VOLUME 16 • NUMBER 10
JUNE 2009
Treating female pattern hair loss
Noticeable hair loss can be deeply distressing. Here are some medical
treatments that may help.
A
bout one-third of women experience
hair loss (alopecia) at some time in
their lives; among postmenopausal
women, as many as two-thirds suffer hair
thinning or bald spots. Hair loss often has
a greater impact on women than on men,
because it’s less socially acceptable for them.
Alopecia can severely affect a woman’s emotional well-being and quality of life.
The main type of hair loss in both sexes—
and the subject of this article—is androgenetic alopecia, or female (or male) pattern
hair loss. In men, hair loss usually begins
above the temples, and the receding hairline
eventually forms a characteristic “M” shape;
hair at the top of the head also thins, often
progressing to baldness. In women, androgenetic alopecia begins with gradual thinning at the part line, followed by increasing
diffuse hair loss radiating from the top of the
head. A woman’s hairline rarely recedes, and
women rarely become bald.
There are many potential causes of hair
loss, including medical conditions, medica-
tions, and physical or emotional stress. If you
notice unusual hair loss of any kind, it’s important to see your primary care provider or
a dermatologist, to determine the cause and
appropriate treatment. You may also want to
ask your clinician for a referral to a therapist
or support group to address emotional difficulties. Hair loss can be frustrating, but recent years have seen an increase in resources
for coping with the problem.
What is androgenetic alopecia?
Almost every woman eventually develops
some degree of female pattern hair loss. It
can start any time after the onset of puberty, but women tend to first notice it around
menopause, when hair loss typically increases. The risk rises with age, and it’s higher for
women with a history of hair loss on either
side of the family.
As the name suggests, androgenetic alopecia involves the action of the hormones
called androgens, which are essential for normal male sexual development and have other
important functions in both
sexes, including sex drive and
Patterns of female hair loss
regulation of hair growth. The
condition may be inherited
and involve several different
genes. It can also result from
an underlying endocrine condition, such as overproduction
of androgen or an androgensecreting tumor on the ovary,
pituitary, or adrenal gland.
Type I
Type II
Type III
In either case, the alopecia
Clinicians use the Ludwig Classification to describe female pattern
is likely related to increased
hair loss. Type I is minimal thinning that can be camouflaged with hair
andro gen activity. But unstyling techniques. Type II is characterized by decreased volume and
like androgenetic alopecia in
noticeable widening of the mid-line part. Type III describes diffuse
men, in women the precise
thinning, with a see-through appearance on the top of the scalp.
role of androgens is harder to
IN THIS ISSUE
Avoiding tick-borne
4
illness
Diseases spread by ticks are
becoming more common. Here
are some ways to help reduce
your chances of getting one.
In the journals
7
Shift work and health; triplenegative breast cancer in
African American women.
By the way, doctor
8
What can I do about strep B
vaginitis? What’s normal
vaginal discharge?
What’s new
Positive Psychology
Hypertension:
Controlling the “silent killer”
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Hair loss continued
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determine. On the chance that an androgensecreting tumor is involved, it’s important
to measure androgen levels in women with
clear female pattern hair loss.
In either sex, hair loss from androgenetic
alopecia occurs because of a genetically
determined shortening of anagen, a hair’s
growing phase, and a lengthening of the
time between the shedding of a hair and
the start of a new anagen phase. (See “Life
cycle of a hair.”) That means it takes longer
for hair to start growing back after it is shed
in the course of the normal growth cycle.
The hair follicle itself also changes, shrinking and producing a shorter, thinner hair
shaft—a process called “follicular miniaturization.” As a result, thicker, pigmented,
longer-lived “terminal” hairs are replaced
by shorter, thinner, non-pigmented hairs
called “vellus.”
A clinician diagnoses female pattern hair
loss by taking a medical history and examining the scalp. She or he will observe the
pattern of hair loss, check for signs of inflammation or infection, and possibly order
blood tests to investigate other possible
causes of hair loss, including hyperthyroidism, hypothyroidism, and iron deficiency.
Unless there are signs of excess androgen
activity (such as menstrual irregularities,
acne, and unwanted hair growth), a hormonal evaluation is usually unnecessary.
Treatment with medications
Medications are the most common treatment for female pattern hair loss. They
include the following:
Minoxidil (Rogaine, generic versions).
This drug was introduced as a treatment
for high blood pressure, but people who
took it noticed that they were growing hair
in places where they had lost it. Research
confirmed that a 2% solution of minoxidil
applied directly to the scalp could stimulate hair growth. How it works is still not
clear. Two double-blind studies of women
ages 18 to 45 demonstrated its effectiveness. In one study, 13% of female minoxidil users had moderate hair growth, and
50%, minimal growth (compared with
6% and 33%, respectively, in the placebo
group). In the second study, 60% of women in the minoxidil group reported new
hair growth, compared with 40% in the
placebo group. As a result of these studies
and others, over-the-counter 2% minoxidil is FDA-approved for treating androgenetic alopecia in women.
Clearly, minoxidil is not a miracle drug.
While it can produce some new growth of
fine hair in some—not all—women, it can’t
restore the full density of the lost hair. It’s
not a quick fix, either. You won’t see results
until you use the drug for two months. The
effect often peaks at around four months,
but it could take longer, so plan
on a trial of six to 12 months. If
Life cycle of a hair
minoxidil works for you, you’ll
need to keep using it to mainA
B
C
tain those results. If you stop,
you’ll start to lose hair again.
How to use minoxidil: Be
sure that your hair and scalp
are dry. Using the dropper or
spray pump that’s provided
Follicle
Dermal
Hair
with the over-the-counter solupapilla
shaft
tion, apply it twice daily to every
area where your hair is thinEach hair develops from a follicle—a narrow pocket in the
ning. Gently massage it into the
skin—and goes through three phases of growth. Anagen (A),
scalp with your fingers so it can
the active growth phase, lasts two to seven years. Catagen (B),
reach the hair follicles. Then airthe transition phase, lasts about two weeks. During this phase,
dry your hair, wash your hands
the hair shaft moves upward toward the skin’s surface, and the
thoroughly, and wash off any
dermal papilla (the structure that nourishes cells that give rise
solution that has dripped onto
to hair) begins to separate from the follicle. Telogen (C), the
your
forehead or face. Don’t
resting phase, lasts around three months and culminates in
shampoo for at least four hours
the shedding of the hair shaft.
afterwards.
June 2009
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Some women find that the minoxidil solution leaves a Hair transplantation
deposit that dries and irritates their scalp. This irritation, Hair transplantation, a procedure used in the United States
called contact dermatitis, is probably caused not by the for more than 50 years, involves removing a strip of scalp
minoxidil itself, but rather by the alcohol that is included from the back of the head and using it to fill in a bald patch.
to facilitate drying. A 5% solution
Today, 90% of hair-transplant sur(available only by prescription and Follicular unit transplantation
geons use a technique called follicuapproved only for men) is more effeclar unit transplantation, which was
tive than the 2% formulation and
introduced in the mid-1990s.
C
may be prescribed off-label for womDuring this procedure, surgeons
en. The 5% version comes in a foam,
remove a narrow strip of scalp and
which appears to cause less irritation
divide it into hundreds of tiny grafts,
B
than the liquid.
each containing just a few hairs.
Side effects and concerns: MinoxiEach graft is planted in a slit in the
dil is safe, but it can have unpleasscalp created by a blade or needle in
ant side effects even apart from the
the area of missing hair. Hair grows
naturally this way, in small clusters of
alcohol-related skin irritation. Someone to four follicles, called follicular
times the new hair differs in color A
units. As a result, the graft looks betand texture from surrounding hair.
ter than the larger “plugs” associated
Another risk is hypertrichosis—
with hair transplants of yesteryear.
excessive hair growth in the wrong
The transplanted hair will shed
places, such as the cheeks or forewithin two to three weeks, and new
head. (This problem is more likely
growth will start at around three
with the stronger 5% solution.) Bemonths. After six to nine months,
cause the patent on Rogaine (the
most people will have achieved 60%
brand-name version of minoxidil)
of new hair growth. Some surgeons
has expired, many generic products This procedure can take several hours. First,
prescribe minoxidil after the operaare available. They all contain the surgeons remove an elliptical strip 3 to 4
tion, but this approach hasn’t been
same amount of minoxidil, but some inches long from the back of the scalp and
studied enough to determine its
include additional ingredients, such trim the hairs short (A). The strip is then divided
effectiveness.
as herbal extracts, which might trig- into 500 to 2,000 separate follicular units, each
containing
only
a
few
hairs
(B).
The
units
are
then
Side effects and concerns: Around
ger allergic reactions.
the time new hair growth starts,
Anti-androgens. Androgen recep- planted in an equivalent number of slits made
in the scalp in the area of missing hair (C).
some women experience folliculitis
tor–blocking drugs such as spirono(inflammation of the follicle). This
lactone (Aldactone) and finasteride
(Propecia) are not approved for the treatment of female minor complication can be treated with compresses and
pattern hair loss, and there is little reliable evidence that antibiotics. A more serious hazard is shock loss, the sudden
they are effective. However, some case studies suggest that loss of hair that normally grows in the area of the transplant.
women who don’t respond to minoxidil may benefit from Shock loss affects 30% to 50% of female hair-transplant
the addition of spironolactone. In the relatively uncommon recipients; fortunately, the loss is usually temporary, and
cases where there is an excess of androgen, a clinician may the hair will regrow. One drawback is that there’s a finite
prescribe 100 to 200 milligrams of an androgen receptor– amount of donor hair, and it may not be enough to fill in
blocking drug daily, together with an oral contraceptive for the transplant site as densely as before, especially if the area
women of reproductive age. (A woman taking one of these of thinning hair is large. A transplant procedure can cost
drugs should not become pregnant because they can cause from $4,000 to $15,000 and is rarely covered by insurance.
genital abnormalities in a male fetus.) Possible side effects
include weight gain, loss of libido, depression, and fatigue.
Selected resources
Iron supplements. In some women, iron deficiency could
A Woman’s Guide to Hair Loss and Excess Hair, a Special Health
be a cause of hair loss. Your clinician may test your iron level,
Report from Harvard Medical School, available from Harvard
particularly if you’re a vegetarian, have a history of anemia,
Health Publications. To order, call 877-649-9457 (toll-free) or
or have heavy menstrual bleeding. Iron supplements are
go to www.health.harvard.edu/WHL.
recommended if a woman’s iron level is less than 70 nanoAmerican Academy of Dermatology
grams per milliliter. However, there’s no reliable evidence
866-503-7546 (toll-free)
that iron supplementation is helpful for female pattern
www.aad.org
hair loss.
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June 2009
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|3
Recognizing and avoiding tick-borne illness
Most tick bites won’t make you sick, but the ones that do can be serious.
J
une is here and the bugs are out—in yards and gar- tick looks like a tiny spider and is not quite onedens, at the beach, and along hiking trails and pathways. eighth of an inch long (other tick species may
Lone star tick*
Most are just an annoyance, but some are vectors, or be slightly larger). An adult tick engorged with blood
transmitters, of disease.
may be the size of a small marble. To mature from one stage
In the United States, the chief culprits are ticks—in par- to the next, the tick needs a blood meal. Larvae and nymphs
ticular, the deer tick (also called the black-legged tick), feed on small vertebrates such as birds and rodents (in parwhich can carry and transmit the bacterium responsible for ticular, the white-footed mouse). Adult ticks attach to larger
Lyme disease. Considered somewhat rare
hosts—chiefly deer—where they mate and
just 25 years ago, Lyme disease is now the How big is a tick?
feed before the female drops off to lay eggs.
most common vector-borne illness in the
Over a lifetime, a tick may feed on a wide
United States. About 20,000 cases are revariety of animals, potentially putting it in
contact with several infectious organisms.
ported annually to the CDC, and the agenIf ticks weren’t bloodsucking, diseasecy says that’s only 10% of the total.
spreading parasites, we might be more inWe consulted tick expert Dr. Jonathan
clined to admire how well engineered they
Edlow of Harvard Medical School and
are. They have receptors on their front legs
Boston’s Beth Israel Deaconess Medical
that
detect small vibrations and the breath
Center, whose book Bull’s Eye: Unraveling
the Medical Mystery of Lyme Disease, outof passing animals and people. A tick that is
Adult “questing”—seeking a blood meal—will perch
lines the history of this emerging infectious Nymph
tick
disease. According to Dr. Edlow, there are
on tall grass or low bushes and wave its front
several reasons for the rising incidence of
legs, which are equipped with small barbs for
Lyme disease. Its geographical range has expanded, mostly latching on to fur, feathers, or skin. Once it gets on its host,
because of the growing deer population, which harbors the the tick may crawl around for several hours before attaching.
ticks. Also, land once cleared for farming has become reTo feed, the tick inserts a tube-like mouthpart called a
forested, attracting more deer (and other tick hosts) as well hypostome into the skin (see the illustration on page 6) and
as suburban development. As a result, says Dr. Edlow, “peo- secretes a salivary cement to hold the mouthpart in place.
ple’s day-to-day activities—their hobbies, their work, and Backward-pointing barbs on the hypostome help secure
where they live—put them in closer contact with wildlife the connection. Tick saliva also contains substances that
than they were 50 years ago.” Finally, both patients and cli- facilitate feeding (and disease transmission), including antinicians recognize the disease more readily than ever before. coagulants, anti-inflammatory and immunosuppressive
Lyme disease is the predominant tick-borne illness in agents, and vasodilators. During the blood meal, pathothe United States, but it’s not the only one. Ticks can spread genic (disease-causing) organisms in the tick’s gut migrate
other bacterial and viral diseases, including babesiosis, ana- to the salivary gland and can be transmitted to the host.
plasmosis, ehrlichiosis, tularemia, Rocky Mountain spotIt’s not clear how long an infected tick must be attached
ted fever, relapsing fever, Colorado tick fever, and southern before it transmits a disease (a crawling tick doesn’t transtick-associated rash illness (STARI). Tick paralysis, another mit anything). For Lyme disease, it probably takes one to
tick-borne disease, is caused not by an infectious organism three days. “It’s a spectrum, but the faster you get it off, the
but by a toxin that the tick itself produces. Most tick bites less likely you are to get sick from it,” says Dr. Edlow.
won’t give you a disease, but some can, and there is no vaccine to protect you from the vast majority of these diseases. Signs, symptoms, and treatment
(There is a vaccine for European tick-borne encephalitis). Tick-borne diseases occur throughout the United States,
It’s almost impossible to avoid ticks completely, especially chiefly in late spring and summer, when ticks are most
if you spend time outdoors. But you can take steps
active and most likely to come in contact with humans.
to lower your risk of getting bitten or, if you’re
Symptoms vary but usually include fever, chills, muscle
bitten, of becoming ill.
aches and pains, headache, and sometimes nausea or a rash.
Lyme disease, caused by the bacterium Borrelia burgdorferi,
Deer tick*
is usually heralded by erythema migrans (EM), an expandWhat makes a tick tick?
A deer tick’s life cycle typically spans two years and involves ing area of redness surrounding the tick bite. Rocky Mounfour stages of development: egg, larva, nymph, and adult. tain spotted fever and tick-borne relapsing fever start with
At the larval stage, the tick is barely bigger than a pinpoint. sudden high fever and chills.
A nymph tick is about the size of a poppy seed. An adult
*Tick photos, courtesy of the CDC, are not true size.
4|
Harvard Women’s Health Watch
|
June 2009
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Most tick-borne illness is caused by bacteria, so it can be
treated with antibiotics. But it’s important to diagnose the
problem early, to avoid complications. For example, a delay
in diagnosing Lyme disease can result in cardiac symptoms,
neurological problems, and arthritis. Luckily, most people
develop EM, the telltale early sign, although you can miss it
if it appears on the scalp or another hard-to-see area. Some
EM clears centrally to form a “bull’s eye,” which is regarded
as a diagnostic sign of Lyme disease and a reason to start
antibiotic therapy. But the most common pattern is “a uniform redness without the bull’s eye,” says Dr. Edlow.
The most lethal tick-borne disease in the United States
is Rocky Mountain spotted fever, caused by the Rickettsia
rickettsii bacterium. Despite its name, the disease is found
Tick-borne diseases affecting humans in the United States
Infectious
organism
Tick vector
Symptoms
Initial treatment
Lyme disease
Borrelia
burgdorferi
(bacterium)
Ixodes (I.) scapularis,
I. pacificus (deer or
black-legged tick)
Erythema migrans (expanding
area of redness or rash around
the bite), fatigue, fever, chills,
muscle aches, headache.
Antibiotics
(doxycycline,
tetracycline,
amoxicillin)
Northeast, Southeast, South Central,
Pacific Coast
Anaplasmosis
Anaplasma
phagocytophilum
(bacterium)
I. scapularis,
I. pacificus (deer or
black-legged tick)
Fever, chills, headache, muscle
pain, nausea, cough, sore
throat—rarely, rash.
Antibiotics
(doxycycline,
tetracycline)
Northeast,
upper Midwest,
Pacific Coast
Babesiosis
Babesia microti
(protozoan
parasite)
I. scapularis,
I. pacificus (deer or
black-legged tick)
Fatigue, fever, sweats, headache,
muscle pain, gastrointestinal
symptoms, enlarged spleen.
Combination
clindamycin
and quinine
or azithromycin
and atovaquone
Northeast,
upper Midwest,
Pacific Coast
Ehrlichiosis
Ehrlichia
chaffeensis,
Ehrlichia ewingii
(bacterium)
Amblyomma (A.)
americanum
(lone star tick)
Fever, chills, headache, muscle
pain, nausea, cough, sore
throat—rash in 30% to 40%
of adults.
Antibiotics
(doxycycline
or tetracycline;
resistant to many
other antibiotics)
Mid-Atlantic,
Southeast,
and South Central
Southern tickassociated rash
illness (STARI)
Unknown, possibly
a new type of
Borrelia bacterium
A. americanum
(lone star tick)
Erythema migrans
(see Lyme disease, above).
Antibiotics
(tetracycline)
Southeast, South
Central, East Coast
into Maine
Colorado
tick fever
Colorado tick
fever virus
Dermacentor (D.)
andersoni (Rocky
Mountain wood tick)
Fever, chills, headache, muscle
pain; fever may remit then
return—rarely, a spotted rash.
Supportive care
(rest, fluids,
ibuprofen or
acetaminophen)
Mostly Colorado,
Utah, and Montana
Rocky Mountain
spotted fever
Rickettsia
rickettsii;
Rickettsia parkeri
(bacterium)
D. andersoni (Rocky
Mountain wood
tick); D. variabilis
(American dog tick);
A. americanum
(lone star tick)
Fever, nausea, vomiting, muscle
pain, headache, elevated
liver enzymes, gastrointestinal
problems—spotted rash two
or three days after fever onset.
May cause coma or death.
Antibiotics
(tetracycline,
chloramphenicol),
fluids
Widespread in
the United States,
except for
the Southwest
Tularemia
Francisella
tularensis
(bacterium)
D. andersoni (Rocky
Mountain wood tick);
D. variabilis (American
dog tick)
Fever, chills, headache, vomiting,
sore throat, skin ulcers, lymph
node enlargement—may affect
the eyes or lungs.
Antibiotics
(streptomycin,
tetracycline,
chloramphenicol,
fluoroquinolones)
Mostly
South Central
Tick-borne
relapsing fever
Various
Borrelia species
(bacterium)
Ornithodoros species
(soft tick)
Recurring episodes of fever,
chills, sweats, headache, muscle
pain, joint pain, vomiting.
Antibiotics
(tetracycline,
erythromycin)
West of the
Mississippi
Tick paralysis
Neurotoxin
produced by
the tick
Various (depends on
region)
Paralysis, starting at the feet
and progressing to the face.
May result in death.
Recovery begins
as soon as tick is
removed, but can
be fatal if the tick
isn’t removed
Mostly in the
Northwest
Disease
www.health.harvard.edu
June 2009
|
Area of the
United States
Rocky
Mountain
wood tick*
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|5
How to remove a tick
Pull tick slowly up and
away from the skin
Hypostome
Tweezers
Barbs
A tick feeds by way of a two-pronged mouthpart
(hypostome) held in place with salivary cement
and secured with tiny backward-pointing barbs.
To remove the tick, use narrow-tipped tweezers
and grasp it as close to the skin as possible; then
pull upward slowly and steadily. If the mouthpart
remains in the skin, try to remove it. If you can’t,
check with your clinician. Wash your skin and
hands with soap and warm water. Never crush or
squeeze an attached tick, don’t try to burn it with
a lighted match, and don’t apply any substance
like petroleum jelly, fingernail polish, alcohol, or
pesticides. If you do, the tick may regurgitate its
stomach contents into your skin, increasing the
chance of infection.
the DEET directly on your face; spray it into your hands
and then apply it to the face. Consult a pediatrician before
using it on young children. Wash your hands afterward to
avoid getting it into your eyes and mouth. Use permethrincontaining products on clothing, footwear, and camping
gear (including cots, nets, and tents). Spray items for 30
to 45 seconds and allow them to dry for two to four hours
before wearing or using them. Permethrin should not be
applied to the skin.
Do a tick drag. This is a way to find out whether there
are ticks in your yard. Attach a square yard of white flannel to a 3-foot stick and tie a rope to each end of the stick.
Drag the cloth over the lawn and leaves, and examine it for
ticks that have latched on. Do this several times. To check
bushy or grassy vegetation, use a tick “flag,” which is similar to the drag but mounted like a flag on a stick. (This tip
comes from the Tick Management Handbook, available
from the Connecticut Agricultural Experiment Station
Web site, www.ct.gov/CAES.) Reduce the number of ticks
in your yard by clearing leaf litter, low
brush, and tall grasses. You may also
How to protect yourself
Selected resources
want to contact a pest-control profesIf you may have been exposed to ticks
Centers for Disease Control
sional about chemical options and wildand you develop flulike symptoms or
and Prevention
life
control.
a rash, see your clinician—even if the
800-232-4636 (toll-free)
www.cdc.gov/Features/StopTicks
Check yourself. If you’re in an area
symptoms go away on their own. Tickinhabited by ticks, check yourself once
borne infection usually causes no lasting
National Institute of Allergy
and Infectious Disease
harm if it’s recognized and treated early.
a day. (Check children and pets in your
866-284-4107 (toll-free)
Of course, it’s better to avoid getting incare, too.) To remove ticks from clothwww3.niaid.nih.gov/topics/tickborne
fected in the first place. To that end, here
ing, you can use an adhesive lint brush
American Lyme Disease Foundation
are some measures you can take:
or masking or cellophane tape rolled
www.aldf.com
Protect yourself. Whenever possible,
around your hand, sticky side out. Unavoid tick habitats—wooded, bushy, or
dress and examine your skin, using a
grassy areas, including those near beaches and sand dunes. mirror (or mirrors) for hard-to-see places, such as the back
If you’ll be outdoors in tick-infested areas, wear light- of the knees, armpits, back of the neck, and scalp. If you
colored clothing (to make ticks easier to spot) with long find a tick attached to your skin, remove it as soon as possleeves and long pants tucked into your socks (to keep ticks sible. (See “How to remove a tick.”) Note the date, and save
away from your skin). Use a DEET-containing insect repel- the tick for a month for reference or testing in case you
lent on exposed skin (but not under clothes). Don’t spray develop symptoms.
mostly in the southeastern United States; 600 to 1,000 cases
are reported each year, but health experts think many more
cases are not reported. Cells in the lining and walls of blood
vessels are infected and organs and systems throughout the
body may suffer. Even with prompt treatment, 3% to 5%
of cases result in death; without treatment, mortality may
be as high as 25%. Other emerging tick-borne diseases in
humans include babesiosis, a malaria-like parasitic infection that was once largely a veterinary problem, and anaplasmosis and ehrlichiosis, which have similar symptoms
but are caused by different organisms. Tick-borne encephalitis, a viral disease, is found throughout Europe and Asia
but is still rare in the United States.
Some ticks transmit more than one disease, sometimes
from the same bite. The deer tick can transmit babesiosis
and anaplasmosis as well as Lyme disease. Lone star ticks
are linked to human ehrlichiosis and STARI, a Lyme-like
disease. The American dog tick carries Rocky Mountain
spotted fever and tularemia; it can also cause tick paralysis.
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Harvard Women’s Health Watch
|
June 2009
www.health.harvard.edu
This Harvard Health Publication was prepared exclusively for Amy Quach - Purchased at http://www.health.harvard.edu/
in the journals
Scientists discover how shift work may threaten health
P
eople who work on night or rotating shifts are at increased risk for obesity, diabetes, and cardiovascular
disease. The biological mechanism leading to such workrelated health outcomes has been largely unknown—until
now. A new study has found that a mismatch between the
body’s circadian rhythms and behavioral “rhythms” such
as the sleep/wake and eating/fasting cycles causes abnormal changes in hormonal and metabolic functions. Such a
mismatch—called circadian misalignment—may also explain jet lag. Results were published in the March 17, 2009,
issue of the Proceedings of the National Academy of Sciences.
To investigate the physiological effects of circadian misalignment, researchers at Boston’s Brigham and Women’s
Hospital studied 10 healthy volunteers for 10 days in a
laboratory free of time cues. The subjects were placed on
a 28-hour day, each day beginning four hours later than
the one before, until their sleep/wake cycles were reversed.
Activities and meals were also carefully controlled. As a result, the volunteers slept and ate at all phases of their internal circadian cycles, or body clocks. The researchers took
hourly measurements of glucose, insulin, cortisol (the socalled stress hormone), and leptin (an appetite-regulating
hormone that sends fullness signals to the brain) and daily
measurements of blood pressure, heart rate, and other functions, including brain wave activity during sleep.
Among the findings: circadian misalignment lowered
leptin levels (a factor contributing to increased appetite and
possibly obesity), raised waking blood pressure, and increased glucose (despite increases in insulin levels). Three
of the 10 subjects showed signs of prediabetes. Circadian
misalignment also disrupted normal cortisol cycling, which
the authors say could contribute to insulin resistance.
Theoretically, a permanent move to night work might
alleviate the unhealthy changes triggered by circadian misalignment. But even people who regularly work the night
shift “typically don’t get their circadian system properly
aligned with the inverted sleep/wake cycle,” says lead author
Dr. Frank Sheer. The reason? Most revert to a normal schedule on weekends and days off. Also, even the small exposure
to daylight during the morning commute home can reset
their circadian system. The researchers concluded that the
changes they observed, if sustained chronically, could contribute to night-shift workers’ increased risk for obesity, diabetes, and cardiovascular disease.
Triple-negative breast cancer rate is triply high in black women
A
frican American women in the United States are less
likely to develop breast cancer than white women,
but they’re more likely to die of the disease, especially at a
younger age. Explanations for this disparity include differences in income, education, and access to health care. Researchers have also been investigating biological factors—in
particular, an aggressive form of the disease called triplenegative breast cancer, which is more common not only in
black women but also in women with BRCA1 mutations
and premenopausal women. A new study has found that
the rate of triple-negative breast cancer is three times higher
in African American women than white women. Earlier research indicated that young African American women were
especially vulnerable, but this latest research finds that age
makes no difference. The results were published in Breast
Cancer Research (online, March 25).
Recognized only in recent years as a distinct subtype, triplenegative breast cancer is so named because it lacks receptors for three substances that fuel most breast cancers:
estrogen, progesterone, and human epidermal growth factor 2 (HER2). Some of the best breast cancer therapies—
anti-estrogen drugs (tamoxifen and aromatase inhibitors)
and the anti-HER2 drug Herceptin—target these receptors
and thus are useless in treating triple-negative breast cancer.
www.health.harvard.edu
The researchers created a database of women treated for
invasive breast cancer at Boston University Medical Center. Data included tumor type, grade, stage, and receptor
status as well as age, body mass index (BMI), and ethnic
group. Among the 415 women in the database, 43% were
black; 36%, white; and 10%, Hispanic; the rest were Indian
or Middle Eastern. Triple-negative breast cancer was found
in 20% of the group as a whole, but black women were disproportionately affected: 30% had triple-negative breast
cancer, compared with 11% to 13% in the other groups. Premenopausal and postmenopausal black women were equally
affected, and BMI was not a factor. In the group as a whole,
the risk of triple-negative breast cancer fell as BMI rose.
Although there are fewer targeted options for triplenegative breast cancer, combinations of conventional chemotherapeutic drugs, including cyclophosphamide, doxorubicin (an anthracycline), and paclitaxel and docetaxel
(taxanes) are often effective. The platinum drugs cisplatin
and carboplatin appear promising, and are being evaluated
in clinical trials. Other approaches now under investigation
include anti-angiogenic drugs (which block the growth of
blood vessels that feed the malignancy) and PARP inhibitors,
agents that may improve the susceptibility of certain cancer
cells to chemotherapy and act on their own as well.
June 2009
|
Harvard Women’s Health Watch
This Harvard Health Publication was prepared exclusively for Amy Quach - Purchased at http://www.health.harvard.edu/
|7
by the way, doctor
Q
incontinence, burning, and more frequent urinary infections. Especially in postmenopausal
women, vulvovaginal symptoms could also result
from skin conditions, including allergic reactions
to soaps, pads, or feminine hygiene products.
You should contact your clinician for another
evaluation. She or he may repeat your exam, reSome vaginal discharge is normal. It helps evaluate the discharge, and prescribe a second,
to protect against vaginal infections and perhaps longer, course of amoxicillin—or maybe
provides lubrication for the vaginal tissues. The try another medication targeting a different condidischarge consists of vaginal skin cells, mucus, tion. If atrophic vaginitis is involved, your clinician
and fluid, as well as Candida (a type of yeast) and may prescribe vaginal estrogen. In the meantime,
vaginal flora, the bacteria normally found in the you could try using Replens, an over-the-counter
vagina. Strep B, or group B streptococcus, is one vaginal moisturizer. Used regularly, it helps relieve
possible constituent of the vaginal flora. Most vaginal dryness and irritation by reducing the
of the time, vaginal flora and Candida co-exist acidity of the vagina and promoting a healthy balpeacefully. But a change in the balance and in ance among vaginal flora and other organisms.
vaginal pH (acidity) may result in vaginal inflammation, or vaginitis.
Group B streptococcus is not usually a cause
Celeste Robb-Nicholson, M.D.
of vaginitis. Even when strep B is found in a labEditor in Chief, HWHW
oratory culture of vaginal discharge, it’s hard to
tell whether it’s the culprit or just an innocent bystander, since it harmlessly colonizes the vagina
What’s normal vaginal discharge?
in up to about one-third of women. If strep B is
All women have some amount of vaginal discharge.
causing the symptoms, then a course of amoxiIt’s produced as part of the process that keeps
cillin would be the right treatment. The fact that
the vagina healthy. Fluids secreted by the cervix
your discharge returned after taking amoxiciland vagina exit the vagina daily, along with sloughedlin suggests that the infection wasn’t completely
off epithelial cells, normal bacteria, and mucus.
treated—or that other factors may be contributing
The amount of normal discharge varies from
to your symptoms. One possible cause is bacterial
woman to woman and in response to changes
vaginosis—a condition in which there is an overin estrogen levels.
growth of certain unhealthy bacteria, often causIn premenopausal women, it’s normal to have oneing a fishy odor. This condition may respond to
quarter to nearly one teaspoon of white or clear
amoxicillin, but metronidazole and clindamycin
discharge every day. It may have a slight odor, but
are more likely to cure it.
it should not smell bad. It’s also normal for this
Another possibility to consider is vaginal atrodischarge to be heavier in women who are pregnant
phy, a common cause of vulvovaginal symptoms
or using estrogen-containing contraceptives. The
amount and consistency may vary depending
in postmenopausal women. Because estrogen
on
the phase of a woman’s menstrual cycle. For
helps maintain blood flow to the vagina and helps
example,
discharge may be minimal and sticky right
keep tissues plump, elastic, and moist, a decline
after
the
menstrual
period and heavy, clear, and
in estrogen can cause vaginal tissues to become
stringy closer to ovulation. Postmenopausal women
thinner and more vulnerable to infection, inhave less vaginal discharge due to the loss of estroflammation, and trauma during activities such as
gen, although the use of hormone therapy can
sexual intercourse. Symptoms of vaginal atrophy
change that equation.
(also called atrophic vaginitis) include vaginal
Signs of abnormal vaginal discharge, and perhaps
dryness, itching, and a burning, watery discharge.
infection, include yellowish, grayish, or greenish color;
The condition can also produce pain with intercottage cheese–like or foamy consistency; and foul
course and a feeling of pressure due to shortenor fishy odor, possibly accompanied by pain, redness,
ing or tightening of the vaginal canal. There may
swelling, itching, or burning in the vulvovaginal area.
also be urinary symptoms, including urgency,
I’m 61 and recently began to have a vaginal
discharge. It’s not itchy, but sexual intercourse
is painful. My doctor diagnosed it as strep B vaginitis and prescribed amoxicillin, which helped.
But the discharge returned within a week. What
do you recommend?
What can I do
about strep B
vaginitis?
Send us a
question for
By the way, doctor
Harvard Women’s
Health Watch
10 Shattuck St., 2nd Fl.
Boston, MA 02115
womens _ health@hms.
harvard.edu
Because of the volume
of mail we receive,
we can’t answer every
letter, nor can we provide personal medical
advice.
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Harvard Women’s Health Watch
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June 2009
www.health.harvard.edu
This Harvard Health Publication was prepared exclusively for Amy Quach - Purchased at http://www.health.harvard.edu/