Month: September 2022

Should a woman consider having her fallopian tubes removed to lower her risk for developing ovarian cancer? Recent recommendations from the Ovarian Cancer Research Alliance (OCRA), endorsed by the Society for Gynecologic Oncology, encourage this strategy, if women are finished having children and would be undergoing gynecologic surgery anyway for other reasons.

Why is this new guidance being offered?

Ovarian cancer claims about 13,000 lives each year, according to the American Cancer Society. The new guidance builds on established advice for women with high-risk genetic mutations or a strong family history of ovarian cancer.

This idea isn’t new for women at average risk for ovarian cancer, either: in 2019, the American College of Obstetricians and Gynecologists (ACOG) floated this strategy in a committee opinion.

A Harvard expert agrees the approach is sound, considering established evidence that many cases of aggressive ovarian cancers arise from cells in the fallopian tubes.

“We’ve known for a long time that many hereditary cases of ovarian cancer likely originate in lesions in the fallopian tubes,” says Dr. Katharine Esselen, a gynecologic oncologist at Beth Israel Deaconess Medical Center. “Although we group all of these cancers together and call them ovarian cancer, a lot actually start in the fallopian tubes.”

Can ovarian cancer be detected early through symptoms or screening?

No — which helps fuel these recommendations.

Ovarian cancer is notoriously difficult to detect. Symptoms tend to be vague and could be related to many other health problems. Signs include bloating, pelvic pain or discomfort, changes in bowel or bladder habits, feeling full earlier when eating, fatigue, unusual discharge or bleeding, and pain during sex.

Disappointing results from a large 2021 study in the United Kingdom reported in The Lancet show that lowering the risks of a late-stage diagnosis isn’t easy. The trial tracked more than 200,000 women for an average of 16 years. It found that screening average-risk women with ultrasound and a CA-125 blood test doesn’t reduce deaths from the disease. By itself, the CA-125 blood test isn’t considered reliable for screening because it’s not accurate or sensitive enough to detect ovarian cancer.

Only 10% to 20% of patients are diagnosed at early stages of ovarian cancer, before a tumor spreads, Dr. Esselen notes. “There’s never been a combination of screenings that has reliably identified the majority of these cancers early, when they’re more treatable,” she says.

What does it mean to be at higher risk for ovarian cancer?

Family history is the top risk factor for the disease, which is diagnosed in nearly 20,000 American women annually. A woman is considered at higher risk of ovarian cancer if her mother, sister, grandmother, aunt, or daughter has had the disease.

Additionally, inherited mutations in the BRCA1 or BRCA2 gene raise risk considerably, according to the National Cancer Institute. (These mutations are more common among certain groups, including people of Ashkenazi Jewish heritage.) While about 1.2% of women overall will develop ovarian cancer in their lifetime, up to 17% of those with a BRCA2 mutation and up to 44% with a BRCA1 mutation will do so by ages 70 to 80.

How much can surgery lower the odds of ovarian cancer?

It’s not clear that all women — even those not scheduled for surgery — should undergo removal of their fallopian tubes to reduce this risk once they finish having children, Dr. Esselen says. This surgery can’t totally eliminate the possibility of ovarian cancer — and surgery carries its own risks. She recommends discussing options with your doctor depending on your level of risk for this disease:

For those at average risk for ovarian cancer: Available data seem to support the idea of removing the fallopian tubes. Studies of women who underwent tubal ligation (“tying the tubes”) or removal to avoid future pregnancies indicate their future risks of ovarian cancer dropped by 25% to 65% compared to their peers. And if a woman is already undergoing gynecologic surgery, such as a hysterectomy, the potential benefits likely outweigh the risks.

Before menopause, removing the fallopian tubes while leaving the ovaries in place is preferable to removing both. That’s because estrogen produced by the ovaries can help protect against health problems such as cardiovascular disease and osteoporosis. Leaving the ovaries also prevents suddenly experiencing symptoms of menopause.

“The fallopian tubes don’t produce any hormones and aren’t really needed for anything other than transporting the egg,” she says. “So there’s little downside to removing them at the time of another gynecologic procedure if a woman is no longer interested in fertility.”

For those at high risk for ovarian cancer: “In a world where we don’t have good screening tools for ovarian cancer, it makes sense to do something as dramatic as surgery to remove both ovaries and fallopian tubes when a woman is known to be at higher risk because of a strong family history or a BRCA gene mutations,” Dr. Esselen says.

Currently, preliminary evidence suggests it may be safe to proactively remove the fallopian tubes while delaying removal of the ovaries to closer to the time of menopause to avoid an early menopause. However, it’s unclear how much this procedure lowers the odds of developing ovarian cancer.

“Generally, the findings so far have focused on the safety of the surgery itself and women’s quality of life,” Dr. Esselen says. “Long-term data in high-risk women takes a great number of years to accumulate. We need this data to know whether removing the fallopian tubes alone is equally effective in preventing ovarian cancer as removing the tubes and ovaries.”

Discussing your options is key

Ultimately, Dr. Esselen says that she advocates OCRA’s new recommendations. “For anyone who’s completed childbearing, if I’m doing surgery that wouldn’t necessarily include routinely removing their fallopian tubes, I’m offering it,” she says. “A woman and her doctor should always discuss this at the time she’s having gynecologic surgery.”

About the Author

Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

You may be familiar with Lyme disease, a bacterial infection from the bite of an infected black-legged tick. While Lyme disease is the most commonly reported tick-borne illness in the United States, another is on the rise: babesiosis. A March 2023 CDC report shows that babesiosis now has a foothold in 10 states in the Northeast and Midwest.

What is babesiosis?

Babesiosis is an illness caused by a parasite (typically Babesia microti) that infects red blood cells. It is spread by infected black-legged ticks (deer ticks). In most cases, the tick must be attached to a person for at least 36 hours to transmit the parasite.

What are the signs and symptoms of babesiosis?

“You may or may not see the tick bite mark on your skin, so your symptoms may be the earliest sign of an infection,” says Dr. Nancy A. Shadick, a rheumatologist and director of the Lyme Disease Prevention Program at Harvard-affiliated Brigham and Women’s Hospital.

Some people with babesiosis experience no symptoms, but the most common symptoms are a combination of

• severe flulike symptoms such as a high fever (up to 104° F), chills, and sweats, particularly night sweats
• general discomfort or feeling unwell
• intense headache
• muscle and joint pain
• loss of appetite
• nausea
• fatigue.

These symptoms can appear within one to nine weeks, or even several months after a person has been infected.

Less often, babesiosis causes hemolytic anemia. In this form of anemia, red blood cells are destroyed faster than the body can replace them. Signs and symptoms include

• fatigue
• dizziness
• weakness
• dark urine
• yellowing skin and whites of the eyes.

Babesiosis can be a severe, life-threatening disease, particularly for adults over age 65 and people with weakened immune systems, such as people without a spleen and those receiving biological therapy or chemotherapy.

Why are cases of babesiosis rising?

Until recently, babesiosis was endemic (consistently present) in seven states: Connecticut, Massachusetts, Minnesota, New Jersey, New York, Rhode Island, and Wisconsin.

However, the CDC report added three more Northeastern states to the list — Maine, New Hampshire, and Vermont — where case rates between 2011 and 2019 matched or even surpassed the other seven states. Vermont cases rose from two to 34, Maine cases from nine to 138, and New Hampshire cases from 13 to 78. The trend is worrisome.

There are several reasons for the rise in babesiosis. “One is warming temperatures driven by climate change, which cause ticks to be more active earlier in the spring and later in the fall,” says Dr. Shadick. Other contributors are an increase in the number of whitetail deer and a rise in housing construction in wooded areas.

How is this tick-borne illness diagnosed and treated?

Babesiosis is diagnosed by a blood test.

It may be treated with specific antibiotics (different than those used for Lyme disease), or with an antibiotic and antimalarial medication. While treatment usually takes seven to 10 days, a longer course may be recommended for people who are immunocompromised.

Can you get Lyme disease and babesiosis?

Yes, though you may also get either one by itself. Some black-legged ticks that carry the Lyme bacterium (Borrelia burgdorferi) also may carry the Babesia parasite, according to Dr. Shadick. “Lyme disease also shares similar symptoms with babesiosis, such as fever, headache, and fatigue,” she says.

How can you prevent tick-borne illnesses?

Tick exposure can occur year-round, but ticks are most active during warmer months. Most cases of babesiosis occur from late spring through early autumn.

Ticks live in grassy, brushy, or wooded areas. Almost any outdoor activity can expose you or your pets to infected ticks, such as camping, walking your dog, and gardening.

To avoid babesiosis and other tick-borne diseases, the CDC offers these tips:

• Use insect repellents recommended by the Environmental Protection Agency (EPA) containing DEET, picaridin, IR3535, oil of lemon eucalyptus (OLE), para-menthane-diol (PMD), or 2-undecanone. Treat clothing and gear with products containing 0.5% permethrin. Permethrin can treat boots, clothing, and camping gear and remain protective through several washings.
• Wear light-colored pants and long-sleeved shirts and a hat during outdoor activities.
• Try to avoid wooded and brushy areas with high grass and leaf litter. Walk in the center of trails.
• Check clothing, pets, backpacks, and gear for ticks after spending time outdoors.
• When you come indoors, remove shoes and put clothes in the dryer on high heat for 10 minutes to kill ticks.
• To remove a tick, use fine-tipped tweezers to grasp the tick as close to the skin’s surface as possible. Pull upward with steady, even pressure. Don’t twist or jerk the tick, as this can cause the mouth-parts to break off and remain in the skin. Clean the bite area with rubbing alcohol or soap and water. Shower within two hours after coming indoors to help remove any unattached ticks. Use the opportunity for a full-body tick check.

For in-depth information about preventing, treating, and living with a tick-borne illness like Lyme disease or babesiosis, see the Lyme Wellness Initiative at Harvard Health Publishing.

About the Author

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Howard LeWine, M.D., is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

Snuff is a smokeless tobacco similar to chewing tobacco. It rarely makes headlines. But it certainly did when the FDA authorized a brand of snuff to market its products as having a major health advantage over cigarettes. Could this be true? Is it safe to use snuff?

What did the FDA authorize as a health claim?

Here’s the approved language for Copenhagen Classic Snuff:

If you smoke, consider this: switching completely to this product from cigarettes reduces risk of lung cancer.

While the statement is true, this FDA action — and the marketing that’s likely to follow — might suggest snuff is a safe product. It’s not. Let’s talk about the rest of the story.

What is snuff, anyway?

Snuff is a form of tobacco that’s finely ground. There are two types:

• Moist snuff. Users place a pinch or a pouch of tobacco behind their upper or lower lips or between their cheek and gum. They must repeatedly spit out or swallow the tobacco juice that accumulates. After a few minutes, they remove or spit out the tobacco as well. This recent FDA action applies to a brand of moist snuff.
• Dry snuff. This type is snorted (inhaled through the nose) and is less common in the US.

Both types are available in an array of scents and flavors. Users absorb nicotine and other chemicals into the bloodstream through the lining of the mouth. Blood levels of nicotine are similar between smokers and snuff users. But nicotine stays in the blood for a longer time with snuff users.

Why is snuff popular?

According to CDC statistics, 5.7 million adults in the US regularly use smokeless tobacco products — that’s about 2% of the adult population. A similar percentage (1.6%) of high school students use it as well. That’s despite restrictions on youth marketing and sales.

What accounts for its popularity?

• Snuff may be allowed in places that prohibit smoking.
• It tends to cost less than cigarettes: $300 to $1,000 a year versus several thousand dollars a year paid by some smokers.
• It doesn’t require inhaling smoke into the lungs, or exposing others to secondhand smoke.
• Snuff is safer than cigarettes in at least one way — it is less likely to cause lung cancer.
• It may help some cigarette smokers quit.

The serious health risks of snuff

While the risk of lung cancer is lower compared with cigarettes, snuff has plenty of other health risks, including

• higher risk of cancers of the mouth (such as the tongue, gums, and cheek), esophagus, and pancreas
• higher risk of heart disease and stroke
• harm to the developing teenage brain
• dental problems, such as discoloration of teeth, gum disease, tooth damage, bone loss around the teeth, tooth loosening or loss
• higher risk of premature birth and stillbirth among pregnant users.

And because nicotine is addictive, using any tobacco product can quickly become a habit that’s hard to break.

There are also the “ick” factors: bad breath and having to repeatedly spit out tobacco juice.

Could this new marketing message about snuff save lives?

Perhaps, if many smokers switch to snuff and give up smoking. That could reduce the number of people who develop smoking-related lung cancer. It might even reduce harms related to secondhand smoke.

But it’s also possible the new marketing message will attract nonsmokers, including teens, who weren’t previously using snuff. A bigger market for snuff products might boost health risks for many people, rather than lowering them.

The new FDA action is approved for a five-year period, and the company must monitor its impact. Is snuff an effective way to help smokers quit? Is a lower rate of lung cancer canceled out by a rise in other health risks? We don’t know yet. If the new evidence shows more overall health risks than benefits for snuff users compared with smokers, this new marketing authorization may be reversed.

The bottom line

If you smoke, concerns you have about lung cancer or other smoking-related health problems are justified. But snuff should not be the first choice to help break the smoking habit. Commit to quit using safer options that don’t involve tobacco, such as nicotine gum or patches, counseling, and medications.

While the FDA’s decision generated news headlines that framed snuff as safer than smoking, it’s important to note that the FDA did not endorse the use of snuff — or even suggest that snuff is a safe product. Whether smoked or smokeless, tobacco creates enormous health burdens and suffering. Clearly, it’s best not to use any tobacco product.

Until we have a better understanding of its impact, I think any new marketing of this sort should also make clear that using snuff comes with other important health risks — even if lung cancer isn’t the biggest one.

Follow me on Twitter @RobShmerling

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

For people with obesity, weight-loss surgery can reverse or greatly improve many serious health issues, such as diabetes, high blood pressure, and pain. But these procedures also change how the body metabolizes alcohol, leaving people more likely to develop an alcohol use disorder. A new study finds that one type of surgery, gastric bypass, may increase the dangers of drinking much more than other weight-loss strategies.

“Alcohol-related problems after weight-loss surgery are a known risk. That’s one reason we require people to abstain from alcohol for at least six months — and preferably a full year — before any weight-loss surgery,” says Dr. Chika Anekwe, an obesity medicine specialist at the Harvard-affiliated Massachusetts General Hospital Weight Center. The new findings are interesting and make sense from a biological perspective, given the differences in the surgeries, she adds.

How does weight loss surgery affect alcohol absorption?

Weight-loss surgeries dramatically reduce the size of the stomach.

• For a sleeve gastrectomy, the most common procedure, the surgeon removes about 80% of the stomach, leaving a banana-shaped tube.
• For a gastric bypass, a surgeon converts the upper stomach into an egg-sized pouch. This procedure is called a bypass because most of the stomach, the valve that separates the stomach from the small intestine (the pylorus), and the first part of the small intestine are bypassed.

The lining of the stomach contains alcohol dehydrogenase, an enzyme that breaks down alcohol. After weight-loss surgery, people have less of this enzyme available. So drinking wine, beer, or liquor will expose them to a higher dose of unmetabolized alcohol. Some alcohol is absorbed directly from the stomach, but most moves into the small intestine before being absorbed into the bloodstream.

After a sleeve gastrectomy, the pyloric valve continues to slow down the passage of alcohol from the downsized stomach to the small intestine. But with a gastric bypass, the surgeon reroutes the small intestine and attaches it to the small stomach pouch, bypassing the pyloric valve entirely. As a result, drinking alcohol after a gastric bypass can lead to extra-high blood alcohol levels. That makes people feel intoxicated more quickly and may put them at a higher risk of alcohol use disorders, says Dr. Anekwe.

Findings from the study on weight loss surgery and alcohol

The study included nearly 7,700 people (mostly men) from 127 Veterans Health Administration centers who were treated for obesity between 2008 and 2021. About half received a sleeve gastrectomy. Nearly a quarter underwent gastric bypass. Another 18% were referred to MOVE!, a program that encourages increased physical activity and healthy eating.

After adjusting for participants’ body mass index and alcohol use, researchers found that participants who had gastric bypass were 98% more likely to be hospitalized for alcohol-related reasons than those who had sleeve gastrectomy, and 70% more likely than those who did the MOVE! program. The rate of alcohol-related hospitalizations did not differ between people who had sleeve gastrectomy and those who did the MOVE! program.

The health harms of alcohol use disorder

Alcohol use disorder can lead to numerous health problems. Some require hospitalization, including alcoholic gastritis, alcohol-related hepatitis, alcohol-induced pancreatitis, and alcoholic cardiomyopathy. As the study authors note, people who had gastric bypass surgery had a higher risk of being hospitalized for an alcohol use disorder, even though they drank the least amount of alcohol compared with the other study participants. This suggests that change in alcohol metabolism resulting from the surgery likely explains the findings.

Advice on alcohol if you’ve had weight-loss surgery or are considering it

“We recommend that people avoid alcohol completely after any type of weight-loss surgery,” says Dr. Anekwe. A year after the surgery, an occasional drink is acceptable, she adds, noting that most patients she sees don’t have a problem with this restriction.

People who undergo weight-loss surgeries have to be careful about everything they consume to ensure they get adequate amounts of important nutrients. Like sugary drinks, alcohol is devoid of nutrients — yet another reason to steer clear of it.

Gastric bypass has become less popular than sleeve gastrectomy over the past decade, mostly because it’s more invasive and slightly riskier. While the new study suggests yet another downside of gastric bypass, Dr. Anekwe says it can still be a viable option for people with severe obesity, as bypass leads to more weight loss and better control of blood sugar than the sleeve procedure.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss

Making friends and finding social opportunities can sometimes be difficult, particularly for children with neurodevelopmental disabilities, such as autism spectrum disorder, attention deficit hyperactivity disorder, or an intellectual disability. Here’s what parents can do to help.

Building inclusive communities

Friendships and social connections are an important aspect of our lives. They provide a sense of belonging and allow people to be included in their communities.

People with neurodevelopmental disabilities may communicate, learn, and behave differently. Sometimes these differences make it harder than usual to develop friendships and participate in social activities.

But parents and others can help create more inclusive communities and opportunities to build social relationships, especially for people with neurodiverse abilities.

Below are some tips and strategies to help children learn and develop the social and emotional skills they need to make friends.

Practice at home: Tips for common social situations

Navigating social settings and making friends involve many skills you can practice with children at home.

• Greetings and questions. Make a habit of practicing greetings throughout the day. Model good listening for your child, and take turns asking and answering conversation starters like, “How are you?”
• Calm body movements. Sometimes it can be hard for children with neurodevelopmental disabilities to keep a calm body. Have your child practice giving their body enough room and keeping personal space between themselves and others by using an arm’s-length distance.
• Appropriate level of voice. Encourage your child to listen and match the level of your voice. Imagine your voice has a volume dial and practice turning the volume up and down.
• Eye contact. Looking directly into someone’s eyes can be difficult, so help your child instead look at different parts of your face or practice looking at their own eyes in the mirror.
• Reading and responding to social signals. People regularly communicate using more than just words. Social signals are the variety of ways in which we communicate through body language and facial expressions. Often this can be tricky to detect for children who are neurodiverse. Help your child recognize common social signals by asking what someone’s body or face might be saying.

Rerouting challenging behaviors to help children build friendships

Challenging behaviors may get in the way of making and keeping friends. It is important to address challenging behaviors like impulsivity and aggression through therapies and programming. Additionally, practicing the following fundamental skills can help reduce challenging behaviors.

• Patience. Learning how to wait for a turn to play or a time to speak in a conversation is an important social skill. Practice waiting with a timer, gradually building up from 10 seconds, to one minute, to five minutes.
• Flexibility. Help your child make compromises using first/then statements, such as, “First we play your way, then my way.” Model flexible play and redirect with new toys to show how play can evolve.
• Communicating strong emotions.Handling strong feelings can be difficult sometimes. Practice communicating these feelings effectively either by asking for help, using an emotions board, or taking a break.

How to throw a wide net socially

Encouraging social opportunities is an important part of supporting friendships and social relationships for children with neurodevelopmental disabilities. Social spaces offer chances for children who are neurodiverse to find activities they enjoy. They are able to practice the social and emotional skills they are learning and even meet other children practicing these same skills.

• Structure and organize play dates. Set up the environment before a play date by making a list of activities to do with a friend, then picking out of a hat which activities to do and in what order.
• Make a list of things that are fun to do and invite others to join. Look for free or low-cost programs or events out in the community.
• Connect with other parents of children with disabilities. Set up an activity for your children like an ice cream date, going on a walk, or a game night with adults and kids together. These encounters can give rise to repeat, planned social interactions.
• Check out organizations in the community for children with disabilities, like Special Olympics, or recreational programs that foster inclusive environments through Unified Sports.
• Look into facilitated recreational activities like a Lego club or pizza parties with teachers. Plan to bring a support person if needed.

Your child’s doctor or teacher may be able to suggest additional community or web-based resources designed to help families support friendships for children with neurodiverse abilities.

About the Authors

Sydney Reynders, ScB, Contributor

Sydney Reynders, ScB, is a clinical research coordinator in the Boston Children’s Hospital Down Syndrome Program. She assists in research investigating educational, behavioral, and medical interventions in Down syndrome and other neurodevelopmental disorders. She received her … See Full Bio View all posts by Sydney Reynders, ScB

Nicole Baumer, MD, MEd, Contributor

Nicole Baumer, MD, MEd is a child neurologist/neurodevelopmental disabilities specialist at Boston Children's Hospital, and an instructor in neurology at Harvard Medical School. Dr. Baumer is director of the Boston Children's Hospital Down Syndrome Program. She … See Full Bio View all posts by Nicole Baumer, MD, MEd