Friday, April 19, 2019

A woman’s testosterone-based vaginal cream linked to elevated testosterone in her husband

 The Supreme Court heard arguments this morning in a case that could threaten the viability of the Affordable Care Act, President Obama’s signature health care law. The law, also known as Obamacare, survived a previous Supreme Court challenge in 2012. But this new one has many people worried, and rightfully so.

At issue in the case are the financial subsidies provided to millions of Americans to buy health insurance through the insurance marketplaces, called exchanges. Without these subsidies, many people of lower income would not be able to afford coverage. Stopping these subsidies would put a big dent in the “affordable” part of the law’s name.

After the Affordable Care Act went into effect, sixteen states and the District of Columbia set up their own exchanges to help their residents buy health insurance. Thirty-four states did not. In response, the federal government created a federal exchange through the website so lower-income residents of those 34 states could still buy insurance.

The case currently in front of the Supreme Court is called King v. Burwell. Plaintiff David King lives in Virginia. He didn’t want to buy health insurance, but felt he had to because the Affordable Care Act requires that everyone have health insurance or pay a penalty. He was able to afford health insurance because of a subsidy from the federal government for it. But if subsidies didn’t exist, King and others like him wouldn’t be required to buy health insurance in the first place. Defendant Sylvia Burwell is the current Secretary of the Department of Health and Human Services, which oversees administration of the Affordable Care Act.

King and his lawyers argue that the Affordable Care Act allows for subsidies to be provided when insurance is purchased on exchanges “established by the State,” but not on the exchange established by the federal government. The outcome of the case may hinge on how the justices interpret those four words in the health law.

The King team says that lawmakers intended to use these subsidies as an incentive to encourage each state to set up its own insurance marketplace. The Obama administration, on the other hand, argues that the word “state” is a more general term that includes both the individual states and the federal government. It also contends that lawmakers in Congress intended for the subsidies to apply to both. If the subsidies are overturned by the Supreme Court, at least 8 million Americans would stand to lose their health insurance.

If this were to happen, it could destabilize the insurance market. Here’s how that might happen: Only the sickest people would hold on to their coverage. Healthy people would quickly drop it. That would make health insurance more expensive. Some observers say this would send the insurance market into a death spiral.

If 8 million people were returned to the ranks of the uninsured, they would not stop receiving medical care. Instead, they would get so-called “free care” in clinics and emergency departments. This care, of course, is not free at all. The costs are covered by uncompensated care pools, which is money set aside for care that has not been paid for. This ultimately comes from taxpayers. So the case has implications for all of us.

Among all the courts in our country’s legal system, only the Supreme Court speaks for the nation as a whole. Much is at stake in King v. Burwell.

My early impressions of today’s oral arguments are that the four liberal justices (Justices Breyer, Ginsburg, Kagan, and Sotomayor) are supportive of the Obama administration’s position, while Justices Scalia, Alito, and Thomas seemed to be with the challengers. The swing votes may ultimately be with the two other members, Chief Justice John Roberts or Justice Anthony Kennedy. (You can read a transcript of the arguments and the justices’ questions on the Supreme Court’s website.)

Although the court heard arguments in the case today, a decision is not expected until late June. That is because the cases with the highest impact on society are announced last in the Court’s term. Until then, the subsidies on the federal exchange will remain intact, but their long-term fate lies in the hands of the nine justices. Nuts, a food you may have been avoiding because of their high fat content, have been gaining traction as an all-natural health food with health benefits. Tree nuts like almonds, pecans, and walnuts are especially prized for their rich cargo of vitamins, minerals, and mono- and polyunsaturated fats.

The downside is that tree nuts tend to be pricey. But a study published online in JAMA Internal Medicine puts the humble peanut squarely in the same nutritional league as its upscale cousins. This work makes the health benefits of peanuts more accessible to lower-income shoppers.

An international team of researchers found that in more than 200,000 people from Savannah to Shanghai, those who regularly ate peanuts and other nuts were substantially less likely to have died of any cause — particularly heart disease — over the study period than those who rarely ate nuts. This adds to the existing evidence from two Harvard-led investigations — the Nurses’ Health Study and the Harvard Professionals Follow-up Study.

“This confirms what we found a few years ago — and our results were greeted with intense skepticism,” says Dr. Meir Stampfer, professor of nutrition and epidemiology at the Harvard T.H. Chan School of Public Health. “Botanically, peanuts are not nuts, but nutritionally they are very similar to tree nuts, and other studies have shown their benefits,” Dr Stampfer explains.

Any botanist worth his or her salt will tell you that peanuts aren’t nuts. They are actually legumes, and so are more closely related to soybeans and lentils than to almonds and walnuts. But like tree nuts, peanuts can be eaten as a filling snack or as a protein-boosting ingredient in many salads and other dishes. An ounce a day of nuts — roughly a quarter cup or a small handful — is a generally healthy portion.
Crossing borders

The JAMA Internal Medicine study looked at nut and peanut consumption in two large groups of people spanning geographic, racial, ethnic, and income boundaries:

    72,000 Americans, ages 40 to 79, living in 12 Southern states. Most lived on low incomes and two-thirds were African American.
    135,000 men and women in Shanghai, China, ages 40 to 74.

The researchers used surveys to tally nut and peanut consumption. They followed the groups for several years and counted how many participants died and from what causes. In the U.S. Southern states group, those who regularly ate peanuts were 21% less likely to have died of any cause over a period of about five years. In the Chinese groups, who were followed for six to 12 years, the death rate in nut-eaters was 17% lower.

For all the groups, the researchers accounted for unhealthy influences like smoking, obesity, high blood pressure, and diabetes, which were especially common in the Southern states group.

The diversity of the participants in this new study is important. Those in the earlier Harvard studies were mostly white health professionals who were more educated and earned higher incomes than most people in the Southern states group. And in studies that just observe large groups of people over time and what they eat, such as the Harvard studies, scientists can’t be certain whether any health improvements have more to do with the participants’ lifestyles or genes rather than what the food is doing. Seeing the same health benefit across diverse groups can be reassuring.
Embrace the health benefits of peanuts

One important take-home lesson here is that the health benefits of peanuts appear to hold up across racial and income differences, which often have a strong influence on health. “This extends it to diverse populations, lending further credibility to the findings,” Dr. Stampfer says.

Another is that eating peanuts appears to be just as potent for preventing heart disease as eating other nuts. Since peanuts generally cost less than premium tree nuts, people on lower incomes can reap the health benefits of nuts on a budget.

Because this study is observational, we can’t truly be certain that it is nuts that are doing the heart-healthy deed. But compared with other “health foods,” nuts and peanuts have some pretty compelling evidence behind them. “Even if you don’t like nuts, it would still be a good idea to eat a handful every day,” Dr. Stampfer says. Testosterone is often called the male hormone. But women’s bodies make it, too, though in lesser amounts than men make. In both women and men, testosterone levels naturally decline with age. This can diminish a woman’s sex drive, just as it can a man’s. Some women try to boost a waning sex drive with a testosterone-based vaginal cream, which can be mixed to order by a compounding pharmacy with a doctor’s prescription.

That could have a downside for their male sex partners with prostate cancer.women's testosterone creams

In the Journal of Clinical Oncology, doctors from the Penn State Hershey Cancer Institute reported on the unusual case of a 68-year-old man who had been diagnosed with advanced prostate cancer and had his prostate removed. The man’s PSA level fell dramatically after the surgery, a sign that the treatment had worked. After his recovery, he “continued having sex with his wife three or four times a week,” said his oncologist, Dr. Joseph Drabick.

A year later, the man’s PSA started rising. It continued climbing even after he underwent radiation therapy, which is often used to treat prostate cancer that recurs after surgery. Meanwhile, his doctors could find no physical evidence that his prostate cancer had returned.

They did notice that the man’s testosterone level was unusually high—780 nanograms per deciliter (ng/dL) at first, increasing to 908 ng/dL nearly a year later. The normal testosterone level for a nearly 70-year-old man is in the 500 ng/dL range. Extra testosterone can fuel the growth of cancer cells lurking in the body.

The man told his doctors that he did not take testosterone supplements. His wife, however, said she had been using a testosterone-based vaginal cream as a sexual lubricant for more than a year. After she stopped using the cream, her husband’s testosterone level plummeted, though his PSA level continued to rise. He was eventually treated with androgen-deprivation therapy, a hormonal approach to treating recurrent prostate cancer.

Dr. Drabick speculates that the man absorbed testosterone into his penis during intercourse. Could that have contributed to the prostate cancer recurrence? “He was headed down that path anyway, but it might have sped it along….the blood levels of testosterone were far higher than what his testicles could produce,” said Dr. Drabick.

The FDA has never approved any testosterone-containing products, including topical testosterone formulations, for non-cancer uses in women. At the same time, the FDA doesn’t regulate off-label uses for lawfully marketed medications, like testosterone. So women can, and do, easily and legally obtain testosterone-based creams.

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, says the case report underscores the need not just for a man’s detailed medical history, but also for a review of medications used by a spouse or partner, including those that can be applied topically or transvaginally.

“Whether this exposure was in any way contributing to the patient’s clinical course, is, of course, speculative,” Garnick said. “But it may have indeed contributed to the elevated testosterone value that Dr. Drabick measured.”

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