Michele G. Cyr

WOMEN AND SUBSTANCE ABUSE

Chemically dependent women face special problems. This article reviews the epidemiology, screening, clinical consequences, and treatment of substance-abusing women. Alcohol, opiate, and cocaine abuse are often linked in women, and the individual and overlapping effects of these drugs are described. Gender difference also are highlighted.

Phytoestrogens: potential benefits and implications for breast cancer survivors.

Phytoestrogens are a group of plant-derived substances that are structurally or functionally similar to estradiol. There has been much interest in the potential role of phytoestrogens in cancer prevention and treatment of estrogen-deficient states. This review summarizes the evidence for phytoestrogen risks and benefits relevant to the breast cancer survivor, including prevention of a second primary breast cancer or metastatic disease, reduction in menopausal symptoms, and interactions with tamoxifen. Epidemiological data suggest a breast cancer protective role for phytoestrogens, and there is some supporting clinical data, but they are far from conclusive. In addition, there is some evidence that genistein, the most prevalent isoflavone in soy, can stimulate estrogen receptor-positive (ER+) breast cancer growth and interfere with the antitumor activity of tamoxifen at low levels. Given current knowledge, women who have ER+ tumors should not increase their phytoestrogen intake. Several studies suggest an inhibitory effect on ER- breast cancer cell growth, and it may be reasonable for women with ER- tumors to safely consume soy and possibly other phytoestrogens. However, the optimal amount and source are not clear. More research is needed to clarify the role of phytoestrogens in breast cancer prevention and in treating estrogen-deficient diseases in women who have had breast cancer.

The service/education conflict in residency programs: a model for resolution.

Residency programs consist of a range of activities involving service to patients and education of residents. The observation that a conflict exists between the service and education components of residency is widespread and has been used to explain many of the problems afflicting such programs today. The authors believe that the service/education conflict is a significant barrier to change in residency programs. A model is presented for residency education that reorganizes the service and education components. First, they present a broad overview of the conflict. Then they provide a brief historical perspective and comment on some of the current recommendations for residency programs. Next, they discuss how principles of adult learning relate to residency and propose a new model of residency that adheres more closely to these principles. Finally, the proposed model is presented in some detail and its implications are discussed. Only if the service and education components of residency are carefully delineated can residency programs adapt to the changing and growing needs of postgraduate medical education.

Alcohol use disorders in women. Screening methods and approaches to treatment.

PREVIEW Alcohol use disorders are a significant problem among women in the United States. The epidemiologic factors, physiologic effects, psychosocial and medical consequences, and detection and management of these disorders in women differ from those in men. Primary care physicians are in a unique position to identify, educate, and counsel women with alcohol problems and to refer them for treatment. In this article, Drs Cyr and McGarry discuss the consequences of drinking in women and outline ways in which physicians can guide them to the help they need.

Caring for Vulnerable Populations: Curricula in U.S. Internal Medicine Residencies

ABSTRACT The Accreditation Council for Graduate Medical Education (ACGME) encourages internal medicine training programs to include specific curricula devoted to health care issues of vulnerable populations. Our aim was to determine the prevalence of curricula involving selected vulnerable populations among U.S. Internal Medicine residencies. We conducted a survey of Program Directors of all US Internal Medicine Residencies assessing whether the program had a curriculum for six vulnerable populations (racial and ethnic minorities, non-English speaking patients, lesbians, gay men, victims of domestic violence and patients with substance abuse problems). Most residencies address substance abuse and victims of domestic violence, while there remains a lack of dedicated teaching on other vulnerable populations, including lesbians, gay men, racial and ethnic minorities and non-English speaking patients.

The Gastrointestinal Tract and Pancreas

Alcohol has pervasive effects on the gastrointestinal tract and pancreas, ranging from subtle microscopic changes to devastating clinical sequelae. As the portal of entry into the body, the digestive tract is vulnerable to the effects of alcohol. The effect of alcohol on the pancreas is mediated by less direct mechanisms. The association between alcohol and liver disease is discussed in Chapter 14 and that with gastrointestinal cancer is discussed in Chapter 18.

Women and alcohol

Primary care providers are uniquely positioned to educate women about alcohol use and misuse. Early identification and intervention can significantly limit the adverse consequences of alcohol abuse. Physicians must recognize the risk factors, presentation, and treatment issues relevant to women.

Postmenopausal hormone therapy in the aftermath of the WHI. What patients need to know.

HT is now relegated primarily to the treatment of menopausal symptoms. It should be used for this indication at the lowest effective dose and for the shortest duration possible. Consideration should be given to other strategies to control symptoms when patients are willing to try less effective but potentially safer alternatives to HT. There is little support for the HT to prevent chronic conditions. The risks of combined HT appear to outweigh the benefits. However, the jury is still out regarding the use of estrogen alone. Ongoing research is likely to provide more informaton about the effects of HT on quality of life, cognition, and prevention of Alzheimers disease. These potential benefits could tip the balance in favour or HT use for some patients. Any decision about starting or stopping HT requires a comprehensive discussion between the physician and the patient regarding benefits, risks, and uncertainties. The WHI results underscore the importance fo well-designed randomized controlled trials to inform our treatment discussions. Even the best observational studies have the portential to mislead us.

Principles of Diagnosing and Managing Postmenopausal Osteoporosis for the Podiatric Physician

Osteoporosis is an asymptomatic disease until a fracture occurs. The prevalence of osteoporosis will rise with the aging of the population. Recent advances have led to more efficacious treatment options. Targeted screening, educating patients about preventive strategies, and providing appropriate treatment for those at high risk will allow physicians to reduce the enormous morbidity and mortality associated with osteoporosis.

Influence of Estrogen Plus Progestin on Breast Cancer and Mammography in Healthy Postmenopausal Women: The Women’s Health Initiative Randomized Trial

CONTEXT The Womens Health Initiative trial of combined estrogen plus progestin was stopped early when overall health risks, including invasive breast cancer, exceeded benefits. Outstanding issues not previously addressed include characteristics of breast cancers observed among women using hormones and whether diagnosis may be influenced by hormone effects on mammography. OBJECTIVE To determine the relationship among estrogen plus progestin use, breast cancer characteristics, and mammography recommendations. DESIGN, SETTING, AND PARTICIPANTS Following a comprehensive breast cancer risk assessment, 16 608 postmenopausal women aged 50 to 79 years with an intact uterus were randomly assigned to receive combined conjugated equine estrogens (0.625 mg/d) plus medroxyprogesterone acetate (2.5 mg/d) or placebo from 1993 to 1998 at 40 clinical centers. Screening mammography and clinical breast examinations were performed at baseline and yearly thereafter. MAIN OUTCOME MEASURES Breast cancer number and characteristics, and frequency of abnormal mammograms by estrogen plus progestin exposure. RESULTS In intent-to-treat analyses, estrogen plus progestin increased total (245 vs 185 cases; hazard ratio [HR], 1.24; weighted P<.001) and invasive (199 vs 150 cases; HR, 1.24; weighted P =.003) breast cancers compared with placebo. The invasive breast cancers diagnosed in the estrogen plus progestin group were similar in histology and grade but were larger (mean [SD], 1.7 cm [1.1] vs 1.5 cm [0.9], respectively; P =.04) and were at more advanced stage (regional/metastatic 25.4% vs 16.0%, respectively; P =.04) compared with those diagnosed in the placebo group. After 1 year, the percentage of women with abnormal mammograms was substantially greater in the estrogen plus progestin group (716 [9.4%] of 7656) compared with placebo group (398 [5.4%] of 7310; P<.001), a pattern which continued for the study duration. CONCLUSIONS Relatively short-term combined estrogen plus progestin use increases incident breast cancers, which are diagnosed at a more advanced stage compared with placebo use, and also substantially increases the percentage of women with abnormal mammograms. These results suggest estrogen plus progestin may stimulate breast cancer growth and hinder breast cancer diagnosis.