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 With it’s passage, the Individual Mandate of Obamacare has been repealed.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 Monday: Breaking News from the World of Obstetrics and Gynecology

Greetings from the heart of Silicon Valley. Please excuse the blog silence over the last few days as, believe it or not, I have suffered from sporadic Internet connection. I have been attending a very busy conference, Stanford MedX, on which I will fully brief you later. I could not blog at the conference but I took a lot of notes and pictures and they will serve as the basis for my reports to you sometime late on Wednesday. Where I stayed was a beautiful residence deep in a grove of old-growth trees so dense that it interfered with us cellular and local Wi-Fi coverage. So I right now without pictures, I will make this dispatch to you because I think medical Monday is so important. Text will go, but pictures will have to wait.


Some continue to doubt the association of the Zika virus infection with the development of microcephaly. However this latest study should put this to rest. The Journal Lancet Infectious Disease reported work that studied newborn Zika babies both with microcephaly and without. It turns out that babies with microcephaly we're 55 times more likely to have been infected with the Zika virus in utero. However, none of the 62 newborns in the comparison group who appeared normal showed any sign of infection.


Of chilling significance is another story published the Journal of Emerging Infectious Diseases. Those authors note that "for infants about four months and up to eight months of age" babies were "born on average on measures of weight length and head circumference" but "fell even further below average as time passed".


The CDC (Centers for Disease Control and Prevention) has now indicated that Zika virus can spread through "contact with bodily fluids such as tears, discharge from infected eyes, saliva, vomit, urine or stool." This has obvious implications for those living with and caring for those affected by the Zika virus.


Florida may offer free Zika virus testing, but that does not mean women are getting results. Apparently results that take a private lab a few days to report are taking weeks for the state run service. Time is of the essence when inquiring about Zika virus infection in pregnancy, since many women consider the option of abortion if there is evidence that their baby could be or is infected. Access to abortion is more restricted in what now could be called the Zika belt of our country.  Women consider this drastic measure because central nervous system manifestations of Zika virus in pregnancy are often devastatingly severe. We now know they're also potentially progressive even after the baby is born.


A recent poll suggests that the risks of Zika virus to pregnant women have caused some Americans to soften their view on abortion. 62% of voters living in the 10 battleground states in the south and along the Gulf Coast have said that they "support abortions after 24 weeks if a doctor believes there is a serious possibility that a woman's fetus could have severe birth defects from the Zika virus."


As of this writing the funding to combat the Zika virus is virtually spent. The Obama administration as well as the CDC, the American College of Obstetricians and Gynecologists and others have appealed to Congress to put aside partisan politics and fund the fight against the crisis


It is worth reiterating news from last week coming to us from the Zika belt state of Texas. Texas maternal mortality spiked from 18.6 maternal deaths per 100,000 live births in 2010 two more than 30 per 100,000 into thousand and 11 and remains at that level through 2014. This statistic may not seem huge but it has increased dramatically and is a higher rate than anywhere else in the country. It is also higher maternal mortality rate than in most other industrial countries. Numerous writers, ACOG and the State Heath Services of Texas maternal mortality task force all recommend an increase in health care services to women as the solution.


Global maternal mortality rates are not where they should be. The United Nations sustainable development goals (SDG) indicate the rate would have to fall by nearly 70% to meet the target globally of 70 maternal deaths per 100,000 live births. It is felt that this should be accomplished by adding an estimated 18 million Women's Health workers including midwives and obstetricians.


A new study by the Urban Institute has indicated that only 31% of women know about the most effective forms of birth control, the LARCs, the long acting reversible contraceptives. ACOG has said that such IUDs and implants are the most effective reversible contraceptives available and are safe to use by almost all women of reproductive age. Of note, weeks ago it was reported that Puerto Rico, which is greatly affected by the Zika virus, had been given a large supply of IUDs but was unable to fully utilize them due to the lack of providers trained to insert them. LARC use in Texas is on the rise.


The rest of the news in brief:


US preventive services task force recommend screening all nonpregnant adults and adolescents at risk for syphilis, which is on the rise.

The British medical Journal reports that pregnant women with higher ambient glucose levels who are not meeting the criteria for gestational diabetes still have an increased risk of complications. These complications would include preeclampsia and overly large infants (macrosomia). Additionally, related complications are noted, such as shoulder dystocia, which is the condition where babies are dangerously difficult to deliver due to a larger girth at the shoulders.


The national Cancer institute is once again encouraging all children adolescents and young adults 26 years of age or younger to obtain the vaccine against the human papilloma virus, HPV. Only 40% of eligible girls and 21% of eligible boys have received the vaccine. Vaccination rates in Australia and the United Kingdom are in the range of 75 to 92%


In the good news and we already knew this department, an article in the Annals of Oncology has reminded us that use of oral contraceptives decreases ovarian cancer risk by 50%. For the record, having children and breast-feeding them also decreases this risk.


In the good news department, The number of Americans without health insurance has fallen to a recent level of less than 10%. This is attributed to people buying insurance on the Affordable Care Act (ACA) exchange.


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

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

Zika infections in the US have taken sharp uptick of late, presumably due to the weather and mosquito activity. Zika infections in American pregnant women now number around 300, the largest number of which are located in Puerto Rico. Numbers are also up since the initially reported numbers did not reflect asymptomatic infections, which can affect fetuses as well. The CDC ( Centers for Disease Control) estimate about 80% of Zika virus infections are asymptomatic. 

The Zika virus is transmitted by mosquito bite and by sexual contact. Consumer Reports has studied the so called natural mosquito repellants and, sadly, found that they last no more than an hour. DEET is much more effective, and has been found to be safe in pregnancy. 

The CDC and Harvard Public Health have analyzed preliminary data. Women who get Zika in section in the first trimester have about a 13% chance of having a baby with microcephaly. The background incidence of microcephaly is on the order of .02 to .12% in the US. So far, it appears that infection in the second or third trimesters is not as consequential.

I wonder if Zika related brain damage is either present or not present, versus a spectrum of damage. If it is spectrum, what do the other 87% of babies have that we should know about ? 

The CDC director has made an impassioned plea to Congress. The House and Senate each have separate Zika funding plans, but they cannot agree. Meanwhile days could make the difference as summer approaches. 

A new study out of U Penn indicates that pregnant women who use marijuana increase their risk of preterm labor by five times. I am more interested in what it may be doing to the brain of both the mothers and the babies, and would be glad to see more research done on this important topic. 

The whole pelvic mesh situation is seemingly going from bad to worse. Mesh sheets are used in surgery to reinforce tissue. Various types of mesh in sheets or ribbons are used for hernias and for urinary incontinence. Johnson and Johnson developed mesh for use in pelvic prolapse patients. However, complications started arising including migration or erosion of the mesh. People were indeed injured, and lawsuits arose.  Washington and California are filing lawsuits against Johnson and Johnson, alleging that the company misrepresented the risks of its use. 

Now some of those same pelvic surgeons who installed mesh are removing it. Is is fitting and customary for a surgeon to handle any of her or his post op complications However in this instance, American Medical Systems has recently alleged that some physicians and lawyers are “ persuading” women to remove their mesh implants in order to make money and inflate damage claims. They also explain that there are now lending companies who work with physicians to fund these mesh removal cases. For shame !!! I will be following this story closely.

I have used Monarc “ ribbon” to suspend the bladder to help incontinence. It has an acceptable complication rate. However, years ago, when a fellow doctor friend of mine and I went to get trained on Monarc insertion, we were also asked if we wanted to train on mesh. I distinctly remember that moment when she and I looked at each other and made bad faces. It gave us both the creeps. We said no because our gut impression told us it seemed prone to complications. Lucky guess. Or maybe it was that the idea of having a piece of screen door sewn just under your vagina skin did not sound OK to us. 

The Republican Governor of Oklahoma Mary Fallin has ignored the party line, and vetoed the recent bill making abortion a felony. This brave politician described herself as “ the most pro-life governor in the nation” but vetoed the bill on the basis that it was “ambiguous and vague" and “ would not survive a constitutional challenge” , i.e. it would be illegal. The Governor was under great pressure from the Christian right to pass the bill. She also received information and pressure from the Oklahoma State Medical Board, the American College of Obstetricians and Gynecologists (ACOG), and the Center for Reproductive Rights.

Acting this presidential could get you a nomination. Similar bills are being put forth in South Carolina and Louisiana. 

Many of you have read my rants about various and sundry public health generated guidelines about women’s health screening tests. These would include mammograms, paps, annual exams and the like. My rants have generally been about the more lax approach seen by generalist governing bodies like the American College of Physicians, and the American Academy of Family Physicians. ACOG guidelines are more stringent, and I believe this is because we rely on more rigorous data produced by specialists in the field. Even so, generalist guidelines hit the press just the same as ACOGs, and it is difficult for a layperson let alone a community physician to understand why the recommendations are so different. 

As an example, ACOG believes the evidence supports mammograms in the 40s for women of average risk, whereas the American Preventive Services Task Force does not advise them until the 50s. In a nutshell, this is because the APSTF did not choose their study endpoints in the most meaningful way. Their harms included trivial things like fear of mammograms, and their endpoint was death rather than years of life. The public and many providers were thrown into confusion. 

Fast forward to the present for some good news.. ACOG will now be partnering with these same organizations to develop what will hopefully be an evidence based rigorous set of Women’s Preventive Services Guidelines. 


Stay tuned for more news next week on Medical Monday.