Osteoporosis Drugs – You Got to Know When to Fold ‘Em …

If you are one of the millions of Americans taking a bisphosphonate drug for treatment of bone loss, you’ve most likely worried about what you’ve gotten yourself into.

Earlier this month, the FDA took the highly unusual step of publishing the results of their investigation into reports of atypical fractures of the femur occurring in long term users of drugs like Fosamax (alendronate), Actonel (risedronate), Boniva (ibandronate) and Reclast (zoledronic acid).

Now we have yet another investigation confirming the association of these fractures with bisphosphonate use, and correlating the increasing risk with increasing duration of therapy.

When categorized by duration of treatment, compared with no treatment, the odds ratio for an atypical fracture vs. a classic fracture were 35.1 for less than two years of treatment, 46.9 for two to five years of treatment, 117.1 for five to nine years and 175.7 for more than nine years.

What’s Going On Here? 

How do drugs that are supposed to prevent fractures cause new ones? That’s a good question. And the answer is complicated, so let’s see if I can simplify it.

Think of your bones as a road system that is constantly being remodeled depending on where the traffic is. There’s a large well-funded road crew constantly digging up the old road and replacing it with new road. They work in small sections scattered throughout the system, so as not to disrupt the road’s integrity. The members of the crew that digs up the old road are called the osteoclasts –

 and the ones who fill in and re-pave it are called the osteoblasts.

Now suppose over time, for whatever reason – age, bad weather (underlying medical conditions), lack of road material (vitamin D deficiency, menopause) –  you’ve dug up or lost more roads than you’ve replaced (Osteoporosis).  So you start treatment with a bisphosphonate like Fosamax or Actonel or Boniva. These drugs work by cutting back on the digging crew, but keeping the paving and refilling going in the areas that have already been dug up, thus rapidly bringing miles and miles of untravelable road into good use. Not to mention it’s a nice strong road, becoming mineralized over time. (That’s your bone density increasing.)

The whole thing is working so well that you send almost the entire road crew on a prolonged vacation. (Suppression of bone turnover, which is how bisphosponates work) Now you’re left with a skeleton road crew (pun intended), which, for most folks is still enough to deal with the usual cracks and potholes that appear over time, and can keep the road (your bones) in good working condition. But in some of you (perhaps those who are genetically predisposed) the downsized crew just can’t keep up with the repair work. As time goes on, the structural integrity of your bones becomes weakened. And then one day, for no apparent reason, just during the course of usual activity,  a small crack that the crew hasn’t yet repaired becomes a large crack – and you’ve just fractured your femur.

You don’t have to be on a bisphosphonate for these kind of atypical fractures to occur. Some folks just get them. But taking a bisphosponate increased the chances in predisposed individuals, and that chance increases the longer you take the drug, especially if your bone mass is in the osteopenic or normal range.

Exactly What are the Risks?

The chance that you’ll get one of these atypical spiral fractures while taking bisphosphonates is extremely low –  one study estimates the incidence at about 32 per million users per year, compared with over 10 times that many fractures prevented in the same million users.  So overall, the benefits of these drugs still far outweigh the risks.

However, drilling down into the fracture data reveals that we can do better than just accepting a rare risk in return for a common benefit.

Those who develop atypical fractures appear to be  individuals whose bone mass in the femur is in the normal or osteopenic range, as opposed to those whose hips show osteoporosis. This happens to be the very same group that recent studies suggest may safely stop Fosamax after 5 years without losing the benefits of having been on the drug.

So, if continuing the drog for longer than 5 years adds little benefit but increases risks, even if those risks are rare, it becomes pretty darned obvious what we need to do.  Stop the drug.

Which reminds me of that song from Kenny Rogers – “You got to know when to hold ’em / Know when to fold ’em / Know when to walk away /Know when to run… ” Not that treating osteoporosis is a gamble, but the Gambler’s advice rings eerily true for this class of drugs.

 

When to Fold ‘Em

New data suggest that as long as your bone density is above the osteoporotic range, you can stop taking your bone meds after 5 years.  Continuing the drug past that time only brings added risk without any benefit.

When to Hold ‘Em

If you’re at increased risk for fracture and have been taking your meds for less than 5 years, you may still be getting benefit without significant risk. Remember that these drugs decrease the risk of conventional osteoporotic fractures at over 10 times the rate that they increase the risk of atypical fractures, so don’t throw the baby out with the bathwater.  But make sure you are getting adequate vitamin D, calcium and weight bearing exercise to maximize the benefits you’re getting while you’re still on these drugs. And discuss with your doctor whether its worth considering coming off the drug in the future if your bone mass improves into the osteopenic range.

If you’ve been on these drugs for 5 years or more, but your bone mass is still in the osteoporotic range, you also may still be getting benefit from continuing treatment. Ditto if you’re at high risk for vertebral fractures. You are not in the group at highest risk for atypical fractures, but are in the group at highest risk for the more common type of osteoporotic fractures. Talk to your doctor about the comparative risks of continuing vs stopping treatment. It may not be a straightforward decision, as we don’t have exactly clear guidance on when to stop in everyone.  But at least have the conversation.

Should You Even Be in the Bisphosphonate Game?

Not everyone taking bisphosphonates needed to start them in the first place. Aggressive marketing and disease mongering by Big Pharma initially led to overuse of these drugs for treatment of osteopenia, a condition we now know does not necessarily need to be treated.  With the help of the FRAX fracture risk calculator, we’re now able to determine which patients with osteopenia are at significant fracture risk and require treatment (very few, it turns out) and which ones can be adequately managed with lifestyle, calcium and vitamin D (most).  Talk to your doctor about using FRAX before deciding if treatment is warranted. 

Remember too that bisphosphonates are not the only drugs that treat osteoporosis. Other medications to consider include hormone replacement,  Evista (raloxifene) and injectable terapeptide. Each of these drugs has its own set of risks and benefits, and some work better than others depending on your type and location of bone loss, so a reflex switch from bisphosphonates may not necessarily be the best option. As always, its best to talk with your doctor about what is right for you.

Bottom Line

The optimal duration of bisphosphonates for most individuals appears to be between 3-5 years. Beyond that point, unless there is osteoporosis at the hip or a high spinal fracture risk, there appears to be added risk rather than additional benefit to prolonged use of these medications, and it may be time to consider stopping therapy.

__________________________________________________________

Resources

 

Behind the Counter in the UK

 

While waiting at Heathrow for our flight home from London, my mother in law Irene, recalling the turbulence on our ride over, decided to get herself something for motion sickness. Off we headed to the airport pharmacy, where we discovered that motion sickness drugs are sold behind the counter in the UK, along with cough and cold syrup, paracematol (Tylenol) and many other drugs that we Yanks can scoop up freely from the pharmacy shelves here in the USA.

Upon questioning Irene about her health and other medications she was taking, the cheerful and helpful pharmacy tech called over the pharmacist, who firmly but politely refused to sell her the drug due to concerns about the potential to worsen her glaucoma. Irene was a bit taken aback, since her eye doctor had told her she could use the meds. But, having no local doc to override the pharmacist, we accepted the pharmacist’s verdict. Thankfully, our plane ride home was smooth sailing.

Overall, I was quite impressed with the caring attitude of the pharmacy tech and the pharmacist, as well as the seriousness with which they took their jobs. The risks of over the counter drugs may seem minimal, but not everyone takes the time (or has the corrected vision) to read the package labeling and warnings. Having someone vet your purchase for you could be potentially life saving.

I asked the pharmacist how the morning after pill is handled in the UK – turns out women requesting the med see him in his office for a private consultation prior to getting the drug, which has no age restriction. Not a bad idea, I think. Maybe we need to expand our behind the counter system in the US.

Then I think about the right to life pharmacists.

And change my mind.

Asparagus with Mustard Vinaigrette

 

A quick post and pic for a quick and delicious asparagus recipe from yesterday’s New York Times. Perfect for using the chives that have had their annual rebirth in my terrace garden. We added some sliced avocado, otherwise made it as written. The gorgeous thin spring asparagus are from Fairway.  We had enough vinaigrette leftover to use tomorrow in something else – I’m thinking of trying it with chopped eggs as an enlightened egg salad.

 

April in London (Part 4) – Shakespeare ‘s Birthday Tour

By sheer coincidence, our visit to see my daughter during her semester studying Shakespeare at RADA occurred during the week of the Bard’s birthday, making her class production of All’s Well That Ends Well seem even more special than it already was for us. Even more coincidental was the fact that we had tickets to see King John in Stratford-Upon-Avon on the day that town was celebrating their most famous son, and chanced upon the Globe Theater’s birthday celebration the following day while heading to the Tate Modern! If we had joined a Shakespeare’s Birthday Tour group we could not have planned it better. In fact, I’m thinking we should do this again next year and call it the TBTAM-SBT. Who wants to join us?…

Stratford-Upon-Avon

The Bard’s birthplace is a reasonably priced, lovely two-hour train trip from London’s Marylebone Station on Chiltern Railways.  Train tickets can be purchased online and retrieved at the station’s kiosk with your credit card. (I bought ours a good three weeks before we left the US.)

At Marylebone, we also purchased a very reasonably priced and delicious breakfast of cappuccino and sandwiches for the trip from one of several purveyors that were open that hour on a Saturday morning.

The train cars have seats with tables, so we ate our breakfast in a leisurely fashion during the train ride while gazing at the lovely English countryside, which was brushed with swaths of bright yellow rapeseed fields,

and the occasional sheep or cattle pasture.

We divided the remainder of the time between napping and reading, and arrived rested and raring to go at Stratford-Upon-Avon. From the station, it’s a short walk along the road into town (just follow your fellow travelers up the low hill), along which we found a lovely little antique store (you see why I want to come back, right?…),

and a Polish grocery and pastry shop.

Then – O my rapturous heart! – we came to Rother Street Marketplace, where the Warwichkshire Farmer’s Market – held between 9am and 2 pm on the 1st and 3rd Saturday of every month, year round – was in full swing. (How ever did I plan this trip so perfectly???)

The veggies were gorgeous

the offerings unusual

and practically every booth was giving out samples.

We tasted the most delicious cheeses, pates, sausages and jams, purchasing gifts to take home and some pastries for later.

To see more photos of the Market, click on the thumbnail images across the bottom of the slide show below. (Click FS to view best in full screen mode, then esc to return to this post.)

[flagallery gid=3 name=Gallery]

After the market, we headed further into town towards the Bard’s Birth house.

By this time, the town’s birthday celebration was in full swing, with a parade, a live band playing American classic rock songs ala’ Jimmy Buffet (???) and plenty of activities for Shakespeare lovers of all ages. The town center has a bit of a Disney atmosphere, and the price of admission to the Birth house was too steep for our taste. But we did stop for tea at the cafe overlooking the Birthplace gardens, and visited a small museum there for free.

Next we walked on to Shakespeare’s school

where we encountered the locals in full birthday parade regalia.

And then it was on to the Swan Theater

where we saw a most amazing production of King John in previews with the Royal Shakespeare Company.

Set in time around the 70’s at a hotel ballroom party (think Bar Mitzvah or family wedding reception), complete with karaoke singing and a perfect rendition of the final dance from Dirty Dancing (we Yanks in the audience went wild – I think the locals didn’t quite get it), this production was powerful, edgy and utterly fantastic.

Don’t let the party  atmosphere fool you – there’s a severed head, a child’s death and a full-out war between England and France taking place here. Alex Waldemann (with whom we had a lovely conversation outside after the show) was brilliant as King John. In a magnificent switch of gender roles, director Maria Aberg cast Pippa Nixon in the pivotal role of the Bastard, adding a whole new layer of heterosexual tension into her relationship with John. The Archbishop was also cast a female – Paola Donisatti – who plays the papal representative with an androgynous air, large sunglasses and a real mean streak. The rest of the cast, male and female, is equally stellar. This production should come to New York – I’m sure it would play to sold out houses at BAM.

Having missed the rain shower that occurred while we were in the theater, we emerged to sunshine and decided to walk along the Avon River,

past Wisteria clad cottages

and a small “on the run” production of Romeo and Juliet,

to Holy Trinity Church, a real working parish,

where, for two pounds, you can enter the chapel where Shakespeare and his wife Anne Hathaway are buried.

As we left Holy Trinity, we were serenaded by the screams of Juliet, who, having wandered in with her on the run production, awoke from her drugged sleep to find her dead Romeo in the corner of the main chapel.

Emily now insisted that we needed to have genuine fish and chips, and so we did, at Barnaby’s Fish Restaurant and Take Away just past the theater.  I smelled a tourist trap, but it was a charming little place, and we had managed to get ourselves inside the restaurant just as another storm broke yet again, so it was a welcome stop despite what turned out to be a rather mediocre meal.

We were rewarded with a rainbow as we exited the restaurant, a sure sign from the Bard himself that this was truly a day to remember. Soon enough, we were back on the train, where we were washed by the setting sun as we headed back to London. Our ride back was a bit longer than the way out, but no matter. We slept, and read, and dreamed of a city by the river where 448 years ago, a writer was born.

I could just as easily have spent the entire weekend at Stratford-Upon-Avon, and just may if I do the SBT again next spring. According to our cab driver at Stratford, who of course knew the play we had seen, there are plenty of places to stay, and the town is a popular weekend home location for Londoners.

The Globe Theater

The next morning, Shakespeare’s actual birthday, as we headed to the Tate Modern on SouthBank, we were approached by a young woman who offered us free admission to the Globe Theater museum and a marathon reading of Shakespeare’s Sonnets. This was the grand opening of the Globe to Globe Shakespeare Festival, in which Shakespeare’s plays will be performed at the Globe in 37 different languages by theater troops from all across the world. The sonnets were read in those same 37 languages, most of which were represented by at least one or more theater goers in the gallery.

We felt part of this amazing worldwide community of people who have been touched by the writings of one man.

It was magical. Next week, Emily will be back at the Globe, seeing Julius Caesar performed in Italian. I wish I could be with her.

So there you have it

The TBTAM Shakespeare’s Birthday Tour. I couldn’t have planned it this perfectly if I had tried. And while I am sore tempted to try it again next year, I wonder if that is tempting fate?  For, as Shakespeare has been quoted to have said (though I do not know from which play it comes) –

Good luck is often with the man who doesn’t include it in his plans.

April in London (Part 3) – Old Spitalfields Antique Market

It’s not Portobello Road, but it’ll have to do for this trip.

On other days Old Spitalfields Market is a mix of new, crafted and retro chic in the midst of a neighborhood known for its trendy shops – a destination for those in search of whats hip and what’s hot.

But on Thursdays, it’s just antiques.

And that’s hot enough for me.

Believe it or not, I bought nothing.

Having arrived at the end of the day after a late lunch across the street at St John’s Bread & Wine, some stalls were already beginning to close.

So I decided to just putter around among the remnants of lives once lived instead of spending my time looking to find that perfect thing.

A new experience for me,

and one that I highly recommend.

Oh yeah.

I forgot.

They also had cookies.

So I guess you could say I did buy something.
____________________________________________________________________

Up Next – April in London (Part 4) – Shakespeare’s Birthday Tour

Old Spitalfields Market

April in London (Part 2) – Where We Ate

We did not eat here –  The Churchill War Rooms Kitchen

On my last visit to London, I was overruled by my kids whenever I tried to plan a meal at a special restaurant – they insisted we allow serendipity to rule when choosing where to eat. This time, with Irene on my side, and half the child contingent at home (sadly, but in this case…), I actually planned a few meals ahead of time, letting the restaurant location drive what else we did that day.  Thanks ever so much to pastry chef and blogger Shuna Fish Lydon, whose London fave restaurant list served as our personal Zagat guide to the city.  I’m hoping this post will serve as helpful to my readers as her post was for me.

St John’s Bread and Wine
94-96 Commercial Street, London E1 6LZ.


Our first dip into Shuna’s list yielded the best meal of our trip – Lunch at St John’s Bread and Wine on a rainy Thursday mid-afternoon.  St Johns specializes in what is called “nose to toes” eating, a traditional British way to use all of the animal, which is why the menu was rife with offal dishes, offal being the word used to describe organ meats such as kidney, tongue and liver, which despite what you may think, do not necessarily taste awful. (Sorry, I just had to do the obvious…)

We played it safe just in case and started with the salted beef broth with dumplings. Irene, who readers know is the best home cook in the world, declared it the best soup she’d ever eaten. (Anyone who has ever tasted Irene’s chicken soup will appreciate just how stellar this beef broth was…)

I think I agree. Next up was the best appetizer I’ve ever eaten – Fois Gras and Duck Liver Toast with a side of cornichons.

If you have any doubts as to how good this really was, just look at this bread.

Irene insisted that we guild the lily, and while I only did this for one bite, that bite was such stuff as dreams are made of…

Finally, a salad that I plan to replicate at home very very soon – cauliflower, leeks and chickpeas with capers and a light horseradish dressing.


The crowd at St Johns that late afternoon was mostly hip bald British chef-types and young male foodies with an occasional woman thrown in for color. The owner of the place was holding court at a table near us and there was lots of wine flowing. I felt a bit like I had crashed a private party, but we were treated quite well despite being the only non-locals in the place.

St Johns is worth making a special trip. Go on a Thursday and combine it with a visit to Spitalfields Antique Market just across the street, which is what we did.

Olivelli Ristorante Paradisio
35 Store St, London WCiE 7BS

This unassuming restaurant on Store Street in Bloomsbury was around the corner from our hotel, and we popped in for lunch on Friday after my daughter’s final performance at RADA (Did I mention she was wonderful?….).The service was excellent, and while the pasta and risotto were quite fine though not especially memorable, the mussels were probably the best I’ve ever eaten. On the smaller side, which I like, perfectly cooked and seasoned and teeming with garlic. If you’re looking for a good meal in Bloomsbury, this place is a sure bet.

Chez Marcelle
34 Blythe Road, London W14 0HA
+442076033241

My sister-in-law Nancy, who frequently visits London for work, recommended this lovely restaurant in Olympia for delicious, well-priced Lebanese food.  It was our first meal in London, and set the tone for what was a great trip food-wise. The #10 bus took us practically there from our hotel in Bloomsbury, making it not as out of the way as one might think.

Chez Marcelle is a one woman show starring Marcelle herself, who hosts, cooks, hosts and serves, along with only one assistant the night we ate there. We arrived on the early side, about 6:30 pm, and had Marcelle’s undivided attention until the place began to fill up, afer which we had to share her with the other diners. That meant we had to wait until she was finished preparing our neighbor’s meal before she could write out our check, but that was fine with us. This is not haute cuisine, but home cooked authentic Lebanese food, every dish freshly prepared by Marcelle and every dish delicious. Here are some examples from our meal –

  • Bazinjan Rahib  – Grilled aubergine peppers, onions, tomatoes and parsley dressed w/ lemon, olive oil & garlic. Like baba ganoush, but better, and added to my list of things to learn to make.

  •  Grllled Halloumih Cheese

  • Jawaneh – Grilled chicken wings with garlic and lemon juice

  • Kebbe Maklieh

If you love Lebanese food, Zagat has compiled their top 5 London Lebanese restaurants, but they don’t list Chez Marcelle. Someone needs to let them know about this special place.

Gourmet Burger Kitchen (GBK)


Okay, I admit this restaurant is part of a chain, but the burgers,”made from 100% West Country beef”, are fabulous, the price is right and there’s a branch on Maiden Lane, making it a perfect place to grab a quick bite pre or post theater.  The service on Maiden Lane was not as good as at the Putney branch, where we ate the last time we visited London.  But the atmosphere was lively, our fellow diners friendly and talkative, and the burgers tasted just as good, if not better than the ones we ate at the more sedate Putney branch. Great fries and milk shakes, too. With branches all around London, GBK is a one place to keep in mind when you need a reliably good meal fast. Or just crave a fabulous burger.

The Modern Pantry
47-48 St John’s Square, London EC1V
4JJ 020 7553 9210

The Modern Pantry was another recommendation from Shuna that I wish I could say I loved as much as she did, but…

Any menu that takes a paragraph to list the title of a single dish is probably making cooking more complex than it need be.  Other than a delicious scallop on a bed of parsnip puree, I found the food overly fussy, with competing flavors and no rhyme or reason as to why certain ingredients were paired.  I know this is called fusion cooking, but it seemed more like mishmash cooking to me – almost as if I had filled my plate with several different dishes from a buffet rather than ordered a single dish. For example –

  • Confit duck leg, sweetcorn, black beans, sugar snaps & coriander, plum & Bramley apple relish
  • Fig, apple & raspberry oat crumble, goats curd sorbet, runny cream

That said, the service was fabulous, the wine absolutely incredible (such legs!…), the atmosphere warm and inviting and the location on St John’s Square – perfect.  So if fusion cooking is your thing, you’ll love The Modern Pantry. The place was packed, so you won’t be alone. Tell them I sent you.

Tea at the Tate Modern Level 7
Bankside, London SE1 9TG

The Food at the Tate is well-priced, with views of St Paul’s Cathedral and the city that alone are worth the visit, and more than made up for the lack of decent art on display downstairs on the day we visited. (Don’t get me started on Damien Hirst..)

The scones with clotted cream were surprisingly and unnecessarily large – but they were moist and delicious and the tea was lovely, served in little tea-press pots. My cheese platter was a bit disappointing – nothing special about the cheeses they chose to feature. The tea sandwiches and baguette were fine. But the views – I could have sat there forever.

Store Street Espresso
40 Store Street, WC1E 7DB

Best place for coffee in Bloomsbury, according to my barista-trained daughter. My one cup of takeaway cappuccino was perfect, so I’d agree. Not to mention great atmosphere, free wi-fi, decent food and a book exchange.
________________________________________________________

More London Restaurant Reviews 

Up next – Old Spitalfields Antique Market 

Nutella Settles Lawsuit for $3 Million – Will You File For Your Piece of the Settlement?

The Ferrero Group has agreed to pay $3 million to settle a lawsuit that claims they are falsely advertising Nutella as a healthy breakfast food. (See their ad above – What do you think?)

The suit was brought by a handful of US consumers, but you can get in on the settlement to the tune of $5 per jar of Nutella that you may have purchased, up to a total of $20, no receipt needed.

The Nationwide Class provides for a settlement fund of $2,500,000 and the California Class provides for a settlement fund of $550,000 for a total of $3,050,000. Class Members can receive up to $4 per jar of Nutella that they purchased during the time periods listed above. Class Members who purchased multiple jars of Nutella during the time periods can submit a claim for up to five jars for a maximum award of $20 per household. If the value of the claims of the Nationwide Class exceeds $2,500,000, or the value of the claims of the California Class exceeds $550,000, then payments will be reduced proportionally.

I think the lawsuit was appropriate

I love Nutella. Who doesn’t?  But marketing Nutella as breakfast food? That moves it from the candy aisle in your brain to the meal part, takes away the guilt component and makes it a part of your daily routine rather than a once in while indulgence. It’s brilliant marketing, actually.

But there’s no way that stuff is part of a daily wholesome breakfast. As a mom and a physician, that the ad truly pissed me off when I first saw it.  Nutella’s first ingredient listed on the label is sugar. And yet sugar is never mentioned in the ad – just hazelnuts, milk and cocoa. So yeah, I think that’s false advertising.

Some have suggested that the lawsuit is frivolous. A Nutella breakfast is no worse than a bowl of sweet cereal, something advertised to kids all the time, they say. Just read the label, others tell us, and anyway, how stupid can you be not to know that Nutella is basically spreadable candy in a jar?

To them, I’d argue that many American consumers, who may have trouble affording a trip to Disney World,  let alone to Europe, have until recently never heard of Nutella. For many of them, this ad was their introduction to the product. Imagine that if the first time you heard what a Hershey bar was, it was being advertised as part of a balanced wholesome breakfast. Would you think that was false advertising?

I do agree that all it takes is a glance at the label to know what you’re buying, and abdicating responsibility for your wallet and your health to advertisers is not smart. But highlighting to ad makers that smoke and mirrors won’t fly is the right thing to do. If this makes the Mad Men pause before writing their next line of copy, then I say $3 million is a small price to pay. Not to mention all the free advertising the settlement is netting Nutella. Hmmmm… I wonder if the whole thing isn’t just one giant marketing scheme?

This isn’t the first time Ferrero has been asked to stop pretending Nutella is healthy

They’ve been slapped on the wrists in Europe for the same thing. The UK actually banned Nutella’s breakfast ads there. But attempts by the EU to ban advertisting of unhealthy foods is meeting opposition, in large part because of fears that it would hurt Nutella’s business.

Please. That stuff is like crack cocaine. It will always have a market.

Do you know what pisses me off even more than that stupid Nutella ad?

I just found out that the Nutella sold in the US is not as good as the stuff they make and sell in Europe.

Now that’s something to sue about…

April in London – Part 1


One of the best parts about having your daughter do a semester abroad is that you have an excuse to cross the pond. Put that child in RADA’s Shakespeare program, then realize your visit coincides with Shakespeare’s birthday, and you begin to feel that the Bard himself has conspired to make that visit one of the most memorable, if not short, vacations you’ve ever taken.

It was just my mother-in-law Irene and I on this trip, and while we had a marvelous time together, we missed Mr TBTAM and my other daughter, who would have loved every minute of this vacation.

Where we stayed

The Academy, 21 Gower Street in Bloomsbury

If you want to hang with the locals, but still be close enough to walk to Covent Garden, Trafalgar Square and the British Museum, with easy access to buses or the tube to take you anywhere else you want to go, then Bloomsbury is where you want to stay. It’s the home of the University of London, the London School of Hygiene and Tropical Medicine and The Royal Academy of Dramatic Arts, so the streets are teeming with students and academic types. Needless to say, I felt right at home.

Our hotel was absolutely wonderful – a linked series of five townhouses, with small but lovely rooms, a conservatory and garden for relaxing or taking your morning coffee, and a restaurant.

Not to mention free wireless internet, great towels and fresh bottled water left at your door each evening by the small, personable staff.

However, in typical British fashion, the place had its quirks, with smallish rooms, a tiny-tiny bathroom, a shower that never really got hot-hot, and perpetually cold hallways due to ill-fitted front doors in the townhouses that let the air in all day and night. (I really think the Brits just don’t feel the cold the way we Yanks do…) None of which took away from the charm of the place, and I’d stay there again in a heartbeat.

The Weather

It rained every single day, but only intermittently, rarely heavily and apparently not enough to halt drought warnings.  The rapid changes in weather, while unpredictable, brought some amazing skies and light –

Spitalfields streets before the rain fell

St Paul’s Cathedral and Millenium Bridge between the rains

Store Street after the rain

And in Stratford-Upon-Avon

we even saw a rainbow.

The Little Things that Make London Different

As always, when traveling I love the little things that remind me I’m not in Kansas anymore . Like the bathroom stalls

the rented opera glasses,

the different words they use

and of course, the people.

The Big Thing That Makes London Different

You really know you’re not in America when it comes to transportation. Taxis are quite expensive and cars pay a fee to enter the center of London. As a result, public transportation is central to the busy life of this international city and puts every American city, including New York, to shame. I’ve never seen more buses in my life, one very few seconds it seemed on the busier routes.

And the train stations! Gloriously bright and beautiful  – Liverpool Street,

Marylebone

and Charing Cross Road.

And although London is not yet Amsterdam, it’s getting there. We saw hundreds of bikes parked overnight at the train station,

ready for retrieval by commuters in the morning rush.

And of course, there’s Barclays’ Bicycle Hire  – launched in 2010 and still expanding. (Pic from Wikipedia)

The Best Thing About London

But the best thing about London? It’s where I got to spend time with two of my favorite people in the world – Emily and Irene.

A fine pair of traveling companions indeed.

Up Next – Part 2: Where We Ate in London

Faure’ Cantique de Jean Racine

 

I’m performing this with my chorus in a few weeks (along with the Faure’ Requiem). I’ve been so enjoying this wonderful recording by the Orchestre de Paris that I just had to share it with you. It is one of the most beautiful pieces of music I’ve ever heard. I hope we do it justice.

Now For the Good News – Depo-Provera Prevents Ovarian Cancer

We’ve known for years that birth control pills protect against ovarian cancer, with an up to 80% reduction in risk with long term use.  Now it appears that use of Depo-Provera may convey a similar benefit.

In a large multicenter case control study in Thailand, published ahead of print in the upcoming issue of the British Journal of Ob-Gyn, use of Depo Provera led to a 39% reduction in ovarian cancer risk. Long term use for three years or more reduced the risk of ovarian cancer by a whopping 83%.  Oh, and by the way, in case you didn’t know it, Depo-Provera also protects against uterine cancer, doing it so well that it is actually used as treatment for uterine cancer.

That’s important information for women using Depo Provera to know, particularly in light of recent media attention to the potential for breast cancer in long term Depo Provera users under age 35.

To put it all into perspective, the risk for breast cancer in women under age 35 is about a 0.2% (1 in 500). The lifetime risk for ovarian cancer is about 1.5% (1 in 66). The lifetime risk of endometrial cancer is about 2.5% (1 in 40). Unlike the possible breast cancer risks, which disappear when Depo-Provera is stopped, the protections against ovarian and endometrial cancer appear to be lifelong.

All of these cancer risks are low in comparison to the risk of unplanned pregnancy, which comprise close to half of the pregnancies conceived each year in the United States. For most women, concerns about raising or lowering cancer risk is not the driving force behind choice of contraceptive.  But on balance, the cancer risk/benefit ratio of Depo-Provera appears to be quite favorable and on par with that of combined oral contraceptives.

For women who need effective birth control, that’s good news.

Depo-Provera Use Does Not Raise Overall Breast Cancer Risk in Young Women

That’s the headline the media should have used when publicizing the results of a recent study comparing Depo-Provera use among women ages 20-44 with or without breast cancer. Because that’s exactly what the study’s authors found.

There was no difference in exposure to Depo-Provera among women with breast cancer compared to controls – about 11% of women in each group had ever used Depo-Provera.

Small Sub-group analysis raised a question

However, the researchers also did what is called sub-group analysis – looking at smaller and smaller groups within the breast cancer study population to see if they could find any women who might have a higher risk from Depo-Provera use, even if the overall group did not.

Before I get to those results, I need to point out that cases and controls, and Depo-Provera users and non-users had significant differences in body mass index, ethnicity, family history, age and pregnancy history – all factors related to breast cancer risk.  In addition, controls had had less mammograms than their counterparts who had breast cancer. There is also a large issue of recall bias at play in studies such as this, since we know that subjects with the disease or condition being studied tend to remember drug exposures better than controls do.

Despite these marked differences between the groups, no statistically significant difference was found between Depo-Provera use in breast cancer patients compared to controls.

BUT, when subgroup analysis was done, there was one group that showed a difference – women who had used Depo-Provera for a year or more within the past 5 years. Here’s the finding that led to the headlines –

However, recent users of DMPA (Depo-Provera) for 12 months or longer had a 2.2-fold increased risk of breast cancer (95% CI: 1.2-4.2).

That was all the media needed to hear, and they were off and running, with headlines such as “Depo-Provera shots tied to breast cancer ” and “Depo-Provera shots double breast cancer risk.” Such headlines fail to convey the overall results of the study in a way that is meaningful to anyone but the lawyers.

The Sub-Group analysis that raised concerns was conducted in less than 100 women

What the media did not tell you was that in this “large study”, the actual number of women in the sub-group that showed this statistically significant and concerning result was extremely small – only 34 controls and 36 cases had used Depo-Provera in the past 5 years. Among these, only 15 and 32 respectively had used Depo-Provera for a year or more in that time!

So there you have it – headlines based on a subgroup analysis of less than 100 women who were poorly matched to start with.

These kinds of studies raise far more questions than they answer

Subgroup analysis is a research tool to look for potential topics for further investigation or to inform questionable findings in the overall analysis. For researchers, this type of analysis can be valuable in defining areas for future larger study. But publicizing the results of a small subgroup analysis as if it were the findings of the larger group mis-represents the strength and reliability of the findings. And in this case, that publicity does nothing more that to frighten women away from using hormonal birth control.

I for one am not changing my prescribing practices around Depo-Provera based on this study. Depo-Provera remains an important contraceptive option for many women, although potential side effects (irregular bleeding, weight gain) limit its acceptability as a first line method for the majority of them.  Overall, about 3% of women who use contraception in the United States currently use Depo-Provera.

The discussion around breast cancer and current hormonal contraception is not new

The magnitude of the risk cited, and it’s relationship to current use of Depo-Provera in younger women, is similar to that which has been reported in the past in studies of oral contraceptives and breast cancer risk.  Specifically with Depo-Provera, the risk that appears in current users in some studies actually disappears with longer term use, suggesting that the mechanism may be acceleration of growth of pre-existing tumors, rather than induction of new cancers over time.

Overall, neither oral contraceptives nor Depo-Provera appear to increase lifetime risk of breast cancer. Both reduce the risk of endometrial cancers, and the pill reduces ovarian cancer risk.

Future research may elucidate better what the effect of medroxyprogesterone acetate, the drug in Depo-Provera and the one studied as hormone replacement in the Women’s Health Initiative, may be on breast cancer risk. For now, that risk has best been defined in post-menopausal women, and not in users of hormonal contraception.

_________________________________________________

Further reading on Breast Cancer Risks and Depo-Provera

  • Depot medroxyprogesterone acetate and breast cancer. A review of current knowledge. Drug Safety Review, 1996
  • WHO Study showed similar results in subgroup analysis for current use in women under age 35.
  • WHO Memorandum on Depo-Provera and Cancer risks.
  • New Zealand study showing risk with longer term use in younger women, with same limitation of small numbers
  • Pooled Analysis of WHO and New Zealand Studies . JAMA 1995

Conflict statement – In the late 90’s, I published two studies of Depo-Provera acceptance and continuation, one of which was partially funded by small investigator-initiated grant from Upjohn that paid part of my research assistant’s salary, along with an NIH training grant.  I have no current conflicts to report.

Making Charoset

Although I was not born Jewish, I did marry into a Jewish family. Now, over 20 years later, the culinary traditions of that religion feel as much like my own as those I share with my own family. One of my favorite of the Jewish traditions is making Charoset for Passover dinner, a task to which I have been assigned for some years now.

Charoset is a pasty mixture of fruit, nuts and wine that symbolizes both the mortar used by the Israelites to build the pyramids of the Egyptians and the sweetness of the freedom they would one day live to see. Charoset is eaten during the Passover ceremony, and later, spread between two motsah halves with a bit of horseradish, it makes Hillel’s sandwich. The Charoset we serve is a traditional Eastern European recipe. Sephardic versions may use dates or figs, mixed nuts and even fruit juice.

The Charoset recipe I use never varies, but every batch is unique. That’s because I’ve never actually written the recipe for Charoset down. It’s impossible really since the flavors evolve as you make it, and vary depending on the size and variety of apple you use in a given year. Thus, every year’s Charoset making is a bit of an adventure to see if I can get it as close to perfect as I can, or at least as good as it was last year.

I begin each year by assembling the tools of the task – an old wooden bowl (did Irene give it to me? Did I get it at a house sale? I don’t remember) and the old rocker-bottom metal cleaver I bought at an antique market. Although the bowl is very occasionally used for salad during the year, the chopper is never used for anything else but this one task, and never unless it is used with this bowl.

I then gather the ingredients – Apples (Fuji or gala with a granny smith or two), pecans (How many? I have no idea – at least a cup but not more than two cups), a bottle of Manichevitz wine (I used about 3/4 of the bottle) and some ground cinnamon (2 tbsp? 3 tbsp?…). maybe some brown sugar or honey if your apples aren’t sweet enough…

There is always one, and sometimes more than one phone call to my mother-in-law. How many apples? (5-6 seems about right ) Which wine again – elderberry or blackberry? (Blackberry) Do I peel the apples? (Yes)

I peel the apples, cut them into eights and toss them into the bowl, working quickly because I don’t want them to brown. Next, I toss the pecans on top, sprinkle some cinnamon and pour some wine over the lot. And then the fun really begins.

There is nothing, I tell you, more satisfying than the Fwick! Clunk! sound the cleaver makes as it slides through the apples and pecans and then bounces against the wooden bottom of the bowl, only to repeat itself again, again and again, interrupted only long enough to sweep across the bottom to gather up more apples into the center so the symphony of chopping can begin anew. Here – just listen to it and see what I mean –


How long to chop? Until the mixture is evenly chopped, almost but not quite mushy, but not chunky either. As the wine is absorbed, you keep adding more. You stop to taste, and add more cinnamon. Then more wine. Maybe some brown sugar or honey, but not too much, just a teaspoon or so. Then more chopping. Until it is perfect. Or as perfect as you can make it until tomorrow, when you bring it to your mother-in-law’s kitchen for the final taste test. There, you won’t mind at all if she tells you that you added too little cinnamon. Or didn’t chop long enough. Or need a little more wine.  She will help you adjust it and she will always be right.

Each time you make Charoset, you remind yourself to stop and write down exactly what you are doing so that you get the quantities right once and for all. But then the Fwick! Clunck! begins, and you are lost in the sounds and a tradition that reminds you to savor this moment, and this task, and to just let what you are making be whatever it will be. And in that moment, you know that, perfect or not, it will be wonderful.
_______________________________________________________________
If you want a recipe for Charoset, here a few –

The War on Women Has Gone Too Far

First they want to take away insurance coverage of birth control. Then they call us sluts and try to force us to have vaginal sonograms.

Now they’re trying to convince us we’re even fatter than we already think we are.

US Women could be more obese than believed

MONDAY, April 2 (HealthDay News) — The way that obesity is currently measured greatly underestimates the actual number of women who are obese, a new study suggests.

Almost half of women currently labeled as not obese by virtue of their body mass index (BMI) turned out to be obese when measured by a newer method focusing on their percentage of body fat by weight, the research found.

A cheap and obvious attempt at psychological warfare.

What the reporter failed to mention that almost a quarter of men were also found to be fatter than their BMI suggested.

So there.