Monthly Archives: August 2015

Uquora – Hope, Hype and Maybe a Case of Diarrhea

uqora

Before you go out and spend $25 for 10 packets of Uquora, the new after-sex UTI prevention drink that launched today, you should consider if it actually works.

What’s in Uqora?

Uqora’s main active ingredient is D-Mannose (2 gm), combined with Vitamin C (600 mg), Vitamin B6, Calcium and Magnesium. (The company website does not list amounts for the last three ingredients.) The ingredients are made into a powder that you mix with water and drink.

The manufacturer claims that Uqora will reduce the chance of getting a UTI if you drink it after having sex, after exercise or during travel, all activities linked to recurrent UTI’s in women.

There is absolutely no data that taking Uqora (or D-mannose) in a single dose after intercourse will prevent a UTI. 

Does Uqora Prevent UTI’s?

Actually, no one knows if Uquora prevents UTI’s.

Uqora’s manufacturers base their claims on a single randomized study of D-mannose powder 2 mg, taken daily for 6 months. The study was published as a brief comment in BJU International. There’s so little data that I can actually post the entire study here –

After initial antibiotic treatment of the acute UTI (ciprofloxacin 500 mg twice daily for 1 week), patients were randomly allocated to three equal groups. The first group received prophylaxis with 2 g of D-mannose powder daily for 6 months, the second received prophylaxis with 50 mg of nitrofurantoin once a day, and the third did not receive prophylaxis. During the 6-month study period 98 of our patients (32%) had a recurrent UTI. The rate of recurrent UTI was significantly higher in the group that did not receive prophylaxis (60%) compared with the groups receiving D-mannose (15%) and nitrofurantoin (20%) which did not differ significantly. The risk of recurrent UTI episodes was significantly higher in the no-prophylaxis group compared with the groups that received active prophylaxis (relative risk 0.24 and 0.34). Also, we found that patients in the D-mannose group had a significantly lower risk of side effects compared with patients in the nitrofurantoin group, although nitrofurantoin was generally well tolerated. In patients who were taking D-mannose, episodes of diarrhoea were the only side effect and were noted in 8% of patients, but they did not require discontinuation of the prophylaxis. Patient compliance (assessed by recording the intake of prophylaxis on a self-report sheet) was very high and there was no difference between patients taking nitrofurantoin or D-mannose.

Note we have no information about the three study populations – were they similar to start with? Did they have similar baseline frequencies of UTI’s? What bacteria caused their infections (not all bacteria have the structure that would make them susceptible to D-mannose)? There is no data on comparative compliance between placebo and study groups, and no controlling for frequency of intercourse during treatment, the factor most important in predicting UTI recurrence in this type of patient.

That’s it folks. A single study, poorly reported, whose authors actually state that “more studies will certainly be needed to confirm the results of our study.”

To make matters worse, Uqora is not taken daily, the way D-mannose was given in this study. It is taken only after intercourse. There is absolutely no data that taking D-mannose or Uqora in a single dose after intercourse will prevent a UTI. And the manufacturers have not done a single study of their product in humans.

What About the Other Ingredients ?

I’m not going to belabor the point, except to say that the data on Vitamin C comes from yet another single study of daily use, this time in pregnant women. There are no data that taking a single dose of Vitamin C after sex will do anything other than turn your urine yellow.

Vitamin B6 is given to “Increase urination and urinary flow”, based on what data I don’t know.

Calcium and magnesium are there “to prevent the loss of these ions through urination”. Which means what, exactly? And how does this help prevent UTI’s?

Uqora Sidesteps the FDA

Uqora’s manufacturers call it a “dietary supplement” so they think they can sidestep FDA oversight. Their site has the usual disclaimer “This product is not intended to diagnose, treat, cure, or prevent any disease”. Yet the same website claims that ‘The Uqora product is an efficacious combination of ingredients that should be taken soon after sexual activity to reduce the risk of developing a UTI.”

This is standard supplement industry behavior.

I have no idea where Uqora is made, but somehow I suspect it’s not in the states or they’d have said it on the website. Being a so-called “supplement”, there is no oversight of the manufacturing process and no one has to verify what’s in it to anyone.

They do have a pretty website and a cute video, which seems to be all you need these days to get your product covered by TechCrunch.com.

You Might Get Diarrhea (and a UTI) from taking Uqora

I wouldn’t believe the website when it says that “There are no known side effects for the active ingredients at any of the suggested doses.”

You can see in the study up there that 8% of women taking D-mannose had diarrhea. Magnesium also can cause diarrhea. So can high doses of Vitamin C. Put them all together in one drink and who knows what may happen.

And of course, diarrhea not uncommonly can lead to …. you guessed it. A UTI.

Bottom Line

$25 is an awful lot of money to spend on an unproven UTI remedy.  Then again, if you happen to be constipated, you may get your money’s worth…

Strategies for UTI Prevention

  • Drink enough water to keep from being dehydrated.
  • Empty your bladder after sex.
  • Wipe from front to back.
  • If you have recurrent UTI’s and are using the diaphragm, consider if another birth control might be worth trying.
  • Cranberry juice may or may not be effective, but as long as you take an unsweetened variety, it is unlikely to harm you.
  • If you want to take Vitamin C, which may be effective if taken daily, you can get it cheaply from the drugstore – take 100 mg daily, and stop if you get diarrhea
  • If these strategies are ineffective in preventing recurrent UTI’s associated with intercourse there are prescriptions that your doctor may prescribe. These include post-coital antibiotics such as macrodantin, and daily suppressive doses of Methenamine hippurate (Hyprex). In post menopausal women, vaginal estrogen has been shown to be effective in reducing UTI frequency.

HPV Myths – BUSTED

Myths

There’s an awful lot of misinformation out there about HPV and the HPV vaccine. Let’s see what I can do to clear up the confusion. Here are eight myths I find myself having to continually address with my patients. Let’s bust ’em!

Myth#1 – HPV is forever

Wrong. 90-95% of the time, HPV infections clear without any treatment. For those women with persistent HPV infection, we have pap smears to detect and treat precancerous lesions (dysplasia) years before they become invasive cancer.

Myth #2 – If I’ve had the HPV vaccine, I don’t need Pap smears.PAP

Wrong again. While the HPV vaccine is highly effective against the HPV strains it targets, and those strains together cause in excess of 70% of all cervical cancers, you are not 100% protected. Sorry. Until we have a vaccine that protects against all the cancer-causing subtypes, you’ll need to get your pap smears.

The good news in this front is that both Gardasil and Cervarix are showing cross-reactivity against other cancer causing strains of HPV so we may be getting a bigger bang for our buck than we initially thought. Stay tuned..

Myth #3 – The HPV Vaccine is dangerous.

danger

Actually, it’s quite safe. A recent comprehensive review of HPV vaccine safety studies to date, some with over a million subjects each, found no serious health risks from the vaccine.

Like all vaccines and injections, HPV vaccination can cause some local irritation on the arm, and some young girls faint afterwards. This is not serious.

Myth #4 – The HPV Vaccine is a Scamscam

No, it’s not.

There are valid arguments to be made as to whether the HPV vaccine is the most cost effective approach to eradicating cervical cancer in the US, where most women are already getting pap smears, and where those at highest risk (women who can’t afford pap smears) probably can’t afford the vaccine either. And we won’t get into the ridiculously high cost of the vaccine, or how fear mongering and politics have been used to market the HPV test and its vaccine. (I’ve written enough about this before). But that doesn’t make it a scam. The vaccine is real and it works.

Some have raised legitimate concerns that the vaccine’s efficacy could wane over time, effectively just delaying but not preventing cervical cancers. Fortunately, this has not panned out to date – the vaccine has shown no decline in immunity for up to 9 years. Time will tell on this one, but so far, so good.

Bottom line is that the HPV vaccine is safe and effective. I see no reason why young women should not get the vaccine. (My kids have gotten it, by the way.)

Myth #5 – The HPV Vaccine causes sexual promiscuity lips2

Nope. It doesn’t. (Research reference here)

Myth $6- If I have HPV there is nothing I can do about it.http://www.dreamstime.com/stock-images-emotion-2-image597604

You’re not powerless – there are some things you can do.  In addition to getting your pap smears, you can help your immune system clear the virus in three ways –

  • Use condoms. By decreasing the exposure of your body to more virus, you’ll free your mmune system up to clear the virus you already have.
  • Get 4-6 servings of fruits and vegetables a day. Women who do so clear the virus sooner than women who don’t.
  • Don’t smoke. If having HPV is your wake up call to quit the cigs, then so be it. Ask your doc for help if you need it to get off nicotine.

Myth #7 – All HPV Tests are the same.

technology

Not true. Some are FDA approved, some are not. Ask your doc which test he/she uses, and be sure its an FDA approved test.

Myth #8- I can’t get the HPV vaccine if I’m over age 26.

Actually you can probably get it if you really want it. But you may not need it.

The vaccine is only FDA-approved up to age 26. That’s because by that time, most women have had one or more HPV infections already. From a public health perspective, it doesn’t make much sense to vaccinate a population against a virus that most are already immune to.

But on an individual basis, the vaccine could be effective if you’ve had very few sexual partners and have never been infected with the HPV strains targeted by the vaccine or had genital warts. Even if you have, there’s no way to know what HPV strains you may already be immune to – the HPV test is not strain specific. (Although one test does detect HPV16/18). I do not recommend getting HPV tested just for this purpose.

I’m hearing that some insurers will pay for the HPV vaccine even in women over age 26. And if they don’t, you can pay for it yourself. Talk to your doctor and make your own choice.

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More TBTAM posts on HPV

Time Makes a Better Bread – and A Better Bread Maker

Jim Lahey Bread 2

I”ve been making Jim Lahey’s bread for about four years now.

My first attempt was in New York City during Hurricane Irene, when I knew I’d be home for at least 24 hours with nothing to do but make this bread. which has a 12 to 18 hour rise, followed by a second two hour rise prior to baking.  The result was delicious, though a little flat.  But hands down the best bread I’d ever baked.

no-knead-bread first attemps
My first attempt at Jim Lahey’s No-Knead Bread

I decided to try making bread during weekends at our cottage in the Endless Mountains, and immediately gravitated to Mark Bittman’s speedier version of Lahey’s recipe. The shortened 4 hour rise time allowed me to start the bread first thing on a Saturday morning and still have it ready by lunchtime.

That bread making schedule made us some very pretty breads and served us well on many a Saturday lunch.

Bittman speedier no-Knead bread

But not really.

You see, we often did not roll into the driveway of our cottage until very late Friday evening, especially if traffic was bad getting out of New York City. By that point, the thought of bread for tomorrow’s lunch was nowhere near my consciousness – all I wanted was bed. Next morning, by the time I got up and thought of bread, it was way too late to start a loaf if we were planning to do anything else that day.

So the sad truth is, though I like to think I did, most weekends on the mountain I did not make bread.

bread

This summer I got smart and took off a bunch of Friday afternoons. Now we leave earlier from New York City (1 pm is the latest if you want an under 4 hour trip), and I work using my laptop and cellphone hot spot while Mr TBTAM drives. The result? One evening, I actually found myself sitting on the front porch on a Friday evening with a glass of wine at 6 pm!

This got me thinking – why not start the bread now instead of in the morning? After all, Lahey’s original recipe has an overnight rise.

The first phase of the recipe is so easy that I have it memorized and can get the bread set up to rise in 5 minutes. I can even start it at home while we’re packing up the food, and let it start to rise in the car while we drive! Next morning, I can sleep as late as 9 am and still have time to finish the second rise and bake it before lunch, leaving me a free afternoon to hike or swim or kayak.

If I want the whole day free, I set an alarm for 5, set up the second rise and head back to bed till 7:00, at which point I get up, heat the oven for a half hour while I shower, then bake the bread from 7:00 to 7:45 am. After cooling (an absolutely essential part of the process), the bread will be done by 8:15 am, and I have a full day to play.

My early morning bread making schedule

Somewhere along the line, I bought Lahey’s book and learned the actual science behind his bread. This brought home the reality of why this longer making bread is just a better bread than Bittman’s speedier version. The overnight rise is really a short fermentation, and the bread attains a wonderful sourdough-like taste. The crust it forms is thicker and the bread sturdier yet still soft – ie., better gluten. Lacey’s book also taught me to respect the rest after baking, during which the bread “sings” as the steam escapes, and never, ever to cut into the bread till it has cooled.

A big advantage of the overnight rise for me is that it is not as temperature dependent. It can get really cool up here on the mountain, and there were times I put the bread in the car and drove to a sunny spot to get a decent rise from Bittman’s speedier rise recipe. But when the yeast have 12 or more hours to do their thing, temperature seems not to be as critical. (If it’s going to be a really cool night, I do increase the yeast just a teeny bit as insurance.)

Speaking of temperature, I’m still wondering just how hot I can go when baking this bread. Bittman’s original article says 450 degrees, but in the NYTimes video Lahey says “500, even 515” degrees, and in his book, he says 475 degrees. (The bread pictured here was baked at 475 degrees.)

Lahey’s pics of the bread making process in his book are invaluable. I also strongly recommend watching this video from Mark Bittman to understand just how wet this dough is. Over time, I’ve gotten the confidence to know that if following the recipe exactly on a given day yields bread dough that’s a little too thick, I can add water and make it “just right”. This is the sort of skill that only comes with time and experience.

So try this bread. Then try it again. And again. And again.

With time, and sooner than you think, you’ll be making one amazing loaf.

Jim Lahey Basic Bread

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More No-Knead Links 

Treating Menopausal Vaginal Dryness

dried roseSex is supposed to be fun, and it’s definitely not supposed to hurt.

But one of the consequences of menopause is vaginal dryness, which for many women means painful sex.

With the loss of ovarian estrogen, vaginal walls that were once elastic, expandable, supple and sturdy can, over time, become tightened and fragile. The vaginal walls can become as thin as tissue paper, unable to withstand the manipulation that occurs with sexual activity, and can tear and even bleed with intercourse.

“Use it or lose it”

When sex becomes painful, the natural response is to begin to avoid intercourse. But without continued sexual activity (masturbation counts, too), the vagina becomes even smaller and tighter, making a bad problem even worse. Add in a partner with erectile dysfunction and it’s not unusual for a woman to present to me not having had sex in a year or more, wondering if there’s anything that can be done to get back the sex life she and her partner once enjoyed.

Fortunately, the answer is almost always a resounding “Yes!”

Non-Hormonal Treatment

The first step for most women is a trial of non-hormonal therapy. You’ll need two things – a moisturizer and a lubricant.

Vaginal moisturizers

Think of how you take care of your skin – you moisturize it daily, right? Well, the menopausal vagina needs the same thing. It doesn’t have to be every day, but it has to be regular and consistent.

I don’t promote products, but I do tell my patients about Replens – it’s been studied and shown to be as effective as vaginal estrogen in restoring the premenopausal vaginal mucosa.

Vaginal Lubricants

Have fun trying out brands, but avoid flavored and scented products if you tend to be sensitive to them. If you need STD protection, stick to water-based lubricants that will not degrade condoms.

Don’t be shy about using lube – slather it on him and yourself and have fun.

Vaginal Estrogen Treatment

Probably the most effective treatment for dryness is vaginal estrogen. It works by restoring and thickening the vaginal mucosa, and by increasing vaginal secretions. Vaginal estrogen comes in one of three forms –

  • Estradiol tablets (Vagifem) – A small tablet inserted into the vagina once a night for two weeks, then twice a week thereafter. The vaginal estrogen tablet is for many women the easiest and least messy option, although not all women can seem to remember to use it regularly on a twice weekly basis.
  • Estrogen creams (Estrace, its generics and Premarin) – A cream inserted into the vagina once a night for two weeks, then twice a week thereafter. Same issue as with the tablet – remembering to use it. Estrogen doses are highest for the cream when used according to the package insert, but one can adjust the dose of cream by simply using less. This allows for higher doses at the onset of treatment, with lower maintenance doses once vaginal integrity and sexual function are restored.
  • Estradiol vaginal ring (Estring) – A ring inserted once every 3 months. Systemic estrogen absorption is lowest for the Estring estrogen vaginal ring, but not all women’s vaginas are large enough to accommodate the ring at first.

Safety of Vaginal Estrogen

Women hear the word “estrogen” and immediately become concerned – not surprising given the findings of the Women’s Health Initiate in 2002 that hormone replacement is associated with a small increase in breast cancer risks. However, estrogen exposure from use of vaginal estrogen is much lower than that with hormone replacement, and blood levels of estrogen remain within the menopausal range.

These small amounts of estrogen do not carry the same risks of blood clots as does hormone replacement, and there is no increase in uterine cancer rates with vaginal estrogen use for up to 5 years. Despite these differences, vaginal estrogens carry the same FDA warnings as systemic hormone replacement, and menopause experts have petitioned the FDA to correct the vaginal estrogen package insert.

All of that said, we do not have long-term data on breast cancer risks from vaginal estrogen, and women at high risk for breast cancer or with a history of breast cancer generally want to avoid even the small amounts in vaginal estrogen, especially if they are taking aromatase inhibitors to lower breast cancer risks.

If non-hormonal treatment are ineffective, some high risk women may be willing to use a short course of estrogen to restore vaginal integrity and sexual function, followed by over the counter moisturizers for long-term maintenance therapy.

What About Estriol Cream ?

Estriol is a weak estrogen that is effective for vaginal dryness, but is not FDA-approved. If you’re avoiding the FDA-approved products because you don’t want to take estrogen, then take estriol off the list as well. It’s just another estrogen.

Oral Treatment

Ospemifine (Osphena) is an oral SERM (Selective Estrogen Receptor Modulator) that was FDA-approved in 2013 to treat menopausal vaginal dryness. In the vagina, Ospemifine acts like estrogen, restoring vaginal moisture and the integrity of the vaginal mucosa. Ospemiphene can stimulate growth of the uterine lining, although in postmenopausal women, this effect is minimal.

In animal studies, ospemiphene has been shown to block estrogen receptors in breast tissue. While this is an intriguing, it has not yet been proven in humans or shown to translate into a lower breast cancer risk for ospemiphene users.

Ospemiphene does carry a small blood clot risk, although it is smaller than that of hormone replacement. It can also worsen hot flashes, which makes it not a good option for women having menopausal symptoms other than just dryness.

What about vaginal laser treatment?

The FDA recently approved a vaginal laser called Mona Lisa Touch for treatment for menopausal vaginal dryness. The biggest potential advantages of this approach is that no hormones are used. The downsides are the need for multiple visits to complete therapy, extremely high cost (One hospital is charging $1500 for three visit treatment, none of which is currently covered by insurers) and very limited data on efficacy and long-term safety.

My biggest concern is what the risks are when this laser becomes more widely used by clinicians outside of clinical trials. It’s being promoted aggressively, and it’s non-covered insurance status could make it a real cash cow for practices. That said, I’m intrigued by the laser as a possible alternative for women unable or unwilling to use estrogen, so stay tuned on this one.

Vaginal Dilators

If you’ve been menopausal and celibate for a long time, the size of the vagina can actually decrease, and estrogen and lubricants may not enough to restore normal sexual activity. In that case, your doctor can prescribe a set of vaginal dilators – soft plastic rods that come in graduated sizes from 3 mm to 10 mm in diameter, allowing for a gradual increase in vaginal capacity.

With patience and determination, I’ve had many patients who’ve re-created the vagina of their youth. But not every patient I’ve offered dilators feels up to the task. In that case, they confine their sexual activities to non-penetrative sex, which for many women is where the fun is anyway.

Which brings me to –

The forgotten art of foreplay

Over years of being together, what with children and a busy life, some couples may have gotten out of the habit of foreplay and have had a very satisfactory sex life just getting down to business.

But with age, her vaginal dryness and his erectile dysfunction, the old “Wham, Bam, thank you Ma’am” may not work so well anymore. The good news is that age also brings the time to take a more leisurely approach to sex and rediscover the joy of foreplay, as well as the wide variety of intimacies beyond intercourse that couples can use to have a fulfilling and enjoyable sex life.

I often refer my patients to this reading list from SEICUS – the Sexuality Education consortium of the United States – addressing the changes to sex that come with age, and strategies for adapting to and enjoying them.

One more piece of advice

If, because of dryness, it’s been awhile since you’ve had sex, don’t start treatment and then sit and wait for the urge to hit you to start having sex again. Your libido is not going to suddenly turn back on just because your vagina is ready.

You’re just going to have to do it anyway, whether you think you want to or not. If all goes well, your body will respond – “Oh yeah – Now I remember – this is fun!”

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A modified version of this post was published on WebMD.com