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

POLICY NEWS 

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

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

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

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

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

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

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

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

MEDICAL NEWS

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

Medical Monday: Delayed Edition

POLICY NEWS 

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

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

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

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

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

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

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

 

MEDICAL NEWS 

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

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

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

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

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

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

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

 

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

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

MEDICAL POLICY NEWS 

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

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

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

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

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

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

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

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

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

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

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

 

MEDICAL NEWS 

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

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

POLICY NEWS :

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

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

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

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

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

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

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

 

MEDICAL NEWS: 

 

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

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

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

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

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

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

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

 

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

Policy

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

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

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

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

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

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

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

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

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

 

Medicine

 

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

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

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

 

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

 

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

 

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

 

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

 

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

 

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

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

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

Policy

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

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

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

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

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

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

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

Medical News

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

Medical Monday: The Women's March Where I Live

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

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

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

Policy News 

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The Trump Administration will continue to use a bundled payment model for Medicare recipients. This means that the government will pay a certain lump some to cover all the inpatient and procedure related medical care given to Medicare patient rendered in a 90 day period of time. If the healthcare providers use less than that amount of money they can receive a bonus. This strikes me as a terribly perverse incentive. Hospitals and caregivers have every incentive to skimp on care so they can pocket the bonus. What if the amount of money allocated is not enough for all the care the patient needs within the 90 days? It is interesting to note that this bundled payment strategy was created under Obamacare (The Affordable Care Act or the ACA) and has been reincarnated in almost exactly the same form under the Trump administration.

Several women’s health organizations including the American College of Obstetricians and Gynecologists (ACOG), have instituted a program called"The Care Women Deserve”. Under this program, there will be an effort to educate all women regarding the health services to which, under the ACA which is current law, they are entitled, at little or no cost. Examples of these services include well woman visits, also known as annual exams, Pap smears, contraception, also known as birth control, HIV screening, mammograms and breast-feeding support. Not all women know that they are entitled to all these services.

The Trump administration has long tried to weaken the contraceptive mandate, the part of the Affordable Care Act which requires insurance companies to cover contraception without co-pay. They have received many legal challenges to these attempts. The Trump administration has paid out over 3 million dollars of taxpayer money to to settle these lawsuits.

For the first time in Medicaid's 50 year history certain states will be allowed to interpose work requirements on certain able bodied adult recipients. The National Health Law Center is preparing to challenge this in court.

Washington DC’s only pubic hospital has been closed due to quality concerns. 

The Wall Street Journal is reporting that the GOP is scaling back plans to reform the ACA and social security type programs. They are focusing on basic problems like funding the government. They are even talking about increasing the debt limit and reaching a compromise on immigration. Since when has the GOP been interested in increasing the debt limit ? 

 

Medical News 

Studies 

  • Once again our own immune system is at the heart of a disease process. Evidence from a mice model suggests that the damage caused from Zika virus infection is actually from the mother’s immune response against the virus in the baby. This was published in Science Immunology. 
  • A large retrospective study has indicated that pregnant women who take methylphenidate for ADHD have a higher likelihood of having a baby with a heart defect. 
  •  A new study published in the Journal Birth looks again at Texas maternal mortality rates. Between 2011 and 2015, there has been an 87% spoke in maternal mortality. The worst has been in mothers over, 40 with that group having a mortality rate 27 times that of women under 40. This is felt to be related to increasing rates on chronic and under treated disease including obesity, lack of insurance and lack of health care. 
  • A 172 woman study published in Menopause made the we-already-knew-this-department. They have shown that one year of postmenopausal hormone therapy prevented depressive symptoms more effectively than placebo. Postmenopausal hormone therapy is FDA approved for hot flashes and vaginal dryness, but not for mood disturbance. Maybe it should be. 
  • The Journal of Asthma has published a study linking prenatal exposure to PCBs ( polychlorinated biphenyls) to asthma and upper respiratory infections and eczema in children. 
  • A new study has indicated that women who work night shifts have a (gasp) 19% higher chance of getting cancer than those who do not work at night. This meta-analysis has shown that the risk is proportional to time worked at night, and that the risks  go up differently for different cancers. The most surprising is skin cancer with a 41% increase in risk. Next is a 32% increase in breast cancer, and an 18% increased risk in digestive cancers. Yikes ! I hope the exact reasons for this get figured out and dealt with ! 

We have a new department ! It is called the stupid and irresponsible department. Our inaugural feature is devoted to the TV show Black Mirror, whose writers decided to depict emergency contraction, aka “ Plan B” or “ the morning after pill” quite incorrectly. In particular, they portrayed a teen who took it as having nausea, which is not typical. A nurse in the show informs her she had taken it “ to terminate a pregnancy”. Basically the show confused the morning after pill with the abortion pill. The morning after pill is progesterone only, thus should not cause nausea. Plan B does not cause abortion of an established pregnancy. It prevents pregnancy. Thanks so much, TV,  thanks. 

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

 

Medical Monday: Belated Bullet Version

Policy News 

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In the name of choice, the Trump administration is proposing new rules to allow small businesses to circumvent the stipulations of the ACA and create cheap/incomplete heath insurance plans exempt from covering various "essential benefits” like: 

 

  • mental health care 
  • emergency services 
  • maternity care 
  • newborn care 
  • prescription drugs

 

How is this even classifiable as insurance ? How many will be duped into buying this ? It will be just like the old days and those that cannot afford to pay for what their insurance does not cover will leave the rest of us and the medical system to foot the bill. Their cheap incomplete insurance will put little into the collective pot, cover little, and leave much unpaid. 

 

Deja vu: 

 

To repair or replace the ACA ( Affordable Care Act), that is the question. That is the question the GOP is asking itself. And it was the same exact question this time last year. GOP moderates say repair, GOP conservatives say replace. Nobody can say what to replace it with.  

 

Forget about the ACA ? Here's FAQs:

 

  • Requires every consumer to hold health insurance of some kind or face penalty fee. (The Individual mandate) 
  • The Fed supplies subsidies to insurance companies to enable them to charge consumers lower premiums and to provide comprehensive coverage. 
  • There are no lifetime limits on health insurance benefits. 
  • Essential health benefits ( see above) must be covered by all new plans. 
  • Contraception should be covered through the “ contraceptive mandate”. 
  • A consumer cannot be dropped by health insurance except through committing fraud. 
  • Covers preventive services and immunizations. 
  • Covers dependents until 26. 
  • Creates a cap on insurance company administrative expenditures. 

 

The law had many more provisions but these are arguably the main ones of consumer interest. 

 

Since the Trump administration came to power, the following have been rescinded, weakened, or questioned : 

  • The individual mandate
  • Federal subsidies 
  • The contraceptive mandate 
  • Essential services 

 

Now that the holidays are over, Congress must find a way to save CHIP, the Children’s Health Insurance Program. Prior to Christmas, Republicans stole from Peter ( preventive health care under the ACA) to pay Paul (CHIP). That stopgap fund will run out in another couple months. 

 

Medical News 

 

First in the no-surprises department: 

 

  • Smoking during pregnancy is associated with increased rates of ADHD. 
  • Puerto Rico is facing an ongoing public health crisis without power, water and food. 
  • Influenza is widespread in the US, especially the South. 
  • Pregnant women in polluted areas have higher risks of birth defects. 
  • Pregnancy weight continue to rise in the US, and with them pregnancy complications. 
  • Maternal mortality is increased yet again in Texas. 

 

Good News Department: 

 

  • A brand new programs on reducing Maternal Mortality, the Alliance for Innovation in Maternal Health, has already reduced maternal death rates in four states by 20%. 
  • Estrogen cream may go generic soon, thereby reducing the very high cost of comfort. 
  • Prescription of multivitamins and/or folic acid during prenatal care is associated with lower risk of autism in offspring. This was a 12 year study on over 40,000 children .
  • The cancer death rate in the US has declined 1.7% just since 2015. Could this be related to the affordability of cancer screening covered through Obamacare ? 

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

  

 

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

Happy new year ! Hopefully this year we will benefit from the upheaval of 2017. Many of us became more political. The issues about which we care came into distinct focus. Perhaps we clarified our priorities. Hopefully health and quality time are high on your list. 

In that spirit, I am going to try to streamline what I hope has already been a streamlined blogging format, and go to what could perhaps be called “ bullet blogging”. Perhaps you have heard of “ bullet Journalling”  or “dot journalling”? I had been doing it for some time without realizing it. Instead of journaling in full sentences and paragraphs, I journal in bullet lists, small graphics and graphs. It is fun, fast, and lets me indulge my visual nature. 

If you have been into any Michaels, Joannes or any other craft store lately, you may have seen prominent displays showing fancy little bound or three ring journals, sticker sets, small format markers, washi tape, and specialized fill pages - all for such enhanced journaling. There are also many cool online resources for bullet journalling. 

I am an incredibly digital oriented person, and so it may seem a surprise that I would be interested in such analog things. I believe that for every person’s life or work management system, there is a particular optimal balance between digital and analog. Everyone one needs a little paper. In my office, I have suggested that my employees keep “ one notebook to rule them all”. Instead of a proliferation of sticky notes and other scraps to get mangled or lost, the one notebook, complete with dates and legible writing, held everything. I gave them some beautiful starter notebooks, and they took it from there. They seem to enjoy it. One co-worker in particular has made hers into what I would call an art form. That is the idea ! It is to take some joy and satisfaction in even the smallest things, like note taking and scratch calculations at work.

And so it has occurred to me to try “ bullet blogging”. It is my hope it will be faster, simpler and easier on the eyes. I’m going to give it a go. 

Policy News 

Via CMS( Center for Medicaid Services) : 

  • 8.7 million signed up for Obamacare, federal health insurance made possible by the Affordable Care Act, likely underestimated 
  • 95% of last years level, despite half the signup period and deep cuts to advertising
  • Final figures due out in March

 

CAN YOU BELIEVE THIS ? 

Employees of the CDC ( Centers for Disease Control) and other federally funded health and science organizations were “discouraged" from using seven words in budget reports: 

  • Vulnerable

  • Entitlement

  • Diversity

  • Transgender

  • Fetus

  • Evidence-based

  • Science-based

#RESIST 

Two separate letters have been issued from > 300 public health organizations urging the HHS ( Health and Human services) to ignore this. The second letter included signatures from

ACOG ( American College of Obstetricians and Gynecologists)

AAP (American Association of Pediatrics) 

APHA ( American Public Health Association) 

 

Blocking the blockers 

  • Last week  Federal Judge in Northern CA blocked the Trump administration’s loophole which let’s objecting employers out of providing insurance with contraception to employees. 
  • The Justice Department is “ evaluating” LOL. 
  • Comment: No one ever has, because of Obamacare, made anyone else use contraception. 
  • Fact: Contraception reduces teen pregnancy and abortion. ALOT. 

 

Kick the can

GOP has kicked the real budget and real health care bill into January. Stay tuned. 

 

Medical News

 

ACOG President-Elect Lisa Hollier, MD MPH, Houston, Texas, brings a new clear focus: the rising maternal mortality in America. 

  • Missouri ranks high is maternal mortality, in the worst ten. 
  • Oregon is creating a special commission on rising maternal mortality.
  • One in four pregnancies in central Oregon are drug affected. 
  • Mississippi has the highest rate of preterm birth, which is high cost in both human and financial terms. The CEO of Magnolia Health in Mississippi is taking aim at this problem. 
  • Infant mortality in Kansas is about three times higher for black babies than it is for all babies. 
  • Dr. Hollier's own state of Texas takes the cake, with the highest maternal mortality this side of the third world. 

 

STUDIES: 

 

Study: Breast pain is not a symptoms of breast cancer. Neither lack of pain nor lack or palpable lumps means lack of breast cancer. Upshot: Get your mammograms ! 

Study: Cervical Pessary may be of use in preventing preterm birth. 

Study: at home STI ( sexually transmitted infection) test kits may increase detection rates. 

Study: Post menopausal Estrogen therapy may protect against some forms of memory loss. 

Study: Income and weight are inversely related for women. This is not true for men. Contemplate. 

FDA (The Food and Drug Administration) plans to increase regulation of homeopathic remedies. Because there are no real studies on these. Contemplate. 

Marijuana update 

  • Mj use in pregnancy has increased in CA from 4 to 7%. In pregnant teens it has increased from 10 to 19%. 
  • ACOG recommends discontinuation of MJ for those who are or who are contemplating pregnancy. For reasons, see HERE: Marijuana Use During Pregnancy and Lactation 
  • It's clear that we as a nation do not value science. Do we value drug induced relaxation over clear thinking or the cognitive development of our children ? Very little contemplation needed. 

Male Contraceptives ? 

NIH ( National Institute of Health) and the Population Council are sponsoring a clinical trial of a hormonal male contraceptive gel. Don’t expect it on the shelves for at least 5 years. I wonder how the GOP will attempt to regulate male methods of contraception. 

It’s best if you follow up on these leads to put together your view of women’s health care in this country. What I have given you should contain enough key words so you can google your way to the source material. Remember to seek out reputable sources like the NIH, the CDC, ACOG, AAP, APHA, or major academic medical centers like Mayo Clinic or Stanford.

2018 is a new year, and a new approach is needed to ensure the best for women’s health care. Get involved. 

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

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How stable are the ACA Affordable Care Act, aka Obamacare)  insurance plans? That remains to be seen. At present there is a bipartisan effort to shore up the so called ACA “marketplaces” . This means that certain lawmakers are trying to find a way to create a realistic budget to fund them. The Affordable Care Act was affordable since the Federal government supplied money to insurance companies to subsidize or pay for part of people’s premiums. 

 

Let’s roll back a second. Let’s make sure all this terminology is clear. 

 

Bipartisan= involving both Democrats and Republicans 

Marketplace = the system of insurance companies from which consumers buy health insurance 

Premium= the monthly amount consumers have to pay the insurance company to have insurance and to ensure that their insurance is in force 

Subsidies, aka insurance subsidies = payments from the Fed ( your tax dollars) to the insurance companies to defray (reduce) what consumers pay for their premiums. 

 

Republican concerns at the beginning of the administration change:

  1. Obamacare cost the Fed too much and made taxes too high (via the payment of subsidies to insurance companies) 
  2. Obamacare funded programs that powerful special interest groups opposed, i.e. birth control (via the Contraceptive Mandate) 
  3. Obamacare took away the choice of not having to get health insurance at all. ( Via the Individual Mandate) In other words, Obamacare law via the Individual Mandate required everyone to hold health insurance. 

 

Democrat concerns at the beginning of the administration change:

  1. Obamacare was not adequately funded and could run out of money if not addressed.
  2. Obamacare needed to continue to fund birth control as a human right and for the social and fiscal improvements it confers, ie. increased education, job productivity, individual savings, better health, fewer teen and unplanned pregnancies, fewer abortions. 
  3. Obamacare needed to continue to fund preventive care and cancer screening since in the long run it prevents serious disease and saves money 
  4. Obamacare need to continue to retain the Individual Mandate since
  • Each person is obligated to contribute to the insurance fund to make it stronger for everyone. The American Academy of Actuaries has gone on record saying that repeal of the Individual Mandate “... would lead to premium increases” and reduce the "incentive for healthy people to enroll and balance out the costs of the sick.”
  • Each person is responsible for covering their own care even if their health takes a downward and expensive turn, and they can only realistically cover it with insurance.
  • Persons who do not hold insurance and who end up getting emergency or unanticipated health care get care whether they can pay for it or not, and their bill is absorbed by everyone else. They are cheating the system. 
  • The ethic of the greater good should inform the Individual Mandate since health coverage enables health care and health care enables broad social benefits of all kinds. 

The deadline to enroll for Obamacare this year has passed. The site for enrollment, healthcare.gov, was getting crushed right through until the end, and at one point, customers were instructed to simply leave contact information with the expectation of a call back. Many did not know the time frame for enrollment since the Trump administration cut funds for promotion of the program by 50%. Numbers on enrollment are not yet in. 

There is bad news and good news for CHIP, the children’s health insurance program. The bad new is that it will run out of money by the end of January. The good news is that there seems to be broad bipartisan support for refunding it. A bipartisan group of Governors has also come forwards and requested that the government renew finding for CHIP. The question is, what with all that lawmakers have left undone, and still need to do, will they get to it in time ? Remember, the Federal Government only has a budget through December 22nd, which is fast approaching. 

In medical news, we find a convergence of holistic medicine and technology. A new study published in the American Journal of Obstetrics and Gynecology uses app-guided acupressure to relieve menstrual cramps. The results compared this technique with medical therapy of oral contraceptive pills or typical analgesics and the results were significant. 

Sugar and inflammation. I do not know the exact relationship. Let’s talk about excessive sugar. In particular, a new study reveals that pregnant women who consume excess sugar in pregnancy are statistically more likely to bear babies who have asthma later in life. Asthma is an condition of the airways and is believed to be mediated by inflammation. Excess sugar in pregnancy is associated with many more problems, like excess weight gain, and gestational diabetes. 

It is well know that pregnant poorly controlled diabetics have increase risks of serious malformations including spina bifida and congenital heart defects.  In new research, pregnant women with high glucose levels in early pregnancy - even those who are not diabetic, are more likely to have babies with heart defects. The relationship is linear. 

Got your flu virus yet ? I hope so. There are TWICE as many cases of flu this year compared to last. Bottom line: the flu shot is safe and effective in and out of pregnancy. Talk to your doctor. It is particularly risky to skip it in pregnancy since influenza is much more dangerous in pregnant women. 

There is some expected fall out after last weeks publication about a small increase in breast cancer risk with long use of oral birth control pills. Authorities are hastening to point out that while this finding about breast cancer risk was noted, it has also been confirmed that oral birth control pills decrease the risk of uterus, ovary and colon cancer, stabilize bone density and obviously, prevent pregnancy and all of its potential complications. Risks need to be weighed with benefits. 

Stay tuned for more breaking news from the world of Obstetrics and Gynecology on the next episode of Medical Monday. I will have to decide what to do for Christmas week, most likely depending on the news at hand. Let's hope the researchers take a nice break for the holidays. The politicians, well, they can just keep working right on through as far as I am concerned. 

Happy Holidays. 

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

The big policy news this week is that we still have a government. Yes, Congress passed a stopgap measure to avert a government shutdown, but that will not even get us to Christmas. At issue is spending. By now you know that the budget of the nation is greatly influenced by the tax structure and also on major expenditures like health care.  Major expenditures that must be resolved to attain a budget including the funding of ACA subsidies and thus stabilization of the ACA insurance market places. There is also a lot of pressure for CHIP or the children’s health program to be refunded. People across the board are NOT happy about that program being in jeopardy. Now if we can just show people that the health of women and the health of children are deeply intertwined, we will be even better off. 

Did you know that health care spending is not first nor even second on the list of big Federal expenditures? It is third. I am lifting a great infographic from pewresearch.org and giving you the link to encourage you to read the whole article.

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http://www.pewresearch.org/fact-tank/2017/04/04/what-does-the-federal-government-spend-your-tax-dollars-on-social-insurance-programs-mostly/

Now that you know the proportions, how about some actual dollar amounts ? 

Health care spending reached it’s new max in the end of 2016 at $3.3 trillion dollars. It increased in 2016, but not as much as it increased the prior year in 2015. The share of the economy devoted to health care went up to 17.9% representing a gradual increase. This grew slightly faster than GDP ( gross domestic product). Expenditure on heath insurance grew to about $2500 per year, while OOP ( out of pockets) grew to about $350 bucks per person per year. 

Is this amount of spending good or bad ? Is it appropriate to spend this percent of income on health? My health means a great deal to me. If you compare countries with health care that is equal to or better than ours, you will find they spend much less personally but generally pay considerably more in taxes. Their taxes are larger,  but the distribution of good health care in their countries is wider. Their higher taxes buys them less income and health disparity as a a country, broader prosperity and better social stability. Do you think that is worth it ? 

You may have noticed from the infographic that number one and two on the list of federal expenditures are Social security at 24% and Medicare at 15%. Do you feel like health care has taken all the budget scrutiny heat ? These other programs may now be in jeopardy too. After the immediate legislative sessions, the GOP is looking at cutting other parts of the social security “ safety net” which old folks have been paying into all this while… Social Security and Medicare. How do you feel about that ? 

The States not the Fed are taking charge of key practical health care issues that need prompt attention. Instead of engaging in the philosophic, sociological or religious debates characteristic of Capitol Hill, they are taking care of business. For example, North Carolina has addressed its high risk pregnancy situation and has created a statewide initiative to identify and give special care to high risk pregnancies. They are doing this through multidisciplinary “ medical homes” where advanced Obstetrical care can be rendered. The District of Columbia has voted unanimously to mandate that insurers offer contraception, breast cancer screening, STI counseling, without raising copays or deductibles. As previously reported, other states such as Massachusetts have protected contraception. 

In medical news, we have a great new data gathering resource, Pregsource. The NIH (National Institute of Health) has partnered with ACOG ( American College of Obstetricians and Gynecologists) to gather a wide variety of data from pregnant women. Research on pregnant women is hard to design and fund, since there are concerns about the fetus. But we need usable information on pregnant women just as much as on other people, and so there needs to be an acceptable way to move forward. The idea of including pregnant women in drug studies is rapidly becoming a hot topic, since to date they have mostly been excluded. But this is often without medical reason, and both caregivers and patients are starting to raise the alarm. 

 

Here is Pregsource: 

 

https://pregsource.nih.gov

 

If you are pregnant, there is no reason not to join. Tell your caregiver so they can make their other patients aware. This is a fantastic example of citizen science in action. It is also a relatively low cost way to assemble a much needed research base of data on pregnant women. 

In the mostly good news department, Sanofi has devoted what appears to be an effective Zika virus vaccine, It has shown good immunogenicity, and a 90% response. However it has been tabled due to “political pressure over pricing”. I think this is promising since it shows that such vaccines are possible. Apparently there are other similar vaccines in the works. I can’t help but connect the dots between the high drug prices we pay and the amazing things that drug companies are able to do with that money. 

Ob/Gyns are becoming a dying breed. I can certainly understand why, what with coverage challenges, political upheaval and malpractice threats. Apparently a new study has shown that 50% of US counties lack an Obstetrician Gynecologist. Just so you know, high risk cases in either Gyn or OB can scarcely be handled by any other types of doctors, except for perhaps general surgeons, and they are generally overburdened to begin with. The number of Ob/Gyns is due to diminish further with a shortage of nearly 8000 by 2020 two years from now. 

A new study on oral contraceptive pills is apt to be misconstrued by the media. It is a large Danish study which has shown a slight increased risk of breast cancer with oral contraceptive pill use of at least a year. They hastened to add the the overall all risk was low, and that it was considered safe. However a twenty percent increased risk on top of a very small number is still a very small number. This is the thing I think the press will miss. I hope the press does not fail to point out the very real DECREASE in risk of ovary, uterus and colon cancer that happens at the same time with oral contraceptive pills. And oh, by the way these prevent pregnancy the vast majority of the time, and pregnancy carries its own risks which are not inconsiderable. 

In sobering news, research out of the CDC (Centers for Disease Control) has shown that black women in dies in childbirth 3-4 times as often as white women. This circumstance of childbirth highlights the worst case of health related racial disparity that we in the US know. We in the US are on a Perinatal Mortality par with Mexico and Uzbekistan.

 If you ask me, now is not the time to be gutting the budget for women’s health. 

 

Stay tuned for more breaking news from the World of Obstetrics and Gynecology. 

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

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So by now all of your know that the Republican Tax bill passed. Most of you also know the tax bill is not just about taxes. With it’s passage, the Individual Mandate of Obamacare has been repealed. Therefore it is now no longer incumbent upon people to hold any health insurance. So, like an uninsured driver in a bad accident, someone else will foot the big bill when fit hits the shan. 

Those of us in medicine realize that in the short term this will save the Fed money. However in the medium and longer term, it will cost far more than was saved in both monetary, productivity and human terms. I only hope that this resultant data will be kept properly so that can see the true results of our lawmaking and course corrections in policy can be made accordingly. I am beginning to consider all such bills on taxes and health insurance as politically charged estimates, and how costs and benefits actually turn out are another matter. How costs and benefits are actually tallied and reported are yet a third concern, and I daresay I will view all reports with skepticism unless their methods are sources are clearly declared. Transparency in reckoning will be critical, and in this climate of alternative facts, something fundamental will have to change. 

The Congressional Budget Office estimates that premiums will go up about 10% for all policies through Obamacare simply because of the loss of the Individual Mandate. The CBO also estimates about 4 million people will either lose or forgo health insurance because of the change. 

The current administration is also trying to roll back in the Contraceptive Mandate. This is the part of Obamacare which requires all health insurance to provide coverage for birth control without copay. The Democratic States Attorneys General have banded together to prevent this from happening. Their argument is that the planned rollback of the Contraceptive Mandate "for employers to include birth control in their health insurance plans is an unconstitutional endorsement of religion” and "violates the constitutional separation of church and state and encourages illegal discrimination against women.” 

In science there is a phenomenon called a natural experiment. This occurs when happenstance set up a comparison between one set of circumstance and another, allowing a later comparison. For example, there have been instances of twins separated at birth and raised under different conditions. The resulting differences can then be studied. 

What if there were a modern country where birth control was not readily available ? What might that be like ? While considering that Venezuela and the United States are very different, one can still view the situation in Venezuela a cautionary tale. Venezuela is experiencing a shortage of birth control. Women are using the “ counting method” otherwise known as rhythm, and using unproven folk remedies. Venezuelan health officials are noting spikes in unplanned pregnancies, sexually transmitted diseases, and unsafe abortions. Data in the United States while the contraceptive mandate was in place show abortion has hit an all time low. 

In the nobody-saw-this-coming department, Ob/Gyn residency training programs in Wisconsin and perhaps across the nation might be at risk of de-accreditation. At present, the Accreditation Council for Graduate Medical Education requires that abortion training be part of residency in Obstetrics and Gynecology. Two Wisconsin state representatives have introduced legislation that would eliminate resident’s  ability to complete this training, thereby putting the program out of compliance with the accrediting body. As it is, a national shortage of Obstetricians and Gynecologists is looming; it is already the case in rural areas, and will be so everywhere if trends continue. 

CMS, the Center for Medicaid Services is floating a proposal to allow individual States to determine what constitutes “ essential benefits”. These are things which insurers MUST cover.  As of right now, under Obamacare, things like annual exams, cancer screening, like paps mammograms and colonoscopies, and prenatal care are covered. Medically necessary surgery is covered. Emergency room visits are covered. However, with this proposal, this might change, and it might vary widely between individual states. Health care providers are worried this will leave many necessities uncovered, and insurers are worried States will want to keep insurers providing benefits, which will cost them more money. 

The deadline to sign up for the ACA is December 15th. As of last week, about a million more people are signed up than at this time last year. That's what I call an endorsement. 

On to the Medical News. 

A new study has shown us something we have always suspected. We have known for some time that obesity is a risk factor for uterine, or more specifically endometrial cancer. (Endometrium is the lining of the uterus. ) The reality is even more stark. It turns out that fat cells drive the growth of endometrial cancer cells. In particular, a protein produced by fat cells “tells” endometrial cels to proliferate. It’s one more powerful reason to make sure your weight is optimized

In the we-already-knew-this department, robotic assisted laparoscopic hysterectomy is looking good. In particular, a recently published study compared robot hysterectomies with “open”  hysterectomies, meaning the ones using a large incision similar to the incision used for Cesarean Sections. Guess what ? The robot cases with the tiny incisions, precise instrumentation and excellent visualization had better results than the open cases with large incisions, manual instrumentation, and variable visualization. In particular, this study shows  they had fewer complications across the board and shorter hospital stays compared to the open cases. I should add that literature and the prevailing experience is that patients having robot cases also have less post op pain. 

 

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

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

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Greetings on this Cyber Monday. I am happy to report that we had a great Thanksgiving Break and that I did not even go into town for Black Friday, the official start of the Christmas season. I may however, patronize Cyber Monday. Accordingly, politics has taken a bit of a back seat to commerce and the holiday, and I rather like it. Nonetheless there are a few things to report. 

Massachusetts is bringing good cheer as Governor Charlie Baker, Republican (!) signs a law protecting free birth control without copay. The Baker administration has declared that women of Massachusetts right to contraception will be protected regardless of what goes on in Washington. All the while, the Trump administration is trying any way it can to demand the contraceptive protections set in place through the Affordable Care Act (ACA). 

Contraception again made the news in that a group of states Attorney's General are filing suit against the Federal government over their weakening of the contraceptive mandate for corporations which hold religious or moral objections to it. I still think it is ridiculous to confer beliefs to corporations. 

Meanwhile enrollment in the ACA is up for this stage compared to last year, despite the enrollment time being cut in half. 

The funding of the proposed Trump tax cuts is really no mystery. They are to be funded by repealing the individual mandate, the insurance subsidies and the contraceptive mandate,  saving the federal government money that would have been spent on health care. The Fed can then garner support from those people who need deductions, i.e. those who have taxable income. The greater the income, the greater the benefit. So yes, the tax plan is a case of robbing Peter to pay Paul where Peter is health care and Paul is people with substantial income. Again, I have have emphasized this so much: Investment into health care pays itself of many times over, in both human and economic terms. The trump Administrations simply does not seem to know or care about this. They are interested in keeping their campaign promise of cutting taxes. However there is no free lunch, and those that elected him should have realized the money for the tax cut would have to come from somewhere. Perhaps Trump supporters value the short term gain of lower taxes more than they value the long term gain brought by comprehensive, universal and affordable health care. 

Math: The Trump administration quietly cut $200 million from Teen Pregnancy Prevention Programs only to greatly promote a $10 million dollar program of their own that they have recently unveiled. Their philosophy: abstinence only. 

On the medical news. In the Fun and Clever Obstetrics category, there is a new study reporting on work by a Canadian charity to foster early prenatal care in African women. Bridge to Health Medical and Dental is bringing early Ultrasound to women of Africa, but more importantly they are bringing women to Ultrasound. How ? By advertising that “ you will see your baby”. They have shown that women are 9 times more likely to show up for early US if they hear this message. 

More Zika data is filtering in. We know that Zika virus infection in pregnancy is associated with a high rate of fetal malformations. However, we now know it is also associated with a very high rate of miscarriage compared to controls. Among those who survive and are assessed at one year, 94 % appear grossly normal. 

In the news that may impact you department, we have the revision in the definition of normal blood pressure. Formerly normal Bp was defined as anything less than 140/90. Now it is anything less than 130/80. What’s your blood pressure ? The best thing to do to answer this question is to get a BP cuff for home, ideally one that is smartphone connected. Take lots of readings under different circumstances, and see where you really live. Share your data with your doctor. 

We used to recommend having a normal period or two before reattempting pregnancy after a miscarriage. However newer data suggests this may not be necessary. 

New data suggests that Advanced Maternal Age patients 35 or older should be induced by 40 weeks. In the past we waited until 41-42 weeks, but this has proven to be associated with increased rate of complications. 

Kratom. This is the newest herbal supplement to a.) become popular b.) cause serious health problems and even 36 deaths. It is Southeast Asian plant used to treat pain anxiety and depression. It produces euphoria. People in opioid withdrawal use it on the street to treat their symptoms. It is clearly dangerous and the word is not yet out. 

In an interesting twist of research fate, a new study has identified risk associated with the discontinuation of hormone therapy. In particular, women under 60 who discontinue hormone treatment had a higher risk for cardiac death and stroke during the first year of discontinuation. The same was not true in those after 60. Clearly more research is needed to understand the reasons behind this. 

Periodically, research comes out noting the association of lower rates of C sections and episiotomies in those who see midwives. Every time I look at this type of research I find it to be disingenuous to some degree. This means, it does not account for the factor of self selection to midwife care or provider veto of midwife care. I am the principal Obstetric backup for our local midwife practice. We work very closely with one another to see that midwife patients are low risk, and that those who become high risk transfer appropriately to a higher level of care. Additionally, Should point out the patients are generally insightful and understand when low risk care is appropriate, and risk themselves out of midwife care when they feel they are likely to have complications. See how all this would skew these studies ? 

We know that obesity has many adverse health effects. Here is a new one: Breast cancers in obese women are larger at the time of diagnosis. They are harder to feel, and harder to image as a result of obesity. Another reason to attain a healthy weight. 

We have a great entry for the we-already-knew -this-deparment. Americans are not eating enough fruit and vegetables ! Only 12% of Americans ate the recommended amount of fruit while only 9 % at the recommended amount of vegetables. Compliance with recommendations tracked with income but even the highest bracket did a poor job. 

Finally, also in the we-already-knew -this-deparment, 71 % of American women would prefer an annual mammogram rather than every two years. Many groups, including ACOG and the American Cancer Society had to publicly disagree with the US Preventive Services Task Force over a controversial interpretation of data in 2009 saying annual mammograms conferred to benefit. Confusion still reigns in the media. In 2016 the USPTF still reaffirmed hat the harms of screening outweigh benefits. Benefits are early detection of cancer, but that is not addressed by their data. Harms they define include pain of mammograms, fear of mammograms, and indicated breast biopsies whose results return benign. I’d say this last one in particular is actually a blessing. 

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

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

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The word must be out that the ACA (Affordable Care Act) is alive and well. In the first four days of enrollment, November 1st through 4th, over 600,000 Americans enrolled. That is to be compared to the 1 million who enrolled in the first 12 days last year. This year so far, 22% were new enrollees whereas last year approximately 24% were. These figures do not include enrollees in independent state exchanges created since last year. Insurance companies corroborate that, at this point, enrollment is up compared to last year.

The Congressional Budget Office has revised its estimate of how much the repeal of the individual mandate would it affect the national debt. Initially it was thought that removing the Individual Mandate (the requirement in the ACA that all people maintain some form of health insurance) will result certain number of people not buying insurance through the ACA. Savings would occur because the ACA would not have to spend money to cover these individuals. The initial estimate of these savings was $416 billion. The new estimate of the savings has been reduced $338 billion which still sounds like a lot of savings. 

I wanted to know if these big sounding ”savings" included an economic analysis the savings or expenditures outside of the coffers of the IRS. They did not. The actual letter from the Congressional Budget Office to Richard Neal of the Committee on Ways and Means in the US House of Representatives is here: 

 

https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/hr1deficitsanddebt.pdf

 

It clearly states that while their calculation indicates a savings to the Federal Government by repealing the Individual mandate, it does "not include the macro economic effects of enacting the legislation”. What are “macroeconomic effects” ? These are the economic effects downstream resulting from poorer health and it’s consequences. Have these macroeconomic consequences been precisely defined ? No. But the general trends are clear and overwhelming. Losing health care coverage depresses individual and nationwide economic well being. 

Repealing the Individual Mandate leaves more money in government coffers, yes. But so would something ludicrous like ending Medicaid and Medicare altogether. Data from multiple disciplines shows us that money spent on health care is well spent, and results in a saving in the long term. Yes there is a savings in human suffering, and that is paramount. But if you are the sort of person who only wants to speak in dollars and cents, you too will realize a monetary savings. We as a society will realize higher levels of educational and vocational attainment, less unemployment, and greater individual and national economic productivity if we pay now for health insurance. You’ve heard of pay now or pay later ? This is a perfect example of this adage. We pay for health insurance for all, covering prevention and health maintenance, OR we pay later, in more unemployment, more welfare recipients, and the unreimbursed cost of advanced diseases and disability. So do not get too exited about that $338 billion in savings. It is not going to jump right back into your pocket as lower taxes. 

The state of Maine is currently a battleground between the people and the Governor's office. Despite a popular vote supporting the Medicaid expansion, the Governor plans to stop it based on his department's analysis of fiscal consequences. He estimates the cost of Medicaid expansion to be somewhere between 63 million and a hundred million dollars, whereas the nonpartisan budget office estimates that the expansion will cost 54 million and bring in an additional 525 million dollars of annual federal aid. I always find these large factual discrepancies disturbing because it seems clear that some of them are informed primarily by party politics. It seems to me that some sort of double-blind research could take place using a high degree of computational analysis. With this, a sound human-free estimate could be generated on pretty much any question. I doubt either side wants this though because it would take away their ability to play politics. 

The Massachusetts House has voted 136 to 16 to approve legislation which would protect birth control coverage for women. The law will require health insurers operating in the state continue offering birth control coverage without copayments for prescription contraceptives regardless of changes in federal policy or repeal the Affordable Care Act. The bill also goes further and mandates coverage for over-the-counter emergency contraceptives without a doctor's prescription. The Governor of Massachusetts, Charlie Baker supports this bill. It will be taken up by the Senate this Tuesday. The Senate is expected to approve the measure. 

A House bill under consideration would the eliminate medical expense deduction. About 9 million households or 6% in our country utilize this deduction. This is interesting because this deduction could apply to anyone who pays their deductible. I am embarrassed to say that when I was a new business owner in the 1990s I was not aware that my medical expenses not paid by insurance were tax deductible. I later learned this from my accountant. I still find that a lot of people are unaware of this deduction. My total family out of pocket currently sits at about $5000 and we seem to utilize it every year. I can easily document how much of it we utilize through my insurance company's website where I can access my EOBs (explanation of benefits). I simply submit this information to my accountant and it counts as a sizable deduction. 

Why the federal government wants to tax expenditures related to health I do not know. You would think they would encourage responsible spending of this nature. You would also think that there are plenty of other things to tax. For example, we already tax vices like alcohol, and tobacco. But we could tax them more. I am a strong proponent of vice taxes because they work. Those intent on buying the substances are willing to pay more to get what they want, and those who are on the fence and want to use less say they appreciate the additional financial disincentive which ultimately results in them using less. 

Americans are known for their consumerism. One could argue that we all have far more stuff than we need, and that we are not adequately responsible for repurposing, repairing, reusing, donating, giving, or recycling what we have before we buy something new. What if these such discretionary items were taxed ? What if we made sure that items like food, hygiene products, cleaning products and other necessities like over the counter medications, were not taxed, while so called luxury items, which we do not necessarily need, are taxed. Wait ! We have this already, and in some states it is called a sales tax. It applies to everyone, people can chose to pay it or not, and it does not disincentivize spending on health. Think about it. Government should incentivize individual spending on health and education. In my opinion, this could happen far more than it is. 

Doulas. By now you’ve heard of them. They are people, usually women, who help pregnant women during labor. They are espoused by all levels of Obstetric care because of their association with better outcomes. However, they are now being utilized in the postpartum period. We are increasingly focused on postpartum depression and its risk factors. We are also focusing on supporting women as they initiate breastfeeding. Postpartum doulas can help with all of this. They can address some of the exhaustion and sleeplessness that new mother experience by helping with nighttime feedings and infant care. They can help with meals and housekeeping. The American College of Obstetricians and Gynecologists has recently formalized its support for such postpartum care in its recommendations. 

For women, the association of moderate to vigorous physical activity and longevity persists even into old age. A recent study where the average age of participants was 72 has shown that those who log an average of 70 minutes of regular exercise a day had a 70% lower risk of death compared to the least active women who move just eight minutes a day. This research is important to me because I have many older women in my practice who feel certain that exercise consists of a leisurely walk. It is true that you cannot take such patients and insist that they suddenly start a program of moderate to vigorous exercise. But you can recommend that they start gradually with supervision, and work their way up to what is actually appropriate. Is high time to stop treating middle-age and older women as fragile.

In sobering news, new data indicates that women treated for early breast cancer still face a risk of recurrence to 20 years later. This data comes from a meta-analysis including 88 smaller clinical trials. The patients surveyed were believed to be disease free. These are patients who completed five years of post cancer therapy with tamoxifen or aromatase inhibitors as recommended. So this study result is an unhappy surprise, but one that should quickly prompt further research, and may even change therapy for such patients in the very near future.

It is interesting to think about this new data in light of the current findings published recently in the Journal Cancer Epidemiology, Biomarkers and Prevention. This study revealed that "many breast cancer patients skip recommended treatment after surgery because they lack faith in the healthcare system”. While these patients did not report distrust of their doctors, they reported a general distrust of medical institutions and insurers. These women were more likely to skip follow-up treatment such as chemotherapy, hormone therapy, or radiation, statistically worsening their outcomes. 

Finally in the we-already-knew this department, the International Journal of Public Health has published a study concluding that sexual harassment whether verbal or physical, can “cause psychological harm”. While this seems entirely within the realm of common sense and conventional wisdom, readers should realize that it is critical that studies like this be performed and published. On the basis of studies like these, tangible harms can be demonstrated in a court of law, and justice can be pursued in a more definite way.

 

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

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

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The big policy news is the ACA (Affordable Care Act). It is still in force. Furthermore, As of November 1st, it is enrollment time again, the fifth so far. Apparently 76% of Americans did not know that enrollment started last Wednesday. This is year is different, with uncertainty and confusion abounding. The public needs to be aware that the ACA is still in force, and that those eligible should enroll. A recent poll indicates that 18% of Americans do not think the ACA is still in force. They must be aware they may not see much about it in the media, since the Trump administration slashed funds for advertising by 90%. Moreover, they should be aware that the time for enrollment has been was cut in half, to 6 weeks, with no service for 12 hours on Sundays. The bottom line is that many consumers MISTAKENLY BELIEVE they will not get insurance the next year. 

Those that do sign up will find premiums have risen by 37 % on average. This is because of fears, loss of subsidies, and fewer insurers who are participating. All would do well to realize, though, that while there were 167 insurers in 2017 participating, there are still 132 this year. While the Trump administration has cited rising premiums as evidence that the ACA has failed, 80% of consumers can get a plan for less than $75 per month after tax credits. 

The States have generally recognized the long term and short term value of the ACA. Accordingly Governors, as a rule, have objected to its weakening. There are, however 12 States, who have taken matters in to their own hands, and run their own marketplaces. These plans will advertise normally, and have appropriate infrastructure to help consumers enroll. They realize that more enrollees makes a more stable market, and one that will run at the least possible cost. 

Preeclampsia has made the medical news this week. A new study has focused on the all too common disease process which pregnant women and their babies. An official at the CDC (Centers for Disease Control) has called it the most common severe problem for women in pregnancy. It leads to morbidity for both mother and baby. It has a price tag of over 2 billion dollars annually. And yet it’s exact cause remains unknown. We do know that it is more common in the very young and the very old who are pregnant, as well as the obese, the hypertensive, and those with certain autoimmune disorders. We do not that daily aspirin can help prevent recurrence, but that many patients are not receiving this simple, safe and inexpensive therapy. More research is needed. 

Contraception is again in the news. Columnist Bryce Covert has rightly summarized a large body of scientific literature in his opinion piece about the relationship between the availability of contraception and the strength of the economy. He points out that the Trump administration’s curtailment of access to contraception is likely to be associated with a gradual slowing of the economy. If women are able to easily chose the size of their family, they are more likely to chose a size they can afford. If they can put off childbearing until they are finished with education, their educational and professional attainments will be higher before bearing children, should they chose to do so. The pool of workers will be larger, and it will be more skilled. Families will be more solvent and have bigger savings. All these things contribute to the strength of the economy in very real terms. 

More good news for breastfeeding. Breastfeeding has numerous benefits to mother and baby. For mother, it helps slow post partum bleeding. It helps loss of pregnancy weight gain. It fosters bonding. It is convenient and hygienic. For babies, it enhances dental health, immunity, and growth of the newborn brain. It fosters bonding. New research also indicates that just two months of breastfeeding lowers the risk of SIDS, sudden infant death syndrome. The American Academy of Pediatrics recommends a minimum of one year of breastfeeding. 

Preterm birth rates are creeping up in the US, disproportionately affecting minority women. Complicating matters, is that the one proven preventive, 17- hydroxy progesterone, brand name Makena, is expensive, and is greatly underutilized nationwide, especially in underserved area. And here, I’d like to speak to insurance companies: Think Makena is expensive ? Try comparing that with a long stay in the Newborn ICU ! 

 

Stay tuned for more amazing news from the world of Obstetrics and Gynecology, next week, here on Medical Mondays ! 

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

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In policy news, President Trump has publicly declared the Opioid Crisis a “Public Health Emergency”. In concrete terms, this means that Medicaid money can be used to combat the problem. Trump also explained it also meant there would be money spent in an effort to develop non-addictive painkillers. Thirdly he indicated that there would be an advertising campaign to address the problem. 

The idea about non-addictive pain killers is interesting to me. I do not view the opioid crisis as an issue of pain control. I view it as an issue of coping with life. Opioid use may start with need for pain control, but then abuse and addiction develop later from different factors. The FDA( Food and Drug Administration) Commissioner Scott Gottlieb as recommended MAT, or Medication assisted therapy, which combines medication treatment of addiction with counseling. 

An undocumented 17 year old at 16 weeks of gestation has succeeded in her appeal to obtain an abortion. Since September, this undocumented immigrant has been detained in a federally funded shelter and has been requesting an abortion. Her case has highlighted the fact that the Trump administration has quietly changed policy on the matter, and now denies abortions to minors in custody. The particular memo is in an email from E. Scott Lloyd, director of HHS (Health and Human Services) Office of Refugee Resettlement. It states “…government funded shelters… should not be supporting abortion services pre or post release; only pregnancy services and life affirming options counseling. “ The position of the Justice Department on the matter was that it did not dispute the Constitutional Right to abortion. However, it asserted that it was not obligated to facilitate abortion by releasing her from federal custody. In order to obtain an abortion, she could either leave the country or find a custodial sponsor. Some accused HHS "anti-abortion zealots" of “holding her hostage” to prevent her from obtaining an abortion. E. Scott Lloyd was an avowed and zealous anti-abortion activist before he was appointed by the Trump administration to the Department of Health and Human Services. 

The lawsuit against the Trump administration over the plan to end insurance subsidies was denied by a US District Judge Vince Chhabria. At issue was whether the cessation of subsidies would cause immediate harm to consumer. Somewhat ironically, the Judge argued that since many States had, on an emergency basis, anticipated and provided for shortfalls, that no immediate harm would come to pass. This decision, of course, simply sanctions the transfer of insurance expenses from the Fed to the States, who are variably able to afford them. The Judge also wrote that it was a “close case” and that it was in an “early stage”. 

In medical news, it is once again confirmed that the teen birth rate and the US abortion rate fell during the years of the ACA (Affordable Care Act). The US teen birth rate has fallen to its lowest rate since the 1940s. The abortion rate fell the fastest among American teens. Evidence points to contraceptive availability as the cause of the decreases. 

At the same time, use of fertility treatments has doubled in the past decade. Twelve percent of reproductive aged women use these services. 

Yet another case has been added to a list of cases of babies who have developed a life threatening infection after water birth. While ACOG ( American College of Obstetricians and Gynecologists) supports water labor, it does not support water birth where there is  potential for babies to inhale not only water, but particulate matter such as non-sterile blood clot and fecal material, not to speak of whatever else in is the pool. Readers should remember that human lungs are not made to accommodate water, even sterile water or saline. Amniotic fluid may look like water, but its chemical composition and properties are far different. 

In the troubling and should-be-easy-to-fix department, we consider US Maternal Morbidity and Mortality. The CDC (Centers for Disease Control) identifies maternal deaths through death certificates. Death certificates are very short documents and do not allow for elaboration. This limited source of information does not allow us to calculate the true rates of maternal mortality or late complications, much less to determine which deaths were preventable. Being simple and brief, these forms foster a gross under-reporting. Surely a more informative digital cloud based solution could be devised. 

Texas continues to struggles with a crisis in maternal morbidity and mortality. In particular, African American women are dying or pregnancy and birth related complications at an alarming rate. These women account for 11.8% of Texas births, but 29% percent of Texas pregnancy and birth related deaths.  Experts believe potential causes relate to obesity, poverty, diabetes, delayed prenatal care, higher C section rates which result form these other factors, drugs, hypertension and related cardiovascular problems. 

In major scientific news, result of the OncoArray Consortium have been published. This is a global project wherein 550 researchers shared genetic data from 300 institutions and 275,000 women, 146,000 of whom have had breast cancer. The work, published in Nature and Nature Genetics, has identified many more previously unknown genetic mutations associated with breast cancer. We have long suspected and counseled patients that BRCA1 and BRCA 2 are probably not the only cancer mutations. Now we have specific confirmation on this. While these results may initially seem daunting, they are the kind of data that can lead to better “precision" methods of diagnosis, prevention and treatment in the not so distant future. 

Reader should take note of the multilaterally of this OncoArray Project. The non-academic person understands that research studies take money, time and test subjects. They also understand that more money, subjects and time mean higher quality results. One might ask then why has it taken this long for researchers the world round to combine resources to get truly powerful results ? Indeed perverse incentives have, until recently, been in place to silo, hoard or hide data, one researcher from the next, or one institution to the next, in a climate of competition for research dollars and accolades. Even at present, the open date movement is not mainstream among researchers, nor is the idea of sharing medical record information including genetic information popular among patients. There are costs to sharing data, but the benefits may well prove to be greater. 

Did you know that there are various sizes and types of IUDs ? There is most likely one that is suitable for everyone, including teens, women who have not had children, and women near menopause. Many misconceptions about IUDS arise among patients and caregivers. For example, we used to believe that IUDs prevent implantation of a fertilized egg. However, ACOG now recognizes that IUDs prevent fertilization. Many who oppose a method which fosters non-implantation of the fertilized egg will be comfortable using this method knowing its mechanism of action. 

“Vaginal seeding” is the deliberate transfer of a mother’s vaginal flora to the infant’s nose mouth or skin. This procedure is under research investigation and should not be attempted at home. Women who undergo C section may have an interest in this as their newborns have not been exposed to vaginal flora like an infant born vaginally would have been. There are very real risks to vaginal seeding, because, as with many things, the devil is in the details. It turns out that vaginally born and cesarean born babies microbiota are slightly different, but that they equalize after about 6 months. It also turns out that breastfeeding provides the best and safest transfer of flora.

 

Stay tuned next week for more fascinating news from the world of Obstetrics an Gynecology.   

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.