A recent study points to a higher risk of breast cancer in women with a history of a false positive mammogram.
Investigators examined the number of breast cancers occurring over 10 years with whose routine screening mammogram had resulted in either a “call back” normal mammogram or a benign breast biopsy (false positive mammograms), and compared it to the number of cancers in women whose mammogram was normal on the first go round (true negative mammogram.)
Women who had a false positive mammogram had a higher risk of breast cancer in the subsequent 10 years compared to women with a true negative mammogram. How much higher? As you can see in the graph above, for every 1/000 women with a true negative mammogram, 3.9 breast cancers occurred within the subsequent 10 years. This is in contrast to women with false positive mammograms who had 5.5 breast cancers for every 1,000 women, and women with a false positive biopsy who had 7 cancers per 1,000 women.
Thought the relative risks between groups is statistically significant, it’s extremely important to realize that ALL these risks are under 1%, so we are making distinctions between very small numbers.
Here’s what the study results looks like in an icon array, a useful tool for illustrating comparative risks that are under 1%. Among the 1,000 women pictured in each array below, the pink ladies are the ones who developed breast cancer within the 10 years, while the grey ladies remain cancer free.
Further stratifying results by breast density, the researchers found that 10 year subsequent breast cancer risk was highest in women with extremely dense breasts and a false positive biopsy (9.01 per 1,000 women), and lowest in women with fatty breasts and true negative mammograms (2.22 per 1,000 women), with the rest scattered in between according to density.
The investigators uses data from the Breast Cancer Surveillance Consortium (BCSC) from 1994 to 2009, studying over 2 million mammograms done in over 1 million women. It’s a robust database that the US Preventive Services Task Force used to advise their recommendations for mammogram screening. They adjusted risk data for age, race/ethnicity, menopausal status, history of breast biopsy, and family history of breast cancer, all factors that are associated with breast cancer risk. The study results are consistent with those of other studies, adding to a growing body of literature linking false positive mammograms with breast cancer risk.
Now What?
A history of a prior breast biopsy is a known risk factor for subsequent breast cancer, and is already incorporated into the Gale Model and other breast cancer risks assessment tools. It may be time to consider incorporating a history of a prior false positive mammogram into these tools. At this point, breast density has not been incorporated into these risks assessment tools, primarily because it is such a subjective measure with not great reproducibility, and because it changes over time.
How to Use This Information
Women and their doctors may want to use this information to help them decide how often to have mammograms, or whether or not to begin to incorporate sonograms into their breast cancer screening regimen.
That said, it’s important to understand that although the risks for breast cancer are increased by a false positive mammogram, the absolute increase in risk is modest – still less than 1% in even the highest risk group.
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.
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.
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.
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 Scam
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
Myth $6- If I have HPV there is nothing I can do about it.
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.
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.
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.
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.
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.
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.
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.
Sex 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!”
It only took us 10 years to get Mr TBTAM’s cousin Lou and his wife Maria up to our little town in the mountains, but it was a visit well worth the wait. Not only did we have a great time, but Lou and Branch caught two trout in one of the feeders streams to the Loyalsock. A real team effort, and on a warm summer day, when trout are supposed to be nowhere to be found in shallow waters.
Of course, I smoked the trout. I’ve been wanting to make smoked trout since I first tasted it in Austria three years ago. My own attempts at fishing last year had yielded nothing more than a few tasty little perch. Now I had not one, but two 12 inch trout to play with! Not to mention, Lou had scaled and cleaned the fish himself. (Thank you Lou!)
How I Smoked the Trout
I cut off the heads and tails and butterflied the trout, then brined them (recipe below) in the fridge for about an hour. While they were brining, I soaked some mesquite chips and figured out how to light the Weber grill – Do you believe I’d actually never lit a grill fire myself? But the boys were all off doing some evening fishing before dinner, so I was on my own.
I waited for the coals to turn grey and the fire to really get hot. Then, I took the filets out of the brine, rinsed them under cold water, patted them dry with a paper towel and brought them out to the grill. Off the fire, I brushed the grill rack with olive oil. I then added a couple of handfuls of drained wet wood chips to the fire, put the grill rack on the grill and placed the filets skin side down on it. Then I put on the lid and watched the fragrant smoke pour out the vent holes while the fish cooked. (Thanks, Janet, for watching the grill!)
When the flesh was flaky but still moist (about an hour), they were done. I pulled out the bones, placed the flaked fish meat into a small bowl, and served it at room temp as an appetizer, along with a bowl of lemon aoli and some small crackers.
OMG – amazing! I don’t think I’ve ever had smoked fish so delicious.
Now that I know the fishing spot to get trout, I am going to head there myself next weekend and see if I can scare up a few more. Next time, though, I’ll be using applewood chips instead of mesquite. And I”ll try drying the brined filets before smoking them – a process that supposedly creates a very pretty surface (called a pellicle) on the smoked fish.
Finally, I’m thinking I should get one of those egg smokers – anyone have one and think it’ll give me even better results than using the Weber?
Brine for Smoked Trout
4 cups water at room temp
1 C. Kosher salt
½ C. brown sugar
3 tbsp lemon juice
8 peppercorns
Whisk ingredients in a glass or ceramic bowl until thoroughly dissolved. Place fish in brine – make sure all pieces are completely covered, if necessary, placing a dinner plates on top of fish to keep them underwater.
Refrigerate for about am hour. Remove fish from brine, quickly rinse in cold water, and pat dry. It’s ready to be smoked.
What I did not do, but will next time –
Place fish skin side down on lightly oiled grill rack (bot not yet on the grill). Season with herbs if you’d like – parsley or dill or cracked pepper. Dry for about an hour till skin is dried to point of being barely sticky – this is called the pellicle. A fan can speed up this process. Now it’s ready to be smoked.
Lemon Aoli to serve with Smoked Trout
1/2 cup mayo
1 tsp lemon zest
2 tbsp fresh lemon juice
1 clove garlic, finely chopped
1 tsp dijon mustard
Sea salt and large cracked pepper to taste
Mix all ingredients in a small bowl and serve alongside smoked trout.
Additional Reading
I read a bit on how to smoke fish before I tried it myself. Here are some posts I found particularly helpful.
A new diaphragm has become available in the United States – It’s called Caya, and it’s available in a single size and by prescription only, and is designed to be used with a nonoxynol-9 contraceptive gel.
Caya was developed as a collaboration between PATH and CONRAD, two non-profits responding to the needs of women for easy to use, effective, non-hormonal, user controlled contraception. Researchers at CONRAD, in a user-centered design process, worked their way through over 200 different prototypes to arrive at the current one-size, non-latex diaphragm, which was initially called the SILCS diaphragm. The SILCS diaphragm was evaluated in research studies in the US and internationally, and proved not only to be equally effective to currently marketed diaphragms, but also easy for women to learn to insert and remove. The diaphragm was licensed to Kessel in 2010, who now markets it as Caya in over 25 countries.
Caya was FDA-approved last year and will now be distributed in the US by HPSRx.
WHO SHOULD USE CAYA?
The diaphragm is a great option for women unwilling or unable to use hormonal contraceptives or the IUD, and who are motivated enough to use a method with every act of intercourse. Breastfeeding women are a group who may especially like the hormonal-free aspect of the diaphragm.
EFFICACY
The diaphragm is by no means the most effective contraceptive available. If 100 women use it for 12 months, 17.8 with will become pregnant; with perfect use, there will be 14 pregnancies. However, in motivated married couples, efficacies close to 95% have been reported with previous diaphragms, a fact I can attest to, having been a highly successful diaphragm user myself for many years.
User coaching could make a difference in efficacy – in Caya clinical trials, correct insertion increased from 76 to 94%. when users were coached rather than simply given written instructions.
Combining the diaphragm with use of the male condom brings contraceptive efficacy close to 100%. Combining it with fertility awareness could also increase efficacy, as women using fertility awareness would avoid intercourse or use a condom during more fertile days. I would predict that breastfeeding women, whose fertility is lower to start with, probably will experience high rates of contraceptive efficacy with Caya.
HOW TO GET CAYA
Caya is available by prescription only. The cost is $85. Spermacidal jelly is extra – cost for this will depend on where you buy it and how often you have intercourse and need to use it.
Prescribers. Although Caya does not require a traditional fitting visit, clinicians can order free “Try Before You Buy’ disposable test units to be sure patients are comfortable using Caya and know how to insert it. Those clinicians who want to stock and sell Caya directly to their patients can order it directly from HPSRx. Otherwise they can simply write their patients a prescription and fax it to the pharmacy or give it to the patient.
Patients:You have three options for obtaining Caya –
Your Clinician. You clinician may stock Caya and be able to sell it to you directly.
Your Local Pharmacy – Get a prescription from your clinician and take it to your local pharmacy. Your pharmacist may have to order Caya if they do not have it yet in stock.
Mail Order – Get a prescription from your clinician and send it by mail with an order form to either American Mailorder Pharmacy ($80 plus $5 shipping) or Health Warehouse pharmacy ($85 w/ free shipping) , two mail order pharmacies who are stocking Caya for distribution. (Click the pharmacy link for the order form and address). You can also order spermacidal jelly along with your diaphragm, but it’s cheaper to get it from other vendors..
Don’t foget spermacidal gel.
Caya won’t work without it.
Spermacidal Gel is available without a prescription at pharmacies and online. The manufacturer is offering Options GYNOL II Gel or Contraceptrol pre-filled applicators at a cost of $18.50 and $17.50, respectively. By comparison, the cost of these spermacides is between 11 $11 and $15 from most online vendors, plus shipping.
Use of nonxynol-9 spermacidal gels can increase HIV transmission rates if you’re exposed to an HIV infected partner. I’d recommend that you and your partner have negative HIV testing before considering giving up condoms and moving to the diaphragm for birth control.
How to Insert Caya
Instructions are here. The manufacturer also has a video.
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ADDITIONAL READING
Learn how Caya was developed – a story of innovation and collaboration between non-profit and for-profit sectors.
At first, I was really, really upset that my flight to Atlanta was delayed, making us miss our 8:30 dinner reservation at Five & Ten in Athens, Georgia.
This was no ordinary dinner reservation. My brother Joe and wife Rachel had arranged a special tasting meal for us with Five & Ten’s executive chef, Jason Zygmont, who they originally met when Joe stopped into the kitchen one day last year unannounced to borrow preserving salt for some charcuterie he was making. Joe returned a few weeks later to give Jason some of the duck proscuitto he had cured, expecting to quickly drop it off with the busy chef, only to have Jason invite him in and then cut into the breast and taste it right there, declaring it delicious. The charcuterie geeks bonded, and after repeat visits to Five & Ten, Joe and Rachel have gotten to know a number of folks there, including Eric, who runs the bar – apparently the place to experience dinner there, as well as to taste Eric’s concoctions which line the shelves. If Eric is one of the first people you meet in the Athens food scene, you will immediately understand the warm and convivial nature of the town.
These guys help run one of America’s finest restaurants, not as a pretentious celebrity chefs and “mixologist”, but as real people who are into what they are doing and just want to excel and share.
True, Five & Ten’s owner and founder Hugh Acheson is a bona fide celebrity chef, with a James Beard award, four restaurants and several stints on Bravo’s Top Chef to his name. The staff at Five & Ten are proud of Hugh of course, but not so impressed by it all, if that makes sense, because they and Hugh are Athenians first, and they know what’s most important is the food not the pretense. And so the T-shirts they wear feature not Hugh’s prominent name, but his prominent unibrow. They mock, yes. But it’s not the Brooklyn-hipster, cooler than everyone and everything mocking that puts off those of us uncool enough to get the joke. It simply says this – Ignore all that. Come. Sit down. Let us feed you.
Joe had been talking about Hugh and Jason and the crew at Five & Ten for ages, and we had tried and failed on more than one occasion to find a weekend for me to come down and enjoy a meal there. So you can see why I was upset when our plane left two and half hours late due to thunderstorms in the Atlanta area.
I called when we touched down in Atlanta. Just meet us at the restaurant, Rachel said. So we did. At 11 pm. After a long, dark and rainy drive. Half an hour after the last seating.
Ironically, that was the best part!
By then the place had cleared out of all but one large table on the front porch of the rambling formerly private home next to the Greek Houses along the Fraternity/Sorority Row known as Milledge Ave.
The wait staff were leaving, and the kitchen crew was cleaning up. But Joe and Rachel were at the bar, relaxed after a long day and well into their second (third?) drink. We plunked ourselves down next to them. By now Jason’s girlfriend, a former New Yorker, stopped by to meet Jason, who by now scrapped his after work plans to make good on his promise of blowing our minds. They just added another place setting for her and we grew by one more. Eric welcomed us all with a glass of wine, and Jason came out to greet us personally.
And then he fed us, right there at the bar, the most wonderful meal I think I ever have had.
THE FOOD
Every ingredient on the menu at Five & Ten has a story, a history, a tale of the making. Not in a way that is precious or off-putting, but in a way that makes you pause before you bite and say a little prayer of thanks to the ranchers and farmers and to the chef, who worked so hard to put it all together so wonderfully, taking the time to infuse those two strawberries with Urfa Chilis, or pickle those blueberries or braise those lamb ribs.
As for the flavors, there an earthiness in these dishes that keeps them accessible despite the complexity of their ingredients. It’s incredible cuisine, but with a taste of home in it. I tell this to Jason, and it seems to not make any sense. How can cooking this complex make me think of mom, of home?
But now I realize it does make sense. The ingredients are of home, of the heartland. Grass fed beef and pork, sorghum and morels, dandelion and tomato, peas and strawberries, blueberries and chard. This is Southern Cooking, but Southern Cooking for the 21st century. Jason has managed to combine these familiar ingredients in remarkable ways that allow you to see and taste them anew, evoking a memory but then layering on a richer, more complex experience.
I’m reminded of how classical composers might evoke a theme from a familiar folk tine in a more complex piece of music. Think “Simple Gifts” in Appalachian Spring by Copeland. (I’ve linked it up there) The listener says, “I know that!” and is immediately at home in an otherwise very challenging piece of music.
That’s exactly what this food does. It makes you feel comfortable and at home, all the while taking you to places gastronomically that you’ve never been before. A most incredible experience.
THE MEAL
All right, enough. Let me tell you about what we ate –
Fried Stuffed Pig Snout Medallions, riccotta gnocci, spring onion vichyssoise, and tomato marmalade. Don’t let the name put you off. These fried medallions are to die for. Nose to tail eating they call it, and this is the nose. With a bit of guanciale and some other magical ingredients, rolled into a galantine, wrapped in cheesecloth, braised in broth, then sliced, rolled in crumbs and fried. The gnocci was tasty and the sauce and marmalade a perfect accompaniment to both. We practically licked the plate clean. I’m not sure if Jason intends to add this dish to the menu, but if he does, all it will take is a little coaxing from the wait staff to become a hit.
Sweet and Sour Lamb Ribs with sorghum gastrique, charred scallion, benne seed, and brussel kimchi. A little translation is in order here. Gastrique = caramelized, sugar, deglazed with vinegar. Sourghum – a traditional Southern sweetener, product of the sugar cane, now the go to sweetener for Southern chefs. According to the NY Times “It’s sweet, yes, but complex enough to hold your interest. Sometimes vegetal, sometimes smoky and always bright, sorghum fits in anywhere” . Benne seeds = Southern for Sesame seeds (Benne comes from the african word for sesame). I assume Jason made a brussel sprouts kimchi, but I’m not sure. But you see what I mean about the complexity of the ingredients?
DAY BOAT SCALLOPS grilled little gem lettuce, field peas, soy pickled mushroom, Meyer lemon, mint. Perfect. I loved how the separate flavors of the ingredients stood out from each other, yet blended so well in the mouth. That’s what was so much fun about eating Jason’s food. Each ingredient beckons you to taste it alone, but you don’t really want to miss tasting them all together, so you find yourself planning strategically, taking teeny little bites of each separate thing first, then grouping them into small bites together, exploring how the tastes play off each. So much more fun than just grabbing a forkful of something and shoveling it in.
PAINTED HILLS BEEF NY Strip, braised veal breast with glazed field peas and grilled carrots, tomato marmalade, broken garlic vinaigrette, dandelion greens. A real meat sampler, neither overdone nor overwhelming. What meat should be. The strip steak was aged two weeks in house (of course!). Kudos to the Painted Hills ranchers in Oregon for raising some amazing meat.
ANDERSON FARMS PORK CHOP sorghum glazed, smoked beets, radicchio, swiss chard puree, pickled chard stems and chard marmalade, strawberry compressed with urfa chili. That’s right. Swiss chard three ways in the same dish. Insane and amazing how much work goes into this food. This was when Joe revealed his truly expert palate, asking Jason “There’s something smoky in those strawberries. what is it?” (The urfa chili infusion).
FAVA BEAN and RAW COWS MILK RICOTTA ANGLIOTTIs with sunchoke puree, sunchoke chips, morel mushrooms, pickled blueberries, smoked pecans and herbs. My favorite dish of the evening. Jason makes each of the pastas himself, telling me how if it took him a couple of years at Per Se to get it right, he couldn’t just pass the task off to someone else in the kitchen now. And the morels? Joe has a friend who forages morels and Jason jumped on them.The forager harvests only “restaurant quality” and leaves the rest for the deer. There were three bags of those babies in Joe’s fridge at home too, and we cooked them up the following night. Joe’s job is putting people together and this connection was perfect.
GROUPER glazed in vegetable dashi with fava beans. soy braised artichokes, cilantro oil and pea shoots. Just lovely. (no pic, sorry!)
ICE CREAMS – Home made, light and delicious. I can’t believe we ate it after that dinner, but we did. I think these were the flavors -banana puddin’ | cherry sorbet | peanut butter brownie chunk | dreamy blood orange.
THANK YOU, JASON & ERIC & THE CREW AT FIVE & TEN
Thank you so much, Jason for a truly amazing meal! And Eric, for your hospitality, warmth and company at the bar. And the crew at Five & Ten for a most wonderful experience. I can’t believe you guys hung around to wait for us – you were just so damned gracious; I’m still stunned thinking about it. This meal will go down in my history as one of my most memorable ever because of the food and because of you two. That Five & Ten is located in an old home seems so incredibly fitting.
If you get to Athens, GA, you need to eat here. That simple.
If I haven’t blogged much in the way of new recipes lately, it’s because not much of what we’ve been trying lately has been blog worthy. Oh, of course, it’s been edible. Maybe even tasty. But not worth sharing with the world.
But this dinner? It’s worth shouting about.
In fact, I’ll go on record and say it’s one of the best meals we’ve ever made. And worth every minute of preparation, which is not a lot of time at the stove, but does include an overnight marinade and a couple of hours braising. So save it for a weekend dinner when you can give it the time it deserves to savor with good friends and a nice tall glass of beer.
This is not a fancy dinner, but it does make a beautifully colorful presentation, and is perfect for a dinner party for four. The main course is Melissa Clarks’ version of the traditional Haitian braised pork dish called Haitian Griot. Marinated overnight in a spicy citrus marinade, braised and then broiled, the meat literally melts in your mouth, while at the same time being crispy on the outside. The flavor is to die for.
We served the Griot with Cuban-style black beans and rice made using a simple but delicious recipe modified from Whole Foods. It’s not authentic, but it’s fast and not heavy the way some bean recipes can be.
The traditional accompaniment for Griot is Haitian Pikliz, or marinated cabbage. We instead served an old family stand by, marinated cucumber salad. The three dishes together on the plate provided a most wonderful complement of smoky, citrus and crispy vinegar flavors, with the rice and beans adding warmth and body.
Not to be mundane, but a good homemade guacamole and chips would be the perfect appetizer for this meal.
My daughter and her friends swooped in arrived just as we were finishing dinner, and cleaned out what we little griot we had left behind – they simply created bowls of rice and beans topped with the meat, then the cucumbers and a bit of cilantro, taking the bowls with them into their room to eat while they watched a movie. Reminded me a bit of Vietnamese or Thai barbecue – vinegar/citrus on rice with meat and cilantro in a bowl. Funny how such disparate nationalities can have such similar flavors.
Traditional griot recipes actually fry the pork in oil, so this one is a bit healthier. Our meat pieces ended up smaller and did not get as crispy as Melissa’s did – we could have definitely braised less and broiled a bit longer. I’ve seen other recipes that use cloves and allspice in the marinade, but not being a huge fan of either, I’m happy with this recipe. Melissa’s recipe uses just one scotch bonnet chile – next time we’ll use at least two. (Traditional recipes use up to 6 bonnet chiles) Next time we may also double the garlic. This is a great all around marinade, so don’t be surprised to see it show up here as a rib recipe sometime very soon.
¼cup fresh chopped parsley (Cilantro would be nice…) more for serving
1tablespoon kosher salt
1tablespoon coarsely ground black pepper
6sprigs fresh thyme
2 garlic cloves, finely chopped
¼cup cider vinegar
Juice of 1 orange
Juice of 1 lemon
Juice of 1/2 lime
1tablespoon Worcestershire sauce
3pounds pork shoulder, not too lean, cut into 1 1/2-inch chunks
2tablespoons coconut oil (melted) or olive oil, more as needed (We used 1 tbsp coconut butter melted into 2 tbsp olive oil
Preparation
Quarter the chile and remove the seeds and inside ribs. Finely chop one quarter; leave the rest in whole pieces.
Transfer chiles to a large Dutch oven. Add onion, bell peppers, parsley, salt, pepper, thyme and garlic. Stir in vinegar, orange juice, lemon juice, lime juice and Worcestershire sauce. Mix in pork. Cover pot and refrigerate overnight.
The next day, remove pot from the fridge about 1 hour before cooking. and preheat oven to 325 degrees. Place pot over high heat and bring liquid to a simmer; cover and put pot in oven. Cook, stirring occasionally, until meat is very tender, about 1 1/2 to 2 hours. ( we cooked 2 hours, but in retrospect probably could have stopped at 1.5 hours.)
Using a slotted spoon, remove meat from pot, allowing all excess liquid to drip back into the pot and picking any bits of vegetables or herbs off the meat. Transfer meat to a rimmed baking sheet. Drizzle meat with 2 tablespoons oil and salt to taste, and toss gently to coat
Strain braising liquid, discarding any solids. Return sauce to pot and simmer over high heat until reduced by about half, about 25 to 30 minutes
Meanwhile, heat the broiler. Broil meat, tossing occasionally, until meat is evenly browned, about 5 to 10 minutes. You want it nicely browned in spots but not so brown that it dries out
To serve, drizzle meat with additional oil and top with sauce, parsley and thyme leaves.
I like the basmati rice flavor here, though it is not authentic. I also use canned beans. By not cooking the beans from scratch, and just adding them towards then end, they feel lighter and have a nice individual bite rather than a goopy texture you get when you cook them for hours on the stove. But that’s just how I like them.
1 tablespoon olive oil
1 large onion,diced
1 red bell pepper, diced
5 cloves garlic, minced
1 teaspoon chili powder
1 (14.5-ounce) can diced tomatoes with their liquid
2 -15 oz cans black beans, rinsed and drained well
Salt, to taste
Ground pepper, to taste
1 cup Basmati Rice
2 cups water
1/2 teaspoon salt
Chopped, fresh cilantro for garnish
1 lime, cut in 4-6 wedges for garnish
Make the beans: Heat a large cast iron skillet over medium high heat. When pan is hot, add olive oil. Add the onion and sauté for 2 to 3 minutes. Add the bell pepper, garlic and chili powder. Continue to sauté for 2 more minutes. Reduce heat to low, add diced tomatoes and simmer, uncovered, 15 minutes. Add beans and simmer 5 minutes longer to heat through. Taste and adjust seasoning with salt and pepper.
Make the rice: Place rice in a strainer and rinse under cool running water. Add salt to water and bring to a boil. Add rice and olive oil and bring back to a gentle simmer. Cover and keep on very low heat till done. When done, remove lid, fluff and let sit a bit before serving.
Serve: Serve beans over rice with cilantro and lime wedges.
Peel cucumbers, slice lengthwise and using a teaspoon, scrape out the seeds. Then slice crosswise into thin slices using a knife or, if you have it, a mandolin. Slice the onion into thin slices and then in half across so they are not too long. Mix together in a large Pyrex bowl.
Meanwhile, mix vinegar and water in a medium saucepan, add sugar and bring to a boil. Cool slightly and then pour over cucumbers and onions and mix gently. Salt and pepper. Cover and place in fridge overnight.
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TIMING THIS DINNER
I wrote this out for future reference for myself, and thought I’d share it here.
The afternoon before
Make the cucumber salad and refrigerate
Make the marinade and refrigerate
The evening before
Cut up the meat, place in the marinade and into the fridge
Put wine and beer into fridge
4 hours before guests arrive
Take meat out of fridge and let it sit for 1 hour at room temp
3 hours before guests arrive
Start the meat braising. You will then make the griot up to the point that you reduce the sauce, but do not broil the meat. Just set the meat aside under foil to keep warm till you’re ready to broil and serve.
Set the table, gather serving platters and utensils, set up bar
Sedate the dog (just checking to see if you’re reading… )
1.5 hours before guests arrive
Make the beans and keep warm till serving
Rinse the rice and set up for cooking, but don’t cook it till guests arrive.
Put the cucumber salad into the serving bowl, but keep in fridge till ready to serve.
Prep ingredients for guacamole, including chopping tomatoes and onions, but do not make it. Put chips in bowl and set out.
When guests arrive
Start rice cooking
Quickly assemble the guacamole and serve with chips, crisp white wine or beer.
15 mins before ready to eat
Broil the meat, heat up the sauce if it’s cooled down.
Fridays nights in winter, Mr TBTAM plays tennis, so I’m on my own. It’s my night out with the girls or a good time to shop, get a cut and color or a mani-pedi.
This Friday night, however, all I really to do was be home. It was freezing cold outside, and I knew the rest of the weekend was going to be busy. After an even busier week, I was craving some alone time.
The default mode would be take out, but I wanted a good meal, not a slice or some lo mein. And something that would hold up well for leftovers tomorrow as a nice Valentine’s Day lunch with Mr TBTAM.
I decided on something tried and true, and a recipe I’ve written about before – rustic shrimp bisque. Not the fastest preparation out there, but I had a book I was listening to, and nothing is more fun than cooking and reading, at the same time. Paired with this winter citrus salad and a baguette, it was the perfect choice for a cold winter evening meal for one. With plenty leftover for lunch tomorrow.
CLEMENTINE, FENNEL AND ARUGULA SALAD
This recipe, which I adapted from Williams-Sonoma, is a nice break from the usual salad, and a great use for winter citrus. I made it as written, but next time I will use garlic instead of shallots in the dressing, and add some red onion, shaved Parmesan and maybe a few black olives to the salad. You could also add some grapefruit. Prepare the fennel and make the dressing ahead, then assemble at the last minute if serving to company.
To make this salad for one, toss a large handful of arugula with the segments of one clementine and a little of the sliced fennel. Toss with 2-3 tbsp of dressing, sprinkle some sea salt and grate some pepper on top and serve.
Ingredients
1/4 cup fresh orange juice
2 Tbs. fresh lemon juice
1 tsp. grated orange zest
4 Tbs. extra-virgin olive oil
2 tsp. Dijon mustard
1 tbsp chopped fresh tarragon
1 shallot, finely chopped
Salt and freshly ground pepper, to taste
1 large fennel bulb
6 clementines, peeled and separated into segments6
6 cups arugula, loosely packed.
Directions
To make the vinaigrette, in a small bowl, whisk together the orange juice, lemon juice, orange zest, oil, mustard, tarragon and shallot. Season generously with salt and pepper. Set aside.
Cut off the stems and feathery fronds of the fennel bulb and remove any bruised or discolored outer layers. Cut the bulb in half lengthwise and cut out any tough core parts. Cut the bulb halves crosswise into thin slices.
Place the fennel and arugula in a large serving bowl, add half of the vinaigrette and toss gently to coat thoroughly. Arrange the orange slices in a pinwheel or other design on top. Drizzle with the remaining vinaigrette and serve immediately. Serves 6.
Worriers out there – take note. You’re probably spending your precious brain energy worrying about the wrong things.
If you want to know what’s most likely to kill you, the British National Health Service’s Atlas of Risk can tell you. The tool does a great job putting health risks into perspective, and can be customized for your sex and age group. It’s interesting to see how the causes of death change with age.
One thing that becomes clear as you play with the risk tool. Most of the things that could kill you throughout your adult life can be prevented by three things which are in your control – exercise (which can lower blood pressure and cholesterol and prevent obesity), not smoking and limiting alcohol intake to healthy levels.
So if you’re spend a lot of time watching TV news and worrying about war and murders, turn off the TV and head out for a walk.
There’s a nice discussion of the practical considerations around breast density notification laws in this week’s NEJM.
The editorial and accompanying podcast summarize what we do and don’t know about breast density, and give practical suggestions for incorporating breast density into the discussion around mammography screening for individual patients. Online access to both the editorial and podcast discussion is free, and I encourage you to read and listen.
Bottom line
Most women under age 60 will have dense breasts on mammography. Breast density is subjective, and we do not as yet have a computerized way of standardizing breast density readings. Breast density can also vary in a given women across the menstrual cycle and with age.
Breast density may increase breast cancer risk from 1.2-2 times, but it is not clear if that increased risk is additive to other factors that already increase breast cancer risk – family history, lifestyle, reproductive history – or just a manifestation of that risk. No current breast cancer risk model incorporates breast density.
At this point in time, mammography is the only breast cancer screening that has been shown to reduce breast cancer mortality. There is little evidence to support routine supplemental screening sonograms in women at average risk of breast cancer who have dense breasts.
In women at average risk for breast cancer with dense breasts, screening breast sonograms will detect less than 1 additional cancer per 1,000 women screened. In this group of women, supplemental sonography has not been shown to decrease breast cancer mortality and carries high rates of false positives. (Only 6% of biopsies will show cancer.)
In women at higher than average risk for breast cancer, sonograms in those with dense breasts pick up an additional 3.2 cancers per 1000 women screened. How this may translate into reduce breast cancer mortality is not known. Women with a lifetime risk of breast cancer >20% are advised to consider breast MRI , which identifies an additional 8.5 cancers per 1000 women screened and has been shown to be cost effective in this population.
My take
Breast density notification laws, while well-intentioned, unnecessarily alarm women with normal mammograms by telling them they “may be at increased risk of breast cancer”.
A better approach would be to simply notify women that breast density may obscure masses that mammograms miss but sonograms may detect, albeit with higher rates of unnecessary biopsies and no proven efficacy in reducing breast cancer mortality in women at average risk for breast cancer. Then let women make an informed choice about sonograms based on this information and their own risks.
One of the arguments made for screening sonograms is that they allow for earlier diagnosis of masses that evade mammography, leading to less need for advanced treatments such as chemotherapy. Given that chemotherapy is now being targeted to tumor type and not just stage, this advantage of earlier stage diagnosis may not prove as large as some would hope.
The best approach to breast cancer screening at this time is to target it based on risk.
You can learn your breast cancer risk here. Talk with your doctor about the benefits and harms of mammography, when to start screening, and how often to be screened. If your breasts are dense, and you are at increased risk for breast cancer, you may consider additional screening with sonogram, although its benefits are not known. If your lifetime breast cancer risk is >20%, consider supplementing mammograms with breast MRI.
Age is one of the strongest risk factors for breast cancer, and it’s why mammograms are recommended every 1-2 years starting at 50 in all women, regardless of other risk factors. Some groups, including the American College of Obstetricians & Gynecologists, recommend annual mammograms starting at age 40 for all women. Others, including the US Preventive Services Task Force, recommend individualized screening schedules for women ages 40-49 based on risk and personal preference. We’ve developed an online decision aid for women ages 40-49 that can help you and your doctor come to a screening decision that’s right for you.
I know the year’s barely begun, but this dish from Yotam Ottolenghi’s Jerusalem is well on its way to being my most memorable meal of 2015. Maybe even the past decade.
And this from a gal who says she doesn’t like eggplant.
If you don’t own Jerusalem, you must. Every recipe in it is a gem. The day after I was given it from my dear friends Karen and Steven, (OMG thank you!), my book club was over for dinner. They all gathered round and placed stickies on their favorite recipe in the book that I simply must make. The entire book is one giant sticky collection, but somehow this recipe escaped their stickies – my turn to give them a Jerusalem must-make!
My husband and I have already decided that this is what we’re serving the very next time we have company for dinner. It’s perfect for a dinner party because you can put it all together ahead of time, then let the eggplant roast for an hour and a half, giving you plenty of time to clean up the kitchen, set the table and make dessert or appetizers before your guests arrive. Not to mention, you can serve it warm or at room temp. It just doesn’t get any better.
I made one change to the recipe, which was to toast the pine nuts before using them. We toyed around the idea of adding some golden raisins to the meat mixture, but in the end did not. We also considered a breadcrumb topping, but again, left that be. It was pretty darned perfect just as it was.
STUFFED EGGPLANT WITH LAMB & PINENUTS From Jerusalem: A Cookbook by Yotam Ottolenghi & Sami Tamimi
Serves 4
This dish is Ottolenghi and Tamimi’s take on a dish served at Elran Shrefler’s restaurant Azura in the Machne Yehuda market in Jerusalem. I’ve Americanized the recipe instructions (we work in volume, not weight), and split the parts to make it a little more idiot-proof. (The original recipe gives total amounts of ingredients then splits them up depending on which part of the recipe you are making. That always throws me if I’m in a hurry.) Don’t let the amount of spices worry you – the flavors are sweet and smoky, but not biting. Don’t cut out anything.
Ingredients
Eggplant
4 medium eggplants (about 2.5 lbs each), halved lengthwise
4 tablespoons olive oil
1 tsp sea salt
Black pepper to taste
Sauce
5 tsp spice mix (see above for spice mix recipe)
2/3 cup water
1 1/2 tbsp lemon juice
2 tsp sugar
1 tsp tamarind paste
4 cinnamon sticks
1/2 tsp salt
Black pepper to taste
Instructions
Preheat the oven to 425 F. Place the eggplant halves, skin-side down, in a roasting pan (I used a La Crueset lasagna pan) large enough to accommodate them snugly. Brush the flesh with 4 tbsp olive oil and season with 1 tsp salt and plenty of black pepper. Roast for about 20 minutes, until the tops are golden brown. Remove from the oven and allow to cool slightly.
While the eggplant is cooking, make the spice mix and stuffing. Mix the cumin, paprika and ground cinnamon in a small bowl. Heat 2 tbsp olive oil in a large frying pan. Add 5 tsp (1 2/3 tbsp) of the spice mixture to the pan along with the onions. Cook on a medium-high heat for about 8 minutes, stirring often, then add lamb, pine nuts, parsley, tomato purée, 1 tsp sugar, 1 tsp salt and some black pepper. Continue to cook and stir for another 8 minutes, until the meat is cooked.
Make the sauce. Place the remaining spice mix (5 tsp) in a bowl and add the water, lemon juice, tamarind, 2 tsp sugar, cinnamon sticks and half a teaspoon of salt; mix well.
Reduce the oven temperature to 375 F. Pour the sauce mix around the eggplant in the bottom of the roasting pan. Spoon the lamb mixture on top of each eggplant. Cover the pan tightly with foil, return to the oven and roast for 1 1/2 hours, until the eggplant are completely soft and the sauce thick; twice through the cooking, remove the foil and baste the eggplant with the sauce, adding some water if the sauce dries out. (Ours did not dry out)
Regular readers will have noted that blog posts of late are few and far between. It’s not for a lack of interest (for I still so love my blog), but it is for a severe shortage of time. I’m cleaning up a backlog of tasks and commitments, administrative duties, grants and paper writing, lecture preparation and giving, and in general all the things above and beyond patient care that consume the life of the academic physician. Not to mention a wonderfully full, busy personal and family life.
Yep, life is good.
Speaking of which, allow me to share this wonderful song I just discovered. Someone must have told me about Noah Gundersen, but I can’t remember who. I had his name in an email I sent myself on Jan 10 – my usual method for reminding myself of something to check out – so thank you, whoever you are.
I know this song is called “Dying now”, but it’s not about dying. It’s about living and moving on. Here’s what Noah says about it –
It was a waving goodbye, a salute to the person I had been, while beginning the metamorphosis into the person I want to become.
I like that – “a salute to the person I had been”. A very positive way to accept ourselves, mistakes and all, while moving on to being the best we can be.
Its a great song for those of us in transition, those of us growing up or growing old, those of us living with regrets and those of us just looking to change.
Enjoy.
(And Emmylou Harris and Mark Knopfler – cover this for us, won’t you?..)
New information strongly suggests that most ovarian cancers originate, not in the ovary, but in the fallopian tube. If this is so, then removal of the fallopian tubes may actually prevent ovarian cancer.
The evidence is powerful enough that the American Congress of Obstetricians & Gynecologists is now recommending that fallopian tube removal be considered in women planning to undergo surgical sterilization or hysterectomy.
The Fallopian Tube Origin of Ovarian Cancer
We used to think that ovarian cancer originated in the peritoneal lining that covers the ovaries and abdominal organs. But the fallopian tube origin of ovarian cancer makes so much more sense when you consider what we know about ovarian cancer.
Think about it. The fallopian tube is an open tube that almost caresses the ovary at its distal end, where it is open to the abdominal cavity. Its blood supply is intimately shared with the ovary, and its inner surface is bathed in fluid that it shares with the fluid of the abdominal cavity. According to the theory, cancerous cells arise in the fallopian tube from small precancerous precursor lesions, where they grow undetected until they metastasize to the nearby ovary, or to the abdominal wall and surface of the pelvic and abdominal organs.
This goes a long way to explain why ovarian cancer is more often spread beyond the ovary to the pelvis and abdomen (Stage 3) and not just confined to the ovary (Stages 1 and 2) at diagnosis.
It also helps to explain how ovarian cancer has stubbornly eluded our attempts at screening. Because by the time the ovary appears abnormal on ultrasound, the cancer has already spread beyond its primary site. (Fallopian tubes are not easily visualized on pelvic sonogram.)
Note that the type of ovarian cancer thought to originate in the fallopian tubes is the so-called “serous” ovarian cancer. Serous cancers account for about two-thirds of ovarian cancers. The other third of ovarian cancers are endometriod and small cell cancers (which are thought to originate in the uterus or within the ovary), mucinous cancers (which may originate in the ovary or in the GI tract), and germ cell tumors (which originate from germ cells in the ovary).
What evidence is there?
Data a rapidly accumulating to support the fallopian tube origin of ovarian cancer. Here’s what we know so far –
In BRCA positive women at high risk for ovarian cancer, prophylactic removal of the tubes and ovaries finds hidden cancers in 7-15 % of women, but over half of these cancers are in the distal end of the tube, not the ovary.
The gene mutations found in serous ovarian cancers are the same ones found in the fallopian tube cancers, and the gene expression of serous ovarian cancer cells is more like that of a fallopian tube cell than an ovarian cell.
Scientists have found precursor lesions at the ends of the fallopian tube, that while not cancerous, look an awful lot like ovarian cancer cells.
Women who have had their tubes tied have 30% lower rates of ovarian cancer than those with intact tubes. The cancer prevented are the types (clear cell and endometriod) that would seem to originate in the uterus, based on the type of cells in the cancer.
Women who have their fallopian tubes removed have a 60% lower risk of ovarian cancer, and the type of cancer prevented are both the types that originate in the uterus and the type that we now think originates at the end of the fallopian tube nearest to the ovary (serous type).
So sign me up, already.
Not so fast.
As safe as it has become, surgery is not without risks. Operating on every woman to prevent a cancer that few (1% or less) will get may not make sense.
But for women who are already planning to undergo surgery for hysterectomy or tubal sterilization, it is not unreasonable at this juncture to consider removing the tubes while you’re there. This will add little to the risks of the procedure already planned, and may have the potential benefit of preventing ovarian cancer.
What if I am at high risk for ovarian cancer?
At this point in time, the standard of care for prevention of ovarian cancer in BRCA carriers and others at high risk is prophylactic removal of both the tubes and ovaries, a procedure called bilateral salpingo-oophorectomy, or BSO.
But there are downsides to salpingo-oophorectomy for ovarian cancer prevention. Even though the procedure is usually performed after completion of childbirth, it can cause early menopause, with its own risks of osteoporosis, heart disease and earlier death. If removal of the tubes proves to prevent ovarian cancer, this would be massively important for high risk women, who would have an option for ovarian cancer prevention that will NOT put them into menopause.
Large clinical trials are in progress to determine whether tubal removal will provide the same protection as BSO, but the results of these trials are years away. If the 60% reduction found in the general population holds up, this may not be a good enough for high risk women, who currently get a 95% risk reduction from salpingo-oophorectomy.
There are reasons other than cancer protection to recommend tubal removal at the time of sterilization
Tubal sterilization is not perfect.
We now know from large longitudinal studies that failures occur more than you’d expect after sterilization, and range from a low of 3.8/1,000 for post partum tubals to as high as 54/1,000 for cautery (burning) of the tube. Failure rates from the Essure procedure are even higher – 96 per 1,000 – that’s almost 10%. Pregnancies that occur after these failed tubals are very likely to be life threatening ectopic pregnancies.
Renowned family planning researcher Mitchell Crenin, MD and colleagues argued persuasively in a recent editorial that the time for sterilization by tubal removal is long overdue. Moreover, if we gynecologists had included women in the discussion from the get go as we began to bandy about sterilization options, including Essure, most women would tell us they want the most effective procedure there is – which happens to be tubal removal.
The recent discoveries of a link between the Fallopian tube and ovarian cancer have brought this issue to the forefront; however, women have not been included in the discussion about their desires, specifically around pregnancy prevention. If failure (pregnancy) is considered a major morbidity, how much more complicated is a bilateral salpingectomy as compared with laparoscopic tubal interruption… the question should not be focused only on ovarian cancer prevention; rather, the more important question should be why we are not offering women a chance for near 100% efficacy by removing the Fallopian tube completely for sterilization.
There’s a nice discussion of the practical considerations around breast density notification laws in
New information strongly suggests that most ovarian cancers originate, not in the ovary, but in the fallopian tube. If this is so, then removal of the fallopian tubes may actually prevent ovarian cancer.