A new study on hormone replacement published in the Annals of Internal Medicine and reported in The Washington Post, entitled “Study Issues Hormone-Therapy Warning” (5/29/2012) has sounded –again—the perennial alarm on hormone replacement therapy. The controversial U.S. Preventative Task Force determined that hormone replacement in postmenopausal women showed an increased risk of heart disease, stroke, blood clots, and breast cancer in women taking Premarin and Provera.
There is a limited benefit in decreased bone fracture risk in women taking Premarin (made from pregnant mare’s urine) and Provera (a progestin, a progesterone analogue which has been modified to fit on a progesterone receptor). The estrogen-only part of the study showed a decrease in breast cancer risk. This study based its findings on revised analyses of the Women’s Health Initiative (WHI)—a 15-year study of over 160,000 women.
On the same day, in The Washington Post’s Health section, there was an article citing the July 2011 issue of Climacteric, the journal of the International Menopause Society. In more than a dozen articles focusing on hormone replacement therapy‘s relationship to breast cancer, cardiovascular disease, dementia, and other conditions, the authors conclude that for younger women using hormone therapy close to the time of menopause, benefits generally outweigh the risks.
A summary of the journals’ findings is as follows:
* Women whose breast cancer risk is low and who suffer from menopausal symptoms like hot flashes, sleep disturbance, and vaginal dryness can benefit from hormone replacement
* Hormone therapy reduces the risk of colorectal cancer and bone fractures
* Hormone therapy can increase the risk of dementia in older women and there is also a small increased risk of stroke
* Oral estrogen (as opposed to transdermal gel and patches) increases the risk of blood clots
How can we interpret all this information?
It’s important to understand the limitations of the WHI’s study. Examining the effects of synthetic estrogen such as Premarin and synthetic progestin such as Provera doesn’t tell the whole story. For example, these hormones have many metabolites. As these are processed through the liver, they produce an increase in inflammatory markers contributing to the risk of blood clots. The WHI “estrogen only” arm of the study interestingly showed a decreased risk of breast cancer, meaning the progestin they were using was the problem. Also, the age range in the WHI study was 50-79, yet when stratified to ages 50-59, risks of everything dropped dramatically.
Are there risks of hormone therapy?
Hormone therapy continues to be an option for many women who wish to reduce the side effects of menopause –including hot flashes, night sweats, and vaginal dryness. But, the answer is yes, there are risks, especially if one has a strong family history of breast cancer, genetic susceptibility to blood clots such as Factor 5 Leiden, and if one has insulin resistance or heart disease.
Are there safer choices?
There are safer choices, such as using more natural hormones (“bio-identical hormones”) like estradiol, estriol transdermal (through the skin), and micronized progesterone. Diets high in indole 3C, contained in cruciferous vegetables (broccoli, cauliflower, Brussel sprouts), supplements like green tea extract, folic acid, fish oil, and flaxseed all decrease risk of breast cancer and heart disease. Daily exercise, good sleep, and healthy digestion also play an important role in breast cancer and heart disease risk reduction.
Suffer from sprains, strains or arthritis pain? Here’s why you should consider prolotherapy.
What is Prolotherapy?
Prolotherapy, which is short for “proliferative therapy,” is a sophisticated, but minimally invasive, method of Regenerative Injection Therapy where natural solutions, such as high concentration dextrose, are delivered to areas of injury to restart and maximize the body’s own injury-healing processes. This healing technique is most often applied to painful and injured joints, ligaments, and tendons to encourage the restoration of normal, healthy tissue. Prolotherapy can help people to postpone and even eliminate the need for surgery in some cases such as rotator cuff surgery or joint replacements, including hip and knee replacement.
How does it work?
Prolotherapy stimulates your body’s own internal healing response in any joint, ligament, or tendon. The healing response itself is triggered when the prolotherapy solution – a plant-based sugar that is not a synthetic chemical foreign to the body – causes the injured tissue to release specific growth factors that attract tissue-healing cells to the injury site.
Health Benefits
Prolotherapy has been in use since the 1930’s, and has proven to be a safe and time-tested treatment for virtually every joint area of the body from head to toe. The amount of clinical research on prolotherapy has increased substantially over the last several years, and dozens of studies have demonstrated its effectiveness in treating a myriad of painful problems. Prolotherapy can be successful in healing the following conditions:
• TMJ (jaw) pain
• neck pain and whiplash injuries
• rotator cuff injuries
• shoulder instability and labral tears
• tennis elbow (lateral epidondylosis)
• golfer’s elbow (medial epicondylosis)
• wrist sprains and tendinitis
• hand and finger arthritis
• mid-back and rib pain
• low back pain
• sacroiliac dysfunction (which often causes sciatica and pain radiating down the leg)
• groin strains
• hip arthritis and bursitis
• hamstring injuries
• arthritis of the knee
• knee tendon, ligament and meniscus injuries
• ankle sprains
• Achilles tendon injuries
• plantar fasciitis
• toe sprains and arthritis
Following prolotherapy, many patients are able to return to their everyday activities with less pain, more mobility, and greater endurance.
Recuperation from a prolotherapy session is generally quick. In most cases, the patient is advised to take it easy for about two to three days following treatment before returning to normal activity levels.
Choosing your prolotherapy provider
The Kaplan Center is truly an integrative medical clinic in that we can provide a service like prolotherapy in the context of getting the person back to peak overall health. Many other practitioners of prolotherapy are focused on treating only the musculoskeletal structure, without addressing other important issues such as diet, sleep, hormone balance, and mental/emotional well-being. We want the whole person to be optimally healthy, so we offer additional therapies such as acupuncture, herbal remedies, in-house physical and massage therapy, and nutritional and/or psychological counseling. Prolotherapy can also be offered in a tailored combination with other therapies such as osteopathic manual treatment.
The beauty of prolotherapy is that it heals injury, and potentially provides a long-term benefit as compared to other treatments which only cover up the pain temporarily.
You’re not imagining it. The majority of individuals who suffer from chronic pain also suffer from depression, and the majority of people who suffer from depression also suffer from chronic pain.
At first glance, these statements may seem like a double-dose of bad news for any patient suffering from fibromyalgia, painful autoimmune disorders, or any other serious, chronic pain condition.
But there is some good news to be found here. Recent medical studies of patients dually diagnosed with chronic pain and depression are revealing that these patients have a unique disease process. And this discovery is pointing toward some promising new diagnosis and treatment options.
The idea that patients with chronic pain in many cases also suffer from depression is hardly shocking, but you may be surprised by the numbers:
Of the 47 million people who suffer from chronic pain each year, over half also meet the diagnosis criteria for a Major Depressive Disorder, and
Fully two-thirds of the millions of individuals who are diagnosed with depression every year are also suffering from chronic pain.
A UNIQUE DISEASE PROCESS
Medical researchers are arriving at a new understanding of the physiological relationship between chronic pain and depression. A growing body of evidence is revealing that the disease processes occurring in a person who has been diagnosed with both chronic illness and depression are quite distinct from the processes occurring in someone who is suffering from only one of these conditions. I expect that this new understanding will lead not only to changes in treating individuals who are dually diagnosed but also to improved protocols for diagnosing and treating patients who currently are diagnosed with only chronic pain or depression.
CSS
The new term “Central Nervous System Sensitization Syndrome (CSS)” describes the unique process governing the interplay of chronic pain and depression within an individual. CSS is an inflammatory condition that damages the structure and undermines the functioning of the nervous system. It is both “neurodysregulatory” and “neurodegenerative.” Neurodysregulation refers to the extent to which CSS interferes with the healthy functioning of the body’s nervous system, undermining neural activity in the brain, spinal cord and other neural pathways throughout the body. Furthermore, when a person’s nervous system is operating sub-optimally, their hormonal and immune systems are likely to falter, which in turn, can lead to even more complicated health problems. Neurodegeneration refers to the actual injury and destruction of neural tissue in the brain and body. Both conditions (neurodysregulation and neurodegeneration) can cause or exacerbate physical pain, emotional suffering, and erode mental clarity. The mediating factor in this process is the production and release of inflammatory substances in the brain.
FACTORS THAT CONTRIBUTE TO CSS
CSS is a complex syndrome; many factors can contribute to its development, and it can manifest in a variety of ways. Underlying conditions that can increase an individual’s susceptibility for developing CSS include Lyme disease, hormonal dysfunction, periodontal disease, post-traumatic stress disorder (PTSD), mold-toxicity disorders, chronic viral infections, celiac disease, heavy metal burden and sleep disorders such as sleep apnea.
AN INFLAMMATORY CASCADE
To protect us, these underlying problems activate an inflammatory cascade within the body and brain. Here’s an example of how it works: A patient with celiac disease remains untreated for years. Consequently, inflammation develops, which disrupts the healthy functioning of her gastrointestinal system. This, in turn, compromises her ability to digest and absorb essential nutrients, eliminate waste and toxic substances, and keep out harmful substances. With her ability to absorb essential nutrients undermined, she develops nutritional deficiencies in magnesium, essential fatty acids, essential amino acids, and calcium. These deficiencies weaken her immune system and lead to more pain and depressive symptoms. In response to her gastrointestinal system’s inability to prevent the entry of harmful substances, the body responds with even more inflammation. It does this to create a hostile environment for the invading toxins, but the reaction also works to intensify the patient’s pain and depression.
CSS helps to explain why the symptoms of so many chronic conditions overlap and why obtaining an accurate diagnosis and effective treatment plan can be so challenging. In my practice, I often see patients who have been “correctly” diagnosed with one condition (accurately in the sense that the patient met the diagnostic criteria), but the patient’s health remained compromised because an underlying problem had not yet been identified or addressed. For instance, I have seen several patients who have been diagnosed and treated for fibromyalgia, but whose symptoms never improved until their underlying condition of mold toxicity was treated. Similarly, patients are sometimes accurately diagnosed and treated for thyroid disease, but the patients fail to regain their full health and vitality until their celiac disease is addressed.
In these examples, the point is to identify what was setting off the neuro-inflammatory syndrome known as CSS. In sum, conditions such as fibromyalgia, chronic fatigue syndrome, peripheral neuropathies, and PTSD and depression associated with pain, may be better understood not as diseases unto themselves, but as manifestations of Central Nervous System Sensitization Syndrome.
TREATING CHRONIC PAIN
Unfortunately, some of the most common ways of treating chronic pain can, in some cases, make a patient’s situation worse. For example, the long-term use of opioids such as morphine and oxycodone, and benzodiazepines, such as Valium, Klonopin, and Xanax, appear to exacerbate the inflammatory processes throughout the brain. Increased inflammation may promote or exacerbate pain and depression and can make both conditions even more difficult to resolve.
TREATING CSS
To combat the damaging effects of CSS, your treatment plan needs to include neuroregenerative therapies, such as sufficient sleep (7 to 9 hours per day), exercise (15-30 minutes aerobic activity per day), meditation (20 minutes per day), good nutrition (primarily low-carb diet with plenty of vegetables, fruit, low-fat protein, and supplements such as fish oil, Vitamin D and magnesium), and medication, as prescribed by your doctor. Second, all underlying medical problems need to be properly identified by completing a comprehensive medical history with your physician and undergoing laboratory testing as appropriate. Otherwise, the symptoms of CSS may persist even if other symptoms are being addressed. Finally, your treatment plan should include time with your physician to evaluate your progress and to discuss strategies that help you achieve your health goals. This may include treatments for sleep disorders, medication changes, physical therapy, acupuncture, psychotherapy or nutritional counseling.
The intersection of chronic pain and depression is complex, but medical research is beginning to show us a way forward. CSS is a new model of disease that I believe will help better equip us to identify the factors that are causing a patients’ pain and suffering. It also provides us with an incentive to adopt a more integrative treatment approach that will help more of our patients regain optimal health.
Have you or someone you know been battling with co-occurring chronic pain and depression? Has the possibility of CSS been discussed with the treating physician? If you have concerns you would like to discuss, call 703-532-4892 and schedule an appointment with one of our physicians.
Hormone Replacement Therapy (HRT) Warning – Benefits, Risks and Options
/in Hormone Health, Treatments/by Lisa Lilienfield, MDA new study on hormone replacement published in the Annals of Internal Medicine and reported in The Washington Post, entitled “Study Issues Hormone-Therapy Warning” (5/29/2012) has sounded –again—the perennial alarm on hormone replacement therapy. The controversial U.S. Preventative Task Force determined that hormone replacement in postmenopausal women showed an increased risk of heart disease, stroke, blood clots, and breast cancer in women taking Premarin and Provera.
There is a limited benefit in decreased bone fracture risk in women taking Premarin (made from pregnant mare’s urine) and Provera (a progestin, a progesterone analogue which has been modified to fit on a progesterone receptor). The estrogen-only part of the study showed a decrease in breast cancer risk. This study based its findings on revised analyses of the Women’s Health Initiative (WHI)—a 15-year study of over 160,000 women.
On the same day, in The Washington Post’s Health section, there was an article citing the July 2011 issue of Climacteric, the journal of the International Menopause Society. In more than a dozen articles focusing on hormone replacement therapy‘s relationship to breast cancer, cardiovascular disease, dementia, and other conditions, the authors conclude that for younger women using hormone therapy close to the time of menopause, benefits generally outweigh the risks.
A summary of the journals’ findings is as follows:
* Women whose breast cancer risk is low and who suffer from menopausal symptoms like hot flashes, sleep disturbance, and vaginal dryness can benefit from hormone replacement
* Hormone therapy reduces the risk of colorectal cancer and bone fractures
* Hormone therapy can increase the risk of dementia in older women and there is also a small increased risk of stroke
* Oral estrogen (as opposed to transdermal gel and patches) increases the risk of blood clots
How can we interpret all this information?
It’s important to understand the limitations of the WHI’s study. Examining the effects of synthetic estrogen such as Premarin and synthetic progestin such as Provera doesn’t tell the whole story. For example, these hormones have many metabolites. As these are processed through the liver, they produce an increase in inflammatory markers contributing to the risk of blood clots. The WHI “estrogen only” arm of the study interestingly showed a decreased risk of breast cancer, meaning the progestin they were using was the problem. Also, the age range in the WHI study was 50-79, yet when stratified to ages 50-59, risks of everything dropped dramatically.
Are there risks of hormone therapy?
Hormone therapy continues to be an option for many women who wish to reduce the side effects of menopause –including hot flashes, night sweats, and vaginal dryness. But, the answer is yes, there are risks, especially if one has a strong family history of breast cancer, genetic susceptibility to blood clots such as Factor 5 Leiden, and if one has insulin resistance or heart disease.
Are there safer choices?
There are safer choices, such as using more natural hormones (“bio-identical hormones”) like estradiol, estriol transdermal (through the skin), and micronized progesterone. Diets high in indole 3C, contained in cruciferous vegetables (broccoli, cauliflower, Brussel sprouts), supplements like green tea extract, folic acid, fish oil, and flaxseed all decrease risk of breast cancer and heart disease. Daily exercise, good sleep, and healthy digestion also play an important role in breast cancer and heart disease risk reduction.
Non-Surgical Joint and Arthritis Pain Options: Harness Your Body’s Natural Healing Power
/in Treatments/by Kaplan CenterSuffer from sprains, strains or arthritis pain? Here’s why you should consider prolotherapy.
What is Prolotherapy?
Prolotherapy, which is short for “proliferative therapy,” is a sophisticated, but minimally invasive, method of Regenerative Injection Therapy where natural solutions, such as high concentration dextrose, are delivered to areas of injury to restart and maximize the body’s own injury-healing processes. This healing technique is most often applied to painful and injured joints, ligaments, and tendons to encourage the restoration of normal, healthy tissue. Prolotherapy can help people to postpone and even eliminate the need for surgery in some cases such as rotator cuff surgery or joint replacements, including hip and knee replacement.
How does it work?
Prolotherapy stimulates your body’s own internal healing response in any joint, ligament, or tendon. The healing response itself is triggered when the prolotherapy solution – a plant-based sugar that is not a synthetic chemical foreign to the body – causes the injured tissue to release specific growth factors that attract tissue-healing cells to the injury site.
Health Benefits
Prolotherapy has been in use since the 1930’s, and has proven to be a safe and time-tested treatment for virtually every joint area of the body from head to toe. The amount of clinical research on prolotherapy has increased substantially over the last several years, and dozens of studies have demonstrated its effectiveness in treating a myriad of painful problems. Prolotherapy can be successful in healing the following conditions:
• TMJ (jaw) pain
• neck pain and whiplash injuries
• rotator cuff injuries
• shoulder instability and labral tears
• tennis elbow (lateral epidondylosis)
• golfer’s elbow (medial epicondylosis)
• wrist sprains and tendinitis
• hand and finger arthritis
• mid-back and rib pain
• low back pain
• sacroiliac dysfunction (which often causes sciatica and pain radiating down the leg)
• groin strains
• hip arthritis and bursitis
• hamstring injuries
• arthritis of the knee
• knee tendon, ligament and meniscus injuries
• ankle sprains
• Achilles tendon injuries
• plantar fasciitis
• toe sprains and arthritis
Following prolotherapy, many patients are able to return to their everyday activities with less pain, more mobility, and greater endurance.
Recuperation from a prolotherapy session is generally quick. In most cases, the patient is advised to take it easy for about two to three days following treatment before returning to normal activity levels.
Choosing your prolotherapy provider
The Kaplan Center is truly an integrative medical clinic in that we can provide a service like prolotherapy in the context of getting the person back to peak overall health. Many other practitioners of prolotherapy are focused on treating only the musculoskeletal structure, without addressing other important issues such as diet, sleep, hormone balance, and mental/emotional well-being. We want the whole person to be optimally healthy, so we offer additional therapies such as acupuncture, herbal remedies, in-house physical and massage therapy, and nutritional and/or psychological counseling. Prolotherapy can also be offered in a tailored combination with other therapies such as osteopathic manual treatment.
The beauty of prolotherapy is that it heals injury, and potentially provides a long-term benefit as compared to other treatments which only cover up the pain temporarily.
Pain and Depression: A Fire in the Brain
/in Conditions/by Gary Kaplan, DOYou’re not imagining it. The majority of individuals who suffer from chronic pain also suffer from depression, and the majority of people who suffer from depression also suffer from chronic pain.
At first glance, these statements may seem like a double-dose of bad news for any patient suffering from fibromyalgia, painful autoimmune disorders, or any other serious, chronic pain condition.
But there is some good news to be found here. Recent medical studies of patients dually diagnosed with chronic pain and depression are revealing that these patients have a unique disease process. And this discovery is pointing toward some promising new diagnosis and treatment options.
The idea that patients with chronic pain in many cases also suffer from depression is hardly shocking, but you may be surprised by the numbers:
A UNIQUE DISEASE PROCESS
Medical researchers are arriving at a new understanding of the physiological relationship between chronic pain and depression. A growing body of evidence is revealing that the disease processes occurring in a person who has been diagnosed with both chronic illness and depression are quite distinct from the processes occurring in someone who is suffering from only one of these conditions. I expect that this new understanding will lead not only to changes in treating individuals who are dually diagnosed but also to improved protocols for diagnosing and treating patients who currently are diagnosed with only chronic pain or depression.
CSS
The new term “Central Nervous System Sensitization Syndrome (CSS)” describes the unique process governing the interplay of chronic pain and depression within an individual. CSS is an inflammatory condition that damages the structure and undermines the functioning of the nervous system. It is both “neurodysregulatory” and “neurodegenerative.” Neurodysregulation refers to the extent to which CSS interferes with the healthy functioning of the body’s nervous system, undermining neural activity in the brain, spinal cord and other neural pathways throughout the body. Furthermore, when a person’s nervous system is operating sub-optimally, their hormonal and immune systems are likely to falter, which in turn, can lead to even more complicated health problems. Neurodegeneration refers to the actual injury and destruction of neural tissue in the brain and body. Both conditions (neurodysregulation and neurodegeneration) can cause or exacerbate physical pain, emotional suffering, and erode mental clarity. The mediating factor in this process is the production and release of inflammatory substances in the brain.
FACTORS THAT CONTRIBUTE TO CSS
CSS is a complex syndrome; many factors can contribute to its development, and it can manifest in a variety of ways. Underlying conditions that can increase an individual’s susceptibility for developing CSS include Lyme disease, hormonal dysfunction, periodontal disease, post-traumatic stress disorder (PTSD), mold-toxicity disorders, chronic viral infections, celiac disease, heavy metal burden and sleep disorders such as sleep apnea.
AN INFLAMMATORY CASCADE
To protect us, these underlying problems activate an inflammatory cascade within the body and brain. Here’s an example of how it works: A patient with celiac disease remains untreated for years. Consequently, inflammation develops, which disrupts the healthy functioning of her gastrointestinal system. This, in turn, compromises her ability to digest and absorb essential nutrients, eliminate waste and toxic substances, and keep out harmful substances. With her ability to absorb essential nutrients undermined, she develops nutritional deficiencies in magnesium, essential fatty acids, essential amino acids, and calcium. These deficiencies weaken her immune system and lead to more pain and depressive symptoms. In response to her gastrointestinal system’s inability to prevent the entry of harmful substances, the body responds with even more inflammation. It does this to create a hostile environment for the invading toxins, but the reaction also works to intensify the patient’s pain and depression.
CSS helps to explain why the symptoms of so many chronic conditions overlap and why obtaining an accurate diagnosis and effective treatment plan can be so challenging. In my practice, I often see patients who have been “correctly” diagnosed with one condition (accurately in the sense that the patient met the diagnostic criteria), but the patient’s health remained compromised because an underlying problem had not yet been identified or addressed. For instance, I have seen several patients who have been diagnosed and treated for fibromyalgia, but whose symptoms never improved until their underlying condition of mold toxicity was treated. Similarly, patients are sometimes accurately diagnosed and treated for thyroid disease, but the patients fail to regain their full health and vitality until their celiac disease is addressed.
In these examples, the point is to identify what was setting off the neuro-inflammatory syndrome known as CSS. In sum, conditions such as fibromyalgia, chronic fatigue syndrome, peripheral neuropathies, and PTSD and depression associated with pain, may be better understood not as diseases unto themselves, but as manifestations of Central Nervous System Sensitization Syndrome.
TREATING CHRONIC PAIN
Unfortunately, some of the most common ways of treating chronic pain can, in some cases, make a patient’s situation worse. For example, the long-term use of opioids such as morphine and oxycodone, and benzodiazepines, such as Valium, Klonopin, and Xanax, appear to exacerbate the inflammatory processes throughout the brain. Increased inflammation may promote or exacerbate pain and depression and can make both conditions even more difficult to resolve.
TREATING CSS
To combat the damaging effects of CSS, your treatment plan needs to include neuroregenerative therapies, such as sufficient sleep (7 to 9 hours per day), exercise (15-30 minutes aerobic activity per day), meditation (20 minutes per day), good nutrition (primarily low-carb diet with plenty of vegetables, fruit, low-fat protein, and supplements such as fish oil, Vitamin D and magnesium), and medication, as prescribed by your doctor. Second, all underlying medical problems need to be properly identified by completing a comprehensive medical history with your physician and undergoing laboratory testing as appropriate. Otherwise, the symptoms of CSS may persist even if other symptoms are being addressed. Finally, your treatment plan should include time with your physician to evaluate your progress and to discuss strategies that help you achieve your health goals. This may include treatments for sleep disorders, medication changes, physical therapy, acupuncture, psychotherapy or nutritional counseling.
The intersection of chronic pain and depression is complex, but medical research is beginning to show us a way forward. CSS is a new model of disease that I believe will help better equip us to identify the factors that are causing a patients’ pain and suffering. It also provides us with an incentive to adopt a more integrative treatment approach that will help more of our patients regain optimal health.
Have you or someone you know been battling with co-occurring chronic pain and depression? Has the possibility of CSS been discussed with the treating physician? If you have concerns you would like to discuss, call 703-532-4892 and schedule an appointment with one of our physicians.