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Category Archives: Women’s Health

Latisse: Are Longer Lashes Worth the Cost and Risks?

January 13, 2012 Dr. Pullen

I find the most interesting thing about Latisse® is how it came to be used for growing longer thicker eyelashes. Latisse follows a familiar story like other hair growth products in that it was an incidentally discovered side effect/benefit of the active ingredient in Latisse® while it was being used for another indication. Latisse® got its FDA approval in December 2008, and was brought to market after discovering that the active ingredient in Latisse® called bimatoprost which was used as an eye drop for glaucoma was incidentally noted to lead to longer thicker eyelashes. This quickly led to a medical diagnosis in order to give an indication for a new drug. The medical term, or if you prefer medical diagnosis, for shorter or thinner than desired eyelashes is hypotrichosis of the eyelashes. Latisse® follows the list of other drugs which were incidentally noted to cause hair growth, Rogaine makes use of minoxidil, a seldom used oral medication for refractory hypertension that was noted to cause undesired hair growth when taken orally. Propecia uses the active ingredient finasteride (brand name Proscar®), which is used to shrink the size of the prostate and allow men with benign prostatic hypertrophy to urinate more easily. It was found later slow male pattern baldness hair loss and is now commonly used for that purpose.

The exact mechanism of action of Latisse is not clearly understood but it appears to be a prostaglandin receptor binder . Prostaglandin receptors are present in here and is thought that prostaglandin receptors are somehow involved in the development and regrowth of hair follicles.

Latisse® is a prescription only product that is designed to be applied once daily to the base of the upper eyelashes with a single use a sterile applicator. Despite the intention to make Latisse® prescription only, much like other drugs for which patients might wish to use but don’t want to get a prescription to see a physician about Latisse® is widely available online without direct physician supervision. This is unfortunate because the teeth can have very annoying and potentially permanent side effects. These include a plum shade discoloration of the eyelid, macular edema which can be very serious even lead to blindness, a condition called punctate epithelial keratitis which can lead to significant itching and irritation of the eyes, as well as dry eye, eyelid swelling and injection of the conjunctival blood vessels making the eye seem reddish or pink. In addition though not mentioned in the product insert there are reports of Latisse® leading to darkening of the iris.

Although Latisse is a prescription only product it’s very easy to purchase this drug online without a prescription. The top of the Google search list for pilot case online is a site where you simply submit a medical form history and a “patient marks licensed physician will carefully ensure Latisse is a safe option free you to use before we send your order.” They even advertise a discount for Valentine’s Day few by two more bottles. The retail price@drugstore.com for one bottle for peace is $115.99, but several online sources appear to be selling Latisse for between $70 and $85 per bottle. A bottle will last one month if applied as directed to both upper lids and even the manufacturer notes that Latisse only works as long as you continue to use it. Whether longer thicker eyelashes are worth approximately hundred dollars a month plus the risk of serious side disorders that could even affect vision and cosmetic or annoying eyelid problems is for each individual to decide.

Resource: Latisse side effects

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How Safe is Oral Sex?

December 12, 2011 Dr. Pullen

Bill Clinton didn’t consider it sex. Lots of teens today consider oral sex a safe alternative to intercourse. Headlines like on ABC news in 2009 cry out, “Oral Sex is the New Goodnight Kiss.” Data suggests that oral sex is becoming more common practice in teens than vaginal intercourse, a major change from a generation ago. In 2002 up to 24% of males and 22% of females teens who had never had vaginal intercourse reported having had oral sex with an opposite sex partner (1). In addition gay men want the real truth, is oral sex a safe alternative to more risky behaviors? The answers seem to all be relative. There are few absolutes in life, but one of the truths is that the only way to completely avoid risk of an STD is to avoid any type of sex. That said, how safe, or alternatively how dangerous, is oral sex?

Let’s look at the evidence for transmission of the various STDs by oral-genital contact.

HIV: Human Immunodeficiency Virus, the cause of AIDS, is the STD many fear most. It can be transmitted when a body fluid containing the virus gains access to another person’s mucous membranes or bloodstream. Unquestionably HIV is transmitted by anal and vaginal intercourse. There are at least a few cases where it is believed that the HIV virus was transmitted to the receptive partner after oral sex with ejaculation. Oral sex without ejaculation into the mouth is theoretically possible, but is felt to be extraordinarily unlikely. The risk of contracting HIV from a single incidence of anal intercourse with with ejaculation and no condom use with an HIV infected male has been estimated at 1:100. Extensive study has been done in trying to find out what the incidence of contracting HIV from oral sex with ejaculation with an HIV infected male, but these studies all have confounding variables. The real problem is that all of these studies have been in gay male populations, and a low percentage of the men had only oral sex. On second and subsequent interviews many times the history changed, and made other routes of transmission more likely. In one study it was estimated that there were zero cases of conversion in a population after over 35,000 incidences of oral sex. All said, although it is possible to contact HIV from oral sex, the chances are very low. Low enough that if oral sex is a behavior that replaces anal intercourse in gay men the benefit of avoiding the high risk behavior likely greatly outweighs the risks of oral sex in this situation.

Herpes Simplex: This may be the most common STD transmitted by oral sex. Up to 70% of teens are estimate d to have been infected with the herpes simplex 1 virus, the cause of >90% of oral herpes cases. Many others, and many of the same people also have been infected with the herpes simplex 2 virus, the cause of >90% of genital herpes. The problem with herpes simplex is that despite popular belief, an infected person can shed the herpes virus at times when they have no symptoms or visible evidence of infection. It is believed to be fairly common to transmit the herpes simplex virus either from the mouth to the genitalia, or from the genitalia to the mouth during oral sex. The incidence of HSV transmission by oral sex is not well studied.

Gonorrhea: Gonorrhea, caused by the bacteria Nisseria gonococcus, is an STD that typically causes painful urination and a discharge of pus from the urethra in men. In women it can be asymptomatic, can cause a vaginal or cervical discharge, or can cause more serious infection of the fallopian tubes and or ovaries, called Pelvic Inflammatory Disease (PID). Gonorrhea can also infect the throat or tonsils. The route of this infection appears to be oral sex, generally receptive oral sex with the penis in the mouth. It is less clear whether cunnilingus can transmit gonorrhea although it is felt that this is very rare if it ever happens. Men likely only contact gonococcus from vaginal or anal intercourse or from an infected partner during receptive oral sex.

Chlamydia: There is less data about transmission of Chlamydia by oral sex. It is generally felt to be possible to transmit Chlamydia both as the person performing and the person receiving fellatio. The incidence of this is just not known.

Syphilis: Syphilis is fairly uncommon in the US, but transmission of syphilis during oral sex is relatively easy, and is felt to be a relatively common cause of transmission, possibly up to 15% of cases in some areas of the US.

HPV: HPV is probably the most prevalent STD in the world today. The HPV virus can be transmitted to the throat or mouth during oral sex. The incidence of this is poorly understood, but there is an increasing rate of HPV positive head and neck cancers in the last 30 years. Many experts feel that this correlates to increasing acceptance of oral sex. Oral cancer has historically been primarily a disease of older adults with a long history of smoking and drinking, or in younger persons who use oral tobacco. In recent years the incidence in younger non-tobacco users has increased, and many of these cancers are HPV positive on testing.

Hepatitis: There is debate whether hepatitis B can be transmitted by oral sex, but if possible it is felt to be very unlikely. Hepatitis A can clearly be transmitted by oral-anal sex, and is much more common in the gay male population than in the heterosexual population.

In summary oral sex is not safe sex, but it is far less risky than either vaginal or anal intercourse regarding STD transmission. In addition the risk of pregnancy in heterosexual oral sex is near zero. Avoiding receiving ejaculate in the mouth greatly lowers the risk of transmission of HIV, though probably not the risk of herpes, gonorrhea, or HPV. Condom use for men, or use of a dental dam in women seems effective in markedly reducing the risk of most STDs with oral sex, but may not be common practice.

Psychological Issues: Oral sex is clearly an intimate act. Most psychologists agree that sex, either oral sex or sexual intercourse, brings a relationship to a different level. How this type of intimacy affects a relationship, the self esteem of the participants, and future feelings about relationships and intimacy are subjects worthy of consideration, but I know of no research into this topic.

So, “How safe is oral sex?” What do you want to tell your children about oral sex as a part of their sex education? You can decide now based on the discussion above and whether it involves men having sex with other men (MSM) vs. heterosexual oral sex. One risk of labeling oral sex a high-risk behavior in MSM is that it may leave gay men feeling that its risk is equal to anal intercourse, which is far from the truth. If oral sex is an alternative to anal intercourse for MSM then it greatly reduces the risk of HIV transmission.

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Give a Gift on Black Friday

November 21, 2011 Dr. Pullen

Add Some Red to Black Friday and I’ll give some Green to the American Cancer Society

Millions of Americans shop for Christmas gift bargains on Black Friday every year. I encourage you to give a gift on Black Friday that costs you nothing more that a little time, and which can help you feel you have truly given life and hope during this holiday season.

My readers will know that I’m a big proponent of regular blood donations. Kay, my wife has ovarian cancer and has been a recipient of donated blood when her blood counts get low from chemotherapy. Cancer patients are among the highest users of donated blood products from red blood cells to platelets. I’m donating regularly to be sure our family puts more blood into the blood banking system than we take out. I want you to join with me on the Friday after Thanksgiving this year by paying a visit to your local blood donation center. There are even potential blood donation health benefits.

I’m putting out a challenge to readers, your friends and anyone else you can contact. Black Friday is a day when many of us are out and about shopping and getting ready for the holidays. The holiday season is also a time when blood donations tend to fall behind need. Here is the challenge:

I’ll donate $1. (up to $1000) for every comment to this post or tweet me @DoctorPullen telling me that you have or intend to go to your local blood donation center on Black Friday and donate blood. $1. may sound like chump change, but I want to get 1000+ people who would otherwise not donate blood to do so this Friday. We are in a world of easy communication, and I bet everyone who reads this knows 10 people who are in a position to get to their blood donation center this black Friday and donate. Just do it!

Take a break from shopping, get off your feet, and relax while you give one special holiday gift. Use the twitter or facebook links to send this off to your friends, tell your coworkers, shout from the roof tops, whatever but let’s make this Black Friday blood red with our generosity.

My daughter, son and I plan to go to the local Cascade Regional Blood Bank center in Puyallup Friday. I checked and they are open 7:30 AM – 5:00PM. I’ll try to keep a counter going on the site to let you all know how we are doing.

They Turned Me Away Today

Egg on my face. I went today to donate, but was turned away because I went to Belize on vacation a couple of months age, an area with malaria exposure potential. I’m now ineligible for a year, joining a majority of the rest of Americans. If you are among the 37% who are eligible donors get to your blood donation center and give. Keep our blood supply safe and plentiful. Happy Thanksgiving.

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Spironolactone Off Label Use: PMS, Acne, Hirsuitism, Male Pattern Baldness

September 9, 2011 Dr. Pullen

Today the medical student working with me asked my why a patient was on spironolactone for acne, as she thought this was a potassium sparing diuretic. Great question as the FDA approved use of spironolactone is just that. In the office I see far more women on spironolactone these days for acne, facial and body hair, or even for PMS than I see patients on spironolactone for its diuretic properties. The anti-androgen properties of spironolactone are well known and frequently utilized in off-label prescriptions of this medication.

Hormonal acne has always been among the more difficult types of acne to treat, and in recent years the use of spironolactone for its anti-androgen effects has been found to be helpful for this particular type of acne. When a woman’s acne is much worse in the week or two prior to her menses or around the time of menopause oftentimes the acne will respond to the anti-androgen effects of spironolactone. The usual dose is 50-100 mg twice daily. In adolescents and young women the combination of low-androgenic oral contraceptives is sometimes more effective than spironolactone alone.

The use of spironolactone for suppression of androgenic hair growth by women is also widespread. Spironolactone can be effective in suppression of facial hair and to a lesser degree body hair. Again the dose often used is 50-100 mg twice daily. Polycystic ovarian disease is one of the common medical problems where spironolactone is used for suppression of facial hair growth.

On the other side of hair growth, spironolactone is being used without much evidence to support its efficacy in men with male pattern baldness. Topical preparations are proported to be helpful for this indication, although I have to say I’m skeptical and the evidence looks pretty sketchy. Some advocates suggest that adding spironolactone topically to systemic finasteride (Propecia) gives additive anti-androgenic effects at preventing male pattern baldness hair loss.

PMS is a less well documented and popular use of spironolactone. Some women find that the drug lessens the severity of the premenstrual dysphoric and fluid retention symptoms. The primary effect of spironolactone is inhibition of the adrenal hormone aldosterone. Aldosterone leads to elevation of blood pressure, so inhibition of aldosterone can cause dieresis and so lessen the PMS symptoms of bloating, fluid retention, and premenstrual weight gain. It is unclear whether the anti-estrogen effects of spironolactone play a role in reducing the emotional symptoms of PMS, or whether any benefit in this regard is related to the diuretic effects.

Traditional uses of spironolactone are more mundane but well documented. Likely the most common FDA approved uses of spironolactone are to spare potassium loss in combination with a thiazide diuretic, in such fixed dose drugs as Aldactazide and for treatment of congestive heart failure in patients. A commonly noted NEJM article showed that in patients with serious heart failure, LV ejection fraction less than 35%, usually also on and ACE or ARB and loop diuretic like furosemide patients on spironolactone had significantly lower death rates than the control group on placebo. For more information about furosemide please visit furosemide side effects for a nice resource online. Other typical diuretic uses of spironolactone are patients with ascites due to cirrhosis of the liver. The theory behind this is that effects of aldosterone may be harmful to the myocardial cell function.

Spironolactone has potential side effects that can bother patients, and can lead to drug interaction issues. Common side effects of spironolactone include elevation of serum potassium levels that can be severe at times, Gynecomastia, and diarrhea. Serious drug interaction side effects can occur with numerous medications, but of special mention are additive potassium elevation effects when used with angiotensin receptor blockers or angiotensin converting enzyme inhibitors, with various other antihypertensive or other cardiac medications.

Spironolactone is pregnancy category D, and carries a black box warning that long term use in rats has been associated with tumor growth and toxicity.

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Aromatase Inhibitors: Breast and Ovarian Cancer Therapy and Maybe More

August 30, 2011 Dr. Pullen

Aromatase Inhibitors are drugs that work within cells to inhibit the function of the enzyme aromatase, which facilitates the chemical change of androgens into estrogens. This process is called aromatization, and in postmenopausal women a large proportion of the estrogen available comes from the conversion of androgens into estrogens. In premenopausal women most of the estrogen comes directly from the ovaries, so inhibition of the aromatization of androgens is much less effective in controlling estrogen available to estrogen dependent cells.
The primary use of aromatase inhibitors is in the treatment of estrogen dependent cancers, primarily estrogen receptor positive breast cancers and ovarian cancers. Most oncologists first treat women with estrogen receptor positive breast cancers with estrogen receptor blocking medications like tamoxifen or reloxifene, but sometimes the aromatase inhibitors can be effective at slowing or stopping the growth of these tumors when tamoxifen has failed.
There are currently three aromatase inhibitor medications available in the United States. Two of these, anastrozole (Arimidex) and letrozole (Femara) are considered non-steroidal reversible competitive enzyme inhibitors, and exemestane (Aromasin) is an irreversible steroidal enzyme inhibitor that binds permanently with the aromatase enzyme and deactivates it irreversibly. Both letrozole and anastrozole are available in the U.S. as generic medications.
Not unexpectedly the primary side effects of the aromatase inhibitor medications mimic menopausal symptoms. Even though these are used primarily in post-menopausal women by reducing the small amounts of estrogen available they can lead to hot flashes, night sweats, vaginal dryness and these menopausal symptoms can be quite severe in some women. Other aromatase inhibitor side effects include bone and joint pain, an increased risk of osteoporosis, and headaches. Unlike the competitive estrogen receptor drugs tamoxifen and reloxifene the aromatase inhibitors are not felt to raise the risk of endometrial cancer or of endometrial sarcoma.
At this time the aromatase inhibitors do not have an indication for reduction of risk of developing breast cancer like tamoxifen and reloxifene have. Research is felt to be needed to see if this potential use of the aromatase inhibitors is going to be effective and whether it is worth the potential risks and side effects these the aromatase inhibitors can cause. One study, the MAP3 study did seem to show a reduction in the incidence of invasive breast cancer in women on exemestane vs. placebo.
All of these drugs are used orally as a once daily dose, and all have similar indications. All are used both as early postmenopausal therapy in estrogen receptor positive postmenopausal women with breast cancer, usually after more aggressive chemotherapy, or as adjuvant therapy after recurrence of breast cancer while on an estrogen receptor blocker.
Generic versions of both letrozole and anastrozole are available in the US as their patents have expired, but online price comparison is not easily available.
There are other potential uses of the aromatase inhibitor medications that do not have FDA approval in the U.S. One of these is for treatment of gynecomastia. These drugs are sometimes used on the black market by athletes using anabolic steroids to prevent the aromatization of the androgens into estrogens which can lead to Gynecomastia. Another use of the aromatase inhibitors is in treatment of benign estrogen sensitive tumors called leiomyomata, or more commonly fibroid tumors. Fibroids are the most common reason for hysterectomy in the U.S. and at least one study showed significant shrinking of the size of fibroid tumors with a 90 day course of anastrazole. An FDA approved treatment of fibroid tumors is embolization of the arterial blood supply of the fibroids. This can be done with coils placed in the arteries by arterial catheterization at angiography, or other similar techniques.

It will be interesting to see if use of the aromatase inhibitors for estrogen sensitive conditions other than breast and ovarian cancer becomes more widespread in future years. Their difficult side effects of the aromatase inhibitors makes this less likely than if they were easy to tolerate.

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Lysteda for the Management of Heavy Menstrual Bleeding

July 29, 2011 Dr. Pullen

Lysteda (tranexamic acid) has been on the market since Nov 2009 and it is beginning to be prescribed a bit more by OB-GYN and family physicians. I suspect the slow adoption of Lysteda is related to its unusual mechanism of action, its high cost ($180.44 for a 5 day course at Costco) and the fairly recent availability of office based endometrial ablation procedures for the largest group of patients with heavy menstrual bleeding, namely women in their 30-40’s who have finished their childbearing.

Like many new drugs on the market Lysteda is not really new. It has been used for years as an IV drug for prevention of bleeding in hemophilia patients for dental extraction and other surgical procedures. Tranexamic acid works as a competitive inhibitor of plasmin at one of its receptors on the fibrin matrix. By inhibiting plamin function the clotting of blood that involves the production of fibrin is stabilized, and bleeding during menses is diminished. In two trials menstrual bleeding by women was reduced by about 38-39% as compared to 13% reduction by placebo.

The major side effects of Lysteda are related to its mechanism of action and include increased risk of blood clots in the form of veinous thromboembolism in the legs as DVT, and of stroke and heart attacks. Use in combination with oral contraceptives significantly increases the risk of thromboembolic adverse events and is recommended only in extreme circumstances. Frankly I cannot imagine what this situation would be, as there are alternatives to Lysteda in this situation. Lysteda is also cautioned in women at higher risk of DVT, including smokers over the age of 35 and obese smokers. Another serious thromboembloic side effect that has been reported with Lysteda is retinal vein and retinal artery occlusion. These can cause loss of vision, and any visual symptoms while on Lysteda need immediate opthalmologic attention.

Less serious Lysteda side effects include headache, nasal symptoms, backache, abdominal pain, migraine, anemia, and various musculskeletal pains and arthralgias. Overall the tolerability in patients using Lysteda seemed fairly good in the published clinical trials. Most of the serious side effects noted above have been reported in after-market experience and although uncommon are serious enough to make Lysteda a drug physicians tend to use only in very select circumstances.

After studying the advantages and risks or Lysteda I think the niche I’ll consider use of Lysteda is in the woman at low risk of thromboembolic events who has very heavy menses, for some reason is not controlled by birth control pills or has problems with birth control pills, who has a reason not to use the Mirina IUD, who wants to maintain fertility, and who can afford the relatively high cost of this drug. See the insured, late teens to late 20’s woman who gets side effects of birth control pills and plans more children yet has extremely heavy menses. Keep in mind that Lysteda is only for heavy menses, and does not treat other PMS symptoms, does not provide contraception, does not protect against STDs, and only reduces menstrual bleeding by less than 50%. Compare this with the alternatives:

Lysteda	Reduces bleeding by 39%, cost high, potential risks high
Oral Contraceptive Pills	Often reduces bleeding significantly, cost relatively low, serious risks low, good contraception
Mirina IUD	Up front cost high, often no menses or very light menses, good contraception
Depo-Provera	Cost moderate, often no menses, good contraception, serious side effects low but common side effects moderate
Endometrial Ablation	One time cost high, often very little or no bleeding, not appropriate if fertility desired, fairly low surgical risks
Hysterectomy	One time cost high, surgical risks moderate, no bleeding after surgery, ends fertility
Placebo	13% reduction in bleeding, no risk, here just for comparison

Overall the niche for Lysteda is small, but it is one more fairly recent addition to our war chest of tools to treat a sometimes very challenging problem that can cause considerable morbidity for affected women.

This is nice to have as an option given the significant morbidity women experience from menorrhagia. Hysterectomy has been suggested by some as the most cost effective treatment of menorrhagia. Endometrial ablation is very popular today among women who percieve hysterectomy as too agressive for their preferences. Lysteda is among the options, especially for women who want to preserve their fertility and who are at low risk for coagulation problems.

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Nitrous Oxide and Pregnancy: Money Before Safety?

May 6, 2011 Dr. Pullen

Nitrous oxide and pregnancy labor pain control seems on the verge of becoming a mainstream option. It seems that the push for hospitals to adopt this option may be driven by a race to gain market share before safety issues have been carefully studied. I’m putting this out for feedback. What do your think? Leave a comment and start a discussion.

Laughing gas, or nitrous oxide seems to be rising in popularity for use in labor for pain control. It has been a mainstay of dental anesthesia for years, and is used as a part of conscious sedation in many hospital and some office settings. My concern is that the effects of nitrous oxide on the fetus have really not been studied. It’s probably safe, but is probably good enough? Check out this article. The advocates seem to be strongly in favor of the use of nitrous for labor, but their argument seems more a business argument than a medical one. What I read is, “Get Laughing Gas for Your Birthing Center” and have a heads up on the competition for patients.

Here are a couple of quotes from the MedPage article:

Another possible hang-up is concern over safety.

There’s been no investigation into the effects of in utero exposure to nitrous oxide, and nitrous oxide exposure to allied health professionals often exceeds federal occupational safety limits, Palmer cautioned.

Here is a back and forth banter. Susanne Serat is a nurse practitioner midwife in New Hampshire who has been using nitrous oxide for her patients. Craig Palmer is chair of the obstetric anesthesia department at the University of Arizona.

Dartmouth may wait to make its final decision on instituting nitrous oxide during labor until they see Vanderbilt’s data and have more safety assurance in hand, Serat noted.

But that would be a mistake, Rooks argued, noting it will be years before that data comes in, whereas the European experience shows millions of women having used it without any evidence of problems.

“Just because people have been using it doesn’t mean we know enough about its safety,” Palmer countered.

It took a long time for epidurals to be accepted as safe, too, noted Rooks.

“Like anything it will come slowly,” she predicted.

But grassroots acceptance is being helped along by women like Jaeger, who has been

Check out the full article at: Laughing Gas Bringing Smiles to More Women in Labor

By Crystal Phend, Senior Staff Writer, MedPage Today
Published: April 27, 2011

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Microcytic Anemia

April 8, 2011 Dr. Pullen

Iron Deficiency Anemia Blood Smear

Microcytic anemia is among the most common problems seen in the family physician’s office. If you are a young woman or child with anemia, most likely it’s microcytic anemia due to iron deficiency. I often see patients who just assume that anemia means iron deficiency.

When a physician sees a patient with anemia the first thing they look at is the size of the red blood cells. Microcytic denotes that the size of the red blood cells is smaller than normal red blood cells, and anemia is the name given to a reduced red blood cell hemoglobin concentration in the blood. The size of the red blood cells is measured as the mean corpuscular volume (MCV) and is normally between 80-100 microns. When the MCV is less than 80 a patient is said to have microcytosis, and when it’s > 100 they are said to have macrocytosis. Microcytic anemia is when the hemoglobin concentration (Hgb) is <12 in women or <13 in men, and the MCV is <80. For more information blood counts see a prior post Complete Blood Count (CBC).

Iron deficiency is by far the most common cause of microcytic anemia. When a patient is found to have a microcytic anemia on a CBC the evaluation usually begins with an assessment of the patient’s iron status, a reticulocyte (newly produced red blood cell) count to assess the percentage of the red blood cells that are newly produced, and an assessment of why the patient is iron deficient. If iron deficiency is confirmed next we try to find the cause of the iron deficiency. Finding the cause of the blood loss may be simple, as in women with excessive menstrual blood loss or patients where there is a clear history of intestinal bleeding. When it is not obvious, testing for occult blood loss in the stool is needed. Treatment of iron deficiency consists of stopping the blood loss if possible by treatment of the cause, and replacement of the iron supplies. This can usually be done with oral iron, but occasionally patients either do not absorb adequate iron from the GI tract or cannot tolerate the side effects of oral iron. Constipation and abdominal pain are common side effects of oral iron supplementation. In cases where iron deficiency is refractory to oral iron, iron can be infused IV. There are risks of severe allergic reactions, even shock and death with IV iron, and this is done only when absolutely needed. Other fairly common causes of microcytic anemia include:

Thallasemia minor: a genetic mutation of the hemoglobin molecule that causes very small red blood cells (MCV typically 60-70) and low normal hemoglobin concentrations or mild anemia. This is usually an easy diagnosis when the patient is asymptomatic, has normal iron levels, and a very low MCV.
Lead poisoning needs to be suspected in children with possible lead paint exposure, adults with occupational or recreational exposure (battery workers, ammunition reloaders). It can be confirmed with serum lead testing.
Other hereditary conditions like hereditary spherocytosis or hereditary eliptocytosis. These are due to genetic mutations in red blood cell wall proteins that can lead to very small red blood cells that have fragile cell membranes. Testing for red blood cell fragility can confirm the diagnosis.
Anemia of chronic disease is typically a normocytic anemia, although it is sometimes microcytic. This is when due to a chronic illness, most commonly renal disease, but sometimes general poor health, the bone marrow under produces red blood cells.

Other causes of microcytic anemia are quite uncommon, and if none of the above diagnoses is made, bone marrow aspiration or biopsy and specialty consultation with a hematologist may be needed for evaluation. Overall most patients with microcytic anemia have benign causes and good response to treatment with iron supplementation, but it is key in iron deficiency to figure out the cause of the iron deficiency. If the anemia does not respond to iron therapy to figure out if the iron is not absorbed, the patient is not taking the iron (non-compliance), or if there is a cause other than iron deficiency. Iron deficiency is so common that in a low risk patient, like a teenage girl with heavy menses, it may be appropriate just to give iron supplementation and get a follow up hemoglobin level without further assessment. In adults, especially adults over age 35-40, it’s key to assess for GI blood loss, and if present to evaluate the colon for polyps or cancer and if not found to consider upper GI sources of blood loss like peptic ulcer or gastritis.

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USPSTF Screening Guidelines

January 20, 2011 Dr. Pullen

New Expanded Osteoporosis Screening Guidelines

It’s interesting that the USPSTF is publishing new guidelines for screening of osteoporosis just as more questions develop about the long term treatment of osteoporosis with bisphosphonates. In the first USPSTF recommendation update that’s been released after the new protocol for posting anticipated updates for public comment, the task force now gives a Grade B recommendation for osteoporosis screening for all women age 65 or older, as well as for younger women who are estimated to have a risk as high or higher than a 65 year old woman with no additional risk factors.

The statement specifically recommends DEXA screening of the hip and lumbar spine, but and even recommends a tool to use to assess risk in younger women called the FRAX Risk Assessment Tool.

No recommendation (Grade I: insufficient evidence) is given to screening for men.

There has been a lot written about the risks of atypical femur fractures and osteonecrosis of the jaw in long term treatment with bisphosphonates. The benefits of these drugs seems to outweigh these risks in general. Still it is not clear how long we should use these drugs, and whether the benefits are lasting after a several year course of treatment, or only last as long as treatment continues. Clearly there is more research needed to answer these questions.

The task force also gives no specific guidelines as to how to assess the risk for women age less than 65. Generally considered risk factors for osteoporosis include smoking, thyroid therapy, corticosteroid treatment, thin body habitus, poor calcium intake, sedentary lifestyle, and prior fractures.

My practice has been to try to screen women in the 50-65 age range if they have multiple risk factors or at 65 if not. I’ll continue this routine, but it’s good to have the new recommendation as it will make Medicare coverage for DEXA a preventative service, I believe with no co-pay or deductible. Comments as to experience with this issue are welcome on this medical blog.

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Lipid Type

December 6, 2010 Dr. Pullen

HDL, LDL, non-HDL Triglycerides – Understand the Jargon

Physicians talk of the lipid profile, or lipid type while most patients want to know about their cholesterol. We really are on the same team, looking for the same goals of reducing the risk of heart and artery disease caused by abnormally levels of the types of lipids that lead to atherosclerosis. We just have different words we use. The jargon physicians use can be confusion, and lipid type is a good example. First some definitions:

Lipid: really another word for fat. A lipid is a substance that disolves in alchohol but not in water. Examples of lipids are wax, oil and other fats.

Cholesterol: a specific lipid that is used for many purposes in the body including cell membranes, hormones, vitamin D production and bile production. It consists of a sterol carbohydrate ring with specific side chains.

Lipoprotein: a particle manufactured in the liver that consists of lipids and protein that circulates in the bloodstream.

Triglyceride: molecule made up of a three carbon molecule glycerin with three long carbon chain fatty acids attached, i.e. “tri” for three + glyceride. Practically these are the fatty particles in the blood stream that did not get packaged into lipoproteins in the first pass of the blood from the gut through the liver.

HDL cholesterol: (High density lipoprotein) Think good cholesterol here. The HDL lipoprotein particle consists of more proteins which are more dense, and less lipids which are less dense, so the lipoprotein is high in density. There are several subsets of HDL, but in general a high HDL level is good. HDL cholesterol functions in part to remove cholesterol from places it does not belong and return it to the liver to be repackaged and better used.

LDL cholesterol: (Low density lipoprotein) Think bad cholesterol here. A lipoprotein that is higher in lipid and lower in protein making it low density. In general high levels of LDL cholesterol are not good, as they increase the risk of atherosclerosis and heart disease. LDL cholesterol is the primary vehicle for carrying cholesterol in the blood stream. When present in large amounts cholesterol is often put where it can cause harm, like on the lining of blood vessels.

CRP: (C-reactive protein or hsCPR for highly sensitive CRP) is a marker of inflammation, and is used sometimes to assess risk of heart disease when the cardiovascular risk based on the rest of the lipid measurements and the other risk factors do not lead to a clear decision on lipid management.

Non-HDL cholesterol: This is simply calculated by subtracting the HDL cholesterol level from the total cholesterol level. non-HCL cholesterol is a secondary target for treating lipids, after the LDL goal is met.

Direct LDL: usually the LDL level is calculated using the formula:

Total Cholesterol – HDL cholesterol – Triglycerides/5 = LDL cholesterol

This formula is quite accurate except when the triglyceride level is over 400-500. High triglyceride levels make this calculation less accurate, so in those cases a more expensive test is used to measure the LDL cholesterol directly.

Physicians use these numbers along with a patients other risk factors to decide on whether to treat them with medication for abnormal lipid measurements. In general the more risk factors for heart disease a patient has the more likely they are to warrant medication treatment.

The risk factors recommended by the National Institute of Health (through the NHBLI) for this decision making include:

Table 3. Major Risk Factors (Exclusive of LDL Cholesterol) That Modify LDL Goals*

- Cigarette smoking

- Hypertension (BP ³140/90 mmHg or on antihypertensive medication)

-Low HDL cholesterol (<40 mg/dL)†

-Family history of premature CHD (CHD in male first degree relative <55 years; CHD in female first degree relative <65 years)

-Age (men ³45 years; women ³55 years)*

* In ATP III, diabetes is regarded as a CHD risk equivalent.

† HDL cholesterol ³60

(table from the NIH site)

The levels of cholesterol are broken down into categories:

Table 2. ATP III Classification of LDL, Total, and HDL Cholesterol (mg/dL)

LDL Cholesterol

<100 Optimal

100-129 Near optimal/above optimal

130-159 Borderline high

160-189 High

>190 Very high

Total Cholesterol

<200 Desirable

200-239 Borderline high

³240 High

HDL Cholesterol

<40 Low

>60 High

(table from the NIH site)

The recommendations for goal LDL cholesterol are as follows:

Three Categories of Risk that Modify LDL Cholesterol Goals

Risk Category LDL Goal (mg/dL)

CHD and CHD risk equivalents <100

Multiple (2+) risk factors* <130

Zero to one risk factor <160

* Risk factors that modify the LDL goal are listed in Table 3

(from the NIH site)

Using these recommendations a woman age 67 who does not smoke, has a BP < 140/90 on no blood pressure medication, has an HDL cholesterol of 38, and has no coronary heart disease in her mother, father, or siblings would have 2 risk factors (age plus low HDL cholesterol) making her goal LDL <130.

Similarly a man age 40 who smokes, is on BP medication, and whose father had his first heart attack at age 50 with an HDL of 33 would have three risk factors (smoking, blood pressure and family history) so his goal LDL cholesterol would be <130 unless his Framingham calculated risk of developing Coronary disease in the next 10 years is >20%.

Here is a link to the calculator provided by the NIH to calculate Framingham Risk:

Framingham Risk Calculator

Using this calculator the 10 year risk of the man above would be 22% if his current systolic BP was 130 on medication, so he falls into the CHD equivalent category and has a goal of <100 for LDL cholesterol.

Treating LDL cholesterol is usually pretty straightforward. We try to get patients to eat a diet low in total fat and saturated fat (primarily animal fat) to avoid trans fatty acids, and to lose weight. If this is not adequate we usually add a medication in the statin family. Many generic statins are available and can keep costs of treatment fairly low, and most patients tolerate statins well. Some patients do not and red yeast rice is sometimes tolerated by those patients. It has a statin-like effect. Statins can lower LDL cholesterol by 25-55% in most patients. If statins are not tolerated, or if you are a woman who may become pregnant (absolute contraindication to statins) then other medications are sometimes used.

Treating low HDL cholesterol is more difficult, and often slow release niacin is used for this purpose, but it is sometimes difficult to tolerate because of flushing and itching side effects.

Treating triglycerides is important if they are extremely high. Levels >500 can put you at risk for pancreatitis, and need to be treated. Levels between 150 and 500 are suboptimal, and are sometimes treated.

In general the goals for non-HCL cholesterol are the LDL goals + 30.

Hopefully this has been helpful in understanding your lipid profile. If you have suggestions for improvement, or other comments, please leave them in the comments section below.

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