Women's Health: The Current State lthough a recently released "Commonwealth Fund 1998 Survey of Women's Health" reveals that more women receive preventive care

and take better care of their health, women still experience alarmingly high rates of violence and abuse. Many continue to have difficulty obtaining quality health care. The survey, which matched data against the same survey completed in 1993, shows no change in smoking rates among women and an increased burden on many women who are taking care of disabled rela- tives while balancing work and family responsibilities.

The survey, regarding women's health issues, included 2,850 women and 1,500 men. Among the results:

More women age 50 and older are receiving mammograms More women are aware of osteo- porosis and how to prevent it More women are exercising More women are using hormone replacement therapy-up to one in three from one in four

Despite these advances, upper- income and college-educated women appeared more likely than low-income women to receive regu- lar preventive care services and counseling on decisions regarding HRT (hormone replacement thera- py). Additionally, despite tight labor markets and a thriving economy, the proportion of working-age women without health insurance increased in 1998. The survey also

Severe PMS Retognized by Health E3cperl;s After years of debate in the medical community about the existence of premenstrual dysphoric disor- der (PMDD), or severe PMS, the nation's experts have concluded what thousands of women have known all along-that the medical condition exists, and that specifically evaluated and approved medica- tions are needed to treat the condition.

The debate surrounding the validation of PMDD, based on a review of scientific literature, appears in the June 1999 issue of The Journal of Women's Health.

"Since 1984 when PMDD was defined as a dis- tinct medical entity, that identification has been debat- ed. Consequently, millions of women have gone undi- agnosed and untreated despite their attempts to seek help," said Phyllis Greenberger, MSW, executive director of the Society for Women's Health Research, which publishes the Journal of Women's Health. "We hope that this first-of-its-kind review will encourage doctors to view PMDD as a serious, yet treatable, condition and propel the FDA to approve medications that are both safe and effective."

Contributing authors reviewed the symptom pro- file, epidemiology, psychosocial functioning, lifetime course, and other areas of research on PMDD. They then concluded that sufficient evidence exists to support PMDD as a separate medical condition.

found that nearly one in 10 women (9 percent) and 4 percent of men were informal caregivers for a sick or disabled relative. For an in-depth look at the survey and tabular results, surf to the Commonwealth Fund home page (wwtu.cmwf.org).

These experts proposed that medications for PMDD should treat the spectrum of premenstrual symptoms associated with diminished quality of life. They agreed that strong data exist to support the use of selective serotonin reuptake inhibitors in treating PMDD.

"The literature suggests to us that women should never again be told they 'just have to live with' their symptoms. PMDD is treatable," said Jean Endicott, PhD, the article's lead author, and director of the Premenstrual Evaluation Unit at Columbia Presbyterian Medical Center.

PMDD affects nearly 9 million women in the U.S. The hallmark of PMDD is a constellation of symp- toms that appears the week before, and disappears a few days after, menstruation. The symptoms are severe enough to interfere with functioning at work, at home, and with a woman's relationships with fam- ily and friends. They include: irritability, depressed mood, anxiety, breast tenderness, and bloating.

The article is based on a meeting of physicians from Columbia University, the University of Pennsylvania, Westem Psychiatric Institute, Massachusetts General Hospital, the University of California, the University of Tennessee, Butler Hospital, the National Institute of Mental Health, and others.

AugusSeptember 1999 A W H O N N L i f o l i n o s 18

Vimin D Deficiency May Increase Hip Fracture Risk

nderlying vitamin D deficiency U in postmenopausal women is associated with increased risk of hip fracture, according to investigators at Brigham and Women's Hospital in Boston, Massachusetts. In a group of women with osteoporosis hospitalized for hip fracture, 50 percent were found to have a previ- ously undetected vitamin D defi- ciency. The control group consisted of women who had not suffered a hip fracture but who were hospital- ized for an elective hip replacement. Of these, only a very small percent- age had vitamin D deficiency, although one-fourth of those women also had osteoporosis.

the April 28,1999, issue of the Journal of the American Medical Association (JAMA). The investiga- tors studied women who were admitted to either Brigham and Women's Hospital or the New England Baptist Hospital, both in Boston, between January 1995 and June 1998. A group o€ 98 post- menopausal women who normally reside in their own homes were cho- sen for the study. Women with bone deterioration from other causes

(continued on page 17)

These findings were reported in

"We know that a calcium- rich diet and regular

weig ht-beari ng exercise can help prevent osteo-

porosis. This new research suggests that an

adequate intake of vita- min D, which the body

uses to help absorb calci- um, may help women to reduce their risk of hip fracture, even when

osteoporosis is present."

New research has found that relaxation and music, separately or together, significantly reduce patients' pain following major abdomi- nal surgery. The study, published in the May 1999 issue of Pain, found that these methods in combination with pain medication reduce pain more than pain medication alone.

Led by Marion Good, PhD, RN, of Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio, the study is supported by the National Institute of Nursing Research (NINR), at the National Institutes of Health.

"There are millions of people who undergo surgery and experience postoperative pain each year," said Dr. Patricia A. Grady, director

of the NINR. "Better pain management can reduce hospital stays and speed recovery, ultimately improving patients' quality of life."

Dr. Good and her research team studied three groups of patients undergoing abdominal surgery. In addition to the usual pain medication, one group used a jaw relaxation technique, another group listened to music, and a third group received a combination of relaxation and music. Findings revealed that, after surgery, the three treatment groups had significantly less pain than the control group, which received only pain medication.

tion are needed for relief," said Dr. Good. "These relaxation and music self-care methods provide more complete relief without the undesired side effects of some pain medications."

The findings have important implications for the 23 million people in the U.S., who undergo surgery and experience postoperative pain annu- ally. Pain can hamper recovery by heightening the body's response to the stress of surgery and increasing tissue breakdown, coagulation, and fluid retention. Pain also interferes with appetite, sleep, and can lead to complications that prolong hospitalization.

Dr. Good and her research staff worked with 500 patients ages 18 to 70, who were undergoing gynecological, gastrointestinal, exploratory, or urinary surgery. Before surgery, those in the music, relaxation, or combi- nation groups practiced the techniques. The relaxation technique consist- ed of letting the lower jaw drop slightly, softening the lips, resting the tongue in the bottom of the mouth, and breathing slowly and rhythmically with a three-rhythm pattern of inhale, exhale, and rest. Patients in the music group chose one of five kinds of soothing music-harp, piano, syn- thesizer, orchestral, or slow jazz.

On the first and second days after surgery, all patients received mor- phine or Demerol for pain relief by pressing a button connected to their intravenous patient-controlled analgesia pumps. The groups receiving the additional intervention used earphones to listen to music, and relaxation tapes during walking and rest, while the control group did not. The research team measured the patients' pain before and after 15 minutes of bed rest and four times during walking to see if the sensation and dis- tress of pain changed. Dr. Good found that on the first and second days postsurgery, the three treatment groups had significantly less pain than the control group during both walking and rest.

According to Dr. Good, "Nurses preparing patients for surgery and caring for them afterward should encourage patients to use relaxation and music to enhance the effectiveness of pain medication and hasten recovery." Dr. Good's findings have implications for future research into the effectiveness of self-care methods for other types of pain, including chronic pain, cancer pain, and pain of the critically ill.

"Both medication and self-care methods that involve patient participa-

16 AWNONW L i f o l i n o s Volume 3, Issue 4

(continued from page 16)

were excluded from the study. There were 30 women with hip fractures caused by osteoporosis and 68 hospitalized for elective joint replacement. Of these 68, 17 women also had osteoporosis as determined by the World Health Organization bone density criteria.

All the participants answered questions regarding their lifestyle, reproductive history, calcium in their diet, and physical activity. Bone mineral density of the spine, hip, and total body were measured by dual X-ray absorptiometry (DXA) technique, as was body com- position. Blood chemistry and uri- nary calcium levels were analyzed.

Between the two groups of women with osteoporosis, there were no significant differences in the time since menopause or bone densities in their spine or hips. They did, however, differ in total bone density. The women admitted for a hip fracture had fewer hours of exercise than the control group.

Fifty percent of the women with hip fractures were deficient in vita- min D, 36.7 percent had elevated parathyroid hormone (PTH) levels (a hormone which can stimulate loss of calcium from bone), and 81.8 percent had calcium in their urine, suggesting inappropriate calcium loss. Blood levels of calcium were lower in the women with hip frac- tures than in either elective group.

These researchers propose that vitamin D supplementation at the time of fracture may speed up recovery and reduce risk of fracture in the future. Current dietary refer- ence intake guidelines contain a daily recommendation of 400 IU of vitamin D for people age 51 through 70 and 600 IU for those over age 70.

"We know that a calcium-rich diet and regular weight-bearing exercise can help prevent osteo- porosis. This new research suggests that an adequate intake of vitamin D, which the body uses to help absorb calcium, may help women to reduce their risk of hip fracture, even when osteoporosis is present," observed Dr. Evan C. Hadley, NIA Associate Director for geriatrics

According to recent data compiled by the American I

Association of Colleges of Nursing, virtually all ranks of full-time fac- ulty realized salary gains during the recent academic year. The gains ranged from an increase of 9.7 percent for nondoctorally prepared professors to 2.6 percent for nondoctorally prepared associate pro- fessors. However, doctorally prepared instructors saw essentially no increase, up .5 percent. Here's a look at where salaries averaged for the 1997-1 999 academic years:

1997-!9911 199b1999 Academic Year Academic Year % Salary

Rank and Degree Base Salary Bare Salary Change

PROFESSOR:

Doctoral Nondoctoral

$64,398 $66.132 2.7 57.41 1 62,959 9.7

ASSOC I ATE PR 0 F E S SO R :

Doctoral 57,762 54,701 3.7 Nondoctoral 44,062 45,220 2.6

ASS I STAN T P R 0 F E S S 0 R : Doctoral Nondoctoral

45,591 47,214 3.6 39,691 40,995 3.3

INSTRUCTOR:

Doctoral Nondoctoral

research. "Osteoporosis leads to more than 300,000 hip fractures each year, causing pain, frequent disability, and costly hospitaliza- tions or long-term care. Prevention of such fractures would greatly improve the quality of life for many older women and men, as well as significantly reduce medical costs."

The bones in the body often undergo rebuilding. Some cells, osteoclasts, dissolve older parts of the bones. Then, bone-building cells known as osteoblasts create new bone using calcium and phos- phorus. As people age, if osteo- porosis develops, more bone is dis- solved than is rebuilt, and the bones weaken and become prone to fracture. Also in many older per- sons, levels of vitamin D in the blood are low because they eat less or spend less time in the sun, which stimulates the body's own produc- tion of vitamin D.

Experts do not understand fully the causes of osteoporosis. However, they do know that a lack of estrogen, which accompanies menopause, diets low in calcium, and lack of exercise contribute to

42,033 42,240 .5 36,777 37,961 3.2

the problem. Eighty percent of older Americans who face the possi- bility of pain and debilitation from an osteoporosis-related fracture are women. One out of every two women and one in eight men over the age of 50 will have such a frac- ture sometime in the future. These fractures usually occur in the hip, wrist, and spine.

New Drug May Help Infertility n investigational drug that A helps insulin to function more

efficiently appears to combat infer- tility in women with polycystic ovary syndrome (PCOS), the most common cause of female infertility, according to a research team fund- ed in part by the National Institute of Child Health and Human Development (NICHD). Ingredients in the drug, D-chiro-inositol, are found naturally in fruits and vegeta- bles and appear to have no side effects in the small number of PCOS patients who took part in this preliminary trial.

The study, conducted by researchers at Virginia Commonwealth University (VCU) in Richmond, appears in the

AugusVSeptember 7999 A W H O N N L i f e l i n e s 17

April 29, 1999 issue of The New England ]oumal of Medicine.

“These early results show a lot of promise,” said Dr. Donna Vogel, Associate Chief for Clinical Research in NICHD’s Reproductive Sciences Branch and NICHD pro- gram officer for the study. “Dr. Nestler and his colleagues have shown that a substance naturally produced by the body to assist in insulin action promotes ovulation in the majority of PCOS patients who take it.”

PCOS affects from 5 to 10 per- cent of U.S. women of reproductive age (as many as 5 million in all), explained the study’s principal investigator, John E. Nestler, M.D., chairman of endocrinology at VCU’s Medical College of Virginia. The ovaries of women with PCOS appear to be filled with numerous small cysts. The cyst-like appear- ance results from an accumulation of immature ovarian follicles, the bubble-like structures which, upon maturation, rupture and give rise to the egg cell.

The features of PCOS may include failure to ovulate or men- struate, abnormally high levels of insulin, obesity, high blood pres- sure, hardening of the arteries, and high triglyceride levels. (Triglycerides are fatty substances used for energy storage, and high triglyceride levels may increase the risk for coronary artery disease.) PCOS patients also have high levels of the male hormone testosterone, which may cause them to grow excess facial or body hair.

“PCOS is not just a reproductive disorder; it’s a major health concern for women who are affected,” Dr. Nestler said. “This is a promising new drug because not only does it dramatically improve ovulation, it improves a woman’s overall health.”

ally, health care practitioners have been able to treat only the symptoms of PCOS, and not eliminate its cause. For example, antiandrogens were prescribed to block the action of testosterone and reduce excessive hair growth. Birth control pills were used to regulate the menstrual cycle,

Dr. Nestler added that, tradition-

and when the women sought to have children, they were treated with fer- tility drugs-either alone or in com- bination with in vitto fertilization.

Two years ago, however, Dr. Nestler and his colleagues were suc- cessful in reducing the PCOS symp- toms of a group patients by treating them with the drug metformin, used to treat insulin resistance in patients with adult onset (type II) diabetes. (Insulin resistance is the failure of cells to respond to insulin properly.) Metformin increases the body’s sensi- tivity to insulin and allows the body to use insulin more efficiently. Troglitazone, another insulin-sensitiz- ing agent, has similar effects in PCOS patients. Although both drugs restore ovulation, both have a number of side effects. Metformin, for example, may cause diarrhea, nausea, and loss of appetite; Troglitazone may be toxic to the liver.

PCOS results from a failure to use insulin properly. Presumably, Dr. Nestler said, this failure causes insulin levels to rise. The high insulin levels, cause a variety of other effects, such as high blood pressure, hardening of the arteries, and high triglyceride levels. Insulin also appears to have an effect on

The current findings suggest that

the ovaries, causing them to pro- duce high levels of testosterone and similar compounds, which halt egg maturation and interfere with the menstrual cycle.

In the current study, the researchers followed 44 obese women with PCOS; half received D- chiro-inositol, and half received a placebo. Of the 22 women who received the study drug, 86 percent ovulated, compared with only 27 percent of the women in the placebo group. Women who received D- chiro-inositol also saw improvements in insulin, blood sugar, blood pres- sure, testosterone, and triglyceride levels. No side effects were reported.

Dr. Nestler explained that the body uses D-chiro-inositol to manu- facture the D-chiro-inositol media- tor, which allows the cell to process glucose after insulin binds to the cell’s surface. According to Dr. Nestler, the research offers insight into the possible cause of insulin resistance in women with PCOS, which previously had been unknown. A PCOS patient’s insulin resistance could be due, in part, to a D-chiro-inositol deficiency.

-Compiled and edited by Carolyn Davis Cockey

1 -800-4-CANCER (1-800-422-6237)

hple wdh TNq- did 1 - 800- 332- 8615

18 A W H O N l l L i f e l i n e s Volume 3, Issue 4