Friends, You post will be delayed due to patient care late in the night. Hopefully when I write there will be not too much in the way of politics, but lots of interesting medical news. I suppose I should not have a preference. It's all important. Until then, happy Monday.
People across the political spectrum continue to debate the merits of Brett Kavanaugh for the Supreme Court. Since we now know that the political and judicial systems play such a large role in the health care of women, we’d all best pay close attention to this debate.
Drug Shortages. We did not used to have them. Now it is common place on routine drugs, even IV fluids. No slight to third world countries, but sometimes it feels like we are in a third world country. The FDA is forming a new task for to more critically and quickly investigate and solve this problem.
Companies that make formula are multinational. The Trump administration is avowedly pro business and this is particularly evident in the international sphere where of late, this had unsavory consequences. In its zeal to unfetter corporate interests, The Trump administration has taken an anti breastfeeding stance. At present advertisements of formula is limited regionally in areas where it could be misused or hazardous. The Trump administration has desired to “ reopen” these markets, under the auspices of free trade, seemingly oblivious to the perils of selling formula in places where literacy (ability to mix correctly) and clean water is unavailable . The entire medical and public health establishment has reacted, concerned that breastfeeding continue to be encouraged as the safe and superior method that it is. Many are pointing out that formula manufacturers have no place at the health policy table. This baby feeding battle resurfaced last year when Ecuador proposed a resolution to the WHO (World health organization) to support breastfeeding. The Trump administration through the US delegation at the World Health Assembly, tried to water down the resolution. When this did not work they threatened Ecuador with a trade war. Can you say “evil empire” ? ACOG (American College of Obstetricians and Gynecologists) and AAP (American Academy of Pediatricians) have responded formally.
Did you know as little as two months of breastfeeding reduces risk of SIDS ?
Did you know breastfeeding reduces mom’s risk of breast and ovary cancer, heat disease, and endometriosis ?
Did you know the US ranks 26th among industrialized countries in breastfeeding ?
The Trump administration seems to want people off the ACA. They have reduced the “navigators” fund from 36 to 10 million per year. Navigators are those who help people enroll in the ACA. The Trump administration says private health insurance agent and brokers do a better job. Do private brokers and agents get a fee for this ?
Abortion facts were highlighted by NBC this last week:
Death by childbirth is 14 times greater than death by abortion.
Banning abortion does not reduce its incidence.
Free birth control reduces abortion rates.
Before legal abortion, 5000 women per died through complications of illegal abortion.
Depression is not the only feature of postpartum depression. A new review has highlighted the fact that anger is often a big component of post partum depression.
Your microbiome is the population of microorganisms that you have on your body and in your gut. This is affected greatly by what you eat. In pregnant women this microbiome is passed to the baby. Thus, what pregnant women eat can influence the microbiome of their child, for better or for worse. Newer research in multiple fields are beginning to describe the role of a healthy microbiome to overall health.
The US birth rate is at an all time low for the second year running. Some site child care expense, wanting to spend time with existing children and concerns about the economy as chief reasons to wait. Germany and Japan have addressed their falling birth rates by putting better child care policies in place. Falling birth rates are not necessarily a bad thing, as they are associated with greater savings and higher levels of educational attainment. It is certainly an oversimplified falsehood to think that a larger population means a better economy.
Stay tuned for more interesting news from the world of Obstetrics and Gynecology this time next week on Medical Monday.
These Summer days are very busy for me and my family. So I am going to keep to an abbreviated or bullet version this summer. A little later, I’ll let you in on a fun little secret about why I am so busy.
The biggest policy new has to do with the need to fill the vacancy in the Supreme Court created by the resignation of Justice Kennedy. The most contentious issue thus far has been abortion, Thus, all conceivable candidates are being scrutinized for their views the subject. Justice Kennedy had been a more liberal justice, and Trump has promised to install an anti abortion justice who would then contribute to the making of law for the rest of their tenure. At present, under Roe V. Wade, abortion is legal. Prior to that it was not, yet many many women and caregivers defied the law, often at great peril. My late father in law, an Obstetrician Gynecologist minted in the early 1960s remembered the days before legal abortion, and while no friend of abortion, told us cautionary tales about the complications that illegal abortions could produce.
The ACA (Affordable Care Act) has more users now than it did last year. As of this last February, 3% more people paid for ACA plans than the prior year. This is especially noteworthy since the Fed decreased funding for outreach about the plan by 90% and halved the enrollment period.
Starting in 2019 the Joint Commission ( a chief governing body for hospitals) will require accredited hospitals to have a newborn identification protocol. Details to follow, though we know it will require “ two factor authentication”.
The Senate has approved 50 million dollars in funding to reduce maternal mortality. Most of this will go to the Federal Maternal and child Health Bureau to expand life saving evidence based programs. Some will also go to the CDC and some will go to Healthy Start programs for mothers and babies.
The Senate also has approved three new bills pertaining to maternal and child well being. In particular the money will be used to reopen closed programs which aim to prevent preterm birth.
One major piece of the maternal mortality puzzle is the lack of Obstetricians and Gynecologists. It is tough job with tough call and its pay lags behind that of similar surgical specialists. It is estimated that there will be a shortage of nearly 8800 Ob/Gyn in just TWO YEARs, in 2020. The shortage is very likely to keep growing.
Non-European women with ovary cancer seek genetic testing less than their peers. Genetic testing after ovary cancer may help identify risk factors for other members of the family dn may define the patient’s tumor type in such a way as to tailer its treatment and make it more effective.
Flight attendants have been found to have a higher incidence of many various types of cancers. The findings were published in the Journal Environmental Health. It is unclear why this is the case. Theories include increased exposure to ionizing radiation, circadian rhythm disruption , or to other carcinogens. More study is needed.
Many older women or their caregivers begin to lessen the frequency of their bone density screenings after about 65 years of age. I have never liked this approach as it smacks of marginalizing older women. Many older women begin their final decline with a hip fracture that could’ve been prevented. Now, new recommendations from the USPTF, US Preventive Services Task Force has produced evidence saying it could be worthwhile. This is true because there are many meaningful potential treatments, which when instituted, could help prevent bone fractures and the debility that those entail.
Probiotics. They are for gut health, right ? Turns out a new study has shown that probiotics given to women protect against the loss of bone density. See the Journal of Internal Medicine.
There are nine vaccine which pregnant women may receive. ACOg has recently released a single page list of these and his encouraging all pregnant women to speak with their physician about these.
Smoking. It’s bad. How bad ? Well its bad enough to increase your risk of miscarriage…. even if it is just your partner who smokes ! Yes, second hand smoke from a partner is associated with an increased risk of miscarriage.
In separate research, smoking also appears to double your child’s chances of having hearing loss.
In clinic, most people report being active. And yet, the CDC report s that fewer than 23 % of US adults are meeting federal standards for time spent exercising.
In rather disturbing news, over 1 in 4 girls have harmed herself in the past year, often by cutting or burning, compared to 1 in 10 boys.
There is more good news about vitamin D. It turns about high levels of vitamin D may help prevent breast cancer. Vitamin D levels in our lab should sit between 30 and 80 to be considered normal. However, there is more and more evidence that sitting on the higher end of that spectrum may have benefits. New research has indicated that having a level near 60 confers 80% lower risk of breast cancer compared to a level near 20. Associated risk factors were depression, suicidal thoughts, buying and substance abuse were risk factors. See the recent edition os American Journal of Public Health.
Oh… my fun little secret ? I am starting a traditional French Bakery and Bistro. No, I will not be baking. Yes, I will continue full time Obstetrics and Gynecology. It has always been a dream, and, along with a great team of people, I am getting to realize it. Stay tuned. We will open in late August. Visit me at
to learn more. And...stay tuned for more news from the fascinating world of Obstetrics and Gynecology, here, next week on Medical Monday.
Gentle readers Medical Monday's reporting of last weeks news will come out soon.
Efforts continue around the country to prevent changes to Title X funding. Title X funding is meant to supply federal funds for family planning and preventive health services. However, since those services have historically included birth control and abortion, the current administration is seeking to redirect these funds. In particular, the Trump administration would like to see those funds go to programs that promote abstinence only, which is not an evidenced based measure. Opponents of the changes including Planned Parenthood are arguiing that such charge are unconstitutional since they have not gone through a federal rule making process.
The House has passed a bill allowing Medicaid to pay for inpatient drug treatment in case of cocaine and opioid addiction. The bill is contested on both sides, with some Democrats saying its focus it too narrow.
The House has also passed more bills pertaining to the opioid crisis, mot notably by extending access to mental health and substance abuse disorder services to children and pregnancy women under CHIP, the Children’s Health Insurance Program.
“Association Health Plans” are potentially bare bones health insurance plans which may be obtained by groups of small businesses even across state lines. The idea there is that lower cost can be achieved by forgoing benefits like birth control or pregnancy care, things which have been mandated under the affordable care act (ACA). Many feel the omission of what are now defined as “essential services” is short sighted and will contribute to the weakening of health care markets overall.
A US District Judge has ruled in favor of two Christian Colleges to bar the enforcement of the contraceptive mandate as it applies to their University sponsored insurance. I understand that many Christians are opposed to abortion, and that many are also opposed to sex before marriage. However, what is the problem with contraception ?
Many people are not aware of the Pregnancy Discrimination Act. It is a clause to Title VII of the Civil Rights Act of 1964 and is for the purpose of prohibiting “sex discrimination on the basis of pregnancy”. Pregnancy is a temporary disability in the eyes of the law. Violating employment law pertaining to pregnancy wold be treated like violating employment law pertaining to disability. The Act protects women not only during pregnancy, but also during “pregnancy, childbirth and related medical conditions”.
In England there is a public health program. In 2008, an HPV vaccination program was instituted. Ten years later, we cannot see that this has resulted in infections with the most serious HPV viruses, types 16 and 18 fell 86%. Experts speculate that the vaccine could lea to the eradication of HPV related diseases such as genital warts or cervical cancer.
Focus on the American Maternal Mortality Crisis continues. New data continue to confirm what many have already observed, that black women die at three times the rate of white women from pregnancy related causes. May have suggested hypertension and racism are playing roles, as well as lesser access to quality care.
New and sobering data are coming in about the common disorder we call “PCOS” or polycystic ovarian syndrome. PCO is complex of hormonal problems leading to problems with ovulation, ovarian cysts, and trouble with androgens, insulin and the processing of fats and carbohydrates. We used to think of PCO as pertaining mainly to infertility, but PCO related infertility is quite treatable. However, now, more physicians like me are even more concerned about the downstream metabolic effects of this syndrome. The carbohydrate intolerance leads to obesity and the obesity leads to more carbohydrate intolerance. All of this leads tot higher BP and abnormal lipids, setting the patient up fro diabetes and heart disease later in life. In fact, we now know that about half of patients with untreated PCO will have diabetes before age 40. If you think you have PCO, please contact your doctor and ask to be referred for appropriate medical and lifestyle management.
Obesity in pregnancy is known to be associated with an increased rate of a number of pregnancy and brith complications. However, it now appears, that offspring of obese mothers are considered a high risk population for endothelial cell dysfunction, meaning cardiovascular problems. In fact, either maternal smoking or obesity predisposes daughters with PCOS. When will the nation and the medical profession come to terms with the obesity epidemic ?
Stay tuned for more news from the fascinating world of Obstetrics and Gynecology, here, next week on Medical Monday.
Under the ACA, the Affordable Care Act, all health insurance providers were required to cover the full range or reproductive health services including birth control and abortion. However, a suit filed by two Christian has succeeded in blocking the part of the mandate that pertains to coverage of the abortion pill. DHHS (Department of Health and Human Services ) will no longer be able to enforce this portion of the mandate against them.
The US provides health care aid to many countries. In those health care systems, birth control and abortion services are provided. However the US Gag rule has prevented funds from continuing to go to countries which provide abortion services. . The Trump administration has created auspices under which exceptions to the gag rule may be obtained. This is because there are some such countries whose national law requires health care providers to include information about such services. Such countries may continue to receive US aid under what is being called the “ affirmative duty defense”. Theater loophole, the “passive duty” exception, the US may continue to supply funding if abortion is legal in that country.
Texas continues to rally. Texas comes in at 47th in vaccination rates. A new group called the Texas HPV coalition aims to increase this rate to 80% before 2026, stemming a tide of HPV related diseases including cancer.
As previously reported, Texas had shot itself in the foot by defunding and otherwise weakening primary health care for the poor, and reproductive health care in general. It has also been early in the race to defund Planned Parenthood and teen pregnancy prevention programs. Now its teen pregnancy rates, and more worryingly, the material morbidity and mortality rates are skyrocketing. Texans are now are trying to circle the wagons. In particular, the Dallas City Council has by itself resolved to spend $300,000 on a program to curb teen pregnancy rates.
Nationally the same logic is at work. This coming week the Senate will vote on a bill which will create “Maternal Mortality Review Committees” that track and investigate maternal mortality.
Physician leadership is again voicing its defense of the Affordable Care Act (ACA). A recent article in Forbes has highlighted the uniform positions of the American Medical Association, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the American Psychiatric Association. How can this not give the administration pause ?
An Oregon county has sued the Trump administration for their new guideline which give preferential funding to health care programs that promote abstinence. If they prevail, it could block these guidelines nationwide.
Because contraception has now somewhat unexpectedly become such a controversial topic, the medical community is lobbying harder and harder for drug companies and the FDA (Food and Drug Administration to make birth control an over the counter medication. The American College of Obstetricians and Gynecologists have long advocated for this regard the oral contraceptive pill. Now the American Medical Association was set to consider a resolution to this effect.
Vitamin D is increasingly in the spotlight. This time, new study has shown that adequate levels of vitamin D protect against miscarriage. Women at high latitudes in areas with little sunlight and little seafood are more prone to vitamin D deficiency.
A new study out of Duke indicates that young women’s exercise rates drop off after high school. Additionally they drop off more quickly than do mens. More research is needed to understand and correct this phenomenon.
Remember the Zika virus epidemic ? A new study shows that over half of Floridians took no precautions whatsoever against the virus. The report has shown that much more education is needed.
Here is a sad commentary on out profession and on our relatively affluent population: Less than10 percent of our population get the recommended screening and counseling pertaining to preventive health care. This pertained to basics like measurements of vital signs and blood tests, but also to imaging studies like mammograms and colonoscopies for colon cancer screenings. Preventive health screening should also include counseling on weight, tobacco and alcohol use, screening for depression and currency on vaccinations.
Alcohol is harder on women than it is on men. This may be related mainly to weight. A new study indicates that young women who drink regularly and heavily ( 4-5 alcoholic drinks) are probably destined for low bone density such as osteoporosis. Women have little androgen (male hormone) compared to men, and androgen protect bone. Estrogen does too, but its production ceases after menopause, when osteoporosis is at its highest risk. Young women need to realize they are likely olive considerably longer than their mother and grandmothers. To do so in comfort and wellness, they need to take really good care of themselves.
Stay tuned for more news from the fascinating world of Obstetrics and Gynecology, here, next week on Medical Monday.
Yet another Federal Judge has put a stop to the defunding of a regional Teen Pregnancy Prevention program. This time .a district court judge in Washington, DC has ruled that that HHS (Department of Health and Human Services) must process the grant for $3 million dollars which provides for 20 health educator jobs and provides for teen pregnancy prevention education.
Many voices have come out in opposition to proposed changes to Title X funding. Title X funding is meant to ensure access to reproductive health care. However, funds are due to be cut from any provider who mentions abortion even as an option. Proponents of the measure say parenting and adoption will also be promoted. Opponents say this is being sought to placate anti-abortion elements of the electorate as well as to close programs and clinics, thus decreasing federal health care spending for those on the lower end of the socioeconomic spectrum.
Thirteen governors have signed a “ sharply worded letter” sent to HHS secretary Alex Azar opposing the proposed Title X changes. The letter cites “reckless policy” which “upends decades of bipartisan cooperation”.
Texas which has struggled mightily with appalling maternal morbidity and mortality, has voiced particular concern that changes to Title X could undermine efforts to combat impact rampant maternal complications in the State.
Newer gene testing is allowing doctors to better target therapies to individual patients. In particular, we are now gaining insight, through genetic analysis, about which tumors in which patients are likely to respond to chemotherapy, and conversely, which are not. Gene testing is allowing some patients to skip chemotherapy and the complications that that entails.
Also in breast cancer news, immunotherapy is being brought to bear in the fight against breast cancer. In one case study a 49 year old woman who had failed all other therapies received immunotherapy with a large clone of her own best cancer killing immune cells. These were produced by identifying and removing theses cells, and then amplifying them to 100 billion then using them as a treatment. This patient, who had no further treatment options, is now three years with NED- No evidence of disease !!!
In similarly encouraging news a pairing of new ovarian cancer drugs have shown themselves to be effective against heretofore drug resistant ovarian cancer.
Zika virus is again upon us in the South and authorities in Florida are taking precautions. Thus far there have been cases noted, but none have been of local origin. Zika Virus is transmitted by certain mosquitoes and is prevalent in tropical and subtropical climates such as in Florida, Central and South America. Zika virus contracted in pregnancy can make serious birth defects in the central nervous system of the unborn.
Many women are identified as having pregnancy associated diabetes. They may require medication or dietary modification in pregnancy. New research now indicates that such patients may benefit from a postnatal lifestyle intervention program. Such women with a history of gestational diabetes are at increased risk for diabetes later in life.
In concerning news, a new meta-analysis has indicated that hypertensive disorders of pregnancy such as chronic hypertension and preeclampsia may be associated with a higher risk of autism spectrum disorders and ADHD (attention deficit hyperactivity disorder). Women with untreated chronic hypertension, over weight women, and others have a higher risk of having hypertensive disorders of pregnancy. Maintaining normal weight and fitness before pregnancy can decrease the incidence of hypertensive disorders during pregnancy.
A new and encouraging study has shown that resistance training helps stave off depression. Most of the exercise literature now supports the combination of light resistance training women for women, especially older women as it preserves muscle and burns fat. The combination of cardio and light resistance is often called HIIT or high intensity interval training. Low hanging fruit !
Stay tuned for more news from the fascinating world of Obstetrics and Gynecology, here, next week on Medical Monday.
It is no secret by now that the Trump administration is systematically enacting policies to ban abortion and limit access to contraception. Medical experts have indicated their concern all along, saying these policies are likely to backfire, increasing unplanned pregnancies and abortions overall.
Legal challenges to Trump administration policies are now coming from many quarters. Mississippi and Louisiana have pending legislation to ban abortion after 15 weeks. Both laws will now go to Federal court to be tested. Meanwhile, New Jersey is suing the Federal government against the exemption which permits corporations to purchase insurance without contraception coverage if they object to it on “moral” grounds. Since when can a corporation have morality ? People, owners, and board members can have morality or the lack of it.
The Federal Courts are going to have a big role in determining how much of this Trump era law stands. For example, a federal judge in Washington struck down the decision by the HHS (Department of Health and Human Services) to withhold funds for the teen pregnancy prevention program. The judge called the cancellation of funds “capricious”. HHS actions have been struck down by federal courts four times to date.
A survey of various health care groups has shown the 95% have strongly criticized the Trump administrations efforts to weaken the ACA (Affordable Care Act). The American College of Physicians has published a paper calling for recognition and addressing of the discrimination against women in health care. Health care disparities include those pertaining to reproduction, family and medical leave, domestic and sexual abuse and inclusion in clinical trials.
Elsewhere in the world, Ireland has voted to repeal the countries ban on abortion. The popular vote passed by a margin of 2 to 1. To put things in perspective in this historically Catholic country, divorce was only legalized in 1995. Gay marriage has also been ratified in Ireland, and an openly gay man has served as Prime Minister.
We all know that genes influence our physical health. But they also influence our mental health. They are a number of genes which are associated with the development of Schizophrenia. However, even if they are present, the odds of actually developing schizophrenia are low. New research has indicated that pregnancy complications such as gestational diabetes and preeclampsia increase the risk of schizophrenia in susceptible individuals, as can smoking. This is all thought to take place via epigenetics and the placenta. More research is needed.
A new study indicates what we have often observed; that those women who introduce a bottle in the hospital are much more likely to give up breastfeeding. Breastfeeding is recommended as the sole food source for babies for six months.
The Nurses Health Study has produced data about nutrition and healing loss. Turns out those who had a diet most closely resembling a Mediterranean or DASH (Dietary Approaches to Stop Hypertension) diet were 30% less likely to experience moderate or severe hearing loss later in life.
You will hear all kinds of unscientific reasons from patients about why they will not get a certain vaccine. We all know vaccines stimulate the immune systems and we all know they can make you feel a bit flu like in the process- no fun. New research has now proven that HPV ( human papilloma virus) vaccine does not cause increased autoimmune activity in girls. This confirms two prior large cohort studies. Despite all this, there is still a lot of push back against vaccines. It is hard for a caregiver to persist when a patient or a parent declines a needed vaccine. However new research indicates that physician persistent leads to 94% of children being vaccinated against HPV.
Many times I hear talk to the affect that obesity alone is not a problem. There must be other factors such as diabetes or hypertension for obesity to be a threat to health. FALSE.. Newer date now tells us that having obesity ALONE makes you 39% more likely to have heart disease.
We have been finding a lot of vitamin deficiency up here in the North Country. This has been true in pregnancy. We have undertaken supplementation regimens with the input of Endocrinology and are tailoring better maintenance regimens for both diet and supplements. New research has now show some good news : that those who take vitamin D in pregnancy are 28 % less likely to have low birth weight babies or stillbirth.
In other vitamin D related news, new research also indicated that women with sufficient levels of vitamin D are 10% more like to get pregnant after a miscarriage, and 15% more likely to have a live birth after a miscarriage.
Folic acid is also important in pregnancy and is known to prevent birth defects such as spina bifida. New research indicates that poorer women rarely takeout before it during pregnancy. This is something that should have a really easy fix.
The “Global Gag Rule” is a rule which prohibits international health care organizations from counseling about abortion lest they lose their aid money from the USA. More recently Title X funds are being withheld from groups in the US who perform abortion or mention it as a choice. Many feel this amounts to a domestic gag rule. However, the Trump administration is back peddling, saying it only relieves Title X recipient caregivers of the requirement to mention abortion as an option. These are two very different things. I wonder which is really the case. I wonder too, if this means the Title X grant givers will requests the medical records documenting patients' visits to see what caregivers and patients are discussing. ACOG (American College of Obstetricians and Gynecologists) has called this an “egregious intrusion” in the doctor patient relationship. Analysts point out that, additionally, these new rules will give those “health clinics" which oppose abortion and birth control easier access to Title X funds.
The Chair of ACOG New York has produced a guide to the Gyn annual exam for the New York Times. In it, she has explained what to expect, including the holistic nature of the visit. Many people think of the annual Gyn exam as just a pap. However, it is wellness and preventive check that addresses the overall health of the patient. Pelvic exams are performed as indicated according to protocol. Patients are also reminded about what should not take place, such as more touching than is necessary. Patients are reassured that they are entitled to an explanation for everything that is done.
Texas is starting to take the bull by the horns. Maternal mortality and morbidity in Texas has been egregious. Authorities are now honing in on the contributing factors, and devising strategies to address it. The Texas Medical association has drawn up a list of recommendations including statewide legislation to improve health care coverage for pregnancy women, to increase access to long acting reversible contraceptives (LARCS), and to increase the quality of record keeping on maternal complications.
Tobacco smoke from a pregnant women damages the unborn baby’s lungs (among other things). New research indicates that vitamin C may mitigate this risk. The changes from smoking do not simply harm the baby in that time frame. In utero exposure to those chemicals induce changes in the baby's genes (epigenetic change) which may persist throughout life.
SIDS (Sudden Infant Death Syndrome) has been a worry for some time. I remember when it was first defined. At that time, we had no clue about its cause. It remains incompletely understood. However we now understand that the odds of it are greatly reduced when the parents do not smoke, and also when the baby sleeps on their back. This knowledge has given rise to the “Back to Sleep” movement which promotes putting babies to sleep on their back. We have also since learn that avoidance of loose bedding and avoidance of co-sleeping is protective. This means newborns must not sleep in the same bed with parents, despite what may seem like convenience. Nonetheless, NPR has recently reported on the disconcerting trend of increasing co-sleeping. AAP the American Academy of Pediatrics has come out again against co-sleeping which iss highly the associated with an increased risk of sleep related deaths in babies under 4 months of age.
The Institute of Clinical and Relational Science at UCSF (University of California San Francisco) has produced research indicating yoga may help incontinence and anxiety in older women. Findings were presented at the American Urological Association in San Francisco.
Marijuana in pregnancy is again in the news, with yet more reports coming out about its disruption of fetal brain development. It is also linked to smaller birth weights and irritable behavior in infants. It is also linked to higher likelihood of still birth. And yet, 70% of Colorado dispensaries are recommending marijuana to pregnant women for nausea in pregnancy. Conflict of interest and flagrant irresponsibility, much ?
Lung cancer in young women has now surpassed that in men. Lung cancer in men and women has decreased over the last two decades, however it is decreasing more rapidly in men.
There is now good data that air pollution is related to infertility and preterm birth. A new study on the subject shows that the closure of oil and coal plants boosts fertility in nearby communities.
There’s an app for that. Maybe. There are many apps pertaining to birth control. There may even be one that can help predict the risk of preeclampsia. However, before you go relying on one of these, Please check with your doctor about the validity of such an app. Quality varies, so buyer beware.
We will start off with novel and beneficial new research. A think tank called “Center for American Progress” has released an analysis of the current state of "sex ed” in America. They found the states to be, as a whole, 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 heartbeat 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 planning 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 health 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 postpartum 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 the 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 healthcare 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 postpartum 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 percentage statistics and trends on maternal morbidity and mortality. However, I have rarely included raw numbers. Here they are. 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. It is called 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 in pregnancy 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 to be checked.
BRCA genes are not the only genes pertaining to breast cancer. Newer multi-gene testing panels are now available for selected patients. Ask your doctor to speak with a geneticist if you are uncertain.
Common sexually transmitted diseases are on the rise in California. 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. The 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 my patient's health habits and healthcare are sustainable. I am concerned that she have the means to grow her family or finish her family'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, or 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 a 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.
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.
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.
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.
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.
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.
Gentle readers, Medical Monday is postponed. There's just too much going on. See you soon.
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.
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 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 ?
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.”
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.
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.
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.
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.
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.
Happy Easter and Happy Passover. We have two weeks to cover. Thanks for reading !
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 ?
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 !
Happy Spring ! Today we rode, but tonight I m awaiting for a delivery. Medical Monday will be delayed a bit. Check back soon.
I thought you might like this photo of Phantom and me, who needs work but has a good attitude.
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.
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.