September is Gynecological/Ovarian Cancer Month

In honor of Gynecological Cancer Awareness Month, let us first discuss the most deadly one, ovarian cancer. According to the Women's Cancer Network, ovarian cancer is the most deadly cancer of the female reproductive system. It is the 4th leading cause of cancer death of women in the U.S., and is second only to uterine cancer in prevalence. According to the American Cancer Society, 22,430 women will be told they have ovarian cancer this year .
One in 57 women will get ovarian cancer, and it usually happens in women over the age of 50. It is 50% more prevalent in white women. The adjusted mortality rate is highest among white women followed by Hawaiian women, and lastly black women.

Why is ovarian cancer so deadly?
Due to it's position in the abdominal cavity, early detection is difficult, showing no or mild symptoms until it is at an advanced stage where the 5 year survival rate can be as low as 11 percent. Early detection could mean a 5 year survival rate as high as 92 percent.

What are the risk factors for ovarian cancer?

According to The Johns Hopkins University, ovarian cancer occurs more frequently with the following:

1. History of ovarian cancer in your immediate family
2. Age over 50
3. Fertility drug use
4. High fat diet
5. White race
6. Never having children
7. Hormone replacement therapy
8. History of breast cancer diagnosed before age 50
9. Being of Ashkenazi Jewish descent

Having immediate family members who have had ovarian cancer raises your risk of having ovarian cancer in your 40's rather than your 50's.

What are the symptoms of ovarian cancer?
It can present with nonspecific symptoms, meaning the same symptoms caused by many other conditions. However, certain symptoms are seen more frequently among women with ovarian cancer:

1. Bloating
2. Pelvic or abdominal pain
3. Difficulty eating, feeling full quickly
4. Vaginal bleeding
5. Urinary urgency or frequency

These symptoms tend to be persistent, and occur daily for 2-3 weeks and require a doctor's evaluation if they last that long. Other less specific symptoms include:

1. Fatigue
2. Indigestion
3. Back pain
4. Painful intercourse
5. Constipation
6. Menstrual irregularities.

How is a person screened for ovarian cancer?

1. Pelvic examination and Pap smear
2. Transvaginal ultrasound
3. Testing for the protein CA-125, elevated in 80% of women with ovarian cancer
4. Culdocentesis- a sampling of pelvic fluid found in a "cul de sac" between the uterus and the rectum.

Don't be alarmed if your doctor says you don't need the CA-125 test or an ultrasound to detect ovarian cancer early. According to the U.S. Preventive Services Taskforce, it is meant for women who have inherited a BRCA (breast cancer) gene change and who still have their ovaries. They get tested annually starting at age 35.


Once ovarian cancer is diagnosed, you have 3 treatment options. The first is surgical removal of the ovaries. The second is chemotherapy, and the third is radiation. The form of treatment is based on the stage of the cancer, the type of cancer cells present, and the patient's age and physical condition.

Can certain things be protective against ovarian cancer?
The Johns Hopkins University says there are no simple preventive measures to take that significantly reduce one's risk of ovarian cancer. However, it is said that the following are associated with a lower risk of cancer:

1. Breastfeeding
2. Hysterectomy
3. Birth control pills
4. Tubal Ligation


What can you do to protect yourself?
1. Get regular pelvic exams
2. Know your family history
3. Reduce the amount of fat in your diet.

The National Cancer Institute advises increasing one's fruit, vegetable, and whole grain intake, lowering fat consumption to <30% of calories, maintaining a healthy weight, minimizing one's intake of cured, pickled, and smoked foods, and only drinking alcohol in moderation if at all.
So many conditions, and ER visits, can be prevented by following this advice.

Be safe, be successful,
Rapp, M.D.

Diverticulitis and The American Diet

I diagnosed yet another patient with diverticulitis today. "What causes it?" he asked. My answer was...

"The low fiber American diet."

What is diverticulitis?
Diverticulitis means inflammation of diverticula. Just having diverticula means you have "Diverticulosis." Diverticula are herniations or outpouchings, marble-sized on average, that form at weak points in our intestines, usually due to excessive force needed to push waste through the digestive system. It's like the herniae that form in our abdominal walls and groin area from repeated, improper heavy lifting. Eighty to eighty-five percent of patients with diverticulosis have no symptoms.

What causes diverticulitis?
In the past, it was thought that nuts, seeds, popcorn and corn caused diverticulitis when caught in the diverticula. According to the Mayo Clinic, research has found that these foods are not the culprits. Another school of thought is that the small openings to the diverticula can trap stool, reducing the blood supply, causing inflammation.

What are the risk factors?
While the cause of diverticulitis has not been agreed upon, the risk factors are straightforward.
They are:
1. Aging-Emedicine says the prevalence before age 40 is less than 5%. According to Drs. M. Schein and R. Paladugn of Cornell University's Surgical Department, it's prevalence is 30% by age 60 and 65% by age 85. The Mayo Clinic suggests that with age may come a decrease in the strength and elasticity of the the bowel wall after age 40.
2. Low fiber diet- Diverticulitis is rare in countries where people eat high fiber diets which soften stool, but it is common in industrialized countries where processed food are more available. As the Japanese adopted western eating habits, the prevalence of diverticulitis has also risen. Diverticulitis has grown in prevalence since the invention of rolling mills that reduce the fiber content of grains and flour.
3. Inadequate exercise- A sedentary lifestyle has been associated with a higher risk of diverticulitis. Why the connection exists is not clear, but exercise helps control constipation, a risk factor for diverticulosis.
4. Obesity-The Mayo Clinic says being seriously overweight is also a risk factor for diverticulitis and diverticular bleeding.

What are the Symptoms of Diverticulitis?
Usually the pain is of sudden onset in the lower left side of the abdomen. Sometimes the pain may come on slowly and worsen over the next several days. The pain may wax and wane, your bowel habits can change, causing diarrhea or constipation. You may experience nausea, vomiting, and even fever. Even less common but possible symptoms or signs are a bloated feeling and rectal bleeding.

What's the Worst that Can Happen?
1. Peritonitis- If the inflammation or infection weakens the pouch wall enough, a hole will form, releasing stool into the abdominal cavity, inflaming and infecting it's lining, the peritoneum. This condition is called "Peritonitis," an emergent condition requiring immediate treatment.
2. Rectal Bleeding
3. Obstruction- Infection can cause scarring of the colon or intestine, which in the wrong place can block the flow of gas and stool.
4. Abscess- This is a pus collection in the pouch.
5. Fistula- An abnormal connection, a passageway, can form between the intestine and structures nearby, like your urinary bladder, abdominal wall, or vagina.

Is there a connection with colon cancer?
A direct connection has not been found, but diverticulosis can make cancer harder to diagnose.
After you recover from an episode of diverticulitis, it may be advised that you get a colonoscopy, and more frequent colonoscopies than the average person to screen for cancer and other abnormalities.

What is the treatment for diverticulitis?
This depends on the severity of your condition, and if it is your 1st time. Mild symptoms typically require a liquid or low-fiber diet and antibiotics. Usually the symptoms lessen in 3 days and you can start increasing your fiber intake then. Stronger pain medication may be needed but watch out, it can worsen constipation and thus the problem.
More severe symptoms and signs, or the increased risk of obstruction or peritonitis, calls for hospitalization and intravenous antibiotics.
The most severe cases, involving perforation, abscess or fistulas may need surgery to remove that part of your colon. One kind of surgery involves removing the diseased portion and sewing the 2 ends back together.
More severe and generalized inflammation requires the 2nd kind which involves the surgeon making an opening (stoma) in the abdominal wall. The healthy portion is connected to that stoma and your waste will pass from that healthy end into a bag attached to the outside of your body, called a "colostomy bag."

How can I prevent diverticulitis?
We cannot say it enough, an ounce of prevention is worth a pound of cure.
1. Eat More Fiber: The National Fiber Council recommends that a healthy adult consume 32 grams of fiber a day. The average American eats about 10-15 grams. The NFC says only about 10% of Americans eat enough fiber. Why? Many Americans are misinformed about foods containing fiber. For example, 53% of American believe steak is a good fiber source, and most meat products contain little or no dietary fiber.

2. Drink Plenty of Fluids. Water is absorbed by fiber. This increases the soft, bulky waste in your colon. If you eat fiber and drink little water, you risk constipation.

3. Respond to the Urge to Defacate (Pass Stool). Holding in bowel movements makes stool harder, which requires more force from the colon to pass it.

4. Exercise. This increases bowel function and lowers the pressure inside the colon. Thirty minutes of exercise on most days of the week is all you need.

Be safe, be successful,
Rapp, M.D.