Link Between Smoking And A Worse Urothelial Cancer Prognosis, Especially For Women

Dr. Enrique Jacome

Smoking significantly increases individuals' risk of developing serious forms of urothelial carcinoma and a higher likelihood of dying from the disease, particularly for women. That is the conclusion of a recent study published in BJU International. While the biological mechanisms underlying this gender difference are unknown, the findings indicate that clinicians and society in general should focus on smoking prevention and cessation to safeguard against deadly cancers of the bladder, ureters, and renal pelvis, especially in females. 

To evaluate the gender-specific effects of smoking habits and cumulative smoking exposure on the health of patients with urothelial carcinoma, investigators led by Shahrokh Shariat, MD, of the Weill Medical College of Cornell University and New York-Presbyterian Hospital in New York City, studied 864 patients (553 men and 311 women) from five international institutions who underwent surgery to treat urothelial carcinoma. 

Cancer was more likely to recur in female current smokers than in male current smokers. In heavy long-term smokers, women were 70 percent more likely to experience a cancer recurrence and twice as likely to die from cancer than men. In female patients only, smoking quantity, duration, and cumulative exposure were linked with cancer recurrence and death. For both men and women, those who stopped smoking for more than 10 years saw their risk of dying from cancer revert to that of non-smokers. 

"The biological and clinical effect of smoking seems to be different in females than in males. More effort needs to be spent on the science of how normal human biology differs between men and women and how the diagnosis and treatment of urothelial carcinoma differs as a function of gender," said Dr. Shariat. "Also, gender-specific smoking prevention and cessation can have a major health care impact in urothelial carcinoma." 

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Study Shows Most Mothers Wait At Least 6 Weeks To Engage In Sex After Childbirth

Dr. Enrique Jacome

Most first-time mothers wait until after 6 weeks postpartum to resume vaginal sex following childbirth and women who have an operative vaginal birth, caesarean section, perineal tear or episiotomy appear to wait longer, suggests a new study published inBJOG: An International Journal of Obstetrics and Gynaecology. 

The study, conducted by the Murdoch Childrens Research Institute, Australia, used data from the Maternal Health Study, a large prospective pregnancy cohort in which data were collected from self-administered questionnaires in early pregnancy and at 3, 6 and 12 months postpartum. The study used a sample of 1507 first-time mother to investigate the timing of resumption of vaginal sex and assess associations with methods of birth, perineal trauma and other obstetric and social factors. 

Results show that 41% of women attempted vaginal sex by 6 weeks postpartum, 65% by 8 weeks, and 78% by 12 weeks, with this figure increasing to 94% by 6 months postpartum. 

The study also found that sexual activity was resumed earlier than vaginal sex, with 53% resuming sexual activity by 6 weeks postpartum. 

Furthermore, women aged 30-34 years were significantly less likely to have resumed vaginal sex compared with younger women, aged 18-24 years, by 6 weeks post partum (40% compared with 63%). 

Women who had a caesarean section, a birth assisted with forceps and those who had an episiotomy or sutured tear were also less likely to have resumed vaginal sex by 6 weeks postpartum compared with women who had had a spontaneous vaginal birth and intact perineum. The results show that 45% of women who had a caesarean section, 32% who had a forceps-assisted birth, 32% who had an episiotomy and 35% who had a sutured tear had resumed vaginal sex by 6 weeks, compared with 60% who had a spontaneous vaginal birth with intact perineum. 

The paper states that only around 10% of women having a first baby will achieve a vaginal birth with an intact perineum. Hence, for the vast majority of women and their partners, it is reasonable to anticipate a delay in resuming vaginal sex related to the events of labour and birth, say the authors. 

Associate Professor Stephanie Brown from the Murdoch Childrens Research Institute, Victoria, Australia and lead author of the study said: 

"The most important finding from the study is the wide time interval over which couples resume sex after childbirth. Most couples do not resume sex until after 6-8 weeks postpartum, and many delay much longer than this. 

"This is useful information for couples to know before their baby is born, and may help reduce feelings of anxiety and guilt about not resuming sexual activity sooner." 

Ellie McDonald, from the Murdoch Childrens Research Institute and co-author of the research said: 

"The study findings provide evidence that both method of birth and degree of perineal traumaplay a role in the resumption of sex after childbirth. 

"It is possible that some couples delay resumption of sex until after the 6-week check-up on the grounds of waiting to check that everything is back to normal. This may explain the relatively large number of women that resume vaginal sex at 7-8 weeks postpartum." 

John Thorp, BJOG Deputy-Editor-in-Chief added: 

"It is very common for women and their partners to want information about when sexual activity may be safely and comfortably resumed, and what to expect in relation to the impact of childbirth on their relationship. 

"Having reliable information to guide clinical practice can dispel common myths about what is normal during the postnatal period as well as enabling clinicians to tailor information to a woman's individual circumstances. 

"This study provides important new evidence to guide information given to women and their partners about what to expect after childbirth. However, it is important to remember that these decisions are down to the individual couple and when it feels right for them." 

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Iron Intake May Help To Protect Women Against PMS

Dr. Enrique Jacome

Women who reported eating a diet rich in iron were 30 to 40 percent less likely to develop pre-menstrual syndrome (PMS) than women who consumed lower amounts, in a study reported this week by researchers at the University of Massachusetts Amherst School of Public Health and Health Sciences and Harvard. It is one of the first to evaluate whether dietary mineral intake is associated with PMS development.

Senior author Elizabeth Bertone-Johnson and others at UMass Amherst, with lead author Patricia Chocano-Bedoya and colleagues at Harvard, assessed mineral intake in approximately 3,000 women in a case-control study nested within the prospective Nurses' Health Study II. Participants were free from PMS at baseline. Results appear in the early online edition of the American Journal of Epidemiology.

Women in the study completed three food frequency questionnaires over the 10-year study period. After 10 years, 1,057 women were diagnosed with PMS and 1,968 remained free from PMS. Adjusting for calcium intake and other factors, the researchers then compared previous mineral intake reported by the women diagnosed with PMS with that of women who had few or no menstrual symptoms.

"We found that women who consumed the most non-heme iron, the form found primarily in plant foods and in supplements, had a 30 to 40 percent lower risk of developing PMS than women who consumed the lowest amount of non-heme iron," says Bertone-Johnson. Women in the highest intake group for non-heme iron had a relative risk of PMS of 0.60 compared to women in the lowest intake group.

She adds, "We also saw some indication that high intake of zinc was associated with lower risk. In contrast, we were somewhat surprised to find that women consuming the highest amount of potassium had a higher risk of being diagnosed with PMS than women consuming the lowest amount of potassium. In general, results for mineral from food sources and minerals from supplements were similar."

Overall, "Our findings need to be replicated in other studies. However, women at risk for PMS should make sure they are meeting the RDA for non-heme iron and zinc."

"The level of iron intake at which we saw a lower risk of PMS, roughly greater than 20 mg per day, is higher than the current recommended daily allowance (RDA) for iron for premenopausal women, which is 18 mg per day," Bertone-Johnson says. This amount may be obtained in 1 to 1.5 servings per day of iron-fortified cereal or with supplements.

"However, as high iron intake may have adverse health consequence, women should avoid consuming more than the tolerable upper intake level of 45 mg per day unless otherwise recommended by a physician," she notes. Iron may be related to PMS because it is involved in producing serotonin, a neurotransmitter that helps to regulate mood, she and colleagues point out.

The unexpected finding of higher PMS risk with high potassium intake, even at levels below current recommendations of 4,700 mg per day, may be related to potassium's role in regulating fluid balance in the body. It may affect PMS symptoms such as swelling in the extremities and bloating by affecting fluid retention. "More studies of potassium and menstrual symptoms are needed to better understand this," they say.

"The level of zinc intake at which we saw suggestion of a lower risk of PMS, greater than 15 mg per day, was also higher than current recommendations of 8 mg per day. However, as high zinc intake may also have adverse health consequences, women should avoid consuming more than the tolerable upper intake level of 40 mg per day unless recommended by a physician."

Intake of other minerals, including magnesium, copper, sodium and manganese were not associated with PMS risk, the authors point out.

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Higher Risk Of Heart Attack And Stroke Found In Women With Polycystic Ovary Syndrome

Dr. Enrique Jacome

A syndrome common in women of reproductive age may place them at greater risk for hardening of the arteries, which predisposes them to heart attack and stroke, according to research published Feb. 15 in the American Journal of Physiology, Endocrinology and Metabolism. 

Glucose can stimulate an inflammatory process that allows white blood cells to enter the artery walls and attract cholesterol. Researchers studied 18- to 40-year-old women, lean and obese, with polycystic ovary syndrome and weight-matched controls. The women were given a glucose beverage during an oral glucose tolerance test to measure the inflammatory response and determine their degree of insulin resistance.

Women with polycystic ovary syndrome often exhibit evidence of insulin resistance, which is associated with atherosclerosis -- the collection of plaque-forming cholesterol in the arteries -- and thrombosis -- the formation of clots in the blood stream. 

The study's principal investigator is Frank González, M.D., associate professor of obstetrics and gynecology and director of reproductive endocrinology and infertility at the Indiana University School of Medicine. Dr. González said the findings suggest that excess abdominal fat and higher levels of the male hormone androgen can contribute to the increased risk for atherosclerosis in women with polycystic ovary syndrome. 

"We have shown for the first time at the molecular level that the glucose-stimulated inflammation pathways that promote atherosclerosis and a cardiovascular event are already active at an early age in women with polycystic ovary syndrome," Dr. González said. 

"The findings point to an immune abnormality that promotes inflammation and metabolic disturbance. It's all about an inflammatory response that damages the internal surface of blood vessels, which then permits entry of cholesterol," he said. 

Polycystic ovary syndrome is the most common female endocrine disorder, affecting about 12 percent of premenopausal women, and the most common cause of female infertility.

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New Study Shows That IVF Does Not Appear To Increase Cancer Risk

Dr. Enrique Jacome

A study on Israeli women receiving fertility treatments found that IVF (in vitro fertilization) does not appear to raise the risk of breast and other female cancers, says a new report published in Fertility & Sterility.

Lead author Louise Brinton, from the National Cancer Institute, Rockville, Maryland, and team wrote that none of the gynecological cancers were significantly elevated after IVF treatment.

Doctors and scientists have wondered whether some procedures used in IVF treatments might increase a woman's risk of developing cancers, such as the administration of ovulation-stimulating medications or puncturing of the ovaries to retrieve eggs.

In fact, some earlier studies had pointed towards a higher risk of breast cancer and borderline ovarian tumors among women who underwent IVF early in life. A 2011 Dutch study suggested that stimulating the ovaries to produce eggs for IVF may raise the risk of developing ovarian tumors, some of which could eventually become cancerous.

However, other studies had found very little evidence of such a link.

Experts say it has been hard to determine whether IVF raises cancer risk in females because there may be other factors in women who have difficulties conceiving.

Brinton and team gathered and examined data from the medical records of 67,608 female patients who had undergone IVF treatments between 1994 and 2011, as well as 19,795 patients who wanted but never received IVF treatment.

They compared those data with a national cancer registry. By the June 22nd, 2011, the following cancer diagnoses had been made (from both groups of women):

• Breast cancer - 522
• Endometrial cancer - 41
• Ovarian cancer - 45
• In-situ cervical cancer - 311
• Invasive cervical cancer - 32

The researchers found that:

• IVF made no difference to a woman's breast cancer risk
• IVF treatment made no significant difference to women's gynecological cancers
• Ovarian cancer risk rose very slightly among those with more rounds of IVF treatment. However, the authors said that this slight increase in risk might have been due purely to chance.

With only 45 ovarian cancer cases in the entire study, the authors said it was not possible to compellingly link IVF to ovarian cancer risk.

In an abstract in the same journal, the authors concluded:

"Our results regarding long-term effects were largely reassuring, but women receiving IVF should continue to be monitored given that the procedures involve potent ovulation stimulators and repeated ovarian punctures."

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Obese Women Taking Certain Contraceptive May Be At Increased Risk For Type 2 Diabetes

Dr. Enrique Jacome

A first-of-its-kind study by researchers at the Keck School of Medicine of the University of Southern California (USC) indicates that healthy, obese, reproductive-age women who use long-acting reversible contraception (LARC) containing the hormone progestin have a slightly increased risk for developing type 2 diabetes when compared to those who use non-hormonal contraception. 

The research concludes that progestin-releasing LARC appears to be safe for use by such women but needs further investigation. 

Nicole M. Bender, assistant professor of clinical obstetrics and gynecology at the Keck School, was the principal investigator for the study "Effects of progestin-only long-acting contraception on metabolic markers in obese women," which appeared online in the journal Contraception on Jan. 2, 2013. 

"Contraceptive studies often only look at normal-weight women," said Penina Segall-Gutierrez, co-investigator of the study and an assistant professor of clinical obstetrics and gynecology and family medicine at the Keck School. "Studies such as this are necessary because, today, one-third of women in the U.S. are overweight and one-third are obese. All women, including overweight and obese women, need to have access to safe and effective contraception." 

Obese women are at increased risk for pregnancy-related complications and are sometimes warned by their doctors not to use contraceptives containing estrogen, such as the pill, patch and vaginal ring. 

"[Those choices] raise the risk for blood clots," Segall-Gutierrez said. "So they need other, viable alternatives. The implanted LARC devices last three to 10 years, are easily reversible, and women don't have to remember to do anything with them, in contrast to the birth-control pill." 

The six-month study observed the metabolic markers in three groups of obese women: a control group using non-hormonal birth control methods, including condoms, the copper IUD, and female or male sterilization; a second group with a progestin-releasing LARC device implanted in the uterus (IUD); and a third group with a progestin-releasing LARC device implanted under the skin. 

"All three methods were found to be safe and effective, and they did not create changes in blood pressure, weight, or cholesterol," Segall-Gutierrez said. "However, there was a 10 percent increase in fasting blood-glucose levels among the skin implant users, compared to a 5 percent increase among the IUD users and a 2 percent decrease among those using non-hormonal methods. The effects on sensitivity to insulin showed a similar trend. It is unknown if these effects would continue if the devices were used and studied for a longer period of time." 

Segall-Gutierrez and her Keck research partners have studied the metabolic effects of other birth-control methods as well. In 2012, they reported findings that obese women receiving a progestin birth-control shot every three months may be at increased risk for developing type 2 diabetes. 

"Overall, we're finding that methods such as the progestin injection and the progestin skin implant, which both have higher circulating progestin, may have an increased risk for metabolic changes compared to methods like the IUD, which only has a local effect - in the uterus," she said. 

Segall-Gutierrez added that the progestin-releasing IUD has other benefits. It is approved by the U.S. Food and Drug Administration for treatment of heavy menstrual bleeding, which often affects obese women. The IUD also protects against endometrial cancer, which disproportionately affects obese women. 

"Choosing a birth-control method requires consideration of many factors, including the patient's lifestyle and willingness to use the method, desire for future fertility, and risk for a host of diseases - diabetes and endometrial cancer being two of them for obese women," she said. "We would like to expand our most recent study by looking at more participants over a longer period of time to see if the metabolic effects we observed in the progestin-releasing implants persist or are only temporary." 

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Pre-Eclampsia Increases Risk Of Complications Following Childbirth

Women with pre-eclampsia are at a higher risk of complications following delivery and should continue to be monitored for up to 72 hours, suggests a new review published in The Obstetrician and Gynecologist (TOG). 

The review analyzes the health risks associated with postnatal hypertension, elevated blood pressure that occurs after childbirth, and looks at the women at risk of this condition and treatments available. 

There is extensive literature on hypertension in the antenatal and intrapartum period, but there is little information on postpartum hypertension. 

Following an uncomplicated pregnancy most women will experience increased blood pressure during the postpartum period; however, sustained hypertension in the postnatal period can be a life threatening condition, states the review. 

Women most at risk of developing postnatal hypertension are those who have had pregnancy induced hypertension or pre-eclampsia. These women remain at risk of serious complications following delivery and should continue to be monitored as an inpatient for at least 72 hours, says the review. However, women can also develop hypertension following delivery without prior risk factors. Symptoms can include headaches, visual disturbance, nausea and vomiting. 

The potential complications of pre-eclampsia in the postpartum period are largely similar to those in the antenatal period with the exception of fetal complications and severe hypertension should prompt urgent treatment to prevent cerebral hemorrhage, says the review. 

The review looks at a previous study which analysed the outcomes of women readmitted to hospital in the postnatal period (up to day 24) who received a diagnosis of pre-eclampsia. The results showed a high incidence of complications: 16% were diagnosed with eclampsia, 9% with pulmonary oedema (a build up of fluid) and one maternal death was reported. 

Recently published NICE guidance for postpartum care indicates that blood pressure should be measured within 6 hours of delivery. Furthermore, at the first postnatal contact, all women should be made aware of the symptoms of pre-eclampsia along with the need to urgently contact an appropriate health professional if they have symptoms. 

The authors of the review emphasise the need for prolonged vigilance in the postpartum period and the importance of investigating reported symptoms in at-risk women. They also recommend that both hospital and community teams need to have referral and management guidelines in place around postnatal hypertension. 

Furthermore, the authors of the review conclude that women at increased risk of hypertension should be offered low-dose aspirin and increased blood pressure surveillance in a future pregnancy. 

Jason Waugh, co-author of the review and TOG's Editor-in-Chief said: 

"There is little evidence to guide clinicians treating postpartum hypertension. Poorly managed postpartum hypertension frequently causes unnecessary concern for the patient and her carers, delays discharge from hospital and will occasionally place women at risk of significant complications. 

"Women with pre-eclampsia should be encouraged to delay discharge and once they leave hospital the community midwife should monitor blood pressure for the first 2 weeks. This is then followed up at the 6-week postnatal visit. If symptoms persist there may be an underlying cause." 

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