Medical Monday: Beaking News from the World of Obstetrics and Gynecology

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We will start off with surprisingly novel and beneficial research. A think tank called “ Center for American Progress” has released an analysis of the current state of "sex ed”in America. Collectively, the states were found to be deficient in teaching about issues of healthy relationships, consent and sexual assault. Only a handful (10) of states programs even mentioned these things at all. 

Backlash continues across states and the nation. Last week, Iowa passed a law which bans abortion once a heart beat is detected. This contradicts the law on the books at this time, Roe VS. Wade. Iowa is being sued by the ACLU and various abortion providers. 

The Trump administration intends to cut all Title X funding to any clinic which even counsels about or refers for abortion. Eighty five separate groups have signed a letter to HHS Secretary (Health and Human Services) Alex Azar to restore Reagan era regulations. 

The Trump administration has shown political and financial preference toward family planing clinics who promote only abstinence for birth control, even though it is neither effective nor evidence based. Since family planning clinics have been organized and staffed by those who endorse evidence based effective contraception not including abstinence only, this effectively defunds all family planning clinics. The States have a serious interest in this, since they realize the health and prosperity of their populace depends on such services. In that light, the States Attorneys General have come together to back family planning clinics nationwide to sue the Department of Health and Human Services over its policy. They argue that the current policy violates the terms of Title X enacted in 1970 with bipartisan support. 

Should Medicaid recipients have a lifetime limit on benefits ? Certain states, in cost cutting bids, have been lobbying for this. However, the Fed, via the Center for Medicaid Services (CMS) has rejected these requests. In doing so, the Fed has broken rank with party conservatives. 

Care for women, pregnant women and postpartum women is not just germane to women. The health of women extends to others in the way that the health of men simply does not. Pre-pregnancy health, we are learning, is more germane to a child’s heath than we previously realized. During pregnancy our opportunities to intervene to prevent morbidity and mortality are obvious. Less obvious are the manifold opportunities in the post partum period. New recommendations from ACOG (American College of Obstetricians and Gynecologists) the Society for Maternal Fetal Medicine, and the Academy of Breastfeeding Medicine reflect a growing understanding that support in the extended postpartum period reaps many benefits. They now recommend that postpartum care should extend to 12 weeks and  become a sustained period of support for the new mother and infant. It has come to light that for every 10 weeks pf paid job protected leave, infant mortality decreases about 5 percentage points. 

With legalization of marijuana all around the country, more and more pregnant and breastfeeding women are using. Until recently, we had only vague warnings for these women. However, now new data indicate that using during pregnancy leads to a 50% increased chance of low birth weight. Use during breastfeeding is associated with decreased motor development in babies. 

The nation is indeed split on the issue of women and children. Part of the country is set on shifting away from collective responsibility toward women and children as they actually live. The current administration is intent on solidifying its base through supporting the explicit ideology of its voters, which gives women certain constraints in society:  abstaining from sex before marriage, using abstinence only for birth control, and rejecting abortion. The administration has combined these emblematic stipulations with their advertisement to cut taxes, and the result is that health care budgets for women have been slashed. And as if to add insult to injury, it is not at all clear if the money lost to the health care system will actually end up back in the hands of the taxpayer. 

The other part of the country is looking at the real problems of maternal morbidity and mortality. They are trying to solve problems with the best available science, rather than with ideology. States are beginning to realize that the lack of good routine health care, prenatal care, and post partum care is expensive. It is expensive in the emergency room and in the workplace. Professional, scientific and legal groups are starting to fight back. 

ABC has just done what amounts to an exposé on the poor quality of pregnant and postpartum care in the US. This column has dealt extensively with the statistics on maternal morbidity and mortality. However, I have rarely included numbers. In the US seven hundred women die each year in childbirth. Sixty five thousand more almost die. In a response to this program, ACOG has publicized its coordinated initiative to reduce maternal morbidity and mortality state by state, AIM, Alliance for Innovation in Maternal Health. It has already been implemented in 18 states. 

Science marches on. 

New research indicates low levels of free t4 are associated with lower non-verbal IQ in children ages 5-8. Most caregivers are now including thyroid labs in their prenatal panels. Ask your doctor and beside you get yours checked. 

BRCA genes are not the only genes pertaining to breast cancer. Newer multi-gene testing panels are now available for selected patients. Ask you doctor to speck with a geneticist if you are uncertain. 

Common sexually transmitted diseases are on the rise in California, 45% in  years.  New data indicate that chlamydia is most increased in women in their 30s, while men account for the majority of new syphilis and gonorrhea cases. 

Fertility rates in the US have fallen to record lows for the second straight year. he same is true for several other developed countries. What are we to think ? We know that at present, 50% of births are unplanned. As women become more educated and have more autonomy, birth rates naturally decline. You hear environmentalists’ concern  about overpopulation, and politicians bemoan declining birth rates. The devil is, as always in the details. Certain subgroups in our population are decreasing and others are increasing. All of this will add up to social and economic change. I have one main concern: that growth be sustainable. Since my life’s work is mainly done one woman at a time, I am concerned that her health habits and healthcare are sustainable. I am concerned that she have the means to grow her family or finish her familie's growth in a sustainable way. I am concerned that my town and my countryside have sustainable growth. However, for me, growth is not the right word. I’d rather my community mature, of flourish. We shouldn’t always need more people, more buildings or a larger economy. What we need is for the family size to be ideal as determined by the parents. We need our towns to function optimally and to improve the space we have until it is optimized. The same is true for our nation. But our financial institutions are geared toward growth: More consumers, more goods, more profit. But this comes at human, societal, economic and ecologic cost. When we think about family size, birth control, population statistics, and even prosperity in general, we have to think about what we want our future to look like. When women lack access to health care, we cannot craft our futures. 

 

Stay tuned for more news from the exciting world of Obstetrics and Gynecology, right here next week on Medical Monday. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

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Maternal mortality is a big topic nationwide. The rates are unacceptable in the US, and particularly bad in the South. Arkansas, in a reasonable move to triage women for eligibility for home birth, have established a screening process. That screening process for women helps the State determine who may legally delivery at home. Heretofore, this screening did not require a vaginal exam. Now it does, and this has brought fire from patients and home birth midwives. It has always been our position that a patient may decline anything for any reason. However, to qualify for certain program certain requirements must be met. My position would be that women who do not want vaginal exams will have to forgo participation in that particular program. And, I must ask, what is the problem with vaginal exams ? Women are not fragile and information is power. This type of overly precious attitude toward the female body, even by women, is counter to the interests of maternal and fetal health. It is case of putting philosophy over responsibility. 

Texas OB/Gyns are starting to speak out about what they see are the causes of excessive maternal mortality rates. They are identifying system errors such as failing to recognize risk, as well as more subtle phenomena, such as unconscious bias. Race is of course a factor as black women are four times more likely to die than white women. A rally in Boston highlighted the same cause of maternal mortality. The centerpiece of the rally was a billion the US Senate which will promote the formation of state review committees for maternal mortality. 

Pennsylvania is also taking measures to try to curb maternal mortality and has established a committee through the State Health Department to scrutinize the problem. 

In an effort to get more pregnancy women into prenatal care, Connecticut has approved a bill to make pregnancy a “ qualifying life event”. This means that pregnant patients in the state my enroll in insurance plans anytime, and need not enroll within the confines of the enrollment period. 

With all this talk on maternal mortality, one might take a moment and discuss maternal morbidity. Morbidity means serious complications short of death. The CDC (Centers for Disease Control) has indicated that for every 1 mother who dies, 70 nearly die. That is an astonishing statistic and goes a long way in my mind toward explaining why Obstetricians have such burn out, and why their numbers are decreasing. Maternal morbidity comes from all the same things maternal mortality: worsening maternal health, worsening access to evidence based care. poorly funded health care systems, unconscious bias, race, etc. 

The Trump Administration is considering implementing the so called “gag rule”domestically. This would prohibit the dispensation of Title X funding to any clinics which even mentioned abortion. I wonder how this reconciles with freedom of speech ? Can you imagine trying to enforce this ? All patient consultation and exam rooms would need to have audio recording equipment and someone would have to review the recordings. Dystopian much ? 

The Trump administration is reappropriating about $15 billion in unspent funds from CHIP (Children Health Insurance Program) and certain part of the ACA ( Affordable Care Act). Democrats feel this is not the time to cap these budgets or reduce rainy day funds. However the Trump administration budget is ballooning and they are trying to cut costs anywhere they can even for vulnerable groups. 

Iowa has banned abortion once a fetal heartbeat is detected, which is at around 6 weeks. However, similar measures have passed in North Dakota and Arkansas but they have both been struck down as being unconstitutional and inconsistent with Roe V. Wade. 

Louisiana has seen a quadrupling of the rate of neonatal abstinence syndrome (NAS). NAS describes the condition of infants who are born to opioid addicted women. A recent feature in teh New You Times has reported that about 90% of pregnancies among addicted women are unintended. The reasonable inference here is that addicted women have a hard time using birth control effectively. 

ACOG (American College of Obstetricians and Gynecologists ) advises pregnant and breastfeeding women not to use marijuana for concerns about developmental delays. Nonetheless, a new study has shown that 69% of Colorado Dispensaries phoned do recommend it to pregnant women for nausea. Dumb and dumber. 

New data is coming out that induction at 39 weeks may be associate with fewer risks and lower C section rates. More research is needed. 

A new study on genetic testing for breast cancer has shown that those who do not meet the criteria for testing have harmful mutations AS OFTEN as those who do meet the screening criteria. Sounds like the screening criteria need broadening. 

In other genetics related news, we find that the number of genetics tests available is increasing. A new study has shown that only a small subset of physicians order genetic testing, and even fewer know how to interpret them. This appears to be a case of the technology moving faster than our understanding. 

The Human Genome Research Institute is developing “ preconceptual screening” for couples. Right now screening is piecemeal, meaning only for a selection of known genes. However, they are developing  a whole genome sequencing program, which has been made possible by NGS, or next generation screening. 3.5 % of participants had a medically actionable finding. As of yet, the majority of the information acquired does not have a clinical application. 

Yet more data has come out of a large study on the HPV (human papilloma virus). In a study of 73,000, it has been shown not only to prevent cervical cancer, it also prevents precancerous lesion of the cervix. Additionally it did not show any increased risk of side effects compared to control. 

Stay tuned for more breaking news from the world of Obstetrics and Gynecology next week, here on Medical Monday. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

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POLICY NEWS

As reported last week, many States are starting to push back against the defunding of teen pregnancy prevention programs in their states. The latest such example is Minnesota, where in Hennepin County, HHS (Department of Health and Human Services) terminated a $214 million teen pregnancy prevention program. The grant had originally been obtained to last through 2020 and was cut as of 2018, and the suit filed asks that it be reinstated until 2020 again. Texas’ Teen Pregnancy Prevention Program is called Healthy Futures of Texas, and its Title X funds are slated to be cut. However, This organization and other Texas grant recipients are filing lawsuits to discontinue the termination of their grants. 

Title X is a federal grant program dedicated solely to providing funds for birth control and family planning. The Trump administration governs the awarding of such grant money. Of late, they have shifted their funding criteria to favor those organizations which promote abstinence rather than evidence based birth control. Several chapters of Planned Parenthood and the National Family Planning and Reproductive Health Association have filed suit against the Trump administration alleging that this strategy violates the mission statement of Title X. 

During the recent years of the Trump administration, the number of uninsured Americans rose by 4 million. These are those who slip through the cracks between the Affordable Care Act plans and private insurance, with a single income of $30,000 and a joint family income of about $61,000. The data comes from the Commonwealth Fund who warned that this trend is likely to continue. 

MEDICAL NEWS

We have known for some time now that women have been concerned about contraceptive access ever since Trump was elected. Long acting reversible contraceptives (LARCs) have been the strategy for many women. In one particular study out of UCLA David Geffen School of Medicine, uptake of LARCs nearly doubled in the two weeks following the election. 

All kinds of stereotypes exist about older people. Some have to do with sexual activity. A new study has shown that 40% of people ages 65-80 are sexually active, and of those, 73% are satisfied with their sex lives. In the subgroup of those with spouses or partners, a little over half are sexually active. Caregivers need to continue to bear all this in mind. 

ACOG (American College of Obstetricians and Gynecologists) recently held its annual meeting. One presenter there highlighted the medical benefits of vibrators, and called upon Gynecologists to identify patients who might benefit from them, and initiate discussions which normalize their use. 

ACOG president Dr. Hal Lawrence has termed the current health care climate a “battle” and “ one that is not going to end anytime soon”. They have called it a “fight to protect women’s health care”. The ACOG president has highlight the advocacy efforts of the organization this past year, along with like minded others, the “Gang of Six” consisting of  internists, pediatricians, family doctors, psychiatrists, ob/gyns, and osteopaths. 

Menopause. It is the cessation of ovarian function and all that results from that. We cease to ovulate and become infertile. Then our hormone production quits, and we may have symptoms of estrogen deprivation, like hot flashes and vaginal dryness. The average age of menopause is 51, but the range is considerable and it takes about two years to get completely through. A new study has highlighted a little know fact, that women with a poor diet, i.e. diets high in refined carbohydrates, get menopause much sooner than those with high quality diets, such as those with lots of whole foods and fish. 

The postpartum period or so called fourth trimester, is getting some much needed attention. A new study has illuminated the prevalence of perinatal depression. Turns out it affects 1 in 7 women. Indeed, a related study found that maternal suicide takes more women than hemorrhage and hypertensive disorders combined, and accounts for 1 in 5 postpartum deaths. The study has also shown that only about a fourth of postpartum moms suffering from depression get treatment. Both the US Preventive Services Task Force and ACOG recommend mental health screening during pregnancy. Pregnant moms take note: Your postpartum visit should cover mood, emotions, infant care, sexuality , contraception, sleep, and health maintenance, to name a few. 

The opioid crisis has brought many problems for pregnant women and their children. However, one such problem can go under the radar: Hepatitis C.The opioid epidemic is driving an increase in Hepatitis C among mothers and children and neither the screening protocols for mothers or infants has kept up. Hepatitis C is transmitted by blood, and thus by needles, and infrequently, from mother to child. There is no vaccine, but just recently, there is a fairly good treatment. 

Stay tuned for more news from the intense world of Obstetrics and Gynecology, here, next week, on Medical Monday. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

POLICY 

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In the good news department, the Federal Government is working toward promoting “ interoperability” which means the ability to coordinate health information technology nationally. During the Obama era, the “Meaningful Use “ program helped doctors and hospitals adopt the EMR, or electronic medical record. This new phase is meant to help all those disparate systems to be able to interact with one another. This will make authorized data sharing easier. To this end the ONC, or Office of the National Coordinator for Health Information Technology is working with innovators by giving out APIs (application programming interfaces) to encourage the making of apps which health consumers can use to control the flow of their data. Patients can choose to share their data with consultants or even with researchers who might be able to use it. 

Last week a Federal Judge in Ohio blocked the defunding of Planned Parenthood in that State. This week the same thing has happened in Washington State. Judge Rice in Spokane argued that HHS (Health and Human Services) “ arbitrarily and capriciously” blocked the funding. 

A measure on Maternal Mortality is on the Senate table for a vote in May. The bill would provide for the formation of review committees in each state which would be charged with tracking pregnancy-related deaths and thereafter to help formulate recommendations. The bill would help standardize state efforts in this regard. 

Texas has become infamous for its horrendous and still increasing rates of maternal mortality. Sweeping cuts to the primary health care system for women were made in 2011 including the defunding of Planned Parenthood. However, now that this maternal mortality crisis has come to light, Texas has formulated the Healthy Texas Women program. Usage is increasing from 70k to about 120K clients per year between 2016 and  2017. 

The USPTF, US Preventive Services Task Force, has formally recommended that all caregivers screen patients of reproductive age for abuse. It appears that there is enough evidence to support this whereas a dearth of evidence has kept them from recommending the same for people past their reproductive years. 

 

MEDICAL NEWS 

 

ACOG ( American College of Obstetricians and Gynecologists) has come out with a new Committee Opinion Document on postpartum care recommendations for clinicians. It used to be that many clinicians requested on postpartum visit at 6 weeks postpartum. However now, they are calling for at least one early checkup before 3 weeks postpartum, and a second more comprehensive visit by 12 weeks postpartum. Those with complications may need even more. I think this a great step in the right direction since many complications are already brewing within the first week alone. We conduct routine postpartum visits at 2 and 6 weeks for patients with normal clinical courses. ACOG is calling this the “ fourth trimester” and indicates it is a fundamental shift in thinking about postpartum care. Now need to get insurance companies to get on board so that more extensive postpartum care can get covered. 

ACOG has now come out saying that not only should caregivers recommend influenza vaccine to pregnant women, it is recommending that they keep the vaccine in their offices for convenient and expeditious dispensation. 

Population is a tricky thing to understand. Many of our environmental troubles stem from overpopulation. In that light, diminishing birth rates are beneficial. however, negative birth rates adversely affects economies, tooled as they currently are, on infinite growth. New data shows Kansas has reached its lowest birth rate ever. Japan, too is facing similar challenges. Economists and demographic scientists far savvier than me must put all this into context. Suffice it to say the devil is in the details. Whether or not a declining birth rate is good news or bad news depends on where you are, your perspective and your endpoints. As a physician, I know fully half of all pregnancies are unplanned. All of my studies have indicated that with women’s reproductive autonomy comes fewer children, increased educational attainment, increased savings, increased employment and widely increased affluence. But does that affluence need to be as it is in the west, at the expense of the environment? And does our affluence in the west need to stay as it is? Can we keep what’s good of western affluence and get rid of the bad? 

More good news: the number of pre-teen mothers has plunged from 8500 in the year 2000 to 2200 in the year 2016. The largest decline is among African American pre-teens. 

 

In the common sense department, we have research on depression. A new study published in the Journal Child Development indicates that maternal depression affects the development of children. These changes are apparent through the use of various tests including tests of verbal aptitude. A mother’s depression, in turn, is linked to the level of emotional verbal, and educational support that she has. It really does take a village. Reach out! 

Stay tuned for morebreaking news from teh world of OBstetrics and Gynecology here next week on Medical Monday. 

 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Policy News

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This week, and maybe from here forward, policy is becoming more State based. A few blog posts ago, I highlighted the fact that the ACA (Affordable Care Act) is run differently in different States. Some States run it entirely themselves, with money coming from the Fed, while others have the Fed run it. Other States use a hybrid model. Many States are looking at potentially rising health insurance premium rates, which will be necessary to keep programs funded, and are beginning to add State based funds to defray the severity of the increases. In other words, they are providing their own insurance subsidies to their citizens who use the ACA for their health insurance. 

Many States are turning to work requirements for Medicaid Recipients. I believe the idea there is to incentive work and the earning of money , with which ACA or better insurance can be purchased. It is both to reduce the burden of Medicaid patients on a State by causing fewer people to actually need Medicaid, either in the short run or the long run. 

There are currently work requirement proposals in ten States, which could potentially impact 1.7 million. As an Obstetrician Gynecologist, I would advocate for separate work requirement algorithms for pregnant women versus others. 

The judicial branch of our government is starting to weigh in on the Trump administration’s changes on the way health care is being delivered in this country. An Ohio law blocked funding to 28 Planned Parenthood clinics. However, a Federal court has blocked this law, saying that while the State may prefer “ childbirth to abortion” defunding planned Parenthood has little to do with that question since this particular money is not used for the support or performance of abortion. In barring this law, many primary care health services will be safeguarded. 

There are several lawsuit against this administration’s defunding of the Teen Pregnancy Prevention Program. A Federal Judge in Washington DC has declared the termination of the program unlawful and ordered the DHHS, Department of Health and Human Services to move forward again with the application of four such applicants within the program. 

Medical News 

If a pregnant woman is a risk for gestational diabetes, her physician may ask her to improve her diet and be more active. It turns out that those who made the changes have better glucose regulation even one year after baby is born. 

Coming from the other direction, we have the following report from the esteemed Journal Lancet. It seems that the environmentally determined health of both mother and father play greatly into the ongoing health of future not-yet-conceived babies. Each parent’s condition, whether well nourished, stressed, obese or fit, has influence on the cells and the DNA from which future children will be made. This us believed to take place through a process called epigenetics in in which an indivudual’s present day physiologic circumstances feed make and alter the expression of their genes and the genes of their germ cell lines (eggs and sperm). The article goes on to conclude that it points to a whole new level of preconceptual counseling which we must do. 

COPD (chronic obstructive pulmonary disease) usually related to smoking, now kills more women than men in this country. The days of “Virginia Slims” a TV ad brazenly directed toward women, are coming back to haunt us. I try to to remind patients that tobacco related poisons are much harder on women than men, and that smaller people in general get a higher relative dose. 

Many breast cancer patients lose their hair, if not from chemotherapy, then more mild so from anti cancer hormone medications like tamoxifen. New research says Minoxidil can help reverse that. 

Newsflash: the USPSTF - the US Preventive Service Task Force feels there is now enough evidence to recommend exercise to prevent falls in those over 65. And while I jest at the commonsensical nature of this announcement, falls are a major concern for most people over 65 and can lead to serious and life threatening injuries. No matter what age you are now, consult with your caregiver to see how you can attain optimal health and fitness for the present and the future. Whatever it is, whether seated stretching or training for an Ironman, start now. You will not be getting any younger. That is, unless you get more fit. 

A recently reported study shows IUD (Intrauterine Device) use has increased in recent years through 2013. This is believed to have been related to dropping out of pocket prices. I suspect newer studies will show use has increased even further with many women chasing long acting methods for fear of losing affordable birth control coverage. 

US maternal mortality has been increasingly in the news. Despite all the press, maternal mortality continues to rise through the present, and is concentrated in certain areas of the country, most notably Texas. Many correlate the most severe statistics with poverty and discrimination. Of late, many also finger the defunding of primary care clinics, particularly those like Planned Parenthood, which served more real and lower income populations. There are, at present two Bipartisan pills stuck in Committees which would support the formation of state committees to track and prevent the phenomenon. 

Stay tuned for more breaking news from the world of Obstetrics and Gynecology, here, next week, on Medical Monday. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Policy News:

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Medical and civil rights organizations have come together to oppose the detention of pregnant women by the agency on Immigration and Customs Enforcement (ICE). They have cited harmful effects on the health of these individuals due to lack of access to proper prenatal care and due to the high risk of rape while detained. 

Senator Tammy Duckworth (D-Illinois) has been the first Senator to have a baby while in office. Adequate lactation rooms were ensured through a measure by Senator Nancy Pelosi in 2008 so that breastfeeding Senators could comply with breastfeeding recommendations from the American Academy of Pediatrics. However, the post partum senator may have more difficulty attending votes unless the current rules barring children from the Senate floor are modified. 

The Trump administration has added two new exemptions to the individual mandate which is the rule that says people must carry individual health insurance or pay penalties. One is an exemption for those who live in a place with only one ACA (Affordable Care Act) insurance carrier whose coverage includes abortion services. On the basis of paying into a fund whose services include abortion, they can be exempted. I can see why people feel such consumers should not be obligated to use such a plan. I believe, however, that same anti-abortion consumer should be obligated to follow through with their execution of conscience and be required, under pain of penalty to buy private health insurance so that the rest of society does not end up footing the bill for their conscience driven but unfunded health care.  

The second exception the the individual mandate is nonsense. It is a “hardship” exemption. Who more than those under hardship need quality health care ? This particular exemption is a recipe for making the poor or those under hardship even poorer. And what does it gain? It gains political brownie points under the guise of freedom, and a better appearing Federal spreadsheet for this administration to tout to the voting taxpayers. We need to do a better job a making it clear to people that they stand to gain much more buying health insurance than they do forgoing it. 

Four abortion restricting laws have been passed by the 2017 Arkansas legislators. However, several influential groups have filed amicus briefs at the 8th Circuit Court of Appeals in St. Louis. One is the American College of Obstetricians and Gynecologists pertaining to the criminalization of “D & E”, the procedure dilation and curettage. This procedure is a safe and effective method for abortion, the safest in fact for the second trimester, and is used in many medically indicated cases where the patient’s life is at stake. 

The New York Times has reported that Scott Lloyd, the director of the Office of Refugee Resettlement keeps a spreadsheet of all detained unaccompanied minors who are pregnant and are requesting abortion. Lloyd has directed that this "captive audience" received non medical “counseling”  regarding their requests. Does anyone else view this as a misuse of power ? Does anyone else view this an incursion of a non-medical authority into the realm of medicine and counseling ?

Medical News: 

 Ever heard of the term “Previvor”? Me neither.  Previvors are those that know they carry a genetic mutation for cancer but have not yet developed cancer. Many are people who have discovered their mutation through non- medical genetic screening such as through the popular company “23 and me”. Others are those with family member with cancer who have been advised to do testing. Either way they are in a grey zone, and do not always get the care they need to address their relatively new predicament. Enter Dr. Heather Macdonald, an Obstetrician Gynecologist at Hoag Hospital in Newport Beach, California. She has created a special tailored program for these patients. It is called the “ Breast and Ovarian Cancer Prevention Program. In it she has outlined the possible ways to address risk, which may range from surgery, to medication to health maintenance strategies. 

The nation is finally mobilizing on the issue of maternal morbidity and mortality. Five states were in on the creation of the Alliance for Innovation on Maternal Health (AIM), California, Florida, Illinois ,Michigan, and Oklahoma. Texas, the nation’s worst offender, has now joined. The initial states have since seen significant decreases in maternal morbidity using protocols called “safety bundles”. 

Young women still suffer stigma even in the confines of an office visit. New research indicated fully half of teens and young women do not feel comfortable discussing sexually transmitted infections (STIs). Moreover, over a quarter lie to their caregivers about their sexual history. Separate research has shown that that the incidence of STIs is at a many decade high. Nonetheless, 62% of women under 25 do not consider themselves at risk for STIs. Only 40% use condoms. What might be a way to change all this ? 

A recent study published in Obstetrics and Gynecology indicates that marijuana does show up in the breastmilk of using mothers. Infants who breastfed exclusively ingested about 2.5 percent of the maternal dose and peaked one hour after smoking. ACOG’s position on marijuana in pregnancy and breastfeeding is as follows: 

There are “...concerns regarding impaired neurodevelopment, as well as maternal and fetal exposure to the adverse effects of smoking”. 

    "There are insufficient data to evaluate the effects of marijuana use on infants during lactation and breastfeeding, and in the absence of such data, marijuana use is discouraged.”

    Reference: 

    https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Marijuana-Use-During-Pregnancy-and-Lactation

    PCO or polycystic ovarian syndrome is a complex medical condition that comprises problems with ovulation, fertility, menstruation and excess male hormones, and problems with acne and unwanted hair growth. It also includes problems with carbohydrate metabolism and may lead to cardiovascular disease and diabetes. New research also indicates is is associated with a higher prevalence of several psychiatric conditions including depression and anxiety. 

    Initial testing of a personalized vaccine against recurrent ovarian cancer cells is showing promise. A patient’s own dendrite cells (DC) are treated and given separately or together with other immunotherapy. The DC vaccine induced potent anti tumor T cell responses and was well tolerated, and was associated with a better prognosis. Further clinical testing is planned. 

    New research in the Journal Menopause has unearthed a connection between the severity of menopausal symptoms and the risk of heart disease. The research found that increased symptoms such as hot flashes were associated with artery stiffness and dysfunction. This research may come to influence the way we think about postmenopausal hormone replacement therapy which reduces both symptoms and arterial dysfunction. 

    The biggest news of the week may be that alcohol is not as safe as once previously believed. A new international study has shown that even one drink of beer or wine per day can increase the odds of hypertension, stroke and heart disease and significantly shorten life. Numerous national and international recommendations are likely to be changed based on this. 

    Stay tuned this week for more exciting news from the world of Obstetrics and Gynecology. 

    Medical Monday: Breaking News from the World of Obstetrics and Gynecology

    Correction 

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    We start first this week with a correction. The error was late in last week’s section on policy. In it I reported that ProPublica reported that the “ US is the most dangerous country in which to give birth”. That should have read, “the US is the most dangerous affluent country in which to give birth”. That’s still an awful distinction and one of the reasons why I write. 

    Policy News

    Title X funding has been denied to clinics in Nebraska who proved abortions. No surprise there. However, what is more noteworthy is that the new law restricts the speech of the caregivers in clinic. In particular, caregivers, when behind closed doors and under patient confidentiality, are prohibited to “ counsel in favor of or refer patients to abortion services”. Does it make anyone else nervous that a state government is attempting to restrict what is said in a private medical visit ? 

    Enrollment in the ACA this year in 2018 did not plummet as was expected. Enrollment dipped slightly by 400,000 to 11.8 million Americans, which represents a drop of a little more than 3%. This was despite the fact that advertising and the time frame for enrollment were slashed. This drop was noted primarily in the 39 States who’s ACA is run but the Fed. The remaining 11 States manage their own ACA programs, and they did not see this drop in enrollment. Of note, among all enrollees, 27% were new enrollees. The average pre credit premium did go ip in 2018 compared to 2017, at $621 versus $476. 

    In the latest turn of events regarding detained pregnant teen immigrants, a Federal Judge has ruled that HHS ( The Department of Health and Human Services) must allow pregnant detainees the right to obtain an abortion. The current policy of the the HHS Department of Refugee Resettlement has sought to block their right to do so. Under the Obama administration, such patients had the right to obtain elective abortion at their own expense, though they were able to get it paid for if it had been as a result of rape or incest or if was a threat to life. 

    Medical News

    Huffington Post interviewed physicians on the subject of hair dyeing during pregnancy. The panel’s conclusion was that “ there is just not enough conclusive evidence or research to suggest they dyeing …hair while pregnant will cause fetal harm”. While this statement is true, it bears examination. Insufficient evidence of harm does not constitute sufficient guarantee of safety. Insufficient evidence of harm does not even rule out the possibility of harm. It does not even rule out the probability of harm. It simply means that there is not enough evidence to say one way or another. The article goes on to says that there is a general consensus that it safe. While this too, is true, it is a weakly based consensus. It is based on the notion that a large number of pregnant women dye their hair and that no one has noticed any disturbing patterns emerging among their offspring. And yet, our notice has not been particularly attentive, since no one has bothered to do even an population based study of pregnant women who dye their hair complete with meaningful follow up of their offspring. I belabor this point to hone the readers' understanding of what the statements they read actually mean. 

    Apparently younger patients typically like to pick younger doctors. This makes some sense to me in that the patient has someone to whom she can relate. However, there is also a shortage of Obstetricians and Gynecologists in many places in the country, especially rural areas. The older Ob/Gyns are still in place, with ever increasing work loads, especially in the underserved areas, while the younger docs want to be in the city with more partners, city lifestyle and higher pay. Services are strained in the areas least likely to bear it, and this may be impacting maternal mortality rates. 

    Every generation thinks teens are worse than they were. Turns out they are wrong. By several metrics, todays teens are quantifiably different than the teens of yesteryear. The incidence of many high risk behaviors among teens have dropped considerably. For example, cigarette use and alcohol have dropped sharply compared to past generations. Teen pregnancy rate are at an all time low. Teens are delaying sex more and even teen driving fatalities are down. It is interesting to note that while most authorities are reassured by these changes, others point out that teens may be less mature, age for age, than their predecessors. In other words, perhaps teens are more immature than they used to be. I was initially dismayed by this assessment. But I suspect they do not mean immature in the sense of irresponsible or silly. I suspect they mean more dependent on parents and more risk averse.  This observation which point to kids behaving “younger” longer, may go along with what some have noted to be a modern extension of adolescence. In the “olden days” perhaps even  75 years ago, a 19 year old male was expected to have a job and a career direction. He could be thinking about marrying once he was settled. Certainly a 19 year old girl, which in those days was in fact, a young woman, would typically be thinking about marriage and independence from family. These days most families are concerned about thier 19 year olds continuing their education or training, for at least another 4 years. 

    The extension of adolescence is a critical topic right now, and I am scarcely qualified to address it. However I am the mother of three grown children including two sons and have shepherded countless women into motherhood. That and the formal literature I have read indicates extended adolescence is real in biologically, developmentally and sociologically measurable terms. We may begin adolescence sooner in terms of menstruation and puberty, but our brains are remaining plastic much longer. Our health and nutrition are better. As implausible as it sounds, society is actually safer, our parenting is actually better, and children are kept from harsher stresses compared to the past. We are more affluent than before. The age of information has made its debut. There is far more novelty in our environment and with our added relative affluence we can extend education until the mid twenties and afford children the opportunity to travel, all of which keeps the brain in a far more plastic and youthful state. This brain “metaplasticity” is based in neurons and their activity and can be measured. As a side note, a new post mortem study published in Cell Stem Cell has confirmed that neurogenesis (the making of neurons) continues in older people, even through the 70s. However in most older folks, they tend to be more poorly vascularized. 

    Extended adolescence can go wrong. It has been credited with the hapless directionless young adult, deadbeat dads, kids who drop out of college, the 40 year old gaming in his mom’s basement, etc. Some say this is related to changes in our economy with a shift more to information based work than labor based work. With extractive industries and jobs with manual labor on the wane, men are less likely to get a job not requiring years of higher education. Acknowledging the breadth of these factors can help us understand why the blame game is fruitless. The bottom line is that older adolescents need parental support which they tell me is a foundation of unconditional love combined with a clear set of reasonable expectations and consequences. 

    All of this bears very much into the work of Obstetricians and Gynecologists as we help women through the phases of their lives. We counsel women on risks to their health everyday. We support them through pregnancies where they may be on their own or poorly supported. We encourage them to move forward with their lives even after their children are born. We support women as they struggle with parenting their own adolescents. 

    Here is some more reading for those of you who are interested. 

    https://www.nytimes.com/2018/03/30/well/family/teenagers-generation-stoneman-douglas-parkland-.html

    https://www.theatlantic.com/health/archive/2016/11/metaplasticity/506390/

    https://www.scientificamerican.com/article/extended-adolescence-when-25-is-the-new-181/

    Whole genome DNA sequencing has become popular for adults. Antenatal genetic screening has become standard prenatal care. Now the two can be combined though amniocentesis and whole genome sequencing. I wonder how long it will be before this can be done with a single maternal blood draw. 

    Mayo Clnic is studying a streamlined form of home based prenatal care. A pilot group of patients is using home monitoring for baby and vital signs. They also have 8 actual clinic visits which is fewer than standard. Motivation for this study is to determine a valid protocol for women in remote areas. 

    Last week I reported that boys were receiving Gardisil vaccine against HPV at a fraction of the rate of girls. Good news this week: that these rates of vaccination for boys are increasing rapidly. from 8 to 26% between 2011 and 2016. Girls’ rates went from 38 to 46 percent in the same time interval. 

    ACOG has created a document called a Committee Opinion and thereby formalized something that most of us have always done. Ob/Gyns play a role in ensuring that women are protected from workplace discrimination. They do so by writing notes for work as documentation for specific health related work restrictions. They can help enforce sick leave, postpartum leave or parental leave for fathers. They can also help patients identify workplace abuses and refer them to the correct authorities. This behooves all providers to familiarize themselves about local laws and local labor offices. Workplace stress is a real health hazard and it is part of the Obstetrician Gynecologists responsibility to help deal with it. 

    Many PCO (polycystic ovary) patients need to take Metformin to get pregnant. They are also advised to stay on it or related medications to prevent gestational diabetes. However, some are concerned about taking it in pregnancy. The available evidence indicates it is safe. Newer research has shown it reduces miscarriage and preterm labor. 

    Vices taxes work. The Lancet has reported that taxing known harmful substances like cigarettes alcohol and soda steers consumers toward healthier choices. This study was a meta-analysis of 5 internal national studies from around the world. Concerns have been raised that these taxes disproportionate burden the poor, but this study examined this question and found that there was no disproportionate harm to this group. Larry Summers, a former Treasury Secretary and emeritus professional at Harvard wrote an analysis for the study, confirming that “ taxes are an underused instrument for the prevention of premature death and disease….” and “ consistently raise prices, reduce consumption, and save lives, while generating additional revenue to support public services. 

    Vegetables work too. A new study confirms that lots of vegetables help older women keep blood vessels healthy. Of note, the ones that worked the best were the cruciferous vegetables, aka the brassica family which include cabbage, brussels spouts, cauliflower, cabbage, kale and the like. On that note, for northerners, I will recommend purchasing and planting spring seed. Those of you in the southern hemisphere can cultivate and plant now for a prompt spring germination. 

     

    Stay tuned for more breaking news from the world of Obstetrics and Gynecology, next week, here on Medical Monday. 

    Medical Monday : Two Week Catch Up

     
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    Happy Easter and Happy Passover. We have two weeks to cover. Thanks for reading ! 

     

    Policy News

    Much of the National Health Policy News this week deals with contraception and reproductive health. Can anyone remember any time in this or any other country when these private matters were ever so much on the national stage ? The politically conservative aspects of my nature questions why this degree of government intervention in private lives is necessary. My medical qualifications and medico-legal experience cause me to classify some of this meddling as practicing medicine without a license. 

    Title X is a federal grant program whose purpose it is to promote positive birth outcomes and healthy families. It provides grants for family planning and health services. So here’s my first question: Why is it not run by health care professionals ? Trump administration officials are now contemplating new wording which would add additional criteria for clinics to receive Title X funding, namely the provision of primary preventive services. Sounds good right ? Well many clinics offer only reproductive health services. These clinics would have to expand or close. This measure seems like just another way of closing family planning clinics.  Now whether pap smears would qualify as preventive health is unclear, or whether paps would be classified as reproductive health, I don’t know. 

    Texas is challenging the federal government’s withholding of funds for its family planning programs. They were withheld several years ago based on the fact that these providers, many of them through Planned Parenthood, also provided abortions.

    Planned Parenthood itself is challenging the Federal Government on its withdraws of funds from the teen pregnancy program. Between this and two other plaintiffs, the Department of Health and Human Services has partially and temporarily restored some of the funding until litigation can be completed. 

    Idaho has failed to solve the problem of insurance for those whose income falls between Medicaid and the Affordable Care Act coverage criteria. A proposal called Plan First Idaho would have funded family planing services for women in the gap. My question is, what rocket scientist designed the State’s the two programs such that their income qualifying criteria do not meet seamlessly ? This is a problem of their own making and it needs solving. Republicans in the Idaho House stalled this measure. 

    Idaho Governor “ Butch” Otter has approved a measure by which prospective abortion patients must a told about “ abortion reversal” a procedure that does not exist. Additionally, he has signed legislation which will require abortion providers to collect personal and demographic information which, in de-identified form they intend to make public. I don't know what they think this will accomplish, but I have a feeling it may backfire, since they will be able to see how many and how diverse a group of women utilize the procedure.

    The Supreme Court is hearing a case between the State of California and a group of "crisis pregnancy centers”, an actual chain of 130 outlets run by “ The National Institute of Family and Life Advocates”. These centers are anti-abortion counseling facilities, however they are licensed as family planning providers. California has a law requiring that all licensed family planning facilities to post notices of the availability of free or low cost birth control and abortion services and they are challenging it. They are arguing that this posting requirement violates their free speech.  So far the Court has expressed concern that these clinics not be singled out from other clinics. California has argued that their staff, many of whom are not medically qualified, present medical misinformation as truth, all to the end of dissuading patients from abortion. Apparently theses non-credentialed counselors actually wear white coats. 

    Along with the opioid epidemic has come a hepatitis C epidemic. Kentucky, having seen a surge of the disease, has passed a law now requiring all pregnant women to be tested for it. Hepatitis C used to be very hard to treat. However, patients have much more hope nowadays due to the availability of effective therapy. 

    Missouri has expanded Medicaid for pregnant women in drug abuse treatment. Their continued coverage will be contingent upon them staying in treatment, and could under those conditions, be continued up to 12 months.  

    And now for more of a purple to blue state review:

    Florida is considering a bill requiring HPV (human papilloma virus) vaccination to be required as part of the vaccinations required of children attending public school. Human papilloma virus causes multiple illnesses most notably cervical cancer and genital warts, and the vaccine has not demonstrated any conclusive evidence of harm.

    It is interesting to note that physicians are not prescribing HPV vaccine equally for female and male children. Doctors recommend the vaccine twice as often for girls as they do for boys. This puts the boys at increased risk for HPV disease, and puts all their future partners at increased risk too. 

    Mississippi passed a law banning abortion after 15 weeks Of course this is unconstitutional based on Roe V. Wade which is still on the books. A Federal Judge over turned Idaho's ban. 

    New Hampshire has passed a bill which will allow pharmacist to prescribe birth control. No doctors visit will be necessary. The medical establishment has concluded that vast majority of the birth control methods are safe for the vast majority of women. They certainly are when compared to pregnancy for those same women. Authorities believe this will eliminate yet one more barrier to contraception. Utah signed a similar law into place earlier in the week. 

    On the other coastline, the state of Washington now has a bill that will require insurance to cover contraception, abortion and maternity care. Additionally, after the first of the year, all contraception has to be co-pay and deductible free. This includes voluntary sterilization. 

    The new budget has failed to shore up the ACA ( Affordable care Act) marketplaces. States will have to tighten their belts and work on their budgets one by one. 

    ProPublica has reported that the “US is the most dangerous country in which to give birth”. States all over the US are creating programs to quantify and address the problem of maternal morbidity and mortality, even as the Federal government under Trump is dismantling reproductive and maternal health care piece by piece. 

    Do you ever get the feeling that the various States in America are becoming like the countries of the European Union with different values, cultures budgets and laws ? 

     

    Medical News: 

     

    Obstetrics: 

    Striking research findings presented at Lancet Global Health conference have shown that the death risk is double among pregnant women who are anemic compared with those who are not. The lead study author also found the correcting anemia is not a sufficiently high enough priority among physicians. 

    Research presented at Diabetes UK conference has shown that excess weight gain incurred during pregnancy by  gestational diabetics is associated with greater risk of cesarean section.

    Women who exercise in pregnancy have shorter labors. This interesting news was published in the May issue of European Journal of Obstetrics and Gynecology and Reproductive Biology. The study group attended a professionally led session of moderate exercise three days per week. Labor was shortened about one hour, mostly in the first stage, or dilating phase. ACTIONABLE ! 

    Children who were breastfed exclusively for at least 6 mores were less likely to become overweight to obese than their counterparts. The conclusions were drawn by analyzing over 38,000 records from children South Korea. The finding were presented at the Endocrine Society Annual Meeting. 

    Gynecology/General Medical News: 

    There may be a male birth control pill on the horizon. Research at the Endocrine Society's annual conference has presented information on a new male birth control pill called DMAU. It contains androgen and progestin,  which is analogous to the contents of the female birth control pill, estrogen and progestin. Once daily tablets appear to be safe and effective. No period required. 

    Menopause and aging in general is characterized by a loss of muscle mass and bone density as well as the deposition of fat. As suspected, the Mediterranean diet may have a positive impact on bone mineral density and muscle mass in postmenopausal women. The Mediterranean diet emphasizes the eating of high quality protein, large volumes of fruit and vegetables, healthy fats such as olive oil and a modest amount of complex carbohydrates such as whole grains. As a whole, the diet is lower in simple carbohydrates than the typical American diet and is also higher in protein and antioxidants.

    There are now over 400 cases of a rare lymphoma which are linked, epidemiologically, to breast implants. Breast implants are not new. Lymphoma is not new. However our ability to collect and parse data is better than it has ever been. The FDA it's taken this ability and created a meaningful database for this type of information. While an association between breast implants and this rare lymphoma is being established through data collection, a causality between the two is not necessary implied. That said, nothing is more likely to lead us to understand the causes of this problem than amassing quality data about it. 

    Federal funding support for cancers is disproportionately low for gynecologic cancers if you rank them by lethality. Cancer of the ovary and the uterus ranked near the bottom of the funding list. Contact your elected officials ! 

    A new modification of the current device used for pap smears can identify cells from endometrial (uterine lining) and ovarian cancer. The investigational PapSEEK uses an analysis of 18 genes and analysis similar to that used in prenatal screening for Down’s syndrome to identical the genetically abnormal cancer cells. THIS IS SO COOL ! 

    A new study on postmenopausal hormone therapy has shown that it does help maintain thinking and memory skills. This is the case IF it is initiated shortly after the onset of natural menopause. This study was presented in the Journal Neurology and was a high quality randomized controlled trial of 75 women between the ages of  42 and 56. 

    In my mountain state, there is not a great deal of sunlight or seafood. As a result we have a high prevalence of vitamin D deficiency. New research indicates that vitamin D deficiency increases a post menopausal women’s risk of metabolic syndrome. Metabolic syndrome includes the unholy triad of diabetes, high blood pressure, and abnormal serum lipids ( cholesterol and triglycerides) which together increase cardiovascular risk. Vitamin D levels are checked by a simple blood test. Ask your doctor about this ! 

     

    Stay tuned for more news from the exciting world of Obstetrics an Gynecology, next week, here on Medical Monday ! 

    Medical Monday: Breaking News from the World of Obstetrics and Gynecology

    Policy News

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    The Trump administration has said that the patients displaced by closures of Planned Parenthood offices can be absorbed by community health centers. However, a new survey out by Kaiser has indicated that fewer than one in five community health center will be able to compensate in this manner. Planned Parenthood may be apt to close if they cannot receive Title X funding through Medicaid on account of including abortion in their counseling or practice. 

    A new Ohio law due to take effect later this month would have criminalized abortions done for Down syndrome. However, a Federal Judge has blocked the law, calling unconstitutional. In particular, it has been determined to violate the 14th Amendment due to violations of both liberty and privacy. 

    Certain crisis pregnancy centers have no medical credentials whatsoever. Instead, they are merely storefronts for anti-choice or religious advocacy. The Supreme Court will hear arguments this week about the nature of their obligation to disclose their credentials and their agenda. 

    The Contraceptive mandate was rolled back in Massachusetts. The state has challenged this but initially has failed to show enough data on adverse effects on the people of the state. The State plans to also argue that the rollback challenges the First Amendment which contains a prohibition against the establishment of religion by the government. 

    New fast track legislation for the FDA ( Food and Drug Administration) called “Right to Try” has been under consideration. This would have streamlined/abbreviated the testing and approval process for certain potentially beneficial drugs, thereby getting them to more patients sooner. Proponents cited potential benefit, while opponents cited potential harms of less than completely tested drugs. The House failed to pass the measure failing to meet a 2/3 majority. 

     

    Medical News 

     

    The problem of appalling and increasing Maternal Mortality in the United States is squarely on the table now. Researchers are now focusing on several factors which may have led to this perfect storm. In addition to funding cuts and clinic closures, a shortage of Obstetric providers and rural hospitals providing Obstetric care is now in the mix. 

    Stepping back, I'd like to remind readers that Mortality means death. However, for every mother who dies a childbirth associated death, there are 70 others who are near death and critically ill. This is the “ Morbidity” part of the equation. A new study has shown that addressing maternal Morbidity and Mortality in the States would greatly bring down the cost of healthcare. 

    I would add that since 50% of all pregnancies are unplanned, that the contraceptive mandate might be worth its weight in gold to decrease maternal Morbidity and Mortality in rural areas and in general. Case in point: Colorado, home of my residency alma mater, the University of Colorado, has made sure safe and effective birth control was available all across the state, rural areas included. As a direct result, rural teen pregnancy rates fell by over half between 2007 and 2014. 

    New research on teen pregnancy indicates that childhood bullying and various forms of rejection seems to be a risk factor in teen pregnancy. It is even more so for lesbian and bisexual girls, something caregivers should bear in mind. 

    The field of Obstetrics is beginning to grapple with gender issues in the field. In 1970, only 7% of ObGyns were women. Now, 59% are. Furthermore, only 17% of ObGyn residents are men, and residents are the future. What are the ramifications for women’s health? Will men be excluded from the field by patient preference or institutional customs? 

    Everyone has hailed the balancing of the field as a good thing. However, is it good if Obstetrics and Gynecology becomes devoid of men? One recent meta-analysis says 8% of patients prefer men Ob/Gyns and 41% have no preference. Here are some factors in the debate: 

    • Patients may legally discriminate regarding who sees them. 
    • Assuming that a certain gender will be insensitive or unprofessional is unfair. 
    • Male medical students going into any specialty may be denied important clinical experience in their training if they are excluded from rooms. 
    • Both men and women can and have made significant contributions to Obstetrics and Gynecology. 
    • Outside of Obstetrics and Gynecology, men dominate 37 of the 42 other specialties, and fewer than a third of other doctors are women. 
    • People want caregivers that are relatable, but their most important priority is to have a good doctor. 
    • Women Ob/Gyns are not good Ob/Gyns because of their biology. It is because of learning, skill, and experience. These are gender neutral. 
    • How male caregivers are introduced has a great deal to do with how well they are accepted. 
    • The healthcare and health status of women is something everyone in society should care about and be able to work on. 

    What do you think? Have had both male and female Ob/Gyns and have liked them all. 

    Marijuana in pregnancy is again in the news. A recent study presented at the Society for Maternal Fetal Medicine has found an association between MJ use in pregnancy and the following outcomes: increased risk for stillbirth, increased risk of preterm birth, increased incidence of hypertensive disorders in pregnancy. 

    Predicting cardiac risk in women is different than predicting it in men. In women, central obesity is a particular concern. Increasing BMI predicts increased cardiovascular risk. However, large waist to hip ratio predicts it even better in women. 

    Dr. Barbara Levy, vice president of health policy for ACOG, has stated that labioplasty for purely cosmetic reasons should be cautiously considered since it is the removal of sexually functional tissue. Labioplasty for cosmetic or supposedly performance-related purposes is becoming increasingly popular, even among young women. I would add that it is often a cash up front business that practices use to bolster their income. 

    Zika virus infection in pregnancy produces discernible malformations of the brain and eyes 7% of the time, across the board. The rate is higher if the infection is contracted in the first trimester. There is some evidence that the rates of malformation varied by country. 

    In the good news department, women who are “ highly fit” in midlife may be less likely to get dementia later in life. This study ran over 44 years on about 1500 women in Sweden. Those only moderately fit saw some delay of dementia as well. 

    Also in the good news department is the following: Scott Gottlieb, FDA commissioner, has announced plans to impose new lower limits on nicotine in cigarettes to make them minimally or non-addictive. While certain people will still roll their own, it seems certain that the population as a whole will benefit. 

     

    Stay tuned next week here, for more breaking news from the world of Obstetrics and Gynecology. 

    Medical Monday: Breaking News from the World of Obstetrics and Gynecology

    POLICY NEWS 

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    Good Monday. The media continues to focus on the Trump administration’s Department of Health and Human Services (DHHS) Policy of promoting “ abstinence only” to reduce teen pregnancy rates. Physicians like me deplore this scientifically disproven strategy. My governing body, ACOG, the American College of Obstetrics and Gynecology espouses and promotes access to evidence based contraception as fundamental to women’s health care. 

    However there is more to the story. There is nothing wrong with the choice of abstinence. There is no problem if a patient choses abstinence as her birth control method. But to offer abstinence “only” in the context of a health care or teen pregnancy prevention setting, is folly. Similarly, there is no problem with discussing the “ benefits of avoiding sex” as the administration proposes. Furthermore, health care providers in particular would be happy to support the DHHS in avoiding the normalization of “ sexual risk behaviors”. I am assuming that they mean high risk sexual behaviors. All of this would be fine if it were not for the deal breaker clause “ abstinence only”, and, oh yes, defunding those who do not march in step with it. The NY Times has published an editorial exposing the shift to Title X funding priorities to abstinence only programs under the direction of Valerie Huber, a longtime advocate of abstinence only birth control. 

    There’s more. The latest healthcare budget proposal not only seeks to redirect Title X funds, it also seeks to defund Planned Parenthood and other family planning programs altogether, as well as scrap, not just reduce, the budget for the Teen Pregnancy Prevention Program. Democrats plan to block this budget proposal. ACOG has stated that half of all pregnancies are unintended and this is a major public health problem.  41% of teens have had sex in high school. 

    Scrutiny of drug prices is increasing in this administration. FDA administrator Scott Gottlieb as criticized drug pricing constructs used by the big drug companies which result in large OOP ( out of pocket expenditures) for patients. He was quoted as saying “ sick people aren’t supposed to be subsidizing the healthy”. Of course this sounds very pro-patient, but the bottom line is that the government current insures a great many people through Medicare, Medicaid and the Affordable Care Act, and it wants to pay less for drugs. 

    Many of you know that I believe data should be free. Accordingly, I believe patients should have access to all their medical information and it should be complete, digital and portable to other providers. The Trump administration has indicated an interest is facilitating this trend. While access to complete digital medical records has many patient and caregiver advantages, it also makes it easier for insurers and regulators to determine eligibility and reimbursement, or lack thereof. For the time being, I think I’d trust Amazon, Google or Apple with my data more than I would trust a government medical database. Although theoretically, de-identified data would make it possible to do a lot of helpful population based research like they do in the Scandinavian Countries which have Universal Health Care. 

    Work requirements for Medicaid recipients sounds like a good idea. However, Medicaid recipients are often pregnant single mothers. Arkansas has approved such regulations. Alabama is examining the idea. Children’s advocates are concerned that work requirements will take these parents away from children, while providing no daycare to supplant them. Single unemployed people on Medicaid rarely can afford daycare or even transportation to and from a job. Why is this not obvious ? My idea: Given these people a computer with internet access and require them to take an online class toward a certification. Make passing required and grades count. This could be done from home and the need for a car or daycare would go away. Maybe I will write my elected officials. 

    The Trump administration wants to test work requirements to see if they improve patient care or reduce costs. ( Who decided those endpoints ? ) However the GAO (General Accounting Office) has asserted that such analyses in the past have not been rigorously conducted, and their results have-not been published, limiting their utility.

    I thought Republicans wanted less government intrusion into our lives. Senate Bill 1394 in Arizona would require hospitals or clinics to report if a woman had an abortion and to report the REASON she had it. Seriously ? As if these reasons weren’t personal and complicated and no business of our elected officials ? It would also require that hospitals require reporting to the State in the event of any abortion complications, though this is not the case for complications of any other procedures. Arizona ACOG has come out in force against this. 

    MEDICAL NEWS

    Preterm birth has been an unmitigated scourge in the US. It is twice as much so for women soldiers recently returned from duty. Preterm birth is poorly understood, but its many associations point to various forms of stress, such as socioeconomic deprivation, racism and abuse. I interpret this to mean anything that makes the women’s body a hostile environment for the fetus. It makes sense that a military environment would meet this criteria. 

    On the other hand, exercise is an entirely different kind of stress, a good stress. Recent research has confirmed not only that pregnancy women may exercise, but that they may safely exercise in warm weather. They may also take hot baths and short saunas. That said, it is critical that patients considering these activities check with their doctor first as there may be caveats. 

    Nurx. My new company crush. Go to Nurx.com. This is a San Francisco startup offering doctor prescribed brith control online, with or without insurance. It currently operates in 18 States and they are looking to hire more docs in more states. Teens are welcome. 

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    In the “ olden days”,  male medical students generally entered surgical specialties and female medical students entered non-surgical specialties. The crossover came with Ob/Gyn which is surgical. Women had a natural affinity for the field, and patients almost always prefer them. When I entered the field, it had already become half and half. However, now, 25 some years later, only 17% of Ob/Gyns are men. Male doctors are worried about getting into the field, and women in the field are worried about the demonstrated historical monetary devaluation of a field once it is predominantly filled by women. The big picture is this: Ob/Gyns are in short supply and the supply is growing smaller by the year. We should welcome and properly reimburse any docs of any gender willing to take on the vicissitudes of the profession. New data suggests bolstering the ranks of Certified Nurse Midwives could also help to address the shortage of skilled Obstetrics care providers, and together improve our deplorable maternal morbidity and mortality statistics.  

    Good news ! A new study has indicated that probiotics and fish oil in pregnancy are associated with reduced allergies and eczema children. The study is of very high quality since it is a meta-analysis, a compilation of 19 other high quality studies onto same subject. That may warrant a policy change in the office. 

     

    Stay tuned more more news from the world of Obstetrics and Gynecology, here next week, on Medical Monday. 

    Medical Monday: Breaking News from the World of Obstetrics and Gynecology

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    The American Civil Liberties Union (ACLU) and the HHS ORR ( Department of Health and Human Services Office of Refugee Resettlement) are battling out a constitutional question. The are debating whether or not unaccompanied undocumented immigrant minors in shelters have any rights to abortion under the Constitution. I am no constitutional scholar, and I am ignorant as to the extent that our Constitution applies to undocumented immigrants. Whether or not they are in shelters, or unaccompanied, seems immaterial. Their age could be germane, but again, perhaps could be handled under the terms of our own age laws. Any insights would be appreciated. For any women or girl, undocumented or otherwise, to give birth or to have an abortion is  a momentous and expensive event. Either one is also a medical event and that is the most important point. We already have medical policies in this country about such things, and I cannot understand why immigration status would alter the medical algorithm such an undocumented minor would follow. We need to remember that these questions are primarily medical, not political. 

    New Hampshire has proposed a bill further reducing barriers to contraception. Currently, contraceptives may only be prescribed three months at a time. However, the state is considering a bill to increase this to a whole year. This seems logical to me as a Gynecologist since, at least with a patient who is established on the pill, I only need to see her once per year. If I am observing her on a new pill, or working to decrease side effects, special arrangements can made to see her sooner. The New Hampshire bill also specifies that insurers must continue to cover it entirely without copays. 

    The very red State of Idaho is espousing contraception. Idaho House legislators are advocating a bill which would obtain a “waiver” ie. federal permission, to expand family planning services to women aged 19-44 who do not qualify for Medicaid, Medicare or other programs. 

    Unlikely bedfellows in Connecticut are trying to secure prenatal care for the newly pregnant. Republican legislators are working with Planned Parenthood to offer health insurance to pregnancy women if they sign up within 30 days of finding out they are pregnant. 

    The red state of Nebraska, on the other hand, is draining funds from Planned Parenthood in a move that will decrease family planning services in an already medically impoverished state. The may com through restriction of Title X grants. 

    Dr. Haywood Brown the President of American College of Obstetricians and Gynecologists, has flatly called out the Trump administration and their “ continued move away from scientific evidence based policies and toward unscientific ideologies”. The particular context this time was the announcement of preferential Title X grant giving to organizations that teach “natural family planning” and abstinence for birth control. Where is the pussy grabbing now ?  This administration has such an on again off again relationship with sex I just cannot keep track. 

    In medical news, culture seems to be playing a big role in smoking. Witness the great discrepancy in smoking rates among pregnant women by state. Worst is West Virginia, at 25%, whereas in California it is a little over 1%. The average across the US is about 7%. But, I am a splitter, not a lumper, and it seems our efforts to curtail smoking in pregnancy should vary state by state, perhaps even county by county, to be the most effective. 

    You may have heard about all the problems and lawsuits having to do with vaginal mesh used in prolapse surgery. You may also have heard of more of a tape or ribbon procedure to fix stress urinary incontinence (SUI). They are different. Vaginal mesh is a large sheet of mesh, whereas the tape/ribbon is narrow like the name suggests. They are not in the same category for complications. A new study has shown what we all have expected and hoped, that the tension free vaginal tape is safe and effective for women with SUI. 

    Probiotics are all the rage, and I mean in the hallowed halls of medicine, not the local vitamin store. A new study of very high quality (a meta-analysis) has found that probiotic and fish oil supplementation in pregnancy may reduce the risk of eczema and egg allergy in the offspring. That’s great, you say, no eczema or egg allergy. Actually, I am going speculate intelligently, and suggest to you that eczema and egg allergy are what I would call marker conditions, meaning conditions which are part of a greater category of tendencies that we call atopy, or the tendency to react to things. Atopic patients are those with troubles like asthma, rashiness, and lots of allergies. Their immune system is likely a little dysfunctional in vaguely defined ways. If simple nutritional interventions during pregnancy can help curtail such tendencies in children, that’s interesting and beneficial. 

    A new document of WHO (World Health Organization) pregnancy recommendations for woman in childbirth strikes me as unwieldy. It seems to address such a wide range of women in a wide range of conditions that it becomes unusable. Yes, it highlights recent findings and recommendations about giving natural unaugmented labor longer to progress. Yes, it advocates for movement and positioning during labor, and the presence of a supportive environment and support people. It mentions delayed cord clamping. But these are already standards of care in the US. However the document gets an identity crisis when it states continuous monitoring is not recommended, and yet allows food in labor, does not mandate an IV, and yet allows pain relief like epidurals. (One cannot have an epidural without an IV). It is a document for caregivers of patients who in many cases have had little or no prenatal care, and so in a modern care environment they would be considered high risk until proven otherwise. In no state of this union would a high risk patient be permitted to go without IV or monitoring. Neither would they be permitted to eat if an epidural was under consideration. In any labor, C section is a real possibility, and to have food in the stomach ahead of that is a real risk. On the other hand, if there were no facilities for C section then perhaps it is fine to allow patients to eat and go without an IV. But one’s ability to allow these things would not, under those circumstance, be because they are safe. It would be because they would not matter. 

    I am afraid this document will entirely confuse practitioners in a modern care environment. The WHO document recommends things which, in our environment, would be indefensible. The document almost needs to be cleaved into two documents, one for those in poorly equipped areas, and one for those unwell equipped area. This document appears to be written by people who would like to think that the rules should be the same for all women in the world, and that all laboring women in the world would have the same standard of care. I am one of those people. However, the authors of this WHO document are trying to torque this equality into being by sanctioning the labor care methods of minimally equipped facilities; in short, they achieve a unified standard of labor care by writing a  document recommending a much lower standard or care for all. We in the US already have enough trouble with our maternal morbidity and mortality without these recommendations. 

    A new headline in “Health Day” covering an article  published in the Journal of Nursing has concluded that "food and drink in labor appear to be safe". ACOG currently sanctions only clear liquids in labor, and this is to avoid the risk of aspiration of solid food particles, something to which pregnant women are vulnerable, especially if they go to C section. When an apparent discrepancy in recommendations like this comes up, it is always good to unpack the details. Did I mention I was a splitter ? It turns out the study was case-control design, done at a smaller Port Jefferson, New York hospital over 4 years. The study was actually comparing just ice chips versus clear liquids like jello and italian ices, the so-called "food". We have known for some time that clear liquids, which is what jello and italian ices are, are safe. The “food”is not solid, the study's conclusion is not news, and the recommendations have not changed. However, I worry that laboring women around the country will be asking to see a menu to order food as they enter labor. 

     

    Stay tuned for more news from the amazing world of Obstetrics and Gynecology, right here, next week, in Medical Monday. 

    Medical Monday: Delayed Edition

    POLICY NEWS 

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    The Department of Health and Human Services wants to expand funding for “ natural family planning” and “ fertility awareness” which are largely ineffective methods of timing based birth control. In other words, DHHS want Medicaid to begin covering visits where patients are told this is a viable method of contraception. In other words, the DHHS wants to spend your tax dollars on an ineffective, scientifically invalid method of birth control. Meanwhile the rest of the administration is working on dismantling the Contraceptive Mandate, the part of current insurance law which states that insurers must cover, without copay, real effective birth control. Additionally, the DHHS has announced it is moving away from “ comprehensive sexual education” which is evidence based, and instead will be using your tax dollars to teach “ abstinence only” which has been proven not to work. It is beginning to seem like the administration wants women to have more babies. Maybe they see this as stimulating the economy through having more consumers, I don’t know. 

    California Judge Haywood Gilliam has stood up to the Feds determined to weaken the contraceptive mandate. He has blocked changes to the ACA in California, saying that he will not allow these changes “ transform contraceptive coverage from an entitlement to a benefit subject to employer discretion.”

    Utah is writing law which will require radiologists to specifically notify women of dense breast tissue. In this warning they are to explain that screening is less effective, and that they may be eligible for other screening modalities. 

    New Jersey has replaced Republican Governor Chris Christie with Democrat Phil Murphy. Governor Murphy has reversed 8 years of policy by restoring funding to Planned Parenthood and other women’s health organizations. He has also signed a bill expanding coverage for Medicaid coverage of family planning, prenatal care and cancer screening. 

    DHHS is working on various plans to reduce the price of prescription drugs to consumers. Sounds good right ? However one of the cost control measures is capping the amount of prescription drug benefit that Medicare Recipients can receive. The other strategies include enabling as many as 5 states to collectively bargain with suppliers over prices. 

    The administration is at it again, proposing bargain basement plans for people. In the words of Admiral Akbar, “It’s a trap !”

    These plans are cheap, and some fear that consumers might not realize their limitations on coverage or pre-existing conditions. These plans which do not comply with the protections and coverage of the ACA ( Affordable Care Act) are a recipe for future disaster. They contribute little to the collective pot and cover little for their purchasers. 

     

    MEDICAL NEWS 

    In the important and alarming department, we have cleaning sprays. New research published in the American Journal or Respiratory and Critical Care Medicine has shown that the “regular use of cleaning sprays can have as much impact on health as smoking a pack of cigarettes a day." In this 6000 person study, “ cleaning even once per week was associated with an accelerated lung decline risk”. I will try to find out more about the types of cleaning agents used. 

    HPV vaccine is still underused. Fewer than a third get their first dose by age 13, and fewer than half of all children are up to date on all their doses

    In other vaccine news, a recent inventory of 400,000 births confirms that both influenza and TDaP vaccines are safe in pregnancy, and confer protection to both mom and baby. 

    When we think of a heart attack, we think of an older man with check pain. However, women suffer heart attacks almost as much as men. However in women, particularly women under 55, symptoms may not be recognized since they are different than mens. These patients are more likely to have what is described as indigestion, shortness of breath, palpitations, or jaw pain. 

    In related news, women’s heart attacks may have a different mechanism, coronary vasoconstriction, rather than the blockage from plaques that male patients often have. A new study confirms that among women with chest pain, and clean arteries, nearly 8% have scarred areas on the heart confirming that a heart attack occurred. 

    About half of all breast cancer patient facing radiation heard “ frightening stories” about it. However after the therapy, only 2% agreed that the stories were true. 

    Illinois has targeted maternal morbidity, specifically maternal morbidity due to severe maternal hypertension. A “quality initiative” specifying a “suite of interventions” was implemented. Participants qualified for the study by having BP at or greater than 160/110 (yikes!). Interventions included prompt pharmacologic treatment of maternal hypertension, specifically designed discharge education, and short postpartum follow up intervals. Severe maternal morbidity such as stroke as already decreased by 41%.

     

    Stay tuned for more exciting news from the world of Obstetrics and Gynecology right here, next week, on Medical Monday. 

    Medical Monday: Breaking News from the World of Obstetrics and Gynecology

    MEDICAL POLICY NEWS 

    The new budget has blown the top off the old budget, and this, from conservative lawmakers. It exceed prior spending caps, and suspended the debt limit for a year. As part of the package it did refund CHIP (Children’s Health Insurance Program) for four years. 

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    CMS is the Center for Medicaid Services. According to their actuaries, health spending in the nation will increase by about 5.5%per year to $ 5.5 trillion dollars, nearly a fifth of the economy. The fastest growing sector of health spending is prescription drugs, estimated to grow by over 6% per year in the next decade. Due to the Affordable Care Act, (ACA) personal spending for health care has been at historic lows, though it is projected to increase, even under the ACA, at over 2.2% per year, which is over the cost of inflation which is 1.9%. Whether or not this is good, bad or indifferent, I cannot say. As a mother and as a physician, I feel we undervalue our health care and its costs. We spend on electronics, vehicles and vacations, which are important, but forget that health is at the foundation of it all. 

    The Trump Administration is disinclined to regulate drug prices. However, they propose “easing government regulations (read: protections) to “spur innovation” to “lower drug prices”. They also proposed expanding drug coverage and  placing a cap on out of pocket spending for Medicare recipients. While the federal government will not regulate drug prices, it will allow up to five states to band together to negotiate drug prices. 

    The ACA has a dependent provision saying that children up through the age of 26 may stay on their parent’s health insurance policies. A study recently published in JAMA, the Journal of the American Medical Association, has revealed that this provision resulted in increased rates of prenatal care, early prenatal care, and reductions in preterm birth. As an Ob/Gyn I can tell you that one of our holy grails is finding a successful approach to preterm birth. Looks like having health insurance might help. 

    Maternal Mortality is four times higher for black women than white women in our country. Access to prenatal care is believed to be part of this. A recent New York Times editorial  featured a free Obstetrics clinic in Florida who accepted clients regardless of ability to pay. They were able to document a 40% reduction in preterm labor and low birth weight in this group. 

    I reported earlier on the Utah bill which will provide for the use of Medicaid funds to provide family planing services to low income women. Part of the genius of this is that these are not just any poor women. These are women who are below the poverty level, but who are not so poor that they qualify for Medicaid. They are the so called women in the gap. Lawmakers would save everyone money if they gathered data about the lowest income at which one can reasonably afford private insurance, and made that the same level at which one qualifies for the Affordable Care Act. From there, the ACA should cover straight down to incomes which qualify for Medicaid. Then there would be no gaps. Rocket Science. 

    Health care is a case of pay now or pay later. By now, everyone including consumers and lawmakers should understand that attending to health and paying for it up front saves both money, productivity and suffering in the long run. This is the single most important message I can tell you. 

    Planned Parenthood has been under scrutiny, defunded in parts, and under continuing threat of more defunding. Planned parenthood provides many primary health care services at very low cost, not just family planning services. Their services disproportionately benefit women. Many associate their defunding in certain states like Texas, with increased rates of Maternal Morbidity and Mortality. This last week, leadership of Planned Parenthood announced they will begin a campaign of legislative action in key states. 

    West Virginia is attempting to supercede Federal Law. Their Senate has passed the “no constitutional right to abortion” amendment, and it now heads to their House. All this is despite the federal law Roe Versus Wade which guaruntees the right to abortion within various age parameters. One opposing Democratic senator, a physician, simply read ACOG’s (American College of Obstetricians and Gynecologists) statement of opposition to the measure as his response. 

    The Trump Administration has developed a “Conscience and Freedom” division of the Department of Health and Human Services. Since when did a Government office dealing with health care need a “ Conscience and Freedom” division ? It sounds very "morality police" to me. Encompassed in this type of approach would be protections for physicians who withheld certain treatments, and punishments for physicians who administered them. This move has also raised concerns in the hallowed halls of academic medicine. Professors from the Bixby Center for Global Reproductive Health and the Department of Obstetrics and Gynecology at UCSF (University of California San Francisco) have written an op ed against the formation of this committee and its enforcers. They have asked the Administration “to stop politicizing medicine and interfering in the judgement of medical professionals.” 

    Think all this sounds implausible ? Think again. The Iowa Senate has approved a bill to ban abortion after a heartbeat is detected. We routinely detect heartbeats at 5.5 to 6 weeks after the last menstrual period. The bill includes a provision to charge physicians who do such procedures non-emergently with a Class D felony. Opponents of the measure are many. The University of Iowa would lose it’s accreditation of it’s residency program in Obstetrics and Gynecology if this were to be the case. This is because,to comply with the state law, the Program's policies have to comply with medical science and recommendations. This would worsen the problem of the shortage of Obstetricians and Gynecologists. 

     

    MEDICAL NEWS 

     

    In the recent past, Betamethasone steroids were only given to women expected to deliver before 34 weeks. More recently, the recommendation is to expand the use up through just before 37 weeks., the so-called late preterm period. Steroid given in this way decreases pulmonary (Lung) problems in the premature newborn. New research presented at the Society for Maternal Fetal Medicine has concluded that up to $200 million in savings could be realized by following this new recommendation. 

     

    Increasing evidence shows that ovary cancer starts in the tubes rather than the ovaries. You might know this already if you have recently been counseled about a tubal sterilization procedure. In the past, we performed sterilization by tying, clipping, or cauterizing the tubes. However now we offer patients removal of the tubes to confer additional cancer prevention. 

     

    American “fertility rates” are falling. This could be misconstrued as meaning more American women are infertile. However, this is not what it means. It does mean our birth rate is decreasing. Researchers believe this is explained by later marriage, smaller families, better adoption of birth control and fewer births among the unmarried. Their are varying assessments of this trend. Some people believe economic prosperity is dependent upon ever increasing birth rate, but this is an outdated and flawed analysis. Some believe that decreased birth rate alone will rescue the environment. I wish it were that simple. Data shows that income, educational attainment, and savings all increase with smaller families. 

     

    HPV vaccine rates are still low. They are rising, but are still low. It is effective and has nothing to do with the choice to become sexually active. It prevents cervical cancer and genital warts. The side effects are limited to the side effects of an injection. What’s not to like ? 

     

    Juice is out. Juice has been out for some time but many people seemed to have missed the memo. Many people still think that drinking 100% pure (even organic) fruit juice is a healthy thing to do. It is not. It is too much fruit sugar, in too broken down a form, for people to metabolize without spiking their blood sugar and risking fat deposition. A calorie is not a calorie. The RATE at which sugar enters your bloodstream is key. The rate with juice is just higher than our physiology can handle. It is far better to eat the whole fruit itself. The fruit has structure, even once chewed or blended in a smoothie, and it will enter the bloodstream in a slow release fashion. New research has shown that postmenopausal women who have a single 6 ounce serving of fruit juice per day persistently gain weight over the years. Of course many factors probably go into this, but the juice drinking may be a marker for misconceptions they have about nutrition. 

     

    New research shows that who who meet criteria for and get MRI for breast cancer screening get more “invasive” (meaning with a needle or some other sharp object) biopsies. They say it like its a bad thing. Of course they get more biopsies. We see more detail and raise more concerns. The research goes on… fewer of these biopsies result in a cancer diagnosis”. AGAIN they say this like its a bad thing ! It is good to have no cancer diagnosis. What we are seeing here is a natural expectation of increased sensitivity and decreased specificity in the testing. There are more false positives, which we as a society have decided to accept as the “cost” of earlier diagnosis and better cures. So we as a group trade more pokes with a big needle for many women in exchange for greater years of life for a few. Sounds like a bargain to me ! Read these sensational headlines with care people, and don’t be afraid of needles. Sharp objects are your friend. And by the way, they talk about “invasive biopsies” like there is even such a thing as non-invasive biopsies. Spin the headlines much ? 

     

    It is still meaningful to get your flu vaccine. If it does not prevent flu, it still will decrease the severity. If you don’t want to do it for yourself, do it for the unwell, elderly, children or pregnant women about whom you care. They are especially vulnerable and the death toll nationwide is appalling. Anti-vaxxers, take notice. There is cost to what you say. 

     

    Stay tuned next week for more intense news from the world of Obstetrics and Gynecology. 

    Medical Monday: Breaking News from the World of Obstetric and Gynecology

    POLICY NEWS :

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    From the “back in my day” department we have the following dispatch: If one of us residents were to refuse to care for a patient out of moral objection or fear for our safety, we would have gotten in big trouble. We would have been told to get cracking or get packing. I remember being horrified one day after I had taken care of a beautiful young Moslem woman who had endured the severest from of ritual Female Genital Mutilation. (FGM) Not only had her labia and clitoris been removed, but her skin had been sewn together to barely leave enough opening, on stretch, to have intercourse.  She had just had a normal vaginal delivery and it was all broken open. Despite the fact that she had frequent urinary tract infections and and constant pain with intercourse, she insisted that I put it all back together after the birth. I spent a great deal of time trying to reason with her about the medical inadvisability of this procedure. Despite my personal and professional objections, I had to do it. The patient explained to me that she would have felt humiliated in the eyes of her family if it were not repaired. It was an awful situation for me. I wonder now what would be the requirements for me in the same setting, given that “moral objections" are playing a role in medical care.

    A new Harris Poll based study has revealed that 8 in 10 Americans “ do not believe doctors, nurses, pharmacists….” “ should be allowed to use their conscience or beliefs to refuse care.” Of course this pertains to many issues in Obstetrics and Gynecology, where one might be facing requests for routine abortion, or for abortion for grave anomalies not compatible with life outside the womb. Some people do not believe in birth control. Some do not believe that welfare mothers should have large numbers of children. Some people do not believe in women having multiple partners. Some people do not believe gay couples or single people should be able to use assisted reproductive technologies. The list goes on. 

    A recent paper described a possible option of 12 weeks of paid family leave secured in a fiscally responsible way. Parents would have a choice to trade 6 weeks of delay in the disbursement of their Social Security checks later in life in exchange for 12 weeks of family leave earlier in life. We’ll see if the idea gets any takers Washington. 

    As of this last Wednesday the Department of Health and Human Services (HHS) has stated Family Planning will continue to be refunded. The grant money for the program is called Title X and amounts to 260 million dollars. 

    North Carolina is connecting the dots. A bipartisan program, YES let me repeat that- BIPARTISAN program in the state, Carolina Cares, is advocating to expand Medicaid. The fetal and infant mortality in the state is unacceptable and available data indicates that expansion of Medicaid can decrease fetal and infant mortality simultaneously. Care through Medicaid targets exactly what places mothers and infants at risk: poverty, violence, lack of education, nutrition, and prenatal care. 

    Several States are considering lifetime caps on Medicaid for those who are not children, pregnant, or disabled. If you are not any of these things, why should you need Medicaid ? The Conservative in me says you wouldn’t since you would simply work and earn and pay for insurance. The Liberal in me says, insurance is expensive, and there will always be people who are just poor, and they need comprehensive medical care more than anyone for them to even stand a chance at a decent life and productivity. 

    Several States are leaving the Federal Government behind, and beginning work on their own versions of the Individual Mandate. These include Maryland, California, Hawaii, Minnesota, New Jersey, Rhode Island, Vermont and Washington, and DC. As reported previously, even more states have begun or finished work on laws guaranteeing contraceptive coverage for their citizens. 

     

    MEDICAL NEWS: 

     

    In the "we already knew this" department, new research has shown that induction may lower complication rates. But the devil is in the details…angels too. It turns out inducing at 39 weeks was associated with less need for C section and fewer complications for mother and baby. However, dates must be accurate and the cervix must be soft and favorable to even consider it. The quality of the study was good and it was presented at the Society for Maternal Fetal Medicine. 

    Think only old women lose urine? Think again. One third of women leak urine before thier first pregnancy. Talk to your doctor if you think there is a problem. Urine loss may signal infection or other medical conditions. Most of the time it is just de-conditioned muscles and bad habits. 

    Ever have preeclampsia ? This disorder, also called toxemia, will go away after delivery. However, mothers who had it either had a pre-existing tendency to high blood pressure beforehand or retain this tendency to high blood pressure afterward. If you had preeclampsia, check your BP regularly and know that you are at risk. I hear they make smart phone connected BP cuffs! 

    The Journal of the American Medical Association has published a report indicating that as many as 10% of US babies are affected in some measure by fetal alcohol syndrome (FAS). This has been unearthed by interviewing mothers of neurologically or behaviorally abnormal children. What was once believed to be primary neurological disorders are now felt to be related to maternal alcohol consumption in pregnancy. Likewise, I am very concerned about what we suspect but have not yet conclusively proven about the effect of marijuana on the brains of the unborn. 

    Syphilis is on the rise, and herpes on the decline. Both infectious diseases are easy to detect, manageable to treat, and potentially catastrophic in pregnancy. Get screening if you have any doubts. 

    Probiotics for babies? Experts are beginning to focus on the neonatal microbiome. That is the group of organisms in and on the baby which are considered to be normal and beneficial. Many of these come from mother, via delivery and breastfeeding. But what if a C section takes place and what if breastfeeding is curtailed? While amateur “seeding” of the flora has been tried, ACOG (American College of Obstetricians and Gynecologists) does not recommend it. However, research interest in this topic is increasing. We do know that pregnant women should eat a pre-biotic diet rich in fruit vegetables and probiotic foods such as plain yogurt, kefir, fermented vegetables, and even Kombucha in moderation. 

    Stay tuned next for more exciting news from teh workd of Obstetrics and Gynecology, here on Medical Monday. 

     

    Medical Monday: Breaking News from the World of Obstetric and Gynecology

    Policy

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    The GOP appears to be giving up on repealing the Affordable Care Act (ACA). Those who support the patient care aspects of the ACA may cheer, but they should not breathe a sign of relief, since the funding mechanisms of this plan remain somewhat undetermined. Encouragingly, there is increasing GOP interest in crafting legislation which will make the plan more fiscally stable. The goals in this case would be to guarantee Federal subsidies to insurers, and to reduce patient premiums while keeping essential benefits.

    Do you think that people realize that the more people sign up for the ACA, the more stable it will be ? Well, it's true. It's easy. Go to heathcare.gov to see if you qualify. 

    South Carolina has argued that a “ human being is a person at fertilization”. They have created a legal category “preborn humans” which incidentally my spell check refuses to recognize, and they propose these preborn humans be afforded due process and all protections under the law. ACOG, the American College of Obstetricians and Gynecologists, opposes the bill since it is not based on science. 

    A 20 week ban on abortion failed the Senate. The bill’s proponents advanced the bill on the basis of their belief that 20 week fetuses can feel pain. ACOG has gone on record saying “ the fetus does not have the physiological capacity to perceive pain until at least the 24th week of gestation.”. We as a medical culture have a great deal of experience with 24 week babies since they routinely come to any large newborn ICU. Had the bill passed, it would have been challenged under the standing Roe V. Wade. 

    Idaho has introduced a bill which introduces misinformation into the informed consent language for medical (pill based) abortion. The bill’s language asserts that medical abortion can be halted after the first of two pills is taken. The bill further requires providers to provide a list of other providers who can advise about “ abortion reversals”. None of the bills assertions are based in fact. A patient contemplating a medically induced abortion should not proceed if she has any doubts, since there is no evidence reversal is possible. I feel angry on behalf of distraught women who may be told this misinformation and who try to rely on it. 

    A group of private donors has bankrolled the provision of medical abortion services for all public universities in California. A bill is under debate which will require public universities to provide this service. 

    Another bill proposed in California would require larger businesses with new construction to provide space for breastfeeding. The bill stipulates these areas need to be be in place by 2019. 

    The Utah bill which will require the offering of IUDs through Medicaid has passed the House and is heading to the Utah Senate. Republican lawmaker Ray Ward, has proposed the measure to decrease unplanned pregnancies, teen pregnancies, and abortions. 

    Medicaid expansions may be able to move forward in several traditionally red states if they are paired with work requirements. What do you think ?

     

    Medicine

     

    Researchers out of UC San Francisco have come out highlighting the adverse effect of marijuana on the unborn. Dr. Dana Gossett has cited several recent studies which indicate marijuana increases risk of still birth and adversely affects how the babies brain develops. ACOG has already come out formally warning pregnant women not to use. This could potentially turn out to be a huge generational problem if these children, as a generation, have significant delays. This research also raises the question of what is marijuana does to the brains of children and adults who use. This research also raises the issue that state policy on marijuana has been made without any reference whatsoever to available science. 

    Preliminary date from a Dutch population based study indicate that women with implants may be somewhat more likely to develop anaplastic large cell lymphoma. Further studies are needed to clarify the risk. 

    It has been well established that obese women have an increased incidence of breast cancer based on weight aone. However it is now becoming clear that even fat/skinny women are also at increased risk. This means even a woman of normal overall weight with a high body fat percentage has increased risk. 

     

    TDAP stands for tetanus diphtheria and acellular pertussis. This vaccine is given to children and to pregnant women. It turns out that that protection is afforded to the baby through the mother no matter when mother gets the vaccine in her pregnancy. Upshot: It is never too late to get a TDAP in pregnancy. Babies first vaccinations are not until 2 months, so baby needs passively acquired immunity from mom getting her shot in pregnancy. 

     

    This season’s flu is on tract to be the worst of the decade. already it has surpassed the 2009 “ swine flu” epidemic. As f this writing, flu has led to 37 pediatric deaths nationwide. You may have heard that this year’s vaccine is only partially effective. This is true, but some protection is better than none. Get you and your loved ones vaccinated. Do not go to work of you are sick. Ask sick co-workes to go home. Do not take sick children to day care. Wash you hands twitch soap when you arrive at home. Be assertive ! If you think you have been exposed to flu, call your health care provider. You may be eligible for preventive medication, and certainly are if you are pregnant or immunocompromised. 

     

    A new Zika vaccine has been fast tracked by the FDA. It is called TAK-426 and is currently being tested on 240 people between the ages of 18 and 49. 

     

    Women have autoimmune disease 9 times more often then men. I will therefore report on two news items of interest to those with autoimmunity. The first pertains to Rheumatoid Arthritis. A new study has shown that women with Rheumatoid Arthritis tend to deteriorate after menopause. This hints at a relationship between autoimmunity and reproductive hormones. Unfortunately the relationship is not yet clear. Meanwhile, those with these issues should talk to their Gynecologist about navigating through menopause in a way that minimizes difficulty and risk. 

     

    The second has to do with lupus, a condition which I have. New research indicates that a gene called “ Toll Like Receptor 7 (TLR-7) ” may be involved. Normally, only one copy (allele) a gene is active in a given individual. However, in lupus patients the second copy of TLR-7 does not deactivate as it should. The normal role of TLR-7 involves activation of type 1 interferon signaling which is critical to antiviral immunity. However too much of this powerful immune response can be damaging. Lupus nerds stay tuned with cautious optimism. 

     

    Stay tuned next week, here, for more breaking news from the world of Obstetrics and Gynecology. 

    Medical Monday: Breaking News from the World of Obstetrics and Gynecology

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    I’d like to take a moment to thank readers for their continued attention to this blog and this site. The Women’s March drove home the point of how important it is for all of us to be aware, and for us to make our voices heard. The beginning is simple: learning what is going on. 

    Policy

    Up to date policy includes one Alex Azar, who will be the new HHS ( Health and Human Services) secretary. As such he will be in charge of health policy in the nation. He has vowed to consider the interests of both parties. 

    The legislature is gearing up to vote on a 20 week abortion ban. I’m not sure how much effect this will have since most elective abortions are far earlier than this. Since Roe versus Wade was based 45 years ago, making abortion legal, approximately, twelve hundred restrictive state laws have been passed. 

    The Trump administration is crafting a program called “ Conscience Rights” which would allow a health care provide to deny a patient care based on their beliefs. This care would obviously include controversial procedures like abortions and assisted suicide, but would also extend to providing contraception and sterilization. Numerous physician groups including ACOG have raised substantial objections. I would not like to see health care devolve this way. I already know physicians who disapprove of people who get abortions, and physicians who disapprove of people who don’t practice birth control to have large families “ as many as God will give”, or people who drink, or people who smoke, or people who get fat or get sexually transmitted infections. Is there no end to our judgmental mentality ? I though we were in this to teach, comfort and cure. 

    Utah is where I went to medical school. It is also the center of governance for the Church of Jesus Christ and the Latter Day Saints, aka the Mormon Church. In general I found the people there an attractive mix of family oriented, strictly religious, and yet interested in and respectful of science and the diverging views of others. So in this progressive atmosphere it comes as no surprise to me that a Republican legislator Representative Ray Ward, has proposed HB 12, which will enable Utah Medicaid to provide birth control, which it currently does not. He is proposing this to save money by decreasing unplanned pregnancies, abortions and reducing all costs associated with those. Brilliant ! 

    Texas lost $35 million in federal funds which it voted to exclude Planned Parenthood from the recipients list. It basically lost $35 million worth of care to Texas women. Could this be related to the astounding increase in Texas Maternal Mortality ? Now Texas legislators are trying to get that money back. They are proposing their own program which will still exclude Planned Parenthood; They are calling it Healthy Texas Women. If they get their money back for their new program, there is concern that other states will similarly overhaul how federal money is delivered to women’s health clinics. 

    Meanwhile, nationwide, women continue to flock to clinic to obtain long acting IUDs ( intrauterine devices) to give them birth control in case the contraceptive mandate of  Affordable Care Act is revoked. 

    The Trump administration is trying to find more ways to “ excuse” people from the mandatory requirement to have health insurance, the so called “ individual Mandate” part of the ACA ( Affordable Care Act).  For all the world, you would think they want fewer people insured. Oh wait ! They do want fewer people using federally sponsored health insurance plans, since those cost the government money which they would prefer to keep for items on their own agenda. They justify this stating consumers should have freedom of choice, meaning the freedom to save for health care expenditures, as if that is common practice, or you could reasonably expect to do it for a large 5 figure expenditure. Last year, there were 3.2 million more people uninsured compared to the year before. Most of this is reckoned to be people who simply chose not to pay for health care. I cannot understand why it is not simply like car insurance. If you are on the road, you must have insurance. If you do not, and something happens, you will cost others a great deal of money and yourself a great deal of trouble. The same is true if people are too irresponsible to obtain health insurance. 

    Medical News

    Hip fractures among women are on the rise. This new study shows what I have considered inevitable. The women of the Diet Coke, Tab and too much coffee age are upon us. Many were smokers, and few drank milk, let alone ate leafy greens. No wonder bones are breaking. Here in Montana, where winter is 9 months long and there are 3 months of bad sledding, vitamin D deficiency is rampant. Vitamin D is crucial to bone metabolism and is manufactured in the skin by sunlight. Pacific Northwesterners and many of us in the Rocky Mountains inland should consider getting checked and supplemented. 

    Breastfeeding may protect against type two diabetes in women. The longer the breastfeeding, the greater the reduction in risk. We have always advised that breastfeeding helps moms lose unwanted weight, and of course that in and of itself lowers risk for diabetes. 

    Placental insufficiency is just what it sounds like it is. All placentas are not created equal. Placentas deliver oxygen and nutrients to a growing baby. However, various medical conditions or just bad luck will result in a poorly functioning placenta. Just about any pregnancy complication such as high blood pressure, poor nutrition, or smoking will result a placenta of  poor quality and a higher risk of complications for baby. The worst complication is of course stillbirth. A new study has suggested that nearly a quarter of stillbirths could be preventable. Placental insufficiency is usually the culprit, and with standard prenatal care it is not hard to diagnose. When we identify the problem, we increase the surveillance with monitoring and Ultrasound. Any problems with access to good prenatal care will interfere with identifying and treating complications that lead to stillbirth. 

    Texas continues to be in the news as researchers and policy people probe the appalling maternal mortality figures. As of this writing we know that many factors are to blame including access to prenatal care, prevalence of black women in the data set, especially those who are underserved, or who have hypertension. Most interesting to me is the contribution of stress from chronic societal discrimination. 

    The spotlight is now on my state, Montana. In the case of 14 child deaths in Montana this year, 3/4 of them took place when an infant slept in the same bed as a mother who was using drugs. Our hospital has addressed this by have an active department of Social Services, an Addiction Specialty service, and the Baby Box program. This is modeled after a common European practice wherein a family with a newborn is sent home with a baby box full of safe supplies. The box itself is made to evidence based standards, having a flat firm mattress , a fitted sheet, and no covers. Baby is kept warm in a sleep sack, a kind of gown in which they cannot get tangled or suffocate. In Finland, for example this has been done for over 75 years with good results. Some say it has helped Finland achieve one of the lowest infant mortality rates in the world. The Baby Box program also includes extensive education about safe separate sleeping practices, but it remains challenging to change people’s behavior of keeping baby with them in the bed. 

    http://www.bbc.com/news/magazine-22751415

    A County Attorney in Big Horn County, Montana has announced a crackdown on pregnancy women who use drugs or alcohol. That office plan to seek civil restraining orders and even incarceration to meet their goals. ACOG has come out against this, indicating it basically keeps high risk women away from prenatal care. Handmaid’s Tale, much ? 

    When medicine and policy collide: More women received indicated mammograms when Obamacare, aka the Affordable Care Act, banned copays. If that does not tell you copays are a barrier to screening, I don’t know what does. 

    Women skip mammograms for money. But, a new study says women skip paps for embarrassment. Young women in particular could identify embarrassment due to body shape, shape of vulva, or smell. We need to do more to help women and girls feel comfortable in their own bodies. 

    A new study reveals that increased long use of oral contraceptive pills confers better and better protection agains endometrial (uterine) and ovary cancer. It also confirms that long term use does not seem to affect risk of colon or breast cancer. You may have in the past heard other studies which have contradicted this. The good news is that our methodologies improve and computing power increases every year, making the quality of our data better and better as time goes by. 

    Not-so-fun-fact: New research incites that a women's risk of dying from childbirth is 14 times higher than her risk of dying from an abortion. 

    Finishing today in the SUPER COOL department, we have two entries. 

    First, those Scandinavians are once again on the forefront of progressive perinatal care, this time using the power of probiotics. A new study shows probiotics consumed in pregnancy lowers the risk of preeclampsia and preterm birth. These Scandinavian countries provide comprehensive prenatal care and keep thorough databases on all patients, enabling them to glean meaningful information of good quality. More research is needed on how to implement this finding. 

    Lastly, Apple has roiled out a new feature in the Health App enabling users, meaning patients, to control and transfer their own medical records. Twelve large medical institutions have begun beta testing. This is great for patient empowerment. It is also partakes of the open data movement, which says that in an ideal world, data should be fully shared, without fear of discrimination. When patient and research data can be shared, we can expect a great acceleration of medical progress on the topics which matter most. 

     

    Stay tuned until next week, for more breaking news from the world of Obstetrics and Gynecology.

    Medical Monday: The Women's March Where I Live

    This year my own small mountain town had an upbeat well attended Women's March. I would like to share some of my photos. I will report on policy and science a little later. For now, it is simply important that you know the government is shut down until there can be an agreement on a budget. 

    I am holding the sign saying, "Make America kind again ". I think this by itself would help so much.