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                         WOMEN’S HEALTH
         From the publishers of   The New England Journal of Medicine                                                     January 2007               Vol. 12 No. 1

To Minimize Weight Gain,                          weight gain might be a persuasive                                          ance test results, and 317 had impaired
                                                  argument to improve sleep habits.                                          glucose tolerance. In models adjusted
Catch More Zzzz’s                                 — Diane E. Judge, APN/CNP                                                  for age, sex, exercise, BMI, smoking,
                                                                                                                             daily alcohol use, hypertension, and im-
S   leep deprivation is associated with
    numerous adverse effects, yet the re-
sults of a 2005 study showed that only
                                                  Patel SR et al. Association between reduced
                                                  sleep and weight gain in women. Am J
                                                  Epidemiol 2006 Nov 15; 164:947-54.
                                                                                                                             paired glucose tolerance, both past and
                                                                                                                             current coffee drinking were signifi-
about 25% of U.S. adults sleep 8 hours                                                                                       cantly associated with reduced risk for
nightly. To investigate the relation be-                                                                                     incident type 2 diabetes in the total non-
tween inadequate sleep and weight                                                                                            diabetic population (odds ratio, 0.38
gain, researchers assessed information            Let’s Have                                                                 and 0.36, respectively). Past and current
about sleep duration and weight provid-           Another Cup of Coffee                                                      coffee drinking also were protective for
ed by nearly 60,000 initially healthy,                                                                                       the subgroup with impaired glucose tol-
nonobese women (age range, 39–65) in
the 1986 Nurses’ Health Study (NHS).              S   ome cohort studies have indicated
                                                      that drinking caffeinated or decaf-
                                                  feinated coffee decreases the risk for dia-
                                                                                                                             erance (OR, 0.31 and 0.36, respective-
                                                                                                                             ly). Effects of decaffeinated coffee con-
                                                                                                                             sumption could not be evaluated due
   Median follow-up was 12 years, and
results were adjusted for age, smoking,           betes (see JWWH Aug 2006, p. 59, and                                       to the small number of participants
caffeine or alcohol use, spousal educa-           Arch Intern Med 2006; 166:1311). To                                        (12) who reported drinking only de-
tion, medications affecting sleep or              explore the association further, these                                     caffeinated coffee.
weight, menopausal status, snoring, and           researchers analyzed a subset of data
                                                  from a California longitudinal study of                                    Comment:
shift-work history. After age adjustment,
                                                  heart disease risk factors.                                                The magnitude of risk reduction for all
women who reported ≤5 hours of sleep
                                                     Nine hundred ten adults (average age                                    individuals is striking, especially those
nightly weighed an average of 2.47 kg
                                                  at baseline, 66 years; 59% women) were                                     with baseline impaired glucose toler-
more at baseline than those who report-
                                                  followed for up to 11 years (mean, 8.3                                     ance. However, as participants were not
ed sleeping for the median duration of
                                                  years) for incident type 2 diabetes. All                                   ethnically or socioeconomically diverse
7 hours. Mean adjusted weight gains
                                                  were free of diabetes at baseline; 593                                     (most were white and middle class) and
after 10 years for women who slept ≤5,
                                                  had normal 2-hour oral glucose toler-                                      few were overweight, these findings
6, or 7 hours were 5.63 kg, 5.16 kg, and
4.91 kg, respectively. During the course
of the study, 9,509 women developed                                                              TA B L E O F C O N T E N T S
obesity, and the risk for obesity in-
creased in women who slept fewer                    To Minimize Weight Gain,                                                 Feature: Effective Skin Care
than 7 hours nightly. Adjustment for                  Catch More Zzzz’s ................................1                      for Women ............................................. 5
confounders, self-reported dietary intake,          Let’s Have Another Cup of Coffee ............. 1                         CME: Preterm Delivery Tops
or physical activity did not significantly                                                                                    Infant Causes of Death ...................... 6
                                                    Does Knowing Fetal Oxygen Saturation
alter the results.                                    Matter? ........................................................2      BRCA Test Negative?
                                                                                                                               Your Patient Is Still High Risk ............... 6
                                                    Maternal Stress
Comment:                                              and Midgestational Fetal Weight ........... 2                          Oral Contraceptive Use
Two reasons to consider asking about                Is Weight Gain Between                                                     and Risk for Breast Cancer:
sleep duration and quality in initial and                                                                                      New Information? ................................. 7
                                                       Pregnancies Associated with
interim health histories are that sleep                Pregnancy Outcomes?........................... 3                      Assessing Chemotherapy’s Effect
disturbance may provide clues to other                                                                                         on Cognitive Function
                                                    Cesarean Delivery Risk
health issues such as depression, care-                                                                                        in Breast Cancer Survivors .................... 7
                                                      and Increasing Body Mass ....................... 3
giver status, gastroesophageal reflux,                                                                                       Muscle Cramps During Pregnancy ........... 8
                                                    Can Amniotic-Fluid Embolism
and sleep apnea; and that inadequate                  Be Avoided? ........................................... 3              Patient Information:
sleep contributes to suboptimal physical                                                                                       The Basics of Skin Care:
                                                    Practice Watch: Breast Cancer Does Not
and neurobiologic function. For women                                                                                          Avoid the Sun and Consider
                                                      Need High-Tech Follow-Up ................... 4
                                                                                                                               Using Retinoids...................Center Insert
who sleep fewer than 7 hours nightly                Bacterial Vaginosis During Pregnancy...... 4
by choice, the possibility of increased

                  Journal Watch (and its design) is a registered trademark of the Massachusetts Medical Society.
                    An editorially independent literature-surveillance newsletter summarizing articles from major medical journals
                                               ©2007 Massachusetts Medical Society. All rights reserved.
Page 2                                                        JOURNAL WATCH WOMEN’S HEALTH                                            Volume 12   Number 1

                                                               may not apply to all women. It is diffi-        Comment:
                   EDITOR- IN - CHIEF                          cult — and premature — to imagine cli-          Reducing the U.S. cesarean delivery
              Sandra Ann Carson, MD                            nicians advising patients to drink coffee       rate, which is almost 30%, is certainly a
    Professor of Obstetrics and Gynecology and                 to prevent diabetes. Perhaps the best
   Medical Director, Baylor Assisted Reproductive                                                              laudable goal. Despite the conditional
  Technology, Baylor College of Medicine, Houston              application of these findings is to reas-       approval of a fetal pulse oximeter, ac-
                                                               sure coffee drinkers that, in terms of          ceptance of oximetry into clinical prac-
                  EXECUTIVE EDITOR
                                                               diabetes, there is no strong medical            tice has awaited further clinical studies.
                Mary A. Nastuk, PhD                            reason to discontinue their habit.              This stands in contrast to the almost
            Massachusetts Medical Society
                                                               — Diane E. Judge, APN/CNP                       universal adaptation of conventional
                    DEPUT Y EDITOR                             Smith B et al. Does coffee consumption re-      electronic fetal monitoring. The results
              Andrew M. Kaunitz, MD                            duce the risk of type 2 diabetes in individu-   of this trial do not support the idea that
   Professor and Assistant Chair, Department of                als with impaired glucose? Diabetes Care
                                                                                                               fetal pulse oximetry, an expensive tech-
  Obstetrics and Gynecology, University of Florida             2006 Nov; 29:2385-90.
         Health Science Center, Jacksonville
                                                                                                               nique, will reduce the current cesarean
                                                                                                               rate or improve neonatal outcomes.
         PAT I E N T I N F O R M AT I O N E D I T O R                                                          — Ann J. Davis, MD
             Diane E. Judge, APN/CNP                                                                           Bloom SL et al. Fetal pulse oximetry and
  Chicago Health Outreach, Heartland Alliance for              Does Knowing Fetal                              cesarean delivery. N Engl J Med 2006 Nov
    Human Needs and Human Rights, Chicago
                                                               Oxygen Saturation Matter?                       23; 355:2195-202.
                 A S S O C I AT E E D I T O R S

                 Wendy S. Biggs, MD
  Assistant Professor, Department of Family Practice,
                                                               D      espite the wide use of intrapartum
                                                                      electronic fetal monitoring, its ben-
                                                               efits have been debated, particularly in
    Michigan State University College of Human
   Medicine; Associate Director, Midland Family                the context of cesarean delivery rates. In
                                                                                                               Maternal Stress
  Medicine Residency Program, Midland, Michigan                2000, the FDA conditionally approved a          and Midgestational
                   Ann J. Davis, MD                            fetal oximetry device that was developed        Fetal Weight
  Associate Professor of Obstetrics and Gynecology             to help characterize fetal condition in
        and Pediatrics, Tufts Medical School,
        New England Medical Center, Boston
              Marian C. Limacher, MD
                                                               the presence of a nonreassuring heart
                                                               rate. Investigators evaluated whether           P    revious studies have examined the
                                                                                                                    effect of prenatal psychological dis-
                                                                                                               tress on prematurity and birth weight, but
                                                               clinical knowledge of fetal oxygen satu-
        Professor of Medicine, Division of                                                                     none have evaluated its effect on fetal
  Cardiovascular Medicine, University of Florida
                                                               ration as an adjunct to conventional mon-
         College of Medicine, Gainesville                      itoring was associated with a reduction         weight in humans during midgestation.
                                                               in the cesarean delivery rate.                     Researchers evaluated 98 women
            Claudio N. Soares, MD, PhD
                                                                  They randomized more than 5000               (mean age, 26 years) who were between
       Associate Professor of Psychiatry and
      Behavioral Neurosciences, and Director,                  healthy full-term nulliparous women             16 and 29 weeks’ gestation. During a
     Women’s Health Concerns Clinic, McMaster                  in labor either to a “masked group” in          single visit, they estimated fetal weight
      University, Hamilton, Ontario, Canada                                                                    by ultrasound; assessed maternal stress,
                                                               which the fetal oxygen sensor was in-
                Anna Wald, MD, MPH                             serted but the oxygen saturation values         depression, and anxiety with three self-
   Associate Professor, Department of Medicine,                                                                reported questionnaires; and obtained
   Epidemiology, and Laboratory Medicine, and
                                                               were hidden from the clinicians, or to
    Medical Director, Virology Research Clinic,                an “open group” in which the values             urinary samples for analysis of norepi-
         University of Washington, Seattle                     were displayed and available to the             nephrine and cortisol levels. In analysis
                                                               clinicians. All women also underwent            that accounted for the independent
      M A S S AC H U S E T T S M E D I C A L S O C I E T Y
                                                               conventional electronic fetal monitor-          variance of sociodemographic variables,
  Robert Dall, Lyn Whinston-Perry, Rebecca Zacks,
                    Staff Editors                              ing. Rates and indications for cesarean         psychological distress, and biochemistry
           Martin Jukovsky, Copy Editor                        deliveries, fetal heart tracings, and vari-     measures, only prenatal cortisol was
               Andrea Parent, Layout                                                                           significantly associated with fetal weight.
                                                               ous markers of compromised neonatal
               Christopher R. Lynch
           Vice President for Publishing                       condition such as Apgar <4, need for            Comment:
         Alberta L. Fitzpatrick, Publisher                     intubation, or admission to intensive
                                                                                                               This study has received attention in the
        David G. Mecsas, Editorial Director                    care were compared.
                                                                                                               popular press, but it has several limita-
    Art Wilschek, Christine Miller, Lew Wetzel,                   The cesarean delivery rate did not
        Wayne Wickman, Advertising Sales                                                                       tions, including the small number of
                                                               differ significantly between the open
           William Paige, Robin Buttner,                                                                       women at each gestational age, the cross-
                Publication Services                           group and the masked group (26.3%
                                                                                                               sectional design, and the use of self-
          Bette Clancy, Customer Service                       and 27.5%, respectively). In addition,
                                                                                                               reported data. In addition, data on ma-
                                                               the condition of the infants did not dif-
 Published 12 times a year. Subscription rates — U.S.: $119                                                    ternal diet, vitamin use, and weight gain
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                                                               no intergroup differences in cesarean
 Intl: US$139 per year; Resident/Student/Nurse: US$75;                                                         that elevated cortisol might lower fetal
 Institutions: US$216. Prices do not include GST, HST, or      delivery rate were observed for the in-
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                                                                                                               weight by causing placental hyperperfu-
                                                               dication of a nonreassuring fetal heart
 P.O. Box 9085, Waltham, MA 02454-9085 or call 1-800-843-                                                      sion and increased fetal energy expendi-
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                                                               rate or for dystocia.
                                                                                                               ture. Certainly, further research aimed
 page at Information on our conflict-of-
 interest policy can be found at                                                          at helping pregnant women limit dis-
 conflict.dtl                                                                                                  tress might improve fetal outcomes.
January 2007                                      JOURNAL WATCH WOMEN’S HEALTH                                                         Page 3

Other research should focus on the un-             As noted in an editorial, further work is     of 40–44.9). Mean birth weight increased
derlying mechanisms by which maternal              required to understand the relative con-      progressively from 3075 g in the refer-
distress exerts its effect on fetal weight.        tribution of weight gain during the first     ence group to 3463 g among women
In the meantime, clinicians should                 pregnancy versus during the interpreg-        with BMIs of 40 to 44.9. The few (71)
encourage stress reduction during preg-            nancy interval. Clinicians might want         women with BMIs of 10 to 14.9 had low
nancy. Women might be more likely                  to inform women that increased weight         birth weight infants (mean, 2856 g).
to take heed with data suggesting that             is associated with adverse outcomes           Maternal height and cesarean delivery
stress might be linked to outcomes such            in subsequent pregnancies and that it         were inversely related: More than 60%
as fetal weight. — Ann J. Davis, MD                makes sense for overweight women to           of women who were 135 to 139 cm tall,
Diego MA et al. Maternal psychological             lose weight before conceiving.                40% of women who were 140 to 144 cm
distress, prenatal cortisol, and fetal weight.     — Anna Wald, MD, MPH                          tall, and 35% of women who were 145
Psychosom Med 2006 Sep/Oct; 68:747-53.             Villamor E and Cnattingius S. Interpreg-      to 149 cm tall had cesarean deliveries.
                                                   nancy weight change and risk of adverse
                                                   pregnancy outcomes: A population-based        Comment:
                                                   study. Lancet 2006 Sep 30; 368:1164-70.       The risk for cesarean delivery increas-
Is Weight Gain                                     Caughey AB. Obesity, weight loss, and preg-   es progressively with increasing BMI.
                                                   nancy outcomes. Lancet 2006 Sep 30;           Obese women also are at risk for having
Between Pregnancies                                368:1136-8.                                   large babies. Although the explanation
Associated with                                                                                  for the increased risk is not understood,
Pregnancy Outcomes?                                                                              the association represents yet another
                                                                                                 reason for obese women to lose weight
                                                   Cesarean Delivery Risk
O       verweight women are at high risk
        for adverse pregnancy outcomes.
To investigate whether this association
                                                   and Increasing Body Mass
                                                                                                 before conceiving.
                                                                                                 — Sandra Ann Carson, MD
                                                                                                 Barau G et al. Linear association between
is causal, researchers in Sweden exam-
ined changes in prepregnancy maternal
BMI between the first and second preg-
                                                   M       orbid obesity and short stature are
                                                           known risk factors for cesarean
                                                   delivery. Obstetricians usually consider
                                                                                                 maternal pre-pregnancy body mass index
                                                                                                 and risk of caesarean section in term deliv-
                                                                                                 eries. BJOG 2006 Oct; 113:1173-7.
nancies in relation to outcomes of the             height and weight thresholds when eval-
second pregnancy in 151,025 women                  uating a patient’s risk for cesarean de-
who had had two singleton births during            livery, but few studies have document-
the period from 1992 to 2001.                      ed linear associations.                       Can Amniotic-Fluid
   Women who gained 3 or more BMI                     This study was undertaken in Reunion       Embolism Be Avoided?
units were more likely to have preeclamp-          Island (Indian Ocean), where 75% of the
sia (odds ratio, 1.8), gestational hyper-
tension (OR, 1.8), gestational diabetes
(OR, 2), cesarean delivery (OR, 1.3),
                                                   population delivers at one public hospi-
                                                   tal and all women have their first prena-
                                                   tal visit at about 6 to 7 weeks gestation.
                                                                                                 A     mniotic-fluid embolism is a rare
                                                                                                       but life-threatening complication
                                                                                                 of childbirth. The diagnosis is based on
stillbirth (OR, 1.6), or large-for-gestational-    Prepregnancy height and weight were           clinical evidence rather than on specific
age babies (OR, 1.9) than women who                recorded in 16,952 women with single-         criteria. Investigators examined medical
had minimal weight change. The risk                ton, full-term, live births. The overall      record data to explore the associations
for adverse outcomes increased linearly            cesarean delivery rate was 17%. Patients      between characteristics of labor and the
with the amount of interpregnancy                  with prepregnancy BMIs of 15 to 19.9          incidence of fatal and nonfatal amniotic-
weight gain. This risk was evident even            served as the reference group.                fluid embolism in a population-based
in women who gained 1 to 2 BMI units                  Compared with the reference group,         cohort of 3 million hospital births in
and was independent of whether women               risk for cesarean delivery increased lin-     Canada from 1991 through 2001.
were overweight. A causal association              early with increasing prepregnancy BMI           Overall, the rate of amniotic-fluid em-
between weight gain and adverse mater-             (odds ratios, 1.4 for BMI of 20–24.9; 1.9     bolism was 6 per 100,000 singleton- and
nal and perinatal outcomes was further             for BMI of 25–29.9; 2.3 for BMI of 30–34.9;   14.8 per 100,000 multiple-birth deliver-
suggested by a decreased risk among                2.7 for BMI of 35–39.9; and 3.6 for BMI       ies. Thirteen percent of singleton-birth
women whose BMI decreased between
The dose-response relation between
temporal changes in prepregnancy ma-
ternal BMI and risk for adverse pregnan-
cy outcomes provides strong evidence                                     Announcing the new Journal Watch Online!
for a causal relation between interpreg-
nancy weight gain and adverse pregnan-                                   New site-wide access, new content, new features —
cy outcomes. Maternal obesity is also as-                                Same great physician editorial boards.
sociated with higher risk for anesthesia                                 Delivering practical perspectives in a clinical context.
complications and postpartum venous
thromboembolic disease and infection.                                    See what’s new. Visit today.
Page 4                                       JOURNAL WATCH WOMEN’S HEALTH                                          Volume 12   Number 1

cases and none of the multiple-birth cas-     elusive, and this study paves the way to     A retrospective, population-based cohort
es were fatal. In adjusted analyses, risk     the development of diagnostic criteria.      study. Lancet 2006 Oct 21; 368:1444-8.
factors for nonfatal or fatal amniotic-       The authors acknowledge that some of         Moore J. Amniotic fluid embolism: On the
fluid embolism included maternal age          the risk associations might result from      trail of an elusive diagnosis. Lancet 2006
older than 35, medical induction of labor,    reverse causality (e.g., cesarean delivery   Oct 21; 368:1399-401.
cesarean delivery, forceps or vacuum          after the onset of amniotic-fluid embo-
delivery, placenta previa or abruption,       lism to save the fetus). However, this is
eclampsia, polyhydramnios, cervical lac-      an unlikely explanation for the increased
eration or uterine rupture, and fetal dis-    risk for embolism when labor is induced.     Bacterial Vaginosis
tress. Induction of labor nearly doubled      Although some of the risk factors might      During Pregnancy
the risk for amniotic-fluid embolism          be difficult to modify, medical induction
(adjusted odds ratio, 1.8), although the
excess absolute risk was small (4–5
                                              of labor is often elective. Clinicians
                                              should be aware that the risk for this       T     he prevalence of bacterial vaginosis
                                                                                                 in pregnant women ranges from 6%
                                                                                           to 32% in studies, but the implications
cases per 100,000 induced labors).            rare but potentially catastrophic event
                                              might be increased by that practice.         of this finding are uncertain. To exam-
Comment:                                      — Anna Wald, MD, MPH                         ine the effect of bacterial vaginosis on
This large study confirms the risk factors                                                 pregnancy outcomes, researchers in
                                              Kramer MS et al for the Maternal Health
for amniotic-fluid embolism that have         Study Group of the Canadian Perinatal        Denmark conducted a prospective co-
been noted in previous, much smaller          Surveillance System. Amniotic-fluid embo-    hort study (supported by the manufac-
studies. As noted by an editorialist, the     lism and medical induction of labour:        turer of a treatment for bacterial vagino-
diagnosis of amniotic-fluid embolism is                                                    sis) in 3200 singleton pregnant women
                                                                                           recruited from 1998 to 2002 before 20
                                                                                           weeks’ gestation.
                        PR AC TI CE              WATCH                                        Bacterial vaginosis was diagnosed by
                                                                                           examining a rehydrated vaginal-smear
     Breast Cancer Does Not Need High-Tech Follow-Up                                       slide for bacterial morphology and scoring
                                                                                           it based on the presence of lactobacilli
  T     he American Society of Clinical Oncology (ASCO) has updated its 1998
        guidelines on breast cancer follow-up. Periodic history taking, physical ex-
  ams, and patient education about symptoms of recurrence remain key factors in
                                                                                           or other bacteria. All slides were scored
                                                                                           by one examiner (Schmidt). The au-
                                                                                           thors report that Schmidt’s method is
  breast cancer surveillance. Genetic counseling is recommended for high-risk
                                                                                           highly concordant with Amsel’s criteria,
  women, including those with Ashkenazi Jewish heritage, family history of breast
                                                                                           the gold standard for diagnosis of bacte-
  or ovarian cancer, or diagnosis of bilateral breast cancer in the patient or a rela-
                                                                                           rial vaginosis.
  tive. All women should perform monthly breast self-exams. Women who have
                                                                                              Overall, 16% of women had bacterial
  had breast-conserving treatment should have mammograms starting 1 year after
                                                                                           vaginosis. This condition was signifi-
  diagnosis (but no earlier than 6 months after radiation treatment) and annually
                                                                                           cantly associated with low birth weight
  thereafter. Routine pelvic exams are recommended, and any vaginal bleeding
                                                                                           (odds ratio, 2.0), preterm delivery of a
  in women taking tamoxifen should be promptly investigated.
                                                                                           low birth weight infant (OR, 2.5), medi-
    Study results have shown no survival advantage or improvement in quality
                                                                                           cally indicated preterm delivery (OR,
  of life for intensive compared with conservative surveillance. Thus, complete
                                                                                           3.6), and clinical chorioamnionitis (OR,
  blood counts (CBCs) and liver function tests, imaging studies, and assessment of
                                                                                           2.7). Bacterial vaginosis also was associ-
  tumor markers are not recommended for routine surveillance. Although magnetic
                                                                                           ated with delivery before 32 weeks’
  resonance imaging and [18F]fluorodeoxyglucose-positron emission tomography
                                                                                           gestation (OR, 2.4). However, in con-
  (FDG-PET) scanning both appear useful in diagnosing recurrent breast cancer,
                                                                                           trast to the results of other studies, it
  data are insufficient to support the use of either method for routine surveillance
                                                                                           was only marginally associated with
  in asymptomatic patients.
                                                                                           delivery before 37 weeks (OR, 1.5). Bac-
                                                                                           terial vaginosis was not associated with
                                                                                           postpartum endometritis. Thirty-nine
  Because breast cancer can recur within 15 years of the initial diagnosis and             percent of women with preeclampsia
  beyond, surveillance is a lifelong process. Coordination of care between the             and 56% with intrauterine growth
  primary care physician (PCP) and specialist is recommended. For a woman                  restriction had bacterial vaginosis.
  with early-stage breast cancer (<5-cm tumor and <4 positive nodes), care can
  be transferred to the PCP 1 year after diagnosis, provided both patient and PCP          Comment:
  are informed about appropriate surveillance. Follow-up by a PCP rather than a            Bacterial vaginosis during the second
  specialist has been shown to have the same health outcomes with equal or better          trimester can either affect or be a mark-
  patient satisfaction. Unfortunately, however, who follows the patient might not          er of risk for adverse pregnancy out-
  matter: 69% of symptomatic recurrences develop between scheduled exams.                  comes. The authors postulate that the
  — Wendy S. Biggs, MD                                                                     production of inflammatory cytokines
                                                                                           might interfere with normal placental
  Khatcheressian JL et al. American Society of Clinical Oncology 2006 update of the        function. Although no previous large
  breast cancer follow-up and management guidelines in the adjuvant setting. J Clin
                                                                                           cohort study has used the vaginal-smear
  Oncol 2006 Nov 1; 24:5091-7.
                                                                                                               (continued on page 6)
January 2007                                   JOURNAL WATCH WOMEN’S HEALTH

                                                                                                                          F O R YO U R I N F O R M AT I O N
                               The Basics of Skin Care:
                     Avoid the Sun and Consider Using Retinoids
               If you’re like most women, you care about your         can cause skin cancer. To reduce sun expo-
               appearance, and you’d prefer that your skin stay       sure, take the following protective measures:
               smooth and youthful looking. In fact, Americans
               care so much about their appearance that they          1. Wear a hat with a wide brim. Baseball caps
               spend billions of dollars annually on over-the-        may be fashionable, but you need a hat with a
               counter products that promise to prevent or cure       brim that measures about 3 inches all the way
               wrinkles, age spots, and sagging. However, there       around to protect all of your face and neck.
               is no medical evidence that nonprescription skin       2. Use sunscreen daily on sun-exposed areas,
               care products actually deliver what they promise.      including your face, ears, neck, chest, and
               So, how can you keep your skin as healthy as           arms. Sunscreen use is key to preventing
               possible? It might be easier than you think.           further skin damage. It should be used every
               As you get older, your skin may develop fine           single day, even if the weather is cloudy.
               wrinkles, dark spots (“age spots” or “liver spots”),   • Use sunscreens that protect against the two
               uneven color, roughness, sagging, dryness, and           damaging types of solar radiation, UVA and
               visible clusters of blood vessels. Genetics, the         UVB. For sunscreen to work properly, you
               characteristics you inherit from your parents,           need to use it correctly. First of all, use
               plays a role in how your skin ages. However, you         enough: about 1 ounce (about 2 measuring

               can’t change your genes — at least not yet! Sun          tablespoonfuls) over your face, neck, arms,
               exposure is responsible for many age-related skin        legs, and any other exposed body areas. An
               changes, referred to as photoaging. Obviously,           8-ounce bottle of sunscreen should last for
               then, one of the best ways to minimize skin dam-         about eight applications. Apply the sunscreen,
               age is to avoid sunlight. But some prescription          or moisturizer that contains sunscreen, to
               skin products may also help reverse or minimize          clean, dry skin. Allow to dry, and then apply a
               the effects of aging and sun damage.                     second layer. Reapply the sunscreen every 4
                                                                        hours or immediately after sweating heavily
                       If You’re a Smoker, Read This                    (such as during exercise) or after swimming,
               Smokers develop more wrinkles than nonsmok-              when the sunscreen may wash off.
               ers of similar age, complexion, and sun expo-          • Every sunscreen has a sun protection factor
               sure. Add this to the many reasons you already           (SPF) number to indicate how long it will
               have to stop smoking now. You can get help               protect you from UVB rays before it must be
               with smoking cessation from your healthcare              reapplied. Multiply the SPF number by the
               provider (doctor, nurse practitioner, nurse mid-         number of minutes you can normally stay
               wife, or physician assistant); local hospitals and       out in the sun before getting sunburned. For
               health departments; local chapters of the Ameri-         instance, if your skin normally burns after 10
               can Lung Association, American Heart Associa-            minutes in the midday sun, a sunscreen with
               tion, or American Cancer Society; or online at           an SPF of 15 will protect you for 10 minutes
                      times 15, or a total of 150 minutes. After that
                                                                        time, it should be reapplied. The SPF rating
                               Sun Protection                           applies to UVB protection only. Most sun-
                                                                        screens do not provide a number to rate
               Avoid the sun from 10:00 am to 2:00 pm (the              their effectiveness against UVA.
               peak hours of solar radiation), or use sun pro-
               tection if you must go out during these hours.         • Older sunscreens were often greasy or thick,
               Just going from home to work or running errands          or they left a white residue on the skin. Newer
               exposes you to the sun’s rays. In addition to            ones provide both UVA and UVB protection
               altering the skin’s appearance, sun exposure             plus feel and look better. Two new technolo-

                 This patient-education material was prepared by the editors of Journal Watch Women’s Health.
                                                                        JOURNAL WATCH WOMEN’S HEALTH                                                      Volume 12   Number 1

                                      gies, Mexoryl and Helioplex, allow manufac-                    you first start treatment and usually go away. If
                                      turers to add UVA protection to sunscreens.                    irritation is a problem, your healthcare provid-
                                      Another new technology, Dermaplex, allows                      er may suggest applying the cream only every
                                      manufacturers to make UVA/UVB protective                       other day. You should also wash with mild soap
                                      sunscreens more appealing to use.                              and avoid abrasive skin scrubs or cleansers.
                                                                                                     Wash and dry your face well, and apply a pea-
                                    3. Avoid tanning beds, sun lamps, and tanning
                                                                                                     sized amount of the cream to your entire face
                                    parlors. Artificial sunlight damages the skin as
                                                                                                     at bedtime, avoiding delicate areas around the
                                    much as natural sunlight and may increase your
                                                                                                     eyes, nose, and mouth. Retinoids can make your
                                    risk for skin cancer even more than sunlight.
                                                                                                     skin more sensitive to sun exposure, so use a
                                    4. Wear sun-protective clothing. The SPF is also                 moisturizer with sunscreen every day.
                                    used to rate protection provided by your cloth-
                                                                                                     In addition to sun avoidance and prescription
                                    ing. Normal clothing provides an SPF of 6–15;
                                                                                                     retinoids, OTC skin preparations (called
                                    the SPF falls below 5 if the clothing becomes wet.
                                                                                                     cosmeceuticals) may eventually prove helpful.
                                    Sun-protective clothing (for example, Solumbra)
                                                                                                     Medical researchers are studying products
                                    is made of special fabric called Solarweave or
                                                                                                     such as antioxidants, vitamins, growth factors,
                                    treated with SunGuard and provides SPFs of 30
                                                                                                     peptides, and botanicals to see if they add sig-
                                    or higher. This type of clothing may be a good
                                                                                                     nificant benefits to regimens that are already
                                    choice if sun exposure is unavoidable, especially
                                                                                                     known to work. In general, proper skin care is
                                    during the hours of 10:00 am to 2:00 pm. How-
                                                                                                     essential even if you undergo more involved
                                    ever, sun-protective clothing is usually more
                                                                                                     procedures such as Botox injections, laser or
                                    expensive than regular or untreated fabrics.
                                                                                                     light treatments, or plastic surgery.

                                        Reversing the Signs of Photoaging
                                                                                                                           In Summary
                                    Most adult women already have some skin pho-
                                                                                                     Your skin normally changes with age as it wrin-
                                    toaging. During the past 20 years, results of
                                                                                                     kles, sags, and becomes thinner and rougher.
                                    scientific studies have shown that substances
                                                                                                     These changes are accelerated by sun exposure.
                                    called retinoids, applied directly to the skin,
                                                                                                     Therefore, avoiding such exposure by staying
                                    safely and effectively improve these changes.
                                                                                                     out of direct sunlight, using sunscreen daily,
                                    Retinoids must be prescribed by a licensed
                                                                                                     and wearing protective clothing even on over-
                                    healthcare provider and are available in seve-
                                                                                                     cast days makes sense. OTC skin care products
                                    ral formulations. They are not recommended
                                                                                                     often make exaggerated claims and usually
                                    during pregnancy or breast-feeding, so talk to
                                                                                                     don’t deliver on what they promise. Creams
                                    your clinician before using retinoids on your
                                                                                                     called retinoids do help reverse some of the ef-
                                    skin if you are nursing or pregnant, or if you
                                                                                                     fects of photoaging; they must be prescribed by
                                    think you could become pregnant.
                                                                                                     your regular healthcare provider or a dermatolo-
                                    Retinoids are usually applied to the face once                   gist (skin specialist) and used as directed. Smok-
                                    daily before bedtime. They improve fine wrin-                    ing damages the skin, as well as the rest of
                                    kles, irregular skin coloration, and rough skin,                 the body; quitting smoking now can prevent
                                    but they don’t do it overnight. Most women                       further skin damage.
                                    start seeing improvement after about 2 months,
                                    with continuing improvement thereafter. After                                            Resources
                                    6 months of use, your healthcare provider may                    US National Institutes of Health
                                    advise reducing applications to 3 times per                      National Institute on Aging
                                    week. Long-term retinoid use is safe and               
                                    provides sustained benefits to the skin.
                                                                                                     American Academy of Dermatologists
                                    The most common side effect of retinoids is                      AgingSkinNet
                                    skin irritation — peeling, redness, and stinging.      
                                    These problems are most likely to occur when

                                    ©2007 Massachusetts Medical Society. Authorization is hereby granted to healthcare providers to photocopy For Your Information
                                          for noncommercial educational use only; not for resale. For more information, please contact Rights & Permissions,
                                                                           Massachusetts Medical Society, fax: 781-893-8103.
January 2007                                 JOURNAL WATCH WOMEN’S HEALTH                                                          Page 5

                                    Effective Skin Care for Women

  E    very day in our dermatology prac-
       tice, women of all ages ask what
  they can do to achieve and maintain
                                              facial protection, the best hat is one
                                              with a brim that is at least 7 cm wide.
                                                 The FDA-approved technique for as-
                                                                                             bined with conventional UVB filters.
                                                                                             These provide 5 hours of UVA protec-
                                                                                             tion.3 Dermaplex, another emerging
  healthier-looking skin. Women are           sessing the efficacy of sunscreens and         technology, requires fewer chemical
  inundated with creams, lotions, and         sun-protective clothing yields a num-          sunscreens to provide UVB protection
  serums touted to reverse the signs of       ber called the sun protection factor           as well as photostable UVA protection.4
  aging and sun damage. Unfortunately,        (SPF) rating. The SPF rating is calculat-         Patient education about proper sun-
  many of these claims are completely         ed by comparing the amount of time             screen application is paramount. SPF
  unsupported or are backed by small,         necessary to produce sunburn on pro-           measurement is based on sunscreen
  uncontrolled studies that have not          tected skin to the amount of time nec-         applied at a concentration of 2 mg/cm2.
  been scrutinized by the FDA. Although       essary to cause the same reaction on           Studies show that most people apply a
  prescription topicals must undergo          unprotected skin. For example, if a            layer as thin as 0.5 mg/cm2, resulting in
  rigorous FDA-monitored examination,         burn normally requires 10 minutes              an SPF significantly lower than stated
  nonprescription topicals — known as         of midday sun exposure, a sunscreen            on the label.5 Sunscreen should be ap-
  cosmeceuticals — are not subject to         with SPF 15 will prolong this time by a        plied to the face every morning, wheth-
  pre-market proof of safety or efficacy.     factor of 15, thereby rendering protec-        er it is sunny or overcast, as follows:
  Even though a healthy skin care regi-       tion for 150 minutes. The SPF determi-         After washing the face, apply a thin
  men may incorporate cosmeceuticals,         nation applies to UVB radiation only.          layer of sunscreen or daily moisturizer
  this article focuses on the two most ef-       Normal clothing may provide SPF             with an SPF and allow it to dry; then
  fective evidence-based methods avail-       ratings between 6 and 15, which                follow with a second layer. Sunscreen
  able to achieve and maintain healthy        drops below a rating of 5 once the             application should be repeated every
  skin: sun protection and the use of         fabric becomes wet. Sun-protective             4 hours and immediately after exces-
  topical prescription retinoids.             clothing products such as Solumbra,            sive perspiration and swimming.
                                              and fabrics made of Solarweave or
  What Is Photoaging?                         treated with SunGuard, offer SPF 30            Topical Prescription Retinoids
     Lifelong exposure to solar radiation     or higher.2 Although there are assays             For more than 20 years, topical pre-
  accelerates the skin’s intrinsic aging      for protection against UVA, none is            scription retinoids have been recog-
  process and leads to photoaging,            universally accepted. Therefore, sun-          nized for their efficacy in reversing
  which is characterized by wrinkles,         screens in the U.S. often are not la-          the signs of photoaging. Topical reti-
  dyspigmentation, laxity, roughness,         beled for their ability to block UVA.          noids approved by the FDA for treating
  sallowness, and telangiectasias. Severe        To be maximally effective, sun-             photodamaged skin include tretinoin
  photodamage may cause actinic kera-         screens should block both UVB and              0.02% and 0.05% emollient cream and
  toses and cutaneous malignancies. His-      UVA radiation. Traditional UVB block-          tazarotene 0.1% cream. Other formula-
  tologically, photodamaged skin shows        ers include para-aminobenzoic acid             tions and retinoid analogues, such as
  keratinocytic and melanocytic atypia,       (PABA), salicylates, and cinnamates.           adapalene, are used off-label. Topical
  loss of epidermal polarity, degenera-       Benzophenones (e.g., oxybenzone)               retinoids are not recommended during
  tion of collagen, deposition of abnor-      block both UVB and UVA radiation,              pregnancy and lactation and should be
  mal elastic tissue, and tortuous micro-     while dibenzoylmethanes (e.g., avoben-         discontinued in women who are preg-
  vasculature.1 Both ultraviolet (UV) B       zone, also known as Parsol 1789) block         nant or are trying to conceive.
  and UVA radiation are implicated in         UVA radiation only. Avobenzone is                 Tretinoin is the most well-studied
  these changes. Smoking and environ-         capable of a high degree of UVA ab-            topical prescription retinoid. It im-
  mental factors, such as wind and pol-       sorption, but, ironically, it is unstable in   proves both the clinical and histologic
  lutants, also accelerate skin aging.        sunlight. Physical blocking agents such        signs of photoaging. Reduction of fine
                                              as zinc oxide and titanium dioxide are         wrinkles, mottled hyperpigmentation,
  Sun Protection                              composed of particles that scatter,            and roughness occur as soon as 2 weeks
    Sun protection starts with avoid-         reflect, or absorb both UVB and UVA            after initiation of treatment.6 These ef-
  ance of peak solar radiation, which oc-     radiation. Older physical blockers were        fects can be sustained with continued
  curs between 10:00 am and 2:00 pm.          opaque and left a white film on the            use.7 Histologically, long-term treatment
  Modifying outdoor behavior and wear-        skin, but newer micronized preparations        (mean duration, 2.3 years) with topical
  ing sun-protective clothing are more        provide broad-spectrum protection              tretinoin 0.05% emollient has been
  effective preventive measures than          without the residue.                           shown to reduce epidermal cellular
  using sunscreen. Hats also play an             The newest generation of sunscreens         atypia and thicken the collagen band
  important role when sun exposure is         addresses the need for broad-spectrum          in the papillary dermis.8
  unavoidable. Although baseball hats         protection, stabilization of active in-           Tazarotene 0.1% cream achieves simi-
  may be in vogue, they protect only the      gredients, and cosmetically appealing          lar success in reversing the signs of
  forehead and nose, leaving the cheeks,      formulations. The technologies Mexo-           photoaging. Compared with nonmedi-
  chin, and neck exposed. For total           ryl and Helioplex add a chemical to            cated vehicle, tazarotene significantly
                                              produce photostable avobenzone com-
Page 6                                         JOURNAL WATCH WOMEN’S HEALTH                                             Volume 12   Number 1

  (continued from page 5)                       nation of sun protection and topical         1. Phillips TJ et al. Efficacy of 0.1% tazaro-
                                                prescription retinoids. Proper skin          tene cream for the treatment of photo-
  improved fine wrinkling and mottled           care serves as a foundation for more         damage: A 12-month multicenter, ran-
                                                                                             domized trial. Arch Dermatol 2002 Nov;
  hyperpigmentation after 24 weeks of           invasive office procedures such as           138:1486-93.
  once-daily application. Clinical im-          botulinum toxin to smooth dynamic
                                                                                             2. Lowe NJ and Friedlander J. Prevention
  provement did not plateau by week             wrinkles, dermal fillers to soften the       of photodamage with sun protection
  52, suggesting that additional im-            appearance of creases and folds, and         and sunscreens. In: Gilchrest BA, editor.
  provements may be gained with                 resurfacing lasers and light sources to      Photodamage Blackwell Science 1995;
  longer treatment.1                            improve dyspigmentation and texture.         201-19.
     Skin irritation is the most common         Given recent advances in sunscreen           3. Data on file, Johnson & Johnson
  side effect of topical retinoid use. Des-     technology and retinoid options,             Neutrogena.
  quamation, erythema, and stinging             women can adopt healthy skin practices       4. Data on file, Skin Effects by Dr. Jeffrey
  generally occur when treatment is first       for the prevention and treatment of          S. Dover.
  initiated and are usually transient.          photoaging more easily than ever.            5. Wulf HC et al. Sunscreens used at the
  Irritation can be ameliorated by short        — Christine M. Choi, MD, and                 beach do not protect against erythema:
  contact or alternate-day application          Jeffrey S. Dover, MD, FRCPC, FRCP            A new definition of SPF is proposed.
  and by avoiding abrasive cleansers. Pa-       (Glasg)                                      Photodermatol Photoimmunol
                                                                                             Photomed 1997 Aug; 13:129-32.
  tient education regarding the proper          Dr. Choi is a Cosmetic and Laser Fellow
  use of topical retinoids cannot be over-      with SkinCare Physicians, Chestnut Hill,     6. Weiss JS et al. Topical tretinoin improves
                                                Massachusetts.                               photoaged skin: A double-blind vehicle-
  emphasized: At night, after washing
                                                                                             controlled study. JAMA 1988 Jan 22/29;
  the face and patting it dry, apply a pea-     Dr. Dover is Director of SkinCare            259:527-32.
  sized amount sparingly over the entire        Physicians, Chestnut Hill, Massachusetts;
                                                Associate Clinical Professor, Department     7. Olsen EA et al. Tretinoin emollient
  face, being careful to avoid delicate                                                      cream for photodamaged skin: Results
                                                of Dermatology, Yale University School of
  areas around the eyes, nose, and mouth.                                                    of 48-week, multicenter, double-blind
                                                Medicine, New Haven, Connecticut; and
  In addition, a daily moisturizer with         Adjunct Professor of Medicine                studies. J Am Acad Dermatol 1997
  sunscreen is recommended.                     (Dermatology), Dartmouth Medical School,     Aug; 37:217-26.
                                                Hanover, New Hampshire.                      8. Cho S et al. Long-term treatment of
  Conclusion                                    The Dermaplex sunscreen technology in the    photoaged human skin with topical reti-
    Despite the myriad of skin products         Skin Effects sun care products was created   noic acid improves epidermal cell atypia
  claiming to “turn back the clock,” the        and commercially licensed by Dr. Dover.      and thickens the collagen band in papil-
                                                                                             lary dermis. J Am Acad Dermatol 2005
  most effective evidence-based ap-
                                                                                             Nov; 53:769-74.
  proach to photoaged skin is a combi-

(continued from page 4)                         for Health Statistics reviewed the Inter-    increase in the infant mortality rate in
                                                national Classification of Diseases, 10th    2002 — the first since 1958. Clearly, the
slide method of this study, the results         Revision (ICD-10) codes in a linked          U.S. healthcare delivery system must
appear to concur with the current litera-       birth and death data set of almost           focus on reducing preterm births to
ture, reaffirming that bacterial vaginosis      28,000 infants who died during               decrease infant mortality. In the mean-
is an important risk factor for pregnan-        their first year of life in 2002.            time, clinicians should continue to en-
cy complications. Unfortunately, the              Researchers identified the top 20          courage healthful behaviors, including
study does not address whether treatment        causes of infant death and assessed the      regular prenatal care in pregnant wom-
prevents these complications.                   role of preterm delivery in each cause       en, and to be vigilant about early signs
— Wendy S. Biggs, MD                            by determining the proportion of in-         of preterm labor.
Svare JA et al. Bacterial vaginosis in a co-    fants who were born prematurely and          — Ann J. Davis, MD
hort of Danish pregnant women: Prevalence       by evaluating the biologic connection        Callaghan WM et al. The contribution of
and relationship with preterm delivery, low     between each cause of death and pre-         preterm birth to infant mortality rates in
birthweight and perinatal infections. BJOG      term birth. The top 20 causes accounted      the United States. Pediatrics 2006 Oct;
2006 Sep 27; [Epub ahead of print].                                                          118:1566-73.
                                                for 80% of deaths. Thirty-four percent
                                                of infant deaths were attributable to
                                                preterm birth — twice the amount
                                                attributed to preterm birth based
Preterm Delivery                                on ICD-10 codes for short gestation          BRCA Test Negative? Your
Tops Infant                                     and low birth weight.                        Patient Is Still High Risk
Causes of Death                                 Comment:
                                                The finding that preterm delivery is the     A     lthough the discovery of BRCA mu-
                                                                                                   tations allows us to identify women
A    lthough 65% of infant deaths in the
     U.S. occur in those born before 37
weeks’ gestation, only 17% are classified
                                                most frequent cause of infant death will
                                                not surprise practicing obstetricians.
                                                                                             at elevated risk for breast and ovarian
                                                                                             cancers, these mutations by no means
as being due to preterm birth. To exam-         One of the Healthy People 2010 objec-        account for all inherited malignancies of
ine this disparity, the National Center         tives is a reduction in the U.S. infant      these organs. To address the hypothesis
                                                mortality rate. However, there was an        that other susceptibility genes are
January 2007                                   JOURNAL WATCH WOMEN’S HEALTH                                                        Page 7

involved in inherited cases of breast can-      Oral Contraceptive                            ed almost 1500 women aged 35–44 with
cer, British investigators studied 277                                                        breast cancer. The results showed that
families with histories of breast or            Use and Risk                                  the odds ratio for breast cancer among
ovarian cancer and assessed the rela-           for Breast Cancer:                            former or current OC users matched
tive risk for breast cancer among fam-          New Information?                              that of never-users. In light of these dif-
ily members who tested negative for                                                           fering results, the clinical importance
   Of 560 first-degree relatives of individ-
uals carrying one or both of the familial
                                                T     he Women’s Health Initiative find-
                                                      ing of an increased risk for breast
                                                cancer with long-term postmenopausal
                                                                                              of the findings of the current meta-
                                                                                              analysis is uncertain.
                                                                                              — Andrew M. Kaunitz, MD
BRCA mutations, 184 (33%) tested nega-          use of combination estrogen-progestin         Kahlenborn C et al. Oral contraceptive use
tive for these mutations. Of these 184          increased the concern that any type of        as a risk factor for premenopausal breast
women, 18 had been diagnosed with               hormone therapy might contribute to           cancer: A meta-analysis. Mayo Clin Proc
breast cancer. During prospective follow-       breast cancer risk. In this meta-analysis,    2006 Oct; 81:1290-302.
up of 153 first-degree relatives (818           investigators assessed 34 case-control
person-years) who had tested negative           studies (published from 1986 to 2002)
for BRCA1 or 2 and who had not been             of breast cancer and oral contraceptive
diagnosed with breast cancer at the time        (OC) use in women aged 50 or younger          Assessing
of testing, 3 of these women were diag-         or who were considered premenopausal.         Chemotherapy’s Effect on
nosed with breast cancer (versus 1.4 ex-           OC use was associated with an in-
pected cases in the general population).        creased risk for breast cancer (pooled        Cognitive Function in
In a retrospective cohort analysis of all       odds ratio, 1.19). This risk was greater      Breast Cancer Survivors
257 relatives who tested negative for the       in women who used OCs before their
familial BRCA1 or 2 mutations, the rela-
tive risk for being diagnosed with breast
                                                first full-term pregnancy (OR, 1.44)
                                                than after (OR, 1.15).
                                                                                              W       ith the increasing awareness and
                                                                                                      availability of screening proce-
                                                                                              dures for early detection of breast can-
cancer from 1975 to the last follow-up
                                                Comment:                                      cer, more women are receiving treat-
was 5.3 in all test-negative relatives, com-
                                                That any possible link between OC use         ment early enough to achieve long-term
pared with the expected incidence in
                                                and breast cancer risk causes concern         survival. A common complaint among
the general population. The risk for ovar-
                                                among clinicians and patients is under-       these women, however, is the effect
ian cancer also was elevated in family
                                                standable. Nonetheless, the importance        of treatment on quality of life and on
members who tested negative compared
                                                of these particular findings is unclear to    cognitive functioning. Even years after
with the general population.
                                                me. As the authors note, their results        receiving chemotherapy, breast cancer
Comment:                                        differ from those of the 1996 Oxford          survivors often report mental slowness
Conventional practice in breast cancer          pooled reanalysis of more than 53,000         and difficulties in concentrating, memo-
risk counseling is to reassure women            women with breast cancer and 100,000          rizing, or maintaining attention. To bet-
who test negative for BRCA mutations,           women without the disease (see JWWH           ter characterize such cognitive deficits,
even if they have relatives who carry ei-       Aug 1996, p. 34, and Lancet 1996;             investigators administered neurocogni-
ther mutation. However, these study re-         347:1713). The Oxford data showed no          tive tests to, and assessed regional brain
sults call such reassurance into question       increased risk for breast cancer one dec-     activity in positron emission tomography
by demonstrating that all female blood          ade or more after OC discontinuation          (PET) scans of, 16 breast cancer survi-
relatives in families harboring BRCA            (i.e., increased risk was limited to recent   vors who had been treated with adjuvant
mutations are at elevated risk for breast       OC users). Moreover, tumors in OC users       chemotherapy 5 to 10 years before study
and ovarian cancer. Earlier initiation of       were less advanced at diagnosis than tu-      enrollment and 8 matched controls who
annual mammographic screening is ap-            mors in OC never-users. The authors of        had never received chemotherapy
propriate for such women. In addition,          the current meta-analysis were not able       (5 with a history of breast cancer).
women from high-risk families may be            to examine these important parameters.           Chemotherapy-treated women had a
candidates for magnetic resonance               One explanation for the Oxford findings       decrease of 13% in performance scores
imaging breast screening ( JWWH Sep             is that current or recent OC users receive    on the delayed-recall test, compared with
2004, p. 66, and N Engl J Med 2004;             more breast examinations and mammo-           the control group. The chemotherapy
351:427) and prophylactic surgery               grams, enabling earlier diagnosis and         group also showed abnormally elevated
( JWWH Jun 2005, p. 41, and Arch Intern         raising the possibility that breast cancer    neural activity in specific regions of the
Med 2005; 165:516).                             mortality might be lower among OC             frontal cortex and cerebellum during
— Andrew M. Kaunitz, MD                         users than among never-users.                 performance of a short-term memory
                                                   The current findings also differ from      recall test. In addition, a subset of 11
Smith A et al. Phenocopies in BRCA1 and
BRCA2 families: Evidence for modifier genes     those of the largest, most recent, and        chemotherapy-treated women who had
and implications for screening. J Med Genet     possibly most relevant study included         also received tamoxifen showed reduced
2006 Nov 1; [Epub ahead of print]               in this meta-analysis: the 2002 Women’s       resting metabolism in regions of the
                                                Care Study (see JWWH Aug 2002, p. 65,         basal ganglia involved in cognitive
                                                and N Engl J Med 2002; 346:2025). This        functioning.
                                                case-control study involved five data
                                                collection centers, with the CDC as the
                                                data coordinating center, and it includ-
                                                                Except as otherwise set forth herein, no part of this newsletter may be reproduced
              Journal Watch                                     or otherwise incorporated into any information retrieval system without the written
   New       Women’s Health                                     permission of the Massachusetts Medical Society. Printed in the USA. ISSN 1521-4710.

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                                                                 JOURNAL WATCH
                                                                       WOMEN’S HEALTH
Can you answer the following
question about the summary                                      Massachusetts Medical Society
“Preterm Delivery Tops Infant                                   860 Winter Street
Causes of Death” (on page 6)?                                   Waltham, MA 02451-1413
Researchers studied the impact of preterm
birth on infant mortality rates in the U.S.
Which of the following statements is true?
A. Infant mortality reached an all-time low
   in 2002.
B. Preterm birth accounts for 80% of infant deaths.
C. Clinicians should encourage prenatal care and
   be attuned to the early signs of preterm labor
   to help reduce the risk for preterm delivery.
D. All of the above.

* Category: Pediatrics/Adolescent Medicine,
  Women’s Health
  Exam Title: JW Women’s Health: Preterm
  Birth, Infant Mortality, Breast-Feeding,
  Sexual Initiation
  Posted Date: Jan 3 2007
             CME Faculty: Allison Oler, MD
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Page 8                                                 JOURNAL WATCH WOMEN’S HEALTH                                                      Volume 12     Number 1

Comment:                                                Muscle Cramps                                        and calcium groups had significantly
These results suggest a neurobiologic ba-                                                                    less muscle cramps than controls.
                                                        During Pregnancy
sis for the cognitive difficulties common-                                                                   Comment:
ly reported by breast cancer survivors.
This is something to keep in mind when
monitoring the long-term effects of
                                                        M      uscle cramps in the lower extrem-
                                                               ities are common during pregnan-
                                                        cy — mostly during the second half of
                                                                                                             Although this small study did not in-
                                                                                                             clude a placebo arm and did not con-
                                                                                                             trol for gestational age and parity, the
chemotherapy on patients’ memory and                    pregnancy and often at night. Proposed
                                                                                                             marked improvement in muscle cramps
cognitive functioning. Further studies                  treatments have included calcium and
                                                                                                             with calcium carbonate and vitamins B1
must examine whether such cognitive                     magnesium, but neither has proved ef-
                                                                                                             and B 6 is impressive. Socioeconomic
abnormalities are associated with other                 fective. In this small study, researchers
                                                                                                             and dietary deficiencies were not ac-
factors that affect memory and cogni-                   randomized 84 pregnant Iranian women
                                                                                                             counted for and could result in varying
tion, such as endogenous hormone levels,                to receive calcium carbonate (500 mg
                                                                                                             outcomes among different populations.
immune responses, or concurrent psy-                    once a day), magnesium aspartate (7.5
                                                                                                             Even though the study did not investi-
chological problems (e.g., depression                   mmoles twice a day), thiamine (B1; 100
                                                                                                             gate side effects, these doses of supple-
and anxiety). Ultimately, we need novel                 mg) plus pyridoxine (B6 ; 40 mg) once a
                                                                                                             ments would be unlikely to pose harm,
breast cancer treatments that minimize                  day, or no treatment for 2 weeks.
                                                                                                             and they seemed to help this annoying
adverse cognitive effects.                                 Results were evaluated 2 weeks after
                                                                                                             symptom of pregnancy.
— Claudio N. Soares, MD, PhD                            cessation of treatment and categorized
                                                                                                             — Sandra Ann Carson, MD
Silverman DH et al. Altered frontocortical,             as no change, relative improvement
                                                        (decrease in frequency and intensity                 Sohrabvand F et al. Vitamin B supplemen-
cerebellar, and basal ganglia activity in
                                                                                                             tation for leg cramps during pregnancy.
adjuvant-treated breast cancer survivors                of cramps), or absolute improvement
                                                                                                             Int J Gynaecol Obstet 2006 Oct; 95:48-9.
5–10 years after chemotherapy. Breast                   (complete absence of cramps). Absolute
Cancer Res Treat 2006 Sep 29; [epub                     improvement was reported most often
ahead of print]
                                                        in the vitamin B1 plus B6 group (72%),
                                                        followed by the calcium (52%) and mag-
                                                        nesium (29%) groups. Only 9% of no-
                                                        treatment controls reported absolute                  
                                                        improvement. Women in the B-vitamin

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