The following is a letter I sent to the Fat Studies Group in hopes that I can get some answers on this issue. I wanted to go ahead and post it here, because I'm sure anything a doc has told me, other docs have told other fatties. Any helpful responses I get, I'll post here as well (if I can get permission) or at least summarize so that others can benefit from whatever wisdom the Fat Studies Group members are kind enough to share.
Also, hey, I know there are plenty more smart and wise people in the world than can possibly be contained in one Fat Studies Group (even as awesome as this group is)! So if you have thoughts/wisdom/knowledge to add, please do! :)
TO: Fat Studies Group
DATE: 11/16/2012
Hi folks,
I need your wisdom and your knowledge, please. I am in
a great deal of distress over some medical stuff and accompanying
weight blaming, and I need to arm myself with information in order to
navigate my way through.
As have so many of us, I have spent a lot of time, energy, and
resources working to unlearn the paradigm that fat=health risk and that
lose weight=better health outcomes. I know to ignore docs when they tell
me to lose weight to improve my blood pressure, cholesterol, prevent
diabetes, etc. I know it's about healthy behaviors, not a weight or a
BMI on a chart. I know that when the myriad medical voices and social
pressures get too overwhelming and gastric bypass starts to sound like a
magic wand, I need to turn to my support system and recharge and remind
myself that it is SO NOT the answer. I am a believer in Fat Lib, HAES,
the whole shebang.
And yet... I've gotten a new argument thrown at me that I haven't encountered before, and it's thrown me for a loop.
Apparently now I need to lose weight or I'm going to get uterine cancer. Let me 'splain...
Over the past few weeks, I've undergone treatment for high level
precancerous cells in my cervix, starting with a bad PAP that identified
the problem, and culminating in a cone biopsy (surgical procedure to
remove the precancerous cells). While the specialist was performing the
biopsy, he also did a d+c, grabbing some of the uterine lining for
analysis. Uterine cancer was in no way indicated by previous test
results nor was there any symptom to suggest I might have uterine
cancer. He recommended doing it because, according to him, excess
adipocytes (fat cells) lead to high estrogen levels, and is one of the
primary risk factors for uterine cancer. Since I have had irregular
periods most of my life (another risk factor) and the test is relatively
non-invasive and low-risk, I agreed. I got my pathology results on
Wednesday, and the uterine lining test results came back clean and
normal.
We know that the cervical precancerous cells were caused by HPV,
nothing to do with my weight, hormone levels, etc etc. Yet he spent most
of my appointment talking about my high risk for uterine cancer due to
my weight, rather than focusing on the abnormal/precancerous cervical cells - the actual
issue I was being treated for, AND the area where actual precancerous
cells were present! When I expressed some worry about the results of the
cervical biopsy and the fact that we hadn't actually gotten all the
precancerous cells from my cervix he stated, and I quote, "I am relieved
that there was no evidence of invasive cancer, and that the... biopsy
did not mandate that we had to do another cone
biopsy or hysterectomy." Where did hysterectomy come in?? Seriously, not
a word you just throw around when talking to a 32 year old woman who is
seriously committed to having babies in the next 5 years. Holy sh*t, I
think he was trying to be reassuring but only ended up scaring the
bejeezus out of me.
Does anyone have any information you can share about the
relationship of fatness and fat cells with risk of uterine cancer? Is
this the exception to the HAES rule? Has my fatness doomed my
reproductive system, as this doc would have me believe? Please share
some science to counteract the doom, gloom, and terror I'm experiencing!
Thanks tons,
Amanda
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(This is not a helpful comment but) This is not a new theory. In 1999, when I was taking biochemistry at university, my professor taught that fat cells are not inert and harmless as we assumed, but exuded large amounts of a mixture of hormones that nearby cells didn't produce, which causes various hormone-related cancers like breast cancer and uterine cancer. I think he used some horrible phrase like 'toxic blanket.' I remember being quite scared by this, but our textbook had almost no information other than what he had mentioned in class; so I never followed up on it. I very much look forward to a follow-up post on this question (and Amanda, I hope you're doing OK and getting the support you need during this time!).
ReplyDeletePremee, I figured I was not alone in being told these things. I'm glad to know you'll find it helpful to hear what I learn.
DeleteI'm doing OK, not great, but OK. Cried a lot in the past few days, naturally. Luckily I have an amazingly supportive boss and fiance and mom and primary doc and friends and.... :)
It sounds like uterine cancer (also called endometrial cancer) is some kind of hobby of that specialist. Maybe he did a report on it in college, or maybe he had a professor who emphasized that irregular periods means a woman (especially a fat woman) should be closely monitored for it.
ReplyDeleteI found a few pages with some actual numbers, which I won't link because of fat shaming talk (which they assume that because fat cells convert testosterone to estrogen, fat people must have elevated estrogen levels). What it boils down to is this: as a Caucasian woman, you have a 2.88% risk of getting uterine cancer ever in your life. 95% of uterine cancers happen after age 60. Things you can do to lower risk include eating fruits, veggies and fiber, not smoking, and taking hormonal birth control with progesterone especially for 5+ years. If the doc is actually worried about uterine cancer, see if you can get a blood test for hormone levels (especially to see if you have elevated estrogen).
The test he did is the most effective at detecting uterine cancer. If he didn't find it, it's almost certainly not there. He's just throwing the words around to scare you into more testing.
*HUGS*
It's not good medical practice for him to be harping about a condition that all tests say you don't have rather than addressing the problem you were referred to him to treat. If you feel up to it, maybe send him a letter or have a talk with your GP about it. You deserve better.
Oh my gosh, SUCH great info. Thank you thank you! Many great points. I am so lucky to have the fat community.
Delete(PS - wish you weren't "unknown" - would love to connect on FB or by email or whatever)
I think sometimes people look at a single process in the body, but forget to step back and look at the big picture. You cannot predict a disease by just concentrating on one process. For example, saturated fat consumption causes hepatocyte (liver cell) membranes to become more rigid, which results in reduced re-uptake of LDL. However, not everyone who eats lots of saturated fat will have high LDL, because LDL levels are affected by other things. Additionally, hepatocyte fluidity is affected by other things; omega-3 fatty acids DECREASE the rigidity of hepatocyte membranes, so if someone eats lots of omega-3 in addition to saturated fat, they might still have optimal membrane fluidity.
ReplyDeleteRegarding cancer and fat cells, uterine cancer is one of the estrogen-fueled cancers, and fat cells do convert androgen to estrogen. However, that's just one part of the picture. Fat cells also produce TNF-alpha (tumor necrosis factor alpha). Although scientists generally concentrate on finding ways to block this inflammatory compound because it can contribute to things like asthma and autoimmune diseases, this compound also kills cancer cells. So, you could argue with doctor that the anti-cancer benefits of the TNF-alpha produced by your fat cells might outweigh the risk caused by (possibly) higher estrogen production. Then you can see what his reaction is. :)
What it comes down to is that fat is a living endocrine tissue that produces multiple compounds, some of which are generally considered unhelpful for health in large amounts(IL-6, estrogen, TNF-alpha), but some of which are very helpful (leptin). In every case, before making a medical decision, you have to consider the risks and benefits. Ovaries also produce estrogen, as well as the estrogen precursor androgen; however, most women would not have their ovaries removed in order to reduce their risk of uterine cancer. Similarly, attempts at fat reduction generally results in yo-yo dieting, which is definitely bad for health. In fact, yo-yo dieting can decrease insulin sensitivity, resulting in increased insulin production by the pancreas (or increased need for injected insulin), and insulin is a growth-promoting hormone that fuels the growth of many cancers (which is why Metformin is currently being used to help prevent recurrence of breast cancer). Additionally, insulin stimulates the ovaries to produce androgen, which is then converted to estrogen. You could explain to your doctor that weight reduction results in disordered eating patterns, which you worry will decrease your insulin sensitivity and cause hyperinsulinemia (high circulating insulin levels), which might indirectly promote uterine cancer by increasing androgen (and thus estrogen) production by the ovaries, and directly promote uterine cancer by enabling the cancer cells to absorb more glucose and grow. (Unlike muscle or fat cells, cancer cells do not usually become insulin resistant in the presence of high insulin. Also, aggressive cancers are strongly reliant on glucose for growth, which is why ketogenic diets are sometimes use to "starve" cancer cells.) If your doctor tells you that weight loss improves insulin sensitivity, remind him that that mostly happens because of the calorie deficit during weight loss, and that 95% of patients who lose weight will not be able to maintain an isocaloric or hypocaloric diet because of powerful biological mechanisms that protect against weight loss.
It sounds like your doctor has a strong bias which is blinding him, so talking with him might not be completely productive, but raising some complex questions might force him to recognize that the human body (and fat) is complex. The statement "If A->B, and B->C, then A->C" is only true if there aren't 10 million other variables interfering with each equation.
Where do I even begin to respond? Thank you so much for all your amazing thoughts and analysis. I cannot believe how generous and wonderful my community is. Actually I can believe it, I just continue to be in awe of it!!
Delete"fat is a living endocrine tissue" - such an important reminder - so often we are encouraged to think it's just this "dead weight" we carry around that should just be got rid of by any means necessary. Duh. The body doesn't produce much of anything by accident. I'm told we even know what the function of the appendix is, these days!
I had a similar frustrating experience where I wanted an endrometrial ablation to deakl with the periods from hell (at the age of 49 and having had my tubes tied,) The gyn refused, saying since I was fat I had a higher risk of uterine cancer, and the #1 symptom of uterine cancer was bleeding, so if she did the ablation to make bleeding unpossible, it would take away early detection. I was essentially made to suffer through two more years (and counting, sporadically) of horrific periods because she was so sure I was going to come down with uterine cancer because of teh fatz.
ReplyDeleteElizabeth, thank you for your excellent response above, too.
Thanks for sharing your experience - I'm sorry it wasn't good. Luckily, even these biased docs seem interested in taking care of me pretty darn well. And my GP is absolutely fantastic, so I am pretty confident that I won't have to suffer through wrong approaches as you did. I hope you have better providers on your team now!
DeleteForgive me if this posts twice; I tried to reply and got an error message...
DeleteThanks for sharing your story; I'm so sorry your doc wasn't helpful. I hope you have better docs on your team now!
Ultimately, even if your doctor is right (which he probably isn't, as everyone has pointed out), what does he expect you to do about it? Become un-fat through sheer force of will? We all know that evidence shows that fat people generally can't become un-fat. So, fine, let's say all of us fatties have an elevated risk of stickitodamaniosis. Unless someone finds a miracle "cure" for our fatness, that's just the risk we've got.
ReplyDeleteTHIS! When are they going to wake up and smell the science and realize that fat bodies don't easily (if at all) change to thin bodies... and even if they can be changed, who's to say whether a genetically fat body made artificially thin through whatever diet/exercise/surgery will now perform like a genetically thin body? Why would it?
DeleteI can't believe no one has mentioned PCOS so far. That's PolyCystic Ovarian Syndrome, which is a hormonal and metabolic disorder that can, among other things, cause irregular periods, "obesity", and endometrial cancer.
ReplyDeleteBecause many women with PCOS are fat, and because PCOS predisposes towards hormonal imbalances that result in more endometrial (uterine) cancer, there is a link between higher BMI and endometrial cancer. But is it the fat CAUSING the cancer or is it the underlying condition of PCOS that causes both the fat and the tendency towards endometrial cancer?
In other words, the link may be about a lot more than fatness. Losing weight won't cure PCOS. There is some evidence it can help reduce symptoms, but it doesn't "fix" anything permanently (get rid of the PCOS) and we all know the long term failure rate means you will likely end up HEAVIER than you started, which might make things worse.
The secret is to TREAT THE PCOS. You should not allow yourself to have irregular periods. We NEED to have regular periods (outside of pregnancy and breastfeeding). When the endometrial lining builds up because you aren't having a regular period, all that unopposed estrogen builds the tendency towards endometrial hyperplasia (overgrowth), which can then lead in time to endometrial cancer. Making sure you have a regular period goes a long way towards reducing the chance of uterine cancer.
You have many choices for regulating your periods. Most docs prescribe birth control pills, which helps in the short term (and it better than irregular periods) but may have other undesirable side effects. You can take Metformin (Glucophage), which reduces insulin resistance and helps even out the hormones; many women start regulating their periods on this. Some have better luck with herbs like chastetreeberry (vitex) or other combos, or with acupuncture to regulate the hormones and cycles. Others need to low-carb a lot...not necessarily for wt loss, but to reduce the excess insulin levels that are a hallmark of this condition. There are a number of treatment choices, and you have to experiment to find out what works best for YOU.
Your doc should have at least brought up the possibility of PCOS with you, given your symptoms, and discussed whether further treatment might be helpful.
Yes, fat women have higher endometrial cancer rates. And estrogen dominance has something to do with this.....but it's probably more an effect of undiagnosed or undertreated PCOS than mere fat itself.
Thanks for this. :) As I had already written a lengthy post myself, I didn't want to add stuff about PCOS too. I also have PCOS--I was diagnosed as a teen--so that combined with an interest in science means I've been very interested in the role that hyperinsulinemia (high insulin levels) has on different disease processes. There's a compelling evidence that insulin signaling is one of the main things driving the growth of the fastest growing cancers (these cancers rely on glucose for growth rather than fats or protein, and they need lots of insulin to access high quantities of glucose). There was a pilot study* completed this year which demonstrated that very-low-carb (ketogenic) diets might be useful for treating fast-growing cancers, and that its usefulness is proportional to the presence of ketosis levels in the patient. Although the study was very small, the author states that according to the data, the benefit from the diet (tumor stability or remission) DID NOT appear to depend on weight loss, implying that the improvement was caused by reduced insulin signaling rather than a calorie deficit.
DeleteInsulin sensitivity CAN be improved without weight loss or a calorie deficit. It can also be done without a ketogenic diet, although some people might prefer that way of eating and people with PCOS can definitely benefit from it (as long as it doesn't result in carb binges). I personally prefer eating carbs, but I choose ones that are lower on the insulin index. (This is similar to the glycemic index, but for me even more informative and helpful because sometimes a food is low on the glycemic index because it provokes an insulin response that is disproportionate to the amount of carbs in the food. For example, although milk is very low on the glycemic index, it is high on the insulin index (100 or above, which means it causes more of an insulin response than white bread) because it contains lots of whey, which is an "insulinogenic" protein (it causes pancreas cells to secrete lots of insulin). I also take Metformin and exercise.
I think one of the most important things in treating PCOS is not yo-yo dieting. I suspect that a standard American diet would be better than alternating between a strict diet and binging. Interestingly, I didn't start yo-yo dieting until after I was diagnosed with PCOS, because I was convinced I could fix it if I was strict enough with my diet. It turns out that smaller dietary changes, such as eating eggs and fruit for breakfast instead of cereal, and decreasing my grain portion while increasing my protein portion at each meal, and snacking on nuts and fruit instead of starches, and limiting foods that contain lots of whey protein, is sufficient for managing my PCOS (along with Metformin). The strict dieting actually made things worse, because it wasn't sustainable and I would end up snarfing down carbs.
*Ketogenic diet study: http://download.journals.elsevierhealth.com/pdfs/journals/0899-9007/PIIS0899900712001864.pdf
Just wanted to add that I didn't mean to imply that stricter dieting doesn't work for some people with PCOS. In fact, I know someone who has had great results with a very-low-carb diet, and doesn't feel deprived.
DeleteAlso, there is a blog post written by the main author of the study I referenced, where he helps break down the study (he will be writing the second part of the blog this week) http://rdfeinman.wordpress.com/category/low-carbohydrate-diet/
Oops, that's the wrong link (although the blog post I mentioned is the first post listed when you click the link).
DeleteCorrect link: http://rdfeinman.wordpress.com/2012/10/15/targeting-insulin-inhibition-as-a-metabolic-therapy-in-advanced-cancer/
Thank you SO MUCH for the amazing and in-depth info. PCOS has been mentioned by my naturopath but not by my GP or by the gynecological oncologist. The gyn oncologist is now referring me down to an OB/GYN, so maybe that person will want to talk about PCOS.
DeleteI had super irregular periods as a teen/early 20s and when they did come they would be accompanied by intense emotions and bad cramps, heavy bleeding lasting for 7-10 days. I went on hormonal BC to regulate my cycles and had about 8-10 years of blissfully regular and mild periods. I just went off the BC this summer, because I am getting married next July and plan to pursue children shortly thereafter. Rather than waiting until we are newlyweds, my naturopath and I agreed it would be good to see what my body is like hormonally now - well in advance of wedding and newlywed life. That way we'd have a chance to treat and balance things. Of course, shortly thereafter came the HPV and precancer diagnoses and all else has been lost track of as I went into 'crisis mode.' Now I've been off BC for about 4 months and have had fairly regular periods and reasonably mild PMS and cramps -- despite all this stress and anxiety. So maybe my body has grown out of the extreme irregularity of my youth? Or maybe it's still transitioning off the hormonal BC and it will eventually be irregular again? Not sure how that works... Anyway, is there a test for PCOS? Because thus far all I've seemed to get from docs is "you're fat and have irregular periods. It's probably PCOS." Seems a bit vague to me.
There isn't one single test for PCOS. A clinician looks for the following things:
Delete1. Excess androgen activity
2. Lack of ovulation or irregular ovulation
3. Polycystic ovaries (PCO)
Doctors can determine if someone has excess androgen activity by looking for physical manifestations (acne, scalp hair loss, hirsutism--coarse arm/leg hair or hair growth around nipples, under belly button, or on face), or by doing blood tests (checking levels of androgen and testosterone).
I don't know if there's a straightforward test to determine if a woman is ovulating regularly. Lack of periods is a good indication that a woman isn't ovulating, but the opposite isn't true--that is, a woman isn't necessarily ovulating just because she's having periods.
PCO (polycystic ovaries) is diagnosed with an ultrasound. I know it sounds strange, but some women with PCOS don't have PCO!
According to wikipedia, two of the three things (excess androgen, anovulation, PCO) need to be present to diagnose someone with PCOS. In my case, I had hirsutism (dark hair under belly button and on arms and legs), severe cystic acne, and absent periods (amenorrhea), but no cysts on my ovaries. I also had a glucose tolerance test, which showed I was prediabetic. My endocrinologist seemed to emphasize the importance of the glucose tolerance test when he diagnosed me. However, a person could be hyperinsulinemic (and therefore more likely to have PCOS) and still have normal glucose tolerance. Impaired glucose tolerance happens when insulin resistance is present and beta cell failure begins to occur. Sometimes hyperinsulemia and hypoglycemia precede the development of insulin resistance and impaired glucose tolerance (prediabetes/diabetes).
Some doctors suspect PCOS if a patient is fat because fatness can be a symptom of insulin resistance, but I don't think fatness is a very reliable indicator. I would have to guess that hirsutism or other outward signs of high androgen levels would be the easiest ways to "screen" women with just a glance (I have read somewhere that any woman over age 25 with moderate to severe acne should be tested for PCOS).
Sorry for the book, but I can't believe PCOS was left out of the discussion.
ReplyDeleteYou can read more about PCOS on my blog, www.wellroundedmama.blogspot.com. Click on the PCOS label. I'll have more posts on PCOS treatment options coming up in a few weeks as well. Stay tuned.
No, please don't apologize. I'm thankful for any and all input!! Everyone has been amazingly generous.
DeleteOh, good, Well-Rounded Mama is here! I was hoping you'd show up when I first saw this!
ReplyDeleteA Elizabeth's comment also makes a lot of sense.
Another thing to always keep in mind is relative risk vs. absolute risk. If women with a BMI <25 have a 2% lifetime risk of uterine cancer and women with a BMI >30 have a 4% risk (just making up some plausible numbers), then "obese" women have double the risk, but most will still never get uterine cancer. Elevated risk does not equal "You're doomed!"
Another excellent point. "Twice as likely" when you start with a tiny percent is still a pretty darn small percent. :)
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ReplyDeleteI just deleted my first comment. I think I'm flattered to have enough readership to get my first concern troll! Whee!
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