More Ways to Reduce Breast Cancer Risk

There are two recent studies that I want to call attention to, that are relevant for our continued efforts to reduce the risk of breast cancer. The first addresses the issue of weight loss. In post-menopausal middle-aged women who lose weight and actually are successful in keeping it off, their risk of breast cancer is lower. Researchers studied over 180,000 women who were 50 years old or older and had their weight recorded three times over about 10 years. (wow—only 3 times!!!). The follow-up period for assessing invasive breast cancer started after the last weight measurement.

Over a period of eight years, more than 6,900 invasive breast cancers occurred. After the researchers adjusted for baseline body mass index, the use of hormone therapy or not, and other select issues, women who had lost 2.0-4.5 kg and were successful in keeping the pounds off, had a 13% lower risk for breast cancer compared to women who had no weight loss and had stable weight. In those who kept off 9 kg or more, had even better results with a 26% reduction in risk. (1 kg = 2.2 pounds). These benefits of weight loss and maintaining weight loss were strongest among overweight and obese women, meaning a body mass index of less than 25, and also among women with no history of using postmenopausal systemic hormone therapy.

Bottom line: If you are overweight and 50 or older, make every effort to lose weight, a minimum of 4.5-10 lbs. and maintain that weight loss—even better risk reduction if you achieve 20lb. weight loss and maintain that.

Teras L, et al. Sustained weight loss and risk of breast cancer in women ≥50 years: a pooled analysis of prospective data. JNCI: Journal of the National Cancer Institute, 2019. (early release online)

The second study is likely more controversial as is common with environmental exposures and disease risk and incidence. In an observational study of approximately 47,000 women in the US, questionnaires about their use of hair care products was used to assess breast cancer risk. These women were followed over eight years. At entrance to the study, women did not have a history of breast cancer but did have at least one sister who had a breast cancer diagnosis. Over the course of follow-up, 2,800 breast cancers were reported and after analysis, any use of permanent hair dye in the prior year was associated with a 9% increase in breast cancer risk, which is considered statistically significant. The risk was even greater for black women in the US, with an increased risk of 45%. Hair straighteners were less risky but did have an increased risk if they were used at least every five to eight weeks.

We know from other research that the chemicals found in human hair dye have been shown to cause mammary gland tumors in rats when those animals are exposed to those same chemicals. We also know that some hair straighteners contain formaldehyde, which is a known carcinogen.

These results on hair dye and hair straighteners are a part of a larger study called the Sister Study. The Sister Study is an ongoing study by scientists at the US National Institute of Environmental Health Sciences (NIEHS) that includes 50,884 women living in the United States and Puerto Rico. The women joined the study between 2003 and 2009. The women were between the ages of 35 and 74 when they joined the study and none of the women had been diagnosed with breast cancer, but all had at least one sister who had been diagnosed. The Sister Study is looking at the causes of breast cancer and other health issues in women, as well as factors that influence quality of life and outcomes after a breast cancer diagnosis.

Bottom Line: Go au natural on the hair color and hair structure. Mother Nature is a beautiful thing!!!

Eberle CE,et al. . Hair dye and chemical straightener use and breast cancer risk in a large U.S. population of black and white women. Int J Cancer; [Online 4 December 2019].

Could Curcumin Be an Option for Hot Flashes?

The most common symptom women experience in perimenopause and menopause is hot flashes—day and or night. They are also called vasomotor symptoms, which are a sudden feeling of heat, burning and/or sweating with a slight increase in body temperature due to increased metabolic rate and vasoconstriction in the periphery. These fluctuating levels of estrogen, and ultimately low levels of peripheral estrogen, affect the hypothalamus temperature control center and the central nervous system, which eventually alters the levels of neurotransmitter activity, including serotonin and norepinephrine—all of which lead to causing the hot flashes.

Anxiety is also a common issue in perimenopause/menopause although it is complex but can include the loss of self-confidence, the sleep disruption, less activity and mobility, financial stressors, and possible an increase in other chronic illnesses that come with aging.

A study out of Iran chose to investigate a combination of curcumin and vitamin E for hot flashes and anxiety in menopausal women. The polyphenols in turmeric and thus the essential turmeric compound curcumin have anti-inflammatory and antioxidant amongst its many mechanisms of action. Vitamin E contains tocopherols also with antioxidant activity. Oxidative stress can be induced by menopause and thus a resulting imbalance between free radicals and antioxidants. While perhaps not a strong choice to investigate for hot flashes and anxiety, this triple-blind randomized controlled trial enrolled women ages 40-60 years who were less than six years postmenopausal and had hot flashes at least twice per week. Participants were divided into three groups with one group receiving a curcumin capsule of 500 mg twice daily for eight weeks A second intervention group received oral vitamin E 200 IU twice a day for eight weeks. The third group received placebo twice daily for eight weeks.

Out of 320 menopausal women who were questioned, 160 women entered the study, and 93 women chose to participate. Each group had 31 women in it to start. Women completed the hot flash questionnaire one week before starting the intervention and again at four and eight weeks. They also filled out an Anxiety Scale form, and the Female Sexual Function Index (FSFI), and the Greene Climacteric Scale.

The average number of hot flashes in the curcumin group and vitamin E group was significantly lower than the placebo group after eight weeks. The first significant difference appeared in the curcumin group after four weeks. There was no effect of vitamin E on hot flashes compared with placebo, after four weeks, but was observed at the end of the eight weeks. This study seemed to report just number of hot flashes, not severity. There were no differences in anxiety, sexual dysfunction, or other menopause symptoms between curcumin, vitamin E, and placebo.

Commentary: Older research on vitamin E is mixed, and I’ve never included it as a robust option for vasomotor symptoms. Curcumin is an interesting choice as there is some PMS and depression research showing efficacy for mood and effects on serotonin. Since serotonin alterations do have a role in vasomotor symptoms, it seems like it is a possible therapy to pursue. Certainly, curcumin has a long list of other conditions that are relevant to aging women, including osteoarthritis, insulin resistance and aging vascular endothelial function relevant to cardiovascular disease. By and large, I will think of curcumin and vitamin E for other conditions other than vasomotor symptoms, although menopause is fraught with a laundry list of symptoms, including vasomotor symptoms, depression, arthralgias and weight gain. Curcumin in particular would be a logical choice when a woman has multiple symptoms and maybe not just vasomotor symptoms. But again, based on the results of this one study, curcumin could be considered an option for treating the pesky number of hot flashes and night sweats.

A note of concern about the legitimacy of this study: Studious and meticulous readers of research, colleagues of mine, have some concerns about at least some of the botanical and nutraceutical research coming out of Iran. In this study, a concern that has been pointed out involves the Iranian Registry of Clinical Trials (IRCT) document; the registration date was June 23, 2018. The expected recruitment start date was July 4, 2018, and the expected recruitment end date was October 5, 2018. For most studies, that would be an unrealistically short time period for assessing 320 women. Also, the IRCT document says, “Recruitment complete,” which does not seem possible if the recruitment had not started when the study was registered (and there have been no updates to the registration document).

Ataei-Almanghadim K, et al. The effect of oral capsule of curcumin and vitamin E on the hot flashes and anxiety in postmenopausal women: A triple blind randomised controlled trial. Complementary Therapies in Medicine. 2020; 48:102267

The Effect of Global Climate Issues on Pregnancies

Two things to focus on here are air pollutants and heat from climate change. There are many other environmental exposure impacts on women’s health, fertility, pregnancies and in utero exposure, but the systematic review of 68 studies from 2007 to 2019 evaluated the association between ambient heat, air pollution, and obstetric outcomes, including preterm birth (PTB), low birth weight (LBW), and stillbirth (SB). There were different types of air pollution components and degree of heat exposure, but air pollution was defined as fine particulate matter <2.5 microns.

In total in all 68 studies, >32 million US births were analyzed. A total of 57 studies showed a significant association with poor birth outcomes—assessing air pollutants in 48 or 58 studies and 9 out of 10 assessing heat exposure. The association of fine particulate air pollutants or ozone was associated with preterm births in 19 of 24 studies and low birth weight in 25 of 29 studies. The data related to stillbirths were limited. The pregnant women at highest risk were asthmatic and minority women, especially African American women throughout the US and Hispanic women living in California. The women with the lowest socioeconomic status and also those living close to power plants and highways had the worst outcomes.

Commentary: As if we did not need more discouraging information about the impact of the crisis of climate change…but this time, specific to pregnant women and their newborns. There are multiple factors involved in poor obstetrical outcomes, including poverty, nutrition, smoking, alcohol and drug use, select legal prescriptions, violence against the women during pregnancy, and more. But now we have more statistics on the inequities borne by minorities and exposure to air pollution and heat exposure during pregnancy, that appears to elevate risks for poor outcomes.

Women and their families and employers and health care providers should do everything possible to meet these additional challenges of pregnant women that affects their risk for preterm births, low birth weight babies, and possibly stillbirths. The bigger picture of course, is for more of us to wake up to the climate crisis and the impact it has and will continue to have on our health. What can each of us do to meet this challenge? We could get involved in organizations with the mission to affect policy and change regarding air pollution, water and ground pollution; we could donate to such organizations; we could vote in local, state and federal initiatives and elections that affect policy and values and actions of the politicians. This blog may not sound like a women’s health-related topic—but from pregnancy outcomes to fertility to breast cancer, trust me, it is.

Bekkar B, et al. Association of air pollution and heat exposure with preterm birth, low birth weight, and stillbirth in the US: A systematic review. JAMA. 2020; June 18.

Guidice L. A clarion warning about pregnancy outcomes and the climate crisis. JAMA. 2020 June 18.

Vaginal Lactobacillus for Bacterial Vaginosis

Bacterial vaginosis (BV) is the most common vaginal infection in women. It is characterized by vaginal fishy odor, vaginal discharge (usually thin, gray or white or even greenish) and irritation and/or burning and/or itching. Women and practitioners can easily conclude incorrectly that the symptoms are due to a yeast infection, but a test of vaginal pH and an amine test of the discharge confirm the diagnosis. It’s not something you “catch” from someone else, meaning it is not considered a sexually transmitted infection, but rather a result of a displacement of the optimal lactic acid producing lactobacilli in the vagina by the already present, but now over-populated anaerobic organisms of BV. There are some potential complications of BV rather than just annoying, including risk of preterm birth if you have BV during pregnancy, an increased risk for sexually transmitted infections, pelvic inflammatory disease, and an increased risk of a pelvic infection post certain pelvic surgeries such as a hysteroscopy or dilation and curettage.

One of the most challenging aspects of BV is that it can easily recur, despite conventional standard of care treatment with antibiotics.

This study was funded by the National Institute of Health to assess whether intravaginal replacement of Lactobacillus crispatus, considered a “good” vaginal bacteria, would reduce the risk of BV recurrence. This double-blind, placebo-controlled trial was conducted in 228 women who had recently been treated with a common antibiotic for BV, called metronidazole. The women inserted a preparation of Lactobacillus crispatus or placebo for four consecutive days during the first week, then twice weekly for 10 weeks.

At week 12, 30% of the women who received the L. crispatus had a recurrence and 45% of those receiving placebo had a recurrence of BV. At week 24, recurrence rates were 39% for the L. crispatus group and 54% for the placebo group. However, the recurrence rate for 19% of the women was unknown.

Commentary: There have been many good studies of lactobacillus species and strains for BV, and now we can add this one. However, I would want the results to be even better, and as you can see, at 24 weeks, the recurrence rates are higher, implying longer treatment is needed. Recurrence rates are famously high for even a first episode of acute BV making it a challenge for all practitioners and women who are dealing with BV, but even more so for women with recurring BV. About 30% of women experience a recurrence of symptomatic BV within 30 to 90 days, and 70% will have a recurrence within nine months. Clearly, a more effective approach is needed. While this one organism, L. crispatus is an important consideration, I find that better results could be achieved when incorporating the other research that has been done on other species as well, such as L. rhamnosus and L. reuteri, and in addition, vaginal vitamin C tablets, and boric acid.

Because the recurrence rate is high for a simple case of BV, I can make a compelling case for using an integrative approach with both antibiotics and natural agents. I also prefer to use vaginal antibiotics, rather than systemic, for this condition. The overriding concept is to restore normal vaginal ecology with lactic acid producing lactobacilli species to be dominant. A normal vaginal pH is more acidic in the range of 3.5-4.5, that is why you see the acidic items of vitamin C, boric acid, and lactic acid producing lactobacilli.

Sample Acute Bacterial Vaginosis Plan, Natural Medicine Only

• Insert vaginal vitamin C tablet (250 mg) daily for 6 days (consider proprietary product such as Vfresh from Vitanica) , then
• Insert boric acid 600 mg suppository 1/day for 10 days, then once weekly for 6 weeks.
• Insert a women’s probiotic that has L. rhamnosus/L. reuteri and with one or more others, including L. acidophilus, L. plantarum, L. salivarius, L. crispatus; insert once weekly for 6-12 weeks
• Oral women’s probiotic same/similar to above: 10 billion per day for 1-3 months

Sample Acute Bacterial Vaginosis Integrative Plan

• Metronidazole gel 0.75% insert nightly for 5 days or clindamycin 2% intravaginally nightly for 7 days or clindamycin ovules insert once daily for 3 days.
• Follow with inserting the women’s probiotic as stated above, daily for 4 days then twice weekly for 3-6 months
• Oral women’s probiotic same/similar to above- 10 billion per day for 1-3 months

Sample Chronic Recurring Bacterial Vaginosis Integrative Plan

• Metronidazole gel 0.75% insert nightly for 5 days or clindamycin 2% intravaginally nightly for 7 days or clindamycin ovules insert once daily for 3 days
• Then insert Metronidazole 0.75% gel once weekly for 4 months.
• Also Insert a women’s probiotic that has L. rhamnosus/L. reuteri and with one or more others including L. acidophilus, L. plantarum, L. salivarius, L. crispatus; insert once weekly for 4 months
• Oral women’s probiotic same/similar to above: 10 billion per day for 4 months
• Insert boric acid capsules once weekly for 4 months (during the same 4 months as the vaginal antibiotic and the vaginal probiotic—just on different nights) .
• If heterosexual, use condoms to avoid the alkalinizing effect of semen. Oral sex with a woman or a man can also be a pH challenge to the vagina

Cohen C, et al. Randomized trial of Lactin-V to prevent recurrence of bacterial vaginosis. NEJM. 2020 May 14;382:1906

Disclosure: Dr Hudson is the director of education and formulator and co-owner of Vitanica.

The Potential Importance of Vitamin D and COVID-19

We’ve all read and heard many things the last three months about viruses, antibodies, testing, treatments and prevention for COVID-19. I’ve hesitated to write about any natural medicines that might have a protective or intervention role, but I have found this current update on vitamin D to be safe and valuable enough, to pass along.

Vitamin D has been well known for quite a long time for its role in bone health, cardiac health, mood, and even immune health. But now, there is emerging and a growing body of evidence that vitamin D status may be relevant to the risk of developing COVID-19 infection and to the severity of the disease.

Vitamin D is important to what is called innate immunity and boosts immune function against viral diseases. Innate immunity refers to nonspecific defense mechanisms that come into play immediately or within hours of an antigen’s appearance in the body. These mechanisms include physical barriers such as skin, chemicals in the blood, and specific immune system cells that attack these foreign antigens. We also know that vitamin D has an immune-modulating effect and can lower inflammation. This may be one of the relevant mechanisms involved in the respiratory response during the COVID-19 cytokine storm.

In some laboratory studies of studies of respiratory cells, some of these effects of vitamin D have been documented. In addition, it has been detected that if one has lower levels of 25-hydroxy-vitamin D in the blood (which can easily be tested in a blood test), then they may be more susceptible to respiratory infections. There is now some evidence that this is also true in COVID-19 patients. In one observational study from three different South Asian hospitals, vitamin D deficiency was much more prevalent in those individuals with more severe COVID illness compared to those who were mildly ill. Specifically, there was about an eightfold higher risk of having severe illness if they had vitamin D deficiency compared to those who did not.

Two years ago, there was a meta-analysis of randomized clinical trials looking at vitamin D and acute respiratory infections. The results showed that vitamin D supplementation was associated with a 12% reduction in these acute respiratory infections. While this is statistically significant, it is small. However, if the deficiency was more profound, in the range of less than a blood level of 10 ng/ml of 23-hydroxym-vitamin D, there was a robust 70% lower risk of respiratory infection when vitamin D was supplemented.

The best source of vitamin D is sun exposure. This leads to increased synthesis of vitamin D in the skin. While we are spending more time indoors—both wintertime as well as “lock-down” guidelines—attention to vitamin D is even more important. Food sources are small, so supplementation becomes the most consistent method of assuring adequate levels. If you cannot or don’t get tested, then most people will get enough from 2,000 I.U. per day of vitamin D in a pill. Some individuals will need more, at least for three months, if they are indeed vitamin D deficient or insufficient, which is determined from a blood test.

You can also look at food labels that list the vitamin D content. Food sources that are higher in vitamin D (although still not necessarily very much) include fortified dairy products, fortified cereals, fatty fish, and sun-dried mushrooms.

Researchers are in the process of planning a randomized clinical trial of vitamin D supplementation in moderate to high doses to see whether it has a role in the risk of developing COVID-19 infections and also in reducing the severity of disease and improving clinical outcomes. I look forward to these results.

Resources

1. Martineau AR, et al.  Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data. BMJ. 2017 Feb 15;356:i6583.

2. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3571484 Mark Alipio. Vitamin D Supplementation Could Possibly Improve Clinical Outcomes of Patients Infected with Coronavirus-2019 (COVID-19). SSRN. 9 Apr 2020 Last revised: 7 May 2020

3. Raharusun, Prabowo and Priambada, Sadiah and Budiarti, Cahni and Agung, Erdie and Budi, Cipta, Patterns of COVID-19 Mortality and Vitamin D: An Indonesian Study (April 26, 2020). SSRN: https://ssrn.com/abstract=3585561 or http://dx.doi.org/10.2139/ssrn.3585561