Wednesday, February 28, 2024

REDEFINING TERMINOLOGY IN ENDOMETRIOSIS

Written by Dr. Tamar Zelovich exclusively for the Women's Health Collaborative
Edited by: Dr. Roberta Kline


Endometriosis (endo') is a chronic, multi-systemic, inflammatory, and estrogen-dependent gynecological disease affecting 10% of women worldwide. Its onset typically occurs between the ages of 20 and 40, with an estimated 170 million women affected. This condition is characterized by the presence of cells, similar to those lining the inner uterus (endometrium), growing outside the uterus, mainly in the pelvic area. These endometrial-like cells respond to hormonal changes, particularly estrogen, leading to symptoms mirroring the hormonal cycle. Bleeding from the endometrial tissue outside the uterus accumulates in situ and causes inflammation, scar tissue, and adhesions that attach pelvic tissues and organs. 


Diagnosing endometriosis is challenging, with an average delay of approximately 12 years. A definitive diagnosis requires laparoscopic surgery and a biopsy of endometrial tissues. Endo’, being a multisystem disease, manifests in diverse symptoms such as severe pain during menstruation and/or ovulation, chronic pelvic pain, lower back pain, pain during intercourse, dyspareunia, various digestive and urination issues, infertility, etc. Each woman experiences a unique set of symptoms that appear at different points in the hormonal cycle. Despite its high incidence, misdiagnosis and inadequate treatment are prevalent, leaving many women to carry the burden of the disease for years. 

The current primary classification and terminology system for endometriosis categorizes it into four stages (I-IV) based on the quantity of lesions and the depth of infiltration: minimal (Stage I), mild (Stage II), moderate (Stage III), and severe (Stage IV). Stage I is characterized as superficial or minimal endo', Stage II as mild with deeper implants, Stage III involves deeper implants and small cysts on the ovaries, while Stage IV is considered severe, featuring large cysts on the ovaries, deeper lesions, and numerous dense adhesions. These classifications solely focus on infertility, suggesting that Stage IV primarily affects infertility. However, they provide no insight into the pain levels experienced by patients and exhibit a poor correlation with symptom intensity, neglecting the broader impact on the body, the exacerbation of other medical conditions, the degree of inflammation, and the resulting disability. 

It is crucial to acknowledge that even Stage I or superficial endo' has a significant impact on infertility, leading to low Anti-Mullerian Hormone (AMH) levels and diminished egg quality. The terms "minimal" for Stage I and "severe" for Stage IV may inadvertently convey misinformation, implying that Stage I is a less severe case of the disease, which is far from reality. Moreover, it inadvertently creates the impression of a less burdensome condition that does not significantly affect the patient's life. Patients expressing severe pain despite having Stage I or superficial endo' may encounter dismissive attitudes that are contrary to the current understanding. It's noteworthy that there are cases where Stage IV only results in infertility issues without pain, while Stage I can lead to the highest level of disability due to endometriosis. This underscores the complexity and individual variability in the manifestation and impact of endometriosis across different stages. It is common to hear patients with endo’ Stage I say, “I suffer from severe pain even though I only have endo Stage I” or “I’m in so much pain even though I only have superficial endo”, or “I experience intense pain from endometriosis, even though it remains unseen in imaging studies”.

Moreover, it's essential to consider the diversity of endometriosis types when delving into imaging studies and surgical treatments. It is well known that deep endo’ has higher odds of being visible in imaging and a greater likelihood of being detected in surgeries. In recent years, the community believed that superficial endo’, or more specifically, non-pigmented endo’, was rare because it was challenging to identify in imaging and surgeries. Today, we know that it is more common than previously thought. The terminology of superficial endo’ is not only dismissive of patients' pain but also a barrier to research funding, as researchers tend to focus on exploring deep endo, believing it to be a more extensive or severe case of the disease that has a greater impact on pain and infertility. Current knowledge suggests otherwise.

It is now clear that the existing classification system fails to correlate with the intensity of pain experienced and provides a great disservice to women, researchers, and clinicians. To rectify this, our top priority should be to redefine the terminology in endometriosis. In my view, the new terminology should encompass the following considerations:


(1) Extent of Disease as a multisystem disease: The terminology should describe the multisystem nature of endometriosis. I propose categorizing the impact into three phenotypes: 

(i) Pain directly related to endometriosis, such as dysmenorrhea, dyspareunia, chronic pelvic pain, dysuria, gastrointestinal symptoms etc. 

(ii) symptoms, pain, or co-morbidities indirectly resulting from endometriosis, such as conditions flaring up due to endometriosis (e.g., autoimmune diseases, fibromyalgia, etc)  or affecting organs beyond the pelvic region (e.g., reflux disease ,foot drop, etc), and 

(iii) symptoms related to hormonal changes, such as migraines, depression, acne, etc. 


(2) Symptom Intensity and Pain Level: The terminology should reflect the intensity of symptoms and pain. 

(3) Disease Sites: Clearly describing the sites of the disease, including peritoneal, ovarian, bowel, ureter, bladder, etc.  

(4) Effect on Infertility: Describing the impact on infertility, considering effects on the ovary itself, AMH levels, and the quality of eggs.  

(5) Surgical Difficulty: Reflecting the surgical difficulty encountered relative to the disease location, whether it's deep endo (challenging to operate) or superficial endo with various characteristics (challenging to identify). 

(6) Level of Inflammation: Attempting to estimate the level of inflammation in the body because of endometriosis and its effects on the entire body.  

(7) Level of Disability: Estimating the level of disability the patient is experiencing due to the multisystem nature of the disease. 


EPILOGUE

I believe it's time to collectively acknowledge the existence of different endometriosis types that demand specific attention in terms of terminology. Understanding that we may need different imaging techniques and surgical approaches to detect and treat them is crucial. Reconsidering, and more importantly, redefining the classification/terminology we use, steering away from the generic endo I-IV or deep/superficial endo, could contribute to a more accurate and nuanced discourse. Embracing a more detailed and tailored classification system would not only better reflect the diverse nature of the condition but also pave the way for more precise diagnosis and effective treatment strategies. This shift in terminology could enhance communication among healthcare professionals, researchers, and patients, fostering a deeper understanding of the complex manifestations of endometriosis, a multisystem disease.


TAMAR ZELOVICH holds a Ph.D. in theoretical chemistry from Tel-Aviv University and the Weizmann Institute, with expertise in quantum chemistry. Following a postdoc at NYU in theoretical chemistry and the publication of nineteen papers in international peer-reviewed journals, she transitioned to computational health, focusing on endometriosis. Diagnosed with the condition herself, Tamar developed a methodology that aids in management of endometriosis symptoms. Today she is collaborating with KI, a non-profit research organization to study symptoms patterns in endometriosis, and she strives to transform her findings into a digital platform for physicians, aiming to revolutionize early diagnosis/treatment and improve the lives of women globally.


ULTRASOUND DIAGNOSTICS OF ENDOMETRIOMA

ENDOMETRIOSIS REVIEW 2023: FROM ESSENTIALS TO ADVANCEMENTS  By: Robert L. Bard, MD


According to the World Health Organization, Endometriosis affects roughly 10% (190 million) of reproductive age women and girls globally.  It is a chronic disorder that can result in life-disrupting pain during menstrual periods, sexual activity and urination.  Currently, there remains no known cure for endometriosis, whereby treatment is usually aimed at managing its known symptoms.  One objective of the medical community is to conduct early diagnosis and research continues to pursue effective treatments.

Endometriosis starts in the endometrium with abnormal cellular proliferation.  Through the use of 3D Ultrasound, this disorder can be measured through the monitoring of the widening or the increased tissue in the endometrium.  Another form of quantitative measure is by the study of blood flow in the endometrium. Its ability to spread can be recognized by the number of vessels in the active tissue.  The big problem with staging endometriosis (or endometriomas) are the cysts that follow it.  Because of its capacity to spread in most areas of the body, a strategic protocol for clinical management is to conduct IMAGE GUIDED treatments, whereby use of real-time scanning of or during therapeutic process helps navigate the focus the treatment area.  Imaging solutions include CT (which has radiation), MRI, or the 3D Doppler ultrasound. 

CASE REVIEWS: We recently had a case where the endometriosis had metastasized under the arm. We've seen it metastasize in post-op scars. We can see the endometrial tissue block the ureters- hence, blocking the kidneys and destroying the kidney function.  Moreover, the scars can cause bowel obstruction.

While it's not categorized as malignant, it certainly can be deadly (as well as a seriously painful and debilitating disease). Women (especially those in advanced age groups) have expressed being completely incapacitated for three out of four days during their menstrual cycle.  A vast majority of them also claimed experiencing mental health issues because of the pain and discomfort. 

The following slides are from Dr. Robert Bard's lecture presented in 2016 for the obstetrics and gynecology department at Mount Sinai Medical Center in New York City (ref: prior lecture from Harvard Medical School/the American Institute of Ultrasound in Medicine).


Use of the modern image guided treatment technologies offer non-invasive blood flow technology, which quantifies the aggression, either the aggressiveness of an inflammatory process like endometriosis or the invasive and metastatic potential of cancers such as endometrial cancer & cervical cancer.

FIG 1: Upon observation, this it is not a primary bladder cancer. This is an inflammatory mass because the vessels are smooth (cancer vessels are wrinkly)- and there is a visible difference between the two.  This is a three dimensional pelvic floor doppler study of the pelvis. If we start with scan A, we see the uterus on the bottom half and the bladder on the top, which is black, and within the black fluid is a mass. By looking below that, we see the (scan C and D) the abnormal blood vessels of the endometriosis. Hence, inflamed tissue is vascular and the same pattern of blood vessels from the abnormal endometrium is also in the bladder, indicating that the endometrial tissue has either invaded or metastasized into the base of the bladder. The two scans (B & D) show the bladder wall is intact. Hence, these are endometriosis that has metastasized or spread to the base of the bladder. 

FIG 2: In this image set, we have an endometrioma, which is (again) a large black area where the fluid is black, and within it, there's another nodule with the circle indicated by the red highlight.  We see that there's no blood flow in this- hence, it's not a primary cancer of the bladder.  In addition,  it is not particularly active inside the bladder, however, there is a stalk that is feeding blood vessels to the cystic area.  With the 3D Doppler, we can quantify the cyst in seconds, because 3D takes a dataset in 15, 20 seconds of a hundred, 150 pictures of the whole area, including the blood flow.  

Notice the 3D images on the left with the red circle (Scan A) is the endometrial cyst, which is black, and the circle shows a small nodule within the cyst. What's important with this as contrasted to the previous study is this is NOT VASCULAR, which means this is inactive or subclinical at this time. On the right (E,F,G,H), we see that the pedicle that's going to the cyst and feeding the cyst, the area has multiple blood vessels in it. Because we're using 3D volumetric technology, we are able to quantify the number of vessels in the pedicle. The more blood vessels in the pedicle, the more aggressive the disease is. So back to the cyst. The cyst, there were no vesicles, but the pedicle feeding the cyst had a 13% ratio of blood vessels to assisted tissue. 

EPILOGUE
Traditional medicine has not assisted with the mental depression, the anguish of the certainty that the pain will be monthly and the possible side effects including infertility. Since we've been using targeted therapies with lasers and focused ultrasound energies years ago, we are now globally using bioenergy treatments that is the near infrared laser and the pulse electromagnetic fields to calm down the, the inflammatory process of this inflammatory disorder.


ROBERT L. BARD, MD  (Diagnostic Imaging Specialist)- Having paved the way for the study of various cancers both clinically and academically, Dr. Robert Bard co-founded the 9/11 CancerScan program to bring additional diagnostic support to all first responders from Ground Zero. His main practice in midtown, NYC (Bard Diagnostic Imaging- www.CancerScan.com) uses the latest in digital Imaging technology has been also used to help guide biopsies and in many cases, even replicate much of the same reports of a clinical invasive biopsy. His most recent program is dedicated to the reporting of mental health diagnostic and innovative solutions including the use of modern neuromagnetic technologies and protocols in his MEDTECH REVIEWS program. 



EDITOR

ROBERTA KLINE, MD (Educational Dir. /Women's Diagnostic Group) is a board-certified ObGyn physician, Integrative Personalized Medicine expert, consultant, author, and educator whose mission is to change how we approach health and deliver healthcare. She helped to create the Integrative & Functional Medicine program for a family practice residency, has consulted with Sodexo to implement the first personalized nutrition menu for healthcare facilities, and serves as Education Director for several organizations including the Women’s Diagnostic Health Network, Mommies on a Mission. Learn more at https://robertaklinemd.com/



Copyright Notice: The materials provided on this website/web-based article are copyrighted and the intellectual property of the publishers/producers (The NY Cancer Resource Alliance/IntermediaWorx inc. and The AngioFoundation). It is provided publicly strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers.  Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately.  This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.



Saturday, February 24, 2024

Cancer Predisposition & the Role of Genetic Testing

By: Dr. Roberta Kline

Cancer comes from one of two ways. One is that you have inherited genetic mutations that significantly increase your risk for specific types of cancer. But overall, that's a minority of cancer cases. The majority of cancers occur because of an interaction between your individual genes and the environment that they've been exposed to throughout your lifetime. Both of them can be tested for.  And if you know what you're dealing with, you can create a plan that's specific for you that enables you to be proactive. This enables you to have that locus of control, that you know what's going on in your body, but you don't know if you don't test. Therefore, TEST- DON'T GUESS!  And then you can create your roadmap that works for you.

Especially with breast cancer, we know that 90% of the cases are not due to known inherited genetic mutations like BRCA1. The majority of them are due to very small changes in your DNA that interact with your environment over your lifetime that predispose you to developing breast cancer. But if you don't know that you have these predispositions, you can unknowingly be exacerbating the problem. If you've been tested and you know what your genes are doing, you can proactively create a plan to minimize your risk throughout your lifetime. 

"INHERITING CANCER & GETTING THE RIGHT TEST"

We understand genetic mutations to cause severe diseases, predominantly causing certain types of cancers. But rather than living in fear of what you may or may not have inherited from your parents, and whether you may or may not develop the same diseases that they carried- get tested, so you won't find yourself guessing.  Through gene testing protocols, you can precisely identify where you need to focus your resources, your attention- and when you can let go of that (unnecessary) fear.

Because genetic testing can be very specific, one of the biggest challenges for proactive people about their health is to know WHAT to test for. What test do you use? Is there a test that's better for you than others? These are important questions and the amount of information available (while great) can be quite overwhelming. The best suggestion is to speak to a trained medical professional or a genetic specialist who can help you navigate through the vast collection of available tests to find what is right for you.  What you want is a test that has value. And in order to have value, it needs to answer your questions and provide you a roadmap for what you can do proactively for your health for the future. 

 

DNA REACTIONS FROM ENVIRONMENTAL TOXINS:
So when you look at the issue of breast cancer in Long Island and how it is tied to these environmental toxins, what you're seeing is these environmental toxins can potentially, if it's a large enough dose, create mutations in somebody's DNA, but what is most likely happening (and this I do have to check on,)what is most likely happening is it's overwhelming the body's ability to process these toxins. When your body processes any kind of chemical, including these toxins, it produces oxidative stress. When you have too much oxidative stress for your body to handle, that creates DNA breaks. So it's not the toxin directly causing DNA breaks necessarily, it's that your body can't get rid of that toxin fast enough or efficiently enough. And so its own biological processes that are supposed to deal with this are the ones that actually cause the DNA breaks (mutation) and the changes in the DNA that increase the risk of breast cancer. 

This is the second part of that pathway by which estrogen as well as other chemicals can cause breast cancer.  Conventional medicine pays attention to the binding of estrogen to the estrogen receptor causing proliferation. Excessive proliferation can lead to a higher chance of DNA breaks. Every time that DNA replicates, (which is what happens when you create proliferation) when the cells grow, every time that DNA replicates, there's a chance that it will cause an error in that replication and leave a mutation in the DNA. Now, we have lots of processes that are built in to safeguard against that. We have DNA repair mechanisms, we have all sorts of machinery that is designed to catch breaks in the DNA before they get integrated into the person's biology. If you overwhelm that, those breaks stay. 

To note, estrogen itself is a toxin, even though we produce it ourselves. Studying the other part of estrogen metabolism, which is the same process that happens with all of these toxins  is that it goes through what we call DETOXIFICATION or BIOTRANSFORMATION. You're transforming something that's potentially toxic, ultimately into a molecule or a chemical that is non-toxic and gets eliminated from the body. Within that process, you are often creating even more toxic chemicals in the intermediary stages, and that's what requires a high level of antioxidant defense as well as other biological systems to keep those contained and keep them in check and funnel them quickly into the benign molecules out of the body. This is the second way that you can create DNA damage, that you can create cancer because you are overwhelming the body's ability to neutralize those toxic compounds that your body is creating as a result of whatever it's taking in. This has to do with oxidative stress, which is linked to INFLAMMATION, which we know underlies almost every cancer process. 



ABOUT THE AUTHOR

ROBERTA KLINE, MD (Educational Dir. /Women's Diagnostic Group) is a board-certified ObGyn physician, Integrative Personalized Medicine expert, consultant, author, and educator whose mission is to change how we approach health and deliver healthcare. She helped to create the Integrative & Functional Medicine program for a family practice residency, has consulted with Sodexo to implement the first personalized nutrition menu for healthcare facilities, and serves as Education Director for several organizations including the Women’s Diagnostic Health Network, Mommies on a Mission. Learn more at https://robertaklinemd.com/


Copyright Notice: The materials provided on this newsletter article is copyrighted and is the intellectual property of Dr. Roberta Kline as the writer/producer and or publisher. It is also under the protection of the  (Integrative Cancer Resource Society  and the AngioFoundation(201c3).  This feature report is published strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers.  Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site (BALANCE & LONGEVITY) and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately.  This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.


Tuesday, January 23, 2024

Balance and Longevity: Starting with RESET

Produced by: Dr. Roberta Kline (Assoc. Editor of the Women's Health Digest)

We all reach a point in our lives where we've gotten stuck in ruts where it seems really hard to even conceive of CHANGE. Change can be very scary, especially when, when it's on a larger scale. You know, the way we eat, the way we exercise our whole lifestyle is often very intertwined with our social interactions, with our work, with our expectations of how we're supposed to behave, how we're supposed to live our lives in our current world. That pressure to do and produce and be busy all the time is actually very detrimental. 

These habits that we create as coping mechanisms sometimes don't really serve us in the long run. So when it comes time to change, how many of you have tried a drastic change in diet, decided to take on a really rigorous boot camp exercise program, thinking that, "okay, I'm going to do it this time". And most of the time it fails. And it's not because you fail, it's not because you don't have the willpower. It's not because you don't have the strength. It's because success comes from building upon success, building upon your inner strengths, rather than trying to push and punish yourself into something that may not work for you.

The idea of reset comes from a different framework. It's about making small changes to reset how we think, how we feel, how we act. That is more in alignment with our goals of where we want to be. In our evolution, we're always, as a species hitting a point of needing to grow, needing to change in order to adapt to a new environment, in order to be better at whatever it is that allows us not just to survive, but to thrive. Initiating a reset at these points in time also applies to our lives. It allows us to take a step back and say, "what do I need to change to grow, to become the person in whatever way that looks like for me, that I wanna be next. Where do I wanna go in my own growth and evolution so that I can have the energy, the vitality, the enthusiasm for living life the way I want".


WELLNESS PHILOSOPHY 101 

LONGEVITY is not just a race to get to however old you can be in terms of chronological age. It's not a competition, but it's rather a form of self-love... and that comes with BALANCE. Life throws us all sorts of curve balls, whether it's internal or external in our lives. Balance is something we need to work towards- in order to give us resilience.  Nature teaches us to (automatically) try to regain balance when we fall or when we stumble. 

As an example, if you've ever tried standing on one leg- it's a challenge, right? If you add to that challenge by maybe lifting that leg higher or doing some other pose that adds more challenge to, to your balance.  When you're focused and you're grounded and calm, it's much easier to stay in that balance. But if your mind starts wandering about, "oh, I gotta do this today, your to-do list" or something that happened yesterday, it's very easy for those thoughts themselves to throw you off balance. And then you'll either put your foot down because you need to some extra stability, or you might fall altogether. The goal of balance is not to be able to stand on that one leg for the rest of your life. That's not possible, but it's about, okay, how do you get back into that place of balance when something throws you off? That's RESILIENCE. And that, to me, is the core of creating health for as long as we can. 

RESET to me, is a very forgiving way that is full of self-compassion to make these decisions without judgment, without guilt, without all the 'woulda-coulda-shoulda's.  We are very good at that negative self-talk. But it really doesn't help us regain balance. It doesn't help us in our RESET. We can take these moments as "the past has passed". I've gotten where I am today with all the choices. What choice do I want to make now to take me down the path that will give me the health and the life that I am desiring now?

PART 1: RESET & EXERCISE
When it comes to longevity of however you're going to RESET your life, whatever new programs, new behaviors, new habits that you decide to incorporate in your health program, the worst thing to do is to do something because you think you should... you usually end up making it boring. Follow somebody else's instructions without really thinking, "is this really the right thing for me?"  As an example, I find that using creativity is the best way for me to exercise is to make it fun. Now, exercising on the treadmill is boring. You're not going anywhere. You're just walking in the same place for 15, 20, 30 minutes, 45 minutes, however long you do it. When you are walking outside, you have an ever-changing landscape. You're out in nature. But indoor in the treadmill. Yeah. Not so much.

This is one of the reasons why so many treadmills purchased with great intentions end up serving as clothes hangers, storage places, uh, you know, get donated or sold on eBay. It's because it really didn't fulfill a need that we all have. And that's for creativity and fun. So the first thing I do when working with clients is to find out what is fun for them. For me, when I started ballroom dancing, I realized this was an exercise I could do forever and never feel like I was exercising. It was just fun. So when, on the days that I work out on the treadmill, I decided to be creative and translate that into my workout. So now I chacha, I salsa, I swing, I foxtrot, I do these dance moves, obviously modified for the treadmill so I don't fall off. And I've done that in the beginning. <laugh>, it helps me have fun. It gives me joy. And before I know it, whatever time I'm on that treadmill flies by because I'm not focusing okay, on how many miles or how many minutes. I'm just one with the music I'm feeling the music, I'm moving with the music. And that for me is the best way to get my exercise in.


ABOUT THE AUTHOR

ROBERTA KLINE, MD (Educational Dir. /Women's Diagnostic Group) is a board-certified ObGyn physician, Integrative Personalized Medicine expert, consultant, author, and educator whose mission is to change how we approach health and deliver healthcare. She helped to create the Integrative & Functional Medicine program for a family practice residency, has consulted with Sodexo to implement the first personalized nutrition menu for healthcare facilities, and serves as Education Director for several organizations including the Women’s Diagnostic Health Network, Mommies on a Mission. Learn more at https://robertaklinemd.com/


Wednesday, January 3, 2024

Uterine Fibroids: New Approaches to an Underdiagnosed Health Issue

Written and produced by: Dr. Roberta Kline for the Women's Health Digest / Balance & Longevity educational seminar series.


FIBROIDS are the most common tumor of the female pelvis and are the number one reason for hysterectomy. While prevalence estimates vary widely, in part due to systemic underdiagnosis, they range worldwide from 4-70%. Globally, Black women have the highest rate, often 3x that of White women. In addition, Black women are more likely to have more severe symptoms and undergo hysterectomy at an earlier age, adding the burden of lost fertility for these women.  The economic burden is also enormous. It is estimated that fibroids contribute to up to $34 billion in direct and indirect healthcare costs every year. [1] 


NEED MORE ATTENTION TO THIS COMMON WOMEN'S DISORDER
For many decades, the understanding of causes and effective treatments has progressed slowly. With the acceleration of technology enabling molecular and genetic expression research and advanced non-invasive treatment, that is starting to change.


WHAT ARE FIBROIDS?

Fibroids are classified based on where they occur in the uterus. 
Uterine fibroids, also known as uterine leiomyomas, are benign growths within the uterine wall that are made up of the same smooth muscle tissue as normal myometrium. But for reasons that are still not fully understood, they form into 3-dimensional spheres rather than the linear, elongated pattern of normal tissue. 

Up to half of all women with fibroids are symptomatic. Although fibroids are typically benign, they can cause significant health effects. The most common symptoms are painful periods and heavy menstrual bleeding. Pelvic pressure and pain during intercourse are not uncommon. Depending on their size and location, fibroids can press on nerves and cause pain; obstruct nearby organs including ureters, bladder, and intestines. Fibroids can also cause reproductive problems including infertility, recurrent pregnancy loss, and other complications of pregnancy.

WHAT CAUSES FIBROIDS?
Fibroids occur after the onset of menses, and typically shrink after menopause, so clearly estrogen plays a role. Other standard risk factors for fibroids include ethnicity, age, family history, time since last birth, hypertension and diet. Vitamin D deficiency in particular, has been consistently linked with fibroids. [2] 

Genetics clearly plays a role. Having a family member with fibroids increases the risk – and if it’s your mother, you are 3x more likely to develop them too. A hereditary mutation in the FH gene (fumarate hydratase) that causes renal cell carcinoma (HRCC) is now being linked to the development of fibroids, especially at younger ages. [3]

GENETIC EXPRESSION PROVIDES NEW CLUES
Emerging research is revealing the role of underlying molecular pathways and the genes and epigenetics that regulate them in fibroid development and growth. These include estrogen metabolism, inflammation, oxidative stress, insulin and glucose regulation, nutrient processing, telomere length and DNA repair. [4] Interestingly, but perhaps not surprisingly, there is significant overlap with other health conditions including endometriosis, as well as many chronic diseases of aging. 

One of the surprising findings of gene expression research is that almost half of all fibroids have chromosomal abnormalities. [5] Despite this, progression to the cancerous form (leiomyosarcoma) is rare – less than 1%. As researchers look deeper, it appears that it is not the genetic changes within the fibroid that have the most influence on the development of fibroids and the progression to cancer. Rather, it is the microenvironment, or the cellular health around the fibroid, that has this role. [6] 

Therefore, it may be that improving the microenvironment in which these fibroids develop could be effective early intervention strategies. Noninvasive therapies that can reduce inflammation and oxidative stress including diet, medication, PEMF, and photobiomodulation may be new opportunities for early intervention for fibroids as well. [7] 

While genetic expression research on fibroids is shedding light on some of the genomic and genetic alterations that contribute to discrepancies between women of different ethnicities, it is clear that these aren’t the only drivers. [8] As with many other health conditions, where a woman lives and works plays an outsized role.

Environmental toxins including endocrine disruptors and air pollution, stress, and socioeconomic status all have been shown to be connected with higher rates of fibroids. These are likely related to bidirectional effects of epigenetic alterations, access to care and bias within the healthcare system, as well as other factors still to be identified. [9] 

DIAGNOSIS
Ultrasound, and preferably transvaginal ultrasound, is the best initial diagnostic imaging procedure for detection of fibroids. 3D ultrasound can provide even more information than the standard 2D. With the addition of hysterosonography, or introduction of fluid into the uterine cavity under ultrasound guidance, impingement on the uterine cavity can be clearly demonstrated.

 


Image source: Freytag, D., Günther, V., Maass, N., & Alkatout, I. (2021). Uterine Fibroids and Infertility. Diagnostics, 11(8). https://doi.org/10.3390/diagnostics11081455 [OPEN ACCESS}


TREATMENT OPTIONS
Despite many women already having symptoms by age 25, most aren’t diagnosed until their 30’s or 40’s. By that time, the fibroids are typically larger and more problematic. 

Current treatment options include medication to address symptoms – accounting for up to 70% of women at some point. Surgery to remove the fibroids (myomectomy) or the entire uterus along with the fibroids (hysterectomy) is the oldest and most invasive option. Newer techniques such as laparoscopy have improved these surgical approaches. Within the past couple of decades uterine artery embolization (UAE) has offered a less invasive option, and newer noninvasive approaches are now emerging that utilize radiofrequency ablation (RFA), and high intensity focused ultrasound (HIFU). [2] 

Here, too, treatment options are impacted by ethnicity and socioeconomic factors. "Despite minimally invasive options, Black women continue to dominate the percentages of women having hysterectomies for benign disease," Marsh says. "We need to understand why." [1]

One of the main limitations for these newer techniques is that they are more effective on smaller fibroids. Since fibroids tend to grow over time, it would seem a benefit to have earlier diagnosis so that women have better treatment options. In fact, a recent study in Ghana showed that routine ultrasounds at yearly clinic visits increased the rate of diagnosis, and at younger ages. [10] 

THE FUTURE OF FIBROIDS
While more definitive research specific to fibroids is needed, we already have noninvasive tools and strategies to address some of the most common underlying contributors. Let’s advance the science with research as we simultaneously give women more options to proactively improve their health.


REFERENCES

(1) Marsh, E. E., Al-Hendy, A., Kappus, D., et al. (2018). Burden, Prevalence, and Treatment of Uterine Fibroids: A Survey of U.S. Women. Journal of Women's Health, 27(11), 1359-1367. https://doi.org/10.1089/jwh.2018.7076  (2) Freytag, D., Günther, V., Maass, N., & Alkatout, I. (2021). Uterine Fibroids and Infertility. Diagnostics, 11(8). https://doi.org/10.3390/diagnostics11081455  (3) Lu, E., Hatchell, K. E., Nielsen, S. M., et al. (2022). Fumarate hydratase variant prevalence and manifestations among individuals receiving germline testing. Cancer, 128(4), 675-684. https://doi.org/10.1002/cncr.33997  (4) Välimäki N, Kuisma H, Oskari AP et al. (2018) Genetic predisposition to uterine leiomyoma is determined by loci for genitourinary development and genome stability eLife 7:e37110.  (5) Kubínová K, Mára M, Horák P, et al. Genetic factors in etiology of uterine fibroids. Ceska Gynekol. 2012 Feb;77(1):58-60. Czech. PMID: 22536642.  (6) Bharambe, B. M., Deshpande, K. A., Surase, S. G., & Ajmera, A. P. (2014). Malignant Transformation of Leiomyoma of Uterus to Leiomyosarcoma with Metastasis to Ovary. Journal of Obstetrics and Gynaecology of India, 64(1), 68-69. https://doi.org/10.1007/s13224-012-0202-4  (7) Tinelli, A., Vinciguerra, M., Malvasi, A., et al. (2021). Uterine Fibroids and Diet. International Journal of Environmental Research and Public Health, 18(3), 1066. https://doi.org/10.3390/ijerph18031066 (8) Edwards, T. L., Giri, A., Hellwege, J. N., et al. (2019). A Trans-Ethnic Genome-Wide Association Study of Uterine Fibroids. Frontiers in Genetics, 10. https://doi.org/10.3389/fgene.2019.00511  (9) Cheng, L., Li, H., Gong, Q., et al. (2022). Global, regional, and national burden of uterine fibroids in the last 30 years: Estimates from the 1990 to 2019 Global Burden of Disease Study. Frontiers in Medicine, 9, 1003605. https://doi.org/10.3389/fmed.2022.1003605  (10) Mesi Edzie, E. K., Dzefi-Tettey, K., Brakohiapa, E. K., et al. (2023). Age of first diagnosis and incidence rate of uterine fibroids in Ghana. A retrospective cohort study. PLOS ONE, 18(3), e0283201. https://doi.org/10.1371/journal.pone.0283201


ABOUT THE AUTHOR

ROBERTA KLINE, MD (Educational Dir. /Women's Diagnostic Group) is a board-certified ObGyn physician, Integrative Personalized Medicine expert, consultant, author, and educator whose mission is to change how we approach health and deliver healthcare. She helped to create the Integrative & Functional Medicine program for a family practice residency, has consulted with Sodexo to implement the first personalized nutrition menu for healthcare facilities, and serves as Education Director for several organizations including the Women’s Diagnostic Health Network, Mommies on a Mission. Learn more at https://robertaklinemd.com/




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Epigenetic Research Notes: Profiling the Dense Breast Paradigm (part 1)
 Coursework written by: Dr. Roberta Kline

LINKING DENSE BREAST WITH BREAST CANCER
We have known for a very long time that there is an increased risk of breast cancer for women who have dense breasts. Until recently, the research has been lagging in terms of what's the molecular mechanism, why do dense breasts present an increased risk of breast cancer? Without this knowledge, we can’t address the root causes, and are left with a lot of trial and error based on incomplete understanding. It's very encouraging to know that currently there are 124 clinical trials ongoing looking at dense breasts and the relationship with breast cancer, anywhere from improved diagnostics, to treatment, to prevention, and, what’s close to my heart, to understanding the molecular mechanisms - what's happening at the cell level, at the genetic level that is causing different women to have an elevated risk of breast cancer. (see feature)



Copyright Notice: The materials provided on this newsletter article is copyrighted and is the intellectual property of Dr. Roberta Kline as the writer/producer and or publisher. It is also under the protection of the  (Integrative Cancer Resource Society  and the AngioFoundation(201c3).  This feature report is published strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers.  Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site (BALANCE & LONGEVITY) and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately.  This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.

Tuesday, January 2, 2024

HEALING, STRESS AND THE PARASYMPATHETIC SYSTEM

Written by: Roberta Kline, MD

Analyzing STRESS & ANXIETY from a holistic point of view means identifying the body’s interconnected systems (ie. circulatory, cardiovascular, nervous, lymphatic, endocrine etc.) and its many touch points for stimulation.   This analysis should also offer a comprehensive breakdown of the body's HEALING capacity- which includes our hormones, digestive system, immune system, brain, heart-- all the way down to our cells and mitochondria.  

Stress is part of life, and comes in many forms including physical, emotional, mental and environmental. Foods we eat, unhealthy relationships, difficulties at work, toxins in our environment, even poor posture or lack of sunshine can all create stress on our bodies. But when stress is catastrophic or becomes chronic, it creates imbalances in this functioning that are much more likely to promote disease while at the same time preventing healing from taking place. [1]

With people under record levels of chronic stress, it is no wonder we have an epidemic of people suffering from all sorts of health issues and chronic diseases. Heart disease, diabetes, obesity, pain, anxiety, depression, infertility, cancer, autoimmune diseases such as arthritis, neurodegenerative diseases such as Alzheimer’s …. These are just some of the many health conditions that have been linked to diet and lifestyle including chronic stress. [2, 3]


But how does this work? And is meditation the answer to reversing this trend? Science is revealing some interesting clues.


THE NERVOUS SYSTEM

One big connection is our nervous system. Our nervous system is our superconductor network of information exchange throughout our bodies, and consists of two main parts. The first is the central nervous system (CNS). As it sounds, it’s our command center where all data comes to be processed, and is made up of the brain, spinal cord, and nerves. The second is called the peripheral nervous system (PNS) and it connects every part of our body to our CNS through individual nerve cells called neurons and clusters of neurons known as ganglia.


The PNS is further divided into the Somatic Nervous System, also known as the voluntary nervous system, and the Autonomic Nervous System. The Autonomic Nervous System (ANS) manages all bodily functions that are not under conscious control. This includes heart rate, blood pressure, digestion, respiration, cellular activity, immune system, hormones, brain function, sexual function, and even body temperature.

The ANS is further divided into two parts: the Sympathetic Nervous System (SNS), which regulates our “fight or flight” response, and the Parasympathetic Nervous System (PNS), which controls our “rest and digest” response. They work closely together in a complex dance, maintaining our bodily functions and ensuring our survival every second of our lives.

Many health issues, including most chronic diseases such as heart disease, autoimmune disease, diabetes, depression and anxiety, and cancer, are related to an imbalance of our autonomic nervous system. Most typically, it is too much of the “fight or flight” and not enough of the “rest and digest” that leads us into this imbalance. [4]


FLIGHT OR FLIGHT

The Sympathetic Nervous System is located in the CNS, and in the spinal nerves from T1 (the thoracic region) down to L3 (the lumbar region) out to the neurons in the regions of the body supplied by these nerves. This sympathetic response is designed to keep us safe in the face of immediate danger. It signals the brain to turn up the volume on any physiological function crucial to staying to fight or running away from the source of the danger. Catecholamines such as epinephrine (adrenaline), norepinephrine (noradrenaline) and dopamine are released and a cascade of events happens rapidly – before we are even consciously aware that there is a threat. These include:

Blood flow diverted to the heart, lungs and skeletal muscle

Increased heart rate, blood pressure and respiratory rate

Enlargement of bronchioles (in lungs)

Dilation of pupils

Rapid conversion of glycogen to glucose for fuel

Activation of immune system


All other functions, including digestion, urination, higher level thinking, even sexual function and cellular repair, are temporarily turned off, so that all of our energy and resources go only toward ensuring our immediate survival. If the threat goes on for a longer period of time, a secondary system called the HPA (Hypothalamic – Pituitary – Adrenal) Axis takes over and relies on elevated cortisol and other hormonal changes to continue the high alert state.

But our bodies are not designed to be in this activated high-alert state for long periods of time. Once the immediate threat is gone, we are supposed to go back to our normal state of relaxation. This is the job of the Parasympathetic Nervous System.


REST AND DIGEST

The Parasympathetic Nervous System (PSNS) is located in the brain stem, includes nerves to the eyes and face, vagus and 10th cranial nerves, and sacral nerves (S2-S4). Regulated in large part by the vagus nerve (75%), it impacts a vast array of crucial bodily functions. When the parasympathetic response is triggered, it counteracts the fight or flight response primarily through release of acetylcholine.

Parasympathetic activation results in production of tears, saliva, and constriction of the pupils; lower and more variable heart rate, lower blood pressure and respiratory rate. It enables creative and critical thinking, normal kidney function and urination, improves immune function, enables sleep, sexual arousal and replenishment of fuel stores in organs; plus everything involved in digesting and utilizing our food including elimination and insulin production. Even mood and social bonding and connection are linked. 




HOW THERAPISTS DIAGNOSE MENTAL HEALTH ISSUES
By:  Jessica Connell, LCSW



HOW STRESS IMPACTS HEALTH AND HEALING

Healing requires coordination of a complex array of biological functional and systems. Research is rapidly expanding our understanding of the importance of the parasympathetic response, and how meditation helps to restore balance. While this impacts every biological system, here are some key areas:


Digestion
Nutrients must be properly digested to extract them from our food and into our cells, where they are critical to every function our bodies must carry out. From vitamins and minerals that are needed in every biochemical reaction, to energy production in our mitochondria, to building blocks of our proteins that form our enzymes, neurotransmitters, hormones, even our DNA - all of our cells need these basic materials to function. Stress shuts down our digestion, and if it goes on long enough our cells become depleted of the very nutrients needed to function and repair. 

Immunity

Approximately 90% of our immune system resides in our gastrointestinal tract. While it is needed to defend us against invaders such as bacteria and viruses, it can also go awry if unchecked. This “runaway” inflammation is linked to most chronic diseases, and paradoxically also reduces the ability espond to infections. Our immune system has other functions, including being a cleaning crew. It removes debris left over from battling invaders. It also removes our own dead or badly damaged cells, and signals new and healthy ones to replace them. Stress results in an imbalanced immune system, making us vulnerable to infections as well as chronic disease.

Mitochondria
These tiny structures exist within every cell in the body, and as the “power plants” of the cell they are responsible for producing all of the energy needed for every single function. This energy is produced as ATP and to make it requires key nutrients from food to be digested and absorbed from the gut. But producing this energy also creates toxic molecules, which are neutralized by antioxidants which also come from our diet. If the demand for energy is too great for too long, the mitochondria – and its cell – become damaged. Without healthy mitochondria, cells become damaged, dysfunctional and even die.

Brain

The brain normally utilizes about 20% of our energy supplies, primarily in the form of glucose or ketones. This requires good digestion and healthy mitochondria to keep the brain supplied with fuel to function.  Acetylcholine is a major neuro-transmitter in the brain and in nerve endings through the peripheral nervous system; it is also anti-inflammatory. It is made in the mitochondria using some of the same ingredients needed for ATP production. 

Serotonin, a major neurotransmitter impacting mood, is mostly produced in the gut. When the stress response is prolonged, this depletes the brain’s capacity for creative and critical thinking and mood regulation, often further impairing the ability to deal with stress.


MEDITATION AND HEALTH

While meditation has been practiced in various forms for centuries, and has long been associated with many parameters of improved health and well-being, science is only recently starting to understand the mechanisms by which it works. Studies are demonstrating the positive impact of meditation practices on various disease conditions, and the potential power for it to change the trajectory of this epidemic of chronic disease. Research findings on HOW it works are not all consistent though, as ways of meditating can be quite varied and this seems to impact the results. However, some common threads are emerging; two main mechanisms are outlined below.

Default Mode Network:
One mechanism by which meditation works is by altering connectivity in the brain – the so-called Default Mode Network, or DMN. This is a network of brain regions that is active when the brain is restful but awake. Meditation seems to decrease this DMN activity, leading to increased cortical connectivity [5] - in other words, there is activity connecting areas of the brain that aren’t normally part of this network that enables us to take a different, more detached perspective on things in our life. When we aren’t so attached to events, the sympathetic response is less likely to be triggered, or if it is triggered it is to a lower extent that is easier to recover from.

Vagal Nerve:
Meditation also activates the parasympathetic response, in large part through the vagal nerve. This not only impacts heart rate and other vascular parameters, it also connects our gastrointestinal tract to our brain. There is now a growing body of evidence that this bidirectional communication through the “brain-gut axis” is a complex system that is key to our health, and when it is out of balance is linked to many health issues. [6]

Meditation has been shown to increase vagal nerve activity, or tone, and restore normal functioning of these many systems including digestion, immune response, and brain neuroplasticity/resilience. [6] It is thought that one way this occurs is through deep breathing, although there may be other mechanisms in play.  As we learn more about how meditation works and how it influences our biology, we can develop more targeted and personalized approaches to maximize its potential – while making it easy and accessible for people to integrate into their daily lives.


EPILOGUE

In a recent MedTech Review of a meditation and brain optimizing device called BrainTap®,  Dr. Kline and her colleagues took on the task of assessing its ‘active ingredients’- binaural beats, isochronic tones, holographic music and blue/red light. (see complete tech review) It is found that these neurosensory applications have had a long history in other devices also supporting the science and wellness communities for their reactive properties.  Having collected the vast majority of user testimonials online, and clinical reports from fellow team mate, Dr. Leslie Valle (Santa Barbara, CA) who had already spent the better part of 3 years with the device on her patients, these reviews added greatly to our peace of mind about consumer safety.  

Academically, the appeal in assessing this specific product is partly due to the diverse and multiple points of wellness that the device was designed to target.  A wide range of brain and mental health-related specialists alike may truly enjoy conducting their own independent case study of this device, each using their specific level of science to assess its array of claimed benefits.  Areas like the parasympathetic nervous system, brain optimizing and stress & anxiety are just some of the key points of interest worth exploring.  If the device in fact aligns and supports Dr. Kline’s multi-layered physiological roadmap to wellness and the user’s reaction(s) in the meditation state, a fair and comprehensive tech review of this device should be best achieved under multiple streams of evaluators.  Reporting on its assessed benefits would then be a matter of the collective team trading notes for all areas of common ground.


ROBERTA KLINE, MD (Educational Dir. /Women's Diagnostic Group) is a board-certified ObGyn physician, Integrative Personalized Medicine expert, consultant, author, and educator whose mission is to change how we approach health and deliver healthcare. She helped to create the Integrative & Functional Medicine program for a family practice residency, has consulted with Sodexo to implement the first personalized nutrition menu for healthcare facilities, and serves as Education Director for several organizations including the Women’s Diagnostic Health Network, Mommies on a Mission. Learn more at https://robertaklinemd.com/



References:

(1) Furman D et al. Chronic inflammation in the etiology of disease across the life span. Nat Med 25, 1822–1832 (2019).

(2) Cohen S et al. Chronic stress, glucocorticoid receptor resistance, inflammation, and disease risk. PNAS April 2, 2012: 109 (16) 5995-5999

(3) Vancampfort D et al. Perceived Stress and Its Relationship With Chronic Medical Conditions and Multimorbidity Among 229,293 Community-Dwelling Adults in 44 Low- and Middle-Income Countries. American Journal of Epidemiology, Volume 186, Issue 8, 15 October 2017, Pages 979–989

(4) Agnese Mariotti. The effects of chronic stress on health: new insights into the molecular mechanisms of brain–body communication. Future Sci OA. 2015 Nov; 1(3): FSO23.

(5) Jerath et al Dynamic change of awareness during meditation techniques: neural and physiological correlates. Front. Hum. Neurosci., 17 September 2012 Sec. Cognitive Neuroscience

(6) Breit et al Vagus Nerve as Modulator of the Brain–Gut Axis in Psychiatric and Inflammatory Disorders. Front. Psychiatry, 13 March 2018


Additional Resources:

Jacob Tindle; Prasanna Tadi. Neuroanatomy, Parasympathetic Nervous System. StatPearls Publishing Jan 2022

The Neuroscience of Meditation. Understanding Individual Differences. Academic Press 2020


REDEFINING TERMINOLOGY IN ENDOMETRIOSIS

Written by Dr. Tamar Zelovich exclusively for the Women's Health Collaborative Edited by: Dr. Roberta Kline Endometriosis (endo') is...