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

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Now here is something we haven't seen in a long time. Four days ago on Thursday Congress practiced bipartisanship. With the news the abrupt cessation of insurance subsidy payments by the federal government, those all over the healthcare sector were scrambling. Lawmakers had to cooperate against Trump’s decision or risk chaos. Senators Lamar Alexander, Republican from Tennessee and Patty Murray, a Democrat from Washington state have announced that they have a viable bill. This bill to reinstate subsidy payments has 12 sponsors divided evenly between Republicans and Democrats. These Congressmen are promoting a bill to resume federal subsidies to insurers that Trump has blocked. The Senate Majority Leader Chuck Schumer has confirmed that all 48 Senators would vote for the bill. They number 48 which, when combined with 12 sponsoring Senators who are already known to support the bill, would give 60 votes at least, enough to defeat a filibuster.

Good thing lawmakers have decided to try to cobble together a solution to this problem. It turns out that several powerful states have banded together to sue the Trump administration over the decision to end ACA subsidy payments. Lead by the attorneys general of both California and New York the states include California, Connecticut, Delaware, Kentucky, Illinois, Iowa, Maryland, Massachusetts, Minnesota, New Mexico, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, Vermont, Virginia and Washington state. Additionally, the healthcare industry and the insurance industry have roundly condemned the interruption of subsidy payments, stating that this move will cost US economic and health harm.

 A group of medical associations, the so-called"Group of six”, the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Physicians, the American Congress of Obstetricians and Gynecologists, the American Osteopathic Association, and the American Psychiatric Association, has made a joint statement “ Our organizations strongly reject a marketplace that allows insurers to discriminate against any individual based on their health status age or gender allowing insurers to sell narrow, low cost health plans likely will cause significant economic harm to women and older sicker Americans who stand to face higher cost and fewer insurance options."

Concerns have already been raised that restoring subsidies paid from the federal government to insurance companies would benefit it insurers more than consumers. The authors of the bipartisan bill, Alexander and Laurie, and explicitly addressed concerns that"Restoring the payments to insurers could be viewed as… a bailout”. They indicated that the agreement would contain"The strongest possible language" to insure that the money provided for the subsidies would go to the benefit of consumers, not insurers. It is unclear at this time whether or not this bill, once enacted, would prevent some or all of the large rate hike that all of us can expect in our premiums this next year.

The fine details of women's reproductive health care are very much on the table in this political climate. As you are no doubt aware Trump has weakened the Affordable Care Act’s contraceptive mandate. Last week he created a loophole which will allow employers to stop providing birth control coverage in their corporate insurance plans if they have religious objections. This week the bill has been introduced to reverse this exception. The bill is called"Protect Access to Birth Control Act”. Unfortunately it does not yet have the bipartisan support that it needs. 

A Denver school teacher, Jessica Campbell, has filed a federal lawsuit against the Trump administration for it's modification of the contraceptive mandate in the Affordable Care Act. The suit names the President and his Secretaries of Health and Human Services, Labor and the Treasury.The suit states that the exceptions “jeopardize women's health and economic success in order to promote certain religious and moral views by attempting to nullify the right equal access to preventive medical care, particularly contraceptive care and services, protected by the US Constitution set forth by Congress in the Women's Health Amendment to the affordable care act.” The suit seeks to prohibit enforcement enforcement of the changes. 

The Omaha World Herald, has surveyed several large Nebraska and Iowa employers. They presented their informal findings in a recent article which explains that according to their survey, most Nebraska and Iowa employers will continue to offer insurance plans with contraceptive coverage.

IUDs (Intrauterine devices)are one of the best and one of the most expensive contraceptive methods. This is because they're extremely effective with very low failure and complication rates. It is also because they are able to be used by women who cannot tolerate hormones. Although the most popular IUDs contain hormones they contain only enough to treat the lining of the uterus and they do not produce systemic effects outside of the uterus. The their side effect rate is low. Some experts worry that because this method is particularly costly i.e. somewhere upwards of $1000, Women may lose effective access to it. 

Dr. Haywood Brown, President of the American Congress of Obstetricians and Gynecologists has written an opinion piece indicating that he is opposed to the Trump administration’s ”…regulation that will threaten contraceptive access for women everywhere, particularly in underserved rural communities”. He argued that access to contraception” amounts to more than just dollars and cents. It can be life saving for women who already faced serious medical conditions such as heart disease, diabetes and high blood pressure."

Access to all forms of reproductive health care have been compromised in various ways under the Trump administration. An important methodology utilized by the Trump administration has been the political appointment of many antiabortion and anti-contraception activists to government positions despite lack of qualifications. It is ironic and disturbing that the restrictions placed on contraception, a benign medical treatment, will lead to a certain increased rate of abortion.

On to the medical news. 

In the good news department, vaginal estrogen is safe for all postmenopausal women. This includes women who have had a hysterectomy, women who still have an intact uterus, women with history of cancer, those with cardiovascular disease, only those with thromboembolic history such as a deep vein thrombosis for a pulmonary embolism. The results of this study presented recently at the annual meeting of the North American Menopause Society also fall under the category of the we-already-knew-this department. This is because we have always known that estrogens given vaginally do not get into the systemic circulation, this research finding is worth reiterating because indicates that no post menopausal woman need suffer with a painful atrophic vagina.

Also in postmenopausal news, and in the we-already-new-this department, a new study confirms that oral estradiol and progesterone may improve menopause related quality of life. While this type of therapy reduces hot flashes and mood instability related to menopause, but it's use is constrained particularly in those who still have a uterus. This is because the administration of the combination of both estrogen and progesterone may only be given for about five years or the shortest amount of time at the lowest effective dose. After five years or so concerns begins to mount for increasing risk of breast cancer and cardiovascular disease.

There is an increasing number of women in South Carolina who are giving birth without any prenatal care whatsoever. It has been long established that lack of prenatal care is a contributor to for birth outcomes.

Tanning addiction is real, and it increases risk of skin cancer. A new study published online any October 11 edition of Cancer, Epidemiology, Biomarkers and Prevention, Young white women with a history of depression were found become prone to tanning addiction. Indeed, over 20% of young white women who have frequented at tanning salon do become addicted to tanning. The study noted that these young women "depend on tending to feel attractive often show symptoms of depression.”

Oral HPV and the disease that it produces are increasing. HPV stands for human papilloma virus and it is the virus responsible for general warts, cervical cancer and cancer of the mouth and throat. Girls and boys between the ages of 926 should be completely vaccinated against the virus. The vaccine remains underutilized and many do not realize it must be given to males as well as females. I'm going data on the vaccine continue to confirm its safety.

At the present 7% of women with breast cancer are younger than 40 years of age. It Is noteworthy that this percent has been increasing since the mid-1990s. With all the debate about mammogram testing frequency and age at first mammogram, I wonder how we can be expected to screen for these cases among young women. At present, the debate is between whether to start mammograms at age 40 or age 50. With increasing cases in women under 40 this provides a good argument for the breast self exam and also to tailor mammogram screening to risk factors.

In related news, the percentage of women who opt for breast reconstruction surgery right after mastectomy for cancer is increasing rapidly. Over the past five years the proportion of breast cancer patients opting for reconstruction grew by about two thirds. In 2009 only about a quarter of women opted for reconstruction whereas more recently in 2014 and 14 the number rose to 40%.

Obstetric history stays important long after your last baby is born. Preeclampsia may indicate a tendency towards high blood pressure later in life. Similarly, pregnancy associated or gestational diabetes can signal a risk for diabetes and even heart disease later in life. Recent study published online in JAMA internal medicine has shown that patients with a history of gestational diabetes can mitigate their risk for cardiovascular disease by healthy lifestyle. In particular, gestational diabetes was not significantly associated with cardiovascular disease risk elevation among women he maintained a healthy diet, were physically active, never smoked, and maintained normal weight. 

A rather fascinating new bit of research indicates that lack of sleep could raise a pregnant woman's risk for gestational diabetes. In particular, women he slept less than 6.25 hours and I were almost 3 times likely this study tells us nothing about which where the causes and which were the effects. Still it is an interesting relationship and one which deserves more scrutiny perhaps even outside of pregnancy.

The CDC(Centers for Disease Control) has released a new data indicating that obesity rates among US adults is steadily increasing with the current rate of about 40%. This is not near overweight where the body mass index is between 25 and 30. This is obesity, with body mass indices in excess of 30. Approximately 30% of people where obis in the year 2000 15+ years later that is increased by 10% to 40% of all people. Of course there's significant state-by-state variation but the numbers are formidable across the board. For every state where the percentage is lower than that there is a state whose percentage is higher. Obesity sits with mental health and addiction as the three topmost priorities the Department of Health Services.

These days, when a patient asks to have her tubes tied, we may suggest that she have her tubes altogether removed. This is because of the relatively new Revelation that many if not most of all ovarian cancers actually come from the tubes. Thus we can get some theoretical and hopefully real cancer reduction by removing the temps instead of merely tying them for cutting them. This interesting conclusion about the origins of "ovarian" cancer have come from the nascent field of molecular genomics.


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