Who Killed HRT ? or “Stick a fork in the WHI – it is so done”

The Warren Commission reconvenes to discuss the WHI findings

I swear, if I read one more article rehashing the Women’s Health Initiative, or one more theory to explain its findings, I’m going to ask the Warren Commission to reconvene and settle this thing once and for all.

The latest WHI rehash, reported in this week’s NY Times, comes from a researcher at the San Antonio Breast Cancer Symposium who is using the WHI findings to state that estrogen protects against breast cancer.

…among 8,500 women with no family history of the disease, use of estrogen lowered breast cancer risk by 32 percent, compared with similar women taking a placebo. Among the 7,600 women with no history of benign breast disease, like lumps or cysts, those taking estrogen had a 43 percent lower risk of breast cancer.

This is not news, folks.

We knew it in 2004 when the findings from the estrogen-only arm of the WHI were published.

We talked about it again in 2006, when a detailed analysis of breast cancer findings from the WHI found a reduction in early and in situ ductal, but not lobular cancers among estrogen-only users. They also found a possible protective effect of estrogen in women without a family history, but no reduction in risk for women who had prior history of ert use. In addition, estrogen only users had a higher risk for breast biopsy and when breast cancer did occur, it was larger and more likely to be node positive.

Not exactly a resounding affirmation of breast safety, but still not what we would have expected given what we thought we knew about breast biology and estrogen, and certainly contrary to years of previous data suggesting that estrogen use should uniformly increase breast cancer risk.

The Gap Time Theory

The best explanation I can find for the parodoxical effect of estrogen-only use on breast cancer risk in the WHI is the so called “gap time” theory, which is not about how blue jeans seem to shrink at the rate of one size per year, but goes something like this –

The Gap Time Theory  – If you wait to start estrogen until 5 years or more after menopause, you will see a lowering of breast cancer risk, compared to estrogen use starting at menopause, which increases breast cancer risk.

Scientists think this is because breast cells that have been deprived of estrogen for a long time become sensitized to the apoptotic effects of estrogen (the ability of estrogen to induce cell death or apoptosis). Since the WHI participants were, on average, about 10 years post-menopausal, they would certainly have had a few years of estrogen deprivation prior to starting ERT, so the Gap Theory seems plausible enough.

But I know what you must be thinking right now – How does the Gap Theory differ from the Window Hypothesis?

The Window Hypothesis

One cannot talk about the WHI findings these days without talking about the Window Hypothesis, which was designed to address the other unexpected WHI finding, which was that HRT use did not protect women against heart disease. This again was contrary to years of prior research suggesting just the opposite – namely, that HRT reduces heart disease risks.

The Window Hypothesis goes something like this –

Window Hypothesis – There is a window of opportunity in the perimenopause for estrogen to be started in order for it to be beneficial for the cardiovascular system and the brain. If you wait too long to start it, estrogen actually becomes harmful to the heart and the brain.

Since the average age of the WHI participants was 64, and about 10 years post menopausal, the window hypothesis would tell us that they were too old to benefit from HRT.  And, when we do subgroup analysis on those women who were in their 50’s at the time they start HRT, we not only do not see a negative effect of hormones on heart disease, we see a possible benefit to its use. So, the window hypothesis seems plausible enough.

Which begs the question –

What if both the Gap Time Theory and the Window Hypothesis are correct?

This would mean that women who start HRT in the perimenopause, which is when we tend to prescribe it most, would experience a reduction in heart disease risk, a benefit to memory and an increase in breast cancer risk.

If women wait for more than 5 years post menopause to start HRT, they will see no benefit in terms of heart and brain. But if these same women also happened to have had a hysterectomy and take estrogen alone, they would see a reduction in breast cancer.

Women who take both estrogen and progesterone, no matter when they start, will have an increased risk of breast cancer.

Hmmm… this is exactly what the WHI seems to have found.

HRT and Menopausal Symptoms

It is important to note that the WHI was never designed to study the benefits of HRT on menopausal symptoms. Because we already know that HRT works extremely well for this.

What the WHI did, and continues to do, is to inform women about the potential risks they might be accepting in return for this benefit from HRT.  These risks are not large, but they are real.

So, who killed HRT?

The biggest objection to the WHI is that its participants were too old, and that the group that should have been studied was women who start HRT at menopause.

I happen to agree with this, so let’s accept it and focus on the WHI findings in this younger group, which at this point is that there may be (the operative word here is “maybe”) some cardio-protective effects of estrogen that we have yet to define, but that might surface in new studies being conducted in this area.

Of course, that leaves us with the risks of estrogen on blood clots, which I have not yet mentioned but which seems consistent across all arms of the WHI. However, this may be mitigated by using low doses of transdermal estrogen, which is what most of us are preferentially prescribing these days anyway.

Okay, now that that’s settled, let’s talk about the deal breaker with HRT – breast cancer. Because, at least among patients in my practice, this is what killed HRT – not worries about heart disease and blood clots.

And, since everyone is supposed to be getting HRT around menopause and not 10 years later, there will be no “gap” to give protection against breast cancer, will there? So can we just stop talking about breast cancer protection from HRT, and accept the breast cancer risk?

After all, it’s not a big risk – 7 per 10,000 per year, or as I tell my patients –

If you take estrogen replacement for 20 years, you should accept a 1% increase in your odds of getting breast cancer.

Now, when I explain all this to my patients, I find they tend to make one of four choices –

The HRT Choice

  • No – For many women, particularly those whose menopausal symptoms are mild, HRT’s small breast cancer risk is high enough to outweigh any theoretical cardiac benefit, particularly if they are doing other things to protect their heart – like eating well, staying in shape and exercising – and so they say “No, thank you” to HRT. Which is totally fine with me.
  • Yes – For some women who may have severe menopausal symptoms, the breast cancer risk may seem a small price to pay for a return to a quality of life they lost with the menopausal transition, particularly when they realize that they will probably only need HRT for a few years. So they say “Yes” to HRT. Also a fine choice.
  • Never – Some women, particularly those with a family history of breast cancer, will never say Yes to HRT, no matter how miserable they may be with hot flashes. Not an unreasonable decision, in my mind, and I have other options to offer them – none as good as estrogen, but perhaps good enough.
  • Yes/No/Maybe – Some women start off in the Yes camp and transition to a No when their symptoms lessen over time, or when a friend gets breast cancer, or when someone famous like Elizabeth Edwards dies of breast cancer – both of which makes any risk, not matter how small, seem too large. Fine by me, I say. Some try to go off, and end up back on hrt again. That’s okay, too. I’ll ride it out with them.

What I don’t appreciate, and why I am so tired of this whole WHI rehashing, is folks trying to use the limitations of the WHI to convince women they should or should not take HRT. Or worse, to use the limitations of the WHI to try to sell hormones – be they Big Pharma-made or bio-identically-hyped.

Could we all just stop telling women what they should or should not do, and let them decide?

Bottom Line

It’s your menopause, not mine, not Suzanne Somers‘ or Oprah’s, and certainly not Big Pharma’s.

Be wary of anyone saying that no woman should ever take HRT because it is too dangerous, and of anyone saying that every woman should take HRT because it is so safe. Reality lies somewhere in between.

Like everything in life, HRT has risks as well as benefits. Do your best to get informed about both and make your decision based on what is most important to you.

And by the way, I’ve always thought that there was a second gunman…

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(For those interested in reading more about HRT risks as well as benefits, I point you to a marvelous review of postmenopausal HRT by the Endocrine Society.)

Warren Commission photo from Wikimedia.org.

Grand Rounds with a Seasonal Shift

I don’t know what I enjoyed more today – reading all the wonderful med blogger posts at this week’s Grand Rounds at Dr M’s blog, or looking at the beautiful images of spring and summer posted alongside them.

Why not head over and see for yourself ?

Clotting Up Office Hours with Talk about Clots

Thanks to the lawyers and the media, this is the conversation I had recently in my practice –

Patient: My mother has been seeing lawyers’ ads on TV about Yaz, and says I should stop taking it. I don’t want to get a blood clot.

Me: Are you experiencing any problems on the Yaz?

Patient: No.

Me: Is there a particular reason why you are taking Yaz vs another pill? (Looking through EMR) I think you had tried another pill and didn’t like how you felt, and wanted to try Yaz, correct?

Patient: Right. My room mate was on it and liked it. But now she’s worried too.

Me: So – let’s run the numbers, shall we?

Patient: OK.

Me: With some variation depending on which study you look at, the background annual risk for blood clots is around 3 per 10,000.

Patient: (nods) OK.

Me:According to one study, women who took Yasmin had a clot risk of about 8 per 10,000. We can probably assume the risk with Yaz is about 20% lower than Yasmin, since the estrogen dose is lower, so let’s call your risk 7 per 10,000. That’s a bit less than a tenth of a percent.

Patient: OK.

Me: Now, if that risk concerns you, we could change you to an older pill containing levonorgestrel. In that same study, women who took that pill had a risk of about 5 per 10,000.

Patient: (silence)

Me: But wait  –  You’ve been on Yaz for what, three years?

Patient: Four

Me: Okay, then, four. Now the biggest risk for blood clots is in the first year of pill use, so you’ve already established yourself as lower risk.  That would lower your risk to around 3 per 10,000. But if we change your pill, your risk will be about 2 per 10,000. So I guess the question is, is the excess annual risk of 1 per 10,000 , or one hundreth of a percent, enough to make you want to change your pill?

Patient: I’m just worried…

Me: Well, you could change to a progesterone only pill, or POP. That has no increased clot risk over the background rate. However, it does have about a 2% higher chance of pregnancy, and is more likely to fail if you miss a pill than the pills containing estrogen. So you need to be pretty perfect taking a progesterone only pill.

In addition, your acne was better on the combination pills – I can’t guarantee it will stay that way on the POP, but we can try. You can always go back. Most patients are pretty happy on POP’s.

Patient: I don’t think I want a POP.

Me: Do you want to go back onto condoms? or be fitted for a diaphragm?

Patient: No way! And I don’t want an IUD.

Me: So what shall we do?

Patient: What do you think I should do? I’m just worried…

Me: Okay, let’s change you to a pill containing one of the older progestins and see how your acne is. It’ll probably be just as good. But if you’re not happy, we’ll change you back.

Patient: (brightens) I like that. My mom will be happy.

Bottom Line

All estrogen containing birth control pills have a small but real increase in blood clot risks. How that risk compares between different pills is complicated, depends on which study you read, and none of the studies are perfect or definitive. In fact, the FDA has yet to make a distinction between standard dose pills (20-35 micrograms) based on clot risk, because the data are so problematic.

Meta-anlayses suggest that pills containing the older progestins such as levonorgestrel and norethindrone have lower clot risks than those containing new progestins gestodene, desogestrel and drosperinone. All of these studies to date have problems, but the data appear to be consistent across analyses. Few of the studies have included norgestimate, but those that have place its clot risk nearer to the older than the newer progestins.

Researchers are now looking at APC resistance as a surrogate marker of clot risk to help us better differentiate pills from one another, but this approach has not been universally accepted.

How to use this information clinically?

We really have no randomized trial data to inform contraceptive choice when it comes to clot risks. All of the studies published to data are problematic in that they do not consistently control for prescribing and diagnostic bias, and varying doses of estrogen between pills, another factor that strongly influences clot risks.

For most women, the choice between pills is made based on factors such as cost, convenience, cycle preferences, side effects and how you feel on one pill versus another. And advertising. At the moment, Yaz is the biggest selling pill, probably due to a large DTC campaign when it first came out.  (Bayer rightly got slapped by the FDA for over-hyping Yaz’s benefits in that campaign.)

If clot risks is your primary concern, there are non-estrogen methods you can use instead – Depo Provera, the IUD, condoms, Diaphragm and implanon. (But even some of these carry clot risk on the package insert, despite clinical trial data to support it.)

The bottom line is that no matter which combination birth control pill you use, you will have to accept a small increase in risks of clots.

What can you do to lower your risk of clots?

Since plane travel and long car rides can increase blood clot risks in anyone, consider wearing knee high travel socks for long plane flights and car rides. Ask for an aisle seat, stay hydrated and move about the plane frequently to avoid clotting. (You can more on avoiding clot risk from plane travel from the CDC.)

If you are at increased risk for clots, you should avoid all the estrogen-containing pills, no matter what dose or brand. 

And by the way, the risk for a blood clot in pregnancy is 1 in every 500-2000 pregnancies.  So it’s pretty much always safer to take a birth control pill than to be pregnant.

Mom

She died in the early hours of Monday morning, surrounded by her girls and her husband of 57 years, in a bed at the wonderful nursing home where she spent the last months of her life, the victim of intractable, unremitting post herpetic neuralgia (nerve pain resulting from shingles) and dementia.

She loved life, yet prayed for its end for almost three years, aquiesing as we tried treatment after treatment, unwilling to accept the futility of our efforts until we had exhausted all possible avenues of therapy that might allow her to live her final days, however long they might be, at least without pain.

How much of her dementia was due to her pain? How much to the medications we tried? A good part to both, I believed, as we saw miraculous awakenings with hydration and cessation of drugs, only to see her return to somnulence, anorexia and confusion when yet another pain med was tried. Even pediatric doses of medications were too much for her fragile mental status, teetering as she was between confusion and remarkable lucidity.

And yet, she maintained her wisdom, kindness and sweet spirit to the end. “How are the kids?” she’d ask me when I called, proceeding to give me the advice I needed to be the kind of mom I wanted to be.

“What am I keeping you from?” she would ask us when we stopped in to visit. “Can I offer you something? The candy is in the drawer there.”

And sweetest of all –  “Do you have enough room?” to my daughters as they took turns cuddling next to her in the bed on their last visit with her a week before she died. (We all fought for that spot next to her, even to the end…)

We tried every conventional pain treatment, some more than once, in varying doses and combinations, all without success. Like so many desperate families, my parents also turned to alternative therapy – in this case acupuncture – which failed. A case report in the literature even led us to try botox injections – also with failure and possibly worsening of her pain. After that, unable to push her any farther, we elected to forgo the latest greatest pain med that had just appeared on the market.

For by then, she was barely eating, accepting only tiny spoonfuls of her favorite foods after much coaxing and cajoling, and then not even drinking. And so, on the advice of her doctors, we turned to hospice to give her relief from her pain. Increasing – but still by most measures tiny – doses of morphine, and finally, ativan and atropine graced her exit. And in her last hours on this earth, thanks to these medications, she was finally comfortable and pain free. Thankfully, she was also conscious enough to let us know it, and to enjoy those moments with us, and we with her.

We tried, Mom. We tried so hard.

In retrospect, we probably tried too hard and over too long a period of time.  Now I understand that Mom knew what we did not – that she would leave this earth with this pain. We kept her longer than she wanted, but being the mother and the wife that she was, she stayed until we were all ready to let her go.

I do not know what lessons, if any, there are for us in her suffering and death, any more than I know how the God she so loved and to whom she prayed could allow her to suffer so.

The only lessons I can take are those she taught us by her life – to live it fully, with kindness, grace and love for others.  In this, I can only think of the beautiful Prayer, written by Mother Theresa and put to music by Rene Clausen, that I could not sing this summer in Cuba without thinking of my Mom, for it embodies everything that she was –

Prayer by Mother Theresa

Help me spread Your fragrance wherever I go.

Flood my soul with Your spirit and love.

Penetrate and possess my whole being so utterly that my life may only be a radiance of Yours.

Shine through me and be so in me that every soul I know will feel Your presence in my soul.

Let them look up and see no longer me but only You.

Bone Density Testing – How Often Should It Be Done?

Not as often as you think, even though Medicare may be willing to pay for it every two years.

Now a new study led by Margaret L. Gourlay, MD, MPH of the University of North Carolina at Chapel Hill School of Medicine finds that women aged 67 years and older with normal bone mineral density scores may not need screening again for 10 years.

“If a woman’s bone density at age 67 is very good, then she doesn’t need to be re-screened in two years or three years, because we’re not likely to see much change,” Gourlay said. “Our study found it would take about 16 years for 10 percent of women in the highest bone density ranges to develop osteoporosis. That was longer than we expected, and it’s great news for this group of women,” Gourlay said. (Via Science News)

The researchers suggest that for T scores > -1.5, repeat testing needn’t be done for 10 years. Women with T scores between -1.5 and -2.0 can be re-screened in 5 years, and those with T scores below -2.0 can have every other year testing as is done now.

To be honest, I’ve been spacing out bone density testing in woman with good baseline scores for some time, but not knowing how long I can go. This is great information for me and for my patients.
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Image from Wikimedia Commons

Fracking Hell

New York State has passed a moratorium in natural gas drilling in the Marcellus Shale.

In Pennsylvania, the drilling continues, and I fear for the future of my beautiful Endless Mountains. We are barely into what we are told will be decades of drilling and already the water supply of one town has been compromised, and streams and wells are being lost on an ongoing basis.

The water supplies of Philadelphia and New York City are at risk, as are the Susquehanna and Delaware Rivers. Over 4 million gallons  of water per well drilled become polluted by fracking chemicals, some of which can be cancer-causing. When these waters spill into fields, cattle die. When they get into streams, there are fish kills. And when they get into people…

Unbelievably, by virtue of what is called the Halliburton loophole in the 2005 energy bill, the natural gas industry is exempt from the clean air and clean water act.

Among the many dubious provisions in the 2005 energy bill was one dubbed the Halliburton loophole, which was inserted at the behest of — you guessed it — then-Vice President Dick Cheney, a former chief executive of Halliburton.It stripped the Environmental Protection Agency of its authority to regulate a drilling process called hydraulic fracturing. Invented by Halliburton in the 1940s, it involves injecting a mixture of water, sand and chemicals, some of them toxic, into underground rock formations to blast them open and release natural gas. (via New York Times)

In the meantime, state DEP agencies are understaffed and cannot begin to regulate the behomoth gas industry in their states. Local water treatment plants are not up to the task of cleaning unknown chemicals from their local water supplies. Farming communities that already must monitor water usage to avoid drought conditions cannot withstand the loss of their precious water to drilling.

Town by town, landowner by landowner, drilling is occurring under the radar

That’s why it’s taken us all by surprise. The Halliburton loophole has kept natural gas drilling below the national consciousness, since the impact of the process on water and air quality is exempt from national oversight. Put it in rural areas, and its hidden in plain sight.

Since 2005, drilling rights have been sold by private landowners to gas companies with no community oversight and no national regulation. Acre by acre, town by town, lake my lake, stream by stream, the natural gas companies are moving through some of the most pristine and beautiful land in America – including public lands, state and national parks – and threatening to turn them into industrial waste zones. The quality of life in these areas is being destroyed, property values are plummeting and futures ruined. Short term profits and cash lining the pockets of the minority are trumping long term concerns and the rights of the majority.

Drilling is proceeding at a breakneck pace, and without national oversight, states and local communities are left to deal with the consequences.

Folks, natural gas is not clean

That’s just how they’re marketing it. When we look at it’s environmental impact of fracking, the process by which we are choosing to extract it, natural gas is downright filthy.

Get informed

To get up to speed on the topic, I point you to the video above and to the resources below. Read them. Link to them.  Tweet them. Email them. Tell someone. Anyone.

Get Involved

Urge congress to move on the FRAC act, which would require gas companies to disclose the contents of fracking water. If you live in a Marcellus shale watershed area, tell your local government representatives that your water is at risk. Read about what Pittsburgh and Philadelphia are doing to protect their water supply.  And if you live in the shale, fight.

We are facing what has been called the environmental crisis of a generation.

Don’t wait until it’s too late to do something.

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Natural Gas Drilling & Hydraulic Fracking – Essential Reading

  • A Colossal Fracking Mess – Vanity Fair’s report on the dirty truth behind natural gas
  • Pro Publica’s Groundbreaking Investigation into Natural Gas Drilling
  • The Frac Act – Which would require gas companies to disclose fracking chemicals – is stalled in Committee since the summer
  • Gasland – the award winning HBO Documentary on Fracking. Watch the trailer, then order the movie online or from Netflicks.
  • Andrew Reinbach’s brilliant solution to stop drilling – sue your neighbor.
  • Pittsburgh bans Natural Gas drilling
  • Mark Ruffulo is leading the fight against fracking in NY State. Pennsylvania needs a star to help us too!
  • Life in the Gas Lane – An honest look at day-to-day impact of drilling in Bradford County, Pa
  • Calvin Tillman, Mayor of Dish, Texas – A blog about the effects of drilling on one small town “We are hard working honest people who have been dealt a raw hand by the pipeline industry.”
  • Frack Tracker – a blog from the U of Pittsburgh allowing readers to track actual drilling activity, water withdrawal permits and potential environmental impacts in the Marcellus Shale.
  • The Department of the Interior held a forum today on fracking – will it lead to passage of the Frac Act?

Vitamin D – New Guidelines from the Institute of Medicine

Taking a lesson from the recent failures of vitamins to live up to their much-hyped potential for disease prevention, the Institute of Medicine is calling for caution in Vitamin D  use, concluding in a recent report that the prevalence of vitamin D deficiency and the health benefits of high dose vitamin D intake have been largely overestimated.

Scientific evidence indicates that calcium and vitamin D play key roles in bone health. The current evidence, however, does not support other benefits for vitamin D or calcium intake. More targeted research should continue. However, the committee emphasizes that, with a few exceptions, all North Americans are receiving enough calcium and vitamin D. Higher levels have not been shown to confer greater benefits, and in fact, they have been linked to other health problems, challenging the concept that “more is better.”

The group concluded that vitamin D intake of 600 IUs daily is sufficient for almost all adults up to age 70, with 800Iu recommended daily for those age 71 and older.

Re-defining normal vitamin D levels

The IOM has redefined normal vitamin 25 OH Vitamin D levels in adults as 20 ng/dL for the overwhelming majority of the population, with no additional benefit seen to having levels above 30 ng/dL, and potential harm when levels are above 50 ng/dL.

An urgent call for more research

The insitute is calling for urgently needed research to further define what, if any, role vitamin D may play beyond maintenance of bone health in normal individuals. Until then, caution is advised.

My take

As a clinician, I find the IOM report reassuring and helpful, since until now it seems as if everyone I screen has been vitamin D deficient, and I have been truly wondering how this could be in a population that is overall healthy, and at least here in NYC, getting some sun exposure every day.

Aiming for levels above 20 ng/dL, I suspect most of my patients will not need to take much more vit D than I am already recommending on a daily basis. I will certainly be backing off on treating those with Vitamin D levels already in the low-to-mid 20’s, which seems to be where most of my patients live.

A group I will still be screening and treating for Vitamin D deficiency are those with bone loss. Some of these individuals are older and have Vitamin D levels significantly below 20 ng/dL, which may be how they ended up with bone loss in the first place. For these individuals, I’ll continue my practice of prescribing short periods of high weekly dose D to get them up into normal ranges, then backing off to standard recommended doses.

Oocyte Preservation aka Egg Freezing – Ready or Not, It’s Here

Oocyte preservation, or egg freezing as it is popularly called, is now being offered by over half of US fertility clinics, and half of those not offering it now plan to do so in the future. This according to a national survey conducted in mid 2009 and reported this week in Fertility and Sterility.

Over two thirds of the 143 centers offering oocyte cryo-preservation will do it electively, as opposed to those that offer it only to women undergoing cancer treatments that threaten their natural fertility.

Go West, but be prepared to pay…

Centers located in the Western part of the US are more likely to offer elective egg freezing than those in the East. Not surprisingly, centers that only accept out of pocket (as opposed to insurance) payments were more likely to offer the procedure, reflecting the history of infertility advancement, which, unlike almost any other area of medicine, has largely been financed by private individual dollars.

Pregnancy Rates – Mother Nature is Still Better

A total of 337 live births from 1,845 cryopreservation cycles were reported, with an overall pregnancy rate of 39%.

Given that 80% of these women would probably be expected get pregnant spontaneously within a year if they had tried to do so naturally, egg freezing is still a far cry from mother nature.  One could argue that egg freezing offers about the same odds of pregnancy a women would have if she delayed natural pregnancy till her early 40’s, begging the question as to whether or not elective egg freezing is worth it for younger women.

There may be an advantage to egg freezing in that younger eggs have less chromosomal abnormalities such as Down’s syndrome than older eggs, and data to date suggest that freezing does not increase chromosomal abnormalities. However, until we have long term developmental outcomes from a large cohort of children born after cryopreserved oocyte cycles, that advantage remains theoretical.

And while these numbers may look good when compared to embryo cryopreserved cycles, which have a reported pregnancy rate of about 21% per thawed cycle, it is important to remember that women undergoing embryo freezing are largely a population with a diagnosis of infertility using IVF, while women electively freezing oocytes would be expected to have normal fertility rates.

Caveat

Only about 60% of clinics participated in the survey, so the actual number of cycles may be higher than reported. Conversely, the actual pregnancy rates could be lower if only centers with good statistics repsponded to the survey.

Slow or fast freeze?

Centers using only slow freezing had marginally higher pregnancy rates than those offering other freeze methods, but this does not control for multiple other factors that can affect a center’s pregnancy rates, including patient age. Because there are so many factors that can impact outcomes, I would not use this measure as a sole reason to include or exclude a center from clinical consideration.  Most good centers are studying this issue closely.

Bottom Line

Oocyte preservation, though increasingly available and promising, remains experimental. Centers conducting the procedure should be doing so under IRB guidance, as recommended by the Association for Reproductive Medicine.

Gold Rush Apples and Ginger Crisps – A Perfect Pair

Maybe it’s the fact that they are only available during a brief period in the late season, but these Gold Rush apples from North Star Orchards in Chester County, Pennsylvania are hands down the best apple I’ve ever eaten. (Yes, even better than the Ginger Golds I found last year.)

Gold Rush apples are crisp, juicy, full of flavor, with the perfect balance of tart and sweet and covered with a skin that is not too perfect so you know you’re getting a real apple from a real tree.  They are best eaten cold from the fridge, where they will hold their flavor for months. (We’ve got ours out on the terrace for now since the 20 lb bag is too big for the fridge…)

While these babies are perfect eaten alone, they also pair beautifully with ginger cookies for a light and lovely dessert for company, which is how we served them last night. I also packed up some apples and a tin of the cookies for my daughter to take back to college today, which made me think that the combo would make a very nice holiday gift package.

Brown Sugar Ginger Crisps

This is a classic recipe from Gourmet Magazine, via my mother-in-law Irene, from whence cometh all great recipes.

2 sticks butter at room temperature
1 cup firmly packed brown sugar
1 large egg yolk
1 tsp vanilla
1/2 cup finely chopped crystallized ginger
1/4 teaspoon ground ginger
1 1/2 cups all-purpose flour
1/4 teaspoon double-acting baking powder
1/2 teaspoon salt

Whisk dry ingredients together (flour, baking powder, ground ginger and salt) and set aside.

In a large mixing bowl, cream together the butter and the brown sugar, then beat in the egg yolk, vanilla, and crystallized ginger. Add the dry ingredients and mix well.

Drop the batter onto ungreased baking sheets (I use a small melon scooper for this, you can just drop by teaspoon if you prefer). Bake in the middle of a preheated 350° F. oven, one sheet at a time, for 10 to 12 minutes, or until they are just golden. Let the cookies cool on the baking sheets for 5 minutes, then transfer them to racks to cool completely. These cookies make ahead and keep well frozen in airtight containers.

Makes about 50 cookies.


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As of today, North Star Orchard’s website states that there are still some gold rushes available for pick up at designated area farm markets, so if you are in the Chester county area, I’d encourage you to get some.

If you know of a local orchard in your area that is selling Gold Rushes, let us know in the comments.

If at First You Don’t Succeed…

New research tells us that in smoking cessation, there are two kinds of quitters. Those who stop right away and those who stop eventually. Amazingly, both end up as ex-smokers.

A substantial proportion of smokers who quit by the end of 12 weeks of treatment smoked in one or more weeks during the first eight weeks before achieving continuous abstinence… Researchers described this as a previously unreported and natural pattern of quitting. Had the delayed quitters quit treatment, continuous abstinence could have been lost for up to 45% of eventually successful people.

What is it they say? ‘The enemy of good is perfect.”  In our strive for perfection, we fail more often at our goal than if we allow ourselves to be a little less than perfect.

It’s an important message for smokers trying to quit. You don’t have to do the program perfectly to end up an ex-smoker.  You just have to persevere.

I suspect the same thing is true for dieters.

I don’t know about you, but in this arena I am definitely a victim of my own perfectionism.

Those who end up at their goal may not be the ones who never broke program, but they are the ones who persist with their diet and exercise program, whatever it is, through times on non-compliance and less than perfect behavior.

Important to remember as we enter the Thanksgiving holidays…

TBTAM Thanksgiving Dessert Recipes

Apple Torte

If you’re looking to break out from the old pumpkin pie for dessert at Thanksgiving, here are a few ideas from the TBTAM recipe collection. They all have that autumn-into-winter, fruits of the harvest feel that Thanksgiving is made for, with just a tad of unexpected flavor or texture to jolt your diners’ taste buds out of their turkey-induced stupor.

Apple Torte – This is a great make-ahead dessert that keeps well in the fridge. It’s impressive appearance belies a very easy preparation.

Ginger Stout Cake – Nothing says autumn like a ginger cake, and this is one of the best. It’s what I’m bringing to dinner this year.

Fig & Plum Tartlets – Adapt this tartlet recipe for a large crowd by making one large tart instead. Enough fruit to feel healthy after a heavy meal, with enough sweetness to feel special.

Prune & Almond Tart with Armanac – Another impressive tart that’s easy to make and delicious to eat.

Apple Crumb Tart – Made with a shortbread crust and a breadcrumb topping, this tart is a nice change from the old apple pie.

Hallelujah Chorus – A Random Act of Culture

The Opera Company of Philadelphia and members of 28 local choruses burst into Handel’s Hallelujah Chorus, accompanied by the famed Wanamaker organ at Macy’s in Philadelphia, much to the delight of the shoppers there.

It’s all part of Knight Art’s Random Acts of Culture project, designed to bring fine arts to a public that may not experience them otherwise, and to enrich and engage the cultural communities in which we live.  Their goal of 1,000 random acts of culture is well on it’s way, with 42 acts to date nationwide.

Watch out – you may be next to experience a random act of culture!