Estrogen Therapy, Now Recommended Again

This is a good column by Gail Collins on the confusing, conflicting medical studies that are reported by the press and how difficult it is to know what to do when it comes to your own health. My own motto might be described as "less is more." I'll excerpt a few passages that I think are particularly apt. In this article she is referring to the recent study released this week that showed in women with hysterectomies, the women who received estrogen alone (without progesterone) showed a decreased rate of breast cancer. I think the jury's out on this one and would need to see more data. Dr. Sidney Wolfe author of "Worst Pills, Best Pills" is quoted in this article. I keep a copy of his excellent book on my shelf as a reference and he recommends that you never take any medication unless it has been out at least 7 years. And that's what I advise my patients also.
(For more information about my practice click here.)

April 6, 2011
Medicine on the Move
By GAIL COLLINS

Sometimes you really do want to tell the medical profession to just make up its mind.

We got word this week that estrogen therapy, which was bad, is good again. Possibly. In some cases.
This was not quite as confusing as the news last year that calcium supplements, which used to be very good, are now possibly bad. Although maybe not...
Back in the day, estrogen was prescribed only for women who were experiencing serious problems with menopause. Then a 1966 book called “Feminine Forever” argued that estrogen therapy was good for almost every middle-aged female on the planet who wanted to avoid morphing into a crone. The idea grew in popularity even after evidence mounted that the author had been paid by an estrogen manufacturer...
Now comes a new study — from the very same Women’s Health Initiative — that appears to show that for some women, estrogen alone may actually reduce the risk of breast cancer and heart attack. As long as you take it when you’re in your 50s...
Americans should know by now that you can’t put a pill in your mouth without risk. Television is full of commercials for wonder drugs that will perk up your spirits, soothe your allergies or lower your cholesterol, improving life altogether except in the cases where they lead to vivid dreams, suicidal thoughts, hair loss, stabbing pains or sudden death.
But it still feels as if we need to be on guard against medical overoptimism. “Doctors are far more knowledgeable about the benefits of drugs than the risks,” said Dr. Wolfe. There isn’t always much talk about the possible downside of drugs on which all the evidence is yet to come in, like many fertility treatments.

Dr. Wolfe believes that most doctors prefer writing prescriptions to having lengthy discussions with their patients about things like long-term behavior modification therapy. My own theory is that they just tend to want to satisfy their patients. Let’s face it, few of us go to the doctor with hopes of getting advice on behavior modification. They’re medical practitioners, and their instinct is to solve your problems with medicine...

Acupuncture inhibits GABA neuron activity in the ventral tegmental area and reduces ethanol self-administration

This is another study looking at alcohol self-administration, in Rats, mind you, but this one looks at the brain physiology behind acupuncture's effects. Their conclusion was "These findings suggest that DOR-mediated opioid modulation of VTA GABA neurons may mediate acupuncture's role in modulating mesolimbic DA release and suppressing the reinforcing effects of ethanol." I did a previous post looking at those tippling rodents here. They use Heart 7 as their therapeutic point, which implies that they think drinking is more related to the heart and spirit than a liver imbalance. It is close to PC 6 which has been repeatedly shown to decrease the stress response, so very thought provoking in terms of clinical utility.

(To read further about acupuncture, HRV, and my practice please click here.)

Acupuncture inhibits GABA neuron activity in the ventral tegmental area and reduces ethanol self-administration.

Yang CH, Yoon SS, Hansen DM, Wilcox JD, Blumell BR, Park JJ, Steffensen SC.

Daegu Haany University, Daegu, South Korea.
Alcohol Clin Exp Res. 2010 Dec;34(12):2137-46. doi: 10.1111/j.1530-0277.2010.01310.x. Epub 2010 Sep 22.
Abstract

BACKGROUND: Withdrawal from chronic ethanol enhances ventral tegmental area (VTA) GABA neuron excitability and reduces mesolimbic dopamine (DA) neurotransmission, which is suppressed by acupuncture at Shenmen (HT7) points (Zhao et al., 2006). The aim of this study was to evaluate the effects of HT7 acupuncture on VTA GABA neuron excitability, ethanol inhibition of VTA GABA neuron firing rate, and ethanol self-administration. A role for opioid receptors (ORs) in ethanol and acupuncture effects is also explored.

METHODS: Using electrophysiological methods in mature rats, we evaluated the effects of HT7 stimulation and opioid antagonists on VTA GABA neuron firing rate. Using behavioral paradigms in rats, we evaluated the effects of HT7 stimulation and opioid antagonists on ethanol self-administration using a modification of the sucrose-fading procedure.

RESULTS: HT7 stimulation produced a biphasic modulation of VTA GABA neuron firing rate characterized by transient enhancement followed by inhibition and subsequent recovery in 5 minutes. HT7 inhibition of VTA GABA neuron firing rate was blocked by systemic administration of the nonselective μ-opioid receptor antagonist naloxone. HT7 stimulation significantly reduced ethanol suppression of VTA GABA neuron firing rate, which was also blocked by naloxone. HT7 acupuncture reduced ethanol self-administration without affecting sucrose consumption. Systemic administration of the δ-opioid receptor (DOR) antagonist naltrindole blocked ethanol suppression of VTA GABA neuron firing rate and significantly reduced ethanol self-administration without affecting sucrose consumption.

CONCLUSIONS: These findings suggest that DOR-mediated opioid modulation of VTA GABA neurons may mediate acupuncture's role in modulating mesolimbic DA release and suppressing the reinforcing effects of ethanol.
Copyright © 2010 by the Research Society on Alcoholism.

Alcohol Clin Exp Res. 2010 Dec;34(12):2137-46. doi: 10.1111/j.1530-0277.2010.01310.x. Epub 2010 Sep 22.

Improvement of menopausal symptoms with acupuncture not reflected in changes to heart rate variability

This undercuts one of my theories that if someone's autonomics, heart rate variability (HRV) are improved with acupuncture then they are more likely to see improvement in their symptoms. In this study, the patients improved in 11 out of 12 of their symptoms from menopause, but their HRV did not change.

(To read further about acupuncture, HRV, and my practice please click here.)

Improvement of menopausal symptoms with acupuncture not reflected in changes to heart rate variability.

Wright CL, Aickin M.

School of Nursing Portland Campus, 3455 SW US Veterans Road, SN-ORD, Portland, OR 97239, USA; cwright80@hotmail.com.
Acupunct Med. 2011 Mar;29(1):32-9.
Abstract

Hypothesis Studies indicate that menopausal symptoms are relieved by acupuncture. Additional studies have suggested that acupuncture may affect heart rate variability (HRV). This paper reports a pilot study that investigated whether menopausal symptoms responded to acupuncture, and if changes in the spectral analysis of HRV, either suppression of low frequency or augmentation of high frequency bands, corresponded with symptom report. Methods/interventions 12 healthy menopausal subjects were enrolled in this feasibility study. At baseline, subjects were experiencing moderately distressing menopausal symptoms, scoring at least 22 of a possible 44 points on the Menopausal Rating Scale. 10 traditional Chinese medicine-based, protocol acupuncture treatments were administered over a 4 week period, three times a week for 2 weeks, followed by twice a week for 2 weeks. Outcome measures Menopausal Rating Scale questionnaire, 11 menopausal symptoms were evaluated on a zero to four severity scale via self-administered daily checklist for 4 weeks. Dynamic measures of HRV (autoregressive model) were captured before, during and after acupuncture at each session. Spectral analysis of the heart rate was used to compute power in the low frequency and high frequency bands, and their ratio. RESULTS: All subjects complied fully with the protocol without any reported adverse events. While all 11 symptoms showed significant improvement, and one HRV measure changed, on average over the study period, there was essentially no support for a relationship between HRV, menopausal symptom report and acupuncture intervention.

Review of Acupuncture for Infertility

From the available acupuncture literature this group concluded that acupuncture can be of benefit for fertility treatments in women with Polycystic Ovary Disease. In addition, it can increase the rate of live births during embryo transfer for invitro fertilization patients if given on the day of transfer. It can also improve sperm count and motility in males with infertility of idiopathic origin. Interestingly, they do attribute some of acupuncture's success to changes in the autonomic nervous system. So more researchers coming around to my way of thinking?

(To read further about acupuncture, HRV, and my practice please click here.)


Acupuncture in clinical and experimental reproductive medicine: a review.
J Endocrinol Invest. 2011 Feb 4. [Epub ahead of print]
Franconi G, Manni L, Aloe L, Mazzilli F, Giambalvo Dal Ben G, Lenzi A, Fabbri A.

Endocrinology Unit, S. Eugenio and CTO Hospitals, Tor Vergata University, Roma, Italy. giovanna.franconi@uniroma2.it.

Abstract

Background: Acupuncture has been used as treatment for infertility for hundreds of years, and recently it has been studied in male and female infertility and in assisted reproductive technologies, although its role in reproductive medicine is still debated. Aim: To review studies on acupuncture in reproductive medicine, in experimental and clinical settings. Methods: Papers were retrieved on PubMed and Google Scholar and were included in the review if at least the abstract was in English. Results: There is evidence of benefit mainly when acupuncture is performed on the day of embryo transfer (ET) in the live birth rate. Benefit is also evident when acupuncture is performed for female infertility due to polycystic ovary syndrome (PCOS). There is some evidence of sperm quality improvement when acupuncture is performed on males affected by idiopathic infertility. Experimental studies suggest that acupuncture effects are mediated by changes in activity of the autonomic nervous system and stimulation of neuropeptides/neurotransmitters which may be involved in the pathogenesis of infertility. Conclusions: Acupuncture seems to have beneficial effects on live birth rate when performed on the day of ET, and to be useful also in PCOS as well as in male idiopathic infertility, with very low incidence of side effects. However, further studies are necessary to confirm the clinical results and to expand our knowledge of the mechanisms involved.

Cost-Effectiveness of Acupuncture Care as an Adjunct to Exercise-Based Physical Therapy for Osteoarthritis of the Knee

In the U.K. and in Canada "quality-adjusted life years" can be part of their study's outcome measurements and cost-effectiveness. Since both countries have a National Health Service, it is in the Health Services interests to keep people well and in the work force as part of their charter. Since we don't have a collective system in the U.S. the main charter of the Health Insurance Companies is to deny care as much as possible, since their first duty is to their stock holders. But we are entitled to wonder why insurance companies are so reluctant to pay for relatively low cost, high safety profile treatments such as acupuncture. My take is that they are somewhat Machiavellian, in that, once they agree to pay for acupuncture it would lead to more acupuncture treatments, and hence more claims. But it is never discussed in terms of comparing one treatment modality to another, or quality of life. There is an ideological bias in favor of allopathic medicine, also, in spite of the higher costs and risks. I discussed that problem here. In this study they found that both non-penetrating acupuncture and penetrating acupuncture were superior to "advice and exercise" as a cost-effective therapeutic modality even though the cost of delivery was higher than for "advice and exercise" alone. I'm quoting the entire abstract in full for those
who would like to see the details of the analysis.

(To read further about acupuncture, HRV, and my practice please click here.)

Cost-Effectiveness of Acupuncture Care as an Adjunct to Exercise-Based Physical Therapy for Osteoarthritis of the Knee.

Whitehurst DG, Bryan S, Hay EM, Thomas E, Young J, Foster NE.

Centre for Clinical Epidemiology and Evaluation (C2E2), Vancouver Coastal Health Research Institute, 7th Floor, 828 West 10th Ave, Vancouver, British Columbia, V5Z 1M9 Canada. Dr Whitehurst also is Honorary Research Fellow, Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire, United Kingdom.
Abstract

Background The delivery of acupuncture alongside mainstream interventions and the cost-effectiveness of "alternative" treatments remain areas of controversy. Objective The aim of this study was to assess the cost-utility of adding acupuncture to a course of advice and exercise delivered by UK National Health Service (NHS) physical therapists to people with osteoarthritis of the knee. Design A cost-utility analysis was performed alongside a randomized controlled trial.

METHODS: /b> A total of 352 adults (aged 50 years or older) were randomly assigned to receive 1 of 3 interventions. The primary analysis focused on participants receiving advice and exercise (AE) or advice and exercise plus true acupuncture (AE+TA). A secondary analysis considered participants receiving advice and exercise plus nonpenetrating acupuncture (AE+NPA). The main outcome measures were quality-adjusted life years (QALYs), measured by the EQ-5D, and UK NHS costs.

RESULTS: were expressed as the incremental cost per QALY gained over 12 months. Sensitivity analyses included a broader cost perspective to incorporate private out-of-pocket costs. Results NHS costs were higher for AE+TA (£314 [British pounds sterling]) than for AE alone (£229), and the difference in mean QALYs favored AE+TA (mean difference=0.022). The base-case cost per QALY gained was £3,889; this value was associated with a 77% probability that AE+TA would be more cost-effective than AE at a threshold of £20,000 per QALY. Cost-utility data for AE+NPA provided cost-effectiveness estimates similar to those for AE+TA. Limitations As with all trial-based economic evaluations, caution should be exercised when generalizing results beyond the study perspectives.

CONCLUSIONS: /b> A package of AE+TA delivered by NHS physical therapists provided a cost-effective use of health care resources despite an associated increase in costs. However, the economic benefits could not be attributed to the penetrating nature of conventional acupuncture; therefore, further research regarding the mechanisms of acupuncture is needed. An analysis of alternative cost perspectives suggested that the results are generalizable to other health care settings.

(Kristen Sparrow, MD Acupuncture, San Francisco)