BY KEITH ROACH, M.D.

Milk thistle, though harmless, not recommended for MASLD

DEAR DR. ROACH: Any thoughts on milk thistle supplements in fatty liver disease that was diagnosed by an ultrasound due to elevated AST and ALT levels? — B.S.

ANSWER: Milk thistle (sylmarin) has had mixed results in clinical trials regarding metabolic-associated steatotic liver disease (MASLD, formerly called fatty liver disease). Although a few individual trials have shown benefit, the major association for liver disease has concluded that sylmarin does not improve the condition as measured by biopsy, and they recommend waiting for larger trials before recommending this treatment.

When the diagnosis of MASLD is suspected due to elevated liver enzymes (ALT and AST are blood tests that look for damage to liver cells called hepatocytes), then a person should be examined for scarring and inflammation in the liver, which is a condition called metabolic-associated steatohepatitis (MASH). Noninvasive tests are very good at determining this, and most people no longer need liver biopsies.

The major treatment for people with MASLD and obesity is weight loss. All people with MASLD should avoid excess alcohol and get the hepatitis A and B vaccines unless they’re already immune. People with MASH who don’t have diabetes are often recommended vitamin E. New drugs, specifically GLP-1 agents such as tirzepatide (Mounjaro), may have beneficial effects. A new medicine, resmetirom (Rezdiffra), is poised to make a dramatic change in the treatment for people with fibrosis.

Because milk thistle is quite safe at recommended doses, I doubt there is any harm in taking it, but I do not recommend it in place of standard treatments.

DEAR DR. ROACH: I’ve no history of nosebleeds, but over the past five weeks, I’ve had five. The first three times, the bleeding stopped after 30 minutes. The fourth time, it took an hour. Today, the fifth time, it’s been going on for two hours! I’m concerned.

Last week, I messaged my doctor, and he suggested Vaseline to moisturize my left nostril. I asked for a referral to an ear, nose and throat (ENT) doctor. He said to use the Vaseline since the referral could lead to cauterization.

At this point, I’m fine with a solution, not a Vaseline Band-Aid. Do you have any suggestions or approaches to help me communicate better with my general physician? — B.W.

ANSWER: I understand both of your perspectives. You are tired of the nosebleeds and want definitive treatment to make you better, while your general doctor wants to avoid an unnecessary procedure.

Nosebleeds in adult women tend to occur after menopause, while men have nosebleeds at a younger age. Nosebleeds tend to be worse during the drier, colder winter months. Allergies and infections predispose people to nosebleeds, and nasal steroids can also precipitate nosebleeds. Uncontrolled high blood pressure, the use of anticoagulants, and (for want of a more delicate term) nose-picking are also known causes of nosebleeds.

Most people will do well with conservative management, which is why I think your doctor wants to avoid cautery. Cautery fails between 14% and 35% of the time and isn’t an especially pleasant process. However, a referral to an ENT, who likely has a great deal of experience with this condition and its treatment, does not doom you to a certain procedure. The ENT specialist has other tools at their command, so a look to see what might be causing your nosebleeds is prudent at this time.

It’s perfectly fine to call your doctor back and say Vaseline isn’t working. Thank him for warning you that cautery might not be the best immediate choice and ask him for a referral to someone who won’t rush into a procedure.