Top 10 Things I am Asked About in my Practice: by Dr. Sharon Orrange/Primary Care Physician: at DailyStrength Doctors and Advisors

Dr. Orrange received her BA in Biology at the University of California, San Diego, and a Masters Degree in Health Sciences at the Johns Hopkins University School of Public Health. She received her MD from the USC Keck School of…

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Assistant Professor of Clinical Medicine, Division of Geriatric, Hospital and General Internal Medicine, Keck School of Medicine, University of Southern California

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Top 10 Things I am Asked About in my Practice:

Posted in Abstinence & Ce... by Dr. Sharon Orrange on May 31, 2009

1) Do I need an annual physical?

As many of you know Medicare does NOT cover annual physicals... so the question is do you really need one?

For females over 40 you need to come in for an annual mammogram, and either a once a year or every three years (in low- risk folks) Pap smear.

For men and women over 40 I say you need to come in and this is why: KNOW YOUR NUMBERS!!!! All of us should know: our weight (and body mass index), fasting blood sugar (you want this less than 110), LDL cholesterol, HDL cholesterol, and SYSTOLIC AND DIASTOLIC blood pressure (120/80 being normal).

2) Should I be taking an aspirin a day?

Yes but only if you have 2 or more cardiac risk factors: high blood pressure, high cholesterol, diabetes, family history, male sex, postmenopausal woman, or tobacco abuse. Take 81 mg of an enteric coated aspirin (ECASA) a day if that is you, otherwise the risks of bleeding from your gut may outweigh the benefits from a once a day aspirin (covered in more detail in another blog http://www.dailystrength.org/blog/95-awesome-power-aspirin.)

3) Should I be taking fish oil?

Yes, probably, and I do. Fish oil supplements are something all of us should consider and discuss with our physicians. They are not risk free as we have been hearing more reports from surgeons about the anticoagulant effects of fish oil causing problems after surgeries with increased bleeding. For most folks there is little evidence that the pharmacologic doses of n-3 polyunsaturated fatty acids found in fish oil supplements (approximately 10 to 20 times the nutritional dose from fish) provide more protection than the intake of one to two servings of fatty fish (eg, salmon) per week..but some of us don't eat that much dietary fish. The beneficial effects of fish oil supplementation keeps piling up including use for joint pain, inflammatory bowel disease, mood , asthma, cognitive decline, and high triglycerides. When a fish oil supplement is used, it should contain both EPA and DHA; a 1 g daily supplement (containing 200 to 800 mg of EPA and DHA) is a reasonable option and you do not need to worry about mercury exposure.

4) What other vitamins or supplements should I be taking? In general, simple multivitamins (containing 0.5 to 1.5 DV of all vitamins) are probably not beneficial for most adults who eat a balanced diet and get regular sun exposure or drink vitamin D-fortified dairy products. More specifically, though......

Folic acid: Women of childbearing age should be taking 400 mcg a day to decrease the risk of neural tube defects in your baby. Folic acid has not been shown to be beneficial for prevention of heart disease or cancer and is not recommended for that use.

Vitamin B-12: Patients after gastric bypass (or other malabsorptive GI conditions), vegans, alcoholics and the elderly must take Vitamin B12 supplements. Subtle B12 deficiency may account for some cases of dementia and for deteriorating balance in some elderly people. The recommended dose for the elderly is 50 to 100 mcg a day but much higher in those after gastric bypass.

Vitamin E: You don't need to take it. Vitamin E supplements do not appear to be beneficial in preventing cancer. We do not recommend supplementation for this purpose, particularly given the possible increase in all-cause mortality found in studies with doses ≥400 IU/day. With respect to cardiovascular disease prevention, randomized trials provide strong evidence against a benefit for supplementation with vitamin E for primary and secondary prevention of heart disease and stroke. Vitamin E is also not recommended for the prevention of Alzheimer disease or infections.

Vitamin A and the carotenoids (beta-carotene): No, you don't need these. Vitamin A and beta-carotene have shown no benefit for prevention of cardiovascular disease in studies. There is also no evidence that Vitamin A and carotenoid supplements reduce the risk of cancer. The results of two recent randomized controlled trials of beta-carotene showed an increase in lung cancer risk and this has dampened enthusiasm for further clinical trials of antioxidants to prevent cancer.

Vitamin B6: Current evidence does not support vitamin B6 supplementation, alone or in combination with vitamin B12 and folic acid, for the purpose of lowering risk of stroke and heart disease.

Vitamin D: I'll touch on this only briefly since I've done a previous blog on it (http://www.dailystrength.org/blog/32-vitamin-d-and-me). In patients with osteoporosis, or previous fracture, we suggest an additional supplement of 800 IU of vitamin D with calcium, particularly if dietary intake is inadequate and sun exposure on the skin is poor. As mentioned in my previous blog Vitamin D supplementation of 400 to 800 IU a day should be considered in elderly patients.

CoQ10: Most of us probably don't need to take this. The best evidence is for neurodegenerative disease (ALS, Parkinson's,) and in a recent study looking at CoQ10 for muscle aches from statins there was no benefit.

5) "My joints hurt when I get up in the morning, is that just old age?"

If your large joints (knees, hips, shoulders) are achy and sore when you get up and the soreness IMPROVES after you get up and move around then yes...it is likely osteoarthritis or "wear and tear" arthritis. Stretching and staying flexible, Tylenol 500 mg tablet at night, over the counter glucosamine, and NSAIDS (motrin, advil, ibuprofen) all help for the joint pain. This is different than an inflammatory arthritis (rheumatoid arthritis, lupus, psoriatic arthritis, etc) which is usually SYMMETRIC, affects the small joints of the hands and wrists, and worsens throughout the day. Specific treatments for osteoarthritis of the knee were touched upon in another blog as well (http://www.dailystrength.org/blog/383-oh-my-aching-knee).

6) "How can I lose weight? I've gained weight over the last couple years"

This is the MOST COMMON thing I hear from patients that I covered in more detail in a previous blog (http://www.dailystrength.org/blog/31-i-want-lose-weight). Briefly, for quick weight loss the low carb diets work: South Beach diet, Zone and Sugar-Busters. Weight watchers has the best LONG TERM data for sustained weight loss. Save the meds (Meridia, Xenical, Alli, and Phentermine) for use only if dietary changes have not worked. As a last resort Gastric Bypass is worth thinking about but only for those with body mass index (BMI) above 30. The lap Roux- en- Y is the current procedure of choice and in the right hands is worth considering. You MUST also move around...20-30 minutes 3 times a week of a brisk walk to start and increase as you tolerate.

7) What vaccinations do I need as an adult?

A pneumonia vaccine (pneumovax) between 50 and 60 years should be repeated once after the age of 65.
Annual flu shot is debated and you can discuss that on an individual basis.
The Shingles vaccine (Zostavax) if recommended for those over 60 and unfortunately Medicare doesn't cover it.... but here is a tip....if you get a prescription from your doctor you can find a pharmacy giving them out for under 100 bucks in some places.
Tetanus booster is recommended every 10 years (one of these should be a TDap so you get pertussis as well).
If you are going to be travelling in any less developed countries the HepA/B vaccine series is a great idea.
HPV vaccine (Gardasil) is given to those 26 or younger who have not yet been exposed to HPV.

8) If I take birth control pills will I hurt my chances of getting pregnant later? NO

9) Why am I so tired?

Here I wish there were more easy fixes. There are rarely medical explanations for fatigue but they are worth checking (anemia, hypothyroidism, adrenal insufficiency). Look at your sleep HYGIENE and make sure you are getting enough sleep and that it is not interrupted. If it is interrupted think about less alcohol, less caffeine, and make sure you are not snoring which could be a sign of sleep apnea (see my blog on steps to better sleep http://www.dailystrength.org/blog/90-10-easy-steps-better). PAY CLOSE ATTENTION to mood as mild mood disorders (mild depression or anxiety) declare themselves with fatigue. A regular exercise regimen has been shown over and over again to improve fatigue.

10)" I have no libido (interest in sex)":

As with fatigue, pay close attention to the connection between mood disorders (depression and anxiety) and decreased libido. Women going through hormonal flux (menopause) also have a high incidence of decreased libido. In men who have no libido and problems with maintaining or achieving erections a testosterone level should be checked among other things. There aren't many great "treatments" for decreased libido...some studies show some benefit for testosterone replacement in women but with side effects. Again read more about this issue in my previous blog http://www.dailystrength.org/blog/20-decreased-interest-sexdoes-testosterone.

What did I miss......

Dr O.

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Ladies - Do your due diligence about HPV, cervical cancer, Gardasil vaccine, and everything gynecological by going to the non-profit HERS Foundation's website www.hersfoundation.com.

Health care in this country would be much more affordable and our citizens would be much healthier if there wasn't so much overtreatment (unnecessary surgeries and tests). The more we're poked and prodded, the more likely they'll find something "wrong." Many pre-cancerous conditions and even early stage cancers never pose a problem and usually resolve on their own, NO TREATMENT NEEDED.

By fighting4change Apr 03, 2012

I think that as on older person an low carb diets is not working well. From my experience I can tell it makes you far too tired. Maybe younger people can deal with this but for me it was a disaster. I was to tired to get in my bed..............

By onlinebingo Sep 09, 2010

I take SAM-e and milk thistle being a liver patient, it works pretty good for me. I wish someone would talk to kaiser cause pegasys interferon really screwed me up to say the least and it's been 5 months and still struggling, getting sick of the pain day in and day out and the weakness. I don't know how much longer I can take it. I wish I could see an outside contracted Dr., I may have to get a lawyer cause they won't answer my questions and they just do tests when they found out like I have low testosterone they won't help me with it. It's ridiculous to say the least that is why I am for healthcare reform so I can get a choice as to what Dr. I can see.

By MikeIntheDesert Oct 11, 2009

Hi, Doc! I am a 51 year old woman, who takes care of a 100% disabled ex-trucker hubby. My problem is, that I am going through menopause really hard, with no HRT, as I do not have any form of insurance...no medicaid or anything. I have asked our local DFACS office for help, but they told me since I was married to hubby, that I am not eligible for any form of health help, plus all they give us in food stamps are $40.00, which I find insulting, because the fact that he and I have no children together, is one of the reasons we get from them the amount we receive, they also said if we were seperated, we could get more benefits, well I don't feel comfortable ripping off the government, and I am not divorcing hubby just to get medical help for me! I also am a stroke survivor, have Hep C, and have serious panic and anxiety attacks, but who wouldn't, having to do what I have to do, and have been doing for 6 years. Do you have any advice as to whom I could talk talk to about this? I refuse to put him in a nursing home, he would not last a month, at least this way, i know he is taken care of to the best of my ability, and I will continue to do so, until I am no longer able to do it!

By rebelovingurl Sep 10, 2009

hope4acure: You are right but there is no evidence that in folks under the age of 40 an annual physical is warranted...as much as that pains me to say. It is also a bummer for folks with medicare to pay the 230 bucks (at least that's the rate at our clinic) for a Physical exam though i think its worth it of course!

By DrOrrange Jul 01, 2009

Dr. Orange,

You never come out and answer the question you are asked re: NEED FOR AN ANNUAL PHYSICAL. The answer to this is YES you do! It has to be paid for by the party responsible and there is no reimbursement for it from Medicare which is a HUGE flaw in this system!

It is nice to talk about mammograms, etc., but a routine physical exam is very necessary. Many things can be wrong and missed, i.e. diabetes, high blood pressure, CANCER, etc. etc. ad infinitum.

I just had my annual physical exam and it was discovered I have virtually NO vitamin D in my system. This would have never been caught without the annual exam.

Don't try to soft soap this over and not answer this very important question! The answer to this very direct question to you should be YES, not a bunch of other stuff.

By hope4acure Jun 29, 2009

One of the "side effects" of Welbutrin is an increased libido (might help women without the side effects of testosterone) especially if depression is present.

By EasyM Jun 12, 2009

Women can get mammogramns and pap tests done free in lots cities. Too important to let go!
http://ezinearticles.com/?Best-Anti...

By nirmay Jun 11, 2009

Women can get mammogramns and pap tests done free in lots cities. Too important to let go!

By sherry595 Jun 06, 2009

Gardasil ~ a cervical cancer vaccine that protects against four types of human papillomavirus (HPV): two types that cause 70% of cervical cancer cases, & two more types that cause 90% of genital warts cases. That's a no-brainer ...

Assuming I had a daughter between nine & 26, how lucky for her I hold no false illusions of a perfect world in which there's no possibility she'd ever mis-step, get involved w/ a wrong person, or have anything done to her against her will ~ of course I'd take advantage of a vaccine raises the odds of her being at risk for cervical cancer.

By JaniceKay Jun 05, 2009

lainey78, i could not agree more!! and this type of misleading 'advertising' has patients walking into their doctor's office and demanding they get 'thia' or 'that' medication....because they saw it on tv??? education! that's the key.. but GOOD education and open communication with a good doctor (if you can find one that will have actual dialog with you).
i'm very sorry for what you have been through and hope this is past for you. brava for your bravery to speak out as a survior! you are, indeed, a great inspiration!

By tadlem Jun 04, 2009

Regarding the Gardasil debate.... do I think the IDEA of a vaccine is good... yes, however, the problem I have is that Gardasil is being promoted as a Cervical Cancer Vaccine, and it is not. It is an HPV vaccine.... I am apt to mistrust Gardasil because of the way it is being promoted. I am a 30 year old woman who is a survivor of Cervical Cancer, and it was NOT caused by HPV. In all, I think that education of the patient and PARENTING are the best steps to take. And by education, I don't mean listening to one doctor and taking their advice as gold. Always do your own research and get second and third opinions.

By lainey78 Jun 04, 2009

Here's what you missed: MONEY
Bottomline is that it takes money (in addition to the life-changing dynamics) to fix many health concerns that most people face in this republic. And good folks don't have that much many (or coverage) anymore.
Probably what most honest, hard-working people need is home remedies or resources to get well without the bankruptcy blood-letting of a typical visit to a doctor.
Ah well.. at least DS is free -for now.

By zounds Jun 03, 2009

findmydream.. agreed that, as in your case, your married partner may be the carrier, but my point is since this is not proven long term and its effects are so limited, is it worth the dangers that we KNOW are associated with Gardasil? i'm just saying that with regular check-ups (which should be done anyway), any abnormal cells can be detected and true treatment and cure of HPV can be accomplished well before it reaches the stage of cervial cancer. that is why PAP's are done. if there was no CURE for ALL forms of HPV, then i might be more inclinded to think this is a good thing.
my other point being, as in your case. men are the carriers. why not treat THEM? treat/vaccinate the carriers and we won't have to worry about HPV in women, or the consequences thereof. thanks for your comments.

By tadlem Jun 03, 2009

There are lots of ways to have fun without cost. Fun without cost is something that many of us used to have when we were children – times when laughter was easy, we didn't worry about personal loans or what many other people thought. Even going to the movies has become an expensive proposition, but there are ways to have fun without spending money. Card games are always fun, taking a walk, riding a bike, or you could dust off the equipment and start skate boarding again. (You still have one, admit it.) Hey, you can always pull out the old Monopoly game. You don't need a cash advance for entertainment, as you can have http://personalmoneystore.com/money...">fun without cost.

By jorge09 Jun 03, 2009

my wife had a gastric bypass 2 years ago & lost about 200 lbs. her health was awful before it. she had sleep apnea,knee troubles.lack of energy, tired all the time.
she is off of her diabetic meds(controlled by diet now). she can sleep now without having to sleep in a chair. she can walk much better now, no more knee trouble.her energy level is much better now. she's alot happier now.
she has to watch how many carbs per meal & can only eat like a 5 yr old.
my sister n a few friends have lost weight by limiting carb intake.

By cowboy357 Jun 02, 2009

geeze doc, you forgot about men over 40 gettin prostrate checked.
the extenze pill does help rejuvinate a sex life for loss of sex drive.

By cowboy357 Jun 02, 2009

Regarding comment #2 for Gardasil. There are a lot of women who are married well before age 26 and may have not had any partners before their marriage (me, for instance), but their partner has had other relations before the marriage. I agree that abstinence is of course the wisest choice for unmarried females and males, but you have to look at our society. Did your husband have physical relations with other women before you? Wouldn't you want to protect yourself and prevent getting cervical cancer??? I agree that the long-term benefits and risks have not been seen yet. I would still want my daughter to have it (when she gets to that age), and I will accompany it with a serious talk about sex and responsibility and risks etc.

By findmydream Jun 02, 2009

Does anyone remember the big fish oil pill scandal? In 1985 or 1986 the FDA ruled that some fish oil pills endorsed by a panel of world renowned scientists are worthless.

By ESI1 Jun 02, 2009

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