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Are you having a little trouble hearing conversations? If so, you’re not alone. An estimated 23% of Americans ages 12 and older have hearing loss. Although most of those people have mild hearing loss, for people ages 80 years and older, it’s more common for hearing loss to be moderate to severe than mild.

But not only is moderate to severe hearing loss disruptive to one’s life, it also makes you more likely to develop dementia. A new study helps explain why — and what you can do about it.

What did the new study look at and find?

A study published in JAMA focused on a sample of adults in the United States from the National Health and Aging Trends Study, which follows Medicare beneficiaries. The participants sampled were 70 or older.

The researchers found that about 33% of participants had normal hearing, 37% had mild hearing loss, and 30% had moderate to severe hearing loss. Dementia occurred least often among those with normal hearing (6%), more often among those with mild hearing loss (9%), and most often among those with moderate to severe hearing loss (17%). That’s a large increase in risk, particularly for those whose hearing loss is moderate to severe.

What else to know about this study

The study sample was selected to make it possible to analyze subgroups by age and apply findings to a diverse population. The sample included additional participants ages 90 years and older, and additional participants who identified as Black. Of the 2,413 total participants, 53% were ages 80 years and older, 56% were female, 19% were non-Hispanic Black, 4.5% were Hispanic, and 74% were non-Hispanic white.

Also, unlike previous research, this study looked objectively at hearing loss and dementia. Prior research had shown that hearing loss is thought to account for about 8% of all dementia cases worldwide. Exactly why the connection exists is not known.

It’s important to note that most large studies that found this link were based on questionnaires that people fill out. In other words, no one actually measured the hearing of those participating in the study to make sure that they had hearing loss — or that their hearing was really normal.

In this new study, however, the investigative team used an electronic tablet-based audiometer to evaluate participants’ hearing for four pure tone frequencies that are most important for understanding speech. So, for the first time in a large study, there was objective measurement of hearing loss.

How do hearing aids reduce the risk of dementia?

If you have hearing loss, does that mean you’re doomed to develop dementia? Not at all. This study found that those with moderate to severe hearing loss could significantly reduce their risk of dementia simply by using hearing aids.

This research helps us understand why hearing loss causes dementia. Here’s the connection:

There is increasing evidence that the more the brain is stimulated, the less likely it is that dementia will develop. When there is hearing loss, auditory stimulation is reduced. This, by itself, likely increases dementia risk. But even more important is that when an individual suffers from moderate to severe hearing loss, they are less likely to participate in social activities. Perhaps they are embarrassed about their hearing loss. Or they may simply find it unrewarding to attend a social event when they cannot hear what is going on.

It turns out that social activities are one of the best ways to stimulate the brain, as there is evidence that our brains evolved to facilitate social behavior. Given all this information, you won’t be surprised to learn that reduced social activity has been linked to cognitive decline. Thus, this new study provides additional evidence that the reason hearing loss increases the risk of dementia is because hearing loss reduces brain stimulation — both directly and through reduced social interaction.

What to do if you have hearing loss

Don’t let hearing loss raise your risk of dementia.

• Keep your ears clean. (But remember, never put anything in your ears smaller than your elbow. Ask your doctor if you’re not sure how to clean your ears.)
• If you can’t hear and you don’t have hearing aids, get them. Hearing aids now available over the counter can help many people with mild to moderate hearing loss.
• If you have hearing aids, wear them.
• If your hearing aids aren’t working, get them fixed.
• Don’t be passive — ramp up your social life and other activities.

All these things will help to reduce your risk of dementia. And you might just find that, despite some hearing loss, you’re enjoying life more.

About the Author

Andrew E. Budson, MD, Contributor

Dr. Andrew E. Budson is chief of cognitive & behavioral neurology at the Veterans Affairs Boston Healthcare System, lecturer in neurology at Harvard Medical School, and chair of the Science of Learning Innovation Group at the … See Full Bio View all posts by Andrew E. Budson, MD

Screening tests, such as Pap smears or blood pressure checks, could save your life. They can detect a disease you have no reason to suspect is there. Early detection may allow treatment while a health condition is curable and before irreversible complications arise.

Some screening tests help prevent the disease they are designed to detect. For example, colonoscopies and Pap smears can identify precancerous abnormalities that can be addressed so they cannot continue to grow and become cancerous. And missed screening tests contribute to thousands of avoidable deaths each year in the US. Yet there’s a point of diminishing returns, as a new study on Pap smears illustrates. And many of us could benefit from a better understanding of the limits of screening, and how experts decide when people should stop routine screening tests.

Know the limits of screening tests

Even the best screening test has limitations. It can miss the disease it’s intended to detect (false-negative results). Or it can return abnormal results when no disease is present (false-positive results).

Equally important, as people grow older life expectancy declines and screening benefits tend to wane. Many conditions detected by routine screenings, such as prostate cancer or cervical cancer, typically take a while to cause trouble. A person in their 80s is more likely to die from another fatal condition before cervical cancer or prostate cancer would affect their health. Additionally, certain diseases, such as cervical cancer, become less common with advancing age.

As a result, many screening tests are not recommended forever: at some point in your life, your doctor may tell you that you no longer need to repeat a screening test, even one you finally got used to having.

Know when screening tests usually end

Expert guidelines for many common screening tests include an “end age” when people can reasonably stop having the test. For example:

• Pap smear: age 65
• mammogram: age 75
• colonoscopy: age 75
• chest CT scan (recommended for people with a significant smoking history): age 80.

There are exceptions, of course. For example, if a colonoscopy found abnormalities in an otherwise healthy 72-year-old, repeat testing after age 75 may be recommended.

Many women have Pap smears after guidelines suggest stopping

Pap smears screen for cervical cancer. In 1996, new guidelines recommended that women who received Pap smears at appropriate intervals before age 65 could safely stop.

Yet many women continue to have this screening after turning 65, according to a recent study published in JAMA Internal Medicine that looked at data from 15 to 16 million women per year between 1999 and 2019. Their average age was 76, most (82%) were white, and all were enrolled in Medicare.

The study found:

• In 1999, nearly three million women over age 65 (almost 19% of the study population) had Pap smears. By 2019, the number had fallen to 1.3 million (8.5%), a reduction of more than half.
• Among women older than age 80, about 3% had Pap smears.
• In 2019, the estimated cost related to Pap smears in these older women was $83.5 million.

Possibly, some women in this study had good reasons to continue having Pap smears. Perhaps they weren’t adequately screened when they were younger. Perhaps they had previous Pap smear abnormalities. Maybe their doctors recommended they continue having Pap smears despite their advanced age. We don’t know, because this study didn’t collect that information. Still, it’s quite likely that many (or even most) of these Pap smears represent overscreening: routine testing with little chance of benefit.

Why does overscreening matter?

Overscreening may cause

• discomfort that may be tolerable when there’s an expectation of benefit, but less acceptable when the test is unnecessary
• anxiety while awaiting the results of the test
• false-positive results that lead to additional testing and unnecessary treatment
• complications of testing, such as infection or bleeding after a Pap smear, or perforation or bleeding after a colonoscopy. (Fortunately, complications are rare.)
• unnecessary costs, including medical appointments and lab fees, time wasted, and taking health providers away from more valuable care.

The bottom line

Screening tests are typically performed for people without symptoms, signs, or a high suspicion of disease. In many cases, they’re looking for a condition that is probably not there. For most screening tests, we have guidelines developed by experts and backed by data suggesting when to start — and when to stop — screening.

But guidelines are only general recommendations, and individual preferences matter. If foregoing a screening test will cause you excessive anxiety, or if having a test will provide significant peace of mind, it may be reasonable to have a test even after the recommended end age. Be sure you understand potential downsides, such as additional tests and complications.

So, never hesitate to ask your doctor when your next screening tests are due — but don’t forget to also ask if they are no longer worth having.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

Understandably, the sensitive topic of weight in children and teens often focuses on the health costs of overweight and obesity. Sometimes, though, a child needs to gain some weight. And while there are lots of ways to make that happen, not all of them are healthy.

What to do if your child seems underweight

If you are worried about whether your child needs to gain weight, it’s very important to check with your doctor before getting to work on fattening them up. It’s entirely possible that your child’s weight is absolutely fine. Given that one in five children in the US is obese and another one in six is overweight, it’s easy to see how a parent might think their child is too thin in comparison. One way to find out if your child’s weight is healthy is to check their body mass index, a calculation using height and weight that is used for children ages 2 and up.

Losing weight or being underweight can be a sign of a medical or emotional problem, so be sure to let your doctor know about your concerns. They may want to see your child to help decide if any evaluations are needed. If your child is less than 2 years old, it’s particularly important that you check in with your doctor about weight concerns, and follow their advice exactly.

Choosing healthy foods when a child needs to gain weight

If your child is older than 2 and the doctor agrees that gaining weight is a good idea, the best way to approach it is by using healthy foods and healthy habits.

Three ways to help encourage healthy weight gain:

• Give your child three meals (breakfast, lunch, and dinner) and two healthy snacks (mid-morning and mid-afternoon). If your child eats dinner early, you could consider a small snack before bedtime. Try to avoid snacks in between or drinking anything other than some water; you want them to be hungry when you give them food.
• Offer healthy high-calorie foods. Think in terms of healthy fats and protein. Some examples are:
  • nuts and nut butters, as well as seeds like pumpkin or sunflower seeds
  • full-fat dairy, such as whole milk, heavy cream, cream cheese, and other cheeses
  • avocados
  • hummus
  • olive oil and other vegetable oils
  • whole grains, such as whole-wheat bread or granola (look for granola sweetened with juice or fruit rather than sugar)
  • meat if your diet includes it
• Every time you prepare a meal or snack, think about how you might add some calories to it. For example, you could add some extra oil, butter, or cheese to pasta — or some nut butter on a slice of apple or piece of toast.

Three traps to avoid:

• Giving your child more sweets or junk food. It’s tempting, as children generally want to eat sweets and junk food, and both have calories. But they aren’t healthy foods, and it’s not a good idea to build a sweets and junk food habit.
• Giving your child unlimited access to food. This, too, is tempting — after all, you want them to eat! But not only does that make it hard to be sure that what they are eating is healthy, snacking can make them less hungry when it’s time for an actual meal.
• Letting your child fill up on milk and other drinks — including nutritional supplement drinks. This, too, makes it less likely that they will eat at mealtime, and they are unlikely to get all the nutrients they need. Don’t give your child nutritional supplements unless your doctor advises you to do so.

Be sure you schedule regular check-ins with your doctor to monitor your child’s progress. Hopefully your child will soon be at a healthier weight that helps them to thrive as they grow.

Follow me on Twitter @drClaire

About the Author

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD

How well are you protecting yourself against heart disease, the nation’s leading cause of death? A check of five important numbers can give you a good idea: blood pressure, blood sugar, LDL cholesterol and triglyceride levels, and waist circumference. Those values provide a picture of a person’s overall health and, more specifically, what factors they may need to address to lower their chance of a heart attack or stroke.

Below are the ideal values for each measurement, along with why they’re important and targeted advice for improving them. Universal suggestions for improving all five measurements appear at the very end.

How do your heart health numbers stack up?

While the ideal values are good goals for most people, your doctor may recommend different targets based on your age or other health conditions.

Blood pressure

Less than 120/80 mm Hg

Blood pressure readings tell you the force of blood pushing against your arteries when your heart contracts (systolic blood pressure, the first number) and relaxes (diastolic blood pressure, the second number). Your blood pressure reflects how hard your heart is working (when you’re resting or exercising, for example) and the condition of your blood vessels. Narrowed, inflexible arteries cause blood pressure to rise.

Why it matters to heart health: High blood pressure accelerates damage to blood vessels, encouraging a buildup of fatty plaque (atherosclerosis). This sets the stage for a heart attack. High blood pressure forces the heart’s main pumping chamber to enlarge, which can lead to heart failure. Finally, high blood pressure raises the risk of strokes due to a blocked or burst blood vessel in the brain.

What helps: A diet rich in potassium (found in many vegetables, fruits, and beans) and low in sodium (found in excess in many processed and restaurant foods); minimizing alcohol.

LDL cholesterol

Less than 70 mg/dL

A cholesterol test (or lipid profile) shows many numbers. Doctors are usually most concerned about low-density lipoprotein (LDL) cholesterol, particles that makes up about two-thirds of the cholesterol in the blood.

Why it matters to heart health: Excess LDL particles lodge inside artery walls. Once there, they are engulfed by white blood cells, forming fat-laden foam cells that make up atherosclerosis.

What helps: Limiting saturated fat (found in meat, dairy, and eggs) and replacing those lost calories with unsaturated fat (found in nuts, seeds, and vegetable oils).

Triglycerides

Less than 150 mg/dL

Perhaps less well-known than cholesterol, triglycerides are the most common form of fat in the bloodstream. Derived from food, these molecules provide energy for your body. But excess calories, alcohol, and sugar the body can’t use are turned into triglycerides and stored in fat cells.

Why it matters to heart health: Like high LDL cholesterol, elevated triglyceride values have been linked to a higher risk of heart attack and stroke.

What helps: Limiting foods that are high in unhealthy fats, sugar, or both; eating foods rich in omega-3 fatty acids (such as fish); avoiding alcohol.

Blood sugar

Less than 100 mg/dL (fasting)

High blood sugar defines the diagnosis of diabetes. Type 2 diabetes is most common. It occurs when the body develops insulin resistance (insulin enables cells to take in sugar) and does not produce enough insulin to overcome the resistance.

Why it matters to heart health: High blood sugar levels damage blood vessel walls and cause sugar (glucose) to attach to LDL. This makes LDL more likely to oxidize — another factor that promotes atherosclerosis. Excess sugar in the blood also makes cell fragments called platelets stickier so they’re more likely to form clots, which can trigger a heart attack or stroke.

What helps: Avoiding sugary beverages and foods high in sugar; eating whole, unprocessed grains instead of foods made with refined grains (white flour, white rice).

Waist circumference

Whichever number is lower:

Less than half your height in inches

OR

Women: Less than 35 inches

Men: Less than 40 inches

Measure your waist around your bare abdomen just above your navel (belly button). A big belly — what doctors call abdominal or visceral obesity — usually means fat surrounding internal organs.

Why it matters to heart health: Visceral fat secretes hormones and other factors that encourage inflammation, which triggers the release of white blood cells involved in atherosclerosis.

What helps: Consuming fewer calories, especially those from highly processed foods full of sugar, salt, and unhealthy types of fat.

Universal advice to improve all five measures of heart health

If one or more of your numbers is above ideal levels, you’re far from alone. Most Americans are overweight or obese and have bigger-than-healthy bellies. Excess weight and waist circumference affect blood pressure, LDL cholesterol, triglycerides, and blood sugar. Eating a healthy, plant-based diet can help. Regular exercise also helps: aim for at least 30 minutes of moderate-intensity exercise like brisk walking most days. Other lifestyle habits that can lower your heart disease risk include getting seven to eight hours of sleep nightly and managing your stress level.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Howard LeWine, M.D., is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

I admit it: I’m not a fan of drug ads. I think the information provided is often confusing and rarely well-balanced. Plus, there are just so many ads. They show up on TV and streaming programs, on social media, on billboards and the sides of busses, on tote bags, and in public bathrooms. Yes, there’s no refuge — even there — from the billions spent on direct-to-consumer ads in the US.

I’ve often wondered how highly-promoted, expensive new drugs stack up against other available treatments. Now a new study in JAMA Network Open considers exactly that.

Many advertised drugs are no better than older drugs

The study assessed 73 of the most heavily advertised drugs in the US between 2015 and 2021. Each drug had been rated by at least one independent health agency. Researchers tallied how many of these drugs received a high therapeutic value rating, indicating that a drug had at least a moderate advantage compared with previously available treatments.

The results? Only about one in four of these heavily advertised drugs had high therapeutic value. During the six years of the study, pharmaceutical companies spent an estimated $15.9 billion promoting drugs on TV that showed no major advantage over less costly drugs!

Why drug ads are not popular

Only the US and New Zealand allow direct-to-consumer medication marketing. The American Medical Association recommended a ban in 2015. While I’ve often written about reasons to be skeptical, let’s focus here on three potential harms to your wallet and your health.

Drug ads may

• raise already astronomical health care costs by increasing requests for unnecessary treatment and promoting much costlier medicines than older or generic drugs.
• create diseases to be treated. Everyday experiences, such as fatigue or occasional dryness in the eyes, may be framed in drug ads as medical conditions warranting immediate treatment. Yet often, such symptoms are minor, temporary experiences. Another example is “low T” (referring to low blood testosterone). While it’s not a recognized illness on its own, ads for it have likely contributed to increased prescriptions for testosterone-containing medicines.
• promote new drugs before enough is known about long-term safety. The pain reliever rofecoxib (Vioxx) is one example. This anti-inflammatory medicine was supposed to be safer than older medicines. It was withdrawn from the market when evidence emerged that it might increase the risk of heart attack and stroke.

Four questions to ask your doctor if you’re curious about a drug ad

Wondering whether you should be taking an advertised drug? Ask your doctor:

• Do I have a condition for which this drug is recommended?
• Is there any reason to expect this drug will be more helpful than what I’m already taking?
• Is this drug more expensive than my current treatment?
• Do my health conditions or the medications I already take make the drug in the ad a poor choice for me?

The bottom line

The AMA recommended banning drug ads nearly a decade ago. But a drug ad ban seems unlikely, given strong lobbying by the pharmaceutical companies and concerns about violating their freedom of speech.

Still, cigarette commercials were banned in 1971, so it’s not an impossible dream. Meanwhile, my advice is to be skeptical about information in drug ads, and rely on more reliable sources of medical information, including your doctor. Consider contacting the Federal Communications Commission if you have complaints about these ads — a step few Americans seem to take. And try this: mute the TV, fast-forward your podcast, and close pop-ups as soon as drug ads appear.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

Want your child to grow up healthy, happy, smart, capable, and resilient? Play with them. Infants and toddlers thrive on playful games that change as they grow.

Why does play matter during the first few years of life?

More than a million new nerve connections are made in the brain in the first few years of life. And pruning of these neural connections makes them more efficient. These processes literally build the brain and help guide how it functions for the rest of that child’s life. While biology — particularly genetics — affects this, so does a child’s environment and experiences.

Babies and children thrive with responsive caregiving. Serve and return, a term used by the Harvard Center on the Developing Child, describes this well: back-and-forth interactions, in which the child and caregiver react to and interact with each other in a loving, nurturing way, are the building blocks of a healthy brain and a happy child, who will have a better chance of growing into a healthy, happy, competent, and successful adult.

Play is one of the best ways to do responsive caregiving. To maximize the benefits of play:

• Bring your full attention. Put the phone down, don’t multitask.
• Be reciprocal. That’s the “serve and return” part. Even little babies can interact with their caregivers, and that’s what you want to encourage. It doesn’t have to be reciprocal in an equal way — you might be talking in sentences while your baby is just smiling or cooing — but the idea is to build responsiveness into the play.
• Be attuned to developmental stages. That way your child can fully engage — and you can encourage their development as well.

Great games to play with infants: 6 to 9 months

The Center for the Developing Child has some great ideas and handouts for parents about specific games to play with their children at different ages.

6-month-olds and 9-month-olds are learning imitation and other building blocks of language. They are also starting to learn movement and explore the world around them.

Here are some play ideas for this age group:

• Play peek-a-boo or patty-cake.
• Play games of hiding toys under a blanket or another toy, and then “find” them, or let the baby find them.
• Have back-and-forth conversations. The baby’s contribution might just be a “ma” or “ba” sound. You can make the same sound back, or pretend that your baby is saying something (“You don’t say! Really? Tell me more!”).
• Play imitation games: if your baby sticks out their tongue, you do it too, for example. Older babies will start to be able to imitate things like clapping or banging, and love when grownups do that with them.
• Sing songs that involve movement, like “Itsy Bitsy Spider” or “Trot, Trot to Boston” with words and motions.
• Play simple games with objects, like putting toys into a bucket and taking them out, or dropping them and saying “boom!”

Great games to play with toddlers

Between 12 months and 18 months, young toddlers are gaining more language and movement skills, and love to imitate. You can:

• Play with blocks, building simple things and knocking them down together.
• Do imaginative play with dolls or stuffed animals, or pretend phone calls.
• Use pillows and blankets to build little forts and places to climb and play.
• Play some rudimentary hide-and-seek, like hiding yourself under a blanket next to the baby.
• Continue singing songs that involve movement and interaction, like “If You’re Happy And You Know It.”
• Go on outings and explore the world together. Even just going to the grocery store can be an adventure for a baby. Narrate everything. Don’t worry about using words your baby doesn’t understand; eventually they will, and hearing lots of different words is good for them.

Older toddlers, who are 2 or 3 years old, are able to do more complicated versions of these games. They can do matching, sorting, and counting games, as well as imitation and movement games like “follow the leader” (you can get quite creative and silly with that one).

As much as you can, give yourself over to play and have fun. Work and chores can wait, or you can actually involve young children in chores, making that more fun for both of you. Checking social media can definitely wait.

Playing with your child is an investment in your child’s future — and a great way to build your relationship and make both of you happy.

About the Author

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD

When caught early through routine screening, cervical cancer is curable. In the US, roughly 92% of women with early-stage cervical cancer survive five years or longer, compared with only 17% of women with late-stage cervical cancer. So recent research that shows a steep rise in new cases of advanced cervical cancer among white Southern women, and underscores the disproportionate burden of advanced cases among Black Southern women, is worrisome.

What factors might be at play, and how can people best protect themselves? Two Harvard experts share their insights.

Human papilloma virus and cervical cancer: What to know

Human papilloma virus (HPV) causes nine out of 10 cervical cancers. In 2023, 13,960 women in the US will be diagnosed with cervical cancer and 4,310 will die from it, according to American Cancer Society estimates.

Pap test screening can detect this cancer early, when it’s easiest to treat. And testing for HPV has been approved as an additional screening test for cervical cancer. It can be used alone or with a Pap test.

What did the research focus on and learn?

The study was published online in International Journal of Gynecological Cancer. Researchers combed through cervical cancer data submitted to the United States Cancer Statistics program between 2001 and 2018, and national survey findings on Pap screening and HPV vaccination. During this period, nearly 30,000 women were diagnosed with late-stage cervical cancer, which has spread to other parts of the abdomen and body.

Early-stage cervical cancer cases have been dropping for most groups in the US in recent years. But advanced cervical cancer cases have not declined within any US racial, ethnic, or age group over the last 18 years.

New diagnoses of advanced disease rose 1.3% annually during the study period. Southern white women ages 40 to 44 saw an annual rise of 4.5% in advanced cases. Southern Black women ages 55 to 59 were diagnosed nearly twice as often as white women with early and advanced cases.

What else is important to understand?

The new study showed that women living in the South are less likely to be vaccinated against HPV or screened for cervical cancer. But lower screening rates likely don’t fully explain the rise in late-stage cases in that region, says Dr. Ursula Matulonis, chief of the Division of Gynecologic Oncology at Dana-Farber Cancer Institute.

“Most cervical cancer cases continue to be diagnosed early,” Dr. Matulonis says. “These new findings suggest that cases involving a more aggressive cell type called adenocarcinoma are also increasing. Often found higher up in the cervical canal, this is harder to detect with a Pap smear.”

Older women are especially vulnerable. Rates of late-stage cervical cancer are higher — and survival is worse — among women 65 and older than among younger women, according to a study in California. One possible reason? They may not have received the recommended number of screening tests with normal results before they stopped having Pap smears, says Dr. Sarah Feldman, a gynecologic oncologist at Brigham and Women’s Hospital.

HPV vaccine protects against cervical cancer

The HPV vaccine is FDA-approved for use in females ages 9 through 26. The first group of vaccinated adolescents, now in their 20s, have clearly benefited: invasive cervical cancer rates among women 20 to 24 dropped by 3% each year from 1998 through 2012.

“That’s pretty impressive,” Dr. Matulonis says. “And those decreases span race and ethnicity, which isn’t always the case in women’s cancers.”

What steps can you take to protect against cervical cancer?

Dr. Feldman offers this guidance around cervical cancer prevention and detection.

• HPV vaccination. All children should be vaccinated against HPV between ages 9 and 12, well before sexual activity begins. “The most important thing for future generations in cervical cancer prevention is vaccinating that generation,” Dr. Feldman says.
• Routine screening. Regardless of vaccination status or whether they’re sexually active, women should begin having screening tests for cervical cancer in their 20s and continue through age 65. Discuss the right intervals with your doctor. Current screening guidelines take into account when you start screening and whether results of tests are normal:
  • If you start at 21: Have a Pap test every three years until 30.
  • If you start at 25: Seek an HPV test first.
  • At age 30: If all screening tests so far have been normal, have HPV testing every five years. Continue this screening until age 65.
  • Don’t stop screening at 65 unless all test results are normal, including at least two results in the last 10 years and one in the last five years.
  • If any testing led to abnormal results, you may need to continue screening beyond age 65.

An HPV infection, rather than sexual activity alone, is the factor that places people at risk, Dr. Feldman says.

“A lot of older women may have a new sexual partner in their 50s. A new HPV infection raises risk for cervical cancer roughly 20 years later,” Dr. Feldman says. “If HPV test results are persistently negative through age 65, the risk of developing cervical cancer in your 70s is low.”

About the Author

Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Howard LeWine, M.D., is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

As many as one in five adults in the US — 50.2 million — experience chronic pain, according to a recent survey. These people usually encounter fluctuations in pain during the day: sometimes it’s better in the morning and worse in the afternoon, or the opposite.

But what happens when the sun sets? Some research — supported by many chronic pain sufferers — suggests chronic pain worsens at night.

“The end of the day doesn’t mean people necessarily get a break from flare-ups,” says Ellen Slawsby, director of pain services at Harvard-affiliated Benson-Henry Institute for Mind Body Medicine. “In some cases, nighttime is when pain is the worst and can drastically interfere with sleep.”

What is chronic pain?

Chronic pain is defined as pain that lasts at least two to three months, often long after a person has recovered from the original injury or illness. The pain may even become a permanent issue. It can strike individual joints or muscles, or affect only certain areas of the body like the back and neck. Persistent pain may be more diffuse from conditions such as arthritis or fibromyalgia.

Symptoms and severity of chronic pain vary and can include a dull ache; shooting, burning, stabbing, or electric shock–like pain; and sensations of tingling and numbness.

Why might chronic pain increase at night?

There are several reasons why pain might worsen at night. Hormones could be a major factor, says Slawsby. “Nighttime is when the production of the anti-inflammatory hormone cortisol is at its lowest.”

New research also has suggested that pain may follow a circadian rhythm like the body’s internal 24-clock that regulates our sleep-wake cycle. “This helps explain why some people regularly have higher pain levels at certain times, such as during the night,” says Slawsby.

While there is no good time for chronic pain, nighttime is especially problematic, as it disrupts sleep. Insufficient sleep affects our ability to manage pain. And sleep problems are common among people with chronic pain. At least 50% of people with insomnia (the most commonly diagnosed sleep disorder) suffer from chronic pain.

“Insomnia can lead to sleep deprivation, which increases the release of proteins called cytokines that are involved in the body’s inflammatory response and makes people even more sensitive to pain,” says Slawsby.

Ways to get the rest you need if pain at night is a problem

If pain at night has been keeping you awake, trying these strategies may help you sleep better.

• Do a pre-bedtime relaxation routine. A soothing transition from a hectic day can help prepare your body and mind for sleep. “Spend at least 20 minutes before bedtime focused on relaxation, which helps slow the heart and breathing rate, decrease cortisol levels, and lower the chance of flare-ups occurring,” says Slawsby. For example:
  • take a warm or cool shower
  • perform a series of gentle stretches or yoga poses
  • do several minutes of deep breathing exercises.
• Create a healthy sleep environment. Make your bedroom as dark as possible and keep it cool (the ideal temperature is 65º Fahrenheit). Consider a sound machine that plays relaxing white noise or nature sounds. “Also, use comfortable pillows and supports for areas that have pain, like under your knees if you have back pain,” says Slawsby. Consistent routines and tools like cognitive behavioral therapy for insomnia can also help improve your sleep.
• Reframe your thoughts. People with chronic pain often worry about when their pain will occur, which can further increase stress and anxiety. “If you fear not falling asleep because of your pain, remind yourself that you’ve slept well in the past and can do so again,” says Slawsby. “If chronic pain does strike at night, remind yourself that it will go away soon, just as before. It’s difficult to change this mindset, but engaging in more positive thinking is important in mitigating pain.”

If pain wakes you up, allow your body time to recover so you can fall back to sleep. Listen to soft music or read, though preferably not on blue light–emitting electronic devices (computers, tablets, and smartphones) that affect sleep cycles. Another option is to count your breaths. Close your eyes and do a simple breathing exercise where you inhale while mentally counting to one, exhale while counting to two, and continue this pattern until you reach 10. Repeat as necessary. This can move your focus away from the pain and help relax the body. “Most of the time, you will fall back to sleep after a short while,” says Slawsby.

About the Author

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

There is no definitive evidence yet that microdosing with psychedelics is either effective or safe.

Psychedelic drugs have been capturing the attention of doctors and patients alike, for their increasingly proven potential to effect long-lasting improvements in the mental health of people who are suffering from conditions such as treatment-resistant depression. Microdosing of psychedelic substances such as LSD or psilocybin involves taking a fraction of a regular dose (a subperceptual dose) that is much lower than one would take if one wanted to “trip” or hallucinate on these substances.

Many people share the idea that microdosing with psychedelics enhances one’s mood, creativity, concentration, productivity, and ability to empathize with others. Or could the benefits be an “expectancy effect”? This means that most people who take a daily pill that they fervently expect will help them feel happier and smarter will feel like they are happier and smarter — just from taking the pill, regardless of what’s in it.

What is microdosing?

There isn’t a single, clearly recognized definition of microdosing for any psychedelic drug, and this complicates attempts to perform consistent research. One definition is approximately 1/5 to 1/20 of a recreational dose. (From anecdotal experience this is accurate, as a medium-strength dose of psilocybin is 2 to 3 grams of dried mushrooms, and a microdose is typically around 0.3 grams.) One obstacle is that the potency of mushrooms can vary greatly, as they are not regulated outside of clinical trials, so this isn’t an exact science. Likewise, LSD is an invisible, tasteless, odorless substance that usually comes either in liquid form or embedded into a piece of paper to be slipped under the tongue.

Given its current illegality and lack of regulation, there is no good way to know what dosage you are taking unless you have an extraordinarily reliable supplier. LSD is an extremely powerful and long-acting drug, and you don’t want to take more of it than intended. Further, psychedelics such as psilocybin and LSD can produce physiological tolerance, which might suggest that, even if microdosing does help, there could be diminishing returns if one stays at the same dosage.

Is microdosing safe?

We don’t know as much about safety as we might have learned if not for the War on Drugs, which curtailed much of the research into psychedelics starting in the late 1960s. This research has been renewed over the last five to 10 years, and many medical centers are conducting research on psychedelics. Psilocybin is generally thought to be safe in low dosages and has been used for centuries by indigenous peoples. However, if one takes too large a dose it can result in a terrifying — even traumatic — experience.

Psilocybin is a compound produced by almost 200 species of fungi (mushrooms), and the mushrooms must come from a trusted source. It is very easy to poison oneself with the wrong type of mushroom, as there are many types of mushrooms in nature that can look quite similar to each other, but some are poisonous and can harm your liver, causing severe illness or even death.

Could psychedelics become safer if legalized?

It is anticipated by experts in the field that some psychedelics may become fully legalized — for medical usage, under supervision — within the next few years, specifically psilocybin and MDMA (ecstasy). Some policy makers and public health experts believe that the safety of these psychedelics would be enhanced if they were decriminalized, and if their cultivation and production were monitored and regulated. At least one state (Oregon), and many cities around the country, have decriminalized psychedelics at the local level.

Some advocates of decriminalization are looking forward to a safer product, and wider access that could include not having to see a medical professional to get a prescription or be under medical supervision when using psychedelics. Skeptics are worried that uncontrolled access to these drugs might affect patients with mental illness, or might even precipitate mental illness such as psychosis in people that are vulnerable.

It is important to mention that the use of all psychedelic drugs should be undertaken with utmost caution — if they should be used at all — in patients with major mental illness such as schizophrenia or bipolar disorder. For safety reasons, these patients are typically excluded from studies involving psychedelic drugs.

Evidence for microdosing of psychedelics is mixed

Does microdosing work? In short, the jury is still out. Some studies indicate a very real and significant benefit from microdosing, whereas others are much less convincing and show little to no benefit. One recent study used a naturalistic, observational design to study 953 psilocybin microdosers compared with 180 nondosing participants for 30 days, and found “small to medium-sized improvements in mood and mental health that were generally consistent across gender, age, and presence of mental health concerns.” This study and others like it appear to confirm many anecdotal reports of people who swear by the benefits they have experienced from microdosing.

Other studies on microdosing are far less impressive. In one example the researchers conducted a randomized controlled study, which represents the strongest type of evidence because it weeds out the placebo effect. The researchers took 34 patients and randomized half of them to receive psilocybin and half to placebo. While there were some intriguing subjective effects (people felt happier and more creative), and even some changes in brain waves recorded on an EEG machine, they concluded that low-dose psilocybin mushrooms did not show objective evidence of improvements in creativity, well-being, and cognitive function. Studies such as this one support the hypothesis that the effect people receive from psychedelics at these subperceptual doses is mostly an expectancy effect, and that one needs to consume a higher dosage to receive a therapeutic benefit.

To microdose or not to microdose?

While any medical or lifestyle decision is an individual’s choice (assuming that they aren’t harming others), I would highly recommend that you speak with your doctor to explore your decision to take psychedelics, and see if there are any medical reasons why you should be cautious or avoid these drugs. It is critical to pay attention to the legality and the quality of your product — you likely can’t afford to get into legal jeopardy, and certainly can’t afford to poison yourself.

Finally, it is important to understand that there isn’t yet definitive proof that microdosing is at all helpful, or even that it is safe in the long term. With these points in mind, it is fair to say that psychedelic drugs are becoming better understood, and are undergoing a resurgence of research and a more widely accepted use.

About the Author

Peter Grinspoon, MD, Contributor

Dr. Peter Grinspoon is a primary care physician, educator, and cannabis specialist at Massachusetts General Hospital; an instructor at Harvard Medical School; and a certified health and wellness coach. He is the author of the forthcoming book Seeing … See Full Bio View all posts by Peter Grinspoon, MD

It used to be that doctors would automatically recommend treating all men with prostate cancer, even if their initial biopsies suggested the disease would grow slowly (or at all). But during the last several decades, the pendulum on treatment has swung the other way.

Doctors are now likely to advise active surveillance for low- to intermediate-risk cancers that may never turn deadly over the course of a man’s life. Active surveillance involves routine PSA checks, follow-up biopsies, and more recently, magnetic resonance imaging of a patient’s tumor. Treatment is initiated only when — or if — the disease shows signs of progression.

Recent evidence from Johns Hopkins University shows that the long-term risks of metastasis and death from low-grade prostate cancer among men on active surveillance averages just 0.1%. But doctors who care for such men also face a nagging question: which of their patients might have more aggressive cancer that should require closer monitoring? New findings published by the Johns Hopkins team in January provide useful insights.

The researchers’ approach

The researchers in this case zeroed in on the prognostic value of so-called perineural invasion, or PNI, on tumor biopsy samples. PNI simply means that cancer cells are moving into the perineural space between nerves in the prostate and their surrounding tissues. A finding of PNI raises red flags because the perineural space “provides a conduit by which tumor cells can potentially escape the prostate and grow elsewhere in the body,” says Dr. Christian Pavlovich, a urologic oncologist at Johns Hopkins who led the research.

Dr. Pavlovich’s team wanted to know if PNI detected on initial or follow-up biopsies would be associated with higher risks for cancer progression. So they analyzed long-term follow-up data from 1,969 men who had enrolled in an active surveillance research protocol at Johns Hopkins between 1995 and 2021. All the men were diagnosed initially with Grade Group 1 prostate cancer (the least risky form of the disease) and had undergone at least one follow-up biopsy since then.

What did the results show?

Among the 198 men with PNI, 44% of them (87 men in all) eventually progressed to Grade Group 2 prostate cancer, which is a more advanced form of the disease with an intermediate risk of further spread. Conversely, just 26% of the remaining 1,771 men without PNI (461 men) had progressed to Grade Group 2.

Pavlovich emphasizes that despite the new findings, PNI “does not make patients ineligible for active surveillance.” Importantly, the research showed that PNI was not associated with high-risk features, such as cancer in the lymph nodes of patients who wound up having surgery, or post-surgical elevations in PSA that show cancer still lurks in the body.

“What we’ve really shown here is that PNI puts men at a slightly higher risk of extraprostatic extension (cancer cells located just beyond the confines of the prostate),” Pavlovich says. “This is not necessarily a new finding. But PNI only occurs in about 10% of Grade Group 1 patients, and this is the boldest statement yet from the largest study conducted so far.” Pavlovich and his colleagues concluded that PNI provides an inexpensive and readily available indicator for identifying which men on active surveillance will benefit from more intensive monitoring protocols, including MRI and genetic tests.

Dr. Marc B. Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, agrees, while pointing out that PNI evaluations aren’t performed often enough. A PNI analysis of pathology specimens, he says, “along with emerging and sophisticated genetic testing of the tissue samples, may lead to more certainty in our recommendations to patients.”

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

About the Reviewer

Marc B. Garnick, MD,

Editor in Chief, Harvard Medical School Annual Report on Prostate Diseases

Dr. Marc B. Garnick is an internationally renowned expert in medical oncology and urologic cancer. A clinical professor of medicine at Harvard Medical School, he also maintains an active clinical practice at Beth Israel Deaconess Medical … See Full Bio View all posts by Marc B. Garnick, MD