At the Heart of Patient Care

More than 90 percent of women have at least one risk factor for heart disease, yet most women are unaware that heart disease is their leading cause of death in the United States.  Less than half (39%) of primary care physicians, including ob-gyns, consider cardiovascular disease to be a top concern for women.

Last month, ACOG and the American Health Association released a joint advisory calling on ob-gyns to use annual well woman exams as an opportunity to assess a woman’s risk for heart disease.  For many women, their ob-gyn is the only physician they see routinely, particularly women during their childbearing years. This emphasizes the important role of the ob-gyn to identify risk factors for heart disease and stroke—long before clinical signs are apparent.  Not doing so is a missed opportunity for early detection and intervention.

Research shows that pregnant women with complications like preeclampsia, gestational diabetes, and growth restricted babies, have three times the risk of later cardiovascular disease than women without these pregnancy complications.  Additionally, cardiovascular events and cardiomyopathy are the leading causes of maternal mortality in the U.S., together accounting for 25 percent of all maternal deaths.

As the leading health care providers for women, we can be a powerful voice for patients, counseling and educating them on how to achieve and maintain long-term heart health. Whether it’s advising patients about healthy diet and lifestyle, or taking advantage of high-tech solutions such as software algorithms that can trigger patient education and referrals by analyzing data contained in electronic medical records, the well woman exam is an opportunity for us to deliver patient-centered care.

I’m so excited to share more with you during my year in office, and to hear from you directly. Connect with me on twitter at @TXmommydoc.

4 thoughts on “At the Heart of Patient Care

  1. Part 3/3:
    Excision of disease removes the DIRECT impact on alterations in the arterial lining that precipitates plaque formation and arterial rigidity WITHOUT tampering with the body’s natural production of estrogen and its contribution to reduce CAD/CVD. Isn’t it time to acknowledge the superior benefits of excision over the current standards of care: hormone suppression, hysterectomy w/ and w/o oophorectomy and ablation/cautery/diathermy? As a person who has battled BOTH diseases now (thank you endo!) despite my prior high activity, athletic and exercise driven lifestyle for years, advances in care options necessitates patient inclusion. ‘Patient Inclusion’ in ALL decisions for their own personal care, and to ensure that women are given ALL viable options for care, to include excision.

    When making clinical decisions in regards to the plan of care for a woman with endometriosis, the concern for long-term impact of the disease on a woman’s body must be taken very seriously. The longer the disease remains within the body, the more opportunity for irreversible damage to the arterial walls to occur.

    The understanding that removal of the disease stops the contribution of endometriosis to advancing CAD/CVD but the use of hormone suppression agents has TWO major impacts: 1) the menopausal status which promotes CAD/CVD by removal of estrogen, 2) the disease remains in place (no thorough investigative studies of these medications and visual measurement of endometriosis lesions have concluded that these medications shrink lesions.

    These are serious concerns. The treatment standards have remained unchanged for decades. The medical management has remained unchanged with regards to applying drugs from the same drug classification through history.

    To think about the impact on a woman who must ingest more and more pharmaceutical products, each to offset the ‘side effects’ of another drug is disheartening and that persistence of the disease in the body is the primary driver to the decline in health that leads to other complications and expenditures. Remove the disease, remove the primary driver.

    a.) World Health Organization http://www.who.int/mediacentre/factsheets/fs334/en/
    b.) Mu F, et al. Endometriosis and Risk of Coronary Heart Disease. Circ Cardiovasc Qual Outcomes.2016;9:257-264. http://circoutcomes.ahajournals.org/content/9/3/257
    c.) Santoro L, et al. Endometriosis and atherosclerosis: what we already know and what we have yet to discover. AJOG.2015. http://www.ajog.org/article/S0002_9378(15)00391_9/pdf
    d.) Zuin M, et al. Should women with endometriosis be screened for coronary artery disease? Eur J Intern Med (2016);http://dx.doi.org/10.1016.j.ejm.2016.08.021.
    e.) Santoro L, et al. Regression of endothelial dysfunction in patients with endometriosis after surgical treatment: a 2-year follow-up study. Gynaecology. Hum Repro.2014;29(6):1205-10.
    f.) Becker CM et al. Reevaluating response and failure of medical treatment of endometriosis: a systemicatic review. Fertil Steril. 2017;108(1). http://dx.doi.org/10.1016/j.fertnstert.2017.05.004.)
    g.) Taylor HS et al. Treatment of Endometriosis-Associated Pain with Elagolix, an Oral GnRH Agonist. NEJM.2017;377(1):28-40.
    h.) National Heart, Lung and Blood Institute. Your Guide to Lowering Your Cholesterol with TLC (Therapeutic Lifestyle Changes). US Dept Health and Human Services. NIH. NIH Publication No. 06-5235. December 2005. https://www.nhlbi.nih.gov/files/docs/public/heart/chol_tlc.pdf (page 9).
    i.) Kingusa S, et al. Increased asymmetric dimethylarginine and enhanced inflammation are associated with impaired vascular reactivity in women with endometriosis. Atherosclerosis.2011;219:784-8.

  2. Part 2/3
    Current treatment recommendations for GnRH use for a lifetime maximum of 12 months. We know suppression of estrogen eliminates the protective properties to the cardiovascular system. Thus, menopause (Natural, Surgical or Chemical Induced via Hormone Manipulation and Suppression) remove the protective aspects of estrogen. The result is elevated blood lipid levels (LDL’s and oft Triglycerides) and arterial stiffness. We also must recognize the fact that these medications do not significantly reduce the size of endometriosis lesions and disease progression (). Their use is for short-term symptom management.

    Prior AND current Hormone Suppression agents in clinical trials or on the market for consumer use, have not presented long-term data that demonstrates trends toward or significant reduction of elevated lipid protein profiles that occur during the use of hormone suppression agents. Most specific, the LDL profiles should be carefully analyzed. Case in point, the most recent publications for Elagolix use at two different doses collected blood lipid profiles pre and post tx. of 6 mths (g). The data noted that almost all subjects’ LDL lipid levels were around 100mg/dl. The study design and published data ONLY reported the number of subjects whose LDL levels exceeded 160mg/dl at the end of 6 mth study. Note: The National Heart, Lung and Blood Institute guidelines for blood values for LDL:

    < 100mg/dL Optimal
    100-129 mg/dL Near optimal/above optimal
    130-159 mg/dL Borderline high
    160-189 mg/dL High. (h)

    Establishment of a ‘trigger point’ of 160mg/dL in a six month period is incredibly high. Furthermore, the majority subjects would require elevated blood lipid profiles to increase an avg of 60% in 6 months! This equates to nearly, or over two full blood lipid levels to become included as an 'n' subject with elevated LDL levels.

    Furthermore 1.) there is NO follow-up to monitor if blood-lipid values remain elevated or trend toward pre-treatment values. 2.) It is acknowledged that hormone suppression agents DO NOT impact lesion size, but their purpose is temporary pain and symptom suppression. 3.) Although these medications may temporarily reduce symptoms, the underlying disease is still in the body. Thus, endometriosis still directly plays a role in cardiovascular disease.

    There are no evidence-based studies that demonstrate significant and valid data that reveal these lipid profiles to be completely reversible. No current therapeutic interventions exist that remove the impact of endometriosis lesions left in the body and its contribution to arterial stiffness and CAD/CVD. Investigators suggest the ‘arterial stiffness/rigidity’ initiated in both endometriosis and CAD/CVD are the result of damage to the endothelial lining of blood vessels. The damage results in reduced nitrous oxide production. Nitrous oxide plays a role in vasodilation of the vessels. Vessels remain constricted due to injury. (i) (All references attached at bottom of part 3/3)

  3. Part 1/3:
    It’s always been my understanding within the medical community, every health care provider, regardless of their niche in practice, should perform a general systems screening (5 min cursory) for all persons seeking medical services. The purpose of this: early identification and follow-up for unresolved concerns that should be addressed with the goal of reduced burden and impairments to the patient. In addition, reduced costs to patient, health insurers, profit-loss of employers and overall healthcare sector burden should be the end result.

    I am delighted to hear that the ACOG and the American Heart Association have collaborated for attempt to assess women’s risk for heart disease. It is true that ob-gyns are in a perfect situation to “identify risk factors for heart disease and stroke – long before clinical signs are apparent. Not doing so is a missed opportunity for early detection and intervention.” (blog excerpt). Particularly among the younger population where fertility is a big topic.

    Dr. Hollier’s focuses on the obstetric side of women’s reproductive health in this blog. All very important and valid concerns. However, I wish to extend the importance of cardiovascular screening and consideration of current ‘Standards of Treatment Practice Guidelines for those with Endometriosis’. It is a disease which very high social and economic burdens across the globe.
    The current standards of practice for endometriosis, in fact, recommend interventions which, contribute to cardiovascular disease progression among this population, in MORE WAYS than the cessation of estrogen production. To bring readers up-to-speed on current affairs within the advocacy of endometriosis sufferers and advocates: This past April, the American College of Obstetrics and Gynecology HQ, Washington, DC. brought together a committee of practitioners to review and revise the Treatment Standards for Endometriosis. The general public is not privy to know names, nor have any results or recommendations of their review been released to the public to date. This is concern for lack of transparency to know who, their credentials and experience treating the disease are present on this committee. The concern is a lack of representation by a true endometriosis expert who focuses all or nearly exclusively treats women with endometriosis. It is also requested that patient advocates be present when review and adjustments to treatment guidelines are completed. As of spring 2018, the request for patient, advocate and endometriosis focused specialists be included in the process, have been denied.

    (Back from my digression). Recommendations for Treatment Standards were provided by Casey Berna, MSW as a patient advocate who represents our collective concerns that ‘nothing about us without us’. The recommendations given were backed by several resources for updated standards of care. Among the concerns discussed include the recommendation for GnRH therapies. A second concern is a failure to acknowledge that excision (cutting out of lesions) from all areas of the body is a superior outcome to use of ablation/cautery/diathermy to address disease. Here lies my expansion on the connection between endometriosis, treatment interventions and cardiovascular disease.

    It is universally agreed that CAD/CVD is the #1 killer in women worldwide (a). It is also acknowledged that a hypoestrogenic state increases the risk of CAD/CVD (b). Most recent, the relationship between endometriosis and CAD/CVD has been deemed more than an association (c). Previously, it was implied that endometriosis and CAD/CVD are chronic inflammatory processes that additively elevate systemic inflammation that contributes to separate disease progression. Update: BOTH diseases have a similar pathological process which reduces plasticity of arterial walls. The PRESENCE of endometriosis lesions within the body impacts physiological changes that occur to the inner-most lining of the bodies arteries (via inflammatory mediators released in response to endometriosis specific)!

    These findings are important because, induction of menopause (surgical/natural menopause or hormone suppression therapy) to ‘treat’ endometriosis, in-fact promotes advancement of CAD/CVD. (d) However, if the disease is removed from the body, the inflammatory prompt has been removed (e). Treatment of endometriosis through temporary or permanent state of menopause not only promotes advancement of arterial stiffness and CAD/CVD, upon cessation of any temporary menopausal state, created with hormone suppression, endometriosis lesions remain in the body and continue to promote an inflammatory state.
    A recent study with moderate size cohort documented REVERSAL of arterial ‘rigidity’ among women with endometriosis compared to a control group. PRE and POST excision comparisons of arterial rigidity were calculated. Pre-excision arterial rigidity was significantly higher among the group with endometriosis. Post-excisional arterial rigidity was significantly reduced among the endometriosis group (compared to their pre-excision values) AND their arterial rigidity values were significantly LOWER than the control group when remeasured two years post excision.(e) Furthermore, in addition to the benefit of lesion removal on ‘arterial rigidity’, the natural production of estrogen among the women who underwent excision of endometriosis lesions was never manipulated pre/during or post-surgery.
    (All references attached at bottom of part 3/3)

  4. and yes wide spread low estrogen states are just fine with ACOG? The risk for small vessel heart disease due to low estrogen states is real, yet ACOG refuses to accept a leadership role in effective surgery reducing the exposure to low estrogen states from attempts to suppress estrogen. A therapy not necessary for most patients undergoing Expert excision of their disease.

Comments are closed.