Stress and Cardiovascular disease

I found this paper I wrote for 4th year Herbal Medicine - seems to refuse to go on a new page.

Assignment 1

From the information presented in Ullian 1999, Kivimaki et al 2002, your understanding of stress physiology, and a review of the relevant literature, discuss how and to what extent chronic stress may influence cardiovascular morbidity and mortality. Suggest appropriate clinical interventions revolving around herbal medicines and lifestyle modification.

Stress and Cardiovascular Disease

Abstract

Stress has long been believed to adversely affect heart disease, however there has been limited clinical and research evidence to support this. Recent studies have clarified the mechanisms and measurable effects of chronic stress on the cardiovascular system and the consequent effects on cardiovascular morbidity.
Studies have shown stressful working conditions can induce sustained changes in neuroendocrine and autonomic activity, increasing atherogenesis. Jobs with high demands and low control are associated with an increased CHD risk and low control is also associated with high levels of the clotting factor fibrinogen, which predicts cardiovascular disease.
The responses to stress include release of catecholamines and corticosteroids, increases in heart rate, cardiac output and blood pressure, and changes in processes relating to clotting processes (coronary vasoconstriction, platelet aggregation or plaque rupture). In patients with atherosclerosis these changes may trigger clinical events. A 2004 study found the increased risk of myocardial infarction associated with psychosocial stressors to be comparable to that from hypertension and abdominal obesity but less than that from smoking. Psychosocial factors contribute to the development and promotion of CHD by direct atherogenic effects, by contributing to maintenance of unhealthy behaviours and further as a barrier to lifestyle modification strategies.
Herbal adaptogens are “natural bioregulators, which increase the ability of the organism to adapt to environmental factors and to avoid damage from such factors.” Eleutherococcus senticosus appears to alter the levels of neurotransmitters and hormones involved in the stress response, primarily at the hypothalamic-pituitary-adrenal (HPA) axis.
Nervines, sedatives and nervine trophorestoratives, such as Leonurus cardiaca, Hypericum perforatum Valeriana officinalis, Turnera diffusa, Scutellaria lateriflora and Avena sativa are beneficial for symptoms related to stress exposure.
Most herbs which positively influence cardiac function also have beneficial effects on risk factors such as hyperlipidaemia. Allium sativa has numerous actions beneficial to cardiovascular disease, including lipid lowering, inhibition of platelet aggregation, prolongation of bleeding and clotting time and enhancement of fibrinolysis. Crataegus spp have been shown to reduce myocardial demands in clinical studies, and also to have antioxidant, coronary vasodilatory and cardioprotective activity. Salvia miltiorrhiza is indicated for angina due to its vasodilatory, antiplatelet and cardioprotective effects, and was found to exhibit anti-oxidant activity and prevent atherosclerosis in rabbits fed a high cholesterol diet. Forskolin in Coleus forskohlii inhibits platelet activation and degranulation, inhibits mast cell degranulation and histamine release, increases cardiac contractility, relaxes arterial smooth muscle and antagonises PAF by interfering with receptor binding. Terminalia arjuna bark has been used in the treatment of CAD, CCF, angina and hypercholesterolaemia. An open study found a 50% reduction in anginal episodes and a significant reduction in systolic BP in patients with stable angina.
A meta-analysis of more than 20 controlled trials found that those receiving psychosocial treatments showed greater reductions in psychological distress, blood pressure, heart rate and cholesterol than controls. In the half of these studies containing morbidity and mortality data, those not receiving psychosocial treatments showed greater mortality and cardiac recurrence rates during the first 2 years follow up.
Lifestyle interventions based on exercise training and yoga can reduce cardiovascular risk factors.
Stress has long been believed to adversely affect health, and specifically heart disease, however, there has been limited clinical and research evidence to support this. Recent studies have clarified the mechanisms and measurable effects of chronic stress on the cardiovascular system and the consequent effects on cardiovascular morbidity. There are limited studies to date addressing the effects of stress on cardiovascular mortality.
Stress can be defined as the external or environmental factors to which people are exposed and the behavioural or biological response to it. ⁽¹⁾ Selye’s general adaptation syndrome describes how prolonged, uncontrollable physical and/or psychological distress may ultimately result in a state of exhaustion. ⁽²⁾ The impact of stress is, however, moderated by the personality and coping capacity. Until the 1990’s the “type A” coronary-prone personality theory dominated, however studies failed to show associations with coronary heart disease (CHD). Recent work suggests hostility (“type D” personality) is the “toxic” component for cardiac risk. ⁽³⁾ Hostility is also associated with behavioural risk factors including alcohol, smoking and dietary fat intake, so some effects on CHD are behavior mediated.⁽³⁾
Feelings of extreme tiredness and lack of energy are amongst the most common premonitory symptoms of myocardial infarction and sudden cardiac death. It is suggested that this exhaustion is a consequence of prolonged psychological distress. ⁽²⁾
Studies have shown stressful working conditions can induce sustained changes in neuroendocrine and autonomic activity, increasing atherogenesis. Jobs with high demands and low control are associated with an increased CHD risk. ⁽²⁾ The Whitehall II study of British civil servants found that low job control predicts future CHD independently of standard cardiovascular risk factors.⁽³⁾ A Finnish study over 28 years had similar results, with a combination of high work demands and low job control resulting in a 2.2 fold cardiovascular mortality risk. For employees with effort-reward imbalance, including low salary and lack of social approval, the risk ratio was 2.4.⁽⁴⁾ Longitudinal studies show that self-reports of low control at work predict CAD in a dose-response gradient. ⁽⁵⁾ Low control is also associated with high levels of the clotting factor fibrinogen, which predicts cardiovascular disease. ⁽⁵⁾
CHD [or coronary artery disease (CAD) or ischaemic heart disease (IHD)] refers to conditions resulting from atherosclerosis – plaque accumulation in coronary arteries. This is an insidious and complex process with a series of biochemical, immune and inflammatory and haemodynamic processes interacting with various risk factors. ⁽⁵⁾ At least 3 studies have shown that mental stress induced ischaemia predicts subsequent clinical events in patients with CHD. One study also reported that patients with mental stress ischaemia were more likely to die over a 3 year follow-up period. ⁽⁵⁾
Ischaemia in CHD patients is caused by increased cardiac demand or decreased coronary supply. Mental challenge tasks induce ischaemia in 30%-60% of CAD patients.⁽²⁾ During “daily life activities”, ischaemia ( defined as ST-segment depression of 1mm or more for a duration of > 1 minute) was preceded by mental arousal but not physical activity in the evening, suggesting increased cardiac demand is not the only mechanism involved. Anger was the emotional state most strongly associated with ischaemia. ⁽²⁾
The haemodynamic and neuroendocrine responses to stress are characterised by release of catecholamines and corticosteroids, increases in heart rate, cardiac output and blood pressure, and changes in processes relating to clotting processes (coronary vasoconstriction, platelet aggregation or plaque rupture). In patients with atherosclerosis these changes may trigger clinical events. ⁽⁵⁾
Stress induced autonomic activation may also predispose to cardiovascular events by promoting the development of atherosclerosis over time, or by endothelial dysfunction or directly triggering lethal arrhythmias. ⁽⁵⁾
These interactions have been succinctly summarised by Kop (1999).

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From 2. Kop WJ . Chronic and Acute Psychological Risk Factors for Clinical Manifestations of Coronary Artery Disease.1999. Psychosomatic Medicine 61:476-487



Acute mental stress has been demonstrated to induce prolonged endothelial dysfunction via activation of endothelin-A receptors, reducing the endothelium-dependent, nitric oxide (NO)-mediated vasodilation by half. The authors assert that this supports the concept of an atherogenic effect of mental stress, and “a new therapeutic strategy in the prevention of atherosclerotic vascular disease and its complications.” ⁽⁶⁾ Corticosteroids can cause hypertension by enhancing renal sodium reabsorption, and by augmenting vascular tone via potentiation of the actions of vasoconstrictor hormones (noradrenaline, angiotensin II) and by direct actions on vascular smooth muscle cells. ⁽⁷⁾
Increasingly the inflammatory nature of coronary disease resulting from endothelial dysfunction is being described. Both biomechanical factors associated with pulsatile blood flow and biochemical factors, such as cytokines and growth factors, appear to promote inflammatory inducers of atherosclerosis (e.g. vascular cell adhesion molecules).⁽⁸⁾ Sympathetic nervous system hyper reactivity (AKA cardiovascular reactivity) is a dispositional tendency to exhibit exaggerated heart rate and blood pressure responses to stimuli experienced as engaging, challenging or aversive. ⁽⁸⁾ The previously noted “hostile“ individuals ( displaying negative orientations toward interpersonal relationships and such traits as anger, cynicism and distrust) have been shown to have higher blood pressure and heart rate responses to mental tasks and higher blood pressure during daily life activities. They also exhibit hypercortisolaemia and high levels of circulating catecholamines, and decreased mononuclear leukocyte beta-adrenergic receptor function.⁽⁸⁾ Studies utilising serial carotid Doppler measurements have demonstrated progression of carotid atherosclerosis was more rapid among individuals manifesting more pronounced heart rate and blood pressure responses to physiological challenge.⁽⁸⁾ Finally, hostile CAD patients have a higher rate of restenosis following angioplasty and manifest more ischaemia during stress testing. ⁽⁸⁾
A Lancet case control study in 2004 ⁽⁹⁾ found the increased risk of myocardial infarction associated with psychosocial stressors to be comparable to that from hypertension and abdominal obesity but less than that from smoking. The article concludes
“the importance of psychosocial factors is much more important than commonly recognised, and might contribute to a substantial proportion of acute myocardial infarction” ⁽⁹⁾

Clinical Interventions:

Clinical therapeutic interventions should address the response to chronic stress, the deleterious effects upon the cardiovascular system, and other risk factors. As the risk factors for CHD work synergistically, reduction in all risk factors is desirable. Stress management should facilitate the reduction in use of alcohol, smoking and poor dietary habits. ⁽⁵⁾
Herbal adaptogens are specifically utilised in the management of chronic and maladaptive stress responses. Adaptogens have been defined as
“natural bioregulators, which increase the ability of the organism to adapt to environmental factors and to avoid damage from such factors.” ⁽¹⁰⁾
Withania somnifera radix has been described as being “ ideally suited to the treatment of patients who are overactive but debilitated, for whom Korean Ginseng would tend to cause overstimulation” ⁽¹¹⁾ In animal studies it reduced plasma cortisol and adrenal weight, and prevented many of the biochemical changes of cold stress and immobilisation stress.⁽¹²⁾ W. somnifera is considered to be adaptogenic, anti-arrhythmic, hypotensive, sedative and a nervine tonic.⁽¹³⁾ It was also found to reduce serum cholesterol and ESR in a randomised, double-blind, placebo controlled trial in healthy men aged 50-59. Another trial in six patients with hypercholesterolaemia showed significantly reduced TC, TGs, LDL and VLDL compared with baseline. ⁽¹¹⁾ Dosage: Radix FE 1:2 2 - 4mls tds.⁽¹²⁾
Eleutherococcus senticosus appears to alter the levels of neurotransmitters and hormones involved in the stress response, primarily at the hypothalamic-pituitary-adrenal (HPA) axis. It degrades the enzyme (catechol-o-methyl transferase) and increases the levels of noradrenaline and serotonin in the brain and adrenaline in the adrenal glands. ⁽¹⁰⁾ The Commission E has a contraindication for use in hypertension, however the glycosides in E. senticosus have been found to lower blood pressure. ⁽¹⁴⁾ Pharmacologic research has found E. senticosus can increase repair in damaged heart muscle, increased the number of mitochondria in cardiac muscle and increased the conversion of fat into glycogen for energy. Clinical studies have been of variable standard, but one randomised, comparative trial found a reduction in total cholesterol, LDL and triglycerides. ⁽¹¹⁾ E senticosus has also been shown to bind to receptors for oestrogen, progestin (sic), mineralocorticoids and glucocorticoids. ⁽¹⁰⁾ Dosage: Radix FE 1:2 1 – 4mls bd. ⁽¹²⁾
Herbs to help with symptoms related to stress: Nervines, anxiolytics, sedatives and nervine trophorestoratives.
Leonurus cardiaca. Commission E notes the paucity of recent research for L. Cardiaca, while supporting its use for nervous cardiac disorders.⁽¹⁴⁾ Traditionally L. cardiaca has been used for heart disease, cardiac debility, tachycardia and effort syndrome, in addition to hysteria, nervous conditions and mild hyperthyroidism.⁽¹¹⁾ It is considered to be cardiotonic, hypotensive, antiarrhythmic, nervine tonic, antithyroid, antispasmodic and an emmenogogue. ⁽¹¹⁾ Ursolic acid has cardioactive, antiviral, tumour-inhibiting and cyotoxic effects, while leonurine produces CNS depressant and hypotensive effects when administered intravenously ⁽¹¹⁾ in animals.⁽¹⁴⁾ Dosage: FE 1:2 2.0 – 3.5mls daily. ⁽¹¹⁾
Hypericum perforatum is useful for anxiety and depression; however its interactions with orthodox medicines including digoxin and warfarin limit its usefulness in CHD management. Dosage: Standard or High hypericin FE 1:2 1 – 2mls tds. ⁽¹¹⁾
Valeriana officinalis is anxiolytic, mildly sedative, hypnotic and antispasmodic. It is traditionally used for treatment of anxiety, nervous tension, restlessness and insomnia. ⁽¹¹⁾ One randomised, controlled, double-blind study using a combination of V. officinalis and H. perforatum found beneficial effects comparable to amitriptyline 75-150mg/day in depression over a 6 week treatment period. A double-blind, multicentre trial of combination V. officinalis (containing 0.9 – 1.8 dried root/day) and H. perforatum (containing 0.45-0.9 mg TH/day) showed a comparable reduction in fear and depressive mood to amitriptyline 75-125mg. ⁽¹¹⁾ Dosage: FE 1:2 0.7 – 2mls tds. ⁽¹¹⁾
Turnera diffusa is a nervine trophorestorative used in managing nervousness, anxiety, depression and sexual inadequacy. There are no clinical or pharmacological studies supporting these actions. ⁽¹¹⁾ Dosage: FE 1:2 1 -2mls tds.⁽¹¹⁾
Scutellaria lateriflora is a nervine tonic, mild sedative and antispasmodic traditionally used for nervous excitability, functional cardiac disorders due to nervous causes and “disorders arising from physical or mental overwork”.⁽¹¹⁾ Dosage: FE 1:2 2 - 4.5mls daily.⁽¹¹⁾
Avena sativa is a nervous system trophorestorative used for nervous exhaustion, debility and depression. The seeds have also been attributed with cardiotonic properties.⁽¹¹⁾ In a randomised, placebo controlled trial green oats reduced tobacco use in habitual smokers compared with controls. ⁽¹¹⁾ Dosage: Seed FE 1:1 1 – 2mls tds. Green (straw) FE 1:2 1 – 2mls tds.⁽¹¹⁾
Herbs specifically to address cardiovascular dysfunction:
Most herbs which positively influence cardiac function also have beneficial effects on risk factors such as hyperlipidaemia. Allium sativa has numerous actions beneficial to cardiovascular disease, including lipid lowering, inhibition of platelet aggregation, prolongation of bleeding and clotting time and enhancement of fibrinolysis. ⁽¹⁴⁾ 2 meta-analyses n the 1990’s found reductions in total cholesterol of 9% (using the equivalent of ½ - 1 clove /day) and 12%.⁽¹²⁾ More recent studies have had mixed results, with some also showing reductions in triglycerides and modest reductions in systolic and diastolic BP. ⁽¹²⁾ A double-blind, placebo controlled study found that 800mg of garlic powder/day for 4 weeks caused a significant reduction in platelet aggregation and circulating platelet aggregates.⁽¹²⁾ Spontaneous platelet aggregation was reduced by 56.3%.⁽¹⁴⁾ This effect is likely due to ajoene modification of the platelet membrane structure. ⁽¹²⁾ Another randomised, double-blind placebo controlled 4 year trial assessed the effects of 900mg dried garlic tablets on atherosclerosis. Plaque volume in carotid and femoral arteries measured by serial ultrasound decreased by an average 2.6% in the garlic group compared with an average increase of 15.6% in the placebo group. The authors conclude this suggests a possibly curative rather than merely preventative effect of garlic in atherosclerosis. ⁽¹⁴⁾ The Commission E supports garlic as a support to dietary measures in hyperlipidaemia, and ESCOP (1997) has added indications based on clinical studies for “ prophylaxis of atherosclerosis. Treatment of elevated blood lipid levels insufficiently influenced by diet. Improvement in blood flow in arterial vascular disease.” ⁽¹⁴⁾ Dosage: Fresh bulb 4g/day. Dried powder 600-900mg/day. FE 1:1 4mls/day. ⁽¹⁴⁾
Crataegus spp have been shown to reduce myocardial demands in clinical studies, and also have antioxidant, coronary vasodilatory and cardioprotective activity. The leaves have a more potent antihypertensive effect. ⁽¹²⁾ Crataegus extract and its isolated flavonoids have been shown to inhibit thromboxane A₂ in vitro, thus acting as platelet aggregation inhibitors,⁽¹⁵⁾ but also to stimulate platelet aggregation by enhancing prostacyclin synthesis.⁽¹⁶⁾ Crataegus inhibits the Na+ K+ ATPase in human myocardial cells, increasing intracellular calcium and thus force of contraction. ⁽¹⁶⁾ Unlike most cardioactive medications, Crataegus has been shown, in animal studies, to prolong the myocardial refractory phase, by prolonging the action potential and delaying sodium channel recovery, ⁽¹⁶⁾ which potentially reduces the risk of arrhythmias. ⁽¹⁵⁾ In most animal models standardised Crataegus extracts reduce ischaemia-induced arrhythmias. ⁽¹⁶⁾ Flavonoids, including vitexin and acetyl-vitexin-2”-O-rhamnoside, inhibit phosphodiesterase (PDE) activity in animal and in vitro studies, resulting in vasodilation, increased coronary flow, reduced vascular resistance and increased cardiac contractility and heart rate. Vasodilation may also be due to PDE inhibition of endothelium-derived nitric oxide. ⁽¹⁶⁾ Dosage: [Mixed parts] FE 1:2 0.5 – 2.5mls tds.⁽¹⁷⁾
Salvia miltiorrhiza is indicated for angina due to its vasodilatory, antiplatelet and cardioprotective effects.⁽¹²⁾ It also has anti-arrhythmic, anti-fibrinolytic, antifibrotic, hypotensive and renal tonic actions, ⁽¹³⁾ and is hypocholesterolaemic and hypoglycaemic. ⁽¹⁸⁾ A water-soluble extract of S. miltiorrhiza was found to exhibit anti-oxidant activity and prevent atherosclerosis in rabbits fed a high cholesterol diet. ⁽¹⁹⁾ S. miltiorrhiza inhibited triol- (an oxysterol) induced aortic endothelial cell apoptosis in a concentration-dependent manner. Oxysterols are responsible for the vascular cell apoptosis induced by oxidised LDL involved in atherogenesis. ⁽¹⁹⁾ Dosage: FE 1:2 1.25 -2.5mls tds. ⁽¹⁷⁾
Coleus forskohlii is an Ayurvedic herb traditionally used for cardiovascular disease, containing the diterpene forskolin. Forskolin activates cyclase, increasing cAMP in cells and producing most of the therapeutic actions.⁽²⁰⁾ Raised cAMP - inhibits platelet activation and degranulation; inhibits mast cell degranulation and histamine release; increases cardiac contractility, relaxes arterial smooth muscle and bronchial smooth muscle; increases insulin and thyroid hormone release and increases lipolysis. Forskolin antagonises PAF by interfering with receptor binding. ⁽²⁰⁾ Dosage: FE 1:1 2 – 4.5mls tds.⁽¹⁷⁾
Terminalia arjuna bark has been used in the treatment of CAD, CCF, angina and hypercholesterolaemia. An open study found a 50% reduction in anginal episodes and a significant reduction in systolic BP in patients with stable angina, but no effect in patients with unstable angina after 3 months treatment. Both groups showed improved left ventricular (LV) ejection fraction.⁽¹⁵⁾ In patients with severe refractory cardiac failure (NYHA Class 1V) treated with T. Arjuna while continuing standard drug treatment, there was improvement in symptoms (dyspnoea, fatigue, oedema) and echocardiographic improvement in stroke volume and LV ejection fraction. After 4 months treatment with T.Arjuna, 9 patients had improved to NYHA Class 11, and 3 to Class 111. ⁽¹⁵⁾ Animal studies show a significant, dose-dependent reduction in TC and LDL compared with controls, although the high dose (100mg/kg and 500mg/kg) makes such results unlikely in humans taking relatively smaller doses.⁽¹⁵⁾ Dosage: FE 1:2 0.75 – 2.25mls tds.⁽¹⁷⁾
Dietary interventions are essential for risk factor modification. Modest salt restriction has been shown to reduce BP in double-blind studies. High potassium and magnesium salt reduces BP, and fish oil 6g/day had a mild BP lowering effect.⁽¹²⁾ A diet rich in fruit and vegetables and low fat dairy products and lactovegetarian diet both reduce BP in trials.⁽¹²⁾ Reducing saturated fats and alcohol and increasing consumption of oily fish, fibre, legumes oats and rice can be beneficial for hyperlipidaemia.⁽¹²⁾ Supplemental Omega 3 (such as maxEPA) 3000-4000mg/day, magnesium 300-600mg/day and calcium 500-1000mg/day, Natural Vit E (mixed tocopherols) 250-500 iu/day (if not on low dose aspirin) Co-enzyme Q10, 10-50mg/day ( especially if taking statin drugs) and chromium picolinate= 50mg elemental chromium tds. Green tea for its antioxidant effects and Tilia tea for sedative and hypotensive effects. ⁽²¹⁾

Psychosocial factors contribute both directly and indirectly to the development and promotion of CHD. Apart from direct atherogenic effects they also contribute to maintenance of unhealthy behaviours e.g. smoking and poor diet and further as a barrier to lifestyle modification strategies.⁽⁸⁾ Amelioration of behavioral risk factors may also promote psychosocial wellbeing – exercise improves functional capacity and may improve symptoms of depression.⁽⁸⁾ Animal studies have shown that while exposure to chronic stress impairs endothelium-mediated dilation of atherosclerotic iliac arteries in monkeys fed a high fat diet, its removal tends to reverse this process. This may explain the mechanism by which behavioural interventions reduce the incidence of cardiac events. ⁽⁸⁾

A meta-analysis of more than 20 controlled trials utilising a variety of endpoints evaluating the impact of psychosocial treatments among cardiac patients found that those receiving psychosocial treatments showed greater reductions in psychological distress, blood pressure, heart rate and cholesterol than controls.⁽⁵⁾ In the half of these studies containing morbidity and mortality data, those not receiving psychosocial treatments showed greater mortality and cardiac recurrence rates during the first 2 years follow up. More recent studies have given both positive and negative results. ⁽⁵⁾
An uncontrolled study of a yoga based 10 day lifestyle intervention on biochemical risk factors for cardiovascular disease and diabetes in 98 subjects showed beneficial metabolic effects. Fasting blood glucose, TC, LDL, VLDL and TGs were significantly lower, and HDL significantly higher on completion of the 10 day course. Changes were more marked in those with hyperglycaemia or hypercholesterolaemia. ⁽²²⁾
Regular exercise training reduces cardiovascular disease risk. Studies support the hypothesis that exercise improves vascular endothelial function, probably by improved nitric oxide bioavailability from increased synthesis and reduced oxidative stress- mediated destruction. ⁽²³⁾

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My recent journey - apologies and explanation

Greetings to all, and thankyou for the cards and good wishes.
First, I want to apologise for the abrupt departure - I felt I didn't have a choice.
Second, my new rules prohibit me from wasting time, so I will not be going over everything looking for typos - my neck and back are not up to it.


So, as any of you who have known me for a while are aware, I tend to overshare.
It was my intention to post something much sooner, however there have been many inconsistencies and I didn't want to provide incorrect information.


Back in march this year my usual disc prolapse low back pain was getting bad and also affecting my hip, and then it became intolerable. Now not only could I barely stand, but I couldn't sit either.
Being the (sometimes) good doctor that I am I went to my GP, to confirm that I needed an xray and a CT, which I did on 26th march at the local x-ray practice. That evening my GP called to say that they had found several metastases in my spine and pelvis, in addition to the disc prolapses and moderate arthritis in my hips. Obviously this was quite a shock, as I wasn't aware I had a primary cancer.
I spent the next 3 days in the x-ray practice having CTs of my chest and pelvis and ultrasound of my breasts, basically just praying it wasn't lung cancer. As you know despite quitting numerous times I am an addicted smoker, and no-one gets less empathy than a smoker with lung cancer.
When the chest CT came back clear, I was so relieved it was almost like I was OK.




The breast Ultrasound was clear, the abdominal CT was clear, and I couldn't get a mammogram for a week. The radiologist managed to get me an urgent appointment at their other practice the next day - I think he felt (rightly) bad. In October 2013 I fractured my rib making the bed - this might seem alarming , but my immune condition also has associated skeletal problems including minimal trauma fractures. However, when it wasn't settling I had an xray - on my birthday which was Melbourne cup day, as nobody ever wants to book in to see me on Melbourne cup day, and I thought xray might be similar. I specifically asked him if the 7th rib fracture found could be a pathological fracture (a fracture through a bone weakened by metastasis) and he said no.
Anyway, the mammogram didn't show anything, so then I'm think it must be a melanoma ( I don't have anything resembling a melanoma, but they can be in the back of the eye or other hidden locations). Then they did another ultrasound with close up views which found a lesion deep in the left breast, and then another mammogram which showed the unmistakable irregular and spiculated lesion.
It was very deep, and even after they found it I couldn't feel it. The doctor asked if I wanted to have the biopsy done immediately, which I did. I didn't even realise it was a core biopsy, having heard how painful they were and this was nothing so I assumed it was a fine needle biopsy.




I had already tried to book in with a breast surgeon - I rang for 3 days and nobody answered the phone on Thursday, Friday or Monday. They eventually rang me back on Tuesday - apparently the receptionist had been on holidays, which seems pretty pathetic. In the meantime I booked with another female breast surgeon, which turned out to be my biggest mistake. I think that was the worst consultation I have ever had, and having seen many orthopaedic surgeons over the years didn't think it could get worse. My sister came with me, which was fortunate as I might have otherwise thought it didn't happen. Don't want to elaborate, but I then had to find another breast surgeon. My sister and I actually had a giggle at the report, which stated the lesion was 13cms deep to the nipple. We didn't realise my boobs were so huge! (especially having shrunk with menopause) Of course this is when squished, but still quite bizarre. Definitely explains why it couldn't be felt.


She did send me to an female oncologist I liked, except when my ankle swelled up like an orange where the pin and plate had been happily in situ for 15 years. Although she did order an xray which showed moderately severe soft tissue swelling over the pin and plate extending up my leg, she didn't seem to think this was odd or required explanation. All good now though.






At this stage I  assumed I would need a lumpectomy and semi urgent radiotherapy to my back, as I was getting signs of spinal cord compression ( I think - I had some weird paraesthesia in my legs which was presumed post polio, but nobody except me seemed to be bothered trying to find out)


Obviously breast cancer was the most likely - my sister, who has a much healthier lifestyle and less risk factors than me, was diagnosed at 50, and a second cousin died at 38 (and her aunt, her father's twin sister, died in her 50's) and my father had prostate cancer.
In addition, I have a genetic immune disorder which not only causes my severe allergies, but also leaves me susceptible to infections and cancer.
So, really it was just a matter of time, but it didn't cross my mind that it would present with metastases. Yes , I had my screening mammograms from age 50 (and copious ultrasounds prior due to very dense breasts and copious cysts - another risk factor) and was due that week.
Since working in a hospital in 1986 I had never seen a woman with metastatic breast cancer.
I had seen elderly men with metastatic prostate cancer during my GP days, and they looked like they had metastatic cancer. I didn't. Due to my increasing immobility I was into the obese BMD range; my nails were over a centimetre, my hair that never grew was at my waist. It seemed very strange. I didn't fit my image of someone with metastatic cancer.
Since working with primarily perimenopausal and menopausal women for 10 years I had only seen 1 woman with breast cancer (who had immune issues somewhat like mine), and 2 weeks before I left someone with a history a copious cysts like me (who only got checked because I insisted she did, even though the lump didn't feel especially concerning) This is in contrast to my GP days when I would see or diagnose a woman every 6 months.






Like 80% of women with breast cancer I had had unusual amounts of stress in the previous 2 years.
Apart from the pain and increasing post polio disability, which I could take no painkillers for, having been told by both the dermatologist and the allergist that they caused the severe allergy ( I thought they were wrong but couldn't risk it. They were), my father had been very unwell, and I was in the impossible position of trying to stop the doctors from killing him while respecting his request not to interfere. (he has pretty much recovered and recently turned 88, and advised me he is not going to die)
The ex-boss from Newtown (not Sandra), with whom we moved to Rosebery, stopped paying everyone in 2012, and then went bankrupt with hundreds of creditors. Even Fair Trade could not help the reception staff. Having 20 % of your salary stolen when you only work 2 days and just get by is a problem. He actually looked me in the eye twice and promised I would get the backpay that evening.
And then a $1500 parcel "disappeared" from the Post Office while awaiting collection, and after a 3 month investigation they concluded proper procedure had not been followed and they could not account for it's whereabouts, but basically tough shit. This pushed me to the limit financially.
I actually forgot perhaps the last straw. The people upstairs were to do a 6 week renovation, and laid thick plastic over the stairs. This is difficult enough to negotiate for a normal person, but try doing it with the equivalent of a severely sprained ankle, mild stroke, slowly recovering knee replacement, fractured rib and spinal fractures ( so I couldn't even drag myself along using the handrail) After 4 months, when work had stopped for 3 weeks over Xmas, I rang the contractor to request the plastic be removed - in addition to me, my elderly neighbour also had a spinal fracture and the neighbour across the hall was heavily pregnant. He verbally abused me regarding the Body Corporate taking too long to approve the removal of a structural wall - I'm not even on the body corporate.
After 6 months I stopped going anywhere except work, as my knee was stuffed from the difficulty of the movements required in trying to not fall down the stairs. The most frustrating part was they would wake me at 7.30 with drilling every day, then leave an hour later. After 8 1/2 months I rang the owner after 3 days of constant jackhammering of tiles, and was advised they were now finished except for hanging 4 doors.
Obviously I am not a tradesman as I didn't realise hanging doors entailed a further week of drilling and hammering, so loud that when I went up and knocked on the door as loudly as I could (injuring my hand in the process) they couldn't hear me.
Finally they finished after 9 months (yes, like gestation), but then every time the hot water was turned on I had water running down my dining room wall, just where I had stacked some prints I was planning to sell.
I should have just fallen down the stairs and sued them, but to me that would entail bad karma.




OK. Now if I was reading this my first question would be did the bioidentical hormones cause this?
I honestly don't believe so, in fact I think if anything they delayed it, but there is no way of being certain.
 I started researching the progesterone when my sister developed significant oestrogen dominance issues before age 40.  When I developed fibroids at around 40 I was determined not to have a hysterectomy - and I didn't. My fibroids shrank during perimenopause, a time when they usually go ballistic. I believe they were protecting my breasts as well, and I was using a very small amount of primarily E3, the least stimulating oestrogen.
During perimenopause I measured my oestrogen one day when my boobs felt like they were going to explode, and the reading was 3201 - the highest reading I had ever seen - the normal range for the preovulatory peak is 600-2500, but I had never seen a reading over 2000. I believe I was very oestrogen dominant from the time I started menstruating at 11.
Strangely, after 15 months without menstruating - thinking I had finally made it to menopause after getting just past the year twice already, 2 weeks before the pain got really bad I had signs of ovulation (at 53!) and sure enough, 14 days later I had a period. That's why I delayed the mammogram for 2 weeks, as I knew my boobs would be way too sore.
As it was, despite having very little oestrogen for nearly 5 years, my mammogram showed "both breasts are very dense with greater than 75% fibroglandular density"








So that was a pretty full on week - I told Peta, my receptionist to cancel the Saturday and Tuesday appointments. By the next week I was pretty much off my face on painkillers - between the pain and the painkillers and being somewhat in shock, I really couldn't concentrate, and didn't think it was appropriate to be consulting with patients, so on Monday I asked Peta to refer everyone to Dr Cabot or Dr Tendek, who had worked with us at Broadway. I wasn't sure if I would be going back to work, but certainly couldn't see going back for months, and it would be unfair to leave people in limbo


I have often joked that unless I was dead I would go to work, and I had pretty much lived up to that - I had worked with bronchitis and pneumonia, a severe allergic reaction (erythema multiforme, while recovering from knee replacement) in a wheelchair and on a walking frame, crutches and walking stick; with a fractured rib and 2 spinal fractures (which made just taking a blood pressure reading excruciating), but this was too much.




I had yet to have a blood test and was very concerned that my calcium would be off the chart, but it wasn't. All my tumour markers were normal (which is unusual but not unheard of); more strange was my normal alkaline phosphatase, which should have been off the chart also with multiple metastases.
I started doing some research and came up with several studies showing osteomyelitis could mimic metastases, especially in breast cancer. I remembered having had a fever for 2 weeks before the pain, and having totally different night sweats - at the time I thought "I wonder if this is what malaria feels like?". Only the radiologists put any stock in this theory, and 2 lots of bone scans and CTs they say are definitely metastases. But when pressed. admit without a biopsy you can't be 100% sure.
Problem was all the lesions were either adjacent to the spinal cord or the heart (they found one in the sternum on the breast MRI, which I didn't want and they didn't advise I would get no rebate from the $700 - strangely if you don't have breast cancer, you do get a rebate)






At this point I realised I was the only one actually thinking - I needed to see me, but obviously I couldn't be objective, and my thinking was a bit clouded (although still seemingly better than most of the specialists I was seeing)


So, I contacted my ex boss, Dr Sue. I describe Sue (with permission) as me on steroids - very good diagnostician, and will do whatever it takes to get a patient what they need, but stay away when in a bad mood. Sue advised me of a blood test for osteomyelitis - procalcitonin. As I have not done general practice for over 10 years there are some things I am not up to date with. This came back negative, but is only positive 60% of the time. She also got me an urgent appointment with a new breast surgeon. Unfortunately she no longer worked at Macquarie, and I had to go to Bella Vista.
Apart from the distance, I'm glad someone drove me because I really might have thought I had hallucinated her. In the starkest contrast, this doctor had an energy that I have never encountered before, but would have to describe as like an angel. Her manner was so welcoming, and she seemed to exude some sort of peaceful calm. All I could think was what a waste being a surgeon - she would be so perfect as an oncologist. Both my brother who drove me the first time, and my friend the second time could sense her "spirit" across the room, although they did not come in with me.
However, she agreed there was no reason to do a lymph node biopsy or lumpectomy, but listened to my theory and requested her radiologists repeat all the scans looking for any evidence for osteomyelitis. Again they ruled it out, while agreeing a biopsy was the only definitive test.
 The other confusing thing was that several metastases, notably one in my right shoulder that I couldn't feel, and in my left hip, did not show up on subsequent xray.
Again no one thought this was strange or required further consideration.








So, I decided to take it as a good thing that I was not going to be mutilated, and I could keep taking my herbs (which I would have had to stop for radiotherapy). I had done a lot of research when I was studying herbal medicine, and one text was extraordinary - written in 2001by John Boik as a thesis, this 500+ page book had all the mechanisms for herbal constituents on cancer cell growth and death (apoptosis) Whenever I am told there is no evidence for herbal medicine, I direct people (or doctors) to this book. I gave a copy to my oncologist and the radiotherapist. In 2004 it cost $90 for the softback, but is available as a download for $25US on the honour system. This is a very scientific book and you need science (probably biochemistry) knowledge to read it but is an awesome book. Please don't abuse the honour system if you do want to read it. It's titled Natural Compounds in Cancer Therapy.
There are some especially useful tables showing synergistic effects of the active consituents, and I based my herbal regime mainly on this. Most anti oxidant herbs have anti cancer and , of course, anti inflammatory effects - helpful as the anti hormone therapy (letrizole) causes major exacerbation of the arthritis.


I also re read the book by Professor Jane Plant - your life in your hands - and went off dairy.
For most people this would not be too problematic, but being allergic to all seafood and eggs, I used cheese as my major protein source.






So after 12 weeks the oncologists suddenly decides I should see a radiotherapist. On the way there a truck runs up my arse when I give way to a police car with flashing lights at a major intersection.
At least he stops - ironically, his truck says Traffic Management Australia.
Anyway, the radiologist won't touch me till a spinal surgeon says my spine is not going to disintegrate, which would mean instant paralysis. Neither he no I can get me an appointment within a month, but Sue gets me in on Monday (this is Friday), then turns up at the appointment to support me.


Sue will tell you I saved her life when she had a serious autoimmune disorder. This is an exaggeration, although I did help to diagnose the disorder that the specialists were clueless about.
Sue and I like to bitch about crappy specialists. Sue is extraordinary, and I would trust her above any emergency physician in an emergency, and she also teaches head and neck anatomy to dentistry students.[ correction - teaches acupuncture to doctors and dentists, requiring in depth anatomy knowledge]. I can't thank her enough - I think I would have totally lost the plot without her input.
But also my friends and family were awesome when I couldn't drive.
My first panic was I had no will, and needed to do one in case I developed brain metastases. No way I was going to let the government steal my unit - I worked bloody long and hard to keep it.


I found a great local GP and a fabulous physio who does acupuncture -will not touch my spine.
I also have several disc prolapses in my neck, and my hands have been going numb then the burning pain, waking me up and lasting well over an hour. Hopefully , not dragging 20 kilos of scans around will help a bit. And I got a new Tempur symphony pillow - this "cured" the same issue 15 years ago.




I also emailed Sandra (Cabot) and she told me they had a Hyperbaric Oxygen therapy tank at Camden. Some research showed this to be quite promising in animal studies for solid tumours (especially breast ) and metastases. The thought of getting to Camden wasn't appealing, but then she advised a new tank was opening in Leichhardt the next week. Leichhardt is 5 kilometres. so I took that as a sign, and had my first session yesterday - fortunately a short one as it was so boring and I hadn't thought of taking music. I have now had 5 sessions, and feel I can recommend this clinic - The Cosmic Tree at 314 Norton St Leichhardt (the quiet end near City West Link) They are very attentive and I felt safe and secure. I was quite astonished when the oncologist seemed to think it was a good thing to try - I was prepared to be talked out of going ahead.




Also amongst all of this I was very pleased the Hay House World ( Internet) Summit was on in june.
Really interesting stuff, and lots of people who were told they were going to die, or who had actually died, and now go around speaking at health summits. Really cutting edge stuff about epigenetics and how you can switch off genes with your mind. Unfortunately my upgrading my internet in preparation was a disaster as it took a week, and I missed most of it, but fortunately they did a 36 hour re run. Of course you could buy the entire summit for $400, but that would be information overload.
I also saw a medical intuitive. I had been told about a doctor in Bondi Junction years ago, but had not gotten around to it (of course) In googling her, I found someone else, called Rachelle. I took this as a sign ( although after nearly 50 years with barely a Rachelle in sight there seems to be one every time I turn on the TV now). I had no idea what to expect, but basically she reads auras and did some chakra cleansing. She was lovely, and her Art Deco bathroom had exactly the same tiles as my previous Art Deco bathroom.






So, my MRI last Monday showed that several of my metastases have disappeared. I could feel a change last week, after being up for 3 hours and realising I hadn't taken any oxycontin or endone.


Obviously it is my plan to cure my cancer, and if successful may start curing others.
I will be writing my autobiography - it will probably have more about music and seeing bands than about being a doctor. I'm about 3/4 way through.

I wanted to get something to thank Dr Sue, and when I saw these in an auction catalogue I knew they were perfect. I visualised taking them to her all week, and was very happy to acquire them for much less than I was willing to pay.

Ok. That's my story. It's all true. The ending is yet to be written.

Calcium and heart disease

Over the past few years there have been several studies suggesting calcium supplements increase the risk of cardiovascular disease events, however the majority of these observational studies depend entirely on recall of supplement use, and do not distinguish between different forms of calcium.
This makes the evidence from these studies low on the scale of reliability, however it is reassuring to have a study with more positive results.
A Canadian study published online May 23rd in the Journal of Clinical Endocrinology and Metabolism  found in those women who were taking calcium supplements up to 1000 mg per day, as opposed to no supplements, there appeared to be a reduction in mortality. And there was a similar trend in individuals who were getting calcium from dietary sources rather than from supplements
The findings are reassuring, said Dr. Goltzman, because some prior research "has suggested that cardiovascular events — heart attacks and strokes — could be increased by calcium supplements." And the new results are consistent with other findings from the Women's Health Initiative*, which also found a slight reduction in all-cause mortality with calcium, as did the Iowa Women's Health Study, he noted. These findings were only found in women.
However, the current research did not produce any conclusive evidence about vitamin D, Dr. Goltzman said. "We couldn't say there was any adverse or beneficial effect of vitamin D on all-cause mortality."
* The Women's Health Initiative (WHI) double-blind, placebo-controlled clinical trial randomly assigned 36,282 postmenopausal women in the U.S. to 1,000 mg elemental calcium carbonate plus 400 IU of vitamin D(3) daily or placebo showed
"Among women not taking personal calcium or vitamin D supplements at baseline, the hazard ratio [HR] for hip fracture occurrence in the CT following 5 or more years of calcium and vitamin D supplementation versus placebo was 0.62 (95 % confidence interval (CI), 0.38-1.00). In combined analyses of CT and OS data, the corresponding HR was 0.65 (95 % CI, 0.44-0.98). Supplementation effects were not apparent on the risks of myocardial infarction, coronary heart disease, total heart disease, stroke, overall cardiovascular disease, colorectal cancer, or total mortality, while evidence for a reduction in breast cancer risk and total invasive cancer risk among calcium plus vitamin D users was only suggestive."

Another recently published study, entitled Calcium intake and serum concentration in relation to risk of cardiovascular death in NHANES III, included serum calcium levels to estimated intake and found
"There was increased risk of overall CVD death for those in the bottom 5% of serum calcium compared to those in the mid 90% (HR: 1.51 (95% CI: 1.03-2.22)). For women there was a statistically significant increased risk of IHD death for those with serum calcium levels in the top 5% compared to those in the mid 90% (HR: 1.72 (95%CI: 1.13-2.61)), whereas in men, low serum calcium was related to increased IHD mortality (HR: 2.32 (95% CI 1.14-3.01), Pinteraction: 0.306). No clear association with CVD death was observed for dietary or supplemental calcium intake."
The conclusion from this study was
"Calcium as assessed by serum concentrations is involved in cardiovascular health, though differential effects by sex may exist. No clear evidence was found for an association between dietary or supplementary intake of calcium and cardiovascular death."

Dr Rachelle Andgel -Moving Again

Effective 29th June 2012 we are moving again. Last time we had to move very quickly, and the premises were less than ideal.
The new premises are much easier for parking, either in the attached carpark or on the street (with no meters) and nice and new inside. We're very happy about this move, and hope to be there as long as we were at Broadway.

 The new address is

 Holistic Medical Practice
 530 Botany Rd Rosebery - near the corner of  Beaconsfield.
 Phone  83949144 (or our old number 95579600)
 Peta and Lili are already there to make appointments.

Dr Rachelle Andgel. Relocation from Broadway Premises

Effective 14th April 2011 Dr Rachelle Andgel will be relocating from The Broadway Shopping Centre to

The Carillon Ave Holistic Medical Practice
Suite G10 (Gound Floor) 100 Carillon Ave Newtown 2042.
This is the RPAH Medical Centre Building, at the corner of Missenden Rd and Carillon Ave.
There is limited parking (expensive) in the building, and local parking is difficult on weekdays, so public transport is advised. There is a drop off area at the front of the building. Buses run along King St Newtown and to RPAH.(details to be advised)
To organise an appointment phone (02) 95579600 to speak with Peta or Lili. They can also advise you of the other practitioners and services at the practice
Dr Andgel has made this move in order to continue to provide the personal service our patients have experienced since 2003. Please bear with us if there are a few teething problems in the first few weeks.