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Swimming is a great activity for children. It’s good exercise, it’s an important safety skill, and it can be a good way to get outside and get some fresh air and sunshine.

But for children with eczema — also known as atopic dermatitis — swimming can be complicated. Here’s how parents can help.

What is eczema?

Eczema is an allergic condition of the skin. It can be triggered by allergies to things in the environment, like pollen or cats, as well as by allergies to food. It can also be triggered when chemicals or other things irritate the skin, or when the skin loses moisture, or by excessive sweating.

Swimming and sun may be helpful for eczema

Swimming in a chlorinated pool can actually be helpful for eczema. Bleach baths, which are a commonly recommended eczema treatment, essentially make the bathtub like a swimming pool.

It also can be good for eczema to get some sun and be in the water. The trick is to optimize the benefits while preventing the possible problems.

What to do before and after swimming when a child has eczema

Here are some suggestions for parents:

• If you’ll be outside, make sure you use sunscreen, preferably one with zinc oxide or titanium. Look for formulations for sensitive skin and avoid anything with fragrance. Consider using UV-protectant swimwear or shirts, especially if embarrassment about rashes is a problem.
• Put on an emollient before swimming, especially in a chlorinated pool. A good grease-up before swimming can protect the skin. Don’t overdo it on the palms or soles; you want your child to be able to hold on to things, and you don’t want them to slip and fall. Talk to your doctor about the best emollient for your child.
• If you are swimming in a pool for the first time, you might want to try a briefer swim than usual to be sure the chemicals aren’t too irritating. If possible, avoid going in a pool right after chlorine has been added.
• Plan to change and shower right after swimming, using a mild soap or body wash without fragrance. Dab the skin dry with a clean towel (don’t use the one you used while swimming) and reapply emollient.
• Look for silicone-lined swim caps and goggles, as they may be less irritating than rubber or other plastics. Be sure to rinse all swim gear after use.
• If your child’s eczema is very inflamed, or is infected, it might be best to avoid swimming until it is better — or at least to get your doctor’s advice.

What else should you consider?

Be aware that some children and teens with eczema are embarrassed by it and don’t like to wear bathing suits that show a lot of skin. Follow your child’s lead on this.

If your child has frequent flares of eczema, or severe eczema, talk to your doctor about whether using regular topical steroids might help — and whether you should use them before swimming. If you are headed on a vacation where your child will be swimming often, or just headed into a time of year with lots of possible swimming, talk to your doctor about the best strategies to keep your child’s skin healthy.

For more information, visit the websites of the National Eczema Association and the American Academy of Dermatology.

Follow me on Twitter @drClaire

About the Author

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD

When you first learned the facts about pregnancy — from a parent, perhaps, or a friend — you probably didn’t learn that up to one in three ends in a miscarriage.

What causes miscarriage? How is it treated? And why is appropriate health care for miscarriage under scrutiny — and in some parts of the US, getting harder to find?

What is miscarriage?

Many people who come to us for care are excited and hopeful about building their families. It’s devastating when a hoped-for pregnancy ends early.

Miscarriage is a catch-all term for a pregnancy loss before 20 weeks, counting from the first day of the last menstrual period. Miscarriage happens in as many as one in three pregnancies, although the risk gradually decreases as pregnancy progresses. By 20 weeks, it occurs in fewer than one in 100 pregnancies.

What causes miscarriage?

Usually, there is no obvious or single cause for miscarriage. Some factors raise risk, such as:

• Pregnancy at older ages. Chromosome abnormalities are a common cause of pregnancy loss. As people age, this risk rises.
• Autoimmune disorders. While many pregnant people with autoimmune disorders like lupus or Sjogren’s syndrome have successful pregnancies, their risk for pregnancy loss is higher.
• Certain illnesses. Diabetes or thyroid disease, if poorly controlled, can raise risk.
• Certain conditions in the uterus. Uterine fibroids, polyps, or malformations may contribute to miscarriage.
• Previous miscarriages. Having a miscarriage slightly increases risk for miscarriage in the next pregnancy. For instance, if a pregnant person’s risk of miscarriage is one in 10, it may increase to 1.5 in 10 after their first miscarriage, and four in 10 after having three miscarriages.
• Certain medicines. A developing pregnancy may be harmed by certain medicines. It’s safest to plan pregnancy and receive pre-pregnancy counseling if you have a chronic illness or condition.

How is miscarriage diagnosed?

Before ultrasounds in early pregnancy became widely available, many miscarriages were diagnosed based on symptoms like bleeding and cramping. Now, people may be diagnosed with a miscarriage or early pregnancy loss on a routine ultrasound before they notice any symptoms.

How is miscarriage treated?

Being able to choose the next step in treatment may help emotionally. When there are no complications and the miscarriage occurs during the first trimester (up to 13 weeks of pregnancy), the options are:

Take no action. Passing blood and pregnancy tissue often occurs at home naturally, without need for medications or a procedure. Within a week, 25% to 50% will pass pregnancy tissue; more than 80% of those who experience bleeding as a sign of miscarriage will pass the pregnancy tissue within two weeks.

What to know: This can be a safe option for some people, but not all. For example, heavy bleeding would not be safe for a person who has anemia (lower than normal red blood cell counts).

Take medication. The most effective option uses two medicines: mifepristone is taken first, followed by misoprostol. Using only misoprostol is a less effective option. The two-step combination is 90% successful in helping the body pass pregnancy tissue; taking misoprostol alone is 70% to 80% successful in doing so.

What to know: Bleeding and cramping typically start a few hours after taking misoprostol. If bleeding does not start, or there is pregnancy tissue still left in the uterus, a surgical procedure may be necessary: this happens in about one in 10 people using both medicines and one in four people who use only misoprostol.

Use a procedure. During dilation and curettage (D&C), the cervix is dilated (widened) so that instruments can be inserted into the uterus to remove the pregnancy tissue. This procedure is nearly 99% successful.

What to know: If someone is having life-threatening bleeding or has signs of infection, this is the safest option. This procedure is typically done in an operating room or surgery center. In some instances, it is offered in a doctor’s office.

If you have a miscarriage during the second trimester of pregnancy (after 13 weeks), discuss the safest and best plan with your doctor. Generally, second trimester miscarriages will require a procedure and cannot be managed at home.

Red flags: When to ask for help during a miscarriage

During the first 13 weeks of pregnancy: Contact your health care provider or go to the emergency department immediately if you experience

• heavy bleeding combined with dizziness, lightheadedness, or feeling faint
• fever above 100.4° F
• severe abdominal pain not relieved by over-the-counter pain medicine, such as acetaminophen (Tylenol) or ibuprofen (Motrin, Advil). Please note: ibuprofen is not recommended during pregnancy, but is safe to take if a miscarriage has been diagnosed.

After 13 weeks of pregnancy: Contact your health care provider or go to the emergency department immediately if you experience

• any symptoms listed above
• leakage of fluid (possibly your water may have broken)
• severe abdominal or back pain (similar to contractions).

How is care for miscarriages changing?

Unfortunately, political interference has had significant impact on safe, effective miscarriage care:

• Some states have banned a procedure used to treat second trimester miscarriage. Called dilation and evacuation (D&E), this removes pregnancy tissue through the cervix without making any incisions. A D&E can be lifesaving in instances when heavy bleeding or infection is complicating a miscarriage.
• Federal and state lawsuits, or laws banning or seeking to ban mifepristone for abortion care, directly limit access to a safe, effective drug approved for miscarriage care. This could affect miscarriage care nationwide.
• Many laws and lawsuits that interfere with miscarriage care offer an exception to save the life of a pregnant patient. However, miscarriage complications may develop unexpectedly and worsen quickly, making it hard to ensure that people will receive prompt care in life-threatening situations.
• States that ban or restrict abortion are less likely to have doctors trained to perform a full range of miscarriage care procedures. What’s more, clinicians in training, such as resident physicians and medical students, may never learn how to perform a potentially lifesaving procedure.

Ultimately, legislation or court rulings that ban or restrict abortion care will decrease the ability of doctors and nurses to provide the highest quality miscarriage care. We can help by asking our lawmakers not to pass laws that prevent people from being able to get reproductive health care, such as restricting medications and procedures for abortion and miscarriage care.

About the Authors

Sara Neill, MD, MPH, Contributor

Dr. Sara Neill is a physician-researcher in the department of obstetrics & gynecology at Beth Israel Deaconess Medical Center and Harvard Medical School. She completed a fellowship in complex family planning at Brigham and Women's Hospital, and … See Full Bio View all posts by Sara Neill, MD, MPH

Scott Shainker, DO, MS, Contributor

Scott Shainker, D.O, M.S., is a maternal-fetal medicine specialist in the Department of Obstetrics and Gynecology at Beth Israel Deaconess Medical Center (BIDMC). He is also a member of the faculty in the Department of Obstetrics, … See Full Bio View all posts by Scott Shainker, DO, MS

Scientific advances have brought us scores of new drugs in recent years. In the US, one major agency — the FDA — is responsible for making sure that the drugs they approve are safe and effective. Yet there were more than 14,000 drug recalls in the last 10 years, according to FDA statistics. That averages out to nearly four drug recalls a day!

Why are drug recalls so common, and how can you maximize safety when taking the medicines you need?

Why do so many drug recalls occur?

The FDA approves prescription drugs if research shows a medicine is safe and effective. Usually the risks are well known by the time approval is granted. For over-the-counter drugs, the bar is lower: proof that they work is not required, but the FDA still maintains oversight for safety.

Drug recalls are common because:

• Rare side effects may be missed in clinical trials. Studies leading to drug approval might have hundreds or thousands of study subjects. But a rare problem may not be detected until tens of thousands of people have taken a drug.
• Study subjects tend to be healthier than the general population. When you’re trying to figure out if a drug works, the chances of success are higher and reliability of results is greater if study subjects are healthy. Once a drug is approved, people taking it may be older, less healthy, or taking multiple drugs for health issues.
• Problems during or after manufacturing can make a safe drug harmful. Examples include bacterial contamination, incorrect labeling, and improper storage.
• Bad behavior by drug makers may affect drug safety. For example, multiple over-the-counter supplements marketed for male sexual performance were recalled in recent years because they were laced with prescription drugs for erectile dysfunction.

Are most drug recalls high-risk?

Fewer than one in 10 poses a serious health risk. The FDA grades risk severity for recalls as follows:

• Class I is dangerous and poses a serious health risk (a hand sanitizer contaminated with methanol)
• Class II might cause a temporary or slight risk of serious harm (a diabetes medicine stored at the wrong temperature)
• Class III is unlikely to cause any harm to health, but there is a violation of FDA requirements (an ointment for dermatitis in damaged tubes).

Between 80% and 90% of drug recalls are Class II.

In 2022, 6% of recalls were Class 1, 86% were Class II, and 7% were Class III.

How do drug recalls happen?

The FDA inspects drug manufacturing facilities every two to three years. The agency also tests thousands of drugs each year.

Problems spotted during inspections, concerns identified by drug makers, or problems reported by patients or health care professionals can prompt a recall. The FDA then assigns a risk classification, supervises actions taken by the drug maker to remedy the problem, and monitors the product to make sure the problem is eliminated.

Drug recalls in the US are almost always voluntary. That means the drug maker acknowledges the problem and takes corrective action rather than waiting for a possible mandate from the FDA.

How can you stay informed about medicines you use?

Here are some practical measures to take:

• Sign up to receive texts or emails about recalls, market withdrawals, and safety alerts from the FDA.
• When filling prescriptions, take a good look at your medicine. Pills should not be discolored or crumbling, or have an unusual odor. If your prescription hasn’t changed, a refill should look similar to what you’ve taken in the past. If you suspect a problem, contact your pharmacist or the health care professional who prescribed it. And if you do confirm a problem, you can report it to the FDA.
• If you learn of a recall for a drug you take, check the lot number on the package to see if your medication is affected. If the risk is classified as high (Class I), contact your doctor right away for advice. For many recalled drugs, there are safe and effective alternatives.
• A recall notice will tell you if the medicine can be replaced or if you can be reimbursed. If you are instructed to dispose of medication, do so safely.

Another way to limit your potential exposure to recalled drugs is to take fewer drugs. Review your medication list with your doctor regularly and take only what you truly need.

The bottom line

News on drug recalls may not inspire confidence. It might make you wonder if the drugs you take are safe. In general, yes: the vast majority of medicines on the market have an excellent safety profile. But with more than 1,000 drug recalls every year, there’s plenty of room for improvement by drug makers and good reason to encourage better regulation of the industry.

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

Ah, ’tis the season for warm-weather allergies caused by trees, grass, and ragweed pollen. You know the signs: sneezing, watery eyes, stuffiness, scratchy throat, wheezing, and coughing. But what about so-called brain fog? That may be true for you, too.

Why do allergies make your brain feel so foggy?

“Allergy symptoms can disrupt sleep and make people feel more tired and groggy,” says Dr. Mariana Castells, an allergist and immunologist in the division of Allergy and Clinical Immunology at Harvard-affiliated Brigham and Women’s Hospital. “Plus, your body can become weaker as it fights the inflammation triggered by allergies, contributing to overall fatigue and making it harder to concentrate and focus.”

What happens to your immune system when you inhale pollen?

When you inhale pollen, your immune system generates antibodies called immunoglobulin E (IgE). Those antibodies trigger the release of chemicals called mediators, such as histamine, leukotrienes, and prostaglandins. The chemicals affect tissues in the eyes, nose, and throat,  causing symptoms like sneezing and watering eyes.

4 ways to prevent or ease brain fog stemming from seasonal allergies

Managing your allergy symptoms when they first appear — or taking preventive measures if you are prone to pollen allergies — is the best way to control the allergic immune response that can cause fatigue and brain fog. These four strategies can help.

Lower your exposure to pollen

• Keep your windows closed whenever possible, and occasionally run an air conditioner or use an air purifier with a HEPA filter to help remove pollen from indoor air.
• Pollen is usually highest from about 4 a.m. to noon, so restrict outside time to the late afternoon or evening.
• You can check daily pollen counts in your area and sign up for high pollen alerts at www.pollen.com.
• Wearing a mask outside when pollen is high can block about 70% to 80% of pollen, says Dr. Castells.

Be prepared with over-the-counter allergy medicines

Over-the-counter (OTC) allergy medicines treat many symptoms, thus helping to lift brain fog. It’s best to talk to your doctor or pharmacist before starting any new medicine, especially if you have any health problems or take other medicines.

Options include:

• Non-drowsy antihistamine pills and nasal sprays. Antihistamines block the effects of excess histamine that causes itchy and watery eyes, sneezing, and a runny nose. Sprays also help with congestion and postnasal drip. “Be aware that even non-drowsy brands have potential for some sedation that can affect thinking,” says Dr. Castells. “People tolerate antihistamines differently, so you may have to try more than one brand to assess effectiveness and potential side effects.” Loratadine (Claritin), cetirizine (Zyrtec), and fexofenadine (Allegra) are less sedating than first-generation antihistamines such as diphenhydramine (Benadryl).
• Decongestant pills, such as phenylephrine (Sudafed PE) and pseudoephedrine (Sifedrine, Sudafed). Decongestants shrink tiny blood vessels, which decreases fluid secretion in nasal passages, helping to unclog a stuffy nose. However, they can increase heart rate and blood pressure. They are not recommended for prolonged use, so check with your doctor if you have heart or blood pressure problems. Decongestant nasal sprays, such as oxymetazoline (Afrin), may be used for several days, but continued use can lead to worsening nasal congestion.
• Combined antihistamine and decongestant medicines have “D” added at end of brand names, such as Zyrtec-D, Allegra-D, and Claritin-D, which combine different antihistamine medicines with the decongestant pseudoephedrine.
• Nasal steroid sprays, such as triamcinolone (Nasacort), budesonide (Rhinocort), and fluticasone (Flonase), reduce inflammation that causes congestion, runny or itchy nose, and sneezing. “It’s often best to take them before pollen season begins, especially if you are susceptible to allergies,” says Dr. Castells. Side effects may include nasal dryness and, rarely, nose bleeds. People with glaucoma should take these cautiously, as they can raise the pressure inside the eye, leading to potential vision loss.

Consider prescription allergy shots or tablets

If allergies are severe or OTC remedies aren’t sufficient, an allergist may recommend allergy shots, or possibly tablets designed to treat certain allergies.

• Allergy shots are regular injections of small amounts of your allergen, with the dose gradually increasing over time. “Allergy shots do not completely eliminate your allergy but change your immune response to better tolerate it,” says Dr. Castells. During a buildup phase, the allergen dose increases gradually in once or twice weekly shots for three to six months. During the maintenance phase, you get monthly injections for three to five years. “When you’re finished, the protective effect can last several years,” says Dr. Castells.
• Tablets to treat grass and weed allergies offer similar protection as injections. These tablets are dissolved under the tongue. Dr. Castells says they should be used daily before and during the pollen seasons for at least five seasons.

Try a nasal rinse

Prefer to skip medications? Try clearing your nasal cavity twice daily using saline solution in a small bulb syringe or neti pot, which resembles a small teapot with a long spout. Both are sold at drugstores and online. Performed once in the morning and in the evening, this simple technique rinses away pollen.

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

Be honest: just how much television are you watching? One study has estimated that half of American adults spend two to three hours each day watching television, with some watching as much as eight hours per day.

Is time spent on TV a good thing or a bad thing? Let's look at some of the data in relation to your risks for cognitive decline and dementia.

Physical activity does more to sharpen the mind than sitting

First, the more time you sit and watch television, the less time you have available for physical activity. Getting sufficient physical activity decreases your risk of cognitive impairment and dementia. Not surprisingly, if you spend a lot of time sitting and doing other sedentary behaviors, your risk of cognitive impairment and dementia will be higher than someone who spends less time sitting.

Is television actually bad for your brain?

Okay, so it's better to exercise than to sit in front of the television. You knew that already, right?

But if you're getting regular exercise, is watching television still bad for you? The first study suggesting that, yes, television is still bad for your brain was published in 2005. After controlling for year of birth, gender, income, and education, the researchers found that each additional hour of television viewing in middle age increased risk for developing Alzheimer's disease 1.3 times. Moreover, participating in intellectually stimulating activities and social activities reduced the risk of developing Alzheimer's.

Although this study had fewer than 500 participants, its findings had never been refuted. But would these results hold up when a larger sample was examined?

Television viewing and cognitive decline

In 2018, the UK Biobank study began to follow approximately 500,000 individuals in the United Kingdom who were 37 to 73 years old when first recruited between 2006 and 2010. The demographic information reported was somewhat sparse: 88% of the sample was described as white and 11% as other; 54% were women.

The researchers examined baseline participant performance on several different cognitive tests, including those measuring

• prospective memory (remembering to do an errand on your way home)
• visual-spatial memory (remembering a route that you took)
• fluid intelligence (important for problem solving)
• short-term numeric memory (keeping track of numbers in your head).

Five years later, many participants repeated certain tests. Depending on the test, the number of participants evaluated ranged from 12,091 to 114,373. The results of this study were clear. First, at baseline, more television viewing time was linked with worse cognitive function across all cognitive tests.

More importantly, television viewing time was also linked with a decline in cognitive function five years later for all cognitive tests. Although this type of study cannot prove that television viewing caused the cognitive decline, it suggests that it does.

Further, the type of sedentary activity chosen mattered. Both driving and television were linked to worse cognitive function. But computer use was actually associated with better cognitive function at baseline, and a lower likelihood of cognitive decline over the five-year study.

Television viewing and dementia

In 2022, researchers analyzed this same UK Biobank sample with another question in mind: Would time spent watching television versus using a computer result in different risks of developing dementia over time?

Their analyses included 146,651 people from the UK Biobank, ages 60 and older. At the start of the study, none had been diagnosed with dementia.

Over 12 years, on average, 3,507 participants (2.4%) were diagnosed with dementia. Importantly, after controlling for participant physical activity:

• time spent watching television increased the risk of dementia
• time spent using the computer decreased the risk of dementia.

These changes in risk were not small. Those who watched the most television daily — more than four hours — were 24% more likely to develop dementia. Those who used computers interactively (not passively streaming) more than one hour daily as a leisure activity were 15% less likely to develop dementia.

Studies like these can only note links between behaviors and outcomes. It's always possible that the causation works the other way around. In other words, it's possible that people who were beginning to develop dementia started to watch television more and use the computer less. The only way to know for sure would be to randomly assign people to watch specific numbers of hours of television each day while keeping the amount of exercise everyone did the same. That study is unlikely to happen.

The bottom line

If you watch more than one hour of TV daily, my recommendation is to turn it off and do activities that we know are good for your brain. Try physical exercise, using the computer, doing crossword puzzles, dancing and listening to music, and participating in social and other cognitively stimulating activities.

About the Author

Andrew E. Budson, MD, Contributor; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Andrew E. Budson is chief of cognitive & behavioral neurology at the Veterans Affairs Boston Healthcare System, lecturer in neurology at Harvard Medical School, and chair of the Science of Learning Innovation Group at the … See Full Bio View all posts by Andrew E. Budson, MD

Screening tests, such as Pap smears or blood pressure checks, could save your life. They can detect a disease you have no reason to suspect is there. Early detection may allow treatment while a health condition is curable and before irreversible complications arise.

Some screening tests help prevent the disease they are designed to detect. For example, colonoscopies and Pap smears can identify precancerous abnormalities that can be addressed so they cannot continue to grow and become cancerous. And missed screening tests contribute to thousands of avoidable deaths each year in the US. Yet there’s a point of diminishing returns, as a new study on Pap smears illustrates. And many of us could benefit from a better understanding of the limits of screening, and how experts decide when people should stop routine screening tests.

Know the limits of screening tests

Even the best screening test has limitations. It can miss the disease it’s intended to detect (false-negative results). Or it can return abnormal results when no disease is present (false-positive results).

Equally important, as people grow older life expectancy declines and screening benefits tend to wane. Many conditions detected by routine screenings, such as prostate cancer or cervical cancer, typically take a while to cause trouble. A person in their 80s is more likely to die from another fatal condition before cervical cancer or prostate cancer would affect their health. Additionally, certain diseases, such as cervical cancer, become less common with advancing age.

As a result, many screening tests are not recommended forever: at some point in your life, your doctor may tell you that you no longer need to repeat a screening test, even one you finally got used to having.

Know when screening tests usually end

Expert guidelines for many common screening tests include an “end age” when people can reasonably stop having the test. For example:

• Pap smear: age 65
• mammogram: age 75
• colonoscopy: age 75
• chest CT scan (recommended for people with a significant smoking history): age 80.

There are exceptions, of course. For example, if a colonoscopy found abnormalities in an otherwise healthy 72-year-old, repeat testing after age 75 may be recommended.

Many women have Pap smears after guidelines suggest stopping

Pap smears screen for cervical cancer. In 1996, new guidelines recommended that women who received Pap smears at appropriate intervals before age 65 could safely stop.

Yet many women continue to have this screening after turning 65, according to a recent study published in JAMA Internal Medicine that looked at data from 15 to 16 million women per year between 1999 and 2019. Their average age was 76, most (82%) were white, and all were enrolled in Medicare.

The study found:

• In 1999, nearly three million women over age 65 (almost 19% of the study population) had Pap smears. By 2019, the number had fallen to 1.3 million (8.5%), a reduction of more than half.
• Among women older than age 80, about 3% had Pap smears.
• In 2019, the estimated cost related to Pap smears in these older women was $83.5 million.

Possibly, some women in this study had good reasons to continue having Pap smears. Perhaps they weren’t adequately screened when they were younger. Perhaps they had previous Pap smear abnormalities. Maybe their doctors recommended they continue having Pap smears despite their advanced age. We don’t know, because this study didn’t collect that information. Still, it’s quite likely that many (or even most) of these Pap smears represent overscreening: routine testing with little chance of benefit.

Why does overscreening matter?

Overscreening may cause

• discomfort that may be tolerable when there’s an expectation of benefit, but less acceptable when the test is unnecessary
• anxiety while awaiting the results of the test
• false-positive results that lead to additional testing and unnecessary treatment
• complications of testing, such as infection or bleeding after a Pap smear, or perforation or bleeding after a colonoscopy. (Fortunately, complications are rare.)
• unnecessary costs, including medical appointments and lab fees, time wasted, and taking health providers away from more valuable care.

The bottom line

Screening tests are typically performed for people without symptoms, signs, or a high suspicion of disease. In many cases, they’re looking for a condition that is probably not there. For most screening tests, we have guidelines developed by experts and backed by data suggesting when to start — and when to stop — screening.

But guidelines are only general recommendations, and individual preferences matter. If foregoing a screening test will cause you excessive anxiety, or if having a test will provide significant peace of mind, it may be reasonable to have a test even after the recommended end age. Be sure you understand potential downsides, such as additional tests and complications.

So, never hesitate to ask your doctor when your next screening tests are due — but don’t forget to also ask if they are no longer worth having.

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

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