OFFICE OF RESEARCH ON WOMEN'S HEALTH

P-R-O-C-E-E-D-I-N-G-S

COMMENTATOR: From the National Institutes of Health in Bethesda, Maryland, America's premier medical research agency, this is Pinn Point on Women's Health with Dr. Vivian Pinn, Director of the Office of Research on Women's Health. Now here's Dr. Pinn.

DR. PINN: Welcome to another episode of Pinn Point on Women's Health. Each month on this broadcast, we're taking a look at latest developments in the areas of women's health and medical research that affects our lives.

Today, I'm happy to welcome Dr. Janine Smith who will talk to us about vision and eye health in women. But first some hot flashes from the world of women's health research coming up in just 60 seconds when we continue with Pinn Point on Women's Health.

(Commercial begins.)

ANNOUNCER: Aristotle had this problem. So did Thomas Jefferson and they went on to do great things. If you stutter, you could do something great, too, by participating in a National Institutes of Health stuttering study. Participants will be compensated. Travel assistance is available and all study-related tests are provided at no costs. Call 866-999-5553 or visit clinicaltrials.gov. Do something great. The NIH is a non-profit government agency at the Department of Health and Human Services.

(Commercial ends.)

DR. PINN: Welcome back to Pinn Point on Women's Health. As promised, I want to take a look at some of the hot flashes in the news recently regarding women's health research and women's health.

Well, let me first start with something that's very important and that has to do with heart disease in women and heart attacks in women. I think we are all well aware now that heart disease is the leading cause of death for women in the United States, but a recent report from the American Heart Association indicated that many women 55 years and younger who have heart attacks don't recognize the warning signs.

Now maybe part of this is related to the fact that probably many of us physicians don't recognize all the warning signs in women because they may be different.

Women younger than 55 constitute a very small percentage, however, of those who are in the hospital with heart disease/heart attacks, only about five percent. But part of the issue is for women as well as their physicians to recognize what are the symptoms of having a heart attack so that women can be aware and make sure their physicians or those who see them in the hospitals are aware and a heart attack is not missed.

This particular report indicated that women still appear to have typical pain often. Maybe about 90 percent of women in the study had typical attack symptoms of chest pain. However, there were other symptoms that women experienced having heart attacks especially younger women under age 55 like pain in the jaw or shoulder, sweating, nausea, shortness of breath, indigestion or heart burn which we typically hear is how women present or just feeling weak or feeling tired.

So with this, if you have any of these symptoms or have any suspicions that you may be having a heart attack, it is better to be safe, go to the emergency room, be checked out and if you then are not having a heart attack, at least you have circumvented the possibility of having worst effects because your heart attack was not picked up early.

But moving on to another issue, we've talked about the HPV vaccine and we've talked about ways to prevent cervical cancer. But, of course, we all know that we cannot eliminate the importance of women getting pap smears. There has been a recent report from the Agency for Health Care Research and Quality that indicates that about one-fourth of uninsured U.S. women between the ages of 18 and 64 reported not having had a pap smear within the last three years. Now, women, we must make sure that we're looking out for our own health and we know that pap smears are important in a noninvasive way to have an early detection of cervical cancer.

So don’t forget to get your pap smears. Make sure that you see your physicians about getting your pap smears.

But moving onto another area, and while I think this is a hot flash, it's something that's a fairly common flash related to women and that is gallstone disease. We know that gallstones are one of the most common problems for women and women between the ages of 20 and 60 years are three times more likely to develop gallstones than men.

The American College of Gastroenterology just recently released information to remind women and men of symptoms related to gallstone disease so that you can be aware and what you might do to avoid having a gallbladder attack. Now risk factors for the development of gallstones include being female, having multiple pregnancies, being over the age of 60, being obese or having rapid weight loss or having diabetes. And some of the symptoms of gallstone disease include pain in the upper stomach, pain in the shoulder or under the right shoulder blade, having nausea or vomiting, being jaundiced or having fever or chills. Now jaundice, I think we all know, is when you see yellow discoloration of the eyes and of the skin and immediately when you see that, you know something is going on either with the liver or with the gallbladder.

Here are some types to help lower the risk of gallstones. Have a healthy body weight. Avoid crash diets or very low intake of calories. Don't go down to less than 800 calories a day or you may find yourself having one of those gallbladder attacks. Exercise regularly and choose a low-fat, high-fiber diet that emphasizes fresh fruits, vegetables and whole grains and haven't we heard that before. Almost all of these are just things that we generally know we should do to protect our health.

If you want more information on gallstone disease, visit the American College of Gastroenterology Web site at www.acg.gi.org. We'll have more updates in the next podcast and coming up next, I'll visit with Dr. Janine Smith for a discussion about women and their eyes and their vision. We'll be right back with Pinn Point on Women's Health.

(Commercial begins.)

ANNOUNCER: Uterine fibroids, the most common noncancerous tumors of the uterus. If you're suffering uterine fibroids and are between the ages of 25 and 50, the NIH invites you to take part in a clinical study. All study tests and related treatments are provided at no cost and compensation is provided. For more info, call 866-999-5053 or log on to clinicaltrials.gov. The National Institutes of Health is a nonprofit government agency, part of the U.S. Department of Health and Human Services.

(Commercial ends.)

DR. PINN: Welcome back to Pinn Point on Women's Health. Our guest today is Dr. Janine Smith who is Deputy Clinical Director of the National Eye Institute here at the National Institutes of Health. She is on the clinical faculty at the Wilmer Eye Institute at Johns Hopkins and is also on the board of directors of the Sjögren's Syndrome Foundation, Inc. and in a moment you'll understand why that's important as we talk about vision and vision impairment in women.

Dr. Smith, thank you for joining us today and why don't we start with you telling us a little bit about why women should be focusing on preserving their vision and giving us some beginning statements relating to women and their eyes.

DR. SMITH: Thank you for inviting me. It's very important for women to be concerned about their eye health because many diseases can be prevented. There are some eye diseases that are inherently more prevalent in women and many people don't know that. In addition, women tend to live longer than men and so since many eye diseases are age-related, there are larger numbers of older women with these age-related eye diseases. And thirdly, there are aspects about women and care-seeking behavior or access to care that may result in a higher rate of certain eye disease or access to certain treatments in women as compared to men.

DR. PINN: Let's just start with getting some basic facts. As a woman who is young or approaching menopause, what are some of the eye conditions that I should be more concerned about?

DR. SMITH: The most common causes of visual impairment are cataract, age-related macular degeneration and glaucoma. While those are more common in older women, they can occur in younger women, even at the age of 20 to 40. It's very important for women to have their eyes examined regularly to pick up early signs of these serious eye diseases.

The second aspect is that many diseases of the rest of the body can manifest in the eye. For example, diabetes can result in abnormal blood vessels in the retina which can bleed into the eye, a condition called diabetic retinopathy. In fact, that may be the first sign of diabetes. So if a woman presents to an eye care provider and is picked up with early signs of diabetic retinopathy, she can then be seen by her primary care provider and have appropriate testing to evaluate her blood sugar levels. Early treatment of diabetes can result in less severe organ damage to the eye, the kidney, the brain, the heart and the rest of the body.

DR. PINN: When you say women should regular eye exams, how often are you talking about?

DR. SMITH: Women under the age of 40 can have eye exams every two to three years if they have no underlying risk factors and are not in a high-risk group. African Americans, Native Americans and others have higher risks for glaucoma and diabetic retinopathy and should be seen more frequently.

In addition, women need to know their family, medical and eye history. If you have a history of glaucoma in a first degree relative, for example, you have a seven times increased risk of having glaucoma yourself and glaucoma is a painless condition. In glaucoma, the peripheral vision is affected first and often people will not recognize this until the visual loss progresses to the center of the visual field. At that point, the vision cannot be regained. It's, therefore, very important for women and everyone to have an eye pressure check as part of their eye exam.

DR. PINN: Why don't you explain a little bit about what glaucoma really means? So many women are afraid to go get checked and they're concerned that they might have glaucoma or they might have a cataract. So maybe this would be a good time to just explain what those are.

DR. SMITH: A cataract is a very common condition and it is an aging condition. It is not necessarily a disease. The lens inside of the eye focuses light onto the retina and makes a clear image for us. As we get older, proteins change their structure in the eye and other chemical reactions occur in the lens that result in it becoming yellowed or opaque. That is a cataract. It's not a growth. It's not a tumor. It's not something that is uncommon as we get older. It's an expected aging change.

Cataracts can be removed surgically quite easily. While all surgery has risk, cataract surgery is one of the safest surgeries that can be performed and one of the most common and can result in significant improvement in quality of life when done appropriately and with appropriate informed consent.

And contrast to cataract, glaucoma is a disease. It is not an expected aging change. It is more common in African Americans and is, in fact, the leading cause of blindness in African Americans.

Glaucoma is a condition in which the optic nerve is damaged. The nerve in the back of the eye that sends the message that vision is going from the retina to the brain is damaged due to poor circulation, through abnormal blood vessels, going to the optic nerve or through elevated eye pressure damaging the optic nerve.

We're learning more and more through our research about critical aspects of the pathogenesis of glaucoma so that we can control that. However, many studies that have already been performed have demonstrated that early reduction in eye pressure with eye drops can result in decreased risk of progression to vision loss in glaucoma. In fact, you can prevent the vision loss aspect of glaucoma by lowering the eye pressure if you catch it early in the disease.

DR. PINN: So the message comes back from research and from just common clinical knowledge that it is important to have those regular eye exams across the life span of women to protect our vision.

Let me ask you about dry eye. We hear about dry eye. I know that I hear about that from women who are approaching menopause. I hear about it from younger women. We hear about it from more mature women. Tell us. What should we know about dry eye? What does it mean and what may it be associated it or just what should we know about dry eye and what is research saying about it?

DR. SMITH: Great question. Dry eye is a very common condition and somewhat of a misnomer in that there are two major types of dry eye. In the first type of dry eye, the eye does not make enough volume of tears and the surface of the eye dries out. In the second type, the quality of the tears is disturbed by disease of the surface of the eye. The tears evaporate from the surface of the eye and secondarily, dry out the surface.

In the second case, the person may actually be tearing. So it's somewhat confusing. But dry eye is an extremely common condition and can be seen in younger women as well as older women. Age is a primarily risk factor. Hormonal changes that occur around the time of menopause and in other conditions like premature ovarian insufficiency or other conditions in which estrogen levels are changing in relationship specifically to androgen levels, there can be ocular surface dryness and symptoms of irritation.

The symptoms of dry eye are a sandy or gritty sensation, feeling like something is in the eye, increase light sensitivity or just overall irritation and burning and stinging. It's important to note that there are some diseases in which dry eye is a common feature and for which women are especially at higher risk.

Sjögren's Syndrome is an example I would like to share with you. The ratio of women to men affected by this condition is nine to one and dry eye is one of the features of this disorder.

DR. PINN: Tell us what Sjögren's Syndrome is. We now know it can affect the eye and we may have what's referred to as dry eye. But what is Sjögren's Syndrome?

DR. SMITH: Sjögren's Syndrome is one of the autoimmune diseases in which the body's immune system directs an immune response against a part of the self, an abnormal immune response that it should reserve for microorganisms or infections or other processes. So the white blood cells of the immune system attack certain parts of the body including the lacrimal gland which produces tears and the salivary glands which produce saliva.

In addition, there are autoantibodies produced by the white blood cells that affect the rest of the body. There are other conditions that can go along with this dry eye and dry mouth including arthritis, breathing problems, kidney problems, etc.

DR. PINN: What have we learned about Sjögren's in terms of treatment, prognosis for women who may have Sjögren's or may be diagnosed with Sjögren's if they go for a check-up because of their dry eye and they're told that they might have this diagnosis? What should women know about this?

DR. SMITH: Before five years ago, there were really no specific treatments, FDA -approved treatments, for dry eye. That's incredible considering how common this condition is, dry eye. But because of basic science research, there is expanded understanding of the pathogenesis of Sjögren's Syndrome and dry eye in general at the tissue level.

The pathogenesis of dry eye has been found to consist of inflammation on the surface of the eye. Laboratory research was very important in us gaining this understanding that inflammatory process is mediated through a specific type of cells.

As a result of this recognition, there has been a development of a topical medication called Cyclosporin which is an immunomodulatory drug and decreases the white blood cells activity and decreases inflammation of the surface of the eye.

Prior to this understanding, medications, or shall I say, palliative measures such as lubricating the eye were only focused upon wetting the eye. With this understanding from basic science research and clinical trials, we now have a treatment that is specifically focused on the pathogenesis of the disease and this has helped Sjögren's patients and other dry eye patients significantly.

DR. PINN: And that's exciting because I know at the time that this office was established, we heard from a lot of women with Sjögren's who had dry eye for which we did not have answers and so called "wetting the eye" was about all there was. So this shows that research can help us solve some of the questions that women and their physicians have about their health and make a difference. So that's exciting.

But let me roll to another area and that's one that you've mentioned before, one that I know so many women as they mature or reach their elderly years begin to be concerned about loss of vision and that is related to macular degeneration, something else we think about as being more common in women. What can you tell us about macular degeneration and what have we learned about macular degeneration over the past few years?

DR. SMITH: Macular degeneration is an age-related condition. You may hear it referred to as AMD. It is leading cause of blindness in white Americans and is characterized by development of deposits, yellowish deposits, called drusen in the back of the eye. They kind of look like yellow polka dots. They are focused in the center part of retina, the part that subserves your best seeing vision. That's the macula.

As a result of the accumulation of these yellow products, there's an increased risk for hemorrhage into the eye, into that area, and for damage to the overlying retina. There are two major forms of AMD, the wet form in which the hemorrhage occurs and the dry form. Both of them can lead to loss of central vision.

Because this was such a common condition and an important cause of vision loss, there have been many studies including the Age-Related Eye Disease Study funded by the National Eye Institute and other NIH partners that looked at using zinc and antioxidants to reduce the risk of AMD. In fact, this study found that certain formulation of zinc and antioxidants along with other vitamins was associated with a decreased risk of progression from moderate AMD to severe AMD. Further, there have been additional studies in the last few years that have introduced anti-bleeding agents, so-called anti-VEG-F medications which can be actually injected into the eye for the bleeding type, for the hemorrhagic type. Those medications can significantly improve vision. In both of these areas, these are important advances for women to know so that they don't have to be fearful that if an early feature of AMD is found there is nothing that can be done about it.

DR. PINN: I think that needs to be emphasized again because for so many years as women were getting older and were told they were developing macular degeneration. They were also told there was nothing that could be done. So make that last statement again. Make it clear so that women will know that there may be hope for them in terms of not losing their vision if they have this diagnosis.

DR. SMITH: It's very important for all women to get examined for age-related macular degeneration. The early features of AMD can be recognized and there are now strategies including specific formulations of zinc and antioxidants that can reduce the risk of progression to the severe form and there are several treatments now available for severe AMD. The diagnosis does not necessarily lead to loss of vision.

DR. PINN: Thank you and I think that's worth emphasizing and, again, it's always nice when we find from research that we can offer hope of prevention of progression of diseases or conditions that just a few years ago we had no hope of doing.

Now I understand from some of your publications, Dr. Smith, that vision impairment and loss of visions occur more often in women because women tend to live longer and we see this as a matter of fact in women around the world. Would you like to comment on vision issues as they relate to women around the globe?

DR. SMITH: That's a very interesting topic. Women around the world are at higher risk for vision impairment and blindness than men and, as you mentioned, some of that is due to women living longer. However, that relationship holds true in industrialized nations as well. Around the world in other continents, for example, Africa, there are other reasons why women may be more affected by a specific disease.

Let's use trachoma as an example. Trachoma is an infectious cause of blindness that is caused by a microorganism called chlamydia trachomatis and can result in scarring of the eyelid, scarring of the cornea, the front part of the eye, and loss of vision.

More women are affected than men because women are often in closed environments in which trachoma is transmitted. That is their enclosed environments where they are carrying for children and cooking. A recently published study, Surgery for Trachiasis Antibiotics to Prevent Recurrence, the Star Study, looked at a single dose of an antibiotic called azithromycin given after the surgical correction of a scarring of the eyelid. This single dose of medication that is commonly available in the U.S. and other locations reduced by one-third the recurrence of the vision-threatening eyelid condition which is trachiasis, inward turning of the eyelashes resulting in scarring of the cornea.

DR. PINN: You are involved in research yourself, Dr. Smith, and you're well aware of research that's being conducted at the NIH and in other parts of the world related to women and eye diseases. What do you think are some of the most exciting developments that we've not talked about so far?

DR. SMITH: There are many studies as you mentioned looking at all aspects of women and eye disease. Expanded understanding and techniques available to detect biologic markers in both the blood and in tissues will really help us to understand what's going on in a specific organ.

For example, we have had a limited ability to study samples from the eye because they are very small. With expanded techniques that can look at a multitude of markers in small samples from tissue and from fluids, we're going to be able to look at the pathogenesis of diseases in many organ systems right at the tissue level when it's occurring.

DR. PINN: Are there some eye conditions that we've not discussed that you think that women should know about?

DR. SMITH: I think it's very important for women to recognize that they're also at risk for other eye diseases. Thyroid disease is much more common in women than in men and can be associated with serious eye disease. Optic neuritis, inflammation of the optic nerve in the back of the eye, which can be associated with multiple sclerosis, is much more common in women than men. And a condition called pseudotumorous cerebri in which increased intercranial pressure, pressure around the brain and the spine cord, can damage the optic nerve is also more common in women than in men.

In summary, it's very important for women to have their eyes examined for all of these conditions. It's also important for women to ensure that their family members have their eyes examined for these conditions as well. We know that women make many of the health care provider choices in our families. Women are the ones who often choose the foods for the diet we take. Women choose the recreational activities often for their children and ensure that they wear eye protection in sports and other activities.

So it's important that women be recognized for that role and take advantage of that to protect eye health of their families.

DR. PINN: And I was told at a recent conference on health that many of the men, younger men, who come into their physician, say they're there because their wives brought them or sent them. So, yes, we do think it's important to remember the caregiving roles of women and in a podcast coming soon, we're going to talk about the effects of caregiving on women and their families because giving care can also bring stress to the lives of women. But that's not what our topic is about today.

I think we've covered a number of the top conditions that can affect the vision of women or visual impairment as I guess is the appropriate way to phrase it and you've touched on a number of issues related to research and how research is helping us to learn more about prevention of blindness.

Are there any other issues that you would like to bring forward that I haven't noted up about to ask you about, Dr. Smith, that we should make sure women know about related to their eyes and their eye care?

DR. SMITH: The last point I'd like to make is that pregnancy can be associated with eye disease. So if visual changes occur in pregnancy, it's very important for a woman to report those to her obstetrician. Often, we don't recognize that things happening in the eye are reflecting the rest of the body. So we don't tell our care providers. We wait to talk to our eye care provider. It's very important to share that information with the physician and I just wanted to remind our listeners about that.

The other important points that I'd like to summarize with is that many diseases that cause vision loss are preventable and without being examined, there is no way the disease could be prevented. The first step is to get in the door to have your eyes examined.

DR. PINN: And the last word I'll ask you about is what are some areas of research that have not yet given us answers but that we should stay tuned for that may, in fact, help us learn more about some of these conditions related to eye diseases in women. Or maybe let me phrase it differently. What are some of the remaining major questions related to vision in women that research is addressing?

DR. SMITH: We know that blood flow is different in women than in men and, as I mentioned, in glaucoma there is an aspect of compromise of blood flow in oxygenation to the optic nerve. I think the area of vascular involvement in many of these diseases has been under recognized.

The second area is the fact that inflammation is involved in many eye diseases, even in age-related macular degeneration and large amount of research is being focused upon inflammation as a pathologic process. Hopefully, the understanding from many studies can be applied to the eye and can be applied to women and eye disease.

DR. PINN: Thank you so much, Dr. Smith. Coming up next, a few final thoughts for this month when Pinn Point on Women's Health continues.

(Commercial starts.)

ANNOUNCER: A key to good health is eating healthy foods. So dash to the produce aisle for fruits and vegetables. Dash to the dairy case for low-fat milk products. Dash to the foods that are lower in saturated fat, trans fat, cholesterol, sodium and added sugars. Dash to foods that help in the fight against high blood pressure.

For more information, visit www.dashplan.org. This message is brought to you by the National Institutes of Health and the U.S. Department of Health and Human Services.

(Commercial ends.)

DR. PINN: And now, a few final thoughts. We've heard today from Dr. Janine Smith who is an expert based here at the NIH at the National Eye Institute who has talked to us about some of the advances from research that can help us prevent or better treat or have better outcomes for women as well as men, actually, who may suffer from conditions that affect their eyes and that can possibly lead to blindness. As we've heard, vision loss meaning blindness occurs more often in women around the world and in this country partially because women tend to live longer but also because of many of the conditions like autoimmune diseases that are more apt to affect women than men.

But the central message from this discussion today is, for example, looking at macular degeneration, looking at dry eye, just a few years ago, we did not have much hope. When you went to your physician and asked about these conditions and got a diagnosis, there was not a lot of hope for preventing their progression to blindness.

Today, you're hearing that research is beginning to reveal some of the cures based on better understanding of what brings about these conditions. But the important thing is while research and the practice of medicine, be it your physician, your nurse, whoever your health care provider is, may have better information. If you don't seek that care and if you don't pay attention to your own symptoms to bring them to the attention of your health care provider, you may not benefit from these advances we're learning. So as we move forward looking at research on women's health and advances we have to continue to recognize that we have a dual responsibility, that of those involved in research to get the answers and those providing health care to make sure they're aware of the answers and then our own personal responsibility and our own role of preventing diseases that might affect us and making sure that we seek attention from the health care community to help us prevent or help us know better how to protect our own health.

I want to thank Dr. Smith again for being with us and I want to thank you for listening to Pinn Point on Women's Health. In a moment, the announcer will tell you where to send your comments and suggestions for future episodes and at this point, I should thank many of you who have, in fact, made comments and sent in questions and raised concerns or given us comments about how we can improve our podcast.

I'm Dr. Vivian Pinn, Director of the Office of Research on Women's Health at the National Institutes of Health in Bethesda, Maryland. Thank you for listening.

ANNOUNCER: You can e-mail your comments and suggestions concerning this podcast to Marsha Love, at lovem@od.nih.gov. Pinn Point on Women's Health comes from the Office of Research on Women's Health and is a production of the NIH Radio News Service, News Media Branch, Office of Communications and Public Liaison at the Office of the Director, National Institutes of Health, Bethesda, Maryland, an agency of the U.S. Department of Health and Human Services.

(End of tape.)