egg and chick-shaped chalk are especially ideal, but any’ll do!

15. Jump Rope
Budget-friendly, yet full of potential, the jump rope is a portable fitness must-have. Print a copy of our 10-minute workout to go with it.

16. Lip Balm
Often a go-to stocking stuffer, chapstick and lip balm also make for a great Easter basket filler. EOS lip balm is even shaped like an egg for a timely basket addition. The small spheres come in fun flavors like pomegranate raspberry, honeysuckle honeydew, and lemon drop.

17. Stationary and an Everlasting Pen

There’s a lot to be thankful for when we get to spend time with family on holidays. Pick up some blank stationary or journal, which can help the writer reduce stress. And for another gift that really keeps on giving for years, invest in a Seven Year Pen; it's an environmentally-friendly miracle utensil—for less than ten dollars.

18. Small Fitness Gear
When the Easter feast and candy have settled, gift your Easter favorite with some small fitness essentials like headbands and athletic socks. And since Spring means more time outdoors, we’re big fans of the Run Lock—a tiny gadget that keeps your car key safely secured to the car door while hiking or running. 

19. Gift Cards
For a small-sized basket filler with a lot of opportunity, throw in an iTunes gift card for fitness apps or music to fuel workouts. Other cards, such as Starbucks, Whole Foods, and Trader Joes allow the basket receiver to feed that coffee craving or pick up a healthy lunch even after Easter has come and gone.

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Study Shows Regular Aerobic Exercise Boosts The Memory Area Of Brain In Older Women

Dr. Enrique Jacome

Regular aerobic exercise seems to boost the size of the area of the brain (hippocampus) involved in verbal memory and learning among women whose intellectual capacity has been affected by age, indicates a small study published online in the British Journal of Sports Medicine.

The hippocampus has become a focus of interest in dementia research because it is the area of the brain involved in verbal memory and learning, but it is very sensitive to the effects of ageing and neurological damage.

The researchers tested the impact of different types of exercise on the hippocampal volume of 86 women who said they had mild memory problems, known as mild cognitive impairment - and a common risk factor for dementia.

All the women were aged between 70 and 80 years old and were living independently at home.

Roughly equal numbers of them were assigned to either twice weekly hour long sessions of aerobic training (brisk walking); or resistance training, such as lunges, squats, and weights; or balance and muscle toning exercises, for a period of six months.

The size of their hippocampus was assessed at the start and the end of the six month period by means of an MRI scan, and their verbal memory and learning capacity was assessed before and afterward using a validated test (RAVLT).

Only 29 of the women had before and after MRI scans, but the results showed that the total volume of the hippocampus in the group who had completed the full six months of aerobic training was significantly larger than that of those who had lasted the course doing balance and muscle toning exercises.

No such difference in hippocampal volume was seen in those doing resistance training compared with the balance and muscle toning group.

However, despite an earlier finding in the same sample of women that aerobic exercise improved verbal memory, there was some evidence to suggest that an increase in hippocampal volume was associated with poorer verbal memory.

This suggests that the relationship between brain volume and cognitive performance is complex, and requires further research, say the authors.

But at the very least, aerobic exercise seems to be able to slow the shrinkage of the hippocampus and maintain the volume in a group of women who are at risk of developing dementia, they say.

And they recommend regular aerobic exercise to stave off mild cognitive decline, which is especially important, given the mounting evidence showing that regular exercise is good for cognitive function and overall brain health, and the rising toll of dementia.

Worldwide, one new case of dementia is diagnosed every four seconds, with the number of those afflicted set to rise to more than 115 million by 2050, they point out.

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Canadian Study Shows Heat Waves Reduce Length Of Pregnancy

Dr. Enrique Jacome

When temperatures reach 32°C (90°F) or higher over a period of four to seven days, the risk of early-term delivery is 27% higher than on typical summer days, according to a study led by Nathalie Auger of the University of Montreal's Department of Social and Preventive Medicine. The study involved data from 300,000 births that took place in Montreal between 1981 to 2010 with summer temperatures recorded by Environment Canada during this period. 

The research team sought to identify, from June through September, the probability of preterm (less than 37 gestational weeks), early-term (37-38 weeks), and full-term (39 weeks or more) deliveries during a heat wave. Specifically targeting summer births, Auger found that nearly 20,000 deliveries occurred in the week following a day when the mercury reached 32°C or higher.

After adjusting for certain variables, including age of mother, birth order, and humidity during heat waves, Auger found that extreme heat did not seem to increase the number of preterm births. "We observed a only a negligible increase in the rate of preterm births between days when the temperature was below 20°C and those when it was above 28°C, from 5.4% to 5.8%," Auger explained. However, in women who reached 37 or 38 weeks of pregnancy, the risk of early-term delivery increased by 17% following a three-day episode of 32°C or more, compared to days without a heat wave. When the extreme heat episode lasted from 4 to 7 days, the risk reached 27%.

Impact on early-term newborns?

According to Auger, the adverse effects of high temperatures on the elderly are well documented, but little research has dealt with the impact of heat on pregnant women. "Small-scale studies suggest that heat-inducedstress increases uterine contractility, during a period of pregnancy when thermoregulation seems less effective," Auger said. "We also suspect that dehydration resulting from high ambient temperature reduces the blood supply to the uterus, increasing the release of pituitary hormones that induce labour."

Auger believes that the increased risk of early-term delivery due to high temperatures may result in increased morbidity in newborns. "Studies have shown that children born at 37 or 38 weeks suffer more respiratory problems compared with children born at term," Auger said. "Early-term newborns are also at greater risk of death."

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Study Shows Quality Of Life For Couples Can Be Improved Despite Vulvar Vestibulitis

Dr. Enrique Jacome

Spouses who regulate their emotions together in a satisfactory manner are more fulfilled sexually, psychologically, and relationally, among couples in which the woman has vestibulodynia also known as "vulvar vestibulitis".

This was discovered by Nayla Awada, a doctoral candidate in psychology at the Université de Montréal, in a study which she conducted with 254 couples in which the woman was diagnosed with PVD. PVD is characterized by often chronic pain felt on the "vestibule," or entrance of the vagina, especially during penetration. The pain is usually burning in sensation. This pain, for which causes are unknown, affects 12% to 15% of women of childbearing age.

Significant impact

The pain caused by PVD has significant sexual and psychological consequences. On the one hand, affected women have greater anxiety, psychological distress, and depression. On the other hand, the pain greatly decreases a woman's ability to achieve orgasm, as well as desire and arousal, which generally causes a decrease in the frequency of sexual relations.

Awada wanted to examine how couples who are better able to regulate their emotions are more satisfied relationally, psychologically, and sexually, compared to couples who are ambivalent in their expression of emotions. First, using a pain assessment questionnaire, she observed that women in her sample suffered from PVD for more than five years on average, illustrating the chronic nature of this type of pain. She then distributed a questionnaire to both partners of couples to measure the degree of ambivalence in each partner's ability to express his or her emotions in various situations.

"Ambivalence in expressing emotions indicates oneself dissatisfaction with the way one expresses emotions," says Awada. "The more ambivalent you are, the less you are able to communicate your emotions satisfactorily, and the more you are likely to be uncomfortable with your partner." For example, when angry individuals avoid talking so as not to be misunderstood, or express themselves more aggressively than they intended to, they are communicating ambivalently. In Awada's study, these situations are associated with a more difficult adaptation to the pain in the couples. "In addition, ambivalence of both partners is related to greater emotional distress and more sexual and relational difficulties in the couples," says Awada.

Lastly, the researcher found that when at least one of the partners is ambivalent in expressing his or her emotions, the couple is more likely to experience relational dissatisfaction and psychological distress. Furthermore, it seems that ambivalent women have greater vestibular pain compared to less ambivalent women. Therefore, links between a better emotional regulation and pain need to be further examined in this population. "Communicating well does not necessarily mean saying everything, but rather that each partner is consistent with his or her needs," she says. This may mean "negotiating" sexual activities, such as having relations without penetration, which does not prevent one from having a satisfying sexual intimacy.

Clinical applications

According to Awada, the study she conducted is the first to focus on emotional regulation in the management of sexual pain in couples. "Emotional regulation has been addressed in studies on chronic pain in a broader sense, but not for pain occurring during sexual intercourse, which is nevertheless frequent and a source of great distress," says Awada, who is currently completing a specialized internship in chronic pain in order to enrich her clinical understanding of this problem.

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