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In this issue we are pleased to bring you the exciting news that Dubai Healthcare City will launch a world-class tertiary care teaching hospital. This story has been developing for several months, as faculty from HMI, health care leaders in Dubai, a team of architects from a top firm, and clinical and administrative experts from throughout the Harvard medical community have worked together to design every component of the University Hospital.
Around Harvard
This article originally appeared in the December 2007 Harvard Men's Health Watch and is provided courtesy of Harvard Health Publications.
Revisiting hormone therapy’s risks and benefits
A more nuanced picture may emerge as researchers re-examine data from the government’s massive postmenopausal hormone trials.
Hormone therapy has long been the standard treatment for relieving menopausal symptoms: hot flashes, night sweats, and vaginal dryness. Until 2002, many clinicians were also recommending it long term to prevent chronic health problems, including heart disease, stroke, and osteoporosis. There was some evidence that estrogen might contribute to breast cancer, but except for women at especially high risk for that disease, cardiovascular disease was a more serious concern — a far greater cause of death and disability. For that reason, most health organizations recommended that postmenopausal women consider taking hormone therapy.
Then, in 2002, the hormonal approach to averting women’s later-life ills screeched to a halt. Researchers had to stop the Women’s Health Initiative (WHI) randomized trial of estrogen and progestin (in the form of Prempro) because the hormone combination was actually causing more heart attacks and strokes than a placebo, as well as more blood clots and breast cancer.
Two years later, the WHI’s trial of estrogen alone (Premarin), also ended early, after it became apparent that estrogen increased the rate of strokes and blood clots without conferring any benefits on the heart.
Although there were some benefits — fewer fractures in both trials and a reduced risk for colon cancer in the combined-hormone trial — they didn’t outweigh the risks. That left hormone therapy back where it started, as a short-term treatment for menopausal symptoms.
Impact and critique of the WHI
Hormone therapy is still the most effective treatment for hot flashes and night sweats. But the WHI results — and the associated media firestorm — left women worried and confused about even such short-term use. They were told to use hormones only for short periods and at low doses, and hormone therapy prescriptions plummeted. (One study reported a 75% drop between 2002 and 2006.) Yet menopausal women looking for symptom relief shouldn’t misinterpret the WHI findings. These studies were not about short-term management of menopausal symptoms. Moreover, the results aren’t above criticism. New questions have arisen as scientists try to reconcile the findings of earlier observational studies with those of the WHI — a randomized, placebo-controlled trial, considered the “gold standard” type of clinical investigation.
Some critics argue that the WHI results may not apply to the typical woman considering hormone therapy because most of the 27,347 participants were in their 60s and 70s — well past the perimenopausal transition and early menopause (the usual time for starting hormone therapy). Others say that the risks were overstated. Each year, for example, the women taking Prempro had only six more heart attacks per 10,000 than the women taking a placebo; among younger women, the difference was even less.
Because of these and other concerns, scientists have been re-examining the WHI data and undertaking new trials. Researchers are also reappraising earlier studies that suggested hormone therapy could prevent cardiovascular disease.
Some scientists now suggest that the cardiac risk and benefit of hormone therapy may depend on a woman’s age, particularly the age at which she starts taking hormones. This new hypothesis doesn’t change current recommendations (see chart), but it may reassure perimenopausal and newly menopausal women who are considering short-term hormone treatment for symptom relief.
Recommendations regarding hormone therapy (HT)* use |
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U.S. Preventive Services Task Force (USPSTF)** |
Recommends against the routine use of HT to prevent chronic conditions in postmenopausal women. |
North American Menopause Society |
Moderate to severe vasomotor symptoms (hot flashes and night sweats) are the main use for systemic HT. |
Food and Drug Administration |
HT should be used at the lowest dose and for the shortest time needed to reach treatment goals, although it’s not known how low you should go to reduce the risk of serious side effects. When hormone therapy is prescribed only for vaginal symptoms, consider topical vaginal products. |
American College of Obstetricians and Gynecologists |
Estrogens are the most effective treatment for menopausal vasomotor symptoms (hot flashes and night sweats). Their use (with or without a progestin) should be reassessed yearly. The lowest effective dose should be used for the shortest possible time to alleviate symptoms. |
American Society for Reproductive Medicine |
Low-dose estrogen is a valid option for many seeking short-term relief from menopausal symptoms. HT does not provide additional health benefits that would justify its use beyond the immediate relief of menopausal symptoms. HT is not indicated for the primary or secondary prevention of coronary artery disease events. |
Canadian Task Force on Preventive Health Care |
HT should not be used for the primary prevention of chronic diseases in postmenopausal women. To maintain heart health, women should use other preventive strategies, such as increased exercise, smoking cessation, and blood pressure control. There’s not enough evidence to make a recommendation on HT regarding stroke and death from stroke. |
*HT refers to estrogen alone, or estrogen plus a progestin. |
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Heart risk: Is it a matter of timing?
The idea that hormone therapy might help protect women from atherosclerosis was biologically plausible. It’s long been recognized that women develop atherosclerosis-related heart problems at an older age than men — that is, after menopause and the decline in estrogen. And in animal studies, estrogen has been shown to slow the development of atherosclerosis.
Nurses’ Health Study researchers found some support for this hypothesis in 2006 in a study undertaken to shed light on the discrepancies between the WHI results and earlier research. They found a 30% reduction in risk for heart disease among women who began hormone therapy within about four years of menopause, but little or no cardiac benefit for women who started hormones either after age 60 or 10 or more years after menopause.
So why might estrogen then increase the risk of heart disease in women who start taking it at an older age? Evidence indicates that estrogen can destabilize atherosclerotic plaques, the artery-clogging accumulations of cholesterol and debris that are a major source of heart disease. Estrogen appears to make plaques more vulnerable to rupture, which can result in a heart attack. Older women are more likely to have developed plaques. So for them, estrogen might do more harm than good. It may be that hormone therapy is good for the heart only during a fairly narrow window, when plaques are starting to form but are not fully developed.
A reanalysis of the WHI data turned up similar evidence that timing may be a factor. Investigators reporting in the Journal of the American Medical Association (April 4, 2007) found no increased risk for heart disease among hormone users ages 50 to 59 and a suggestion of reduced risk among women who started hormone therapy within 10 years after menopause. Thereafter, the greater the gap between onset of menopause and start of hormone therapy, the greater the risk for heart disease, especially in those with a history of hot flashes and night sweats. Stroke remained a problem, regardless of time since menopause, for women receiving either estrogen alone or combined therapy. The risk for breast cancer rose after five years in women taking combined hormones, although not in those taking estrogen alone.
In an ancillary study, WHI investigators assessed coronary artery calcium, which is a marker for atherosclerosis, in 1,064 women ages 50 to 59 who’d had a hysterectomy before entering the WHI estrogen-only trial. The women took their study medications for an average of 7.4 years and then, a year after the trial ended, they underwent CT scans of the heart. Results, published in the June 21, 2007, issue of The New England Journal of Medicine, showed that the estrogen-takers had less calcified plaque in their arteries than the placebo takers, suggesting a reduced risk for future cardiovascular events. But it’s not known how long this benefit would have lasted — or whether it would have actually led to fewer heart attacks or strokes — if the women had continued taking estrogen. According to WHI investigator (and the study’s lead author) Dr. JoAnn Manson, these findings lend support to the idea that estrogen, when it’s started near menopause, may slow the early stages of plaque buildup. “But estrogen’s effects are complex, and it has other known risks,” Dr. Manson points out, so it “shouldn’t be used for the express purpose of preventing cardiovascular disease.” Also, this study did not include older women, so there’s no indication of whether age makes a difference in the way estrogen affects plaque buildup. Only a randomized trial can test the “timing” hypothesis, and until then it remains unproven.
What about breast cancer?
Initial results from the WHI’s estrogen-only trial indicated that estrogen alone reduced the risk for breast cancer by 23% over about seven years. The effect was not statistically significant (meaning that it could have been due to chance), but it was still surprising in light of the increased risk found in the combined-hormone trial after four years. So investigators decided to take a closer look. In a final report — published in the April 12, 2006, issue of the Journal of the American Medical Association — they concluded that the women taking estrogen alone were at no greater risk for breast cancer than those taking a placebo.
In the meantime, several groups of researchers reported in 2007 that the rate of new breast cancers began to decline in 2003, the year hormone therapy prescriptions fell off sharply.
Selected resourcesHot Flashes, Hormones, and Your Health, by JoAnn E. Manson, M.D., and Shari S. Bassuk, Sc.D., McGraw Hill, 2007. |
What it means
When it comes to prevention, hormone therapy reduces the chances of fractures and colon cancer. Whether its adverse effect on the heart is related to timing still needs more study. But you can reduce these risks in other ways without increasing your odds for breast cancer, blood clots, and stroke. Avoid tobacco; exercise at least 30 minutes a day; adopt a healthy eating plan; and control your blood pressure, cholesterol, and blood sugar — with medications, if necessary. Be sure to get adequate calcium (1,200 milligrams per day) and vitamin D (800 to 1,000 IU per day). And if you’re at high risk for osteoporosis, there are many medications to choose from that curb bone loss.
Topical drug treatments for age spots
A bit of sun may give skin a youthful glow but, over time, too much can leave it looking old.
The upper layer of the skin (the epidermis) protects itself from the sun’s ultraviolet rays by thickening and producing more melanin, the pigment responsible for tanning. Age spots arise when melanin clumps together after years of sun damage, in much the same way that a callus develops in response to repeated contact and pressure. Solar lentigines (a single one is called a lentigo) are most common on sun-exposed areas of the body, including the backs of the hands and parts of the face, back, arms, legs, feet, and shoulders.
Even without years of sun exposure, some kinds of skin form the small brown spots that we call freckles. Age spots differ in that they do not typically fade when protected from sunlight and they are often larger in size. Several can mass together and form more noticeable mottled patches.
Age spots are harmless, but they can be unattractive and give skin an older appearance. At one time, the only remedy was to cover them up with cosmetics. Now, there are therapies that help reverse the signs of photoaging at the physiological level. One approach is physical removal — by laser surgery, cryosurgery (freezing), microdermabrasion, or chemical peel. Physical removal can be very effective, but it can be expensive and sometimes has harsh side effects, such as pain and reddening of the skin. Many women prefer to start with something gentler — topical medications that help fade age spots over time.
Age spots or something else?
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Sunscreen first
The first line of defense against age spots is a sunscreen with a sun protection factor (SPF) rating of 30 or higher. According to Dr. Mollie MacCormack, a dermatologist at Lahey Clinic in Burlington, Mass., the best sunscreens contain one of the following active ingredients: zinc oxide or titanium dioxide in a concentration of 9% or higher, ecamsule (Mexoryl), or helioplex (a proprietary formulation that includes both avobenzone and oxybenzone). These kinds of sunscreens, she says, “will give you long-lasting protection against UVA and UVB light,” the ranges of ultraviolet radiation wavelengths that damage skin. “Regular use of such broad-spectrum sunscreens will vastly increase the response to any prescription medication for photoaged skin.”
What are age spots?
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Mostly by prescription
The topical drugs used in the treatment of age spots work mainly by interrupting melanin formation. Prescription topicals generally do the best job because they have active ingredients in higher concentrations than over-the-counter products. One downside is that people with sensitive skin may not tolerate them as well.
The most commonly used agents include the following:
Hydroquinone. Many dermatologists consider hydroquinone the best choice for treating age spots. As a prescription drug, it’s available in a 4% cream, which is usually applied twice daily. (Over-the-counter preparations may contain up to 2% hydroquinone.) You can expect to see results in four to six weeks, with the greatest improvement after four to six months. The most common side effect is irritation or reddening of the skin.
Hydroquinone may soon be harder to come by. In August 2006, the FDA proposed a ban on all over-the-counter sales of hydroquinone-based cosmetics because studies turned up evidence that the drug may cause cancer when it is fed to rats and mice. This is very different from how it is used in humans, and so far, there are no studies showing any increased risk to humans when the drug is used topically. As we went to press, the FDA was still responding to challenges from critics who oppose the ban.
Tretinoin. One of the vitamin A–related compounds known as retinoids, topical tretinoin first received FDA approval in 1971 for treating acne. Since then, it has also been approved (at a concentration of 0.05%) for the reduction of wrinkles, roughness, and age spots. Randomized placebo-controlled trials have consistently demonstrated that tretinoin improves photoaged skin. Tissue studies indicate beneficial changes in collagen production and melanin distribution. Applied once a day at bedtime, tretinoin works by accelerating the turnover of skin cells and suppressing melanin-producing cells (melanocytes). It can take several months to lighten age spots. Brand names include Retin-A, Retin-A Micro, Renova, and Avita.
Possible side effects include irritation, redness, scaling, itchiness, burning, and dryness, though these generally subside after a few weeks. The irritation may actually be beneficial, because it helps tretinoin to penetrate the dermis (the layer below the epidermis) and stimulate the production of new blood vessels, collagen, and elastic tissue. A warning: tretinoin makes the skin more sun-sensitive, so if you use it, you must apply a high-SPF, broad-spectrum sunscreen before going outdoors.
Animal experiments have shown that oral tretinoin can harm a fetus. It’s not known whether topical tretinoin has any effects on developing humans, but because of the potential risk, women should not use it during pregnancy or lactation, or if they are trying to conceive. To help avoid side effects, be sure to tell your doctor if you’re taking other skin medications, such as the oral psoriasis drug acitretin (also a retinoid) or oral tretinoin.
For overall improvement in photoaged skin, tretinoin and other retinoid drugs are a better choice than hydroquinone. But if you need to treat specific age spots, hydroquinone or the depigmenting agent mequinol (4-hydroxyanisole) are preferable. In a pair of randomized trials involving 1,175 subjects, a combination of mequinol with tretinoin in a liquid preparation (brand-named Solagé) was found to be superior to either of the active ingredients alone, and to a placebo, for the treatment of age spots on the forearms and face.
Adapalene gel. This prescription drug is approved only for treating acne but sometimes is used off-label to improve photoaged skin. In one controlled trial involving 90 men and women, solar lentigines lightened more in patients using adapalene than in those using a placebo.
Other prescription topicals. Another topical agent, azelaic acid, inhibits tyrosinase, an enzyme involved in melanin production. Although more irritating to the skin than hydroquinone, it may be an alternative for people reluctant to use hydroquinone because of the possible cancer connection. Both drugs are effective in treating a condition known as melasma that often develops during pregnancy — diffuse mottled pigmentation on the cheeks and forehead and around the eyes.
Because age spots are considered a cosmetic problem, health insurance may not cover the cost of topical prescription medications. A 45-gram tube of generic tretinoin sells for $50 to more than $80 and lasts up to three months; a one-month supply of generic hydroquinone (30 grams) costs about $50. A 30-gram tube of Tri-Luma — a popular combination of hydroquinone and tretinoin, plus a steroid to reduce redness — costs more than $100. Although these prescription drugs seem expensive, they may actually cost less than some over-the-counter skin-improvement products.
With summer behind us, it may be a good time to start treating photoaged skin. But remember that after any treatment for age spots, you must unfailingly use sun block. If you don’t, just 10 minutes of sun on a spring day can cause them to become dark again, reversing the months of effort it took to lighten them.
What about applying vitamins and antioxidants to the skin?When vitamins and antioxidants are used in cosmetics, they are often called cosmeceuticals — a word that refers to topically applied ingredients with druglike effects that change the skin’s appearance. The FDA does not recognize the term, but it regulates some of the substances involved and makes recommendations on others. The use of vitamins and antioxidants (such as vitamins A, C, and E) in moisturizers and other cosmetics makes sense theoretically because antioxidants counter harmful molecules called free radicals, which cause oxidative deterioration. Several cosmeceuticals have shown promise in treating symptoms of photoaging, including age spots. |
From the Journals
Herbs and supplements for anxiety: Kava, inositol may help
Anxiety disorders are among the most commonly diagnosed psychiatric illnesses, affecting some 40 million adults each year in the United States, women more often than men. They encompass a wide variety of diagnoses, including generalized anxiety disorder, panic disorder, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and phobias. Anxiety disorders can be treated effectively with psychotherapy and drugs such as benzodiazepine tranquilizers, antidepressants, and beta blockers. But major surveys suggest that many people seek complementary and alternative medicine to relieve their symptoms.
Various studies have found some herbs and dietary supplements helpful for mild to moderate anxiety. But a review of the evidence published in the August 15, 2007, issue of American Family Physician found little or no scientific support for the use of most such treatments. One notable exception was the herbal supplement kava. Here’s a rundown on the evidence for and against the top contenders:
Kava (Piper methysticum). Usually prepared as a tea, kava is made from the dried rhizome (root) of a shrub found throughout the South Pacific, where it is used for social, ceremonial, and medicinal purposes. Kava is reported to have a relaxing effect without impairing mental and physical function. Several randomized controlled trials have shown that kava is slightly superior to a placebo in relieving anxiety. One trial indicated that it was as effective as the anti-anxiety drug buspirone (Buspar).
Kava inhibits an enzyme used by the liver to metabolize several medications, so it’s important to consider possible drug interactions before using this herb. Do not take alcohol, barbiturates, benzodiazepine drugs, or alprazolam (Xanax) while taking kava. You should not take kava if you have liver problems. Kava should not be used for longer than four months because its health effects beyond that haven’t been established. With long-term use, a rash or skin yellowing may develop, but these symptoms usually go away when you stop taking the herb. Rare cases of serious liver disease have led several countries to ban kava, but it remains available in the United States. (The FDA has issued warnings but questions the accuracy of the liver toxicity reports.) As with many herbs, different plant parts can have different types of activity; it may be that some preparations are potentially more harmful to the liver than others. Look for supplements made from the root (rhizome) rather than the leaves or stems.
Inositol. This supplement, a member of the B-vitamin complex, has been found somewhat helpful for the treatment of panic disorder in two controlled trials. One study showed that inositol was superior to a placebo in reducing symptoms. The other found it to be as effective in treating panic disorder as the selective serotonin reuptake inhibitor (SSRI) fluvoxamine. The side effects are mild and similar to those of SSRIs. Results of studies for OCD have been mixed.
St. John’s wort (Hypericum perforatum). No controlled trials have found that St. John’s wort has any beneficial effects on generalized anxiety disorder, PTSD, OCD, or any other anxiety disorder. (The evidence favoring its use in mild-to-moderate depression is better.) In one controlled trial, it was effective in treating somatoform disorder — persistent physical symptoms with no apparent physical cause. Somatoform disorder is not an anxiety disorder but is often accompanied by anxiety. Drug interactions can be a problem with St. John’s wort. It interferes with the activity of many drugs, including carbamazepine (an anti-epileptic drug), cyclosporine (an anti-rejection medication), the anticancer drug irinotecan, birth control pills, simvastatin (a statin), antidepressants, the blood-thinner warfarin, and digoxin (a heart drug).
Valerian (Valeriana officinalis) and passion flower (Passiflora incarnata L.). Valerian and passion flower are considered sedatives and are sometimes combined in the same supplement. Although valerian has long been used to treat anxiety, most studies are small and poorly designed. One small controlled trial found valerian to be no more effective than a placebo in the treatment of generalized anxiety disorder. In a study comparing passion flower with a tranquilizer, both drugs appeared to reduce patients’ anxiety, but there was no placebo group for comparison. The Cochrane Collaboration, an international not-for-profit organization, has concluded that there is insufficient evidence to support the use of either valerian or passion flower in the treatment of anxiety.
5-HTP (5-hydroxytryptophan). This substance is a serotonin precursor — a naturally occurring amino acid from which the body makes the neurotransmitter serotonin. The supplement 5-HTP is made from the seeds of an African plant and used to treat depression, anxiety, and insomnia. A small randomized controlled trial found 5-HTP to be more effective than a placebo in preventing an experimentally induced panic attack. In another trial, it was slightly better than a placebo for the relief of mixed anxiety disorders, but not nearly as effective as the antidepressant and antianxiety drug clomipramine (Anafranil). Serotonin precursors were temporarily removed from the market several years ago after users of a related substance, L-tryptophan, developed a potentially fatal neurologic condition called eosinophilia-myalgia syndrome. Although the problem may have resulted from impurities traceable to one manufacturer, there’s still uncertainly about the safety of these drugs, and clinicians are advised to warn patients against them.
Caution always warranted
To sum up, there is good evidence that kava can help in treating mild to moderate symptoms of anxiety disorders in people who are not using alcohol or taking medications metabolized by the liver. There is some evidence for inositol in treating panic disorder and possibly OCD. Some evidence favors 5-HTP for the treatment of anxiety, but safety is a concern. There’s not enough evidence to recommend St. John’s wort, valerian, and passion flower for anxiety disorders.
Herbal medicines and dietary supplements are not regulated as drugs, so their safety and effectiveness are not established. And there’s no guarantee that you’re getting exactly what appears on a supplement’s label. Herbal supplements in particular can have many active constituents, not all of which have been tested or even identified. If you’re considering an herbal or dietary supplement to treat symptoms of anxiety (or any other condition, for that matter) discuss it with your clinician first. If you decide to go ahead, check for reliable brands through independent sources such as ConsumerLab.com, LLC (www.consumerlab.com). For more information about herbal supplements, visit the Web sites of the National Center for Complementary and Alternative Medicine (nccam.nih.gov/health), the Alternative Medicine Foundation (www.amfoundation.org), and MedlinePlus (www.nlm.nih.gov/medlineplus/druginformation.html).
In Brief
Dietary lutein and zeaxanthin may slow macular degeneration
People whose diets are rich in two substances commonly found in fruits and vegetables have a lower risk of developing advanced age-related macular degeneration (AMD), according to a study published in the September 2007 issue of the Archives of Ophthalmology. Lutein and zeaxanthin are carotenoids, the substances that give fruits and vegetables their deep green, yellow, and orange colors. Both are also found in high concentrations in the macula, the area of the retina that gives us the sharp eyesight we need to read, drive, and recognize faces. AMD occurs when cells in the macula break down. Lutein and zeaxanthin are thought to slow the progression of AMD by helping shield the macula from oxidative damage caused by short wavelengths of light.
Food sources of lutein and zeaxanthin
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Scientists with the Age-Related Eye Disease Study (AREDS) evaluated 4,519 adults, ages 60 to 80, who had some degree of AMD but at least one eye without advanced disease. Study participants were divided into groups by the severity of their symptoms. From the subjects’ responses to questionnaires, the researchers estimated their dietary intake of vitamins A, C, and E, lycopene, and the carotenoids beta carotene, lutein, and zeaxanthin. Subjects who got the most lutein and zeaxanthin had a 35% lower risk for neovascular (“wet”) AMD, an advanced form of the disease, compared with those who consumed the smallest amount of these nutrients.
Wet AMD, which affects about 10% to 15% of people with the disorder, results from an overgrowth of blood vessels in the macula and can lead to sudden vision loss. The more common but less damaging “dry” form is characterized by deposits called drusen. In this study, lutein and zeaxanthin were also associated with reduced risk for large intermediate-stage drusen and geographic atrophy (late-stage dry AMD). None of the other nutrients studied seemed to have an effect on AMD risk.
What is age-related macular degeneration?
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In an earlier study, AREDS researchers reported that a supplement containing 500 mg vitamin C, 400 IU vitamin E, 15 mg beta carotene, 80 mg zinc, and 2 mg copper slowed the progression of AMD by about 25%, compared with a placebo. Lutein and zeaxanthin weren’t included in the supplement because they weren’t commercially available in the 1990s, when the study was designed. Investigators are starting a controlled study, AREDS2, which will assess the impact of high doses of lutein, zeaxanthin, and certain omega-3 fatty acids on AMD progression. (An AREDS study published in the spring of 2007 linked omega-3 fatty acids to a reduced risk for advanced AMD.) Participants will be followed for five years. For more information, visit the AREDS2 Web site at www.areds2.org or call 877-273-3780 (toll free).
By the way, doctor
Do I need to take a cholesterol-lowering drug?
Q. I’m 53 and on the fence about taking a medication to lower my cholesterol. My father had three heart bypass surgeries during his lifetime. My cholesterol is high (256), but my good cholesterol is also high (62). My LDL cholesterol is 161, and my triglycerides are normal. Should I take a medication?
A. I can understand why you’re uncertain about the need to treat your cholesterol. On one hand, your total cholesterol and low-density lipoproteins (LDL), or “bad” cholesterol, are elevated, and you have a significant family history of coronary artery disease. On the other hand, your high-density lipoprotein (HDL) — the “good” cholesterol — is very good.
Ideal levels for a healthy woman are: total cholesterol less than 200 milligrams per deciliter (mg/dL); HDL greater than 50 mg/dL; LDL under 100 mg/dL; and triglycerides less than 150 mg/dL. We should try to meet these target numbers through diet and exercise first. Your clinician’s recommendation about cholesterol-lowering medications will depend on your LDL cholesterol level and other factors that influence your risk for having a heart attack within the next 10 years.
Two tools can help you assess that risk. One of them, the Framingham risk calculator, takes into account age, total cholesterol, HDL cholesterol, smoking, and blood pressure. The other, the Reynolds Risk Score calculator, takes these factors into account, too, as well as a history of heart attack in a parent and level of high-sensitivity C-reactive protein (hs-CRP). Elevated hs-CRP levels are associated with a heightened risk for heart disease. You can calculate your Framingham risk score at http://hp2010.nhlbihin.net/atpiii/calculator.asp and your Reynolds Risk Score at www.reynoldsriskscore.org. According to the Framingham calculator, and assuming you neither smoke nor have untreated high blood pressure, your risk of having a heart attack in 10 years is low — about 1%. Still, anyone with this degree of risk who has an LDL cholesterol of 160 mg/dL or higher should try to get it down to less than 130 mg/dL through diet and exercise. If that doesn’t work, your doctor may want to add a cholesterol-lowering medication.
Even if you decide to take a cholesterol-lowering medication, you’ll still need to make some lifestyle changes to reduce your risk for cardiovascular disease, because that risk increases with age. At age 53, you can probably afford to stay “on the fence,” but that stance may be harder to maintain by the time you’re 65 or 70.
— Celeste Robb-Nicholson, M.D.
Editor in Chief, Harvard Women’s Health Watch
By the way, doctor
Why do I yawn when I exercise?
Q. I’m 40, and for the past few years I’ve been starting to yawn whenever I get an intense aerobic workout. Is this something I should worry about?
A. We usually think of yawning as a sign of sleepiness or boredom, but experts say that isn’t the whole story. True, we tend to yawn toward bedtime as we get sleepy, but we also yawn in the morning when we wake up. Athletes yawn before they compete — not a time associated with boredom or sleepiness. And we yawn in response to seeing someone else yawn, even if we’re not sleepy or bored.
Yawning is a semi-voluntary action — partly a reflex — that’s under the control of several neurotransmitters in a part of the brain called the hypothalamus. All vertebrates yawn, and in humans, yawning starts as early as 12 weeks after conception. We know that yawning distributes surfactant, a biochemical that coats tiny air sacs (alveoli) in the lungs, helping to keep them open. So yawning in fetuses may help prepare them for life outside of the womb.
One novel theory is that yawning cools the brain, helping keep it at the right temperature for optimal function. In a study in 2007 in the journal Evolutionary Psychology, researchers reported that subjects who cooled their brains by breathing through their noses or holding cold packs to their foreheads — proven brain-cooling strategies — were less likely to yawn when shown videos of other people yawning.
There’s no ready explanation for your “aerobic yawn.” Perhaps your alveoli need a boost to stay open. Or maybe your brain needs cooling to stay alert. Or it may simply be a reflex. Whatever the case, there’s probably no reason to worry about it, and you should keep up with your aerobic exercise.
— Celeste Robb-Nicholson, M.D.
Editor in Chief, Harvard Women’s Health Watch
