Want Timeless Beauty Like Your Favorite Hollywood Stars? Renowned Plastic Surgeon Gerald Imber Reveals His Anti Aging Secrets

1. Don't smoke.

By now everyone knows this, but it demands reinforcement. Smoking constricts small blood vessels and reduces blood flow to the skin. The result is a decrease in nutrients and oxygen to the skin, and an oxidation and denaturing of collagen. That causes loss of elasticity, sagging and wrinkles. It's as simple as that. The evidence is so clear that most plastic surgeons won't perform face-lifts on smokers -- the blood supply to the skin is so compromised that portions of the skin are actually at risk of dying. This problem doesn't appear in nonsmokers. That's how severe the damage can be. Add to that the vertical lines that develop in the lips from puffing away, and you can see some measure of the damage you are doing to yourself. All this without mentioning the risk of lung cancer and cardiovascular diseases so closely associated with cigarette smoking.

2. Don't gain and lose weight repeatedly.

Maintaining a relatively constant weight makes great sense for a volume of reasons. For our purposes, it is important to avoid the stretching of the skin caused by weight gain and the laxity that follows weight loss. At some point, we can no longer get away with this. The skin loses just a touch of elasticity and doesn't snap back as quickly. That is the first warning signal. People in their thirties and forties are well advised to lose weight very slowly, not simply for physiological reasons but also in order to give the more slowly reacting skin a chance to shrink and fit the underlying structures. Slightly later in life, even this won't help. At this point, the skin will not respond to weight loss by shrinking, and will look loose, empty and haggard. Not a very nice reward for having the fortitude to lose weight. The older you are or the more weight you need to lose, the more likely this problem will arise. Weight loss of more than a few pounds should be at the rate of half a pound per week. It is quite acceptable to lose two or three pounds the first week, as that is primarily water. After that, moderation is crucial. The lesson, of course, is to avoid significant weight gain, lose slowly and, above all, find your optimal weight and maintain it.

3. Don't get too thin.

Yes, you can be too thin. Hollow cheeks and thin skin may work for nineteen-year-old fashion models, but it makes an adult look frail, weak and old. And there is nothing at all attractive about the look of anorexia. In fact, normal subcutaneous fat does much to plump out wrinkles and help the skin look and feel healthy. I am not proposing obesity, but you can surely be too thin. Mental and physical health considerations aside, being excessively thin is simply unattractive in an overall sense.

4. Don't run. Hear me out!

I know everyone's doing it, I know it feels great and has great mental and physical benefits, but that doesn't make it right. At very least, don't be a long-term, long-distance jogger. Take a look at the serious runners you know who are in their mid-forties. Serious runners of normal weight have haggard, sunken faces, due primarily to a loss of subcutaneous fat. It takes a while to manifest itself, but that is the price extracted for the benefits running offers.

Just as with any weight loss, the total reduction of body fat that results from running affects the face first. First the face, then the breasts, then the buttocks and abdomen. Running is more specific still in the loss of facial padding. The constant rising and pounding down, rising and pounding down, lifts and pulls the facial skin away from the underlying muscles and bones. You surely have seen this in slow-motion films of runners. The skin rises and falls, and as the foot impacts, it continues to fall for another fraction of a second, then bounces up again. The elastic fibers in the skin absorb the repeated trauma until they eventually cease to fully bounce back and ultimately stretch a bit, causing laxity of the skin. The combination of excessive loss of fat padding on the face and accelerated loss of elasticity have a decidedly negative impact on one's appearance. Jogging bras are universally worn for comfort and support against the tearing effect of the constant trauma of bouncing. Facial skin suffers the same fate, and yet it goes unprotected. Add to the brew arthritic knees, ankles and backs, and one would doubt running is the aerobic exercise of choice.

It is not my intention to indict limited-frequency, limited-distance running, but be on guard. The beneficial effects of running are undeniable, but for most people low impact activities like biking, swimming, walking on the inclined treadmill, elliptical trainer or stair-climber offer equal benefits with fewer pitfalls.

5. Facial exercises are a wrinkle workout!

Don't do them. They cause wrinkles. The facial muscles, or muscles of facial expression, are that group of muscles that originate on the facial bones and end, or insert, at the skin. They are thin, flat muscles that are just beneath the skin and serve to animate the face, or give it expression; hence the name. To understand how they work, try this: Tighten the orbicularis oculi muscle. That's the muscle that encircles the eyes and makes up much of the bulk of the eyelids. Tightening the muscle makes you squint.

Now do it again in front of the mirror. The squinting pulls the skin into wrinkles alongside your eyes. Now look in the mirror and smile and frown. The muscles of facial expression are attached to the skin, and repeated tightening, or exercising, of those muscles folds the skin over and over until wrinkles form.

Don't stop smiling. It's very human and very attractive, and it's a lot different than doing a wrinkle workout. The idea behind facial muscle exercises is surely well-intentioned, but it's ignorant of anatomy. One day, years ago, teaching facial anatomy to a class of first-year medical students at Cornell University Medical College, I whizzed through the anatomy of the muscles of facial expression, then prepared for questions. One of my students asked how facial exercises, which had become quite popular, actually worked. It made me think, and I told them what I tell you. The muscular attachment to the skin is meant to graphically reflect our expressions. Exercises in no way enhance the tone or strength of the skin and, when done repeatedly, indelibly etch wrinkles into the skin. Facial muscle exercises are a wrinkle workout.

6. Avoid the sun.

Nothing new or revolutionary here. Besides causing skin cancer, exposure to the sun is the primary accelerator of the breakdown of collagen and elastic fiber, causing loosening and wrinkling of the skin. If all this wasn't enough, the sun also causes pigment changes, sunspots and various other unsightly eruptions. The intangible allure of a bit of color should be tempered with common sense, as there is absolutely no question that ultraviolet rays accelerate skin aging. Worse still, the effect is cumulative. Those days at the beach without sunblock will surely be paid for tomorrow, and the wise person would avoid adding today's insult to yesterday's injury. So the obvious decision is no sun. Cover up, stay inside, or slather on that sunscreen. The topic of sun protection will be dealt with in much greater depth in the section on sunscreens.

But the issue is much more complicated and important than the simple "just say no" implies. The problem is vitamin D. Vitamin D is manufactured in the epidermis in response to exposure to sunlight. It doesn't happen in the dark. Vitamin D is necessary to maintain the body's calcium balance. Calcium is necessary for many physiological functions within muscles, the immune system and internal organs. Without adequate vitamin D, calcium is mobilized from the bones, resulting in reduced bone density. Decreased bone density leads to osteoporosis, brittle, thin bones and fractures. Vitamin D deficiency in children leads to a condition known as rickets, in which bones do not calcify properly and become weak and bowed. Physicians and nutritionists complacently thought that decalcified bones were a thing of the past, but osteoporosis has become ubiquitous, particularly among postmenopausal women. This is the same osteoporosis we hear about endlessly on television, and apparently no one is immune. Calcium intake itself has been estimated to be inadequate for more than 55 percent of the population. The issue may be that sunscreen protects the skin but blocks out the UVB spectrum of the sun necessary to produce vitamin D. So: Protect against skin aging and skin cancer, or produce adequate vitamin D for your bones? Obviously a compromise is necessary. Some experts believe that ten minutes of midday sun on the face, arms and legs three times a week during spring and summer is adequate for vitamin D production and bone health, as well as storage of enough vitamin D for the winter. The farther north one goes, the less potent the sun. Also, the darker one's skin, the less vitamin D produced by exposure, with the skin pigment acting as a sunscreen. But even individuals with outdoor lives and excessive sun exposure appear prone to inadequate vitamin D levels, and many experts recommend vitamin D supplements.

The standard recommended dose of vitamin D supplement has been 400 international units (IU). Many experts believe that is inadequate for most adults, and recommend 1,000 IU daily for older people, whose skin is significantly less efficient at vitamin D production. After menopause, even larger doses are suggested, usually 1,500 IU daily. Excessive vitamin D intake has significant toxicity. The Institute of Medicine established the upper level of safety at 2,000 IU daily. The Linus Pauling Institute at Oregon State University put the upper limit of safety between 5,000 IU and 10,000 IU, and recommends a daily adult dose of 2,000 IU. I recommend a more conservative approach and, for those who get virtually no sun, a daily supplement of 1,000 IU. So the whole thing is very confusing, and no one knows what is actually optimal. For now, drink milk, get a few minutes of sun, and take a 400 IU supplement if you cannot.

7. Nutrition.

Change your diet! This absurd generalization is still far more universally applicable than it should be in our information-rich society. Since the majority of readers, women or men, are individuals concerned with their appearance, you would expect this group above all others to understand and follow healthy eating habits. Not true. The majority of Americans are either overweight or on weight-gaining/losing yo-yo diets. The metabolically thin individual can get away with careless and excessive eating habits. The chronically overweight are bearing a potentially lethal load. For different reasons the chronically diet-thin represent an equally precarious situation. Which leaves a fairly small minority of well-nourished, consistently thin individuals free from eating disorders, hormone imbalance and calorie-counting.

Anyone old enough to be interested in this book has been nurtured on overindulging in an unhealthy pattern devised for us by authority figures and condoned by the government. A full measure of the burden of guilt lies with the medical profession at large -- not intentionally, of course, but by complicity and avoidance, compounded by lack of understanding and inadequate knowledge and attention to facts that one can hardly avoid. The leading cause of death among American males is heart disease. Women, especially postmenopausal women, are increasingly close behind. Among the root causes of the epidemic of heart disease is diet. Though the importance of other risk factors such as heredity, smoking and lack of exercise cannot be underestimated, the fat-rich American diet is terminally related to the problem and is a reversible component in many cases. Study after study shows a rise in heart disease with introduction of fat-rich Western diets. Asians, boasting a negligible incidence of heart disease, develop increasing evidence of coronary artery disease as they assume Western dietary habits. Primitive cultures existing on vegetarian, animal-fat-deprived diets are free of significant heart disease until they are introduced to the bounty of civilization.

Conversely, there have been numerous low-fat dietary programs that have helped reverse heart disease with diet and exercise. Examples are legion, and the topic represents a book of its own. The point here is to direct you to reasonable eating habits. A diet that can kill you is certainly unhealthy. But it is unhealthy in so many insidious ways that the damage almost seems unrelated to the cause. It's hard to register that the eating habits with which we grew up are wrong. We simply ingest too many calories for the work we do. We are continually over-fueling the machine. And too much of the fuel is derived from fat. Besides being a source of cholesterol and cholesterol building blocks, each gram of fat contains nine calories, while each gram of carbohydrate or protein contains only four. So in addition to basic health hazards, fat delivers more than twice the calories per unit of the other food sources. That alone is cause for change. We eat too much, and we eat too much of the wrong things.

The effect of all this on one's appearance is both obvious and implied. Good health may not always be reflected in one's appearance, but overweight and out of shape is not attractive. As I mentioned earlier, assuming we all understand the health value of proper weight maintenance, the hazard to one's appearance is in cyclical gain and loss. Elastic and collagen fibers become increasingly unforgiving with the years. A twenty-pound weight fluctuation leaves loose skin in its wake. Small weight loss without rapid regain is well tolerated at any age. Larger weight loss must be spaced over months to allow the skin to compensate. Obviously, the greater the necessary loss, the less likely the skin will shrink to fit. The best tactic is to achieve one's optimal weight and stay there. That needn't be model slim or unrealistically small for who you are, but maintain a good and healthy level that your body can adjust to.

Over the years, I have often been called upon to give diet advice, and have learned as much as I have taught. If one is to have any lasting success with dietary changes, several rules must apply.

a. The plan must be easy.

b. There must be a sizable initial change to fire enthusiasm.

c. The goals must be clearly defined and within reach.

The plans I suggest may be no more effective, and certainly less radical, than those you have already tried -- which speaks to the real problem. You shouldn't have needed more than one diet. Over the short haul, they all work. Even four grapefruits and a prune a day will do the job for a week or two. The real issue is stabilizing your weight. That means forever. A fluctuation of three or four pounds is often seasonal or psychological and perfectly acceptable. Such a small amount, 2-3 percent of body weight, is easily shed without consequence. Maintenance requires a whole new mind-set. In order to be effective, it should require no thought at all once the changes have been learned. The following points have repeatedly proven their value. They are simple, painless, and in no way interfere with the enjoyment of food or the social aspects of meals.

a. Begin every meal by drinking a full glass of water. It occupies volume and will slake some of the immediate hunger. Water takes up space, it has no calories, and it's good for you.

b. Eat salads as the first course -- not, as in the European tradition, after the main course. The purpose is obvious. Salad is filling and, bite for bite, far lower in calories than anything that will follow. Salad dressings are fine, and the health benefits of olive oil cannot be overstated. Use it.

c. Eat half of what is on your plate, then stop and think. You are no longer hungry, so why keep shoveling the calories in? Always leave food over. The portions we are served or serve ourselves are unnecessarily large.

d. No second portions. Period.

e. No desserts.

f. Between-meal snacks should be limited to low-calorie drinks, preferably water, and fresh fruit. An apple, in addition to tasting great, provides complex carbohydrates, which are digested slowly and, through feedback mechanisms, repress hunger far longer than prepared snacks made with refined sugar. Fresh fruit contains far fewer calories than snack food and is rich in vitamins, nutrients and naturally occurring antioxidants.

Obviously, one should be concerned with the quality of food consumed. Fruits and vegetables are critically important. Fat and cholesterol in all forms should be controlled, and trans fats banished. Most of all, calories do count. Yes, exercise burns calories and even raises your basal metabolic rate a bit for a couple of hours afterward, but is not an excuse for overeating. Don't overestimate how many calories you are burning. An hour of tennis singles burns off barely 250 calories. Less than a Snickers and a Coke. Running a ten-minute mile consumes only 145 calories. Weight is controlled by taking in (eating) only enough calories to support baseline body requirements plus physical work. This means far fewer calories than one would imagine. Happily, it can all be managed with ease, if one is devoted to the task. A forty-five-year-old woman, five-feet-five-inches tall, weighing 110 pounds, needs about 1,600 calories daily for weight maintenance. Find a food calorie chart on the Internet and learn the basics. It will confirm what you already know about most foods.

The body mass index (BMI) is a good indicator of total body fat and is calculated based on height, weight and age. Federal guidelines suggest a BMI of 24 or less as an appropriate and healthy goal. There are BMI calculating services on the Internet. Plug in your statistics and see the truth. The rest is common sense. Find the right level for you and stick to it. The few tricks offered above will help, but remember: This is a maintenance aid, not a quick weight-loss diet.

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8. Learn about antioxidants and free radicals.

Two scientific terms that have become unavoidable are free radicals and antioxidants. These are now understood to be crucial issues in the health and beauty of one's skin, so pay attention. Free radicals are charged chemical particles of oxygen that enter into destructive chemical bonds with organic substances such as proteins. The result is an oxidation, or chemical burning, of the substance, which destroys it. Protein is denatured, genes may be broken, and dangerous residual substances may result from the chemical changes. Examples of oxidation in nonscientific daily life include the rusting of an iron grill left in the atmosphere, the quick browning of cut potatoes, peaches or avocados left in the open air. It is interesting to consider that when a sliced avocado or peach is treated with lemon juice (a source of the antioxidant vitamin C), it does not brown. But before we jump to the conclusion we wish to see, immersing them in water inhibits the oxidation as well. Knowledge of all this has been around for a long time, though only recently has the process become a consuming interest of researchers and health faddists alike. At the same time that the destructive capabilities of free radicals were becoming known, many compounds that combat this destructive oxidation were identified. They are known as antioxidants, and include among their number many vitamins that were felt to be healthful even before the reasons were clarified.

Various activities of daily life have been shown to increase the presence of oxygen free radicals associated with destructive oxidation. Exposure to sunlight is known to lead to oxidative destruction of the skin, including increased incidence of skin cancer and the collagen-destroying processes causing wrinkling. Strenuous aerobic activity has been associated with increased free radical formation. But while athletes produce more free radicals, they may have also developed a more effective method of combating the damage with natural antioxidants. The evidence of free radical production leading to oxidation and tissue damage is real; some of the findings are confusing, and we are only just scratching the surface of understanding a very important mechanism.

Vitamin C has been given credit for all sorts of miracles, proven and unproven. It is a potent antioxidant and a necessary component of tissue collagen production. Again, we are advised that normal diets, including citrus fruit, provide adequate vitamin C. Over the years scientists and clinicians have waffled over claims for the ability of vitamin C to prevent colds and lessen the length of time that symptoms persist. It is generally believed that these qualities are overstated or wrong. One study did show vitamin C to be effective in preventing cold symptoms in 50 percent of marathon runners tested but only a tiny percentage of the general population. Since I'm so set against subjecting one's body to marathon running, I nearly opted to leave that bit of information out. The significance of all this is confusing.

Antioxidants such as vitamin C are key players in the prevention of cholesterol plaques forming in the arteries and are generally necessary for sustained good health. The importance of vitamin C is well-known for its role in the healing of wounds and maintenance of the integrity of tissues. It is important in collagen synthesis, and its absence causes the disease scurvy, which results in tissue breakdown and open wounds. This was in the past a common condition suffered by sailors during long sea voyages. The association of citrus fruit with prevention of the disease led to British ships carrying stores of limes for consumption on extended passages, hence earning British sailors the nickname "limey."

Excess vitamin C is quickly and harmlessly excreted in the urine. Most proponents believe that 1,000 milligrams per day is adequate for the desired antioxidant effect. A 2008 study quantified the ability of 1,000mg/day of vitamin C to clean up the free radical in muscle after exercise, but questions whether this is beneficial. I'm confused, and I'm sure you are too. Stay tuned -- there is surely more to come.

Everything considered, I continue to recommend, and use, daily supplements of 1,000 milligrams of vitamin C.

Vitamin C has also been shown to be a powerful antioxidant when applied to the skin. This is where real progress is being made. Free radicals derived from metabolic processes interfere with the production and maintenance of collagen in the skin. When collagen fibers are inadequate in number or misaligned, the skin structure breaks down and loss of elasticity and wrinkling result. Vitamin C protects the collagen in the skin and is necessary for new collagen production and wound healing. Free radicals from the environment have also been said to enter the skin and cause tissue damage, though how this happens is a mystery to me. The function of the skin is to keep the outside environment outside. That's how it works. And the difficulty in getting topical vitamin C into the skin illustrates that fact. But mechanisms aside, vitamin C applied to the skin can work if it can get into the skin in sufficient quantities. We will deal with this issue in depth a bit later in the text.

Vitamin E Along with the knowledge of the destructive capability of free radicals is the knowledge that they are products of normal metabolism and are neutralized by antioxidants. These antioxidants are either enzymes within the body systems or antioxidants derived from the diet. The diet-derived group includes vitamin E (tocopherol), vitamin C (ascorbic acid), carotenes (vitamin A), and many others. Vitamins C and E are among the major nonenzymatic antioxidants that protect skin from the adverse effects of aging and sun damage, and for this purpose, topical application seems far more effective than oral supplements. We don't yet know how much is optimal for this function, but we are discovering how to most effectively deliver it to the skin. The fat-soluble vitamin E molecule is too large to penetrate the skin and significantly raise circulating levels, but application of vitamin E to the skin has consistently shown the ability to retard the inflammation from sun exposure and UVB damage and, in fact, reverse the sun damage. There is also a great deal of evidence that vitamins C and E are enhanced in their antioxidant function when applied together. Current conservative advice is that a diet rich in fruit and vegetables should be adequate for normal healthy adults. Daily oral supplements of vitamin E have long been recommended but have fallen into scientific disfavor due to conflicting reports. Some studies claim it promotes cardiac health; others contradict the findings. A 2009 study indicated that most basic studies were universally flawed and suggested that larger (and perhaps larger than tolerated) doses might be necessary to be effective. I no longer encourage taking vitamin E supplements until more information is available. The effect of vitamin E on the skin is another matter. All evidence indicates that it is an important element for maintaining youthful, healthy skin and preventing and reversing sun damage.

Topical antioxidants like vitamins C and E are potent tools for reversing sun damage to the skin. No one doubts their value; the issue is getting the large molecules through the skin, and a great deal of progress has been made on this front. Effective vitamin C serums are available, and they work. But delivering enough of the antioxidant remains a problem; measuring its effectiveness objectively is another. A relatively unexploited but easily documented property of topical antioxidants is their ability to prevent redness from sun exposure. Both vitamins C and E reduce the red inflammatory reaction from the sun when applied half an hour before exposure. This can be documented and crudely quantified, so we have a way of measuring results and comparing them. When C and E are applied together the effect is cumulative, in other words, more effective than either alone. When another antioxidant, melatonin, is added to C and E, the protective effect is many times greater than using C or E alone, or C and E in combination. Apparently, the addition of melatonin eases the entry of the antioxidants into the skin. This breakthrough has made the topical delivery of antioxidants into the skin a more effective reality. The unique quality of the combined antioxidants has been known for a number of years. Whether the reduced inflammatory response translates to fewer skin cancers is not yet clear. What is known is that vitamins C and E, combined with melatonin, drive antioxidants into the skin, and these same antioxidants have been shown to protect the skin from the inflammatory response to the sun and help reverse previous sun damage to the skin.

About natural antioxidants and antioxidant supplements: There are many antioxidant supplements available. Most of these compounds have beneficial properties in their natural state, which should not be overlooked. But the question is whether antioxidant supplements actually provide the help they promise. Systemic antioxidants are necessary to prevent the oxidation of LDL (bad) cholesterol, which then becomes layered into artery walls as life-threatening plaque. As recently as June 2009, the American Heart Association declined to underwrite the use of antioxidant supplements for this purpose. It concluded there is not enough evidence that vitamins C or E or beta-carotene supplements are of any benefit, though it encouraged the dietary intake of foods high in antioxidants in the natural state. Foods such as citrus fruits, carrots and pomegranates are high on the long list of healthy sources. Green tea is a great source of the powerful antioxidant group called catechins. Catechins have been credited with improving cardiac health, among other benefits, and many experts encourage consuming multiple cups of green tea daily. Numerous studies show the benefit of these catechins in boosting immune response and protecting against cancer. Green tea extract applied to the skin is active in protecting against skin cancers caused by UVB rays, the most dangerous wavelength in sunlight. There appears to be enormous value in consumption of green tea and its use in skin-care preparations.

Decaffeinated tea retains its antioxidant value as well, so you can drink your antioxidant all day, buzz-free. Apparently, green tea is not baked in the production process and maintains more of its active catechins than other types of teas. Green tea has no calories, and though it is admittedly an acquired taste, once you get into it, it tastes great. Over the long haul, it may stain teeth slightly, as does coffee; but the simple expedient of brushing a few times daily seems to neutralize the problem.

Lycopene is perhaps the most potent dietary antioxidant. It is found in abundant supply in tomatoes, carrots and other yellow, red and orange fruits and vegetables. Its importance in cardiovascular health has been established, and one can infer that if it gets into the arteries it will also reach the skin. Here's the good news about lycopene: It appears to be most effective in the cooked state in tomatoes, and is most readily digested and absorbed in combination with fats such as olive oil and cheese. Which makes an excellent case for pizza.

Coldwater fish supply abundant amounts of healthy omega-3 fatty acids, while supplements may not. This does not mean that supplements do not help, simply that there is no evidence of that help. That is not the same thing. In the case of beta-carotene supplements, there is evidence of significant negative impact of high doses on the survival of some cancer patients.

The point of all this is, don't let any food faddist, vitamin salesman or profiteer fool you. There is no clear, scientific evidence that supplements can do the same job as healthy eating. So, why do I continue to use and suggest vitamin C supplements? The evidence of its effectiveness comes and goes in waves. There is nothing to indicate vitamin C is harmful, and reputable scientific investigators have taken both sides of the question over the years. But one would not be wrong in abandoning vitamin C supplements as well.

9. Get the facts about hormone replacement therapy.

Hormones are integrally involved with the overall state of bodily functions. Diseases excluded, there are changes in certain hormone levels that are predictably associated with aging. Just as testosterone levels decrease in the aging male, so estrogen levels in females dip slowly through adult life, finally reaching symptomatic levels at menopause. The importance of estrogen is well-known beyond hot flashes and loss of childbearing ability. The incidence of heart disease in postmenopausal women nearly equals that of men of the same age, in sharp contrast to the very low incidence of heart disease in premenopausal women. Consequently, it has long been thought that estrogen is profoundly protective effect against heart disease; but the latest information strongly refutes this theory. There does seem to be unanimity in believing hormone replacement therapy is effective against loss of bone density. Estrogen withdrawal is followed rapidly by skin changes. Dryness, marked wrinkling and loss of skin quality are the hallmarks. These are but two of the changes, but they are striking and important to consider. Both are preventable, and perhaps reversible, with estrogen therapy. Unfortunately, that is only half of a complicated and incomplete story.

Hormone replacement therapy is known to increase the risk of uterine cancer. In women who have undergone hysterectomy and therefore have no uterus, the risk of uterine cancer is absent and estrogen replacement therapy had been routinely suggested for its alleged cardiovascular protective effects and skin-salvaging qualities. The overwhelming preponderance of women undergo natural menopause and therefore incur increased risk of uterine cancer with estrogen therapy alone or estrogen-progesterone combination therapy. The best evidence is that estrogen therapy may increase the risk of breast cancer as well. All this was announced in July 2002, when the largest ongoing study of the estrogen replacement issue was stopped because the evidence against estrogen use was so overwhelming that it was deemed too much of a risk to continue. Current thinking seems to have softened, and further complicated a confusing situation. A 2012 Danish study concluded that hormone replacement therapy does not increase the risk of cardiovascular disease or breast cancer. Criticism of that study has already begun.