Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

Menstrual cycles and rhythm of disease

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What if you had breast cancer and discovered that timing surgery to coincide with a particular point in the menstrual cycle might make a difference in your prognosis?

Or what if you had diabetes and learned that insulin sensitivity varies with menstrual rhythms?

And what if you were plagued by other miseries, like migraine headaches or yeast infections or systemic lupus erythematosus, that also seem to wax and wane along with the menstrual cycle?

Would you use menstrual cues to time your surgery, to watch your blood sugar extra closely, or to predict the onset of troubling symptoms?

Chances are you would — in these and many other cases.

In fact, if you’re among the millions of women who have not yet hit menopause, you’ve probably already become a kind of amateur scientist, searching for connections between your own monthly rhythms and the ups and downs of your health.

The problem is, the medical establishment hasn’t exactly shared in this enthusiasm for finding links between menstrual rhythms and patterns of disease. Until recently.

Like the circadian, or daily, rhythms now known to be part of many basic biological processes, like hormone secretion and temperature control, our bodies also have longer rhythms, none more obvious than the menstrual, or monthly, cycle.

To be sure, the question of why humans and many other primates menstruate — pass blood from the uterus periodically when conception does not occur — is still an open one.

Perhaps evolution just isn’t done with us yet. In fact, if women held the evolutionary cards, maybe we’d get rid of menstruation, especially if we could have babies without it.

Or perhaps menstruation, just as the textbooks say, is what happens when something else — conception — doesn’t happen, though in energy costs to the body, it seems a high price to pay for a fancy reproductive design.

Or perhaps, as maverick scientist and MacArthur “genius” award recipient Margie Profet contends, menstruation is the female’s way of getting rid of all sorts of nasty bacteria and other pathogens that ride into the body on the tails of sperm.

Profet, an enthusiastic visiting scholar at the University of Washington in Seattle and author of a controversial article on menstruation three years ago in the Quarterly Review of Biology, thinks menstruation, far from being an evolutionary accident, is a nifty adaptation to the threat of infection.

Citing evidence from numerous species, including those that may menstruate invisibly, she says that “sperm are vectors of disease” and that menstruation exists “to protect the uterus and oviducts from colonization by pathogens.”

Whatever its reason for being, the menstrual cycle in humans is a lot more complex — and potentially more closely linked to the rhythms of health and disease — than scientists used to think.

Susceptibility to AIDS infection, for instance, may vary as hormone levels fluctuate across the menstrual cycle.

In May, scientists at the Aaron Diamond AIDS Research Center in New York and the National Institute of Child Health and Human Development found that monkeys given a high dose of progesterone were more likely than other monkeys to become infected by SIV, the monkey AIDS virus, following vaginal exposure to the virus.

Cindy Pearson, executive director of the National Women’s Health Network, notes in a soon-to-be-released newsletter that this study involved monkeys, not women; SIV, not HIV; and progesterone implanted in pellets under the monkeys’ skin, not the body’s own natural surges of the hormone.

Still, the network is “extremely concerned” because the study showed that when progesterone is high, vaginal tissue thins, perhaps making it easier for the AIDS virus to gain entry.

This suggests that women who have sex with HIV-positive men might be more vulnerable during the second half of their cycles, and that women using progesterone-based birth control, such as Norplant and Depo-Provera, might also be at extra risk.

And there are other potential links between health and menstrual rhythms, though the quality of the research varies from study to study, says epidemiologist Sioban Harlow of the University of Michigan, who has combed the medical literature looking for such links.

Basic metabolic rate, for instance, appears to be higher in the second half of the cycle, with women often consuming — and expending — 500 extra calories a day. “You’re hungrier and with reason, not because of lack of will power,” says Harlow.

Immune function also seems to fluctuate with the time of the month — in still-perplexing ways. Some researchers say progesterone acts as an immune suppressant; others have found that infection-fighting white cell counts are lowest when estrogen is highest.

In one study, Dr. Barbara Mittleman, an immunologist at the National Institute of Mental Health, found that the kind and degree of immune fluctuation across the menstrual cycle seems to vary from woman to woman.

Yet some auto-immune conditions clearly wax and wane with menstrual rhythms, among them rheumatoid arthritis and systemic lupus erythematosus, says Dr. Balu Athreya, a rheumatologist at Thomas Jefferson University in Philadelphia. The worst flare-ups of lupus, for instance, often come in the luteal phase.

And with arthritis, some hormones — like those in pregnancy — often offer relief, while those of lactation may make it worse.

Asthma, too, seems to flare just before menstrual periods, many women say, though a 1989 review found that detailed studies on the subject showed no clear pattern.

It has also been shown that progesterone, the dominant hormone of the second half of the cycle, can trigger adverse changes in cholesterol, says Dr. JoAnn Manson, co-director of women’s health at Brigham and Women’s Hospital. Because younger women are at low risk of heart disease to begin with, however, these fluctuations may not pose a huge risk.

Far more likely to cause grief are migraine, acne, panic attacks, changes in bowel function and an increased tendency toward epileptic seizures — all of which have been shown to get worse before a woman’s period, says Dr. Karen Carlson, director of Women’s Health Associates at Massachusetts General Hospital and a co-author of the Harvard Guide to Women’s Health.

Diabetic women, too, may have an extra tough time just before their periods, she says, because progesterone increases resistance to insulin. This means it takes more insulin to get sugar into cells — so diabetic women may need to increase insulin as their periods approach.

But of all the potential links between menstrual rhythms and health, perhaps none has greater implications than the timing of breast cancer surgery to ovulation.

“This is really where the rubber meets the road,” says Dr. William Hrushesky, senior attending oncologist at the Samuel Stratton Veteran’s Administration Medical Center in Albany, N.Y.

For years, says Hrushesky, the idea that the timing of breast surgery might be important was greeted “with ridicule; then [it] went to outright hostility, then has been ignored.”

But even skeptics like Dr. Kent Osborne, chief of medical oncology at the University of Texas Health Science Center in San Antonio, now say “what’s really needed is a prospective trial” in which menstrual data are correlated with timing of surgery and results are compared.

So far, there have been about 20 retrospective studies in women with breast cancer. About a dozen of them have concluded that, at least in women whose cancer has spread to underarm lymph nodes, the best time for surgery may be just after ovulation, when estrogen is falling and progesterone is surging. This is the early part of the luteal phase, or second half, of the menstrual cycle.

In 1991, an American study of nearly 300 women found the luteal phase was best for surgery, as did a British study of nearly 250 women. In a 1994 study, the British team noted that the high progesterone in the luteal phase seems to contribute to “significantly better survival.”

A 1994 Italian study of nearly 1,200 women came to a similar conclusion, finding that women who had surgery in the luteal phase had a “significantly better prognosis” than those who had surgery in the follicular, or first half of the month.

Some other studies have found no relationship between the timing of surgery and prognosis, but there are theoretical reasons why there might be a connection.

In the first half of the cycle, women have high levels of estrogen without any accompanying progesterone. Estrogen can trigger a tumor growth factor called IGF-1 and may increase enzymes like cathepsin-D that help cancer spread.

By contrast, there are hints that progesterone may damp down such enzymes and keep small blood vessels from leaking cancer cells into the bloodstream. Both estrogen and progesterone may also influence immune response to cancer, though how this plays out across the menstrual cycle is difficult to pin down.

The bottom line, as the Society for Menstrual Cycle Research has been saying for nearly 20 years, is that more research is needed into the menstrual cycle’s effects on health.

Until that research is done, one of the best things you can do for your own health is to keep records of recurring symptoms and chart them against your menstrual cycle.

Whichever way your data turns out, says Carlson, you’ll get valuable information. You may find some connections with menstrual rhythms that you never suspected.

And some troubles that you might have linked to monthly periods may turn out to be utterly random strokes of fate.

 

SIDEBAR:

The premenstrual syndrome paradox

One of the most controversial conditions linked to menstrual rhythms is PMS, or premenstrual syndrome, now also called premenstrual dysphoric disorder.

Politically, PMS represents a no-win situation for feminists.

The risk in legitimizing it is in “medicalizing” the normal menstrual process and potentially branding all women as sufferers of emotional distress before their periods, says Ann Voda, director of the Tremin Trust Research Program on Women’s Health at the University of Utah College of Nursing.

On the other hand, failing to recognize the genuine suffering of some women — perhaps 5 to 8 percent, according to Nancy Fugate Woods, director of the center for women’s health research at the University of Washington in Seattle — is no solution either.

Clearly, some women do have a terrible time as their periods approach, with bloating, breast tenderness, irritability, changeable moods, depression and fatigue among the symptoms.

One hypothesis is that this misery is caused by low levels of the brain chemical serotonin, though this is not proved.

Still, for some women, the premenstrual time does seem to be “almost a serotonin-deficiency state,” says Dr. JoAnn Manson, co-director of women’s health at Brigham and Women’s Hospital. And some, she says, get “a good response to Prozac,” an antidepressant drug that increases serotonin levels.

For others, the anti-anxiety Xanax taken for a week before the period may also help, says Dr. Karen Carlson, director of Women’s Health Associates at Massachusetts General Hospital.

Working with the body’s rhythms

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The night belongs to asthma.

If you’re one of America’s 10 million asthmatics, you may find that your symptoms vary like, well, night and day, with the odds of an attack vastly greater in the wee hours — about 4 a.m.– than in daylight.

But if it’s heart attacks and strokes that worry you, early morning is definitely prime time. That’s when cardiovascular problems — as well as more minor troubles like allergies and rheumatoid arthritis — are most likely to strike.

And if pain is your worst enemy, you probably already know when the witching hour comes: late evening.

For years, scientists have known that nearly everything in biology seems to be imbued with its own distintive circadian — or daily — rhythms, from the lowliest bacterial colony to the deadliest of cancer cells to the most complicated human hormones that ebb and flow through our veins according to timetables laid down long ago by evolution.

They’ve found, for instance, that adrenal glands in a test tube secrete hormones at precise times of day, just as they do in the body. And that plants, stashed in closets, furl and unfurl their leaves according to deep, genetically-set rhythms.

Researchers are now making the leap from chronobiology, the study of these basic rhythms, to chronotherapy, the tailoring of drugs to the rhythms of the body and of disease.

“In the old days, doctors used to think that a `steady state’ of drugs in the system was best,” says Michael Smolensky, a physiologist at the University of Texas-Houston School of Public Health, largely because they had been indoctrinated with concept of homeostasis — the idea that the body likes to keep its internal milieu reasonably constant.

But with 24-hour monitoring of blood pressure, hormone secretion and other variables, chronobiologists have shown that homeostasis is more complicated than that. It’s now clear there is fluctuation in many body rhythms every 24 hours — and that it can pay to synchronize treatments to these rhythms.

This insight has led to a such a scramble among researchers and drug companies that doctors are struggling to keep up. According to a Gallup survey done for the American Medical Association, only one doctor in 20 really understands chronobiology.

But most said they were eager to learn, recognizing there’s more to chronotherapeutics than, say, just popping a sleeping pill or even melatonin, the popular but controversial hormone, in the evening to get a better night’s sleep.

Consider asthma, for instance, an inflammatory lung disease with a clear circadian pattern — and treatment strategy.

One reason asthma flares at night is adrenalin, a stress hormone that is also a bronchodilator, or airway opener. Adrenalin peaks in mid-afternoon, then sinks to its nadir 12 hours later, so that airway function is best in mid-afternoon and worst at 4 a.m., says Dr. Richard Martin, head of the division of pulmonary medicine at the National Jewish Center for Immunology and Respiratory Medicine in Denver.

Histamine, a natural substance that constricts airways, makes things worse. At night, when adrenalin is low, histamine soars, adding to the tendency of airways to narrow.

And then there’s cortisol, a hormone that dampens immune response and inflammation. Cortisol peaks in the early morning, but during the night, when it would help to have cortisol available to curb inflammation in the airways, levels are low.

The result is that airway function varies somewhat in everybody over a 24-hour period. In people with severe asthma, the difference can be as much as 50 percent — potentially the difference between life and death.

To combat this pattern, researchers years ago developed the first genuine chronotherapeutic drug, Uniphyl. If the drug is taken in the evening, its efficacy peaks when it’s needed most — in the middle of the night — then wanes during the day.

Other asthma remedies have also been shown to be most effective at particular times of day, including oral steroids, which seem to work best when given around 3 p.m., says Martin. But he cautions that patients should not alter the timing of these medications without talking to their doctors.

Other chronotherapeutics are fast becoming available.

Last month, Searle, the pharmaceutical arm of Monsanto — began marketing its recently-approved drug, Covera-HS, for high blood pressure and the chest pain of angina.

Doctors have long known that the odds of heart attack, angina or stroke peak in the early morning, as blood pressure soars and platelets become sticky and more likely to form clots.

One obvious solution is to get blood pressure medications into the patient’s system before he wakes up and enters this danger zone. But this can be trickier than it sounds, says Dr. William B. White, chief of hypertension and vascular disease at the University of Connecticut Health Center in Farmington.

Taken at bedtime, some anti-hypertensive drugs may lead to a too-severe drop in blood pressure during sleep, when blood pressure is already comparatively low, and leave too little in the system to be effective in the morning, he says.

Covera-HS, a once-a-day bedtime drug, is designed to get around that problem. The pill has coatings that delay absorption for four to five hours, so that it kicks in early in the morning, says White, who has studied the drug.

Other studies show it can help to take cholesterol-lowering drugs at night, when the liver is busiest making cholesterol.

And just 10 days ago, a Charlestown company, Ergo Science, released tests of a new diabetes drug designed with chronobiology in mind.

Scientists have long known, say Ergo physiologists Anthony Cincotta and Albert Meier, that in healthy, lean animals, certain brain chemicals — notably dopamine — surge in the early morning, then taper off at night. The same pattern is believed to hold for people.

But in Type II diabetes, a condition in which the body becomes resistant to the sugar-transporting hormone insulin, the body clock seems to go haywire: Dopamine drops in the morning.

Ergo’s new drug, still unapproved, seems to fix this errant biorhythm. Taken at breakfast, it dissolves fast, providing a quick blast of a dopamine substitute just as the body needs it.

In 400 people with diabetes, the drug has improved blood levels of glucose, cholesterol, triglycerides and fatty acids.

Timing of treatment may also be important in cancer chemotherapy, says Dr. William Hrushesky, senior attending oncologist at the Samuel S. Stratton Department of Veterans Affairs Medical Center in Albany.

Hrushesky, a pioneer in the study of biorhythms in cancer treatment, says there is a distinct rhythm for cell division, for cell suicide, for the growth of new blood vessels around tumors and for the metabolism of drugs given to combat cancer.

Because of these rhythms, he says, “timing is everything” — with different drugs having different windows of effectiveness.

Adriamycin, for instance, may work best in the early morning, 5-FU (Fluorouracil) does best at night and platinum-based drugs like Cisplatin in late afternoon, he says. Pumps worn by the patient make it relatively easy, he adds, to take drugs on a schedule that’s most effective, not just convenient for doctors.

Though the timing of chemotherapy to fit biorhythms is not yet mainstream practice, Hrushesky and French researchers have evidence that survival rates can be quadrupled in ovarian cancer and doubled in advanced colon cancer if chemotherapy is timed right.

And Canadian researchers have shown that children in remission from acute lymphoblastic leukemia who take the drug 6-MP (mercaptopurine) in the evening are three times less likely to relapse than those who take it in the morning.

As with any other new field, of course, much research still needs to be done. But the field is clearly exploding, says Smolensky of Texas. Ten to 15 years ago, when chronobiologists began promoting their findings, “people would look at us as if we had stepped out of a spaceship,” he says.

Now, they’re eager to know more.

SIDEBAR:

With medication, timing is everything

While researchers are developing new drugs to take advantage of the daily rhythms of the body or to fix errant rhythms, research in chronobiology suggests you may be able to enhance the effectiveness of old ones by taking them at just the right time.

If you suffer from hot flashes, for instance, taking estrogen replacement therapy at night — when hot flashes can wake you — may make sense, says Dr. Gary Richardson, director of the neuroendocrine clinic at Brigham and Women’s Hospital.

Rheumatoid arthritis, an inflammatory disease, is often worst in the morning, says Dr. Martha Barnett, a rheumatologist at Beth Israel Hospital. Though she believes morning stiffness stems from inactivity at night, others think it may be a result of circadian rhythms in hormone secretions and other factors.

Whatever the reason, taking nonsteroidal anti-inflammatory drugs (NSAIDS) may help most in the evening. But be sure to take them with food, to help prevent ulcers and other stomach problems. In fact, ulcers have their own circadian rhythms, with many flare-ups occuring during the early hours of sleep.

On the other hand, osteoarthritis, which results from wear and tear on joints, is worse at night, after a day of activity, so taking medications in the morning may be most effective.

Runny noses, colds and nasal allergies are often worst in the morning, notes Michael Smolensky, a physiologist at the University of Texas-Houston School of Public Health. Thus, time-release anti-histamines taken at nighttime may help.

Aerobic exercise, while not a drug, does impact health and can also be timed for optimal effect. Studies by the US and German armies suggest that the biggest increase in endurance comes if you exercise in the afternoon and early evening, says Dr. William Hrushesky, a chronobiologist in Albany, N.Y. It’s also much easier to exercise at this time of day, he adds.

Sunlight isn’t exactly a drug, either. Though it can increase the risk of skin cancer, it is also beneficial because it suppresses the sleep hormone melatonin and helps re-set circadian rhythms so you sleep better at night, says Dr. Michael Holick, chief of endocrinology at the Boston Medical Center.

In fact, one explanation for “winter depression” is that the weaker sunlight in winter may not suppress melatonin well enough.

And there’s another reason sunlight may make you happy. In skin cells at least, sunlight boosts levels of the feel-good hormone, beta-endorphin.

A common sense heat-survival guide

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Last summer, a record-setting, five-day heat wave scorched Chicago, making headlines nationwide not just because of the sizzling temperatures — as high as 106 degrees Farenheit — but because older people died by the hundreds. By the time the heat wave was over, there had been more than 700 “extra” deaths, numbers so shocking that researchers from the city, state and the federal Centers for Disease Control and Prevention began poring over the data, searching for common denominators among people who died and those who did not.

Their conclusions, published earlier this month in the New England Journal of Medicine, and those of other advocates for the elderly, are closer to common sense than rocket science.

But their advice, simple as it is, could save your life or the life of an older person you love:

Lesson One — Don’t ignore the early signs of heat-related problems, because later stages — heat stroke — can be fatal.

Heat-related problems range from the mild and reversible — heat stress and heat fatigue — to heat stroke. In the early stages, you can recover quickly by drinking fluids, taking off excess clothing and getting yourself into a cooler environment, including a cold bath. If you wait until the later stages, it may take emergency medical help — intravenous fluids, ice packs and other interventions — to save your life.

Lesson Two — Drink fluids.

You can’t rely on thirst to tell you when to drink. In older people, the thirst mechanism, a built-in safeguard against dehydration, doesn’t kick in as readily as it does in young people, says Dr. Kate Ackerman, medical director for the geriatric section at Boston Medical Center. This means you must drink before you get thirsty.

The rule of thumb is that everyone should drink six to eight glasses of fluids a day — and more during a heat wave — and this is especially true for older people. You need to drink mainly because you need to sweat — evaporation of moisture from the skin is one of the body’s main ways of getting rid of heat.

But remember, some drinks don’t count. Water is good, as are some juices and drinks that contain minerals and electrolytes that your body also needs. But anything containing alcohol or caffeine — coffee, tea and some sodas — can act as a diuretic, making you lose water through urination, not sweat, and actually making it harder for the body to cool down.

Lesson Three — Be wary of diuretics and other medications.

Many older people take diuretics to control blood pressure. But if you’re dehyrated from the heat, diuretics can make things worse, says Dr. Jeanne Wei, chief of gerontology at Beth Israel Hospital. In heat waves, she says, older people may keep taking their diuretics “because nobody told them not to. So there they are lying on the floor because they forgot to drink, they lost all that water and now they’re too weak to get up.”

If you take diuretics, she says, ask your doctor whether you should continue at the same dose in hot weather. Many of her patients, Wei says, cut back and take diuretics only on a limited, set schedule, either three or four days a week, to prevent dehydration during hot weather.

Tranquilizers, sedatives and some drugs for cardiovascular problems can also interfere with sweating, so ask your doctor whether you should modify your medications during a heat wave.

Lesson Four — Don’t be a stranger.

One of the most sobering findings of the Chicago study was that social isolation raises the risk of heat-related death. The solution is obvious, though difficult to implement for those who are shy or fearful of their neighbors.

If you know an older person living alone, check on her or him every day when the temperature soars. If you are that older person, find someone else in your building or neighborhood and create a “buddy system” for checking on each other.

“Neighbors can do this for each other. This does not require government intervention,” says Al Norman, executive director of Mass Home Care, a consumer organization for the elderly.

Lesson Five — Take off that sweater.

Your ability to perceive temperature declines with age, says Terrie Wetle, deputy director of the National Institute on Aging. Older people “tend to feel colder at higher temperatures, to bundle up in sweaters,” she says, but overdressing can be dangerous. When it’s hot, you’re better off in light-weight, loose clothes, preferably natural fabrics like cotton, not fabrics that cling to your skin like polyester.

Lesson Five — Don’t put too much faith in fans.

Fans can speed evaporation by blowing dry air over sweaty skin, which helps cool you. But when the air gets too hot and humid, “even blowing it across the skin” doesn’t boost evaporation much, says Wetle.

Dr. Knox H. Todd, an Emory University emergency medicine specialist, was even more emphatic in an editorial accompanying the Chicago study: “Many agencies give electric fans to poor citizens to help them cope with the heat, but fans are useless when heat and humidity reach dangerous levels.” Which brings us to . . .

Lesson Six — But do try air conditioning.

In the Chicago study, researchers found that having an air conditioner or spending a few hours a day in air-conditioning can be protective. So if you have an air conditioner, don’t hesitate to use it, even if this means getting someone to help you turn it on.

“I had one patient who called saying she was so hot,” says Wei. “We asked if she had an air conditioner and she said yes, but it was not turned on” because she couldn’t figure it out. Once she did, she called back, amazed that she felt much better.

Wetle adds, “If you have an air conditioner and you know someone who doesn’t, invite them in for the hot part of day.”

And if you’re worried about the electric bill, remember that your health comes first; you can fight with the electric company later. Besides, electric companies, including Boston Edison, may help by setting up a budget plan to spread payments over the year and by offering discounted rates to people on public assistance such as supplemental security income (SSI).

But there’s a caveat to this. If you are in air conditioned area and get too cold, turn it off for a while and move around if you can. Some older people with air conditioning actually win up with hypothermia — a dangerous drop in body temperature — not hyperthermia, overly high body temperature.

Lesson Seven — If you can’t stand the heat. . .

If it’s too hot at home, try to get away to an air-conditioned mall, senior center or apartment lobby. But many older people cannot or will not leave home, even for a few hours, and if that’s your situation, open the windows when it’s cooler outside than in and and cross-ventilate by opening windows on opposite sides of your home. In the morning, however, it may help to trap cooler nighttime air inside by closing windows and blinds.

Lesson Eight — . . .stay out of the kitchen.

Not really, of course, but don’t use the oven when it’s hot. Have salads or sandwiches instead.

Lesson Nine — Get help.

If you think you — or the buddy you’re checking on — are becoming ill from the heat, don’t hesitate to call your doctor, a nearby emergency room or 911.

SIDEBAR:

Heat’s many miseries

 

Heat fatigue is a feeling of weakness brought on by even higher temperatures. Symptoms include cool, moist skin, a weak pulse and feeling faint. Remedy: Same as above. If you don’t feel better in a hour, call someone to check on you.

Heat syncope is dizziness, often after exercising in the heat. The skin is pale, sweaty and cool. The pulse may be weak and the heart rate rapid. Body temperature is normal. Remedy: Lie down immediately. As soon as you can, call a doctor.

Heat cramps are muscle spasms in the abdomen, arms or legs that often follow strenuous activity. The skin is moist and cool and the pulse is normal or slightly raised. Body temperature is usually normal. Heat cramps are caused by a lack of salt, but don’t take salt supplements without checking with a doctor. Remedy: Drink fluids, such as tomato juice, that contain minerals and electrolytes, sodas containing sodium or preparations like Gatorade. Call a doctor if in doubt or if cramps persist.

Heat exhaustion is a sign your body is getting dangerously hot. You may be thirsty, giddy, weak, uncoordinated, nauseous and sweating profusely. Body temperature is usually normal and the pulse is normal or raised. The skin is cold and clammy. Loss of water and salt can cause heat exhaustion but again, don’t take salt supplements without checking with a doctor. Remedy: Drink fluids and call a doctor.

Heat stroke can be life-threatening — in fact it kills 1,300 to 1,500 a year. Body temperature rises above 104 degrees Farenheit. Heat stroke also can cause confusion, combativeness, bizarre behavior, faintness, staggering, strong rapid pulse, dry flushed skin, lack of sweating, possible delerium or coma. If you find someone with these symptoms, call 911 immediately and get patient to an emergency room nearby.

For more information on coping with the heat, call:

– 911 or your local hospital emergency room if you are concerned about someone with dangerous heat-related symptoms.

– Your local council on aging for tips on coping with heat and information on shelters. In Boston, call the mayor’s 24-hour hotline, 617-635-4500 begin_of_the_skype_highlighting              617-635-4500      end_of_the_skype_highlighting or the Commission for the Elderly, 635-4366. During heat emergencies — defined in part as three consecutive days of temperatures of 86 degrees or more — there is also special heat hotline, 635-HEAT (635-4362).

– For general information, call 1-800-AGE-INFO begin_of_the_skype_highlighting              1-800-AGE-INFO      end_of_the_skype_highlighting (or 800-243-4636 begin_of_the_skype_highlighting              800-243-4636      end_of_the_skype_highlighting), a hotline run by Mass Home Care, a consumer rights group.

– For more general information, 1-800-882-2003 begin_of_the_skype_highlighting              1-800-882-2003      end_of_the_skype_highlighting, the hotline of the state Executive Office of Elder Affairs.

– Your local electric company, if you have SSI (supplemental security income) and want a discount on your electric bill.

 

Heat stress is a general term for the strain placed on the body by hot weather. Remedy: Drink fluids — a quart an hour — and try to stay out of the heat. If you can’t, doctors suggest that you sit in a cold bath with light clothes on, get your hair wet, then walk around the house with your wet clothes on. 

SIDEBAR:

Heat’s many miseries

 

Heat fatigue is a feeling of weakness brought on by even higher temperatures. Symptoms include cool, moist skin, a weak pulse and feeling faint. Remedy: Same as above. If you don’t feel better in a hour, call someone to check on you.

Heat syncope is dizziness, often after exercising in the heat. The skin is pale, sweaty and cool. The pulse may be weak and the heart rate rapid. Body temperature is normal. Remedy: Lie down immediately. As soon as you can, call a doctor.

Heat cramps are muscle spasms in the abdomen, arms or legs that often follow strenuous activity. The skin is moist and cool and the pulse is normal or slightly raised. Body temperature is usually normal. Heat cramps are caused by a lack of salt, but don’t take salt supplements without checking with a doctor. Remedy: Drink fluids, such as tomato juice, that contain minerals and electrolytes, sodas containing sodium or preparations like Gatorade. Call a doctor if in doubt or if cramps persist.

Heat exhaustion is a sign your body is getting dangerously hot. You may be thirsty, giddy, weak, uncoordinated, nauseous and sweating profusely. Body temperature is usually normal and the pulse is normal or raised. The skin is cold and clammy. Loss of water and salt can cause heat exhaustion but again, don’t take salt supplements without checking with a doctor. Remedy: Drink fluids and call a doctor.

Heat stroke can be life-threatening — in fact it kills 1,300 to 1,500 a year. Body temperature rises above 104 degrees Farenheit. Heat stroke also can cause confusion, combativeness, bizarre behavior, faintness, staggering, strong rapid pulse, dry flushed skin, lack of sweating, possible delerium or coma. If you find someone with these symptoms, call 911 immediately and get patient to an emergency room nearby.

For more information on coping with the heat, call:

– 911 or your local hospital emergency room if you are concerned about someone with dangerous heat-related symptoms.

– Your local council on aging for tips on coping with heat and information on shelters. In Boston, call the mayor’s 24-hour hotline, 617-635-4500 begin_of_the_skype_highlighting              617-635-4500      end_of_the_skype_highlighting or the Commission for the Elderly, 635-4366. During heat emergencies — defined in part as three consecutive days of temperatures of 86 degrees or more — there is also special heat hotline, 635-HEAT (635-4362).

– For general information, call 1-800-AGE-INFO begin_of_the_skype_highlighting              1-800-AGE-INFO      end_of_the_skype_highlighting (or 800-243-4636 begin_of_the_skype_highlighting              800-243-4636      end_of_the_skype_highlighting), a hotline run by Mass Home Care, a consumer rights group.

– For more general information, 1-800-882-2003 begin_of_the_skype_highlighting              1-800-882-2003      end_of_the_skype_highlighting, the hotline of the state Executive Office of Elder Affairs.

– Your local electric company, if you have SSI (supplemental security income) and want a discount on your electric bill.

 

Heat stress is a general term for the strain placed on the body by hot weather. Remedy: Drink fluids — a quart an hour — and try to stay out of the heat. If you can’t, doctors suggest that you sit in a cold bath with light clothes on, get your hair wet, then walk around the house with your wet clothes on.

Painkillers often take toll on stomach

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Gabriel Belt, 66, a retired Brookline accountant, figured he was doing the smart thing by taking an aspirin every other day.

Both his father and brother had died of cardiovascular problems in their sixties and he knew aspirin could reduce his own risk. He also figured that if he took the aspirin only every other day and took a type that was enteric-coated to protect his stomach, he should have no problems.Wrong.

Last October, Belt was rushed to Beth Israel Hospital with internal bleeding from an ulcer probably caused by the aspirin.

Len Levin,34, tells a similar story. A health science librarian at New England Baptist Hospital, he had been the picture of health, his only complaint an occasional bad back. One day two years ago, Levin helped move heavy furniture and the next day, felt what seemed like the old, familiar back pain.

After checking with his health practitioners, who also assumed the problem was a sore muscle or ligament, he started on ibuprofen, a popular pain-killing, anti-inflammatory drug. But by Thanksgiving, the pain was no better and he was so anemic he “felt like I would pass out if I stood up,” he says.

In retrospect, Levin believes he had a tiny stomach ulcer all along. But the NSAIDs – that’s shorthand for non-steroidal anti-inflammatory drugs – made it far worse, causing it to bleed so much that Levin needed emergency surgery to save his life.

In recent years, Americans have taken to popping aspirin, ibuprofen and other drugs in the NSAID (pronounced EN-SAID) class like candy – and often for good reason.

These pills – with names like Anacin, Bayer and Bufferin for aspirin-type drugs; Advil, Motrin IB and Nuprin for ibuprofen-based drugs, and Aleve for naproxen sodium-based drugs – help.

They kill pain. They lower fever. And perhaps most important for millions of older people with arthritis, they often work like a charm to combat the inflammation that makes joints ache.

In fact, 80 million of us take over-the-counter NSAIDs whenever we feel like it, with 200 brands to choose from. We also gobble 75 million prescriptions for stronger NSAIDS, to the tune of $ 1.8 billion a year, according to IMS America, an outfit that tracks such things for the pharmaceutical industry.

But the more popular NSAIDS become, the more doctors are becoming aware of a serious downside: sneaky, often totally painless ulcers that can bleed, with potentially fatal consequences, as well as other types of internal bleeding that can leave people so anemic they pass out or bleed to death.

An estimated 40 to 60 percent of people who chronically use NSAIDS, either in prescription or over-the-counter form, develop “erosions” in the lining of the stomach or upper intestine, says Dr. Helen Shields,a Beth Israel gastroenterologist. And 10 to 30 percent get deeper lesions – ulcers.

Prescription NSAIDS alone trigger bleeding in 1 to 3 percent of people who take them, says Dr. Linda Katz, a rheumatologist at the US Food and Drug Administration.

Indeed, NSAIDS now cause 41,000 hospitalizations and 3,300 deaths a year from ulcer complications such as bleeding and perforation, a condition in which stomach contents spill into the abdomen, according to testimony presented to the FDA last fall by Dr. Sidney M. Wolfe, president of Public Citizen Health Research Group in Washington, a consumer activist group.

The risk is particularly serious for older people, says Dr. David Cave, chief of gastroenterology at St. Elizabeth’s Medical Center. Shocked relatives may “find grandma on the floor in a pool of blood,” he says.

When an ulcer bleeds, Cave says, “the blood comes out under pressure. This is arterial bleeding. . . With a big, bad ulcer, you can bleed out – die – in an hour,” though this does not always happen. If bleeding is severe, cauterization of the ulcer through a tube called an endoscope or emergency surgery can staunch the flow, provided the procedures are done in time.

Despite such problems, however, many doctors say that NSAIDS overall “are very safe,” as Dr. David Puera, associate chief of gastroenterology at the University of Virginia Health Sciences Center, puts it.

“Problems don’t occur often, but when they do, they can be life-threatening,” says Puera, who co-authored a recent study that found the risk of stomach or intestinal bleeding was three times higher in people taking NSAIDS, a figure consistent with other research.

To be sure, about 80 percent of stomach ulcers are caused by a bacterium called Helicobacter pylori. But half the rest are caused by NSAIDS, according to data presented recently at a meeting of the American Gastroenterological Assocation. And even when ulcers are caused by bacteria, doctors say, NSAIDS make things worse by causing ulcers to bleed.

Biochemically, the reason that NSAIDS are both good painkillers and dangerous triggers of bleeding is one and the same. NSAIDS work by blocking chemicals called prostaglandins, which are made all over the body. Prostaglandins are often seen as “bad” because they cause pain.

But some prostaglandins are “good” because they help regenerate the mucus lining of the stomach and duodenum (the upper part of the small intestine) and maintain a healthy blood supply to these tissues.

When prostaglandins are blocked with NSAIDS, the lining of the GI tract becomes more vulnerable to normal digestive fluids – acids and pepsin – that are always present.

In addition, NSAIDS may trigger ulcers by interfering with production of bicarbonate, a natural antacid. They may also trigger bleeding by reducing the clotting of platelets in the blood, a special problem for people taking blood-thinning drugs.

But not all NSAIDS are created equal.

Consumer advocate Wolfe, for instance, has tried repeatedly to get the FDA to ban Feldene, made by Pfizer. He is convinced it “is by far the worst of all the NSAIDS” and says it “should not be on the market in the US. . . Do not use Feldene.”

Wolfe cites data obtained from the FDA linking Feldene to 299 deaths between 1982 and 1994, including 144 in which deaths were related to gastrointestinal problems like ulcers and bleeding.

Others disagree.

“Certainly drugs that stay in the body longer, like Feldene, have the theoretical potential to do more harm and if they cause a problem, it’s likely to be more serious,” says Dr. David Trentham,head of rheumatology at Beth Israel. “However, usage of Feldene over several decades has not indicated that Feldene has a greater risk than other commonly used NSAIDS.”

A recent FDA advisory committee agreed with that assessment, finding there was not enough evidence to consider Feldene different from other NSAIDS, a position with which Pfizer, not surprisingly, concurs.

So what should you do if, as the ads of yesteryear used to put it, you don’t want to trade your headache or aching knees for an upset or bleeding stomach?

One option is Tylenol (acetaminophen), a drug that reduces fever and pain. It is not an NSAID because it has little anti-inflammatory action, but this may also make it less useful against arthritis. Some people also that feel Tylenol doesn’t attack pain as well as NSAIDS, and it has other problems, too.

Regular alcohol consumption – about three drinks a day – can change liver metabolism so that when the liver breaks down Tylenol, a toxic compound may be produced. The result can be serious liver damage, on rare occasions with as few as five 500 milligrams of Tylenol a day.

But alcohol may increase the ulcer risk with NSAIDS, too, says Shields of Beth Israel.

Another option is to stick to the weakest NSAIDS, notably aspirin – especially the enteric-coated kind that is absorbed in the intestines, not the stomach, though this coating can make absorption erratic. Buffered preparations, which neutralize stomach acids, may also help, and some doctors advocate ibuprofen-based drugs. But as Belt and Levin discovered, even these relatively benign medications can cause trouble.

If you need stronger prescription NSAIDS, ask your doctor about newer types like Relafen or Disalcid, which may be less toxic to your stomach.

Another approach, which some gastroenterologists recommend, is to take other stomach-protecting drugs with your NSAIDS.

One such drug is Cytotec, a synthetic prostaglandin that can replace the prostaglandins in the stomach destroyed by NSAIDS.

Increasingly potent acid-blocking drugs are also pouring onto the market, including Prilosec and Prevacid, available by prescription, and the so-called H-2 blockers such as Zantac, Pepcid or Tagamet. These three are available over-the-counter, though these doses may be too low to help much, and by prescription for higher doses.

But the most important advice is this: Tell your doctor about all NSAIDS you’re taking – including over-the-counter – and the doses.

“Your doctor may be able to suggest an alternative that can control your pain or inflammation yet be less dangerous to your stomach,” says Shields of Beth Israel. “And there are more and more such alternatives available.”

Signs of problems from painkillers

If you take non-steroidal anti-inflammatory drugs – NSAIDS – and have any of a number of symptoms, you may have an ulcer or internal bleeding from some other cause. You should call your doctor promptly.

It is a medical emergency if you have black stools, which may indicate bleeding in the upper gastrointestinal tract, or if you vomit blood.

It is a potential problem if you have other signs of ongoing bleeding and possible anemia, such as dizziness, weakness, fainting, sudden confusion or shortness of breath.

And it may be a sign of an ulcer if you suffer nausea, loss of appetite or indigestion or a gnawing pain in the upper abdomen, especially if it is relieved by food or antacids but returns several hours later. Pain that wakens you from sleep can also be a sign of an ulcer.

Don’t be afraid of . . . your Dentist

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You’d rather face the IRS than the dentist? Relax, there are ways to fight the phobia;

Michele DerVartanian, a 25-year-old student in Medford, says she was 10 when she learned to fear the dentist.

She had a very sore, abscessed tooth, and “I had to have it pulled immediately,” she recalls. The whole family had plane tickets to Florida that they would have had to cancel unless her tooth was treated right away, she says.”From there on, it was downhill,” says DerVartanian, who adds that she’s “not completely” dental phobic, but does “get really stressed when I have something done to my teeth.”

For Amy Rothstein-Teehan, a 30-year-old sales rep from Randolph, the trouble began nine years ago when a dentist jabbed a needle in the roof of her mouth prior to wisdom tooth surgery.

“My feet literally went up in the air,” she recalls.”It’s the worst place to have a needle.”

She was left so frightened that when she later needed periodontal surgery, she delayed it for months, a pattern of avoidance that Jean, a 37-year-old Winchester mother, knows all too well.

“People think I’m nuts,” says Jean, who did not want her last name used, “but I’d rather have a child than go to the dentist. I just don’t like the needles. The smell alone gags me.”

If you hate going to the dentist and don’t go even when you should, you may have dental phobia.

And plenty of company.

Rationally, of course, we all know that we should brush and floss every day to get rid of the bacteria that can invade not just the teeth, but gums and the bones beneath them.

We all know, too, that we’re supposed to see a dental hygienist every six months. And that if we mess up on this basic stuff, the dental gods have ways of punishing us – like making our gums rot and our teeth fall out.

We even know, the cagey among us, that we can offer realistic-sounding excuses for skipping appointments, like the fact that dentistry can be very expensive – $ 47 to fill a cavity, according to national averages, $ 500 for a crown, $ 250 and up, up, up for a root canal.

The fact that most of us don’t have dental insurance – and that prices in Boston are higher than the national average – doesn’t help.

And then there’s always the old “if it ain’t broke, don’t fix it” rationale, which the American Dental Association says half of us use to justify going anywhere but the dentist’s.

Yet for all this, the fact remains that for many of us, it’s cold, sweaty fear that really keeps us away from the dentist, sometimes with unpleasant consequences.

An estimated 7 to 10 percent of adults feels “very afraid” to “terrified” of going to the dentist, says Tracy Getz, a psychologist and researcher at a place where they actually study such stuff, the Dental Fears Research Clinic at the University of Washington in Seattle. Another 13 to 20 percent feel “somewhat fearful” or “scared,” he says.

More than 90 percent of the time, these fears result from a bad experience at the dentist, often during childhood, though this pattern of fear, dentists hope, may get better as fluoride treatments, dental sealants and better dental hygiene keep more and more children from having cavities.

Typically, dental phobias start with fear of pain, then expand to become all-encompassing, says Dr. Michael Krochak, who runs the Dental Phobia Clinic at Mt. Sinai Hospital in New York.

A person “might have initially feared the pain. Over time, he says, ‘I should go,’ and now he fears, ‘The dentist will yell at me for not having gone.’ So the fear of embarrassment almost supersedes the actual fear of physical trauma.”

But recently, researchers have begun to recognize another significant cause for dental phobia as well – sexual abuse.

Childhood sexual abuse is an “identifiable factor” in dental phobia in about 7 percent of cases, says Getz, a co-author of a study on abuse and women’s dental fears published in April in Journal of the American Dental Association.

“Some women with early experiences of forced oral sex may have difficulty later with oral health care because of a symbolic re-creation of the experience,” his team wrote.

Adding to some patients’ fears is “the intimacy in the way you are positioned” in the dental chair, says Dr. Howard Howell, associate dean for dental education at the Harvard School of Dental Medicine.

“The patient is in a seated or supine position where they can’t get up and get out of the office. They feel trapped. And most of what goes on around them is in the region of the head and mouth, so they may feel suffocated by having people that close to them,” he says.

Nor are our cultural anxieties assuaged by the fact that we use root canals as a metaphor for any number of horrific things, says Dr. Robert Amato, an endodontist at Limited to Endodontics in Boston.

“You hear it all the time – ‘I’d rather have a root canal than see my accountant or pay my taxes.’ It’s almost a universal term for something people perceive as unpleasant,” he says.

Yet increasingly, dental work – including root canals and gum surgery – is much less painful than many patients think, in part because drugs for local anesthesia have gotten better and in part because dentists are getting better at dealing with patients’ fears and pain.

Many dentists now pinch the lip on the opposite side from where the anesthesia needle will be placed to distract the nervous system from the sting of the needle. Many dentists also routinely use topical anesthesia – a painkilling gel – on the gums before the needle goes in.

If you’re really scared, dentists may also suggest nitrous oxide, or “laughing gas,” before work begins. This short-acting gas can dramatically relieve anxiety.

But behavioral tricks – both yours and the dentist’s – may in some cases do the most to offset fears. For instance:

–     Consider using the initial appointment just to talk. Phobia specialist Krochak says the interview process “serves as a catharsis, a release of angst, of anxiety.” While some clinics have psychologists talk to scared patients, he believes it works better for patient and dentist to discuss fears directly.

–     Consider having a nurse in the room at all times, especially if you’ve been sexually abused. “I don’t even talk to patients without a nurse in the room,” Krochak says.

–     A process called systematic desensitization may also calm fears. This involves calming the patient with techniques such as deep breathing, muscle relaxation and guided imagery, then gradually exposing him or her to the feared stimulus, such as the sound of the drill, and then the drill itself.

–     If you fear gagging – such as when the dentist makes an impression of your teeth by putting trays of puttylike material in your mouth – you may feel better if you sit up straight and keep your chin tucked in. It may also help to have the dentist count off the minutes aloud as the impression is made.

–     Distraction also helps. Some patients listen to music. Others watch tiny TVs placed near their eyes.

–     If you hate the smell of dental offices, ask your dentist to use a bit of “aromatherapy” – scented candles and essential oils may mask medicinal odors.

–     Consider having a few short visits instead of one long visit, to minimize anxiety, suggests Susan Cottrell, a hygienist at the Harvard School fo Dental Medicine.

–     It can also help to work out in advance a system – such as raising one hand – to flag your dentist’s attention if you want him or her to stop, says Howell. Some dentists also make it a point to stop every few minutes and ask how you are doing.

–     Many patients also feel reassured if the dentist talks to them as he or she works, explaining each step of the procedure.

Former dental phobics like Amy Rothstein-Teehan have their own hard-won advice. In her case, talking through her fears with Howell of Harvard helped substantially.

“He knows how to relax someone who’s nervous,” she says. “He walked me through the whole thing and said, ‘You can stop at any point.’

She has also learned not to listen to other people’s “horror stories . . . That makes you more nervous than you have to be.”

Michele DerVartanian is similarly grateful fo endodontist Amato because “he just totally took care of me.”

“He was wicked nice,” she says, adding a heartfelt, “and he was fast.”

The dire consequences of dental phobia

Although some people seem able to neglect their teeth and get away with it, at least for a while, for many others, avoiding basic care at home and at the dentist’s office can have dire consequences. The reason is bacteria.

Bacteria on the surface of teeth use sugars from food to produce an acid that weakens teeth by taking the minerals out of tooth tissue, says Dr. Howard Howell, associate dean for dental education at the Harvard School of Dental Medicine.

Initially, the result is tooth decay and cavities, which can be fixed by drilling away damaged parts of the tooth and filling the hole with silver or plastic materials. In recent years, campaigns to put fluoride in water supplies and in mouthwashes and toothpaste have greatly reduced the incidence of decay.

If decay is severe and the infection has invaded the nerve of the tooth, a root canal may be necessary, says Dr. Robert Amato, an endodontist at Limited to Endodontics in Boston and an assistant clinical professor at the Tufts University School of Dental Medicine. A root canal involves removing the inflamed tissue from deep inside the tooth under local anesthesia.

But as tooth decay has declined in recent years and more people are keeping their teeth, the unintended effect has been that periodontal disease in the gums and jaw bones has soared.

Periodontal disease begins with a bacterial infection in the gums, called gingivitis. You’re likely to notice gingivitis first when specks of blood appear during flossing or brushing.

Each side of the tooth surface may be home to a different strain of bacteria. Usually, the bacteria congregate in a kind of pocket called the sulcus where the gum meets the tooth.

Brushing and flossing – once a day is enough if you do it thoroughly – gets rid of most bacteria mechanically, by dislodging it so you can rinse it out with water. Listerine – and a slew of other mouthwashes that also carry the American Dental Association seal of acceptance – have also been shown to get rid of bacteria, as do prescription mouthwashes such as Peridex or PerioGard.

But home care is often not enough, which means you should see a dental hygienist at least every six months. The hygienist’s job is to measure the depth of the pockets around your teeth and remove bacteria, plaque (bacterial deposits) and calculus (a calcified layer of plaque) from the pockets.

If gingivitis is not taken care of, it can turn into periodontal disease, which can destroy the gums, ligaments and bones that support teeth, ultimately causing teeth to fall out. Periodontitis is not caused by bacteria per se, but by the body’s attempt to fight this infection – the inflammatory response which brings huge numbers of white blood cells to the area. Recent research suggests low doses of non-steroidal anti-inflammatory medications like ibuprofen may slow this process.

Sometimes, periodontal disease can also be controlled by scaling or root planing – deep cleaning of the teeth under local anesthesia. In severe cases, surgery may be necesssary to remove inflamed gum tissue and reconstruct damaged bone.

Bone grafts may also help. When she was 10, Michele DerVartanian of Medford had a bad experience with a hasty tooth extraction, and 15 years later she still finds going to the dentist stressful. 3. Dr. Howard Howell engages a patient in conversation to ease her fears about a dental procedure.

The other heart attack risks – Anger, grief, fear

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But just as you can protect against physical triggers, you can protect against the dangers of emotional stress

Fifteen years ago, at 10:53 on a February evening, the people of Athens were jolted by an earthquake that measured 6.7 on the Richter scale. Within an hour of the quake and for three days afterwards, terrified Athenians were dropping dead at more than twice the normal rate.

This suggested, at least to Harvard School of Public Health epidemiologist Dimitrios Trichopoulos, that mental stress had triggered the increased deaths, most of them from heart attacks.

Back in 1983, when Trichopoulos published his findings in a medical journal, the notion that strong emotions could trigger a nearly-instant heart attack was anathema to many doctors, though lay people were often inclined to believe it.

Although it had been popular since the mid-70s to think that people with hard-driving “Type A” personalities were more prone to heart attacks than others, these early attempts to link emotions to heart disease had looked mainly at lifelong traits, not at a person’s mood right before a heart attack.

But after years of focusing on longterm personality styles and chronic physical factors like high blood pressure and cholesterol, researchers are now finding considerable evidence that heart attacks can be “triggered” by immediate events as well, including powerful emotions like grief, fear and anger in the hours before an attack.

Lest merely reading about such triggers set hearts dangerously aflutter, a bit of perspective:

“We all have stressful experiences and most of us don’t have heart attacks” because of them, points out David S. Krantz, a medical psychologist at the Uniformed Services University in Bethesda.

Furthermore, most of the people who do have a heart attack after an identifiable triggering event have underlying heart disease that puts them at higher risk, says Dr. James Muller, chief of the cardiovascular division at Deaconess Hospital.

“And even people with underlying heart disease may not be vulnerable to a trigger, including emotional stress, at any given moment,” he adds.

Yet heart specialists are taking emotional triggers increasingly seriously because both mental stress and cardiovascular disease are so common. Cardiovascular disease is the No. 1 cause of death in America, killing one person every 34 seconds. About 1.5 million Americans have a heart attack every year, and a quarter of a million die before reaching a hospital.

Futhermore, evidence is mounting that emotions can trigger heart attacks, especially in people with heart disease. The primary villains:

— Anger. Last year, in a study of more than 1,600 heart attack survivors, Dr. Murray Mittleman and others at Deaconess found that in the two-hour period after someone feels intense anger, heart attack risk more than doubles, just as it does in the two hours after sex.

To be sure, says Mittleman, because the baseline risk of a heart attack is about one in a million for a healthy 50-year-old man in any given hour, this means anger — or sex — temporarily raises the risk to just 2 in a million, a seemingly small hazard. For people with known heart disease, the average baseline risk is 10 in a million in any given hour; anger or sex raises it to 20 in a million.

“But while this may seem trivial,” he says, “it’s not, because people get angry far more often than they have sex.”

In fact, people who are chronically angry — especially those with what researchers now call a “hostile” rather than a Type A personality — are at increased risk of dying not just from heart attacks but from all causes, says Dr. Redford Williams, a Duke University internist and author of the 1993 book, “Anger Kills.”

Hostility is defined as an unlovely combination of cynicism, anger and aggressiveness.

— Grief. In a study of 1,774 heart attack patients reported at an American Heart Association meeting, Mittleman found that the death of a loved one raises the risk of heart attack 14-fold for the next 24 hours — significantly more than anger or sex.

As with anger and sex, grief seems to pose the greatest risk for people with underlying heart disease. But unlike anger and sex, the heightened risk from grief declines very slowly, often persisting a month or more, albeit at ever-lower levels.

— Fear. Israeli researchers reported last year that on the January day in 1991 that the SCUD missile attack began during the Gulf War, there was a marked increase in deaths, even though nobody died of injuries caused by the missiles.

Most of the deaths were attributed to cardiovascular disease, including sudden cardiac death, which can be caused by blockages in arteriesor by abnormal heart rhythms. This year, other researchers also found the incidence of sudden cardiac death was higher in the first 10 days of the Gulf war, but not enough to be statistically significant.

Yet researchers say there is virtually no question that fear played a role in the nearly 5-fold increase in deaths from cardiac causes on the day of the 1994 Los Angeles quake.

— Stress. This month, Duke University researchers led by psychologist James A. Blumenthal found that stress — like public speaking anddoing arithmetic — significantly increased the risk of potentially fatal heart problems and ischemia, or decreased blood flow to the heart, at least in people who have heart disease and score poorly on exercise treadmill tests.

The more researchers study emotional triggers of heart attacks, the more they think mental stresses affect the heart in ways different from physical stresses like sudden exertion.

Both types of stress cause a surge of hormones, including adrenalin and noradrenalin, that make blood pressure and heart rate soar. The increase in the force and flow of blood through arteries can cause fatty plaques in artery walls to rupture, allowing clots to form and block blood flow to the heart.

Adrenalin can also trigger potentially fatal disturbances in heart rhythm, especially in people with heart disease. And it can make platelets in the blood more likely to clot and cause spasms in arteries, causing them to constrict too much.

In healthy people, a physical stress like running makes the arteries dilate, sending more blood to the heart to meet its increased demand, says medical psychologist Krantz.

But in someone with coronary artery disease, the arteries do not dilate properly, which means the heart gets too little blood. Angina, or chest pain, often results.

With emotional stresses, however, the heart does not “demand” as much blood as it does with physical stress, says Krantz. But because blood vessels often constrict in emotional stress, the heart may still get less blood than it needs.

Unlike ischemia caused by physical stress, ischemia from emotional stress is more often painless.

Fortunately, researchers are finding ways to reduce heart attack risk from both physical and emotional causes.

To combat longterm, chronic risk, Mittleman says, the old standbys still hold: Quit smoking, eat sensibly and exercise to keep blood pressure and cholesterol down.

In fact, if you’re sedentary and have heart disease, regular exercise can virtually abolish the risk of heart attack from sudden exertion.

And if it’s acute triggers like anger that worry you, there’s also lots you can do, including taking aspirin.

“It’s like the straw the broke the camel’s back,” says Mittleman. “The longterm, chronic things like high blood pressure are the straws that have accumulated over time.

“Anger or other strong emotions can be the final trigger. But it’s all the risk factors together that determine whether or when a heart attack occurs.”

SIDEBAR:

You can reduce your risk

 To reduce risk further, you might also consider taking aspirin — if your doctor agrees. Aspirin can reduce chronic heart disease risk, probably by making it harder for the blood to clot, and there is evidence it protects against damage from anger, too.

Other drugs, including beta-blockers that dampen the effect of adrenalin and calcium channel blockers that dilate blood vessels, may also combat heart problems triggered by emotional stress, researchers say, though this has not been proven.

Psychological approaches may also reduce risk.

Recent research has shown that socially isolated people fare more poorly after a heart attack than others. That has prompted a consortium of researchers from Harvard, Yale and other centers to begin a study called ENRICHD to see if cognitive or group therapy improve outcomes in such people after a heart attack.

Dr. Herbert Benson, president of the Mind/Body Institute at Deaconess Hospital, advocates “the relaxation response” to offset emotional stress. If you meditate for 10 to 20 minutes a day for several weeks, he says, the stress hormone adrenalin has less effect. People who meditate also get less angry, he says.

And if you do get angry, how you manage that anger counts, too, says Mara Julius, a psychosocial epidemiologist emeritus at the University of Michigan School of Public Health.

The evidence is mixed, but she says expressing anger may be more healthful keeping it in. The best approach, she says, may be to practice “reflective coping” — rationally trying to solve the problem that prompted the anger in the first place.

Dr. Redford Williams, a Duke University internist, says when you get angry, you should ask yourself three questions:

— Is this really important to me?

— Is my anger appropriate to the situation?

— Is there anything I can do to fix the situation?

If you answer no to any one of these, just chill out.

If you answer yes to all three, he says, “action is called for. If it’s a problem with another person, the solution is to be assertive, rather than blowing up or screaming.”

“If it’s a situational problem and there is no other person to be assertive with, like when an airline cancels your flight, go out and run to discharge adrenalin,” he says, and if you can’t do that, meditate or think about your next vacation.

“This is all damage control when you’re angry,” he says. But it’s better to reduce anger in the first place, which may be easier than you think.

Regular physical exercise — such as walking 20 minutes a day — has long been known to reduce longterm risk factors like high blood pressure and high cholesterol. More recent data suggests regular exercise also buffers the heart against acute “triggers” like sex or sudden exertion. 

SIDEBAR:

You can reduce your risk

 

To reduce risk further, you might also consider taking aspirin — if your doctor agrees. Aspirin can reduce chronic heart disease risk, probably by making it harder for the blood to clot, and there is evidence it protects against damage from anger, too.

Other drugs, including beta-blockers that dampen the effect of adrenalin and calcium channel blockers that dilate blood vessels, may also combat heart problems triggered by emotional stress, researchers say, though this has not been proven.

Psychological approaches may also reduce risk.

Recent research has shown that socially isolated people fare more poorly after a heart attack than others. That has prompted a consortium of researchers from Harvard, Yale and other centers to begin a study called ENRICHD to see if cognitive or group therapy improve outcomes in such people after a heart attack.

Dr. Herbert Benson, president of the Mind/Body Institute at Deaconess Hospital, advocates “the relaxation response” to offset emotional stress. If you meditate for 10 to 20 minutes a day for several weeks, he says, the stress hormone adrenalin has less effect. People who meditate also get less angry, he says.

And if you do get angry, how you manage that anger counts, too, says Mara Julius, a psychosocial epidemiologist emeritus at the University of Michigan School of Public Health.

The evidence is mixed, but she says expressing anger may be more healthful keeping it in. The best approach, she says, may be to practice “reflective coping” — rationally trying to solve the problem that prompted the anger in the first place.

Dr. Redford Williams, a Duke University internist, says when you get angry, you should ask yourself three questions:

— Is this really important to me?

— Is my anger appropriate to the situation?

— Is there anything I can do to fix the situation?

If you answer no to any one of these, just chill out.

If you answer yes to all three, he says, “action is called for. If it’s a problem with another person, the solution is to be assertive, rather than blowing up or screaming.”

“If it’s a situational problem and there is no other person to be assertive with, like when an airline cancels your flight, go out and run to discharge adrenalin,” he says, and if you can’t do that, meditate or think about your next vacation.

“This is all damage control when you’re angry,” he says. But it’s better to reduce anger in the first place, which may be easier than you think.

Regular physical exercise — such as walking 20 minutes a day — has long been known to reduce longterm risk factors like high blood pressure and high cholesterol. More recent data suggests regular exercise also buffers the heart against acute “triggers” like sex or sudden exertion.

Getting a Fix on the Thyroid

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Three years ago, Ruth Hertz, 66, a self-described “LOL” or little old lady, began feeling lousy.

A normally avid tennis player, she found herself dragging around the court. “The tiredness sort of seemed to come on suddenly,” she recalled last week.

In fact, Hertz, who lives in Framingham, was “more than tired. I was lethargic. I was doing a lot of sleeping,” she says, “and I was beginning to be a little depressed.”

She finally confided her growing list of symptoms to another woman in her water aerobics class who immediately — and correctly — diagnosed her problem: an underactive thyroid gland.

Thyroid troubles, especially the mild, early stages of hypothyroidism or underactive thyroid, are among the most common and easily missed of medical problems, especially for older women, whose complaints of fatigue or malaise may be dismissed as anxiety, loneliness or part of menopause.

Yet more than 6 million Americans, most of them women, suffer from hypothyroidism. Another million have the opposite problem, hyperthyroidism, in which the butterfly-shaped thyroid gland in the neck makes too much, not too little, hormone.

And while some women do encounter thyroid problems right after childbirth, many more — an estimated 10 to 20 percent — first begin having thyroid abnormalities around age 60.

But increasingly, doctors are getting better not just at diagnosing these problems, but also at avoiding what used to be a major pitfall: Overtreating hypothyroidism, which can cause osteoporosis, or bone loss.

Today, thanks to increasingly sophisticated versions of a sensitive test called TSH, doctors can adjust medications precisely, allowing virtually all patients to maintain normal thyroid function.

Researchers also have a more detailed picture of what causes most thyroid troubles in the first place. As we age, the immune system, for unclear reasons, sometimes begins to attack organs in the body, especially in women.

In hypothyroidism, immune cells mistakenly attack the thyroid gland, a process known as Hashimoto’s thyroiditis.

Hyperthyroidism can also be caused by an auto-immune disorder — Graves’ disease — in which proteins called antibodies attack the thyroid.

The half-ounce thyroid gland is far more important than its diminutive size would suggest. In fact, the iodine-laced hormone it makes, thyroxine, is essential — and not just in humans.

It is thyroxine that turns tadpoles into frogs, notes Dr. Reed Larsen, chief of the thyroid division at Brigham and Women’s Hospital. If tadpoles’ thyroid glands are removed, they keep growing — up to a foot long — but never change into frogs.

Thyroid hormone makes kids grow, too, and is essential for normal brain development as well. A baby born with a defective thyroid will, unless treated, develop cretinism, a form of mental retardation endemic in parts of the world where iodine deficiency causes goiter, an enlargement of the thyroid.

Thyroid hormone is also essential for bone growth and for maintaining the basal metabolic rate — the speed at which the body uses sugars, fats and proteins.

With increasing age, many of us — perhaps 50 percent — develop nodules in the thyroid that doctors can feel. These usually do not interfere with thyroid function and are almost always benign, but occasionally, larger nodules may contain cancer. This is rarely fatal and can be treated by removing the affected part of the gland and treating with replacement hormones.

For most of us, however, it’s the more mundane problems that are the biggest troublemakers in later life.

If your aging immune system goes bonkers and attacks your thyroid, you may suffer fatigue, weight gain, intellectual dullness, depression, a tendency to feel cold, constipation, dry skin and other signs of an underactive thyroid. An overactive thyroid is no better — it can cause fatigue, heart failure and heart palpitations, mood swings, nervousness, weight loss, heat intolerance and other problems.

Either way, you may be miserable, though it’s worth remembering that few people die of either over- or underactive thyroid problems.

But in rare caes, hypothyroidism can cause such a sluggish metabolic rate that coma and death result. And hyperthyroidism can produce a fatal “thyroid storm,” in which the heart races and temperature soars.

But it’s usually the tiny, non-life-threatening changes in hormone function that cause most people misery. And how much hormone you produce is controlled by chemical signals sent out by the pituitary gland, which lies just underneath the brain.

If the pituitary senses that the thyroid gland is not making enough hormone, it puts out extra TSH, or thyroid stimulating hormone. If the pituitary senses the thyroid is making too much hormone, it decreases TSH to damp the system down.

In the old days, before TSH testing allowed doctors to measure miniscule changes in thyroid function, the only way doctors could assess function was by measuring blood levels of a thyroid hormone called T4. And the only rememdy they could offer was a dessicated powder made from the thyroid glands of pigs or cows, which varied greatly in strength from dose to dose.

“But now there are better ways both to test for and treat thyroid problems,” says Dr. Gilbert Daniels, co-director of Thyroid Associates at Massachusetts General Hospital.

Now, most patients’ blood is tested for TSH levels, which is “much more sensitive” than T4 testing at detecting miniscule changes in thyroid function, he says. If the test shows you have hypothyroidism, the solution is straightforward.

“Just give back thyroxine,” says Larsen of the Brigham. Nowadays, most doctors prescribe synthetic hormones such as Synthroid, which costs roughly $10 for a month’s supply, or Levoxyl and Levothroid, which cost $5 and $7 respectively.

But getting the dose right can be tricky, so doctors advise taking the hormone for 4 to 12 weeks, then having your TSH measured again. Once you’re on a medication, some doctors say you should stick with that brand, because formulations vary, though others say all the major drugs are equivalent.

“Don’t let people play musical brands with you, because one brand may not be 100 percent equivalent to another,” says Dr. Harold Rosen, an endocrinologist at Beth Israel Hospital.

And definitely don’t fool around with the dosage. If you take too much thyroid hormone, you may wind up with hyperthyroidism.

“Some people think overtreating is a neat way to lose weight,” says Rosen, and some people do feel better if they are slightly hyperthyroid.

But thyroid therapy rarely turns a chubby person into a svelte one. Even if you lose five or 10 pounds on hormones, you may gain the weight back. Overtreating with thyroid hormone can also cause dangerous thickening of the heart muscle.

And hyperthyroidism, whether it arises spontaneously or from overtreatment of hypothyroidism, can also cause osteoporosis, the bone-thinning disease that women already face at menopause from falling levels of another hormone, estrogen.

Thyroid hormone acts directly on bone, and too much can result in bone loss, says Dr. Meryl Le Boff, director of the Brigham’s skeletal health and osteoporosis program. The rate of loss can be slowed by estrogen therapy or other drugs.

For hyperthyroidism not caused by overtreatment, the best long-term solution is often radioactive iodine, says Larsen of the Brigham. Some patients panic at the idea of taking radioactive chemicals, he says, but this treatment “has been used for 50 years without any radiation-related side effects.”

For some patients, surgery to remove the thyroid gland can also help. And others benefit from drugs like propylthiouracil (PTU) or methimazole (Tapazole) that block the thyroid from making hormone.

The take-home lesson, says Larsen, is that because thyroid problems are so common and the symptoms can be so easily dismissed, patients should not be afraid to ask their doctors for a TSH test.

Ruth Hertz emphatically agrees. Taking thyroid hormone, she says, has “changed my life. It gave me much more energy. And I’m more interested in doing things.”

Disease du jour

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You’re convinced you have chronic fatigue syndrome, though you can’t get your doctor to believe you. Or maybe you think you’ve got multiple chemical sensitivity because you seem to be allergic to everything from fabric softener to perfume.

Or perhaps it’s some kind of chronic Lyme disease – after all, ticks are everywhere and you haven’t felt right in years.

Or you think that your kid – unlike your neighbor’s truly unruly brats – has attention deficit or hyperactivity disorder because she’s so moody and has trouble in school.

Although we live longer and more healthily than ever before, we have become a nation of worriers – hypochondriacs, even – convinced that we have what some doctors now call “fad diseases” or the latest “diagnosis du jour.”

Now before anybody goes ballistic, let’s be clear here.

Just because a disease might be called “trendy,” in the sense that lots of people suddenly seem to have it, doesn’t mean it’s not real. And there’s no question that the medical establishment has a lousy history of telling people – especially women – that some very real diseases are all in their heads when they aren’t.

But while some of these trendy new diseases are unquestionably real, it is also true that certain syndromes like chronic fatigue, attention deficit disorder and the vague muscle aches of fibromyalgia – to name but a few – seem to act like magnets for people who don’t really have them.

What sufferers of these and other mysteriously modish maladies may have – and definitely don’t want to hear about – is depression, or some other more mundane but stigmatized problem.

At least that’s what Dr. Kevin Ferentz, associate professor of family medicine at the University of Maryland School of Medicine, thinks, and to say that this thesis is as welcome as a blizzard in June is putting it mildly, even though depression is highly treatable, especially compared to these exotic diseases people often think they’d rather have.

Ferentz acknowledges that a doctor can miss a diagnosis that a patient gets right. Furthermore, he says, “Every one of these fad illnesses has a piece that is real.

“But unfortunately,” he goes on, “the criteria for making the diagnosis are sometimes vague. And sometimes, even if there are criteria, those of us in primary care may be unaware of them. So these illnesses are often overdiagnosed. . ..”

They are indeed. Take chronic fatigue syndrome, for instance.  Though some doctors are skeptical, others, among them Dr. Anthony Komaroff, chief of general internal medicine at Brigham and Women’s Hospital, are convinced that CFS is real and that it has a genuine, albeit undiscovered, biological cause.

Many people with genuine CFS, he says, show neurological abnormalities on brain scans, have persistent immune system hyperactivity and abnormalities in blood pressure regulation, perhaps because they have a deficiency of the hormone, cortisol.

For several years, the federal Centers for Disease Control has estimated that CFS affects 4 to 10 people per 100,000 adults, but newer research suggests the real prevalence may be closer to 100 in 100,000, or 1 in 1000. Yet 20 times that number without CFS complain to their doctors of constant fatigue.

“It’s very true that many people think they have CFS and don’t,” says Komaroff. “If you take 100 people walking into the doctor’s office saying they’re tired, maybe three will have CFS and maybe 50 percent will have an underlying depressive disorder. Depression is a far more common and important cause of fatigue than CFS, but a lot of people who are depressed want a physical explanation.”

Or take Lyme disease, a tick-borne illness that has struck nearly 80,000 people since the CDC began keeping track in 1982 and now causes at least 8,500 new cases annually.

There’s no doubt that both acute and chronic forms of Lyme disease are real, that they’re caused by a spirochete passed by the bite of an infected tick and that they are treatable with antibiotics, says Dr. Allen Steere, director of the Lyme disease program at the New England Medical Center.

“But along with that has come the ‘other’ Lyme disease,” he says, a syndrome of pain and fatigue of unknown cause.

Diagnosis is tricky because people who’ve had Lyme disease score positive on antibody tests long after the infection is over – even if their later problems have nothing to do with it.

Of nearly 800 patients who visited Steere’s clinic during a five-year period, he says, 23 percent had chronic Lyme disease; another 20 percent had had it and then developed something else, usually pain and fatigue that could be called genuine post-Lyme disease; and 57 percent had a pseudo-Lyme disease, usually a pain and fatigue syndrome.

Like Ferentz, Steere believes that “fad diseases absolutely exist” and that many people are convinced they have Lyme disease when they don’t. But that doesn’t mean, he says, that they aren’t suffering or don’t have an illness.

“These pain and fatigue syndromes can be awful, debilitating problems,” he says. And while depression is one cause, so are infections, head trauma, other injuries or emotional trauma.

And what of attention deficit disorder, chemical sensitivity and other trendy troubles?

Even Dr. Bruno Anthony, a clinical psychologist and director of the Maryland Center for Attention Disorders, says that while ADHD (attention deficit/hyperactivity disorder) “is not a fake, bogus disease,” it is often misdiagnosed.

Officially, attention deficit disorder is a genuine disorder. That means that a bunch of psychiatrists got together, gave a name to a collection of symptoms such as distractability, disorganization and impulsivity and printed it in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, the psychiatrist’s bible.

But increasingly, it’s become a catch-all diagnosis that medicalizes troublesome behavior in kids – and adults – and is used to justify treatment with drugs such as Ritalin.

“Parents and teachers can be eager to label a child as having ADHD,” says Anthony. “That’s not to say that they might not be correct, but there are other reasons for inattentive and disruptive behaviors – anxiety or depression for example. And sometimes it’s just plain rowdiness.”

But it’s multiple chemical sensitivity that is perhaps the most controversial “fad illness. “At least from a scientific point of view, it’s total bull,” says Ferentz, “but that doesn’t mean that patients aren’t genuinely suffering from something.”

To be sure, it is sometimes recognized as a disability by the Social Security Administration and the US Department of Housing and Urban Development under the Americans with Disabilities Act.

But the matter is hardly settled. Just last month a federal judge ruled that a Millis woman claiming to have MCS was not entitled to force visiting nurses to accommodate her because there was not enough evidence to show that MCS is a disability.  “Too many people are walking around thinking they have a medical problem when they just have life,” says Ferentz. “A lot of these illnesses are ‘bad feelings.’ But there’s no such thing as good feelings and bad feelings – we all have a range of feelings – happiness, anger, sadness, grief.”

And when people insist they have a fad illness when they don’t, “the harm is that they don’t get treated for their true illness,” says Dr. Mark Ehrenreich, director of consultation psychiatry at the University of Maryland School of Medicine.

Often, the underlying illness is depression, but it can be other treatable problems like anemia, thyroid dysfunction or even cancer.

The bottom line, says Dr. Thomas Delbanco, chief of general medicine and primary care at Beth Israel Hospital, is that “medicine remains more art than science,” which means patients should “stay away from the doctor who says ‘This is all depression’ or ‘This is all chronic fatigue.’ “

Indeed, says Dr. Kathleen Mogul, immediate past president of the Massachusetts Psychiatric Society, “It’s not impossible to have both.”

To some, like Dr. Jerome Kassirer, editor in chief of the New England Journal of Medicine, the best bet “is to get a good doctor . . . and if no physical cause can be found, consider the possibility that there are other factors responsible.”

Ferentz thinks this is backwards. It would be far better, he says, if doctors made more effort to “rule in” depression or anxiety and less trying to rule out everything else.

This may not be music to your ears. Giving up a cherished self-diagnosis is always tough, perhaps especially if it’s not true. But you could end up feeling a lot better faster.

Depression common, easily treated

The great irony about thinking you have a faddish or “socially acceptable” disease, if what you’ve really got is depression, is that depression is usually far more treatable – and much more likely to be the right diagnosis because it’s a kit more common.

Epidemiological studies show that over the course of a lifetime, women have a 10 to 25 percent chance of having a major depressive disorder, and men, a 5 to 12 percent chance, says Dr. Mark Ehrenreich, director of consultation psychiatry at the University of Maryland School of Medicine.

On any given day, 5 to 9 percent of women are seriously depressed and 2 to 3 percent of men, he adds, noting that these figures refer to “major depression.” Many more people suffer less serious depressive problems.

Unfortunately, depression still carries a social stigma, but it shouldn’t. It is a genuine disease with real physiological characteristics.

It is also highly treatable. Anti-depressant medications are effective at least 70 percent of the time, doctors say, and psychotherapy can boost this success rate further.

And unlike some “fad illnesses,” depression is well defined, though both doctors and patients often miss what should be an obvious diagnosis, sometimes because patients don’t say they feel down even if they exhibit other signs of the disease.

Typically, only a third of depressed patients tell their doctors that they feel depressed. Of the rest, 80 percent go to the doctor complaining of other things like insomnia or weight loss. In this group, doctors make the correct diagnosis – depression – only about 12 percent of the time.

If you have had at least five of the following nine symptoms for at least two weeks, there is a good chance you have a major depression and should seek treatment. Those signs are:

–     Depressed mood, which can include pervasive feelings of sadness or irritability.

–     Sleep disturbances – both too much and too little.

–     Distubances in appetite – usually eating too little but sometimes, eating too much.

–     Loss of energy.

–     Difficulty concentrating.

–     Feeling guilty.

–     Psychomotor retardation or agitation – being very slowed down in your movements or being unable to sit still.

–     Thoughts of suicide or death.

–     Anhedonia, or the inability to enjoy things.

 

From Biotech to bees, new answers to MS

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Kelly Ames, a staff assistant at Harvard Business School, is only 28 years old.

But in the six years that she’s had MS, a neurological disease that causes loss of coordination, partial blindness, even paralysis, she’s tried nearly every remedy in sight.

Drugs — steroids — helped some, she says, but she hated the side effects: “I’d eat like there was no end.”

At her mother’s urging, she went to France to bathe in the holy water in Lourdes, to no avail. Finally, when she could barely walk, she joined a support group, where one woman spoke of a horrifying remedy Ames had never thought of: bee stings.

Susan Graber, a 37-year-old South Carolina woman with MS, wouldn’t go near a bee, she says, because she’s “chicken to explore something where there’s nothing proven.”

She’s put her faith in mainstream science, becoming one of 301 human guinea pigs in a study of a new drug likely to be approved soon by the US Food and Drug Administration.

For years, MS patients had few options beyond steroids to soothe acute attacks, physical therapy and drugs to manage symptoms of the disease, which in some cases progresses steadily and in others, waxes and wanes mysteriously.

But recently, the tide has been turning for the 300,000 Americans with MS, two-thirds of them women in their 20s, 30s and 40s.

Doctors now have better tools to diagnose and track the disease, like MRI (magnetic resonance imaging), for instance.

They also have a firmer grip on the mechanisms by which this debilitating, though rarely fatal, disease gets started in the first place.

A leading theory now is that multiple sclerosis starts when the immune system gears up to fight a virus. Then, mistaking tiny markers on the myelin sheath surrounding nerve fibers in the brain and spinal cord for the virus, the immune system keeps up its attack, destroying the body’s own tissue.

But most important to people fighting MS, researchers have a whole slew of new remedies in the pipeline designed to slow progression of disease and reduce flareups.

Some of these drugs, like Betaseron, approved in 1993 by the Food and Drug Administration, and AVONEX, awaiting approval now, tinker with components in the immune system, suppressing levels of natural, inflammatory substances that contribute to MS flareups and boosting levels of anti-inflammatory chemicals.

“The net effect of both these beta-interferons is to dampen down an overactive immune system,” says Dr. Howard L. Weiner, co-director of the center for neurologic diseases at Brigham and Women’s Hospital.

The drugs may work by decreasing levels of gamma interferon and boosting anti-inflammatory substances like interleukin-4 and interleukin-10, among other effects.

Other drugs, like Copaxone, which is also awaiting FDA approval, work through somewhat different means to stop immune cells from attacking the myelin sheath around nerve fibers.

Still other drugs increasingly used against MS are old standbys on the market for other uses, like cancer remedies methotrexate and cyclophosphamide. These drugs work by attacking rapidly-dividing cells, like tumor cells and immune cells that attack myelin.

And other medications, like Myloral, a kind of vaccine, use a totally different approach, taking advantage of a phenomenon called oral tolerance.

The theory here is this: When a person swallows Myloral, which is made of proteins from the myelin sheath, immune cells in the intestines become programmed to recognize the myelin.

When these cells then travel through the bloodstream to the myelin sheath in the brain and spinal cord, they secrete anti-inflammatory substances that should stop the immune attack against myelin. Curiously, notes Weiner, if these same proteins were injected instead of swallowed, the response could be just the opposite — immune cells could attack the myelin sheath.

For many people like Graber of South Carolina, these drugs offer hope for a vastly improved quality of life, despite MS.

During the 2-year AVONEX study, researchers purposely did not tell Graber or any other participants which patients were getting Avonex and which, a harmless placebo.

But Graber, who had no feeling in her legs and could barely walk when the study began, knew right away. Each time she got an injection, she had flu-like symptoms — and relief from MS.

She also “started to fail tremendously” when the test was over and she had to stop taking the drug. Now taking the drug again in a follow-up study, Graber is thrilled.

“I have done so well on this drug,” she says. She still can’t work, but she no longer needs a cane to walk.

But it’s not just mainstream drugs that have people with MS buzzing these days — it’s honeybees.

When Ames first heard of bee venom therapy, she was appalled, especially when the woman in her group who’d been stinging herself “never showed up again. . . We thought she had died.”

But Ames was curious, too, and desperate. So she bought honeybees from a local beekeeper and began stinging herself — “screaming and crying” — every other day.

Popularized in recent years by alternative medicine gurus, among them, 90-year old Vermont beekeeper Charles Mraz, author of the self-published “Health and the Honeybee,” the idea of using bee venom medicinally is probably as old as Hippocrates.

But it was not until the 1950s that scientists, chiefly in Bulgaria and Germany, began taking bee venom seriously. Later, researchers at the Walter Reed Army Institute of Research got interested, too, among them Robert Brooks, a Pennsylvania beekeeper and pharmacologist.

Bee venom contains about 40 ingredients, says Brooks, including anti-inflammatory substances, one of which may be 1,000 times stronger than indomethacin, a nonsteroidal anti-inflammatory drug.

And two ingredients in bee venom, and bee venom as a whole, may stimulate release of cortisol, an anti-inflammatory chemical made in the body that also damps down immune response.

But Brooks warns that “the action of bee venom is much more complicated than the simple release of cortisol,” and Dr. Christopher Kim, a pain researcher in Red Bank, N.J., agrees.

In one study of 180 patients with arthritis and similar diseases, Kim found that injections of true venom reduced pain significantly more than injections of “sham” venom. But “bee venom therapy is not pleasant,” he says, and should be used only by patients who do not respond to conventional therapy.

Bee venom can also cause fatal anaphylactic shock, though this is rare. There are 40 reported deaths a year from all stinging insects, including bees and yellow-jackets, according to the National Institute on Allergy and Infectious Diseases.

To be safe, Kim tests patients first with a small dose of venom to see if they are allergic and keeps antidotes on hand.

Still, there is no scientific evidence that bee venom therapy helps in MS, says Stephen Reingold, vice president for research at the National Multiple Sclerosis Society.

But that could change.

Dr. Fred Lublin, acting chairman of neurology at Thomas Jefferson University in Philadephia, is now studying bee venom in mice, though he, too, stresses that the data are not yet in.

“Just the stress of being stung, as opposed to what’s in the venom,” could stimulate cortisol, he says. And “the placebo effect seems to be especially strong because of the nature of the disease,” which waxes and wanes on its own.

But try telling that to Kelly Ames or her friend Karen Davies, 32, who brings her own bees — obtainable by mail or from beekeepers — three times a week so Ames can sting her. She puts the bees on spots of the body that are also acupuncture points, thus triggering — perhaps — a double-whammy effect.

“I’ll try anything,” says Davies, who gets 120 stings a week. “I feel great,” she says. But she also takes Betaseron.

Ames, however, uses nothing but bee stings. “My eyesight came back and I stopped using a cane,” she says, as soon as she worked her way up to 13 stings every other day.

“I know it works for me. . .I don’t have MS anymore.”

SIDEBAR

What’s new for MS

These are among the new drugs recently approved, likely to be approved soon or under investigation for MS:

  • Betaseron (interferon beta-1b), an every-other-day injection made by Berlex Laboratories, was approved by the FDA in 1993.
  • AVONEX (interferon beta-1a), a weekly injection, made by Biogen, Inc., expected to be approved soon.
  • Copaxone, by Teva Pharmaceuticals, a daily injection, also awaiting FDA approval.
  • Myloral, a vaccine developed by AutoImmune Inc., now in clinical trials.
  • Linomide, by Pharmacia & Upjohn, Inc., now in clinical trials.
  • Cladribine, by Ortho Biotech, Inc., also in clinical trials for MS. It is on the market for leukemia, but can be toxic.
  • Fampridine (4-aminopyridine), by Elan Pharmaceuticals, in clinical trials for management of symptoms of MS.
  • Zanaflex, by Athena Neurosciences, Inc., to treat spasticity, is awaiting FDA approval.

For more information on MS and treatments, call:

  • National Multiple Sclerosis Society, 1-800-FIGHT-MS.(1-800-344-4867); for Massachusetts residents, 617-890-4990.
  • Multiple Sclerosis Association of America, 609-488-4500 or 1-800-LEARN-MS.
  • American Apitherapy Society, 1-802-436-2708.
  • MS support group for people using or considering bee venom therapy, 617-641-3109.
  • For books on bee venom therapy, Honeybee Health Products, 1-800-603-3577.

It helps to prepare for surgery

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In late December, Ellen Wolk, a 36-year old Arlington woman, lay on a gurney amid the other patients awaiting surgery at Deaconess Hospital, getting more anxious by the minute.

Her doctors weren’t sure, but they were worried that she had cancer of the thyroid, a plum-sized gland in the neck that makes a hormone critical to normal metabolism.

Hoping they were wrong, Wolk agreed to have one lobe of her thyroid removed, leaving the other in place to make hormones so she wouldn’t need to take medication the rest of her life. If she did have cancer, she figured, she’d have another operation later to remove the other lobe.

As it turned out, Wolk did need another operation, which was done earlier this month.

Although both operations were done at the same hospital, by the same surgeon, her experiences were as different as night and day, and not simply, she says, because she was a surgical veteran the second time she went into the operating room.

The first time, she was not only scared before surgery, but had considerable pain and several complications afterwards.

The second time, Wolk took control in every way she could, managing her own pain medication patient-controlled analgesia, and reducing her anxiety to speed her recovery.

She lined up friends for emotional support, including one who stayed with her before and after surgery. She went to a cancer support group at the hospital. She listened to relaxation tapes twice daily before the operation and during it as well.

She even asked her surgeon, Dr. Charles Norris, Jr., chief of head and neck surgery at the Deaconess, to talk to her as he operated, saying things like, “After this operation, you will feel comfortable and you will heal very well.”

Surgery is a booming business in America, with more than 30 million procedures expected this year, according to SMG Marketing Group, Inc., a health care market research firm in Chicago.

But with two-thirds of these operations now done on an outpatient basis, and with insurance companies insisting on ever-shorter stays, how well you fare as a surgical patient increasingly depends on you – and your family and friends.

“Because patients are spending less and less time in the hospital, they have to take more responsibility for caring for themselves at home before and after an operation,” says Dr. George Sheldon, chairman of the surgery department the University of North Carolina and a spokesman for the American College of Surgeons.

In the old days, for instance, a person taking blood-thinning drugs to prevent strokes or heart attacks would spend a night or two in the hospital being monitored as he was weaned off the drugs to prevent excess bleeding during surgery.

Now, people are told to wean themselves off such drugs at home under a nurse’s or doctor’s supervision by telephone.

Diabetic patients, too, must work extra hard prior to an operation to keep insulin levels under control, particularly during the immediate pre-op period when they’re not eating.

This balancing act used to be done in the hospital, says Sheldon: “Now we have to educate patients to do it at home.”

At many hospitals, including Beth Israel in Boston, pre- and post-op education has become such a fine art that many patients now skip the traditional pre-op hospital visit.

Instead, a nurse calls them a week or so before surgery to answer questions and screen for any unusual problems.

Patients love it, says Mary Jane Costa, nurse-manager of ambulatory surgery at Beth Israel: “It’s a working society, and patients had a hard time getting the day off to come in.”

Patients also get detailed instructions by mail, including a list of drugs containing aspirin or ibuprofen to be avoided before surgery, and specifics on when to stop eating and drinking before operations.

Considerable evidence, including data from a decade ago when patients had longer hospital stays, also suggests that the more patients are told what to expect – especially how they will feel as they recover – the better they fare after surgery, says Harvard Medical School psychiatrist Dr. Malcolm Rogers.

Some people take self-preparation even further.

Prior to her second operation, Wolk consulted with self-healing guru Peggy Huddleston, the Cambridge-based author and publisher of “Prepare for Surgery, Heal Faster,” a book of anecdotes, common sense and some scientific reports.

Huddleston, who has a master’s degree in theological studies from Harvard Divinity School and practices psychotherapy, says “people can do a lot emotionally and spiritually to speed healing.” To wit:

“Learn to get deeply relaxed” before surgery, says Huddleston, who sells relaxation tapes with her book. You can also ask doctors to play such tapes in the operating room.

Before and after surgery, she continues, try to “actively visualize the healing process. Don’t imagine the worst.”

It also helps, she says, to organize a support group, as Wolk did, and ask someone to be with you before and after surgery.

And you might trying asking your surgeon or anesthesiologist to make “healing statements” during the procedure.

The jury is still out on all this, but studies from Scotland, Canada and Atlanta suggest that people may retain the ability to hear, even under general anesthesia, and that “therapeutic suggestions” may diminish pain and help speed healing.

If you’re worried about anesthesia, she says, ask for a face-to-face appointment with the anesthesiologist.

Dr. Susan Troyan, surgical director of the BreastCare Center at Beth Israel, endorses Huddleston’s approach, but she adds that people should not fear that “how well they do in surgery depends on doing these techniques.”

But Wolk, a Cambridge chiropractor, is utterly convinced that she did better with her second surgery because she took control in these and other ways, and her surgeon doesn’t disagree.

Norris says he had never made healing statements during a procedure before. But Wolk “was very organized and made the request,” he says, “and I freely admit she had a much smoother time the second time around.”

“With both surgeries,” says Wolk, “I was back to work in eight days. But the second time, I felt much more like myself and was more ready to take on my full workload.”

They’re not exactly rushing mindlessly into the 20th century over at the 184-year-old New England Journal of Medicine.

In fact, the top editors at the nation’s most prestigious medical journal still use different color pens to show who made which changes when they edit manuscripts.

But the Journal took a big step into the information age this week when it announced that abstracts of its major articles and the full text of editorials are now available on the World Wide Web, at http://www.nejm.org by 7 a.m. on Thursdays.