Month: February 2014

Refusal to take a flu shot

Published Wednesday, February 19, 2014

by C. Nicole Swiner, M.D., Columnist

Why didn’t you get a flu shot this season? I asked this question recently on my Facebook page, and people were surprisingly silent.

This is interesting because, when asked in person, patients are very vocal about why they refuse to get the seasonal vaccine. I’ve heard reasons that vary from “Doesn’t it give you the flu?” to “My Mom/insert any other family member got really sick after she got one” to “I’m healthy, I don’t need one.” I think the most interesting reason is always the one that suspects the government is behind it in some way and involves a conspiracy theory.

Over my seven years of practice, I think I’ve heard them all, coming from a variety of ages, races and backgrounds. Since this particular influenza season has been a severe one for our state, I wanted to delve more into the thoughts behind this issue.

As a doctor, I encourage all of my patients, if safe for them, to get all sorts of vaccinations. I see babies from the newborn stage to adulthood, so I recommend all of the well-child shots and talk to parents about any concerns they may have about them. The same is true for adults to geriatric age. I discuss all vaccinations, their benefits and potential risks. But, for some reason, the refusal of the flu shot is visceral for many people. They are vehemently opposed to it.

Let’s address some of these misconceptions.

First, we are all susceptible, no matter how healthy we are. This season, which started in October, we’ve had 64 deaths from the flu. The season doesn’t end until March or April. The majority of these deaths were between the ages of 25 and 49 years old. They were young, healthy adults.

We can be exposed to influenza at our jobs, church, schools, day cares, grocery stores, gyms or anywhere you come into contact with people. Some people who have the flu early on don’t even appear ill until days after they’ve been exposed.

So just think about that person you may have been sitting next to, talking to or shaking hands with who was infected but wasn’t showing signs yet. This is not to raise fear but awareness, and to educate some of those ignorant theories.

My next “favorite” excuse is the one that proposes the flu vaccine gives one the flu. This is incorrect. The flu shot has a killed and inactive version of the influenza virus. When injected, your body will elicit an immune response as it learns to recognize the virus and is able to fight it off when it comes into contact with it the next time. When we have an immune response, sort of similar to an allergic reaction, our body may have some milder, less dangerous, similar symptoms to that of the flu.

These include, but are not limited to, fever, headache, body aches or rash. The next question is usually “So why put myself through something that feels like the flu in order to prevent the flu?”

So you don’t catch the actual flu infection, which can feel 50 times worse. That sounds reasonable, doesn’t it? To many, it doesn’t.

The only excuses I’m willing to accept is if someone is allergic to eggs or has a history of a rare neurologic disorder called Guillain-Barre’ syndrome. Outside of these two reasons, there are no other acceptable excuses for preventing a preventable disease that can lead to serious or deadly complications for yourself and others around you.

So, seriously reconsider this year of all years to vaccinate yourself and your loved ones, particularly those who are of young and old age. Think of someone other than yourself as you can prevent the spread of illness in your community. As always, ask your health- care provider if you ever have any questions.


Dr. C. Nicole Swiner works at Durham Family Medicine, where she treats newborns to elderly patients. She and her colleagues are accepting new patients and can be found

Hormone replacement vs. ‘natural’ hormones

Published Wednesday, February 12, 2014
by C. Nicole Swiner, Columnist

By the age of 50, most women have experienced or are experiencing menopause. This feared phenomenon is a natural progression of a women’s menstrual cycle, and after a full year without a period, we consider it done.

However, the stopping of menses is just one of the many effects menopause causes, and almost every woman is familiar with the others but may not know of all of them. I’m talking about the feared hot flashes, along with mood changes, weight changes, vaginal dryness and irritation, hair loss, decreased sexual desire and memory difficulty, to name a few. As a doctor that treats women of every age, I blame almost anything on menopause.

“Doc, why am I starting to get acne again at 50?” Menopause. “Why am I gaining weight and I exercise every day and eat the same amount of food? Menopause.

Most women welcome this natural change of life, if for nothing else than the fact of not having to worry about a menstrual cycle. However, I do have patients and friends who are fearful, as it signals the end of child bearing. For others, it’s an issue to explain why they are breaking out their handheld fans or plugging in fans at work when everyone else is cold.

Because there can be other causes for these symptoms, such as thyroid disease, iron deficiency or even depression, I like to test a woman’s hormone levels to judge where she is in her cycle of life. I test FSH and LH levels, which can correspond to a lady’s estrogen and progesterone level, respectively. If perimenopause (meaning near menopause) or menopause is confirmed, then treatments can be considered.

There are many ways I treat these symptoms – both natural and pharmaceutical. I generally like to start with offering natural treatments as they are widely available and have less side effects. Supplements such as soy, evening primrose oil, black cohosh and wild yam extract are available in almost every store now. Each one works differently for each woman. You have to try a couple of weeks on each to see which works best for you. Somehow, these natural replacements stimulate estrogen or behave like estrogen in the blood stream.

The same is true for a product called Estroven, which has a combination of these types of supplements, primarily soy or black cohosh, which is also over the counter. Side effects are minimal, but there are some cases of vaginal bleeding, which we have to carefully monitor and evaluate. There also aren’t many contraindications to trying them since they are natural. These products can be purchased on your own, or you can go to a pharmacy that performs bioidentical hormone treatments that can mix up and prescribe a specific formulation just for you. Testing can be done there via the blood or saliva, and your own recipe is made for you. This is usually a cash-only service and not covered through insurance, but it’s often very beneficial.

Another class of medications to consider if natural isn’t the way is for some of the antidepressants and anti-anxiety medicines. Surprisingly, medicines such as Effexor and Zoloft are used to treat symptoms of menopause and have proven to be helpful. The dopamine, serotonin or epinephrine released by these medicines are “feel good” hormones that fight the hot flashes and mood changes that occur with the change of life.

There are other medicines that have been proven to help in other categories not generally thought to help hormones like clonidine. Clonidine is a type of blood pressure medicine that dilates the blood vessels and somehow reduces night sweats.

Lastly, there are the hormone replacement treatments that are still widely used. You may have heard of Premarin or Prempro. We still use these for menopausal symptoms, but try to limit the amount of time to a year, if possible, to reduce the potential of side effects. The most worrisome of these negative effects are heart attack, stroke and some cancers. A patient’s personal and family history, as well as the presence or absence of their gynecological organs, need to be weighed to make sure she is a good candidate to use these medicines.

All in all, there are many ways to make this transition smoother, and you don’t have to suffer in silence. Ask your doctor which category of medicine is right for you.

Dr. C. Nicole Swiner works at Durham Family Medicine, where she treats newborns to elderly patients. She and her colleagues are accepting new patients and can be found at

Heart Healthy Month–New cholesterol treatment guidelines

Get heart healthy this month
Published Wednesday, February 5, 2014

by C. Nicole Swiner, M.D., Columnist 

What better way to celebrate February, heart healthy month, than by thinking about prevention of heart disease. In light of this, I decided to review the brand new recommendations on screening and treatment of patients with high cholesterol. It came out last November, written by the American College of Cardiology and American Heart Association. 

What it reviews and recommends is slightly different and a bit more complicated than our usual way of thinking about treating cholesterol. Generally speaking, patients with a total cholesterol of more than 200 or LDL cholesterol of more than 130 were considered at high risk for artery or heart disease. Before, if diet and exercise didn’t bring numbers down, medications were usually the next step. This was thought to be the case for almost anyone of adult age, not necessarily children, especially if there was a positive family history of heart attack or stroke, or similar cardiovascular issues.

However, after reviewing the new guidelines, here’s my new understanding of how I will approach my patients from now on.

No longer will I primarily focus on just the numbers. Now, let me start by saying I almost never just “treated the numbers” and not consider the person in front of me. Medications aren’t for everyone – some people will outright refuse them, some will beg for a chance to make improvements naturally, and others have medication allergies and can’t tolerate them.

However, in the past, I would use the numbers to help motivate a patient to change his bad habits to avoid medicines. If any patient walked in with a total cholesterol of more than 200, especially someone in his 40s or 50s, cholesterol medicines would have been definitely considered. But the new guidelines for cholesterol put much more weight on the future risk of “atherosclerotic” (artery disease and plaque) and heart disease, and help you to calculate a person’s risk of having problems in the future instead of just focusing on one factor alone.

We can now estimate a person’s risk by using “calculators” that were created with research studies. I’ve used one for a while now called the Framingham Risk Calculator that takes age, gender, blood pressure and smoking history into account. It can estimate a person’s 10-year risk of having a heart attack. 

If one’s risk is greater than 20 percent, it’s a sign that he may need medicines to treat his blood pressure and cholesterol, or need further testing of the heart. I would use this generally to estimate whether I needed to send patients to have a stress test or not if they were having chest pain. If their risk was low, I would consider less emergent causes such as muscle pain, acid reflux or even emotional stress. 

A newer calculator used for cholesterol and heart disease is called the 10-year ASCVD risk calculator, and it takes into account similar history factors (along with race and history of diabetes) as the other calculator, but also estimates risk of stroke and coronary heart disease death, along with heart attack. If risk is >7.5 percent with this, it is important to treat a patient for his cholesterol with diet, exercise, lifestyle changes and, when necessary, medicine.

The medicine of choice is still a statin, which you may recognize as Lipitor, Zocor or Crestor. Each in their generic form end with the word “-statin”, which helps to pick them out from the rest. The study has shown these medicines still work the best for controlling cholesterol and are better than the others we’ve used as alternatives. This part is a little disheartening, given I have many patients that are on Niacin, fish oil or krill oil nowadays, in hopes that this will help lower cholesterol. From this study’s standpoint, they may not match up to the power of the statin.

All in all, here’s the breakdown of which patients benefit from being on statins for cholesterol:

1. All patients with history of heart attack, stroke, TIA or artery disease 

2. Patients with LDL-cholesterol > or equal to 190, regardless of age

3. Patients age 40-75 with diabetes, having LDL 70-189

4. Patients without heart disease or diabetes, but have LDL 70-189, with 10-year ASCVD future risk >7.5%

Let’s all focus on trying to be healthier this year and have our annual checkups with blood work for prevention of disease.



2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults