"These are a few of my favorite things"

Green Tea and its Effects on Breast Cancer Metastasis and Recurrence
Abstract/summary: 472 women were studied who had invasive breast carcinoma. 117 had stage I, 273 stage II, and 82 stage III and all had undergone a partial or total mastectomy. This epidemiological survey was carried on for 9 years from 1984 to 1993. The questionnaire included intake of green tea, coffee, black tea, various food groups such as soy and seaweed and fish and vegetable, cigarettes, alcohol as well as breast tumor characteristics, tumor markers, adjunct treatments, medical history and various physical parameters.

The researchers determined that in stage I and II breast cancer, increased consumption of green tea was associated with less metastasized axillary lymph nodes in premenopausal women and an increased progesterone and estrogen status in postmenopausal women. No such associations were seen in stage III breast cancer patients. The consumption of green tea among the 349 women without a recurrence of breast cancer was significantly higher than among the 123 women with a breast cancer recurrence. In stage I and II patients, there was a 16.7% recurrence rate for those consuming 5 cups or more of green tea (average 8 cups) per day. For those who consumed 4 or less cups per day (average of 2), there was a 24.3% recurrence rate. Disease-free survival was also significantly improved in stage I and stage II breast cancer patients with a greater consumption of green tea. Of all the predictors, green tea was the most statistically significant predictor for a decreased rate of recurrence in the stage I and II patients. No improvement in prognosis was seen in stage III patients.

Commentary: The estimated risk of developing breast cancer in one's lifetime for Western women is at least one in nine and dropping. In Japan, it is estimated to be 1 in 40. This paper points to the discrepancy being due to green tea although there is also a significant body of data to suggest that the difference in rates of breast cancer is due to soybean product consumption as well as fish consumption.

Green tea (Camellia sinensis) contains several polyphenols including epigallocatechin gallate (EGCG). EGCG enhances glutathione peroxidase and catalase as well as being a potent free-radical scavenger. It has also been shown to inhibit the growth of several breast cancer cell lines in vitro, inhibit urokinase that is involved in tumor invasion and metastasis and induces apoptosis. The suggestion is that EGCG found in green tea has multiple anticancer properties.

A possible bias influencing this survey study is that perhaps those individuals who drink so much green tea are also those who are more health conscious. It is also my experience that getting a Western woman to drink an average of 8 cups of anything per day besides coffee or soft drinks is very difficult. However, once these results are shared with new breast cancer patients, advising something as benign and potentially significant as merely drinking tea, may inspire greater compliance. One option might be to use green tea extract in tablet form. It is estimated that one cup of green tea contains 30 to 40 mg of EGCG.

In the spirit of common sense, it would seem that your average non-breast cancer patient and women at higher risk for breast cancer, should extrapolate this data to the point of drinking green tea as a preventive measure.

Green tea has not been associated with any significant side effects or toxicity. Due to the caffeine, it may produce a stimulant effect, although for some reason the caffeine in green tea does not often produce the symptoms of anxiety and irritability and insomnia that other sources of caffeine may induce.

Nakachi K, Suemasu K, Suga K, et al. Influence of drinking green tea on breast cancer malignancy among Japanese patients. Japan J Cancer Res 1998;89:254–261.

Ginger for Nausea and Vomiting in Pregnancy
Seventy pregnant women at or before 17 weeks' gestation were randomized in a double-blind design to receive either ginger 1gm per day (250 mg four times daily) or placebo for 4 days. The women graded the severity of their nausea and recorded the number of vomiting episodes in the previous 24 hours before treatment, and again during 4 consecutive days while taking the ginger or placebo. The median change in nausea scores in the ginger group was significantly greater (P=0.14) than that in the placebo group. All 32 women in the ginger group and 33 of 35 women in the placebo group had one or more vomiting episodes during the 24 hours before treatment. After 4 days of treatment, the proportion of women who had vomiting in the ginger group(12 of 32) was significantly less than that in the placebo group (23 of 35). Patients also reported their subjective response to treatment. 28 of 32 (87.5%) ginger-treated women reported that their symptoms improved, compared with only 10 of 35 (28.6%) in the placebo group.

Commentary: Only one previous randomized cross-over trial of ginger for hyperemesis gravidarum (severe nausea and vomiting) has been published in the English literature. In that study, 70.4% women preferred the ginger treatment compared with 14.8% of women receiving placebo. There was also a significant reduction in the number of vomiting episodes in the ginger group. It's a testimonial to the desire of women to utilize safe effective natural substances that ginger has gained as much popularity as it has with only one previous clinical trial on pregnant women with nausea and vomiting. Side effects were minimal in this study with five women experiencing headaches in the placebo group and six in the ginger group. One ginger patient had abdominal discomfort, one heartburn and one had diarrhea for one day. There were three spontaneous abortions in the placebo group and one in the ginger group. There were no differences in term delivery and no infant congenital abnormalities.

Vutyavanich T, Kraisarin T, Ruangsri R. Ginger for nausea and vomiting in pregnancy: randomized, double-masked, placebo-controlled trial. Obstetrics and Gynecology 2001;97(4):577–582.

Walking and the Prevention of Hip Fractures after Menopause
In this analysis to determine the effect of just walking on risk of hip fractures, researchers studied the relation between hip fracture and walking and leisure-time activities in 61,200 postmenopausal women from the Nurses Health Study. (ages 40 to 77; 98% were Caucasian). Study participants did not have histories of osteoporosis, cancer, or cardiovascular disease upon entry. The intent was to more clearly understand the intensity of exercise activity required to increase bone mineral density and reduce hip fractures.

During a follow-up of 12 years, 415 hip fractures were reported. After an analysis that controlled for age, BMI, hormone therapy use, smoking and diet, it was determined that the risk for hip fracture declined by 6% for every increase of 3 metabolic equivalent (MET) hours per week (equivalent to 1 hour of waling at average pace). Women with at least 24 MET-hours per week had a 55% reduction in risk compared with women with less than 3 MET-hours per week. Women who were heavier in body weight were at lower risk for hip fracture and their risk reduced further by increasing exercise. For the women who walked as their only activity, 4 hours per week had a 41% lower risk for hip fracture than those who walked less than 1 hour per week.

Commentary: We have known for some time that exercise will increase muscle mass, improve muscle strength, improve balance, increase bone mineral density, and reduce falls that can cause a hip fracture but it has not always been clear as to what intensity of activity is required to achieve these benefits. Observational studies have short comings, but the message for postmenopausal women is still strong: Walking as few as 4 hours per week reduces hip-fracture risk and more exercise yields further reductions in risk. For clinicians, we should use this information to further encourage our patients to engage in regular exercise, even though it may be as simple as walking. It's easy, without expense, accessible, convenient, and does not require complex skills. For those postmenopausal women with health problems that limit their ability to walk, we must continue to be creative in searching for a regular physical activity that they can perform.

Feskanich D, et al. Walking and leisure-time activity and risk of hip fracture in postmenopausal women. JAMA 2002; Nov 13; 288:2300–2306.

Estriol and Pelvic Floor Muscle Exercise for Stress Incontinence
Sixty-six postmenopausal women with stress incontinence (SI) were randomized to a group treated with estriol 1 mg per day and pelvic floor muscle exercise (PFME) and a group treated with PFME alone. Patients were evaluated every 3 months and efficacy of treatment was evaluated in patients who had been treated for two years.

A significant decrease in urinary incontinence (UI) scores was observed in mild and moderate UI women in both groups at the first three month follow-up. The improvement was greater in the estriol plus PFME group for up to 18 months in mild UI and for up to 12 months in moderate UI.

Commentary: It can take a long time for PFME alone to bring about desired results in women with SI. Estriol is an appropriate and appealing tandem treatment because the carcinogenic effects of estriol seem to be lower than with other estrogens with both the breast and uterus, and the effects on the urinary tract are considered to be stronger. Estrogen receptors are present in the urethra and vagina. Estrogen stimulates the smooth muscle, epithelial cells, connective tissue around the urethral tract and the blood vessel floor by binding to the receptors in the urethra and bladder trigone. This then increases the concentration of alpha-adrenergic receptors that leads to improvement of the urine-collecting function.

The findings of this study demonstrate that oral estriol and PFME was significantly more effective even after only three months than PFME alone. It is also encouraging that even moderate cases were able to benefit significantly. It is important to use estriol with PFME for at least one year in women with SI.

Once again, researchers and practitioners outside of the U.S. take the lead in estriol research.

Ishiko O, Hirai K, Sumi T, Tatsuta I, Ogita S. Hormone replacement therapy plus pelvic floor muscle exercise for postmenopausal stress incontinence. J Reprod Med 2001;46:213–220.

Calcium and PMS
Reports have suggested that problems in calcium regulation may underlie some of the symptoms of PMS and that calcium may have a therapeutic benefit. A recent randomized, double-blind, placebo-controlled, multicenter clinical trial was conducted to test this hypothesis.

Four hundred ninety-seven women were enrolled and given either 1,200 mg of calcium carbonate or placebo for three menstrual cycles. During the luteal phase of the treatment cycle, a significantly lower symptom complex score was observed in the calcium group for both the second and third months. By the third month, calcium effectively resulted in a 48% reduction in total symptom scores from baseline compared with a 30% reduction in the placebo group. All four symptom factors (i.e. negative mood affect, water retention, food cravings, and pain) were significantly reduced by the third treatment cycle.

Thys-Jacobs et al. Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Am J Obstet Gynecol 1998; Aug: 444–452.

Osteoporosis and Essential Fatty Acids
Osteoporosis is a growing concern with postmenopausal women due to its prevalence in 75 year-olds and older and the disability and even mortality it can cause. Although EFAs have not been talked about much in relationship to this disease, there is a growing body of evidence and research to warrant our attention. EFAs have been shown to increase calcium absorption from the gut, in part by enhancing the effects of vitamin D, to reduce urinary excretion of calcium, to increase calcium that is deposited in the bone and improve the bone strength and to stimulate the synthesis of bone collagen.(1) Other findings have demonstrated that patients with osteoporosis who are given fish oil show an increase in serum calcium levels, and others given a fish oil/evening primrose oil combination had increased osteocalcin as well as an increased procollagen, all suggestions that these supplements may enhance bone formation.(2) In this study, serum and urinary markers of bone turnover were monitored in 40 women eighty years or older, with osteoporosis. Patients were divided into four groups, each group receiving one of the following:
1) 4g EPO
2) 4 g fish oil
3) 4 g of a mixture of EPO and fish oil and
4) olive oil.
Patients were supplemented for 16 weeks. A number of meaningful parameters in the fish oil and combined groups changed as a result of the treatment. In the fish oil group alkaline phosphatase fell significantly, procollagen rose and calcium clearance rose significantly. The observations were similar in the combination group except that the osteocalcin also rose significantly. EPO alone had no significant effects. Even though this study was short term, and it only measured markers of bone turnover and not bone density, the findings do suggest that supplementation with fish oil or a combination of fish oil and EPO may improve bone formation.

In animal studies, EFA deficiency leads to the development of severe osteoporosis along with increased calcifications in the kidney and the walls of the arteries. This is similar to what we see in elderly patients with osteoporosis, i.e. loss of bone calcium and increased calcifications in soft tissues, particularly the arteries and the kidneys. These calcifications outside the bone may be more dangerous than the osteoporosis itself, since the great majority of osteoporosis related deaths is due to a vascular problem such as a blood clot formation.

Supplementing our diet with oils high in GLA may improve absorption of calcium and enhance the calcium content in the bone. Supplementing with fish oils may improve the blood levels of calcium and help to correct a deficient calcium effect in the bone.

Kruger M, Horrobin D. Calcium metabolism, osteoporosis and essential fatty acids: a review. Prog Lipid Res 1997; 36(2–3):131–151.
Van Papendorp D, Coetzer B, Kruger M. Biochemical profile of osteoporotic patients of essential fatty acid supplementation. Nutrition Research 1995; 15(3):325–334.

Speculum Lubrication Does Not Adversely Affect Pap Smear Results
Most all medical students and residents are trained to avoid using lubricants on vaginal speculums when doing a Pap smear. Two studies investigated this presumptive practice.
One study randomly assigned 182 patients who were to receive Pap smears to speculum insertion with either warm water or 2 to 3 cc of water-soluble lubricant. Cytopathologists were blinded to which slides were from which group. No significant difference in Pap smear results was found.

In a similar study, clinicians were randomized in 5 family planning clinics to use either a water soluble gel or no lubrication or water on the speculum prior to insertion. There were no significant differences or abnormal cells detected.

I recall that in one of my early preceptorships 20 years ago, the Ob/Gyn I studied with was my first exposure in dispelling the myth that lubricants should not be used on the speculum because it would interfere with the accuracy of the pap smear. I've been using a thin film of lubricant applied to the superior blade of the speculum ever since. The findings of these two studies should clearly dispel this long-held belief. The use of a thin layer of a water soluble lubricant on the blade of the speculum provides a more comfortable exam and may improve compliance of pap smears in those who avoid exams for fear of pain.

Harer W, et al. Lubrication of the vaginal introitus and speculum does not affect Papanicolaou smears. Obstet Gynecol 2002; Nov; 100:887–888.
Amies A-M, et al. The effect of vaginal speculum lubrication on the rate of unsatisfactory cervical cytology diagnosis. Obstet Gynecol 2002; Nov; 100: 889–92.

Boric Acid and Yeast Vaginitis
Ninety-two women with chronic yeast vaginal infections were followed during prolonged therapy using anti-fungal agents and boric acid for a period of six months. Microscopic examination of the discharge and symptomatic evaluation tools were used to assess response. In women who had failed conventional mycotic treatment for chronic yeast vulvovaginitis, boric acid suppsitories given once in the morning and once in the evening for 2 weeks and in some cases 4 weeks, was effective in curing 98% of the patients. It was also clearly indicated as the treatment of choice for prophylaxis.

Commentary: The criteria for cure in this remarkable study was determined with microscopic examination and a resulting normal vaginal discharge. Forty-eight (52%) of the 92 study patients experienced an initial disappearance of symptoms after conventional antifungal therapy but had abnormal microscopic findings. All of these women suffered a recurrence of their symptoms within a few days, weeks or months.

Of the 92 patients who failed the usual antifungal therapy, 78 (85%) were cured with boric acid during the six-month study period. An additional 12 (13%) required periodic prophylactic treatment to control their infections. In total, the boric acid suppositories in the form of a gelatin capsule, was successful in 90 (98%) of the study patients.

Of the two patients who were not cured, one felt worse on the boric acid and discontinued the treatment after three days. The other refused to continue the treatment after not responding to the first course of therapy.

I find the results of this study remarkable in that basically, 100% of the women who completed the study, were cured with something as inexpensive and easy as boric acid vaginal suppositories. That the pharmaceutical and natural products industry has found it necessary to develop dozens of yeast vaginal treatments for women when we seem to have little or no need for any of them.

Boric acid therapy appears to be a far more effective medication for chronic yeast vulvovaginits than any of the available agents, although this study was done prior to the use of diflucan.

The regimen used is as follows: Insert one 600mg boric acid gelatin capsule in the vagina twice a day for two weeks. Repeat treatment for 2 weeks if not completely symptom free. For prophylactic use, insert one suppository daily during the menstrual period only, for 4 months. Continue prophylactic therapy if required to sustain cure. Having used this therapy with patients for some time now, I have found that some women will need to apply vitamin E oil to the external genital area. For some individuals, the tissue has become so irritated and raw due to the infection, that when the capsule dissolves, and the boric acid disperses, some of it can leak out onto the vaginal tissue and cause a burning sensation. The vitamin E will protect the tissue.

Jovanovic R, Congema E, Nguyen H. Antifungal against versus boric acid for treating chronic mycotic vulvovaginitis. Journal of Reproductive Medicine 1991;36(8):593–597.