In June 2006, the US Food and Drug Association (FDA) approved the vaccine Gardasil which is the first vaccine against the Human Papilloma Virus (HPV). HPV is a known cause of cervical cancer, which is why this vaccine has received so much attention since its release. There are over 100 different strains of HPV. It is important to remember that Gardasil only protects against 4 of these strains, including strains 6, 11, 16, and 18. Two of these strains, 16 and 18, cause approximately 70% of the cases of cervical cancer in the United States. The other two strains cause approximately 90% of the cases of genital warts.

Gardasil is approved for girls/women age 9-26 years old. Since the FDA’s approval of Gardasil, the Advisory Committee on Immunization Practices of the Federal Center for Disease Control and Prevention (CDC) has recommended that all girls age 11-12 begin receiving the vaccine. Because Gardasil is relatively new, there continues to be close monitoring of the safety of this vaccine. You can learn more about the vaccine’s safety reporting on the CDC’s website. Remember that Gardasil does not protect against all types of cervical cancer, so routine cervical cancer screening and gynecologic care remains necessary to optimize your health prevention screening. To learn more about Gardisil, you can visit their website at www.gardasil.com.

With the evolution of oral contraceptive pills (OCPs), it is now known that it is ok to eliminate the menstrual cycle through a continuous or extended-cycle OCP regimen. You no longer need to have a monthly withdrawal bleed when taking the birth control pill. Some women find that this fits their life better and allows them to eliminate the stress of a period during their busy lives. It may also help to decrease some of the menstrual symptoms that women experience near or during their period. Some women use these regimens to manage conditions such as endometriosis or premenstrual dysphoric disorder (PMDD). Physiologically, continuous OCPs suppress follicular development, inhibit ovulation, and keep the lining of the uterus thin. Contraceptive efficacy appears to be the same with continuous OCP regimens. There are no harmful effects from taking OCPs this way versus the more traditional route of 21 days per month. While OCPs do have risks, including increasing the risk of clotting, they also have many noncontraceptive benefits which your doctor can review with you. We would be happy to discuss whether this approach to contraception and menstrual management would work for you.

As Minnesotans, we spend more time inside and less time outdoors in the sunshine due to our long winters. Limited sun exposure puts us at a higher risk of Vitamin D deficiency. In humans, synthesis of vitamin D depends on skin exposure to sunlight. Vitamin D is an important element to maintaining our optimal bone health. Vitamin D helps to absorb dietary calcium and phosporous from the intestines. It also suppresses the release of parathyroid hormone which can cause bone resorption. In addition to limited sun exposure, others who are at risk of Vitamin D deficiency include people with limited mobility, institutionalized, hospitalized, or nursing home patients, children, people who have undergone gastric bypass surgery, and others with kidney, liver, or gastrointestinal diseases such as Crohns and celiac disease that may impair absorption of Vitamin D. African Americans and other ethnicities with dark skin may also be at increased risk of deficiency.

It is not recommended to expose yourself to the sun or tanning beds to make up for a Vitamin D deficiency due to the risk of skin cancer. It is, however, important to assess your risk and your dietary intake of both Calcium and Vitamin D. With normal levels of Vitamin D, it is recommended that you receive 1000-1200mg of Calcium per day and 800IU of Vitamin D per day. If your Vitamin D level is low, you may need higher dose supplements. Maintaining adequate vitamin D levels will minimize the risk of reduced bone density (osteopenia or osteoporosis), and bone fractures with aging. Adequate Vitamin D may also benefit extraskeletal/muscular support, enhance the immune system, and affect glucose and lipid metabolism. There is also a growing body of research around the implications of Vitamin D deficiency and many types of cancer, including breast cancer. Not everyone needs to have a Vitamin D level checked, but your doctor can help assess your risk and whether or not your dietary and supplemental intake seems appropriate.

For additional information, visit the Up To Date patient website.

Bioidentical hormones are hormones marketed as being similar to those produced by your own body. They are often compounded in pharmacies that dose medication based on salivary or blood hormone levels. While intuitively this seems to make sense, hormone levels are not consistent from day to day, and vary quite a bit. Hormone levels can be useful to diagnose menopause, but not necessarily to guide therapy. They can also be quite expensive to obtain. Because compounded hormones are not FDA approved, these pharmacies are also not required to track and report problems that may arise from taking these medications.

Compounded hormones have not been studied as well as FDA approved “bioidentical” hormones. These include both estradiol, a natural, plant based estrogen, and prometrium, a natural form of progesterone. It may be important to note that the Women’s Health Initiative, the large study which helped clarify some of the risks associated with hormone replacement therapy, did not use either of these natural hormones.

Hormones have benefits and risks, and are not safe for everyone. There is no evidence that compounded hormones are more safe or more effective than traditionally prescribed hormone replacement therapy. While there are likely benefits to these medicines, there are surely risks as well, and these are largely unknown. As your physician, our job is to support you through this time of transition, to help you make educated decisions that are based on science, and above all, keep you safe. There may be some circumstances in which we decide trying bioidenticals may be the best option for you, but please make an appointment to discuss this with your physician before making any decisions regarding hormones.

Learn more about Bioidentical hormones on the FDA website.
The Buzz on Bioidenticals (3MB .PDF from femalepatient.com)

Breast Cancer is the most common cancer in women in the United States, other than skin cancer. The chance of developing an invasive breast cancer in a woman’s lifetime is approximately 1 in 8. In November 2009, the US Preventive Services Task Force (USPSTF) released its newest recommendations for routine breast cancer screening by mammography. The USPSTF is now recommending that women undergo screening mammograms every two years, starting at age 50. This is for women without additional risk factors, such as family history. Other organizations continue to stick to the previously well known recommendations of mammograms at age 40.

Why delay mammograms? Within this debate are concerns that too many women are undergoing unnecessary procedures, such as additional imaging studies, biopsies, or treatment. There are also limitations of mammography, particularly in younger women with denser breast tissue, as well as the risk of false security with a “normal” mammogram . Others raise concerns about radiation exposure with longer term mammogram use.

In response to the new USPSTF recommendations, other societies and organizations have spoken up on this controversial topic. The American Cancer Society continues to recommend screening mammography and clinical breast examination annually for women beginning at age 40. The American College of Obstetrics and Gynecology (ACOG) also recommends that women continue to have routine screening mammograms every 1-2 years starting at age 40 and annually at age 50. The National Cancer Institute (NCI) plans to continue to evaluate the recommendations based on the data in light of the USPSTF’s latest change, but has previously recommended screening every 1-2 years starting at age 40. In addition, the Society of Breast Imaging (SBI) and the American College of Radiology (ARC) have also published new recommendations in January 2010, that state breast cancer screening should begin at age 40.

At Haugen OBGYN, we understand that this information can be very confusing. As a practice, we are continuing to recommend screening mammography in your 40’s, but we understand that every woman’s health and family history is unique. We will continue to follow this topic closely and keep you updated as recommendations and new evidence emerge. The doctors at Haugen OBGYN would be happy to review the best screening plan for you at your next visit. Use the links below to obtain more detailed responses from the agencies listed above.

• American Cancer Society Responds to Changes to USPSTF Mammography Guidelines
• ACOG Statement on Revised US Preventive Services Task Force Recommendations On Breast Cancer Screening
• NCI Statement on Breast Cancer Screening
• U.S. Preventive Services Task Force Screening for Breast Cancer