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Dec 8, 2017

OCPs and IUDs

The story

There are no known health consequences to the rush of hormones on fellowship match day, when the light at the end of the residency tunnel sparkles like never before. But what about for hormonal contraceptives? We’ve got the latest.

The background

Generally speaking, estrogen fuels breast cancer the way saving money fuels you to eat at the hospital cafeteria against your better judgment. So it’s been well known since 1996 that oral contraceptives (OCPs) increase the risk of breast cancer by about 20%. But while your mom’s OCPs contained high doses of estrogen, newer formulations use lower doses, progestin-only formulations, or deliver hormones locally through intrauterine devices (IUDs).

The study

Modern hormonal contraceptives still increase breast cancer risk by about 20%, says a nationwide study from Denmark that followed women aged 15 - 49 for over a decade. The prospective study found similarly increased risk for progestin-only contraceptives and the levonorgestrel IUD. Risk increased with length of use, as women who stayed on hormones for 10 or more years had a 38% increased risk of breast cancer compared to nonusers.
NEJM

The analysis

Women in their 40s, already at 5x increased risk of breast cancer compared to women in their 30s, were disproportionately affected. The absolute increase in risk with hormonal contraceptives was 13 breast cancers per 100,000 women overall, but only 2 per 100,000 in women younger than 35. Keep in mind that the study did not evaluate the relationship of OCPs to other malignancies, where they are thought to reduce the risk of ovarian, endometrial, and colorectal cancer.

The takeaway

Digging past the headlines helps reduce alarm around the issue. For women younger than 35, hormonal contraceptives are still very much in play. For patients in their 40s, consider alternative contraception like condoms or non-hormonal IUDs.

Say it on rounds

When you're not quite sure what's in the food served in the ICU

You'll probably be safe. But the millions of men and women who use internet supplements may want to pay closer attention. An analysis of 44 products labeled as selective androgen receptor modulators, a relatively new and popular class of performance-enhancing substances available on the internet, found that only 52% actually contained the advertised drug. About 39% contained another unapproved drug, and 9% had no active compounds. No wonder experts are calling for stronger oversight of online supplement markets. 
JAMA

When you're hoping for a Christmas miracle

Science has your back, even if what you really wanted was holiday coverage. In the latest stunning achievement for gene therapy, a single infusion of the gene for Factor IX, the missing clotting factor in hemophilia B, decreased yearly bleeding events by 97% in 10 men with the disease. The therapy combined a special hyperactive Factor IX gene with a gene promoter that helps localize the treatment to the liver. Two patients experienced elevated liver enzymes that improved with steroids, but there were no serious adverse effects. A brief video offers a visual explanation.
NEJM

When you take a deep breath before a jam-packed clinic schedule

Think of it as therapy. Proton pump inhibitor (PPI) therapy helps with heartburn in severe gastroesophageal reflux disease (GERD) but leaves disease-associated belching unaddressed. A prospective study of 36 patients with GERD refractory to PPI therapy found that a diaphragmatic breathing program reduced belching frequency in 80% of patients vs. 19% in an untreated control group. Patients also reported improvements in quality-of-life and other GERD symptoms.
Clin Gastroenterol Hepatol

Brush up

Aortic dissection

While you're taught to recognize severe chest pain radiating to the back, the diagnosis of aortic dissection may be more subtle. Be wary of sudden tearing chest pain in patients with hypertension, connective tissue disorders, or other chronic inflammatory conditions. Use CT angiography for diagnosis. Ascending dissections (type A) need urgent surgery, while descending dissections (type B) are treated medically with aggressive blood pressure control, usually achieved with drips.

What's the evidence

For endovascular repair in type B aortic dissections? Following initial stabilization and blood pressure control, thoracic endovascular aortic repair (TEVAR) can be used to prevent late aneurysmal expansion. While 2009's INSTEAD trial found no mortality difference at 2 years between medical therapy and TEVAR vs. medical therapy alone in uncomplicated dissections, 5-year data from INSTEAD-XL found that endovascular repair protected against late complications and cardiovascular death. 

What your health policy friends are talking about

It's hard to pin down how the recent House and Senate-passed tax bills affect healthcare delivery and insurance. Find some basics in this Q&A.

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