Hello, SOGC

Hello.  It’s Me.  I am ranting once again about HPV

Well, not about HPV, just the vaccines.  Actually, not just the vaccines: pretty much everything I heard at a day-long SOGC workshop with the long-winded title, “Women and their Reproductive Health Across the Continuum: Setting Priorities for Women’s Reproductive Health Research”.  Attending were both health professionals and interested individuals.  And me: women’s health advocate and HPV vaccine skeptic.

Regarding the latter, I waited till the very end of the day to finally screw up my courage.

“I am about to state a very unfavorable opinion.  There are reputable health professionals who are opposed to mass HPV vaccination; in part, because some of the research has been tainted by conflict of interest; and also because of the way public messaging has stigmatized parents who have decided not to vaccinate their children.”

I added that equating infection prevention and cancer prevention is what has made public health and Big Pharma messaging so compelling to the general public.

There was absolutely no response.

The Sunnybrook Hospital meeting space was set up like a dinner party, with long lines of tables, labelled with discussion topics for the afternoon.  Speakers’ topics were preceded by the title, “State of the Evidence”: Human Papillomavirus, Fertility, Contraception, Menopause and The Environment.  Three out of five talks set my teeth on edge.

First up, Dr. Nancy Durand.

After giving some basics about HPV types and statistics (10 – 30% of adults are infected at any given time – good one) and the risks for persistence (being over age 30, smoking, having multiple sub-types and immunosuppression) she launched into straight into HPV vaccines as public health strategy.

Dr. Durand assumed, correctly, that she had the room in terms of the evidence she presented on the three available HPV vaccines regarding efficacy and safety.  She said that doctors should treat these vaccines like flu shots and encouraged doctors to say, “Have you had your HPV shot yet?”  She suggested it could be administered to babies with their childhood vaccines.  She quoted research that indicated there should be no upper limit in vaccinating; and that even if one had already been infected, vaccination was still effective (first time I’d heard that).  And yet…

Hello from the other side

My electronic files are full of evidence of conflict of interest (COI) between researchers and pharmaceutical companies and the attempts to expose them.

Moreover, the accepted medical evidence also insists that the only adverse side effects are irritation at the site of injection and increased fainting.

Japan has changed direction on HPV vaccination.  France, Spain  and Denmark have also reconsidered their position.

Fertility

Dr. Heather Shapiro did not mention potential environmental causes of infertility.  When I asked her about this, she said that was a whole other talk.  She leapt into Assisted Reproductive Technologies starting at IVF without passing through less invasive techniques like IUI.  I did find out that 90% of IVF babies are healthy; and the rates of success decline with age; and that there are now fewer multiple births.  Her talk was less about fertility and infertility that assisted reproductive technologies.  One presumes the research is directed towards treatment rather than prevention.  No mention of Pelvic Inflammatory Disease.

Contraception

I was glad to hear Dr. Dustin Costescu discuss unintended births in the context of the social determinants of health.  He said they occurred more often in younger, racialized, poor and Indigenous women; and that the greatest risk was due to systemic factors.  Among the contributors to non-use were being a sexual or gender minority, funding, and failure to initiate contraception.  He also blamed health care providers who sometimes recommended a “washout”; i.e., stopping a method to see if side effects subsided without offering a replacement method.

He pointed out changing trends.  With women having their first child around age 30, they require about 11 years of contraceptive use.

I was glad to hear him say that researchers needed to understand women’s experience through qualitative research regarding access, counselling, decision making and understanding side effects.  In our discussion session in the afternoon, he acknowledged that front-line workers have a lot to contribute to research.  Here are some of my contributions in WordPress:

 

Menopause

Any of the women attending who had not already gone through menopause and were listening to Dr. Jennifer Blake were probably bug-eyed looking at the list of what sounded like inevitable symptoms.  Early on in her talk, she said that perimenopause, the 2 – 3 years preceding the cessation of menses, was the “best time to get help”.  Now if that isn’t a clear medicalization of menopause, I don’t know what is.

Dr. Blake was quite definitive.  The “pleats” that make women’s vaginas stretch more easily smooth out.  You’re going to shrink, was the message.  Not to mention the loss of bone mineral density, the release of lead stored in the bones, changes in blood vessels, changes in abdominal fat metabolism, decreased carbohydrate tolerance, loss of lean muscle mass, vasomotor symptoms (hot flashes that could last up to 20 years), mood changes, reduced stress tolerance and memory changes (or as comedian Sandra Shamas tells us, loss of nouns.

And, oh, yes, loss of libido.  I’ve had a few thoughts on that one as well.

Dr. Blake gave a nod to the importance of exercise and good nutrition before moving ahead with hormone therapy (HT), “the single most effective treatment”.  She spent a good deal of time discussing the history of research on the effects of estrogen, in particular, how the Nurses’ Health Study was written and interpreted.  One telling statement at the end of her remarks on HT: “there is a higher risk of breast cancer with later pregnancy than with hormone therapy”.  In other words, you don’t need to worry about using HT.

Not all women experience menopause the same way – and that also applies to women around the world, their diets and lifestyles.  Women who suffer greatly from menopausal symptoms who consider HT are well advised to limit the duration of its use.

Environment

I’ve saved the best for the last. Dr. Eric Crighton laid it all out.  There are currently 80,000 registered chemicals currently in use.  7,000 new industrial chemicals are introduced annually.  Pregnant women have 43 different chemicals in their bodies.

He pointed out that some people are at higher risk than others, most notably those Indigenous people who are living with contaminated water and mercury poisoning.  Of course, we are all exposed to environmental toxins.  According to Health Canada’s 2010 statistics, they caused 13% of disease burden, an increased risk of prenatal and early childhood effects.  He talked about pesticide exposure and its effects on the brain development of four year olds…in short, he scared the *&*^% out of his audience.  I was sadly familiar with some of these issues, in particular through the Canadian Women’s Health Network.

There is good work being done by CPCHE which has published a number of useful brochures, but he pointed out that individual actions are not enough.  Moreover, he said when someone is struggling, for example, to feed their family, environmental toxins are low down on their list.  If you can barely afford formula, the plastic in the bottle becomes a non-issue.

I spoke with him afterwards, thanking him for mentioning the struggle of nail salon workers to limit their exposure to workplace toxins.  He was aware of the work of the Toronto Healthy Nail Salon Network.

Hello from the outside.  At least I can say that I’ve tried

I’m not sorry I went.  I did learn a few things and have checked out a dozen links to the studies quoted.  But there was little opportunity to challenge the experts or change the tone of the discourse.  It does make me wonder why the SOGC invited us in the first place.

Menopause – whose information do you trust? – October 22, 2014

A friend asked me if I was going to talk about menopause during a workshop I am offering on sexuality and aging. She is 68 and still getting hot flashes. News “flash”: I’m 66 and still getting them too. It made me wonder what has been going on in the world of menopause since I first started getting hot flashes in my late 40s.

I was lucky. Apart from driving everyone around me insane with my perimenopausal moodiness, I was not disturbed by night sweats. For many women, night sweats are debilitating, because they affect sleep and therefore the ability to function.

Thank Google; there is lots of useful information out there. The website 34 Menopause Symtoms gives a plausible explanation about later life symptoms and some common sense advice about relief.

Common sense advice is not the approach you are likely to get when you visit your doctor. Big Pharma continues to dominate the discussion, and Big Pharma probably has your doctor’s ear.

Back in the day, I found common sense in every issue of Janine O’Leary Cobb’s newsletter A Friend Indeed and her book Understanding Menopause, reading both from cover to cover. Other books, like Menopause Naturally by Dr. Carolyn Dean, put this natural part of a woman’s life into perspective. But doctors were offering women hormones like they were candy.

The Women’s Health Initiative (WHI), a.k.a. the nurses’ study in the States, made great headway in debunking the dangerous practice of offering HRT to every woman with symptoms (and in many cases those without).

“Consistent with WHI randomized trial findings, estrogen plus progestin use is associated with increased breast cancer incidence. Because prognosis after diagnosis on combined hormone therapy is similar to that of nonusers, increased breast cancer mortality can be expected.” (Estrogen Plus Progestin and Breast Cancer Incidence and Mortality in the Women’s Health Initiative Observational Study, 2013).

The problems with hormone replacement therapy (HRT) are well documented, yet the controversy continues. Women’s health advocates had thought the WHI results represented definitive research that was universally accepted. But in 2013, Anne Rochon Ford, executive director of the Canadian Women’s Health Network and editor of the book The Push to Prescribe, was reported as saying she’d like to see most women abstain from HRT altogether; that the new push to prescribe hormone replacements is being driven in part by the drug manufacturers that make them.

“There is a strong current . . . of concern and skepticism for taking potentially problematic medications for natural life events,” she said.

“Menopause is not a disease. Menopause is a natural life event in every single woman on this planet and the move to medicate it had a tremendous marketing machine behind it going back to the 1940s.”

But hormonal prescriptions were just being refined.

“Menopausal hormone therapy remains the most effective treatment for vasomotor symptoms, which are experienced by more than half of menopausal women and are most likely to be bothersome during late perimenopause and early menopause with mean duration >10 years (NEJM Journal Watch, Women’s Health May 12 2011). This long-term analysis confirms that the risk–benefit ratio of HT is most favorable when initiated in younger menopausal women, and for estrogen-only versus estrogen-progestin therapy. While HT should not be used to prevent cardiovascular disease, use of low-dose HT specifically to prevent osteoporosis is appropriate in selected women at elevated risk for this condition” [my emphasis].

There is a great difference between “bothersome” and debilitating. Moreover, women with an elevated risk for osteoporosis have non-hormonal (and non-pharmaceutical) options. Osteoporosis experts have long recommended weight bearing exercise and adequate intake of calcium and vitamin D to prevent osteoporosis. Other drugs with questionable results are bisphosphonates, which have also been widely prescribed for people with osteoporosis (Read the Therapeutics Initiative Letter 78).

Women were sold a bill of goods in hormone therapy. Hormone replacement therapy (HRT) was portrayed as a panacea, at first touted as relief for menopausal symptoms, and then as prevention for heart disease, osteoporosis, Alzheimer’s – you name it. And, lest we forget, staying young. Feminine Forever was first published nearly 50 years ago. The author, Dr. Robert A. Wilson, warned that a woman’s body “ultimately betrays her. At the very moment when she is most able and eager to enjoy her achievements, her femininity – the very basis of her selfhood – crumbles in ruin.  But now, at last, medicine offers a practical escape from this fateful dilemma.”

Have attitudes towards support for perimenopausal women changed at all? I recently posted a Medscape article on my professional Facebook page about “treating menopause” [sic]. I was hoping that the discussion had evolved. But no. Even though it wasn’t all hormones all the time, treatment of menopausal symptoms still translated into drug prescriptions.

Sadly, even the North American Menopause Society has chimed in regarding support for the prescription of hormone therapy (HT) be it estrogen therapy (ET) or estrogen and progestin therapy (EPT). Their position paper concludes:

Recent data support the initiation of HT around the time of menopause to treat menopause-related symptoms and to prevent osteoporosis in women at high risk of fracture. The more favorable benefit-risk ratio for ET allows more flexibility in extending the duration of use compared with EPT, where the earlier appearance of increased breast cancer risk precludes a recommendation for use beyond 3 to 5 years.”

Drug companies are aware that women have become more wary of hormonal treatments and have developed new drugs to maintain their market share. Since some women’s menopausal symptoms include extreme vaginal dryness and a loss of vaginal elasticity, a drug company in the United States developed Osphena, a drug that does not contain estrogen to treat painful intercourse, vulvar and vaginal atrophy. It acts on estrogen receptors without actually being an estrogen. Osphena is a selective estrogen receptor modulator (SERM), like tamoxifen. It has been approved for use in the US. Like any medication, it is not risk free. American women would be well advised to read the boxed warning about the possible serious adverse effects, including stroke, blood clots, as well as common side effects including hot flashes.

The advice to “use it or lose it” as well as lubricants and rehydration products are a reasonable and safe starting point for dealing with vaginal dryness. This is the first line of advice one would hope to hear from a health-care provider.

I recognize that some women will choose the big hormonal guns for a limited period of time having tried other less risky remedies with no relief. As for me, I’ll throw off the covers when I feel hot at night; I’ll stick my head out the window during the day; I’ll drink my coffee and eat my spicy food because I love them even if they trigger a hot flash. I’ll continue to go to the Y and pretend to work out to maintain bone health. And one way or another I’ll ensure that my vagina continues to function.

But I do wonder what my 70s will hold?