Low back pain is a part of life—common across sexes, age groups, and countries, it’s something that almost all people experience at some point. Treatment for low back pain often includes a combination of medication and non-medication options. What should you start with? What treatments have the best evidence? And more importantly . . . what’s coming our way for low back pain treatment?
To start #OldSchool—the best evidence exists for these three treatments:
- Non-steroidal anti-inflammatory drugs (NSAIDS). Which NSAID? Ibuprofen (Motrin, Advil), naproxen (Aleve), and celecoxib (Celebrex) are common examples. There does not appear to be a “best” NSAID for low back pain from the evidence. Start with low doses and go higher if needed, aiming for short term use. If you can’t take NSAIDS (stomach issues, kidney problems) take acetaminophen (Tylenol) instead.
- Muscle relaxants. Adding a muscle relaxant to an NSAID improves low back pain. Start with one that doesn’t make you tired like methocarbamol (Robaxin) or metaxalone (Skelaxin). See my previous blog here for full discussion on muscle relaxants for low back pain.
- Heat. Superficial heat for low back pain has been shown to help. There is moderate evidence from a small number of studies that heat wrap therapy provides short-term reduction in pain and disability in those with acute or sub-acute low-back pain (less than 12 weeks). When using heat wraps, use them only for 15-20 minutes at a time. Don’t fall asleep with them on.
Ok, then what’s next for back pain?
- Physical therapist or chiropractor. To sum up the evidence here: for low back pain, physical therapy and chiropractic manipulation have similar effects on symptoms, function, satisfaction with care, disability, recurrences of back pain, and subsequent visits for back pain. So think of them as being equally effective. I’d pick whichever one is more convenient and covered more by your insurance.
- Other exercise therapy. For example,yoga, tai chi or qigong. There is fair evidence that yoga and movement therapies will help for your back pain. Pursue them on your own and stick with one that interests you the most and is the most convenient.
- Other alternative therapies. Mindfulness stress reduction (meditation + yoga) and cognitive behavioral therapy outperformed NSAIDS in a recent study. Both are worth a try for sure if you are struggling with low back pain. Acupuncture, though—not so much. In the last two years a review of scientific evidence found the practice of acupuncture was no better than placebo in treating those living with low back pain and sciatica. Gua sha is another alternative therapy that may exhibit a more long-lasting anti-inflammatory effect relative to hot pack for pain relief and improved mobility in elderly patients with chronic low back pain.
What’s next for those with chronic, neuropathic (nerve-like) low back pain?
- Gabapentin (Neurontin) or duloxetine (Cymbalta) have the best evidence in addition to the above listed options for nerve-like pain in your low back that may radiate down your buttock or leg. Tramadol (Ultram) may also be added to your regimen at this point.
- The hot-button issue: Opioids for low back pain. Opioids are no more effective than NSAIDS for low back pain and have a high rate of adverse effects (the understatement of the year). Avoid opioids at all costs for low back pain.
Moving on—invasive procedures:
- Epidural steroid injections. Steroid injections in the lumbar spine are performed by pain management or interventional radiologists, and they do work. Epidural injections done with several approaches (interlaminar, caudal, or transforaminal) have been shown to reduce pain and disability short term (usually at 2 weeks) and help delay the need for surgical intervention. Epidural steroid injections may provide relief for a period of time and additional repeat injections are an option if pain recurs.
The future—and beyond:
- Radiofrequency denervation aka radiofrequency ablation (RFA) was the rising star, but a recent large study revealed disappointing results. RFA is a medical procedure where the nerve is ablated (the nerve endings are deadened) using high frequency alternating current. But does it work for chronic low back pain? Not so well. A recent study (JAMA July 4; 318(1):68-81) found radiofrequency denervation added to a standardized exercise program for chronic low back pain resulted in either no improvement or no clinically important improvement compared with a standardized exercise program alone. To sum it up: the findings do not support the use of radiofrequency denervation to treat chronic low back pain originating in the facet joints, sacroiliac joints, or intervertebral disks. Disappointing.
- Platelet rich plasma. Platelet rich plasma (PRP) has shown promising results when injected into the intervertebral disc and is currently being studied. PRP is high in growth factors, which is why it’s being studied, yet there are no active studies for low back pain being done. Will PRP help for low back pain? We don’t know yet, and won’t for a while.
- Stem cell therapy to regenerate cells and increase disc matrix production (the gel- like central part of the disc) is also currently being researched. This may be coming our way for low back pain, but no results yet.
- Cannabis. Studies on cannabis/medical marijuana are limited because it is still illegal under federal law, but several trials have evaluated the effectiveness of cannabis for patients with neuropathic pain. Patients with nerve pain from spinal stenosis or degenerative disc disease show a 30% improvement in chronic pain score following cannabis therapy. Pain relief provided by cannabis is dose-dependent, with higher THC content producing more pronounced pain relief. Know this: the strains of cannabis containing high levels of CBD (cannabidiol) generally make patients feel less high, since CBD acts as an antagonist to the psychoactive effect of THC. Consider starting with high-CBD, low-THC strains if you are concerned about feeling high.
What has helped for you?
Female Pattern Hair Loss (FPHL) is the most common cause of hair loss in women. While the cause is unknown, FPHL is more common in women with obesity, high blood pressure, and insulin resistance (pre-diabetes).
FPHL mainly affects the mid and frontal regions of the scalp, while preserving the frontal hairline. Your part gets wider, and hair near your temples may recede, but you will not lose all of your hair. Noticing that your part is widening, or your ponytail is thinning, may bring you to your doctor. Help! What works?
Common myths about hair loss in women
- Genetics do not appear to play a role in female pattern hair loss. No definitive familial inheritance has been identified in women, unlike in men with androgenic alopecia (“male pattern baldness”) where genetics play an important role from both mom and dad’s side.
- The majority of female hair loss is NOT tied to high levels of androgens (male hormones). Only 39% of women with FPHL have high androgen levels whereas male balding is a genetically determined androgen-dependent trait.
- Taking oral estrogen (hormone replacement therapy) has no clear effect on hair growth and in some studies showed an inhibitory effect.
Medical causes for hair loss in women
Before you make the diagnosis of Female Pattern Hair Loss (FPHL) which has no known causes, look for these:
- An under or overactive thyroid. Hypo or hyperthyroidism may cause hair loss, and is easy to rule out with a blood test called TSH (thyroid stimulating hormone).
- Iron deficiency anemia. A common complaint in iron-deficient women is hair loss, with increased loss reported in women with ferritins less than 100ng/dL. That’s an easy blood test.
- Psychological and emotional stress. A major illness, severe psychological trauma, significant weight loss and childbirth may precipitate an episode of hair loss that begins a few months after the episode. This is called telogen effluvium, and hair loss occurs in all areas of the scalp.
- Polycystic Ovarian Syndrome (PCOS). Sometimes this condition causes your body to produce too many androgens, which can decrease the growth of hair on your scalp.
- Medications. Some common culprits include beta blockers, antidepressants, anticoagulants, and chemotherapy drugs. Read more about this in our blog here.
Options for treating hair loss
Once your hair loss has been determined to be FPHL, and not related to one of the above-listed conditions, here are your options:
- Topical solutions of 2% minoxidil (Rogaine). Minoxidil, applied as 1 ml twice daily, is the only drug approved by the FDA for the treatment of female pattern hair loss. What is interesting is that minoxidil 2% and 5% have basically the same result.
- Oral finasteride (Propecia). While finasteride 1 mg tablets have not been shown to be helpful, a few studies have shown improvement with finasteride 5 mg daily.
- Zinc sulfate + calcium pantothenate. These are over the counter supplements. For those using daily topical minoxidil adding zinc sulfate capsules 220 mg + calcium pantothenate tablets 100 mg twice a week was better than with minoxidil alone. Worth a try!
- Spironolactone (Aldactone). There is some evidence that using Aldactone (spironolactone) at a dose of 100-200 mg a day benefits women who haven’t responded to the use of topical Minoxidil.
- Platlet rich plasma (PRP) scalp injections. Very recent studies have shown that PRP injected into the scalp can improve both hair density and thickness. The basic idea behind PRP injection is to deliver high concentrations of growth factors to the scalp, which the hope of stimulating hair regrowth.
Hope this helps!
Menopause is the period in a woman’s life when menstruation stops. It typically occurs between 45 and 50 years of age and can increase the risk for medical conditions like heart disease, osteoporosis, urinary incontinence, weight gain, and painful intercourse.
The FDA has approved Intrarosa to treat dyspareunia (painful sexual intercourse), a common symptom of menopause, and it is now available in pharmacies.
What is Intrarosa indicated for?
Intrarosa is a steroid indicated for the treatment of moderate to severe dyspareunia, or painful sexual intercourse. This condition is a symptom of vulvar and vaginal atrophy (VVA), due to menopause. Intrarosa is unique in that it treats dyspareunia without using hormones.
VVA is a chronic condition commonly associated with the loss of estrogen due to menopause. Symptoms of VVA include vaginal dryness, itchiness or burning.
Intrarosa is available as a vaginal insert in the strength of 6.5 mg.
How do I use Intrarosa?
Intrarosa is to be inserted vaginally once daily at bedtime.
What are the common side effects associated with Intrarosa?
Common side effects include vaginal discharge or noticeable changes on a Pap smear.
Are there any treatments similar to Intrarosa?
Over the counter (OTC) medication DHEA (prasterone) is an oral supplement that is sometimes used to treat dyspareunia. However, the FDA has not evaluated it for safety or efficacy.
OTC vaginal lubricants and moisturizers may also help to avoid discomfort during sexual activity, and can usually be found in the feminine care aisle of your grocery store or pharmacy.
“Doctor, what vitamin or supplements should I be taking at my age?” It’s a good question, and one I hear often.
When you pick up a prescription medication you receive the long list of potential side effects and ingredients, along with proof that it worked and was safe before it was approved. On the other hand, with vitamins and supplements it is important to remember they are unregulated and untested as to their safety and their efficacy (whether or not they work).
It is unpopular to criticize supplements, which many think are “more natural,” but for those who are harmed every year by unregulated, untested, and easily available supplements—and spend money on them—here goes.
- Supplements and vitamins are a 34 billion dollar a year business.
- Many megavitamin companies are owned by pharmaceutical companies (Pfizer owns the huge megavitamin company Alacer).
- There is medicine that works and medicine that doesn’t work and the best way to figure out which is which is by looking at scientific studies. Supplements and vitamins don’t have to prove they work before they are sold to you.
- A large percentage of adults take supplements and vitamins they deem more “natural” and reject medications made by big pharmaceutical companies—when really most megavitamin companies are owned by big pharma. Just know that.
- Whether or not you need to take a multivitamin, some individual supplements—vitamin E, vitamin C or vitamin A for example—have been studied for years.
- The vitamin E studies done year after year show an increased risk of heart failure and cancer in the groups taking vitamin E. Please know this. Just as one example: in 2010 the Cleveland Clinic published results on a huge trial done on 36,000 men where they studied vitamin E and selenium (either alone or together) and found a 17% increased risk of prostate cancer in the group taking the vitamins.
- With exception of folks with vitamin deficiencies (gastric bypass patients, celiacs, low vitamin D) not a single public health organization recommends the routine use of vitamins or supplements in most adults. This is because studies have never shown them to be effective and in some cases they are harmful.
- Vitamins and minerals can make claims about safety and effectiveness without evidence and the FDA does not approve herbal products before sale. The only change occurred in 2007, where the FDA can make sure a product contains what the label says it contains. When they started doing this, at least half of those inspected had problems and didn’t contain what they said they did.
- Most adults do not need a daily multivitamin. Of course there are situations where vitamins and supplements are helpful, and you and your doctor can discuss these. Examples include: AREDS eye vitamins for those with early macular degeneration, fish oil supplements for dry eyes, iron replacement for those with iron deficiency anemia, etc.
Regular birth control pills are already available over-the-counter in many countries including China, Greece, India, Turkey, Mexico, South Africa, Russia, and Korea. In the U.S., we are slowly but surely starting to provide women with greater access to birth control products without requiring a prescription.
In 2013, Plan B One-Step, the emergency contraceptive that can prevent pregnancy, was made available without a prescription (“over-the-counter” or OTC) without an ID or age restriction.
This was a step in the right direction for the over-the-counter approval of other birth control products (the pill many women take monthly, for example). Why is this? Plan B One-Step contains levonorgestrel, the same hormone used in many birth controls—just at a higher dose.
How can a medication like birth control become available without a prescription?
Over-the-counter (OTC) medications are drugs that are considered safe and effective for use by the general public—without the requirement that you seek treatment from a health care professional.
In the past several years, many drugs have made the transition from prescription-only to being readily available over-the-counter in your pharmacy and grocery store medication aisles.
In order for a medication to be available over-the-counter, it must meet a few requirements. First and foremost, it must be easy to use—that is, you have to be able to self-diagnose and decide you need the medication, with little to no negative effects.
The Federal Food, Drug, and Cosmetic Act of 1938 requires all new drugs to be found safe before they go on the market. Changing a previously prescription-only drug to make it available over-the-counter is no different.
OTC medications must also have clear and concise labeling, so you know how to take the medication properly. In 1997, the FDA created rules for the labeling of OTC products, making them standardized and easier to understand and read.
Is there anywhere in the US I can get birth control pills without a prescription now?
In Oregon and California, and in some Washington state pharmacies, women can get access to birth control just by visiting their local pharmacy.
In these states, birth control pills do not yet truly have over-the-counter status, but there is no need to go to the doctor to get or renew a prescription. A short-questionnaire and consultation with your pharmacist will have you out the door in no time with oral contraceptive in hand.
Many other states like Tennessee and Missouri are following suit by creating and/or passing bills allowing women greater access to birth control pills by allowing the pharmacist to essentially prescribe and dispense the medication.
Are there any drawbacks to pharmacist-prescribed birth control?
Some have expressed concern that not requiring women to have an annual checkup could mean that some skip important tests and screenings.
A Pap test is recommended every 3 or 5 years for most women ages 21 to 65. Pharmacists cannot write a prescription for a woman who is unable to provide evidence that she has visited a women’s health provider within 3 years of the pharmacist’s initial prescription for a contraceptive.
However, some birth control advocates believe that pharmacist-prescribed birth control still limits access for women because of the age restrictions in some states, and the requirement in some states that women see a doctor every few years.
What type of birth control pill could be available without a prescription?
One pharmaceutical company, HRA Pharma, is researching a progestin-only pill that could be the first OTC oral contraceptive.
HRA Pharma is a French Pharmaceutical company that is collaborating with Ibis Reproductive Health to conduct the research necessary to get birth control over-the-counter.
Are there advantages to a progestin-only pill?
Progestin-only birth control pills present the fewest barriers for the most people.
First, progestin-only pills are not associated with the increased risk of high blood pressure or cardiovascular disease that can be an issue with some other birth control medications. They can also be used if you have some health conditions that would normally prevent you from taking a birth control pill—for example, uncontrolled high blood pressure or deep vein thrombosis.
They also don’t interfere with sex, can reduce menstrual bleeding or stop your period altogether, and can be used after child-birth even if you are breast feeding.
The possibility of birth control without a prescription may become a reality in the near future.