November 2009

Q. Just got your latest e-mail and am wondering if I have had a complete hysterectomy and don't have a cervix, is there still need for a pap test? And do I still need to see a gyn for a pelvic exam? As a breast cancer survivor, I am being seen by my oncologist on a regular basis, but, of course, that does not involve any gynecological exam.

A. You had a complete hysterectomy with ovaries et al removed if I remember correctly?? I remember your family history/recent breast history so well. In any event, I also presume you never had abnormal Paps from HPV in the distant past? Since cervical cancer is now clearly caused by a persistent high risk strain of the HPV - which is sexually transmitted and not hereditary - there would be no reason for you to have a Pap test. You don't have a cervix, and your vaginal/ vulvar tissues would only need a "pap" test if you had a chronic HPV infection or prior cervical cancer.

If you had everything removed, I guess no real reason for a pelvic exam..and I know many of my patients with a similar history would rely only on me to examine them (no pelvic, but annual rectal and physical exam). You may also want an occasional vaginal exam if you have trouble with atrophic vaginitis/dry vaginal tissues from low estrogen. Are you on Arimidex? which is a total estrogen blocker?. That said, you DO need a colonoscopy/colon screen/rectal exam on a regular basis and a good general exam. Do you have a great internist?

Q. At a basic level I understand the relationship between leptin and ghrelen, and how a diet soda could theoretically be recognized by the brain as sweetness-with-no-calories with the possible reaction that either leptin levels are not increased and therefore that there is insufficient leptin to bind with neuropeptide Y neurons in the brain, and hunger is not fully shut off.

The conclusion you and others reach is that since there are *no* calories in diet soda, the brain can sense the absence of calories and is not deceived into releasing leptin. But suppose a food has *some* calories, but not as many as there would be if sugar had been used as an ingredient? What does research tell us in that case?

Conversely, I can see how a food high in fiber could in principle be interpreted by the brain as a carbohydrate, despite the fact that we cannot digest the calories that it contains. This could in turn cause leptin to be released, shutting off hunger signals without consuming usable calories. Suppose you have a muffin that is very high in fiber, such as a bran muffin, that is made with Splenda instead of brown sugar.

Would a high calorie, low net calorie, sweet food fool the body into secreting leptin in proportion to the net calories consumed (including the fiber calories), or wouldn't it? Has this question been answered (or addressed) by a controlled study?

My personal experience with this suggests that hunger is reduced somewhat after consumption of low-calorie, high-fiber foods, but not quite as much as I would have expected given the nominal number of calories consumed (including the fiber false-calories). For example, eating an apple seems to produce a satiating effect for as long as 3 hours, whereas the same number of calories in a low-calorie, high-fiber muffin sweetened with Splenda seems to satisfy for less time, and also to satisfy my hunger in a qualitatively different way. Eating a "diet muffin" satisfies a need for a bread-like food in a way that the apple doesn't, and the apple seems to satisfy a need for a proprioceptive "chew" feeling, such as we might also get from meat, portabello mushroom, a firm roasted carrot, or other firm foods. This a separate dimension of satiety that as far as I know has not been adequately explored.

A. These are all great questions and yet I have not found research to support the issues you have raised. I presume you saw the report last week from the nurses’ health study linking diet soda to decline in kidney function as well? This research all remains an association and not direct link but it is compelling. I think researcher's are eager to learn more about the connection so it is just a matter of time.

Q. Can thyroid nodules disappear after having them for at least 5 years? I had thyroid surgery back in the late 80’s because of nodules and a goiter. My two lower lobes were removed and have since come back and a goiter. I started to see a endocrinologist who monitors my blood work (which remains normal) However, I have had several nodules biopsied in the past few years and they have been negative. My most recent scan showed no nodules? Can that happen, despite my thyroid lobes growing in size? I want my thyroid removed, but the surgeon I saw said it is risky because I had surgery before. I never feel really good, I have a large lump on the right side of my neck which I wear turtlenecks to hide. I’m afraid it will affect my swallowing. (I can feel the enlargement when I swallow now.) I am afraid they are being too conservative and when they finally decide to do something, I’ll be too old and at risk for complications. (I am 52) What should or can I do?

A. Thanks so much for reaching out to me. I will try to answer as best I can. I presume you have not received childhood radiation to your neck/sinus/chest for any benign or malignant conditions? This would place you at increased risk for thyroid cancer.

Are you on suppressing therapy with thyroid hormone such as Synthroid? Only when cancer is suspected would a surgeon risk removing your complete thyroid gland - and this because even in best of hands the chances of removing the essential parathyroid glands behind the thyroid and attached to them is too great.

True thyroid nodules would not likely completely disappear and I suspect you still have nodules as your own descriptions suggests you can feel them. I am not sure what the scan showed? Am concerned however that you say your gland is growing? Are you in the best of hands? Most experienced thyroid endocrinologist in your area? Best of luck - and keep advocating and speaking up!!