27/04/2019

New guidelines aim to help women prevent stroke

When the SELECT trial started in 2001, there were high hopes it would prove that taking vitamin E or selenium could help prevent prostate cancer. The newest results from the trial show just the opposite—that taking selenium or vitamin E can actually increase the odds of developing prostate cancer.

Bottom line: men shouldn’t take selenium or vitamin E as a way to prevent prostate cancer, or anything else for that matter.

“I counsel all of my patients to absolutely avoid any dietary supplements that contain selenium or vitamin E—including multivitamins,” says prostate cancer expert Dr. Marc Garnick, a clinical professor of medicine at Harvard Medical School, an oncologist at Beth Israel Deaconess Medical Center, and editor in chief of Harvard’s Annual Report on Prostate Diseases.
The case against selenium and vitamin E

Studies done in the 1980s and 1990s suggested that vitamin E and selenium each somehow provided protection against prostate cancer. The Selenium and Vitamin E Cancer Prevention Trial (SELECT) was started in 2001 to see if that was true. The 36,000 healthy, middle-aged volunteers were divided into four groups. Each man took two pills a day: 400 international units (IU) of vitamin E plus 200 micrograms of selenium; vitamin E plus a placebo; selenium plus a placebo; or two placebos. Neither the men nor their doctors knew who was taking what.

Although SELECT was supposed to last until 2011, it was stopped three years early because neither vitamin E nor selenium were showing any benefit—and there were hazy warning signs they might be doing some harm.

A new report in the Journal of the National Cancer Institute clarifies the picture. A team of researchers from across the U.S. looked specifically at almost 5,000 of the SELECT volunteers who sent in toenail clippings when they joined the trial. Toenail clippings are a great way to measure how much selenium is in a man’s (or woman’s) body. The new study showed that:

    Taking vitamin E alone boosted the risk of developing high-grade prostate cancer, but only in men who started the study with low selenium levels.
    Taking selenium, either alone or in combination with vitamin E, increased the risk of high-grade prostate cancer in men who started the study with high selenium levels, but not in those with low selenium levels.
    Among men who didn’t take either vitamin E or selenium, those who started the study with high selenium levels were no more likely to have developed prostate cancer than men who started it with low selenium levels. (This means the culprit is added selenium from supplements, not selenium from food.)

“The new data are very troubling, and emphasize that supplements can cause real and tangible harm,” says Dr. Garnick. “Any claims of benefits from dietary supplements must be ignored unless large, controlled, and well-conducted investigations confirm such benefits—which I believe will be a very rare occurrence.”
Shortly after my grandfather died, I stood next to my grandmother at his grave. Her loss was palpable, and painful to watch. I vividly remember her leaning down toward his gravestone and crying out, “I’ll be with you soon, Irv.” My grandmother spoke these words out of grief, but they were prophetic. Her own health soon began to fail, and months later she joined her beloved husband.

The grief of losing a spouse or partner affects not just emotional and mental health, but physical health as well. Numerous studies show that the surviving spouse or partner is likely to develop health problems in the weeks and months that follow.

A study published this week in JAMA Internal Medicine found that individuals who had lost a spouse or partner were more likely to have a heart attack or stroke within the next 30 days. “Emotional stress will clearly wreak havoc with the sympathetic nervous system, and that can lead to problems as the authors described,” says Dr. Peter Stone, professor of medicine at Harvard Medical School and senior physician in the Cardiovascular Division at Brigham and Women’s Hospital. The sympathetic nervous system is responsible for revving up the body’s fight-or-flight response.

Keep in mind that while the association between bereavement and cardiovascular events is real, it is also very small. Although the risk of having a cardiovascular event was doubled—from 8 of every 10,000 individuals whose partners were still alive to 16 of every 10,000 among those whose spouse or partner had died—the absolute increase is small, Dr. Stone points out.

It’s also worth noting that the people in the study were ages 60 to 89. “Often the individual who has a spouse or loved one die is older and part of a group that’s more prone to coronary disease,” Dr. Stone adds.
Grief and the heart

The researchers offered several possible reasons for the cardiovascular decline. These include stress-induced changes in blood pressure, heart rate, and blood clotting.

There is also a tendency after such a profound loss for the surviving spouse or partner to disregard his or her own health and become resigned to dying, as my grandmother did. “There’s a kind of giving up or self-neglect that can set in, and some people just really don’t want to go on,” says Dr. Michael Craig Miller, senior editor of Mental Health Publishing at Harvard Health Publishing.
Focus on You

Losing your spouse or partner—especially after many years of being together—can shake up your entire world. “If the main person in your life is suddenly not there, that in itself is extremely stressful. There’s also the stress of restructuring your life, which has been one way for decades and now has changed,” says Dr. Miller.

Mourning for a loved one is important. At the same time, don’t forget about your own needs during this difficult period. Here are a few things you can do to take care of yourself:

Don’t forget the basics. Eat a healthy diet, walk or get another type of exercise every day, and take your medicine. Attending to your health will make you feel better physically, and take your mind off your loss.

Get out. When friends or family call and invite you out to dinner or to the movies, say yes even though you might be tempted to stay home alone. Maintaining social connections is an important part of the healing process.

Join a grief support group. No one knows what you’re feeling better than other people who’ve been through a similar experience. Your local hospital, senior center, religious organization, or community center can point you to a support group in your area.
Give it time

It can take several months to a year to work through grief and grieving. Allow yourself enough time to let go. However, if a year has passed and you’re still grieving, or if you’ve lost interest in activities you once loved, your grief may have transitioned to something more serious—like depression. Then it’s time to talk to your doctor or mental health professional to help you work through the pain and move forward with your life. The first-ever guidelines for preventing stroke in women don’t fool around. They offer ways to prevent this disabling and potentially deadly event from adolescence to old age.

A stroke strikes when something stops blood flow to part of the brain. That something can be a blood clot or a burst blood vessel. Without a steady supply of blood-borne oxygen and nutrients, brain cells quickly begin to die. Depending on the location of the blockage or bleed, a stroke can cause trouble speaking, swallowing, walking, and more.

More than half of the 800,000 Americans who have strokes each year are women. Nearly 4 million American women are living with the aftermath of a stroke. And because women live longer than men, their lifetime risk of having a stroke is higher.

Those numbers are why stroke prevention is especially important for women.
A high-pressure situation

High blood pressure is a leading cause of stroke. That’s why the guidelines, published yesterday in the journal Stroke, focus heavily on blood pressure, along with other risk factors—and not just among older women, as is the case with other stroke guidelines.

Take young women who are thinking about going on the birth control pill. Oral contraceptives boost the risk of having a stroke, even among women under age 45. Smoking further increases the chances of having a stroke. The new guidelines recommend that a woman have her blood pressure checked before taking oral contraceptives, and that women work to reduce other risk factors while taking these medications.

Pregnancy is another life stage that gets special attention in the guidelines. About 1 in 12 women develop preeclampsia or other blood pressure problems during pregnancy. Preeclampsia is a gradual rise in blood pressure combined with increasing amounts of protein in the urine. It can be harmful to mother and baby. Although preeclampsia disappears after delivery, women who develop it are more likely to develop high blood pressure later in life.

That’s why the task force from the American Heart Association and American Stroke Association recommends that women who have had preeclampsia, or those who are at risk for developing it, take low-dose aspirin from the 12th week of pregnancy until delivery. Some women may also need to take extra calcium. The guidelines also say that certain women who have high blood pressure during pregnancy may need to take medicine to lower their blood pressure.

Taking estrogen and other hormones after menopause was once seen as a way to prevent heart disease, stroke, and other chronic conditions. No longer, not since the Women’s Health Initiative showed long-term use of hormone therapy could actually increase heart disease and stroke risk. The new stroke prevention guidelines agree, and state that hormone therapy should not be taken to prevent stroke.

The guidelines also speak to women who have migraines with aura (sensory changes such as seeing blinking lights or smelling a strange odor). Such headaches have been linked to stroke. Women with this condition are urged to work hard to stop smoking, since the combination elevates stroke risk. Taking medications to prevent migraine attacks may also be in order.

Atrial fibrillation, a fast and irregular beat in the heart’s upper chambers, is a leading cause of stroke, more so in women than in men. Anyone with this condition should take a “blood thinner” to help prevent stroke.

The guidelines also recommend that women between the ages of 65 and 79 think about taking a daily baby aspirin (81 milligrams). Aspirin helps prevent the formation of blood clots, which are often at the root of a stroke.
The basics

The guidelines don’t ignore the fundamentals of stroke prevention, which are essentially the same for women and men:

    control high blood pressure
    don’t smoke
    aim for a healthy weight
    stay physically active
    limit sugary drinks and foods
    strive for a Mediterranean-style diet.

The release of new guidelines rarely gets much attention in the media. The attention that these new stroke guidelines are getting is well deserved. Let’s hope they succeed in what they were designed to do. Let’s face it, ladies: Sex is a topic you usually discuss behind closed doors with your partner or during lunch with your closest friends (glass of wine optional). But I’ve noticed as I’ve gotten older that sex isn’t the hot lunch topic it used to be. That’s no surprise, considering how the activity that once consumed us now has to fit into the patchwork of our lives that also includes work, kids, aging parents, and, oh yes, glorious sleep. But it does make me wonder about the future. Is there a time when sex will no longer be on the agenda? And can we—should we—change that?

The answer, it turns out, is that it’s likely up to each of us. A research letter in JAMA Internal Medicine reports that women between the ages of 40 and 65 who place greater importance on sex are more likely to stay sexually active as they age. In other words, if it’s important to you, you’ll keep on doing it. “Having taken a lot of sexual histories from midlife women, it’s probably true!” says Dr. Jan Leslie Shifren, associate professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School, and co-author of the Harvard special report Sexuality in Midlife and Beyond.

Dr. Shifren points out that the research letter did not find that sex was more satisfying for women who stated it was important to them, just that they were more likely to remain sexually active. It’s also not clear how often they had sex.

There are many reasons why sex may slow down for women when they get older, not least of which is menopause. When the ovaries stop making estrogen, the vaginal lining becomes thinner, there’s less vaginal elasticity, muscle tone, and lubrication, and arousal takes longer. As a result, women may experience

    decreased libido (a lack of interest in sex)
    difficulty with lubrication
    pain with penetration
    difficulty or inability to climax.

Some women may have sexual dysfunction that’s related to social or psychological issues, such as stress, anxiety, body image problems, relationship problems, or the lack of a partner.

Poor health can also get in the way of having sex. Heart disease can reduce the amount of blood that reaches sex organs, making it difficult to fill the blood vessels around the vagina that are crucial for adequate lubrication and arousal. High blood pressure, diabetes, depression, and incontinence can all nudge sex aside. Medications for a variety of conditions can have anti-sex side effects. For example, some drugs used to treat depression or high blood pressure can blunt interest in sex or cause difficulty reaching orgasm.

So what’s a woman to do? Seek treatment. That may not be as complicated as you think. Many sexual problems can be reversed with appropriate therapy, especially if they’re relatively new. Dr. Shifren says treatment is often successful.

Some therapies are simple, such as using a lubricant or low-dose vaginal estrogen for dryness and pain, or swapping one medication with negative side effects for another. Sometimes the treatment may be more involved, such as hormone therapy for decreased libido or sex therapy for inability to climax.

But clinical therapy is just part of the prescription. These lifestyle changes can also make a difference:

Exercise—it can improve your sexual function by improving blood flow and strengthening your heart.

Quit smoking—it will improve blood flow to the sexual organs and may also stave off menopause for a few years.

Drink alcohol in moderation, since large amounts of alcohol can dampen sexual reflexes, trigger hot flashes, and disrupt sleep.

Control your weight to give you the body image you want.

Eat a healthy diet, which helps prevent heart disease and diabetes, and helps you maintain a healthy weight.

Dr. Shifren also offers this advice: “Bring some novelty to your life. Take vacations. Go on date nights.”

Why bother with all this? Sex is important to women’s health. It revs up metabolism and may boost the immune system. Frequent sexual intercourse is associated with reduced heart attack risk. It can help the vagina stay lubricated, elastic, and healthy. And it’s fun.

If it’s important to you, you should be able to enjoy sex well into your older years. And that’s something worth talking about.

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