Menopausal transition period is a "critical window" for cardiovascular prevention in women

A healthy lifestyle during the perimenopausal and menopausal years reduces the risk of cardiovascular events in later life report the result of a prospective, cohort study published in in the December 4 issue the Journal of the American Heart Association.

The study is a secondary analysis of data from the ongoing, multicentric, multiethnic, prospective Study of Women's Health Across the Nation (SWAN) initiated in 1996 to know more about transition across menopause.  The researchers looked at data from 1143 women to create a composite 10-year average Healthy Lifestyle Score (HLS) involving smoking, diet quality, and physical activity. All three are modifiable behavioral risk factors for CVD and earlier studies have shown an inverse association between healthy lifestyle and various CV outcomes.

The study participants were followed for an average of 15 years with the last follow-up in the year 2015-2016. Carotid ultrasound scans were performed after 14 years to measure the markers of subclinical atherosclerosis which include common carotid artery intima‐media thickness (CCA‐IMT), adventitial diameter (CCA‐AD), and carotid plaque.

Information about the diet was collected at baseline, visit 5, and visit 9 using a modified version of the Block Food Frequency Questionnaire (FFQ) and the amount was quantified using the Alternate Healthy Eating Index (AHEI).

To assess whether the recommended physical activity (≥150 minutes/week of moderate-intensity physical activity) is met or not, the participants were asked to fill the sports and exercise questions on the Kaiser Physical Activity Survey.

Data on smoking were collected using the standardized questions from the American Thoracic Association.

The HLS was calculated based on the sum of individual scores on all the three parameters at baseline, visit 5 and visit 9 and averaged to get the final score. Other covariates included in the study at baseline were age, race/ethnicity, education, financial status, marital status, depression, self-reported health status, and menopausal status.

Physiological risk factors, including BMI, high blood pressure, impaired fasting glucose, serum triglycerides, total cholesterol, HDL cholesterol, LDL cholesterol, use of antilipidemic medications, and use of antihypertensive medications were adjusted in a separate model.

The association between the individual component of HLS and the three markers of subclinical atherosclerosis were also looked at.

At 10 years follow-up, average HLS was found to be inversely and statistically significantly associated with CCA-IMT and CCA-AD — an association that persisted, even after "extensive" adjustment for confounders (P = .0031) and physiological risk factors (P < .001 for both CCA-IMT and CCA-AD).

Compared with participants with the lowest range of HLS, those with highest HLS had a 0.024 mm smaller CCA-IMT and a 0.16 mm smaller CCA-AD.

After adjusting for various physiological risk factors, the researchers did not find a statistically significant association between carotid plaque and average HLS.

Analyzing individual component of HLS, smoking conferred the highest risk for a CV event and those who never smoked had a 0.047 mm smaller CCA-IMT, a 0.24 mm smaller CCA-AD, and 49% lower odds of having a higher carotid plaque index.

The investigators message for the physicians “the menopausal transition represents a crucial, yet understudied, window of increased cardiovascular risk in women. For the prevention of future cardiovascular disease among women undergoing the menopausal transition, the physician should focus on modifiable health behaviors including smoking, diet, and physical activity."

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What should midlife women know about preventive cardiology?

We are all aware that sex and gender differences are important in the diagnosis and management of cardiovascular diseases. A woman’s risk of a cardiac event and stroke sharply increases after the onset of menopause. Here is an informative video regarding preventing and managing the increased risk of a cardiac event after menopause.

Dr. Beth Abramson is a preventive cardiologist and helps women manage the risk of heart disease.  In this video by North American Menopause Society (NAMS), she answers many vital questions about menopausal hormone therapy, midlife weight gain, smoking, alcohol, and aspirin therapy.  

The Dos and Don’ts in Pregnancy: An evidence-based review

Every Pregnant woman receives tons of advice regarding precautions she needs to take to optimize the pregnancy outcome. In this digital age, she is constantly exposed to ideas and suggestions about the dos and don’ts in pregnancy, a lot of which is confusing and conflicting, as a result, the woman is often unsure of what is correct for her and the baby. She often turns to her healthcare provider to direct her regarding her daily routine in pregnancy, but the healthcare provider is also exposed to myriads of opinion on this topic.

This recent article published ahead of print as a part of clinical expert series in the Journal of Obstetrics and Gynecology provides an evidence-based review on things routinely advised or avoided during pregnancy.

The author has looked upon Cochrane systematic reviews, guidelines from the American College of Obstetricians and Gynecologists(ACOG) and other international organizations to formulate the recommendations that can be used to direct a pregnant woman on this confusing and much-advised topic.

Prenatal Vitamins

The necessity of taking or not taking a prenatal vitamin for women has not yet been proven, especially in women taking a balanced diet. But, they are not harmful and may be consumed during pregnancy. Any simple multivitamin will suffice and there is no ideal formulation for a prenatal vitamin. A woman needs to take:

• Folic acid 400–800 micrograms (until the end of the first trimester)
• Iron 30 mg (or be screened for anemia)
• Vitamin D 600 international units
• Calcium 1,000 mg

Nutrition and weight gain

According to the National Academy of Medicine, weight gain in pregnancy is determined by pre-pregnancy BMI. A woman should consume an additional 350–450 calories per day in the second and third trimesters but it also depends upon her activity levels, height and weight and her metabolism rate.

So, the exact calories required should be individualized.

Alcohol consumption

The safe threshold for alcohol intake is not known and higher alcohol consumption is known to cause fetal alcohol syndrome. It is best avoided in pregnancy.

Artificial sweeteners

Artificial sweeteners are safe in pregnancy as no evidence exists to link them with an increase in birth defects, but it is advisable to keep the intake at the lowest possible level.

Caffeine

Low to moderate caffeine intake is presumed to be safe during pregnancy based on most human studies. It is advisable to limit the intake to less than 300 mg/day. An 8-ounce cup of brewed coffee has about 130 mg of caffeine while a cup of tea or soda has about 50 mg of caffeine.

Eating Fish

Fish intake during pregnancy is associated with improved neurodevelopment in children and is also linked to decreased risk of preterm birth. But, because of increased mercury content, the fetus may suffer neurological damage.

Women should try to eat 2-3 servings of fish/week that is low in mercury and high in omega-3 long-chain polyunsaturated fatty acids and docosahexaenoic acid (DHS).

Raw fish should be avoided during pregnancy.

Other Food choices

Food restrictions are mainly put in place to avoid toxoplasmosis and listeria infection.

To prevent toxoplasmosis, pregnant women should avoid eating raw and undercooked meat, and should wash all fruits and vegetables before consumption.

To avoid Listeria, pregnant women should avoid unpasteurized dairy products, raw sprouts, unwashed vegetables, and unheated deli meats. However, Listeria outbreaks can happen from many other food sources and are difficult to compile a list of foods to be avoided. Pregnant women are in general asked to be aware of local outbreaks of food poisoning and listeriosis and avoid those specific foods.

Smoking, Nicotine patch and vaping

Women are advised against smoking in pregnancy but the use of nicotine patch or gum to help quit smoking is acceptable while pregnant.

Marijuana

No long-term data about fetal neurodevelopmental outcomes after Marijuana consumption is currently available, hence women are advised against Marijuana use in pregnancy.

Physical activity and bedrest

Women with uncomplicated pregnancies are advised to have regular aerobic and strength conditioning exercise during pregnancy. They should aim at average 20–30 minutes of moderate-intensity exercise four to five times per week.

Bed rest or activity restriction has no role in pregnancy and has not shown to prevent preterm birth or pregnancy loss nor does it benefit women with hypertensive disorders of pregnancy, premature rupture of membranes, fetal growth restriction, or placenta previa.

Precautions while driving

Women are advised to continue using three-point seat-belts while pregnant, the belt should be placed low in lap, below the uterus. ACOG recommends against disabling the airbags, but the benefits or harm of airbag is unclear in pregnancy.

Oral Health

The importance of maintaining good dental hygiene should be emphasized during prenatal visits. Routine preventive dentistry should be practiced while pregnant and procedures like cleanings, extraction, scaling, root canal, radiographs and restoration and fillings should be carried out while taking appropriate precautions for exposure to X-rays.

Swimming and Hot-tub baths

Hot-tub baths are not advisable in pregnancy because they raise the risk of miscarriage and birth defects as they increase the maternal temperature.  On the other hand, a woman can continue to enjoy swimming while pregnant.

Travel

Air travel is safe during pregnancy as the cosmic and screening radiation exposures are below the threshold for any sort of fetal risk. Women should be aware of their travel destination and the necessary information on potential infections prevalent in those areas.

But, as the pregnancy progresses, it is difficult to adjust to the demands of traveling. There is no specific cut-off for gestational age after which travel is not advisable. Each woman should take her decision keeping in mind the benefits and harms of the proposed travel.

Intimacy

Sexual intimacy and orgasm are not associated with increased risk of pregnancy complications. In women with placenta previa, intercourse is avoided after 20weeks of pregnancy, although no data exists. In cases of vaginal bleeding or PROM, it is not known whether intimacy increases the risk of bleeding or infection.

Sleeping position

Currently, no data exists to advice a pregnant woman about exact gestational age at which she should start sleeping on her side.

Hair-dye and insect repellents

Hair-dye results in minimum systematic absorption and hence presumed to be safe during pregnancy. Topical insect repellents can be safely used in pregnancy, especially in areas where mosquito-borne illnesses, including West Nile and Zika virus, are rife.

All these are general guidelines and can be appropriate for a broad class of pregnant women, but still, each case needs to be evaluated at an individual level and the advice should be tailored to the specific circumstances.

Abstract

Media courtesy: http://www.webfeed360.com/health-fitness/pregnancy-tips/

ACOG updates guidelines on investigating microscopic hematuria in females.

courtesy: wn.com

Microscopic hematuria detected during urine analysis without any symptoms is an important clinical indicator of malignancy. Over the years, the definitions of microscopic hematuria have changed, but the data was primarily based on studies done on male patients.

The American College of Obstetricians and Gynecologists(ACOG)  and the American Urogynecologic Society (AUS) has updated its guidelines for low risk women presenting with microscopic hematuria.

The committee opinion was published online on March 30, 2017 ahead of print in Journal of Obstetrics and Gynecology.

Sex specific guidelines for microscopic hematuria were not available till now, although the differential diagnosis of microscopic hematuria varies considerably according to the sex of the patient.

Risk of urinary tract malignancies are considerably less in females.

In women older than 60 years, gross hematuria with a history of smoking is a strong predictor of urologic malignancy.

In women younger than 50 years, not presenting with gross hematuria with no history of smoking and fewer than 25 red blood cells per high-power field on microscopic urine examination the risk of urinary tract malignancy is less than .5%.

Evaluation of such patients is not cost effective and may result in more harm than benefit. Hence, the data supports changing the guidelines in low risk groups.

ACOG and AUS has recommended the organization formulating guidelines to analyze sex specific data and formulate sex specific guidelines.

In the meantime, ACOG and AUS recommend that women between 35-50 years of age, who do not have any symptoms or a history of smoking should undergo evaluation only if they have more than 25 red blood cells per high-power field.

ASRM and SREI issues guidelines to optimize natural fertility in absence of evidence of infertility.

 

Courtesy:Pixabay

American Society for Reproductive Medicine(ASRM) in collaboration with the Society for Reproductive Endocrinology and Infertility(SREI) issued counseling guidelines for achieving pregnancy in couples who are perfectly normal or no abnormality is detected in any test results.

These guidelines were published in January,2017 issue of Fertility and Sterility. [1]

The guidelines and recommendations are:

1) Fertility declines with increasing age in women and women > 35 years of age should be advised to consult a physician if they do not achieve pregnancy after 6 months of uninterrupted intercourse. For women < 35 years the time window is 12 months.

2) Specific recommendations regarding frequency of intercourse brings in unnecessary tension among couples. But, reproductive efficiency is maximum if intercourse occurs every 1-2 days, but the couple should be counseled about it and advised to follow “their own preference” within the context.

3) The fertile window in the cycle is best defined as the 6 days’ period that ends on the day of ovulation, because viability of both sperms and ovum is maximum during that time. Chances of fertilization is highest if intercourse occur on the day prior to ovulation.

4) Most postcoital practices adopted by couples like lying supine after intercourse and avoiding using the bathroom has no scientific backup. Some commercially available vaginal lubricants inhibit sperm motility by as much as 60- 100% in vitro but no results in vivo. But if needed mineral oil, canola oil, or hydroxyethylcellulose-based lubricants should be recommended during this time.

5) Fertility decreases at the extremes of BMI but, variations in daily diet or any specific diet does not have an effect on the fertility. Healthy eating may help improve fertility and diet high in mercury because of seafood consumption is known to be associated with infertility.

6) Women who are trying to conceive should receive 400 mcg of folic acid daily.

7) Smoking has very deleterious effect on fertility with the odds decreasing by 60% in women who smoke and increasing the rates of miscarriage. Smoking also causes rapid follicular atresia accelerating the occurrence of menopause.

8) Alcohol and caffeine in heavy doses have a deleterious effect on pregnancy and should be avoided. That amounts to > 2 drinks/day, with 1 drink >10 g of ethanol for alcohol and 500 mg; >5 cups of coffee/day per day. Moderate coffee consumption of 1-2 cup per day have no effect.

9)Similarly, recreational drugs, environmental pollutants and toxicants are all recognized to decrease fertility and exposure to them should be avoided.

The full text of the article can be accessed from here.

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[1] http://www.fertstert.org/article/S0015-0282(16)62849-2/fulltext

Is the age at natural menopause predictable using Ovarian Reserve Tests or Mother's Age at Menopause? A systemic review.

The first signs of aging are ineludible. The decrease of ovarian function is an important turning point in a woman’s life. But, with current increase in life expectancy women will be expected to live one-third of there lives in this hormone deficient stage.

The average age at final menstruation period (FMP) is 51 years, but menopause occurs between 40-60 years. There is discrepancy between the ability to maintain a normal ovulatory cycle and actual cessation of fertility potential, which is largely  controlled by a set of genes. These genes carry heritable variants, modifying the wide range of ovarian and reproductive aging seen in population based studies.  But, there is a fixed interval of 10 years between the end of fertility and the natural menopause.

 

In recent years we have seen an increase in age- related infertility in women because of postponement of childbirth due to career choices, education, control over fertility, financial concerns, late and second marriages, and infertility.  So, researchers are looking for markers which can accurately predict the end of fertility life span, limiting the number of women unknowingly facing age related infertility. This prediction could also help in timely planning the family or cryopreservation, and decreasing involuntary childlessness.

Currently, no marker has been yet identified that can accurately predict the end of human fertility, hence the final menstrual period is taken as a proxy variable to signify the end of fecundity. Personalized forecast regarding the approximate age at menopause is usually predicted based on age in relation to regularity of cycles.

According to the stages of Reproductive Aging Workshop (STRAW) FSH is very accurate in determining the current state of reproductive aging, but it does not predict the timing of final menstrual period (FMP). Similarly other parameters of Ovarian reserve tests such as antimüllerian hormone (AMH) and antral follicle count (AFC) and levels of inhibin-B lack standardized assays limiting their incorporation and utility as clinical tools for staging reproductive aging.

Researchers also turned towards identifying genetic markers responsible predicting age at natural menopause, but despite identifying potential genetic loci, no dominant alleles responsible for ovarian depletion have been discovered to date. Mother’s age at menopause seems promising to the researchers as it has demonstrated high degree of heritability. Pedigree analysis has shown a dominant pattern of inheritance of natural menopause.

This systemic review was published in February issue of Journal Menopause, aims to evaluate data on prediction of age at natural menopause based on antimüllerian hormone (AMH), antral follicle count (AFC), and mother's ANM so as to use in clinical practice and future research.

The authors conducted three searches and systemic review and included studies up to September 2014, which met the inclusion criteria.

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Six studies were selected for AMH, out of which 5 were prospective studies and 1 was cross sectional study. These studies had limitations as the levels of AMH were determined by three different assays, and different laboratories making pooling of data impossible. Furthermore, smoking affects the levels of AMH and most of the studies did not correct for it.

For correlating the AFC and predicting age at natural menopause 2 studies were found that met the criteria. AFC measurement was performed on cycle days 2 to 4. It was seen that although in univariate regression AFC showed be promising predictor, when corrected for age and smoking the results were statistically non significant (P=0.13)

Mothers’s ANM is a promising variable in predicting ANM, studies of mother’s ANM consistently stated that among women who had early menopause, their mothers or daughters are highly likely to have early menopause. Daughters of mothers with early menopause also have low levels of AMH and low follicular count.

The studies included have many limitations as only including women with regular cycles, dominance of studies with women of  particular ethnicity,  lack of  including women taking external hormones  and  women with chronic illnesses, such as malignant diseases, genetic diseases, and autoimmune diseases.

The main rationale for predicting ANM is to prevent unwanted childlessness, knowledge of which would encourage women to start family early or to timely cryopreserve eggs.

Knowing mother's age at menopause may be pivotal information for the daughter. Further implications of knowing the ANM will also help in earlier treatment of bone loss and CVDs.

This systematic literature review is the first to use variables AMH, AFC, and mother's ANM in predicting menopause. This review has shown that AMH and mother’s ANM are the most promising variables to be used in daily clinical practice. The models used to predict ANM lack precision at both end of the spectrum and provide wide intervals. A single reading is not capable of predicting the exact age. A large cohort of women with variable age, corrected for smoking and other chronic diseases are followed for a long time with repeated measurements for   AMH and AFC and incorporating mother ANM than a firm conclusion can be drawn. However, all these markers need further research and improvement before they can be applied into day to day clinical practice. At present mother’s ANM seems to be most promising for future research.

References:

http://www.ncbi.nlm.nih.gov/pubmed/8582512

http://www.medscape.com/viewarticle/858678

http://www.ncbi.nlm.nih.gov/pubmed/12099629

http://www.ncbi.nlm.nih.gov/pubmed/9922101

http://www.ncbi.nlm.nih.gov/pubmed/9871906

http://www.ncbi.nlm.nih.gov/pubmed/3536609

http://depts.washington.edu/endolab/Publications_2012/Harlow_etal_2012.pdf

http://www.reproductivefacts.org/uploadedFiles/ASRM_Content/News_and_Publications/Journals_and_Newsletters/Menopausal_Medicine/2011/MenMed_0511.pdf

http://newsroom.ucla.edu/releases/researchers-find-a-way-to-predict-244164