2019 women’s health update- new meds to control pain and prevent disease

In this post I review some new drugs that treat conditions exclusive to or common in women.

In a previous post I gave you updates about hormones, the heart, and HPV. Here is the link-

Women’s health update, part 1

In this post I’ll review some new drugs that treat conditions exclusive to or common in women.

I’m illustrating this post with covers of books written by women; I have reviewed all of these books on my blog, so I’ll include those links also. Please note these are affiliate links, so if you do happen to use them for a purchase you will help me fund this blog.

Photo by rawpixel.com on Pexels.com

Relieving the pain of endometriosis

Women with endometriosis suffer infertility, excessive bleeding, painful periods and pelvic pain unrelated to periods. In endometriosis, uterine tissue grows outside the uterus. It can be difficult to diagnose, requiring invasive procedures to discover. Treatment depends on the goal, whether pregnancy, pain relief, or both. Short of surgery, hormonal therapy has been the mainstay of treatment.

A new hormonal drug released last year, elagolix, brand name Orilissa, is the first of its kind specifically developed and approved to treat “moderate to severe” endometriosis pain. It does not help with infertility. AbbVie, the pharmaceutical company which developed the drug, has priced it at $844 per month, or about $10000 per year, retail.( per Reuters report) Patients may pay less depending on insurance.

 

Stop bleeding fibroids

Researchers are studying elagolix and another hormonal drug ulipristal for treating uterine fibroids. Fibroids are growths within the uterine that can cause pain and excessive bleeding. Initial trials show both of these drugs can significantly decrease bleeding and pain. However, neither is currently FDA approved for treating fibroid.

Easing dyspareunia

After menopause many women develop atrophy of the vagina, making it thin, dry, and easily irritated, leading to painful sex, or dyspareunia. A new intravaginal medication, prasterone,brand name Intrarosa, can help relieve the discomfort. Studies show it may also help improve sexual desire and arousal, but it is not labeled for this.

Manufactured by AMAG Pharmaceuticals, it is for “moderate to severe” symptoms. Also known as DHEA, it is a steroid that transforms into estrogen in the vagina ,administered as a once daily vaginal insert at bedtime, applied with an applicator. According to goodrx.com,a 30 day supply costs about $213.

DHEA can be purchased as an over-the-counter, non-regulated product, whose effectiveness and safety are unknown. A one-month supply of 50 mg tablets may cost $5.

Other options for treating vaginal atrophy symptoms are oral or vaginal estrogen and/or vaginal lubricants.

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Prevention of migraine pain and disability

Migraine, although not exclusive to women,occurs much more frequently in them than men. For infrequent headaches,non opiate pain relievers are effective and recommended. But for severe, frequent, or persistent symptoms prevention is recommended to improve quality of life. Several oral meds are effective but two new injectable drugs show promise.

Botox, onabotulinumtoxin A, has been FDA approved for treating chronic migraine, meaning patients with frequent headaches and other migraine symptoms for at least 3 months.

Yes the same drug used to treat wrinkles,Botox, can prevent migraine

Manufactured by Allergan, a vial containing 200 units costs $1452, per goodrx.com. For migraine, the drug is injected in the upper facial muscles by a physician specifically trained in its use.

Another novel therapy uses the immune system to fight migraine. Monoclonal antibodies bind to a calcitonin gene-related peptide receptor which is responsible for transmitting migraine pain. The antibodies are produced in a laboratory but work like antibodies naturally produced by the body. They are being used to treat cancers and some forms of arthritis.

Three of these drugs are available

  • Erenumab-brand
  • Fremanezumab-Ajoovy
  • Galcanezumab-Emgality

 

They are administered as subcutaneous injections (under the skin) monthly. According to a Medscape, average cost is $600 per month.

You may want to review my previous post about non-drug ways to manage migraine.

Simple and effective ways to manage chronic pain

Preventing cervical cancer with the HPV vaccine

I mentioned this in my previous post about women’s health but it fits here also.

Infection with the HPV, human papillomavirus, causes genital warts and changes in the cervix called CIN which can lead to cervical cancer.

According to a review of clinical trials by Cochran, vaccination against this virus effectively prevents infection and thus fewer cases of CIN. Since a significant percentage of CIN progresses to cancer, we can expect fewer women will develop invasive cervical cancer, the 4th most common cancer in women worldwide.

The vaccine, Gardasail 9, originally approved for use in females ages 9 to 26 years,received FDA approval for use up to age 45 years.

Stopping shingles with the zoster vaccine

And speaking of vaccines, a new zoster (shingles) vaccine, Shingrix, prevents the painful rash much more effectively than the original vaccine Zostavax. It ranges in effectiveness from 91% to 97% at preventing shingles, depending on age. The first vaccine was 51% effective.

Zoster is a reactivation of the varicella virus that causes chickenpox. It causes a painful rash known as shingles;the pain may continue after the rash is gone. It can happen at any age, but symptoms tend to be worst in older persons.

exploring the HEART of health through books

Thanks for joining me to review new steps in women’s health and review some fine women authors. I hope you will follow the links to my reviews and read some or all of these books. When you do, I would love to know your reaction. I might use your comments in an update.

I appreciate all of you who follow this blog; there are numerous other blogs to choose from so I am honored you chose to spend some time here. A special welcome to all my new followers from this past month.

To start following Watercress Words , use this form to get an email notification of new posts . Please find and follow me on Facebook, Pinterest and LinkedIn. Thanks so much.

                              Dr. Aletha 

This blog may earn a commission if you use these affiliate links from Barnes & Noble , AvaCare Medical, and Aaptiv.
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Simple and effective ways to manage chronic pain -part 2 of a series

The most important ingredient in managing a chronic or persistent condition is having a therapeutic relationship with your physician and other healthcare professionals- physical therapist , mental health counselor, nutritionist.

In a previous post I talked about non-drug methods to manage pain in the spine-neck and back. You may want to review it now, but reading  this one first is fine. This post will focus on other painful conditions.

While people often discover methods to relieve pain that work for them, I am focusing here on treatments that are supported in the medical literature or recommended by knowledgeable professionals. For this post, I reviewed many articles which summarized current studies.

Finding trustworthy medical information

How do doctors know what works and what doesn’t? Since medical knowledge has changed since we went to medical school , how do we know what is current information?

We read literature pertinent to our fields on a regular basis, attend conferences, and talk to other doctors. But when we need a specific question answered , we do what you do-we Google it.

shelves in a library with adjacent computers
the Centers for Disease Control and Prevention (CDC) Library, located on the organization’s campus, in Atlanta, Georgia. The CDC collections span the field of public health. Print and electronic resources cover such topics as disease prevention, epidemiology, infectious diseases, global health, chronic diseases, environmental health, injury prevention, and occupational safety and health. The main library in Atlanta and selected branch libraries are open to the public. used courtesy CDC/ Emily Weyant; MSLIS; ORISE Fellow

One of the most frequently reviewed is PubMed listing  more than 28 million citations for biomedical literature from MEDLINE, life science journals, and online books. The service is free and anyone can use it. PubMed is a service of  the National Library of Medicine, the largest biomedical library in the world ,located in Bethesda, Maryland,

Another major reference is the Cochrane Library, a collection of databases in medicine and other healthcare specialties ; a fee is charged to use this service.

Basic points about complementary treatments for pain management

We should use medication and surgery when appropriate, but when these can’t be used or are not helpful, we can consider alternative methods, or what I and other doctors prefer to call complementary or integrative treatment.

This post focuses on symptom relief, not necessarily curative treatment.

Herbals and supplements are drugs and can be effective for certain conditions, but this post will discuss non-drug treatments only.

Many cases of pain improve spontaneously with no specific treatment.

Almost everything works sometimes.

There are few if any down side to any of these treatments. Used under supervision they are unlikely to have adverse side effects or result in long term complications.

The most important ingredient in managing a chronic or persistent condition is having a therapeutic relationship with your physician and other healthcare professionals- physical therapist , mental health counselor, nutritionist.

SIMPLE AND EFFECTIVE WAYS TO MANAGE CHRONIC PAIN-WATERCRESSWORDS.COM

Migraine

Migraine is more than just a bad headache; it is a disorder of the brain which causes pain as well as other common symptoms including nausea, vomiting, and sensitivity to light and noise.  Dizziness, numbness, and  loss of vision occur less frequently.

diagram of the human brain.
The major parts of the brain, including the pineal gland, cerebellum, spinal cord, brain stem, pituitary gland, and cerebrum are labeled. I photo courtesy of Source: National Cancer Institute Creator: Alan Hoofring (Illustrator)

Most people with migraine require some type of medication for relief, but non-drug treatments can supplement meds and can be helpful for prevention. Integrative treatments that work according to studies include

  • acupuncture
  • biofeedback
  • CBT-cognitive behavioral therapy
  • exercise
  • meditation
  • relaxation training
  • yoga

Fibromyalgia

I mentioned fibromyalgia in my post about back and neck pain, but  include it here  since it causes pain in other body areas.

Fibromyalgia seems to be a disorder of nerves which makes them super sensitive, leading to diffuse muscle and joint pain that can become disabling. Complementary treatments recommended include

  • Mind-body-guided imagery, hypnosis, biofeedback, mindfulness meditation , relaxation
  • Tai chi
  • Hydrotherapy, balneotherapy

Osteoarthritis of the knees (degenerative arthritis)

It is likely that arthritis in other joints responds to these therapies but there aren’t enough large studies to confirm.

  • Acupuncture,
  • tai chi
  • walking and  strengthening exercises
  • Balneotherapy-bathing in hot water mineral baths

people in a gym exercising
photo courtesy Amanda Mills, CDC.gov, Public Health Image Library

 

 

 

 

Tessa Frank  discusses how she became frustrated when increasing doses of opioids didn’t relieve her chronic pain, and what she’s doing now to manage her pain.

How I’m Managing My Chronic Pain Without Opioids

“While I no longer use opioids, I do use non-opioid prescription medications and a spinal cord stimulator to provide pain relief for my CRPS, complex regional pain syndrome, a chronic, debilitating neuropathic pain condition.

I’m also hyperaware of how stress triggers my increased feelings of pain, so to mitigate stress, I personally have found relief in meditation, relaxation and yoga among other approaches.” (excerpt)

 

 

 

 

If you didn’t read it earlier, here’s a link to the previous post about treating pain, along with a brief excerpt.

Surprising effective ways to relieve back pain

“Pain in the spine results from many medical conditions, ranging from minor to life threatening. Most cases are due to routine or excessive physical activity or a minor injury causing strain of the muscles, tendons, and ligaments, and will go away with no or minimal intervention in less than 12 weeks.”

 

 

The affiliate product links in this post are for illustration and information only, and do not imply endorsement.

I am grateful when you like and share this post on social media.

Please consider helping support this blog by using my affiliates. You’ll find links in the side bars, on the home page, and on the resource page.

In a future post I will talk about  non-drug treatments for other conditions.

always exploring the HEART of health with you.

                       Dr. Aletha  WATERCRESSWORDS.COM-exploring the HEART of health

7 underused medications

Here are 7 medications we should use more often

This week I discuss 7 groups of medications that are underused. ( A previous post discussed 7 that are overused. ) Both of these posts contain a lot of information and several links; you may want to bookmark to review later. (This post also has affiliate links, which when used to make a purchase, help fund this blog. )

I call these drugs underused.  However, I do not mean

  • That you should always take them
  • That you should start using them
  • That your doctor should prescribe them
  • That you should take them even  if your doctor recommends against them
  • That they are good or perfect drugs

We should think more about when, why and how to use these drugs.

By drugs and medications, I consider any substance we put into our bodies to treat or prevent a disease or symptom, whether prescribed or over-the-counter (OTC), synthetic or “natural”. I’m not considering foods nor any substance that is illegal or mostly recreational in this discussion.

I picked classes of drugs that I am familiar with as a family physician, excluding highly specialized medications like cancer chemotherapy, cardiovascular drugs, anti-rheumatics and neurological drugs.

I based my assessment on my experience as well as medical literature and the opinions of other physicians. As always, your best source of information about the right drugs for your conditions is your personal physician.

I easily came up with the list of 7 overused drugs but this list was harder. I tend to be a minimalist in using drugs, both in prescribing them for patients and in using medication myself. But once I started considering the issue, I realized there are helpful meds that can be better utilized.

No smoking sign
Smoking cessation meds are available and effective.

Smoking cessation medications

I suggest  reviewing 7 surprising reasons to be smoke free 

Many people use e-cigarettes as a way to stop smoking cigarettes. But other smoking cessation aids are available and effective. There are several types of nicotine replacement products as well as non-nicotine pills which help with the craving for cigarettes. Patients sometimes complain about the cost of these products but if you are already paying for cigarettes, what’s the difference? And you may qualify to get them free through the smoking hot line www.quit.com.

Allergy medication

Many people suffer from seasonal or year round allergy symptoms-sneezing, itching, runny nose, itchy/watery eyes. Once you get the diagnosis confirmed, effective medications available without a prescription  can manage the symptoms.  The key is using them soon enough and consistently enough. Sometimes finding the right ones is trial and error. I see people give up too quickly.

Asthma control medications

In the last post I talked about the overuse of rescue inhalers. Persistent wheezing and shortness of breath indicate uncontrolled asthma that will not be completely controlled by using a rescue inhaler over and over.  You should check with your doctor as to if and  when it is wise to  start or stop an asthma maintenance medication.

The human respiratory system
Respiratory allergies and asthma involve the breathing tract from the nose all the way down to the lungs. (photo complimentary from Pixabay)

Migraine medication

Most people with “sinus headaches” have migraine, a complex disorder that involves more than a headache. While many sufferers get relief with OTC pain relievers, many do not. Opioid pain medication does not work well for migraine but there are other prescription options, mainly the triptan drugs. I find that many patients with migraine have never tried these, or the various preventive drugs available. It’s worth talking to your doctor about these options.

Psychotropic medications

While milder forms of depression and anxiety can be managed without drugs, the more severe forms often require medication to achieve remission. In cases where one’s personal life and work suffer due to a mental illness such as severe depression, mania, panic disorder, PTSD, and alcoholism,  medication may restore control and function. Unfortunately, many of these people quit medication once they feel better, and ultimately relapse.

Anti-viral medications

In my last post I told you we use too many antibiotics, drugs used for bacterial infections. We mistakenly use them for viral infections like colds and bronchitis even though they don’t help. We don’t have anti-viral drugs for colds, but we do have some for other viruses. You may already be familiar with the use of oseltamivir, Tamiflu, used both for prevention and treatment of influenza (flu). 

Here are 6 things you need to know to get through the flu season

Antiviral meds  are available for these infections- 

  • HIV-human immunodeficiency virus
  • HBV, HCV- hepatitis B and hepatitis C 
  • HSV, HZ – herpes simplex virus and herpes zoster (shingles).

For many of these, treatment needs to be started very soon after onset of symptoms, within a few days, for maximum effectiveness.

Supplements

This class made both lists. While there is little evidence that supplements in general are helpful, medical studies suggest some specific ones may be effective.  

Folic Acid, also known as folate a B vitamin (B9) . The USPSTF recommends folate intake for women who may become pregnant. Medical studies suggest that taking folic acid during pregnancy decreases the risk of neural tube defects such as anencephaly-impaired brain formation and spina bifida- spinal cord malformation. All women with childbearing potential should take 400 to 800 micrograms daily. Learn more at this link 

Fish oil lowers blood triglyceride (fats) levels. Triglycerides contribute to heart attack risk but we don’t know if lowering them with fish oil  decreases the risk. It is available as both OTC and prescription versions.

The herb ginkgo biloba improves mental and behavioral function in people with dementia, including Alzheimer’s patients. Results were similar to those for the prescription Alzheimer drugs.

Probiotics, such as Lactobacillus, Bifidobacterium and Saccharomyces can prevent or limit diarrhea from antibiotics. They should be started within three days of starting  the antibiotics and continued for one week after.

St. John’s  Wort (Hypericum perforatum) shows effectiveness for treating mild to moderate depression.

This information is presented for your information only and should not be considered a recommendation for treatment or prevention of any condition.

Discuss the use of these medications with your personal physician if you think they may be helpful for you. 

Please follow this blog for future discussion of non-drug treatments for several common conditions, including allergies, colds, migraine, insomnia, pain, depression, and anxiety.

How to tell your doctor what’s wrong with you.

It may sound simple, but I find that patients often have difficulty describing how they feel. They may say they hurt, cough, itch or get short of breath, but give few details. Maybe we have become too used to text messaging with its brevity, abbreviations and emoticons. We have forgotten how to use descriptive words.

eliciting the HPI through an interpreter can be challenging
at a clinic in Latin America-eliciting the HPI- history of present illness- through an interpreter can be challenging

When I see a new patient I may ask why they left their previous doctor. One of the most common reasons I hear is, ” My doctor wasn’t listening to me.”

Accurate communication between doctors and patients is vital for effective diagnosis and treatment but can be difficult for many reasons. One is that doctors and patients may approach the medical encounter from different viewpoints and have different goals.

Patients already know what is “wrong” and want to know what can be done to help or fix their problem as quickly as possible. The physician’s focus is on getting an accurate medical history to help narrow down the possible diagnoses so they can proceed to testing and then treatment.

Medical students are taught to take a “history” from a patient, one of the first skills taught in medical school. The history is the most important part of the medical encounter because, as we are taught,

“Listen to the patient and the patient will tell you what is wrong.”

This doesn’t mean the patient should  give the doctor a diagnosis, although that is what often happens.

What we usually say

Physician: “Hello, I’m Dr. Oglesby. Why are you here today?”

Patient:” I have a ________.”

Fill in the blank with any number of diagnoses that patients believe they have- a bladder infection, the flu, bronchitis, a sinus infection, pulled muscle, poison ivy, ankle sprain, etc.

What it does mean is that the history of the patient’s problem– how and when  it started, how it has progressed, what the current status is- gives the doctor the necessary information to develop a “working diagnosis”- in other words, the most likely explanation for the symptoms. Then the doctor can proceed with further evaluation to confirm or refute that diagnosis, and possibly lead to an alternate diagnosis to explore.

This process is called obtaining the HPI- the History of Present Illness. That distinguishes it from the PMH- the Past Medical History. (Medicine loves acronyms.)

We want to hear from patients a description of the symptoms in their own words. Then we ask questions to clarify and expand.

What we should say

Patient comes to me with complaint of headaches. And says-

“Dr. Oglesby, I have terrible headaches all the time. I think I have a brain tumor and want an MRI as soon as possible.” 

But what I need to hear is –

“Dr. Oglesby, I have headaches. The headaches are brought on by stress. Loud noise aggravates the pain. Lying in a dark room improves them. There is a throbbing pain in one of my temples and it shoots to the top and back of my head. The headaches are so severe that I cannot take care of my family. I have a headache once a week, and it lasts for at least 2 hours.”

It may sound simple, but I find that patients often have difficulty describing how they feel. They may say they hurt, cough, itch or get short of breath, but give few details. Maybe we have become too used to text messaging with its brevity, abbreviations and emoticons. We have forgotten how to use descriptive words.

patient encounter in VietNam

There are various mnemonics used to organize the elements of the HPI .(Medicine also loves mnemonics.)This is the one I learned in medical school- PQRST. The letters stand for the the different types of information we try to elicit in the HPI.

P- Precipitants- what happens to make the symptom begin or recur; Provocation– what makes it worse, increase, more frequent, etc: Palliation– what makes it better, less intense, less frequent

Quality- sharp, dull, cramp, piercing, numbing, tight, burning, tingling, throbbing,

Region and Radiation- where on the body does it occur and where does it move to

Severity– how bad is it- mild, severe, disabling, tolerable, unbearable, worst ever; can also rate  1-10,

Timing- when in the past did it start, how often does it occur now; how long do episodes last; length of intervals between occurrences

Now we can apply this to the above example:

“Dr. Oglesby, I have headachesregion

that are brought on by stressprecipitant

Loud noise aggravates the painprovocation

Lying in a dark room improves them-palliation 

There is a throbbing pain in one of my temples and it shoots to the top and back of my head.-quality, region, radiation 

The headaches hurt so much that I cannot take care of my family- severity 

I  have a headache once a week, and it lasts for at least 2 hours.” –timing 

With this description, I would feel confident that the patient has migraine, not a brain tumor. If  the physical examination is normal, she likely will not need an MRI and we can proceed to planning management of her headaches.

How we can work together

We doctors don’t expect our patients to always recite a rehearsed narrative  about “why I came to the doctor today.” But it does help if you come prepared to answer questions as specifically as possible.

You might try thinking about your problem using the PQRST mnemonic. It will help your doctor identify possible causes for your symptoms, and may also help you understand your problem and even suggest ways you can help yourself.

Here is an entertaining story about how some people tell a “country doctor ” what’s wrong.

Cave: The Patient Who Suggests a Diagnosis Before Telling You His Symptoms

“I have finally come to realize that Hedda carries with her more than a lifetime’s worth of grief, which now and then erupts as a sensation she has no words for. ”

sharing the HEART of health

I appreciate all of you who follow this blog; there are numerous other blogs to choose from so I am honored you chose to spend some time here. A special welcome to all my new followers from this past month.

To start following Watercress Words , use this form to get an email notification of new posts . Please find and follow me on Facebook, Pinterest and LinkedIn, links are on the left side bar here and the Home page. Thanks so much.

                              Dr. Aletha