Millions of American women are being diagnosed with osteopenia, which is not truly a disease, and many are told to take medication they may not need to prevent broken bones they might never get.

At the same time, millions of others are never properly diagnosed – or treated – for osteoporosis, a serious condition that can lead to potentially devastating fractures.

The widespread confusion about what degree of bone loss really is a red flag for future broken bones and what is simply a sign of normal aging has been rampant since, in 1994, the World Health Organization defined “osteopenia” and “osteoporosis” as certain ranges of scores on a bone density test.

Some doctors consider this range skewed, labeling too many — 34 million — Americans as having osteopenia, and too few — 10 million — at risk for the broken bones of osteoporosis. (Osteoporosis is generally considered a disease of women, but men can get it, too.)

Things have become even more muddled since 2002, when many older women stopped taking hormone therapy — which can help prevent bone loss – after a major study showed that it also raised the risk of breast cancer, heart disease and stroke. Between 2002 and 2003, sales of Fosamax, a drug used to prevent bone loss soared 19 percent, to $2.7 billion.

In essence, nobody quite knows what, if anything, an older women whose only sign of potential problems is mild bone loss should do. Should a woman at 50 start taking drugs like Fosamax, Actonel or Evista to guard against possible fractures in her 80s, when most fractures occur? Or should she wait until her bone tests get worse or there is a very real red flag, like having a fracture triggered by a minor fall?

The problem comes from “calling osteopenia a disease when it is not,” said Dr. Robert Neer , director of the osteoporosis center at Massachusetts General Hospital. The WHO defined osteoporosis too narrowly, leading many people to think they are not at high risk, and osteopenia too broadly, encouraging too many women to take medication, he said.

“We are overtreating a large number of healthy women who have a relatively minor risk of fracture and we are ignoring a sizable number of individuals at high risk of fracture,” Neer said.

The term “osteopenia” has “nomedical meaning,” added Dr. Steven Cummings, an epidemiologist at the University of California, San Francisco, who has led a number of large studies on osteoporosis and osteopenia. “I’ve seen patients who come in scared that they will become disabled soon because they have this ‘disease’ called osteopenia, when in fact they are normal for their age.”

Other critics, like Gillian Sanson , a women’s health educator in New Zealand and author of “The Myth of Osteoporosis,” go further. The medical establishment, she said, is “manufacturing patients” by over-medicalizing the normal bone loss that occurs with aging.

For the record, osteopenia is defined by the WHO as a score of minus 1 to minus 2.4 on the so-called DEXA test, which stands for dual energy X-ray absorptiomety. Osteoporosis is defined as a DEXA score of minus 2.5 or worse. Osteopenia can, but does not necessarily, progress to osteoporosis.

Indeed, while osteoporosis clearly raises the risk of fractures, many fractures also occur in people without it. A 2003 study showed that the proportion of fractures attributable to fragile bones was “modest” — somewhere between 10 and 44 percent.

“Low bone mineral density does raise the risk of hip fracture, but it’s only one of several factors like bad eyesight, bad coordination, use of Valium or similar drugs, overactive bladder and other conditions that contribute to the falls that can lead to broken bones,” said Dr. Nananda Col , an internist and women’s health expert at Rhode Island Hospital in Providence, RI.

In other words, a finding of mild osteopenia on a bone density test is not, by itself, enough reason to take medications. If there are no other risk factors, even a bone density test score as low as minus 2 “in an otherwise healthy young person may be normal,” said Dr. Eric Orwoll , an osteoporosis specialist at Oregon Health Sciences University in Portland, OR.

On the other hand, because osteopenia can, though does not always, lead to osteoporosis, many doctors believe it’s important to start treatment early to avoid broken bones later in life.

Dr. Joel Finkelstein , an osteoporosis specialist at Massachusetts General Hospital, said he sometimes prescribes medication to postmenopausal women with bone density scores of minus 1.5 to minus 2, even if they are still in their 50s.

“I do believe in treating a lot of these people to prevent the development of osteoporosis….I may be more aggressive than some other physicians.” Dr. Suzanne Jan de Beur , director of endocrinology at the Johns Hopkins Bayview Medical Center, said she prescribes medication to women with scores of minus 1.5 to minus 2 if there’s a family history of osteoporosis or other risk factors.

Dr. Joseph L. Melton, III, an epidemiologist at the Mayo Clinic in Rochester, MN, put it this way: Doctors who advise women to ignore osteopenia “are wrong, and people who advise everybody to treat it are wrong. It’s a personal decision based on family history and personal values.”

So, when should a woman be screened for potential bone loss? And how safe are the drugs for long term use?

In 2002, the US Preventive Services Task Force, a panel of independent experts convened by the government’s Agency for Healthcare Research and Quality, concluded that women aged 65 and older should be screened routinely for osteoporosis. It said screening should begin at 60 for women at increased risk, which includes a family history of hip fractures, current smoking, thinness and use of steroids such as Prednisone.

As for drug safety, a study published in March, 2004 in the New England Journal of Medicine showed that Fosamax (alendronate) appears to be safe for as long as 10 years. But a 1998 study showed that while Fosamax helps prevent fractures in women with osteoporosis, it does not do so in women with osteopenia and no previous fractures.

Fosamax and Actonel can cause small ulcers in the esophagus, or food tube; Evista can cause hot flashes, and rarely, blood clots.

There is no evidence yet that the widespread use of Fosamax and Actonel is causing any problems, said Col of Rhode Island Hospital. But the drugs do get incorporated into bone. “If 10 years down the line, it turns out that something is dangerous, it will be sitting in a lot of people’s bones. The benefits of treatment need to outweigh the risks.”

That applies to another drug, too: Forteo, the only medication that actually increases bone growth. The catch with Forteo is that it carries a special warning because, in rodents, it can trigger bone cancer.

Bottom line? Try to prevent thinning bones in the first place. Do weight-bearing exercise several times a week and walk briskly for 30 minutes a day or more. Get enough calcium — 1,200 to 1,500 milligrams (but not more) a day, plus 800 International Units of vitamin D, from food and, if necessary, supplements. Minimize use of Valium-type drugs. If problems like overactive bladder or poor eyesight are raising your risk of falls, get those treated, too.

And if one doctor recommends drugs to protect your bones on the basis of mild bone loss, consider getting a second opinion. Obviously, no one wants a broken hip. But no one should take any drug for decades without careful thought, either.

At teaching hospitals around the country, medical students routinely practice doing pelvic exams on unconscious, anesthetized female patients — often without the patients’ knowledge or consent.

Some of the nation’s 126 medical schools have forbidden the practice, but Dr. Ari Silver-Isenstadt, a Baltimore pediatrician and co-author of a 2003 paper on the topic, said the practice continues to be widespread.

According to his research, 90 percent of medical students surveyed said they had done pelvic exams on anesthetized women. He did not track how many of the patients had given permission for those exams.

Medical students on surgical “rotations” are in the operating room primarily to learn, not to care directly for the patient. For that reason, he said, “medical students who are not central to patient care should not be doing this without explicit permission. It’s a no-brainer.”

Dr. Marcia Angell, senior lecturer in social medicine at Harvard Medical School said the reason doctors don’t ask is that women might refuse — “which makes it even worse,” she said. “They have no right to use humans as tools. It’s exploitation.”

Doctors often justify having medical students perform pelvic exams on anesthetized women by saying that asking consent would take too much time, might scare patients and that patients already know medical students will be involved in their care by the sheer fact of choosing to go to a teaching hospital.

In gynecological surgery, “the exam under anesthesia is a crucial part of the procedure, it’s not separate from the surgical procedure,” said Dr. Andrea Rapkin, a professor of obstetrics and gynecology at the University of California at Los Angeles Medical Center.

Doctors must inform patients that they will be examined under anesthesia, but “we don’t specify that it is a pelvic exam,” Rapkin said. “We have no reason to specifically state that a medical student will (perform the exam)…It’s not the whole team of medical students —
it’s usually one or two.

Silver-Isenstadt’s team also found that as medical students proceeded through their training, they became less and less concerned about seeking consent, a sign that they were becoming acculturated to a medical system that, as he put it, “assumes patients are not in control of their own bodies.” In a previous paper, Silver-Isenstadt found that if asked to give permission for medical students to do a pelvic exam in the operating room, roughly half of patients would agree.

Since publication of the 2003 paper, which ran in the American Journal of Obstetrics and Gynecology many medical organizations have condemned the practice as clearly unethical.

The American College of Obstetricians and Gynecologists says that “if a pelvic examination that is planned for an anesthetized woman undergoing surgery offers her no personal benefit and is performed solely for teaching purposes, it should be performed only with her specific informed consent obtained while she has full decision-making capacity.” The Association of American Medical Colleges calls the practice “unethical and unacceptable.” The state of California now explicitly forbids it. (A UCLA spokesman said his school’s consent process meets state guidelines)

Some argue that there is simply no need to use unconscious women as teaching tools. Judy Norsigian,executive director of the Boston-based advocacy group, Our Bodies, Ourselves, noted that paid volunteers have allowed medical students to practice pelvic exams on them for years, coaching the students on how to do the exams gently and effectively.

At Harvard, the policy was changed six or seven years ago after a group of medical students objected to performing exams without express permission, said Dr. Daniel Federman who was then dean of medical education and is now senior dean for clinical teaching. Now, “a student directly involved in that patient’s care may do a pelvic exam under anesthesia if the patient’s doctor has asked her about it in advance, has introduced the student and obtained consent,” he said.

The Medical College of Wisconsin changed its policy last year to say that physicians must discuss with the patient prior to surgery the fact that a medical student may participate in a pelvic exam, and those exams must not be performed by multiple students.

At Tufts University School of Medicine, “all women coming in for obstetrical-gynecological surgery are told that if they need a pelvic exam before surgery, a medical student may be involved in that exam,” said Dr. Steven Ralston, director of the third year clinical clerkship program in obstetrics and gynecology. “But no student will be doing that unless he or she is involved in the surgery and the exam itself is necessary for the surgery. Absolutely, patients can say no.”

At the University of Massachusetts Medical School in Worcester, “every woman who is getting a pelvic exam and any man getting a genitourinary exam from a medical student has given consent for the student to do the exam,” said spokeswoman Alison Duffy.

Dr. Linda Heffner, the new chief of obstetrics and gynecology at Boston University School of Medicine, said in a prepared statement that the school does not have a written policy on this issue but is developing one. “Personally, ” she wrote, “I believe that patients should always be asked for their permission to be examined by a medical student. We need to help patients understand the importance of these examinations in the medical education process.”

Silver-Isenstadt said he became sensitized to the issue a decade ago while a student at the University of Pennsylvania School of Medicine. In the operating room one day, the surgeon did a pelvic exam on the patient — a totally appropriate and necessary pre-operative step — and then asked Silver-Isenstadt to do likewise.

“I asked, ‘Does she know I am going to do this?’ ” The surgeon said no. “I said, ‘I am really uncomfortable doing this,” — and he didn’t, though he took some grief for it.

Judi Bartnicki, 53, had been an artist all her life. Then MS, or multiple sclerosis, struck four years ago, doing its worst damage in her left hand, the one she needs for painting and drawing.

“I kept trying to paint and I would drop everything,” she said. Finally, her fiance David Richardson, figured out a way to tape her paintbrush to her left hand. Painting is still painful, the Georgetown resident said, “but I am so happy to be able to do it. I am doing my best work.”

MS is a nasty, chronic disease in which the immune system attacks the myelin sheath that insulates nerves. It rarely shortens lives, but it does seriously diminish the quality of life of 400,000 Americans, two-thirds of them women. Until recently, doctors had only a sketchy idea of what goes wrong in the brains and spinal cords of people with MS and few drugs to combat it.

But in the last several years, MS “has gone from a mysterious disease with no treatment to a disease we understand, have treatments for, and have a way forward to cure,” said Dr. Howard Weiner, head of the Partners MS Center at Brigham and Women’s Hospital.

For instance, researchers now think MS may be not one disease but four. They know that even in the early phase when symptoms come and go, the brain is being continuously damaged. They think hormone treatments may help, as may some new medications.

Many, if not most people who get MS have no family history of the disease, although having a parent or an identical twin with MS does raise the risk, said Dr. David Hafler, a professor of neurology at Harvard Medical School.

There appears to be no “MS virus” per se. But doctors believe that some invader, probably a virus, activates so-called TH1 immune cells, which pump out pro-inflammatory chemicals called cytokines. The TH1
cells then mistakenly attack bits of myelin that “look” like the invading virus. The result is severe, patchy inflammation throughout the brain and spinal cord, which cause temporary blindness, muscle weakness, tingling, trouble walking and double vision. TH1 cells also
get into the brain, destroying myelin in brain cells, which causes problems in thinking.

In MS, in other words, the immune system is out of whack, with the pro-inflammatory, TH1 side of the equation overactive, and the anti-inflammatory side — TH2 and TH3 cells — underactive.

In recent years, five injectable, prescription drugs have become available to restore this balance, relieve symptoms and slow the disease’s progression. Betaseron, Avonex and Rebif directly damp down TH1 cells. Copaxone calms “activated” T cells. Novantrone, reduces the activity of both T and B cells (which make antibodies). A sixth, Antegren, which is still awaiting federal approval, blocks activated TH1 cells from crossing into the brain.

Bartnicki started taking Avonex two months ago and finds it ” excellent.” “I don’t have bad, bad bouts like I used to,” she said. “I don’t have the terrible muscle spasms I used to have. I can paint for longer periods.”

The new understanding of MS is based on several studies, including one by Weiner, who recently published a book, “Curing MS : How Science Is Solving the Mysteries of Multiple Sclerosis. His team used MRIs to regularly scan the brains of 40 MS patients for a year. Even between acute attacks, he found, “the disease is actually progressing.”

Dr. Jack Burks, an MS specialist at the University of Nevada School of Medicine in Reno, said “for every attack I see in my office, there are probably 10 attacks that could be seen on an MRI…Now, the big push is to treat early, when patients feel really good.”

At the Mayo Clinic in Rochester, MN, Dr. Claudia Lucchinetti, a neurologist, has looked at samples of brain tissue taken from MS patients who were undergoing brain biopsies to exclude other diseases, and at tissue obtained at autopsy from MS patients. She found that the lesions — damaged spots in the myelin sheath — are different in different patients, suggesting MS has at least four major subtypes. In one, the damage comes from TH1 cells and macrophages, another type of immune cell. In another, the damage is done by antibodies made by B cells. A third type resembles a viral infection or stroke; the fourth type is characterized by damage in the cells that make myelin. If doctors can find a less invasive way to sort out the types, they might be able to tailor drugs better to each patient.
Hormones also play a role. It’s long been known that MS gets better during pregnancy. That’s because the fetus consists partly of foreign tissue (from the father), so a woman’s immune system must be quieted during pregnancy so that it does not attack the fetus.

In a pilot study, Dr. Rhonda Voskuhl, head of the MS Center at the David Geffen School of Medicine at UCLA, set out to mimic pregnancy by giving estriol, a type of estrogen, to women with MS. She saw a reduction in brain lesions on MRI scans and a favorable shift in the immune balance. When she took the women off the hormone, they got worse.

When she put them back on, they got better again, she said.
Other researchers have been trying, so far with mixed results, to create individualized vaccines to restore immune balance, said Dr. Henry McFarland, chief of the neuroimmunology branch at the National Institute of Neurological Diseases and Stroke, part of the National Institutes of Health.

For symptom relief, injections of Botox, made from the botulinum bacteria, may help relax stiff muscles, allowing some patients to move more easily, said Dr. Michael O’Dell, professor of clinical rehabilitation medicine at Weill Medical College of Cornell University in New York.

The growing understanding of MS clearly provides new hope. But in the meantime, it’s important not to “sit around waiting for a miracle,” said Dr. Lisa Iezzoni, 49, who has had MS for 27 years and zips around Beth Israel Deaconess Medical Center, where she is a researcher, in a scooter
.
The key, said Iezzoni, who is not taking any MS drugs now, is to “find a doctor who feels comfortable working with you on your terms.”

Years ago, Boston University psychiatrist Dr. Bessel van der Kolk tried a simple experiment to understand one of the most disturbing, and bizarre, of all psychiatric disorders: self-mutilation, or more simply, cutting.

He asked his cutters, mostly young women, to come see him when they felt the urge to scratch, slash or burn themselves. When they came, he asked them to put their hands in ice water. They were able to keep their arms buried in ice much longer than normal people, he found, because they didn’t feel the pain.

Then, when he gave them an injection of a drug that blocks endorphins, the body’s natural painkillers, they felt pain again “and with that, a sense of feeling alive,” van der Kolk says.

To the uninitiated, cutting may seem like a suicide attempt or a cry for attention, and in rare cases that’s true. In reality, both cutters and psychiatrists say, the urge to self-mutilate is a coping behavior triggered by an inner sense of numbness or deadness. Far from a wish to die, cutting is a terrible urge to feel something , even physical pain, rather than nothing at all. And far from flaunting their cuts to get attention, cutters usually hide them.

The numbness that these teenagers – and some older cutters – feel is usually triggered by overwhelming trauma, family conflict, sexual or physical abuse, emotional neglect and, perhaps, genetics. This deadness “is so terrifying, that to feel one’s physicality brings relief — that one is still present and has definable boundaries,” says Dr. Michael Strober, a professor of psychiatry and director of the eating disorders program at the UCLA Neuropsychiatric Institute.

No one knows how prevalent cutting is, nor why it seems to be on the rise, though in some schools, contagion – kids copying each other’s strange behavior – may be involved. Nor do researchers know why roughly 75 percent of cutters are female, though one theory is that girls turn their feelings against themselves while boys attack others.

But researchers do know far more than they did a few years ago about what triggers cutting and, more important, and how to help kids stop.

Cutting often overlaps with anorexia or bulimia. In fact, roughly half of girls who cut themselves with pins, knives and razors start out with eating disorders, says New York psychotherapist Steven Levenkron, author of “Cutting: Understanding and Overcoming Self-mutilation.”

Curiously, black and Latina girls may be less prone to cutting than white girls, says psychologist Wendy Lader who, with Karen Conterio, started the SAFE program (Safe Alternative – Self Abuse Finally Ends) at Linden Oaks, a psychiatric facility at Edward Hospital in Naperville, Ill. 18 years ago. Perhaps darker-skinned girls, she says, may have more realistic ideas about what a healthy body looks like and may feel freer to express anger.

Levenkron agrees. Most of his cutters are white, perfectionistic and, contrary to outward appearances, filled with self-loathing. “I never met a cutter who liked herself.”
One way to help cutters is to teach them how to talk about their emotional pain so that they don’t express it nonverbally. “I teach cutters a full vocabulary for feelings and mental pain,” says Levenkron. By the time they learn to talk “in the language I taught them,” he adds, “they are not cutting anymore.”

All of this, of course, takes time, money and commitment. Levenkron sees patients twice a week for several years, and insurance rarely pays full freight. But like their desperate offspring, desperate parents often hang in, writing the checks and learning, slowly, how to deal with a more emotionally expressive, but less self-abusive, daughter.

He recalls one terrified teenager who came to him straight from a locked psychiatric ward and stayed in therapy for four years. “When I started seeing you,” Levenkron recalls her saying, “I thought I couldn’t breathe between appointments. I would kill to see you.” Three years later, she told him, “You’ve helped me a lot. Is it okay if I stop coming?”

That kind of intense support is also part of the SAFE approach, says psychologist Lader.
In the first phases of treatment, giving up the crutch of cutting – the one behavior that brings relief – can be terrifying, adds Lader.

“This is a nihilitive fear, the fear that they won’t exist, that they will explode… If we ask them to give up this coping strategy, we have to be there for them.”

But, despite some web sites that seem to glorify cutting, Lader says the emphasis should be teaching that cutting “is not a healthy coping strategy.” In fact, SAFE makes cutters sign a “no harm” contract. That’s partly common sense, but partly good biology as well.

That’s because cutting may produce transient good feelings by triggering trigger a flood of endorphins, the endogenous opiates. In fact, many doctors now do just what van der Kolk did in his early experiments – give opiate- blocking drugs such as Naloxone or Naltrexone.

By blocking the good feelings that cutting stimulates, cutters often stop injuring themselves because cutting no longer has the desired effect, says Dr. Alan Langlieb, a psychiatrist at The Johns Hopkins School of Medicine.
Other drugs help, too, because most girls who cut are “some combination of depressed and anxious,” says Dr. David Herzog, a psychiatrist at Massachusetts General Hospital who heads the Harvard Eating Disorders Center.

Some cutters, like Lydia Gibson, 38, a Baltimore woman who has been cutting herself off and on for 25 years, must take a number of drugs simultaneously. Gibson, who says she ” had to hurt myself because I had to get the anger out somehow,” now takes Buspar for anxiety, Paxil for depression, Naltrexone to blunt the positive effects of cutting, as well as Depakote, a mood stabilizer, and Seroquel, a tranquilizer.

In fact, not only do drugs and psychotherapy often work, cutting, perhaps surprisingly, is actually less dangerous than anorexia. Longterm outcome studies suggest that the mortality rate for anorexia is about 10 percent , says Herzog. Longterm mortality data from women without anorexia who cut themselves is scant, but doctors say that, except for accidentally deep cuts, the risk of death from any given cutting episode is minimal.

Herzog of MGH puts it this way. “It may sound nuts, but most of these girls are not nuts.” They’re stressed, depressed and scared. But what they really feel Herzog says is that they look good on the outside, but inside, they feel empty.

Do men and women handle stress differently? Or, to put it more provocatively, do women have a built-in hormonal advantage when it comes to dealing with chronic stress?

That’s the (highly loaded) question at the heart of a fascinating body of research that’s got the Net humming, with enthusiastic emails flying from woman to woman.

The case for this feminist theory of stress management is circumstantial  – built largely on inferences from animal studies and, at some points, frank leaps of faith. Still, the hypothesis has intuitive appeal, at least to women, so it’s worth exploring.

For decades, scientists who study the body’s physiological response to stress have focused on the “fight or flight” model. This view says that when an animal perceives danger, a number of hormones kick into action (among them, cortisol, ACTH, CRH, vasopressin and others). These hormones rev up heart rate and blood pressure, get sugar to the muscles and generally speed things up, the better to fight predators or get out of harm’s way, fast.

And there is absolutely no question that both males and females have – and need – this system.

But this view of stress is both male-biased and incomplete, say a number of researchers, most notably Shelley E. Taylor, a professor of psychology at the University of California at Los Angeles.

Taylor’s theory, based on more than 200 studies by other people, mostly biologists and psychologists, is that women have a powerful system for fighting stress that’s based in part on a hormone called oxytocin.

Granted, there’s no clear evidence that women on average actually have more oxytocin in their bloodstreams than men. But they do have more of another hormone, estrogen, which does boost the effectiveness of whatever oxytocin is around.

Oxytocin, which some dub the “cuddling” or social attachment hormone, is best known as the hormone produced during childbirth and lactation and during orgasm, in both sexes. But it’s also secreted during other forms of pleasant touch, such as massage, and has been shown to stimulate bonding in animals, most notably prairie voles and sheep.

Even more intriguing, there’s evidence from the laboratory of Kerstin Uvnas-Moberg at the Karolinska Institute in Stockholm and elsewhere that oxytocin may act as a genuine “antistress” hormone.

For instance, the Karolinska group reported in 1998 that daily oxytocin injections, into both male and female rats, decreased blood pressure and the stress hormone, cortisol, and promoted weight gain and wound healing. The group has also shown that injections of oxytocin in rats enhanced sedation and relaxation and reduced fearfulness.

To Taylor and her colleagues, the thrust of this evidence suggests that women may be programmed by evolution to deal with stress, not just in the “male” way, by fighting aggressors or running away, but also by “tending and befriending,” that is, turning to each other for moral support and nurturing the young.

In other words, “there appears to be a counter-regulatory system that may operate more strongly in females than males, that leads to engagement of oxytocin and social contact,” which in turn may reduce stress, says Taylor, author of the book, “The Tending Instinct.”

“If we want to get a complete picture of how people manage stress, we need to look at both men and women,” she adds. “Historically, researchers have looked mostly at men.” Indeed, prior to 1995, women constituted only 17 percent of studies of the hormonal responses to stress. Things have gotten somewhat better since then, she says, but of nearly 15,000 people in 200 stress studies between 1985 and 2000, only 34 percent were female.

What, then, is really known about oxytocin? Quite a bit.

First, it’s a tiny molecule of only nine amino acids that is made in a part of the brain called the hypothalamus. It works closely with a related molecule, vasopressin, which is carried on the same chromosome as oxytocin and is so similar that the two chemicals fit into each other’s receptors in the brain, notes Sue Carter, a behavioral neuroendocrinologist at the University of Illinois in Chicago.

But while oxytocin, which acts in tandem with estrogen, often has calming effects, vasopressin, which acts in tandem with the male hormone, testosterone, can act as a stress response enhancer, among other things, raising blood pressure.

In most species, says Carter, male brains contain more vasopressin than female brains, especially in an area called the amygdala, a fear processing center. Vasopressin has also been linked to increased aggression and male territoriality.

Put another way, oxytocin “is associated with typically female behaviors, such as childbirth and nurturing the young, whereas vasopressin is associated with male behaviors, such as territorial aggression,” writes Dr. Norman Rosenthal, clinical professor of psychiatry at Georgetown University in his new book, “The Emotional Revolution.”

The most intriguing feature of oxytocin is that it seems to act as both a cause of bonding between animals and a result of it, suggesting that perhaps through bonding behavior, it can be a stress reducer.

For instance, a number of studies have shown that oxytocin promotes bonding in animals: between mothers and babies, and between adults. In prairie voles, Carter’s studies show, injections of oxytocin lead to increased bonding. And when stressed, Carter has found, both male and female voles choose to bond – with females.

 “Many things stimulate production of oxytocin, including breast stimulation, orgasm or even contact with a friendly companion,” says Carter. “All these are  known to release oxytocin, which may help damp down the body’s reactions to stressful experiences, in men as well as women.”

Several studies, for instance, have suggested that women who nurse their babies have lower anxiety compared to bottle-feeding mothers and that lactating rats exhibit less fear.

In one 1995 study, for instance, Carter and Dr. Margaret Altemus, a psychiatrist at Weill Medical College, Cornell University, asked about 20 new mothers to undergo an exercise stress test – running on a treadmill. About half the women were nursing and half were bottle-feeding. The women who were bottle-feeding showed steeper increases in stress hormones than the nursing mothers. Other studies, notes Altemus, have suggested that panic disorder is relieved during pregnancy and lactation.

In other words,  “there may be something going on in a woman’s nervous system that may protect her against stress, at least transiently,” says Carter. And because any kind of positive social experience has the potential to trigger release of oxytocin in both men and women, she adds, men as well as women can  benefit from positive emotional contact with other people.

Beyond oxytocin, there are other chemical clues to differences in the ways in which women and men may handle stress.

At Ohio State University, Janice Kiecolt-Glaser, professor of psychiatry at Ohio State University  and her husband, Ronald Glaser, an immunologist, have studied hormonal and immunological responses to stress and found some striking gender differences.

In one experiment, the Ohio team asked 90 young, happy, newly-wed couples to spend 24 hours, including a night’s sleep, in the hospital lab. “They were in absolutely pristine mental and physical health,” says Kiecolt-Glaser. The researchers placed a catheter in each subject’s arm so that blood could be drawn every hour to test for hormone levels and various aspects of immune function.

Early in the stay, each couple was asked to spend 30 minutes discussing an area of disagreement. This conflict was recorded on videotapes that were later scored by trained observers, both male and female, for evidence of negative behavior such as hostility, sarcasm, put downs, etc.

The results were stunning:  Marital strife was much tougher on women than men. The women showed a faster and more enduring response to hostility, says Kiecolt-Glaser, noting that women’s stress hormones (particularly epinephrine, norepinephrine and ACTH) rose more sharply and stayed up longer than men’s. Women also showed a lowering of certain aspects of immune function.

In a follow-up study, the Ohio team found that women whose stress hormones had risen the highest during the earlier phase of the study were the most likely to get divorced.

 “Women show greater sensitivity to negative marital interactions than men,” says Kiecolt-Glaser. And this can’t be chalked up to over-reacting, or to some female hypersensitivity to stress in general because in other situations designed to induce stress in the lab, such as being asked to perform mental arithmetic, men show larger increases in stress than women.  

In other words, in a marriage, Kiecolt-Glaser says, women are actually more accurate judges of what’s going on emotionally. Indeed, when the outside reviewers rated the videotapes of the couples’ interactions, their assessment of hostility and negative behavior correlated with the women’s. Women simply experience a bigger stress response to men’s sarcasm and hostility than men do to women’s, she says.

The bottom line? If you feel stress in an interpersonal relationship, you’re probably right that the stressors are truly there. If you do feel stressed out, call a friend. If you don’t have a friend, make one, or more. And if all else fails, snuggle up with a prairie vole.

Judy Foreman is  Lecturer on Medicine at Harvard Medical School and an affiliated  scholar  at the Women’s Studies Research Center  at Brandeis University.. Her column appears every other week. Past columns are available on www.myhealthsense.com.

SIDEBAR

Do Women Have More Stress than Men?

At least in terms of behavior and feelings – as opposed to physiological measures of oxytocin and other hormones – there are clear differences in the ways men and women experience stress.

For one thing, women seem to have more of it, even though they outlive men, says Ronald Kessler, a sociologist and health care policy professor at Harvard Medical School.  

In one 1998 study done with colleagues at the University of Arizona, Kessler had men and women keep daily mood diaries for a week. “There were large sex differences,” he says. Men and women were equally good at getting rid of minor “spells of depression,” says Kessler, but “women have more bad stuff going on.”

“What really gets to people is the little crap,” says Kessler, “the daily hassles,” which women may have more of because they are often the ones who take responsibility for coordinating family and work schedules. “It’s the coordination that kills you, and when something gives, it’s the woman who fills in the gap.”

And while women often do relieve their own stress by turning to each other, the fact that women also often have more people in their lives to care -and worry – about may actually increase stress, says Kessler. “Men and women have the same emotional reactions” when something bad happens to people close to them, he says, but women often have more people in those networks, a phenomenon he calls the “cost of caring.”

Psychologist Alice Domar at the Mind/Body Medical  Institute at Beth Israel Deaconess Medical Center in Boston agrees that data clearly show that women are more stressed day to day than men, and it’s not, as was once thought, because they ruminate more.

“Men worry about three things: their immediate family, their job and money,” she says. “Women worry on a daily basis about up to 12 things – their immediate family, their job, money, their extended family, their friends, their kids’ friends, the way the house looks, their weight, the dog, etc.”

That same gender breakdown seems to occur in one of life’s most stressful situations, being diagnosed with cancer, says Barrie Cassileth, a psychologist and medical sociologist who runs the integrative medicine service at Memorial Sloan-Kettering Cancer Center in New York.

When first diagnosed with cancer, “men and women do respond very differently,” she says. “Women always talk…and women gain as much from giving as from receiving support from others. Women have such a nurturing instinct that even when facing harsh realities, they do reach out to others.”  

Let those biostatisticians slug it out down at the National Cancer Institute – I’m getting my yearly mammograms anyway.  Then again, the way things are going, should I?

Last week, the latest panel of experts took a crack at sorting out the decades-old mess about mammograms: Do these X-rays really save lives? Or do they just make us feel like we’re doing something, no matter how mystical,  to reduce the risk of dying from breast cancer?

The panel, called the P.D.Q. screening and prevention editorial board, is an independent group of specialists convened by the cancer institute. Its job is to sort out complicated data – the mammogram debate surely fits the bill – and put it up on NCI’s web site (www.cancer.gov).

Its specific mission was to review controversial assertions published last fall as a letter in the British journal Lancet by Danish researchers, Ole Olson and Peter C. Goetzsche, who looked at data from the seven key mammography studies.

The Danes concluded, and last week the P.D.Q. panel concurred, that there is insufficient evidence to prove that mammograms prevent deaths from breast cancer, according to Donald A. Berry, a panel member and chair of the biostatistics department at M.D. Anderson Cancer Center in Houston.

Among the flaws? Assessment of cause of death may not have been done in a “blinded” way in some research, that is, without knowing whether a woman was in the screening group or not. Some researchers did not exclude women with pre-existing cancer at equal rates in mammogram and control groups and other “egregious “mistakes, says Berry.

According to the Danish researchers, two of the seven studies were so flawed as to be completely useless  – the New York and Edinburgh studies, both of which found a benefit to mammography. Three other studies  – the  Two-County Study in Sweden, the Stockholm study and the Goteborg study,  all of which found a benefit to mammography – were deemed  of poor quality.

So far, that’s five studies, all showing a benefit, all deemed unreliable.

The two studies that the Danes thought were done properly were the Malmo study and the Canadian study. The Malmo study found a slight benefit to mammography. One part of the Canadian study found no benefit at all, and the part that focused on younger women found more deaths in the screening group, though this could have been due to chance.

Needless to say, the P.D.Q. panel’s interpretation of the Danes’ interpretation of the seven key studies is not universally accepted.

Dr. Daniel B. Kopans, director of the breast imaging division at Massachusetts General Hospital and a staunch advocate of mammography calls the Danish analysis and P.D.Q.’s acceptance of it ” a travesty…It’s a mistake to use the nonscience from the Danish study to dissuade women from potentially life-saving screening.”

The five studies the Danes rejected were actually “among the best done,” says Kopans, and the Canadian study, which the Danes applauded, was poorly done. “These guys don’t know what they’re talking about.”

This morass is both big news and same old, same old.

It’s big news because invasive breast cancer is estimated to have hit 192,000 women last year to have killed 40,200. It’s also important because women have fought hard to get mammograms covered by insurance and because many women believe (or have been led to believe) that if they just get mammograms, they’ll either be magically protected against breast cancer, or at least will have a better shot at surviving it if we do. (The first is obviously untrue, the second is what’s up for grabs.)

Among the continuing believers in mammography are the American Cancer Society and, with more ambivalence, the National Cancer Institute.

Dr. Robert C. Young, president of the American Cancer Society, stresses that the death rate from breast cancer has been declining in recent years. (It’s not clear, however, whether this is due to wider use of mammography or more aggressive treatments.) 

“With widespread use of mammography,” he argues, the presence of cancer in lymph nodes at the time of initial surgery “has gone from 60 percent in the 1980s to less than 30 percent in the 1990s. And the size of breast cancer lesions on average has gone from 3 centimeters in the 1980s to 2 centimeters now.” Furthermore,  he says, the real benefit of mammography may not be seen for another 15 to 20 years.

Dr. Peter Greenwald, director of cancer prevention at the National Cancer Institute, acknowledges that the institute’s recommendations “have not been totally consistent.” But he is sticking by current NCI recommendations: a mammogram every one to two years for women, starting in their 40s,  and starting earlier, for women at high risk whose doctors recommend it.

But this whole mess smacks of same old, same old, too. The seven studies now at issue are the same seven studies that researchers have been fighting about for years, particularly with regard to younger women.

At a consensus conference called by NCI in January, 1997, that panel of experts concluded that women in their 40s should make up their own minds about mammography because the survival benefit to younger women is so small.

That turned out to be a politically incorrect decision. The American Cancer Society disagreed vehemently. In February, the National Cancer Advisory Board, which oversees the NCI, got into the act. Then Congress, which oversees the NCI’s budget, weighed in, making it clear that if the NCI  did not recommend mammograms for younger women, its budget could be cut, recalls Berry.

Surprise, surprise, the NCI then reversed itself, recommending mammograms for younger women.

All of this might be considered academic squabbling were it not for one thing.  Many women dutifully have mammograms in part because they take  a “Why not? It can’t hurt” attitude.

But mammography can hurt (and not just the compression during the X-ray). One outcome of mammography can be more testing, some of it painful, most of it, anxiety provoking. The good news is that most suspicious mammograms turn out to be false alarms, but to be sure of this, women put themselves through biopsies and other tests.

Mammograms aren’t exactly foolproof in the other direction, either. In younger women, mammograms miss 25 percent of cancers; in women 50 and over, mammograms miss 15 percent of cancers.  That’s bad, too, obviously, because women may delay treatment.  

Women’s health advocates have long held a more nuanced view of mammography than lay women, arguing that while mammograms may detect breast cancer earlier than clinical (manual) exams, this is not really early detection, merely earlier.

The latest mess “confirms what many of us have suspected,” says Fran Visco, president of the Washington,D.C.-based National Breast Cancer Coalition. “The evidence behind screening mammography is poor, certainly for women under 50. For too long, we feel, mammography has taken up too much space in the world of breast cancer…we need to look more at how to prevent the disease, how to detect it early, at access to quality care for all women….those are the big issues.”

 “Mammography is not the answer to the breast cancer epidemic,” the coalition added in a prepared statement last week. ” In any age group, mortality reduction associated with mammography is less than 50 percent….Although it may be difficult to accept, it is vital that women know the truth about breast cancer screening and the false sense of security it provides.”

Cindy Pearson, executive director of the Washington, D.C.-based National Women’s Health Network, agrees. “It’s better that we know this and are confused than we are kept in the dark like in the old days.

 So, ladies, where does this leave us? Among other things, in the same boat as men, who are often urged to have PSA testing for prostate cancer without understanding that this test may lead to more and more invasive interventions, some of which may be damaging or of little survival value.

As for mammograms, the P.D.Q. panel is writing up its conclusions now and expects to finalize them in March. At that point, the NCI may or may not decide to alter its current recommendations.

None of this uncertainty is going to go away. It would probably help if everybody (the media included), obsessed a bit less about breast cancer, terrifying though it can be, and a bit more about statistically greater threats, like heart disease, for which there is ample evidence that improvements in exercise and diet can reduce risk.

Ultimately, the answer is not an endless series of expert panels endlessly re-hashing old data on an obviously imperfect test. The real answer is genuine prevention and cures that work.

Meanwhile, I’m keeping that mammogram appointment.