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New Guidelines for Hormone Replacement Therapy

In 2002, we learnt that in post-menopausal women, hormone replacement therapy (HRT) with estrogen was doing more harm than good. The study, Women’s Health Initiative trial, involved 16,608 post-menopausal women, aged 50 to 79. Because of these findings, the study was discontinued early.

The harmful effects of estrogen therapy were: 41 percent increase in stroke, 29 percent increase in heart attacks, doubling of rates of blood clots in the legs and lungs, 26 percent increase in breast cancer and 22 percent increase in total cardiovascular disease.

But the report also said HRT has benefits: 37 percent reduction in cases of colorectal cancer, 33 percent reduction in hip fractures, no difference in total death rate from all causes and controls hot flashes.

Women have been taking estrogen to relieve post-menopausal symptoms for many years. In 1940s, pharmaceutical companies started producing estrogen from pregnant mare’s urine called Premarin. Twenty years later, the drug was being recommended for women who showed evidence of estrogen lack. Practically, all women over the age of 50. But things changed after 2002. According media reports, the highly publicized research led to a sharp drop in HRT prescriptions, to about five million prescriptions last year from 12 million in 2002.

The new guidelines from the Society of Obstetricians and Gynaecologists of Canada say hormone replacement therapy is safe and effective when used immediately at the onset of menopause and for a relatively short time. That means it would be safe to use HRT in women in their 50s to relieve their hot flashes, night sweats and vaginal dryness. And they should discontinue using HRT within five years.

The new guidelines were announced after a committee of experts re-examined the data from the previous study and came to the conclusion that the age at which women begin taking HRT, the dose and the duration all have an influence on risk. The guidelines do not endorse the use of complementary therapies as there is little or no evidence that herbal products sold for the treatment of menopausal symptoms have any benefit.

Women are advised to take control of their lives. Many problems (mood swings, insomnia, osteoporosis and difficulty concentrating) can be alleviated with lifestyle changes – weight control, healthy eating, exercise, no smoking, stress relief and meditation.

So, what should women do now? Why do experts change their minds about such things? First they create a panic then it takes them seven years to come back and say you are ok to take it within certain limitations.

I guess that is the nature of medical science. There is so much we know and again there is so much we do not know. Physicians find this as frustrating as the general public. Some women are going to be quite upset, may be even angry and frustrated, that they were deprived of HRT when they needed it. But it is never too late to sit down with your doctor and discuss your symptoms and indication for HRT.

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Breast Lumps Should Not Be Ignored

Breast lumps are very common. Breast lumps appear in women and men. They may appear in children. But mostly the breast lumps appear in adults. A breast lump is always an important clinical finding – never to be ignored. It is also a source of anxiety for the patient and his or her family. The first thing they want to know is, “Doctor, is this cancer?”

Investigations of a breast lump starts with a history and physical examination. Physical examination is best done between seven to 10 days from the first day of the menstrual cycle. The clinical history will establish how long the lump has been present. Whether there has been any change. And if there is a previous history of breast biopsy or breast cancer.

Risk factors for breast cancer will be noted (patient’s age and family history). It is important to remember, absence of risk factors does not decrease the probability of cancer.

Careful examination of the breasts will confirm the presence and establish the character of the lump. Hard, irregular, tethered, fixed or painless lump may be suggestive of cancer. Axillary (armpit) and neck areas are checked for lymph glands. The predictive value of physical examination (to say whether the lump is benign or malignant) in experienced hands is about 75 percent.

Mammograms in younger women are not very helpful. But after mid-30s the value of mammography increases. Quite often mammography can clarify the nature of the lump. It can also detect non-palpable lumps.

The overall level of sensitivity of mammography in palpable breast cancers may be no more than 82 percent. It may be even lower in premenopausal women. A negative mammogram in the presence of a persistent lump does not exclude malignancy.

Fine-needle aspiration biopsy done in the office can establish whether a breast lump is solid or cystic. When the lump is solid, cells can be aspirated for examination under a microscope. If fluid is obtained during aspiration and the lump disappears then it is a cyst.

In a cystic lump, if the fluid is not bloody then no specimen needs to be sent for examination and no further investigation is necessary. Bloody fluid may be suggestive of cancer and should be sent for microscopic examination.

Fine-needle aspiration biopsy should provide satisfactory specimen for microscopic examination in 90 percent of the cases with an accuracy rate of 95 percent to detect presence of cancer cells.

When physical examination, mammography, and microscopic examination of aspirated specimen indicate cancer then the probability of this being confirmed by surgery is more than 99 percent. If all three tests are negative then the lump being cancerous is less than one percent.

Core-biopsy, where a bigger sample (a core of tissue) is taken from a breast lump, has 90 percent predictive value for breast cancer. A negative biopsy may make it unnecessary to do an open surgical biopsy.

Ultrasound of the breast lump is an alternative method to distinguish a cyst from a solid lump. Ultrasound is useful when a non-palpable lump is seen on a mammogram.

Nuclear medicine techniques (Miraluma scan) have been used to evaluate breast cancer. Its predictive value for cancer is around 80 percent for a palpable lesion and 50 to 70 percent for a non-palpable breast lump found on mammography.

Whenever reasonable doubt remains about cancer (since none of the tests have a one hundred percent accuracy rate), a surgical open biopsy is undertaken. Only about one in every five to 10 breast biopsies leads to a diagnosis of cancer. But every breast lump should be investigated thoroughly.

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Mummy Flu From The Land Of Pharoes

The picture shows Noorali on the camel at the Giza pyramids with Sabiya, Alia and Hussein in the foreground.
The picture shows Noorali on the camel at the Giza pyramids with Sabiya, Alia and Hussein in the foreground.

Christmas on the River Nile, New Year’s eve party in the land of the pyramids in Cairo and a dance with a belly dancer (with two belly buttons – just kidding) in the Dubai desert on our last day summarizes (in a simple way) our holiday in the Middle East.

International travel has its dangers. We had taken all the precautions to prevent mummy’s tummy and we had our flu vaccination and other vaccinations up-to-date. But the flu virus was every where. Almost every other tourist I met had flu. So, my wife and I fell victim to the devious virus.

Canadians returning from Hawaii and Paris have been down with flu and pneumonia as well. I guess the changing weather conditions, jet lag, cramped airplane seats, poor hygienic conditions of the public washrooms, long days sightseeing, late nights and fatigue contribute to low immunity and susceptibility to flu virus. This is my second bout of flu since I had my flu vaccine. Does it say something about the flu vaccine or my immunity?

Politically, the Israeli assault on Gaza was generating big headlines and street demonstrations but it did not affect us. Security is intense to protect the tourists.

In spite of all the hassles of travel, it is worth taking a holiday. Few days away from the daily grind of work and stress does help our mind and body to recover and get energized. It does not matter what you do, camping, fishing, golfing, skiing or just getting away with a nice book to read in the rocky mountains or to a cottage helps recharge your batteries.

The land of the Pharoes is something out of this world. Most of Egypt’s estimated 82 million people live near the banks of the Nile River, in an area of about 40,000 square kilometers (15,000 sq mi), where the only arable agricultural land is found. Eighty per cent of Egypt is Sahara Desert which is sparsely inhabited.

Cairo has 20 million people. And who knows how many million cars on the road. Driving in the city of Cairo is scary. There is continuous honking and sort of organized chaos in the streets where almost five cars drive side by side in a 3-lane road. Passing each other and changing lanes is like watching a video game except this is real and looks very dangerous. For our taxi driver (30 years’ experience driving in Cairo) it was fun. We used the same guy for four days. He kept on saying, “Drivers in Cairo are crazy.”

We started our holiday from Aswan and Abu Simbel. Then we took a four-night (five days) Nile Cruise which covered Kom Ombo Edfu, and Luxor, the old capital of Egypt. From Luxor we took an overnight train to Cairo (some people prefer to fly). After few days in Cairo we went to Dubai.

Egyptian history goes back over 5000 years BC. In Dubai, the history of development is pretty new. You see how money can conquer desert and water to create a miracle metropolis. Your eyes will not believe what you see. It is like a mirage. This has happened in the last 10 to 20 years. Egypt and Dubai are two different worlds.

People in Egypt and Dubai go out of their way to be nice to tourists. Tourists bring in lot of dollars. Vendors are little aggressive in their sale but you need to learn how to bargain. Tourist guides are all well educated in the history of Egypt. Tourist guides have to go through four years of college and should know at least two to three international languages to be certified as a tourist guide.

We could not see everything in Egypt. There is so much to see. But we visited some of the world’s most famous monuments, including the Giza pyramid complex and its Great Sphinx. We also saw the mummies in Cairo Museum.

Now that 2008 is over with, let us see what is in store for us in 2009. I pray for good health and happiness for all.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Ten New Year’s Resolutions for 2009

Do we really have to make New Year’s Resolutions?

Many people make resolutions concerning their health. Studies have shown that people understand their health risks but do not necessarily change their lifestyle. Then why make resolutions and then suffer from sense of guilt?

Surveys have shown that 57 per cent of people are not motivated to stay healthy. Thirty four per cent of people have no time and 30 per cent have financial barriers to pursue a healthy life style.

In any case, if you are planning to make resolutions for 2009, then here is a list of top 10 New Year’s resolutions as per Albrecht Powell (about.com). See if you would like to incorporate some of them or all of them for your resolutions for 2009.

1. Spend More Time with Family & Friends
Polls conducted by General Nutrition Centers, Quicken, and others shows that more than 50 per cent of people vow to appreciate loved ones and spend more time with family and friends.

2. Fit in Fitness
Regular exercise has been associated with more health benefits than anything else known to man. Exercise keeps you healthy and makes you look and feel better and younger.

3. Tame the Bulge
Over 66 percent of adults are considered overweight or obese by recent studies, so it is not surprising to find that weight loss is one of the most popular New Year’s resolutions. Setting reasonable goals and staying focused are the two most important factors for success.

4. Quit Smoking
On average, smokers try about four times before they quit for good. Talk to your doctor and get help.

5. Enjoy Life More
It’s an important step to a happier and healthier you.

6. Quit Drinking
It is not easy to quit drinking. You need help. Talk to your doctor.

7. Get Out of Debt
With the economy the way it is, getting out of debt should be a priority.

8. Learn Something New
It is never too late to learn something new.

9. Help Others
There are many nonprofit volunteer organizations that could really use your help

10. Get Organized

Good luck and happy New Year.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!