Watching Women's Health

Vitamin D may reduce risk of urinary incontinence

The medical community's growing realization that many Americans are low in Vitamin D has led to an explosion of interest in this vitamin's effects on bones, muscle, pregnancy outcomes, cancer risks and other medical concerns. 

Vitamin D is a fat-soluble vitamin that aids the absorption of calcium from the GI system. In addition to helping mineralize bone, calcium is important in neuromuscular and immune system function.

Vitamin D is produced in skin that is exposed to sunlight. It naturally occurs in only a few foods, fatty fish and cod liver oil (a hardy few consider cod liver oil to be a food). According to the most recent National Health and Nutrition Examination Survey (NHANES), only 17% of US women get enough vitamin D from food alone.

Most health-conscious women protect their skin from the sun and obtain vitamin D from supplements and vitamin D fortified foods. Recently, I have been including serum vitamin D levels in blood work at annual exams, and have found many of my patients have low vitamin D levels, despite our ongoing discussions about adequate calcium and vitamin D intake.

Other risk factors for vitamin D deficiency besides low sun exposure include being over 50, having darker skin pigmentation and being overweight. Breastfed infants have also been found to be at risk, as adequate vitamin D can't be obtained from human milk alone.

A new paper in the gyn literature looked at how vitamin D levels relate to women's risks for pelvic floor disorders — urinary and rectal incontinence and pelvic organ prolapse. In the NHANES data, results from 1,881 women 20 and older included information on pelvic floor disorders and vitamin D.

The mean age of the surveyed women was 47.9 and more than 80% had suboptimal vitamin D levels. 23% reported symptoms of a pelvic floor disorder. Higher vitamin D levels were associated with a lower rate of pelvic floor disorders. The strongest inverse association was in women over 50 with urinary incontinence.  The authors conclude

Given the increase in the number of patients with pelvic floor disorders, further evaluation of the role of vitamin D is warranted, particularly future research to assess the relationship between vitamin D levels and pelvic muscle strength in women of all ages and racial/ethnic groups. Our findings suggest that treatment of vitamin D insufficiency and deficiency in both premenopausal and postmenopausal women could improve pelvic muscle strength, with a possible reduction in the prevalence of pelvic floor disorders including urinary incontinence.

It is encouraging to think that the hugely annoying problem of urinary incontinence could be improved by something as simple as supplementing vitamin D. If you have not had your vitamin D level checked, it is worth doing at your next annual exam. If you have problems with urinary incontinence, it may be worthwhile having it checked sooner.

Screening for ovarian cancer — focus on genetic risks

Most women have just over a 1% lifetime risk of developing cancer of the ovary. However, in some families, there are multiple cases of ovarian and/or breast cancer, and risks are much greater. What do we know about inherited susceptibility to ovarian cancer?

The biggest breakthrough has been the discovery of harmful mutations in the BRCA 1 and BRCA 2 genes. BRCA 1 and 2 are tumor suppressor genes located on chromosome 17 that prevent uncontrolled cell growth. With certain mutations, BRCA genes are less effective in regulating cell growth, and ovarian, breast and other cancers are more likely to occur.

A BRCA mutation can be detected through a blood test. There are well-accepted recommendations about which family cancer histories should trigger genetic counseling and possible BRCA testing. Genetic counseling is helpful, so an accurate family medical tree is constructed and appropriate candidates for BRCA testing are identified. Before getting the blood test, it is important that women fully understand the implications of both positive and negative BRCA results, and also of declining to do the test.

When possible, it makes sense first to test a family member who has been diagnosed with breast or ovarian cancer. If a BRCA mutation is found, other family members can undergo limited testing for that specific mutation.

Both females and males can inherit BRCA mutations. Men with BRCA mutations have an increased risk of breast cancer, as well as pancreatic, early-onset prostate, and possibly, testicular cancer.

Women with BRCA mutations have an increased lifetime risk of ovarian cancer ranging from 20-50%. Risks for developing breast cancer are even higher, in the 60-80% range.

If a harmful BRCA mutation is found, most physicians recommend prophylactic removal of the ovaries after childbearing is complete, in most cases by age 40. (Along with removal of the ovaries, additional steps would be taken to reduce breast cancer risk.)

Prior to completion of childbearing, BRCA positive women should be aware of ovarian cancer symptoms and have regular vaginal ultrasounds and CA-125 testing — though imperfect, these tests are the best we have for screening high risk women. We also recommend younger women use oral contraceptives when feasible. Oral contraceptives can reduce ovarian cancer risk by 50%, though the exact benefit in BRCA positive women is not known.

What if BRCA testing is negative? That means cases of ovarian and/or breast cancer in a particular family are not due to a BRCA mutation, but may be associated with other mutations that have not yet been identified. With high risk family histories, the same risk reducing strategy is appropriate.

Improving ovarian cancer screening in the future, for both high and average risk women, will almost certainly involve more accurate serum markers and better ultrasound discrimination between normal and abnormal ovarian structure.

Screening for ovarian cancer —still a work in progress

With good reason, ovarian cancer is the most feared gynecologic malignancy. Hardly a clinic day goes by without one of my patients asking if we've figured out how to screen for cancer of the ovary.

Most often discovered after it has spread from the ovary, ovarian cancer is the leading cause of death from gyn cancers and the fifth-leading cause of cancer deaths in women. Yet, an effective screening test for ovarian cancer, comparable to a pap smear or a mammogram, remains an elusive goal.

Why is it so hard to screen for cancer of the ovary?

The foremost reason (fortunately) is that ovarian cancer is not among the most common cancers — it affects 1.4% of US women. It is easier to develop effective screening tests for more common conditions, especially if we are trying to screen everyone potentially at risk.

Secondly, the ovaries are relatively small organs that are deep in the pelvis. Only with surgery can the ovaries be visualized directly. And, as part of their normal function prior to menopause, they change size and create cysts that come and go. A normal ovary can at times feel concerning on pelvic exam and look concerning on ultrasound, especially in the second half of the menstrual cycle. Even postmenopausal women can have cysts on their ovaries that are completely innocent.

During my residency in the 1980's, there was great hope that regular pelvic ultrasounds and blood tests for a serum marker, CA-125, would prove to be effective screening tests. Unfortunately, these tests did not pan out. 

Compared to control groups, women regularly screened with ultrasounds and CA-125 blood tests had more surgery for benign conditions that didn't actually threaten their health. And they did not have a reduced risk of dying from ovarian cancer. The ovarian cancers that were found in the screened group were often in advanced stages. The goal of finding ovarian cancer early was not met.

There have been ongoing efforts to identify women with ovarian cancer based on family history, genetic testing and a constellation of symptoms involving the pelvic organs. There have also been attempts to create more accurate ultrasound criteria for early diagnosis.

In future posts, I will discuss recent studies involving these approaches. But be forewarned — diagnosing ovarian cancer early enough to save lives remains a formidable challenge.