Medical Monday: Breaking News from the World of OB/GYN

Contraception: Get yours while it's hot ! 

GOP leaders again met to discuss repeal of the ACA (Affordable Care Act). The same measures were discussed this week as last: health savings accounts, tax credits, and state high risk pools for the chronically sick. A bill is anticipated next week. 

A measure passed in the House which enables States to pull funding from any facilities who perform abortions. This funding is not specific to paying for abortions. It pulls funding from the facility altogether for all the care it provides, whether it is flu testing, mammograms, or pap smears. This will directly defund Planned Parenthood. In the short term, i.e. one year, it will save money, but in the long term, researchers estimate it will cost much more than current expenditures because of diseases untreated, disease caught later, and and of course, due to unplanned pregnancies and the costs they incur. 

Indiana is voting on a so called “ abortion reversal” procedure which has no basis whatsoever in scientific fact. The American College of Obstetricians and Gynecologists have weighed in, saying that it has “ not been scientifically proven to work”. There is no reason to believe that it would. 

Many states are working on measures to reduce abortion at a time when abortion rates are at a modern low. Today's rate is the lowest since Roe versus Wade was made law in 1973. According to the a broad base of research data from around the world, restrictive abortion laws do not prevent abortion. They simply prevent legal abortion, and lead to illegal abortion and it's consequences. Moreover, research has shown that access to contraception DOES prevent abortion. However, distressingly, these same states who are moving to pass restrictive abortion laws are also moving to restrict access to contraception. Teens have the highest rates of unintended pregnancies. Teens are also the most likely subgroup with unintended pregnancies to get abortions. Data from the Contraceptive Choice Project have shown that when teens have access to the free birth control of their choice, abortion rates plummet. In this study of 9000 subjects, the abortion rate went from 41.5 abortions per 1000 teens to 9.7 per 1000. 

In the fake out department, The current administration is introducing rules to help keep insurers in the ACA (Affordable Care Act) . This is ostensibly being done to stabilize the market. This sounds good, right ? However, it is being done in such as way as to make criteria for inclusion in the ACA stricter. Additionally the enrollment period will be reduced from 3 months to 45 days. Tightening the criteria and shortening the enrollment will shift costs onto patients and off insurers. 

The ACA will lose its teeth. Why ? The Trump administration no longer plans to withhold tax refunds from those who ignore the requirement to have health insurance. Instead these uninsured people can show up on the doorsteps of hospitals everywhere with God only knows what needs, get them promptly and properly taken care of.  As uninsured people, they then either pay their medical bills regular price out of pocket (fat chance, especially with something costly like heart disease, diabetes, cancer, trauma or worse) or leave hospitals, caregivers, and ultimately taxpayers and those of us that pay for insurance in the lurch. Meanwhile data has come in for 2016 that the uninsured rates dropped to record lows in 2016, to 8.8% to be particular. This is felt to be due to the ACA. 

In medical news, two new studies show that scalp cooling cuts chemo related hair loss in half. This study was done on women with early stage breast cancer. Hopefully it will reduce some of the insult that comes with this all too common injury of breast cancer. 

There is a widespread shortage of ObGyns in rural America, with only 6% of us working in the rural setting. People decry this and classify this as an “ access to care” issue. However, it makes sense that Ob/Gyns do not want to work in isolation, far from hospital and community resources. Truthfully, birth should take place within a community, however small, which has access to surgical services and support people of various kinds. I believe people who live remote even from these small scale services should plan according and make arrangements to “stay in town” when they have complications or get near term. I have many such patients who have rudimentary services near their homes on the plains or in the woods, but prefer to come an hour and a half  "to town” for their care. They are clear about valuing the beauty of their countryside or wilderness homes, but also clear about realizing that a modern medical facility just cannot be there. I appreciate their insight on the situation. 

In the good news department, our extreme preemies are surviving not only longer, but better, that they have in previous years. Specifically, they are doing measurably better in their neurodevelopment parameters. Kudos to our friends in Neonatology and the newborn ICUs around the US. Kudos too to all the ObGyns working to treat moms at risk for preterm delivery, and to those researchers who developed antenatal steroids. 

Also in the good news departments, LARCS (Long acting reversible contraceptive such as IUDs) are proving acceptable for the vast majority of users. No surprise there on these elegant and effective methods. 

And finally, in the we-already-knew-this department, exercise is proving effective at improving hot flashes and QOL (quality of life) in postmenopausal women ! 

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

Medical Monday: Breaking News from the World OB/GYN

Policy news is once again front and center this week. For starters the Senate approved the controversial nomination of Representative Tom Price to be Secretary of Health and Human Services. The legislator is an outspoken proponent of repealing the Affordable Care Act (ACA). He has suggested replacing it with tax credits, health savings accounts, and high risk pools for sick costly consumers. 

Meanwhile more than 12.2 million people have enrolled in the ACA despite its uncertain fate. At the same time, insurers are warning that insecurity in the sector by itself could drive up premiums in the near future. 

The current CEO of the American College of Obstetricians and Gynecologists (ACOG) Hal Lawrence III has stated that there have been clear benefits to women's healthcare contained in the ACA. Accordingly, ACOG  is combating GOP efforts to completely repeal the ACA, urging lawmakers to confirm preserve a provision which prevents insurers from charging women higher premiums than men. Key physician groups including ACOG who provide care to women and children went to Washington last week to lobby for retention or expansion of features of the ACA which provide benefits for women and children. They along with increasing numbers of GOP lawmakers are advocating a repair not repeal approach. Nonetheless, House Speaker Paul Ryan has insisted that repeal and replace will be passed this year though acknowledges it may take several years for it to be implemented. Speaker Ryan has given the GOP semantic permission to repair the ACA by stating that repeal and repair  “essentially amounted to the same thing.” 

The federal government has been looking at Medicaid block grants as a way to save money. This means each state would receive a grant of a fixed amount of money and it would be up to them to allocate it as per their state specific needs. Those favoring this approach cite the amount of money that would be saved. Those against this approach, divided, not surprisingly bye party lines, argue that it would result in slashed benefits and increased costs to states.

On medical news, obesity is back in the spotlight. Obesity is epidemic, and it is costly. It also happens to affect fertility. New research from the National Institute of Child Health and Human Development found that among couples where the woman is obese the time taken to become pregnant is longer. When both members of the couple are obese, i.ewith the body mass index of 35 or higher, it takes 60% longer to become pregnant.

Polycystic ovarian syndrome or PCOS is a cluster of signs and symptoms that relate both to fertility, menstrual functioning, carbohydrate metabolism, and cardiovascular health. It is often accompanied by high body fat percentages, if not obesity. New research indicates that disordered eating behaviors are four times greater among those with this syndrome compared with controls. Is already well-known that when PCOS patients lose weight, their menstrual functioning infertility improves.

Obesity is a risk factor for many forms of cancer. New research published in the Journal of Clinical Oncology has indicated the converse. Intentional weight loss may reduce postmenopausal women's risk of uterine cancer.

Is strange and concerning report, it has been discovered that large amounts of maternal licorice consumption during pregnancy may be associated with lower IQ, ADHD like behavior and early puberty in children. This was reported in February 3 online edition of the American Journal of Epidemiology. The study was a community based cohort study of 1049 people in Helsinki Finland. The compound in licorice thought to be the culprit is glycyrrhizin. This substance apparently blocks an enzyme we have which shields the developing baby from maternal steroid fluctuations. More research is necessary. 

It has also been shown that the prevalence of certain types of bacteria in the cervix may affect a woman's risk of preterm birth. Bacteria which we have considered normal, such as Lactobacillus, are protective against preterm birth, while other bacteria, specifically several anaerobic bacteria greatly increase the risk. These findings were presented at the Society of Maternal Fetal Medicine’s annual meeting.

There are new recommendations for HPV vaccine. Children less than 15 would obtain it need only get two doses. Older children still need the three shot regimen. TapHOPV vaccine protects against cervical cancer and genital warts and may be given between the ages of 9 and 26.  

Stay tune for more exciting news from the World of Obstetrics and Gynecology, next week, on medical Monday.

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

We start this Monday with the piece of grossly under reported news. few seem to be aware of the fact that prenatal cannabis use is linked with cognitive impairment academic under achievement in children. Both the American Academy Pediatrics and the American College of Obstetricians and Gynecologists advise against its use because best. Many patients assume that because it is legal it is safe. Marijuana’s main psychoactive ingredient THC or tetrahydrocannabinol crosses the placenta to reach the fetus. It not only affects brain development and cognition but also birth weight as well. Have you seen anything about this lately? 

Planned home birth is again in the news. A new study shows that planned home birth  is associated with increased risk of complications, especially in women who are having their first baby or in those 41 weeks or more. This particular study looks at the rate of neonatal death, the most severe complication.  Researchers found that those who delivered with midwives at home had a neonatal death rate of 24.4 per 10,000 birth compared to 5.09 per 10,000 births delivering with a midwife in the hospital. 

300,000 babies are born in United States every month. Typically 273,000 women take time off of work to care for newborn whereas 22,000 men do the same. A recent study in the American Journal of Public Health as shown that maternity and paternity leave rates in the United States have been constant over the last 20 years. This may be related to the fact that only 12% of workers in the private sector have access to pay family leave. This lags far behind other developed nations of similar socioeconomic status.

Recent work from the Pew Research Center revealed the new president's views on vaccines are not shared with the majority of Americans who overwhelmingly support requiring children to be vaccinated before attending school. 82% of Americans support children receiving the MMR vaccine before attending school. 

Representatives from numerous physicians organizations have descended upon the halls of the Senate offices to lobby their respective representatives about the need to retain certain characteristics of the Affordable Care Act (ACA). These organizations include the American Academy of Pediatrics, the American Academy of Family Physicians, The American College of Obstetricians and Gynecologists, and the American College of Physicians, and the American Osteopathic Association. They have placed particular focus on the provisions for the care of women and children as these provide the foundation for lifelong medical care and wellness. They have placed particular emphasis on the need to have a replacement in place before the current plan is repealed. The same groups, representing over half a million United States physicians, sent a letter to the White House and Congressional leaders leaders asking them to ensure that women's health, including preventive prenatal and neonatal care, be protected. 

A subcommittee within the House is beginning to work on replacing the ACA. They are looking at the issue of preexisting conditions, and at age ratings which determine the charges paid for insurance by age. They're also considering a shorter grace period for those who fail to pay premiums on time. The process is contentious between Democrats and Republicans,  but it is also reportedly contentious between different Republican legislators as well. Republican lawmakers nowassert that they intend to “repair not repeal” the ACA. 

Last week, a meeting between State Insurance Commissioner's and brokers met with the Senate Health Education Labor and Pension Committee. They warned the Committee that more healthcare plans are likely to”defect from the Affordable Care Act marketplaces unless Congress and the Trump administration provide concrete assurances within the next two months”. They also warned that those insurers that remain are likely to increase their rates by as much as 20% if this occurs. Specifically, the insurance industry wants GOP lawmakers to ensure that they will fund ACA subsidies in 2018. They need this information so that they can make their budgets for the next year. ACA subsidies are currently the subject of court battle between Republican Representatives and the White House. Amidst all this, the Department of Health and Human Services introduced a rule, the "Patient Protection and Affordable Care Act; Market Stabilization”, which is meant to stabilize the health insurance market for individuals. The GOP appears to understand that it is in everyone’s best interest to stabilize the insurance markets. 

Threat of repeal of the ACA continues to spur women women into seeking long acting reversible contraceptives (LARCs) such as MIrena (IUD) and Nexplanon (subderrmal insert). Month-to-month adoption of these methods is at record highs and continues to rise. Women are also stockpiling prescriptions of contraceptive and the prescriptions Some states such as New York are addressing the problem by requiring State governed insurance agencies to cover contraception with no or minimal copays. Massachusetts has developed a bill to provide free contraceptives to all of its residents. 

The is busy time for women’s health  and health care in general. Find out the names and contact information for your elected officials. Make your views known. 

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

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

On last Monday , President Trump signed an executive order “ granting relief” from the stipulations of the ACA (Affordable Care Act). Among other things, this means the Department of Health and Human Services (DHHS) may reduce what insurers are obligated to cover for patient’s care. 

Planned Parenthood reports that the number of women trying to get IUDs in their clinics has gone up 900% since early November, i.e. the election. IUDs are a very reliable long acting contraceptive.  They are obtaining these IUDs under the contraceptive benefit under the ACA, which they fear will be repealed under the current administration. 

The Democratic Governor’s Association has urged Congress not to overturn the Medicaid Expansion or to convert to block grants. They stand to lose a great deal of coverage and funding for their constituents. 

Two moderate Republicans, Senator Susan Collins of Massachusetts, and Senator Bill Cassidy of Louisiana, a physician, have indicated a partial replacement for the ACA, which would allow states to continue to operate under it if they chose. Under this proposal, states who opted out of the ACA could get a block payment to administer on their own. The authors have emphasized that the bill is a work in progress. 

At the recent GOP policy repeat, a plan was made to have a replacement for the ACA  to the House floor by the end of March. The House Speaker, Paul Ryan indicated that they intend to get these replacement laws made in 2017. 

The US has frozen funding to health care providers in poor countries who discuss abortion as an option. This policy is called “ The Mexico City Policy” and it is been enforced and revoked back and forth through the administrations of Clinton, Bush, Obama, and now Trump. 

The CDC (Centers for Disease Control) reports that consumption of sugar drinks is still “ well above” the recommended limit. Consumption of these drinks has decreased steadily for the last ten years but now seems to have plateaued. 

The South has higher cancer mortality rates that the rest of the country. These are areas of the country where poverty, smoking and obesity are more prevalent, and these factors are believed to be the reasons. Overall, the US health rate from cancer has decreased 20% in the last ten years. 

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

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

This Monday the world has become a different place. A new Administration has taken office in the United States. But more importantly, women across the country and across the world have become galvanized. Many marches of hundreds of thousands each took place on Saturday. These were largely demonstrations by and for women to make a statement against sexism, misogyny and against the loss of health benefits in the US. I’m not sure the world has ever seen political activism for one goal on such a large scale. 

Democratic lawmakers made a last ditch appeal on Friday, urging that the GOP halt the repeal. They cited the many clauses of the ACA which prohibit practices which are discriminatory to women, such as denying coverage of contraception and coverage for women-only health screenings such as mammograms. They cautioned that this, along with defunding Planned Parenthood, would harm women in every state. 

It is becoming clearer and clearer that many Republican governors do not favor a wholesale repeal of the ACA. They know that repeal would cause chaos in health care, as well as increasing costs for their state programs. 

In the shocking numbers department, it has been determined that HALF of all men have genital infections caused by HPV. One in four of those have viral strains which can cause cervical cancer. 

Meanwhile, New York State is reporting a 50% decline in cervical cancer deaths since 1976. This is attributed to women obtaining regular paps to detect precancerous conditions and the introduction of the HPV (human papilloma virus) vaccine Gardisil. 

It is interesting to note that abortions are at a new low since the institution of Roe versus Wade case law in 1973. Researchers attribute this new low to the increased availability of affordable and longer lasting contraceptives. 

If the ACA is repealed, both these important gains might likely be lost since the ACA has covered contraception and health screening for women. 

As if to add insult to injury, repeal of the ACA would also strip breastfeeding protections from the workplace. These protections are in place through the ACA. 

The ACA deals with more than women’s health issues. The ACA contained provisions to authorize a fund to combat the costliest of our chronic diseases: diabetes and heart disease. Repeal of the ACA could eliminate this fund, which is for state public health programs.

Americans may be divided, but 40% across both sides of the aisle agree that health care should be a top priority for the new administration. Meanwhile, the popularity of the ACA is steadily climbing in the polls. Forty eight percent of Americans strongly approve of the ACA. Of those 22% of respondents who want it repealed, half want to do so only when a replacement is in place. The Congressional Budget Office itself has calculated that if the ACA is repealed, 18 million people will lose their insurance in the first year. Over a decade, 32 million would lose insurance. They also estimate that individual premiums would double. 

In Zika news, officials have been debriefing from the season. They feel the greatest failure has been of prevention in the areas most affected by Zika. They have emphasized that the toll taken has scarcely been counted. 

Fetal alcohol syndrome (FAS)  is still a scourge. Over a hundred thousand babies are born yearly with this condition. Britain has one of the highest rates of FAS in the world, with 40% of British pregnant women drinking during pregnancy. 

The American College of Obstetricians and Gynecologists has continued to take issue with the FDA on their overly conservative and out of context warnings on anesthetics in pregnancy. Their concern is that caregivers and patients will be reluctant to have critical procedures such as appendectomies and gall bladder removals in pregnancy should they become necessary. Surgical illnesses such are these are very much threats to both mother and babies in pregnancy and should be dealt with in the standard fashion. To put theoretical concerns from animal studies ahead of clear and present dangers is missing the forest for the trees. 

Contact your elected officials with your concerns. It is not enough to march. 

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

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

More than one organization is working hard on vaccines against the Zika Virus. Currently trials are with inactivated vaccine. These take longer to develop than vaccines, with live virus. However live virus vaccine trials are more risky, and it might be difficult to find volunteers for such a trial. And that is all the Zika news for this week. 

Leading the news is the ACA, the Affordable Care act and it’s fate. 

More information is coming in about how the ACA affected us. For one, it’s institution seems to have been associated with increased mammography utilization among older women. Unfortunately the same increase in utilization was not seen with colonoscopy screening for colon cancer. In practice, this is indeed a harder sell, but the truth is, it saves lives, and is not that bothersome of a procedure. 

Senate Majority leader Mitch McConnell has stated that the ACA will be “ replaced rapidly after repealing it”, though he provided no details. He did admit that “ There ought not to be a great gap between the first step and the second.” Many GOP leaders estimate that it will take 2-3 years to devise a replacement. 

Hospitals are continuing to voice their concerns that repealing the ACA could cause a major crisis in health care. Increasing numbers of GOP lawmakers are voicing concerns about a lack of replacement for the ACA. They fear the financial consequences to their states and their constituents, as well as allegations of being reckless and the political consequences that that entails. At the same time President elect Trump has demanded an immediate repeal and replacement. . On January 12th, GOP Senators voted 51-48 on a non-binding measure approving a budget blueprint to repeal the ACA.  Personally, I think it is still worthwhile to contact your elected representatives and tell them how you feel about this. 

Enrollment in the ACA continues to outpace that of last year. As of December 24th, more than 11.5 million people have enrolled. Twenty million Americans altogether have their health care through the ACA. 

Oddly, Mr. Trump made certain campaign promises regarding 6 weeks of paid maternity leave and reductions in child care costs. Last week he held meetings about these issues while urging his party to gut health care. 

Speaking of women’s health care, contraception is currently covered by the ACA. it’s repeal would of course threaten this benefit. However, states have the ability to require insurance companies to cover it entirely. Not surprisingly, many states are moving to establish laws that will resemble the ACA in their coverage of contraception. 

In medical news, the flu is clinically worse this year than in other years. But, good news ! The vaccine this year is a good match, and is very helpful. There is still time to get one. 

In other vaccine news, there is a herpes vaccine under development. It is showing promise to decrease frequency and severity of outbreaks. 

Breastfeeding moms need to take prenatal vitamins, Calcium and Vitamin D. Many people including pregnant women and nursing mothers are low in Vitamin D. All breastfeeding moms should be supplementing their breastfed babies with vitamin D drops. This message is not getting out as well as it should. Consult your Pediatrician. 

 

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

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

The Society for Maternal Fetal Medicine (SMFM)  recently convened a special session to summarize our current knowledge about the Zika virus. Maternal Fetal Medicine Specialists are also known as Perinatologists. They are essentially Ob Gyns who drop Gyn and take a couple additional years of training in Ultrasound and high risk pregnancy management. They also tend to comprise the research side of Obstetrics. They may or may not continue to deliver babies. They, together with general Obstetricians have been the group of health care providers most affected by the Zika epidemic. As such, the group as convened a special session to review CDC (Centers for Disease Control) recommendations pertaining to the Zika virus. Together with the CDC director, they have emphasized the the concern over Zika is ongoing. Pregnant or potentially pregnant women are encouraged to stay away from places where Zika is spreading. They have cautioned that the worst is not over. 

Meanwhile, insights are being gained into the pathogenesis of the Zika related disease process. (Pathogenesis means the particular way something causes disease.) In looking at the Zika virus genome and several important proteins produced by the virus, researchers from the University of Maryland have obtained what they classify as “ really valuable clues for future research”. 

President Obama meets with Congressional Democrats this week to devise a strategy to save the ACA (Affordable Care Act). Meanwhile some commentators have noted that even repealing the ACA will not make it possible to roll back all of the changes the ACA has wrought. Americans have become accustomed to a new standard in the expansion of health care coverage. Meanwhile, the incoming Republican administration has seemingly settled on a repeal and replace strategy. The health coverage of 20 million Americans is at stake. This December, 8.8 million people enrolled in the Federal Exchange. This is more than the 8.6 million of last year. The American College of Obstetricians and Gynecologists (ACOG) and others have come forward with a recommendation that there should be a replacement plan in place before repeal. Yet ate last week, Republican leaders including the House Speaker Paul Ryan as well as Senate Majority Leader Mitch McConnell have asserted that a quick repeal and replacement "within this year" is needed. Senator McConnell classifies the ACA as a “ failed, partisan experiment”. 

A new analysis presented by CNN Money indicates that repeal of the ACA will cost the Federal Government $350 billion dollars over the next ten years. In comparison, the ACA was crafted to be budget neutral. 

ACOG and the AMA (American Medical Association) concur that oral contraceptives are appropriate for over the counter use. The FDA (Food and Drug Administration) is in the beginning steps of this regulatory process. 

There are many patients who have trouble attaining a healthy weight, even some who exercise regularly and eat appropriately. A new study has focused on this group and found some good news. These “non responders” benefit from rotating their exercise routines. Truthfully, I have heard this from many trainers. 

Also in the good news department: a 25 percent decline in cancer death rates since 1991. This is a fresh statistic from the American Cancer Society. They attribute this decline to reductions in smoking, as well as early detection, and better treatment. 

Finally, in the easy and lifesaving department, peanuts are now recommended for the very young. The National Institute of Allergy and Infections Disease has issued new guidelines recommending that parents introduce peanuts into their child’s diet early (before 6 months !) and often. This is to prevent the development of peanut allergy in the future. This recombination is a “ significant departure from the past”. These new guidelines could dramatically reduce the prevalence of this deadly allergy. 

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

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

Zika is still in the news this new year, but this is definitely the off season. In good news, the CDC (Centers for Disease Control) has released $184 million dollars to the states and territories to fight to Zika virus. The funds will be used to improve testing and to enable the states to track pregnancies and births affected by Zika. In other good news, two studies published in the New England Journal of Medicine and the Journal of the American Medical Association reported that the risk of Zika associated microcephaly maybe less than previously estimated. Microcephaly is one of the more severe side effects of perinatal infection with the Zika virus. However it is not the only side effect as Zika affects many other organs and many other aspects of the central nervous system, many of which are yet be fully quantified. It may be that while microcephaly is less prevalent than previously estimated, serious less well defined or obvious side effects are more common than previously estimated.

New research published in the Journal Gynecologic Oncology indicate that there is a new up-and-coming ovarian cancer drug. In this small study, progression free survival was increased from 6.8 months to 15.4 months. This may not sound like much but it's a step in the right direction which, ultimately, may be combined with other such steps.

Republican Representative from Georgia Tom Price has been nominated for Health and Human Services Secretary. This has been a controversial nomination. Dr. Price is an orthopedic surgeon, and as such has been endorsed by the American Medical Association. At the same time, many in the medical field voiced their opposition to this nomination. Several thousand physicians have signed a  petition indicating their displeasure and stated that the American Medical Association does not speak for them. Meanwhile, the President of the American Congress of Obstetricians and Gynecologists, Dr. Thomas Gellhaus, has expressed concerns that some of the bills supported by Dr. Price would “…not serve women's health well”.

In other political news the GOP is divided on the issue of the ACA (Affordable Care Act). Basically, the two camps are as follows: repeal and do not replace versus revise and rebrand. GOP leaders have tried to assuage concerns about the repeal or revision of the ACA promising that "no one is worse off". There is concern however that ensuring that "no one is worse off" will be difficult to accomplish, given that the GOP intends to repeal certain taxes which have been used to fund the ACA.

In sobering news, alcohol consumption, bingeing and alcohol related deaths are up sharply among American women. This is the case as reported by the Washington Post on analysis of Federal health data. Analyzing the data has revealed that this is particularly true among American white women. At the same time, findings published in the current issue of the Journal Drug and Alcohol Dependence show that between 2005 and 2013 binge alcohol use and alcohol use disorders are increasing among older adults.

The Journal of the American Medical Association has produced new research which has broken down how we spend on healthcare. Not terribly surprising are the first two diseases that cost us the most as of 2013: coming in at number one for $101 billion dollars is diabetes, number two at $88 billion is heart disease and a surprising tie for number two is back and neck pain at $88 billion. These are nontrivial numbers which are generally spent in the hospital setting. Therefore it comes as no surprise that hospitals have been voicing their warnings to the incoming  administration about the possible repeal of the ACA. They have calculated that they stand to lose $165 billion if the estimated 20 million people lose their insurance they gained under the ACA. They warned of “an unprecedented public health crisis" and possible collapse of the whole healthcare sector.

In perhaps the most interesting news of the week the American College of Obstetricians and Gynecologists is going head-to-head with the FDA over the issue of anesthesia for pregnant women. The FDA recently issued a warning against the extended or repeated use of "general anesthetic and sedation drugs in infants and toddlers and pregnant women in their third trimester”, indicating these "might damage children's developing brains”.  Their recommendation is based on observational studies on animals. ACOG has issued a statement indicating that they are unaware of data on pregnant women that support the FDA's claims. They go on further to state that these warnings may cause patients and providers to inappropriately reject the use of these medically indicated drugs.” As a practicing Obstetrician, I can imagine the difficulties this warning is going to cause with pregnant women who need surgery for trauma, gallbladder removal, appendectomy, or even C section where spinal blocks or epidurals do not work or are contraindicated. 

Back in the good news department, Texas, of all places, has produced seven lawmakers that have filed bills for the upcoming legislative sessions seeking to "eliminate the sales tax on feminine hygiene products". The state of Texas has a 6.25% sales tax on all retail sales. Additionally certain local entities can impose an additional 2% tax. Currently certain hygiene products such as pads, tampons and menstrual cups are designated as luxury items and as such are subject to the retail tax. Changing this law would repeal this so-called"Tampon tax" which is considered unjust because it targets only women. Besides, everybody knows these items are not luxuries, they are necessities.

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

Wellness Wednesday: A Thousand Small Cures

Not a day goes by that I am not asked about one “cure all” or another. Wellness Wednesday has been a column devoted to just the opposite- the many, sometimes small things, which done repeatedly, amount to the “cure”. The “cure” offered by longstanding attention to wellness is none other than prevention. 

Even when unpreventable illness or injury happens, wellness behaviors can make the difference between a good outcome and a bad one. We have so much power over our health but people scarcely realize it. Some realize it but are not up to taking that responsibility. It feels better to ascribe their poor health to genes, “toxins” in the environment, or something else. Strangely, empathy rather than blame is in order here. Why ? Because empathy is empowering and empowerment works. Once people get the message (though empathy) that they are not alone, they have the courage to begin improving their health related behaviors. 

Taking charge of your health is easy and empowering from day one. That is the secret that popular media and medical professionals alike keep obscuring. It is not so much a matter of discipline as it is of planning. It need not take place all at once. Once people get the message that wellness behaviors are easy, and need not be hard to be helpful, they are more apt to do them. 

How do people get these messages ? There is of course the popular media. To find this material about health maintenance you must be seeking it. These people are already on the right track. But what about others ? Here is where I believe the responsibility falls on all doctors to talk to patients about their health maintenance. Even before that, I believe it behooves all physicians to set a good example in this regard, and keep themselves as healthy and fit as possible. Nobody is perfect, and nobody should be held to an unrealistic or extreme standard. Yet, doctors should practice what they preach and lead by example. 

Physicians offices should be set up to refer liberally to nutritionists, physical therapists, counselors and others who can specifically teach and monitor health maintenance behaviors. Physicians themselves should learn how to discuss sensitive matters like weight. They should ask about life at home and work to screen for interpersonal issues or abuse. 

It is my hope that popular culture will increasingly embrace legitimate ideas about nutrition, fitness, mental health, and health care.  By now, most people know how ideas travel though communities and social media. Good ideas are sticky, and should be circulated. For example, food and workout posts which we love to hate actually bring these ideas to the fore. 

My website is a repository for health information related to Obstetrics, Gynecology and Health Maintenance. However, it has a limited readership. My plan to curtail blogging to Medical Mondays only is an attempt to get "more bang for the buck” and try another format for distributing this information. There are a couple decent books out there in this subject area, but mainly the field is lacking. I will be looking at the possibility of an ebook versus apps to serve as resources for women looking to improve their health. I hope you stay with me along the way. 

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

For the first time in many months, there is nothing new to report about the Zika virus. I am going to take this is as a good thing and report on the rest of the news. 

With the end of 2016 approaching, ACA (Affordable Care Act) signups have reached a new high. At the same time many fear loss of their contraceptive method if the ACA is repealed. The ACA as it currently stands, pays 100% for contraceptives. 

The ACA seems to have enabled more people to keep up on preventive care. Also according to a new study, the number of adults who skipped recommended medical care fell about 20 % between 2013 and 2015. Similarly, a new Vanderbilt study showed that patients accessed emergency department care more quickly since cost was not a consideration in choice of hospital.  

Texas has noticed all Planned Parenthood Clinics that it is removing them from the Medicaid Program. This means that no Medicaid recipients may be seen at Planned Parenthood, which normally serves predominantly the Medicaid population. I’m wondering if this will have unintended consequences. For example, perhaps Planned Parenthood will have to start filing their clinics with well insured women, while the private and hospital owned clinics uptown will start to fill with medicaid patients ? It will be interesting to see how this will play out. It almost certainly will mean less access to care and a shift in who sees whom. Planned Parenthood is appealing the Texas Health and Human Services Division. 

ACOG (American College of Obstetricians and Gynecologist) has officially endorsed 30-60 seconds of delayed cord clamping. This procedure allow baby to get more blood from the umbilical cord. This is especially beneficial for smaller, early babies, but can be good for term babies as well. It results in higher blood hemoglobin counts, but also, understandably more jaundice, since jaundice comes from the breakdown products of blood cells. As an obstetrician, I can tell you that this works out most of the time. However, if baby is not breathing well, I get them to the nursery staff right away. Also, if there is excess maternal bleeding, we cut this procedure short, and move to get the placenta delivered. 

On a personal note to readers, I have appreciated all the attention to my posts. However, I plan to curtail my blogging to once a week come January 1st, 2017. I will continue Medical Monday since I believe this information to be very important to you. Additionally, I do plan to put out an occasional digest of existing website pages and posts on selected topics, which I think will be high value. However, based on my numbers of readers and subscribers, it seems clear to me that I need to get my information out in more accessible forms, such as in books or apps. There is so much material on the site now, that most topics are really well fleshed out, though the material is deep in the pages. I will need some time to pull this content out and organize it. At the same time, you are of course welcome and encouraged to access the website anytime via the menu, the search page, or the blog tags on the right of the home page on your own and free of charge. My website will be there free for all as an up to date medical resource.  

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

A total of 4575 Zika cases have been documented in the United States including 1172 pregnant women. We are now beginning to collect data on these pregnancies and the resultant births. It turns out that about 6% of Zika infected pregnant women in the US had a baby with at least one birth defect. This new research was published in the Journal of the American Medical Association. The data was gleaned from a total of 442 Zika infected women who completed their pregnancies this last year in 2016. In stratifying this group it was discovered that those who were infected in the first trimester had an 11% chance of delivering a child was birth defects, higher than the average of 6% indicating that Zika poses the greatest risk earlier in the pregnancy. Moreover, these rates are on a par with what is being seen in Brazil at this time indicating that the virus is working in a similar way in both populations. 

Personally I see these numbers evolving as the duration and post natal effects of Zika virus have yet to be fully described. CDC (Centers for Disease Control & Prevention) researchers have indicated that Zika can replicate in the fetal brain for up to seven months after the mother has become infected with the virus. They have noted that babies born to Zika are very likely to have brain damage even in the absence of obvious abnormalities like microcephaly and that the virus may keep replicating long after birth.

The CDC  has added Brownsville Texas to its list of Zika travel advisories. This is because five locally transmitted Zika infections were recently reported. Texas has had a total of 274 Zika cases.

Also in Texas news, it has been discovered that a booklet titled “A Woman's Right to Know" was revised earlier this year to contain misinformation about the relationship between abortion and breast cancer risk. This booklet must, by law, be given to any woman seeking an abortion. 

New research published in the journal Science Translational Medicine as reported that researchers have described two antibodies that appear to be important in the fight against Zika. Apparently these two antibodies were able to eliminate Zika virus in animal subjects in the lab. Hopefully we will hear more about this in the future.

In other news, fears about the repeal of the Affordable Care Act continue. Republican lawmakers are gaining appreciation for the ramifications of a fast repeal including the loss of insurance by over 50 million people and a huge loss of revenue for hospitals across the country, on the order of $165 billion dollars. Even with fear of a repeal looming, sign-ups for the ACA are occurring at a higher rate compared to this time last year. Moreover the Fed is extending the healthcare.gov deadline until Monday, December 19th. 

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

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

Zika has crossed the Atlantic to the United Kingdom. There are 265 known cases there already, including one whose transmission is believed to have been sexual. People traveling from moderate or high risk areas are asked to abstain, or contracept and use reliable barrier methods. HA ! That’s an oxymoron: reliable barriers. 

It is winter in North America, and that includes the US territory most affected by Zika: Puerto Rico. While Zika transmission continues, it is decreased at this time of year, due to reduced mosquito activity. Attention turns now to the pregnant Zika infected women. There have been 2600 confirmed cases of Zika in pregnancy in Puerto Rico. Many have miscarried, but many are yet undelivered. 

Texas now joins Florida as the only continental US state to document a local transmission of Zika. Local transmission means a Texas mosquito bit a person in Texas and transmitted the Zika virus. What this says about the number of mosquitos in Texas which have Zika is unclear, but it says something. Until now, all other Texas cases of Zika have been linked to travel. 

In other news, the ACA (The Affordable Care Act) has top billing. As mentioned last week, the ACA is now integral to our healthcare system and cannot be easily dismantled. Twenty million Americans now depend on the ACA for their health care. It is becoming more widely acknowledge that for the time being, it will have to stay as it is, notwithstanding the change in administration. Enrollment for 2017 is beginning, and it seems, continuing apace, 2.1 million so far, despite GOP’s vows to dismantle it. 

GOP lawmakers have started discussions with insurers to try to prevent a collapse of the insurance market if they pass a repeal of the ACA. GOP lawmakers are now indicating that it may take them “ years” to repeal the ACA, hopefully more than four. 

As a physician, completely unrelated to politics, I am for some form of the ACA. I have seen women whose only health care was during their pregnancy, who can now come in with pride just for their annual. They are able to get the recommended screening tests, and can begin to think about health maintenance and limiting family size if they chose. I know, as a physician, that prevention saves money. I also know that disease caught early and treated is far cheaper than disease caught late. GOP lawmakers MUST factor this in if they are to modify the ACA or create their own plan in such a way as to make it affordable and sustainable in the long run. 

The GOP is mixed on the Medicaid expansion. Many Republican Governors are glad to get so many more or their poorest patients insured. 

New research published in the Journal of Women’s Health indicates that women with chronic conditions do worse without access to the internet. This may have to do with access to information and social connections with others, especially others who share the same conditions. 

Many women and many providers believe that there is an age cutoff after which mammograms are no longer beneficial. I am unaware of such data. New research using data from 6 million mammograms between 2008 and 2014 confirms there is no clear cutoff point. Mammogram decisions should be made between a patient and her caregiver, and factor in the best available data and the patient’s overall health. 

Tom Price, the Health and Human Services Secretary elect is said to be both anti-abortion and anti-birth control. It is beyond me when someone who is anti-abortion is also anti-birth control. The theoretical planned repeal of the ACA will not ban these things per se, but a report out of Kaiser indicates  that the costs of contraception will rise during this time period. Drug costs across the board will likely rise whether or not the ACA is repealed. 

In the good news department, the House, in a landslide vote, passed the 21st Century Cures Act. This provides an increase in finding to the FDA ( Food and Drug Administration) by $500 million, for drug development and testing,  and would also provide $1 billion to address opioid addiction. There’s a billion dollars we theoretically should not have to spend but, we do. This is why we cannot have nice things. 

Planned Parenthood, ACLU, and the Center for Reproductive Law and Policy are filing lawsuits which challenge several laws which limit women’s rights to various reproductive services. The lawsuits are arising as quickly as the limitations these days. 

The House Energy and Commerce’s Subcommittee on Health has taken what I consider to be a monumentally positive step in reigning in the US Preventive Services Task Force. They have recommended that the small, non-clinical committee receive more input on formulating their recommendations, from (surprise!) medical authorities before they make recommendations which influence patient care and insurance coverage of various screening procedures. The bill comes from Republican Marsha Blackburn from Tennessee who has pointed out that USPTF recommendations on many issues pertinent to women’s health including mammograms differ from those of, for example, ACOG, the American College of Obstetricians and Gynecologists. The bill provides for input from both primary care medicine and specialist authorities. Bravo Representative Blackburn, and bravo to you for reading all this. 

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

Medical Monday: Breaking News from the World of Obstetrics andGynecology

Regular readers of this column know that for many months we have started with news pertaining to the Zika virus epidemic. This is of special interest to those in the field of Obstetrics and Gynecology, since it is both perinatally and sexually transmitted. This means that once a person acquires Zika virus from a mosquito, she may pass it to her unborn child, and anyone may pass it to a sexual partner. Zika has been widespread in South and Central America and has come as far north as the southern part of the United States. During the warm spring and  summer months, officials were frantic to control it, employing measures of all kinds, but without anything truly effective. Many thousands were infected, and many of those were pregnant. This column has not only served to educate readers about Zika; it has also documented in realtime the painstaking progress of work that has been done, bit by bit, to understand and control the disease. 

As a physician of 27 years, I have read about many disease processes. I have never, however, witnessed the observation, diagnosis and gradual clarification of a new disease quite like this. I was in college when HIV/AIDs came to the fore (1979-1983), but by the time my third year of medical school (1987) had come along, we had wards of patients with HIV/AIDS related complications like Kaposi’s sarcoma, pneumocystis  pneumonia, and disseminated herpes. We understood only a bit at that point, and we felt rather helpless. I am by no means a caregiver on the front lines of the Zika Virus battle. However, I can imagine how they must feel, based on my limited experience with HIV. 

Zika is different in that in can affect the next generation. HIV can also be passed perinatally and also by sex. However, when it affects a baby, it leaves that baby neurologically and developmentally alone. Not so with Zika. For some reason, Zika targets the baby’s brain and sets some process into motion which disturbs and potentially stops the brain's growth, while the rest of the baby continues to grow. As with other perinatal viral infections, contracting Zika early in pregnancy makes matters worse, and interferes with development at an earlier stage. This makes sense. However, the latest revelations about Zika are even more troubling. A new study by the CDC (Centers for Disease Control) indicates that a Zika affected mother may produce a term baby who appears entirely normal at birth. However, that baby may well go on to develop microcephaly, the hallmark of the Zika's affect on the central nervous system. This seems to indicate that we do not know how long the effects of Zika virus infection can last. It raises questions about newborns, toddlers, or growing children getting their own Zika infections. This has far reaching implications for how all families in Zika affected areas live their lives. It clearly has implications for the medical community and society at large. 

Meanwhile, the WHO (World Health Organization) has declared that Zika is no longer a public health emergency. Well, of course it is. However this designation simply means that the crisis should no longer tap emergency funds, but rather should have it’s own proper ongoing budget. Nonetheless, some authorities feel this is premature, and have urged the WHO to reevaluate the decision come warmer weather. The CDC, by contrast, will retain Zika at the highest emergency level. Brazil, the epicenter of the outbreak, will continue to consider it an emergency. The hope is that these deliberations and administrative designations will not get in the way of efforts at infection control, basic research and of course, the much hoped for VACCINE. 

In other news, a new study has emphasized the importance of thyroid function in pregnancy. The immune system changes in pregnancy and so does thyroid function. Not uncommonly pregnancy is the time when low thyroid is diagnosed. This new study has highlighted the very important fact that optimizing thyroid function in pregnancy improves birth outcomes in measurable ways. We know that seriously low thyroid functioning pregnancy is associated with mental deficits in children, a condition called Cretinism. However, optimizing thyroid replacement also prevents still birth, and low birth weight infants. 

 A majority of the news otherwise on this short week had to do with the new administration’s plans to dismantle or alter the ACA (affordable Care Act). As time goes by, we hear different things about this. I get the feeling that reality will set in and that pragmatism will have it’s way with lawmakers and their promises. Perhaps the new administration will be satisfied if they can shuffle and rename a few things, then take credit for the good ideas. 

Wellness Wednesday: DNA testing

Your DNA is the code to your programming. It is literally your genetic code. It determines your physical makeup, from appearance, to reproductive potential, to disease states. It may also determine certain hardwired aspects of temperament and cognition. Wouldn’t such information be useful for maintaining health and curing disease ? The answer is of course yes. However, the science of the use of DNA for medical purposes is still in its adolescence if not its childhood. 

DNA (deoxyribonucleic acid) is made like a set of modular children’s toys, K’nex for example. The subunit is a pair of tiny molecules called bases which bind to one another to make a base pair. These are held in a long structure like rungs on a ladder, and this ladder itself bunches and curls depending on the particular molecular sequence of base pairs. A certain series of base pairs codes is a gene for the manufacture of a certain animo acid, and strings of amnio acids are the proteins of which we are made. One famous gene mutation is BRCA, which allows breast and ovary cancers to form much more easily. Another is the gene for ALS ( Amyotrophic Lateral Sclerosis) or Lou Gehrig’s disease, which afflicts Stephen Hawking. 

DNA contains the keys not just to disease, but to health as well. Understanding DNA can help us understand any inborn vulnerabilities to disease in time to take action against them. Understanding which genes go with which diseases may help us come to understand how diseases are caused, and thus, how to cure or mitigate them. The vast majority of human genetic material, also called the human genome, is not understood. However we all have DNA, and we all have a health history, even if all that it says is that we are healthy.  Just think: If we had lots of people record their health history, and the same large number of people sequence their genome, we could use modern computing power to look for patterns between the clinical histories and the DNA. 

DNA tests are now sold direct to consumer (DTC). People are using them to search for their ethnic heritage. This is an imperfect science, and it can only narrow it down to a continent level. Some people use DNA tests to find long lost relatives, but results depend on your long lost relatives having been tested as well. 

I have been thinking about giving my family members the gift of DNA testing. My initial thought was simply to throw our data into the big pool, and add to the collective accumulating accuracy of DNA and disease correlation. It was also my hope that in the process, it would be useful in the future, when hopefully, health enhancing measures could be taken based on a person’s specific DNA profile. 

There is another kind of DNA testing which I should mention for completeness. It is testing for specific genes, and not just testing to view the whole genetic code. Physicians and researchers test for specific genes when a person’s family history is strong for a certain disease process, say colon cancer. If the unaffected relative tests positive for the risky gene, preventive measures may be able to be implement to help them avoid the disease. Genetic tests can also be done on tumor cells themselves to determine what treatment is the absolute most targeted for the specific tumor cell type. This is becoming the norm when treating breast cancer. This helps both improvement in outcomes and decreases side effects of treatments not likely to be helpful. 

In doing the research for this post, I have discovered some good advice. First, it is important to think about why you want this information. Do you really want to know about long lost relatives ? Do you really want to know your ethnicity ? What if it is not as you expected ? What if you discover a gene for a bad disease that you do not already have ? 

There are several companies that do DTC DNA testing. I found a good chart which details some of the differences. 

http://isogg.org/wiki/Autosomal_DNA_testing_comparison_chart

Some systems of testing, analyzing and reporting are better for genealogy, and some are better for medical care, and still others are best for research. Some tests go deeper, and research paternal or maternal family lines, but this requires analysis of the X and Y sex chromosomes, rather that just the autosomal chromosomes. 

All of the tests are expensive, ranging from $79 to over three hundred. My research has raised more questions that it has answers. I plan to speak to our genetics counselors at our hospital to see what they think and I will get back to you about what they say. 

Meanwhile, it is Thanksgiving week. It is a good time to think about being grateful for what you are and what you have in the present. You may be coded by genes, but that is not the whole story. Our genes are not a static set of molecules. Instead, they switch on and off like the holiday lights that people are putting up this season. Additionally, a lot of this gene regulation depends on lifestyle choices. This is where we can leverage our health habits to make the most of the genetic cards we have been dealt. 

Happy Thanksgiving 

More reading: 

http://www.legalgenealogist.com/2015/02/02/2015-most-bang-for-the-dna-buck/

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

The World Health Organization will have convened on Friday to evaluate whether Zika is still to be classified as a “ public health emergency of international concern.” I am not sure of the criteria for such a classification, but it does not seem to me that we have yet seen most of the consequences of Zika in those yet to be born. Furthermore, it is not clear how Zika will fare though the turn of the seasons. 

The effects of Zika are generally serious to devastating. It is fascinating and confounding that these effects vary by geography. This means Zika has different effects depending on where the infection is contracted. The American Society for Tropical Medicine recently convened and examined this question which needs much more formal study. 

Women are more likely to get Zika from men than men are to get it from women. This is because the virus is now believed to suppress the vaginal immune response (Vaginal immune response ! Who knew ? ) and thus go undetected so it can establish infection in both mother and baby. 

Blood banks in affected states have been screening for Zika. Only 40 out of 800,000 positives have been found. This is not meant to represent an assessment of Zika prevalence in these states since the people who come to donate are screened and kept from donating if they have risk factors for the infection. 

In other news, there is another option for women with vaginal atrophy. Many older women and those who have had cancer have vaginal atrophy, which manifests as dry, thin, inelastic tissue. It also manifests as pain during intercourse. Fourteen percent of all women have low equal desire and sex related personal distress. Part of this in older women may related to vaginal atrophy. Unfortunately, this is not always addressed at the doctor’s office. Many such patients are not able or wiling to use vaginal estrogen. They may now use DHEA, dehydroepiandrosterone, an adrenal androgen, as a daily vaginal capsule, to help with this. The trade name will be Prasterone and it has recently been approved by the FDA ( Food and Drug Administration) for this use. 

The idea of using vaginal estrogen in breast cancer survivors has, until recently, not been considered due to concerns that the hormone enters the systemic circulation and might cause increased risk of recurrence. However a recent study published in JAMA Oncology has shown that estradiol secreting vaginal rings and intravaginal testosterone cream are both safe and effective therapies in those breast cancer patients who are receiving aromatase inhibitor (AI) therapy. 

In insurance news, President elect Trump has indicated that he favors preserving the prohibition against insurers denying coverage due to preexisting conditions. He also favors allowing parents to keep children on policies until the age of 26. An article in the Wall Street Journal recently opined that keeping these provisions without keeping the universal mandate (requirement for everyone to have insurance or be fined) and the funds it would bring in, would strain the coffers of health insurance companies bound to keep the first two provisions. 

At this point, hearsay reigns in matters of the new administration’s policies. Before the election, Republican politicians spoke of eliminating the individual mandate on health insurance. Now, there is talk of revamping it. Similarly, and more realistically, it is said that Medicaid under the new administration is more like to be altered than it is to be shrunk, as Republican candidates suggested. 

This column has covered the falling teen birth rate. Recent analysis of this data has shown that this is the case much more in urban compared to rural areas. Between 2007 and 2015, the teen birth rate fell 50% in cities, but only 37% in rural areas. Teen birth rates fell most among white and hispanic girls. 

In related news, a recent study in the American Journal of Public Health showed some interesting relationships between childbearing and longevity. Over 20,000 women were followed for over 16 years. Researchers discovered that a larger number of children is associated with less longevity in black women, but more longevity in white women. They also found that women who delay their first birth until at least 25 are more likely that their counterparts to live until age 90. 

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

Wellness Wednesday: Post Election Stress Disorder

PESD is not a diagnosis listed in the DSM-5, the widely used manual of psychiatric diagnoses. And yet professionals and ordinary people are seeing it. The morning after the election, I saw and heard about it everywhere, from people on both sides of the aisle. Yes, that’s right, from both sides of the aisle. 

I have heard from hither and yon that people felt that our presidential election was a choice between lesser evils. How sad and disturbing to wake up and have a lesser evil for your President elect. How sad to have members of a family or friends fighting, arguing and estranged. 

While there may not be such a thing as PESD, there certainly is PTSD, and the signs are clear: 

• sleeplessness
• undue tearfulness 
• nightmares
• intrusive memories of past traumas
• disinterest in food or inability to eat

Women have been particularly affected. Regardless of politics, no woman has supported Trump’s vulgar and abusive treatments of women. To seat him in the highest office in the land has made many of us feel vulnerable, on an institutional and cultural level. Election is endorsement, and endorsement is usually approval, though in this election, it certainly has the feel of concession. Events of this campaign show that while our society has made great strides toward fairness and decency towards everyone including women, sexism is still alive and well. 

Today’s sexism is not as bold as it once was. Nowadays, it can be workplace bullying, or being passed up at meetings or for raises. It is unwanted subtle advances. It does not have to be “pussy” groping, though now that has officially been recategorized at the highest levels as “locker room talk”. It is being made to feel odd because you were a girl who was also a math and science nerd. 

Lucky for you, I am a math, science and numbers nerd. And I don’t feel the least bit odd. Here is what the numbers had to say, before the election even took place: 

• 10 % of women suffer from PTSD. 
• 31% of women suffer form an anxiety disorder
• 12% of women suffer from depression
• 25% of women will experience a sexual assault in their lifetime
• 33% of women report having experienced sexual harassment in the workplace
• 100% of women report experiencing some type of sexual harassment in their lifetime. 

reference : 

https://www.psychologytoday.com/blog/workings-well-being/201611/post-election-stress-disorder-in-women

Are we women really doing so well ? The number are roughly half this for men for PTSD, anxiety and depression. The election has caused us to collectively and individually revisit much of what has troubled us.

What to do ? 

First of all, this needs to be taken seriously. It needs to be taken seriously on a personal and a societal level. If you know someone who was derailed by the election, make yourself available. Practice empathy and be a good listener. Do not debate politics, or ask about the the innermost workings of their mind or heart. Suggest general stress reduction techniques like regular meals, exercise, yoga, and sleep. Suggest a visit with a counselor or physician if there is genuine disruption in health or regular life activities. Do not force a plan on them. Do not add to their overwhelm. I am guilty of constantly trying to fix people even if what they really need is space. If you try to help too much, it feels like you are trying to take control and this is disempowering, pretty much the last thing they need.  

I learned a new phrase when researching this post. It is, HOLD SPACE. This means to create a safe space for someone, a space where they will not be judged, and where no one will try to change them. It is space where they can be heard. It is unconditional support. I will be researching this gem of a concept further. 

Have a better week. The holidays are coming. Take some time to plan to make them low stress and lovely. 

Additional reading: 

http://www.huffingtonpost.com/news/election-stress/

http://www.theatlantic.com/health/archive/2016/11/how-to-cope-with-post-election-stress/507296/

https://www.wired.com/2016/11/critical-role-self-care-handling-post-election-stress/

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

After a season of crisis with the Zika virus, the director of the CDC, (Centers for Disease Control) Dr. Thomas Frieden, has stated that the Zika virus is not “ controllable with current technologies.”. He has also indicated that he believes Zika "will become endemic in this hemisphere.” He states a Zika vaccine is probably 2-3 years away. 

Delays in public funding to combat the Zika virus in Florida have motivated private and corporate donors to step up. Pfizer, contributed $4.1 million, and Community Health Charities and March of Dimes will contribute and fund raise. 

The CDC (Centers for Disease Control) and ACOG (The American College of Obstetricians and Gynecologists) have identified use of long acting lot reversible contraceptive, or LARCs, inserted in the immediate postpartum period as key in curbing unintended pregnancy. Happily, many states are changing Medicaid regulations to cover IUDs inserted immediately after delivery. LARCs are highly effective safe methods of birth control which require little in the way of maintenance or remembering on behalf of the patient. The complication rate is low but not zero. Complications that do exist are well described and manageable.

At my institution, we practice evidence-based medicine. Moreover, Obstetrics and Gynecology is a very highly studied and regulated field. Because of all of this, many of our practices for example on the labor unit our policy driven. For example, we permit and encourage laboring in water because the literature shows that has clear benefits and no known side effects.. Others have also advocated, In the absence of any supporting data, for birth in water as well mistakingly assuming that amniotic fluid is similar to water. Indeed, as regular water is irritating to your respiratory passageways, so it is as well to the respiratory passageways of a newborn. Based on this,we do not endorse water birth. Updated guidelines from ACOG indicate that the first stage of labor may take place in water but when it comes time to push women should get out.

American College of Obstetricians and Gynecologists sponsored a special briefing last week in Washington DC on the subject of us maternal mortality rates. United States overall maternal mortality rates are actually increasing in contradistinction to the rest of the world. They are increasing disproportionately among minority women particularly African American women.

A recent study by Harvard researcher Dr. Julie Silver indicates that female physicians are still chronically underrepresented as healthcare leaders. She indicates that this may contribute to the persistent salary gap that exists between male and female physicians.

While women and men are still not equal in many ways, equality has been gained in one category. The British Medical Journal recently presented research which indicated women are now drinking as much alcohol has men. The differences between men and women in three categories, any alcohol use, problematic alcohol use, and alcohol-related harms, are diminishing.

We have two items in the "We are already knew this” department. First, education and support may help women stick with breast-feeding. This groundbreaking research was supported by your tax dollars through the Department of Health and Human Services Agency for healthcare research and Quality through the US Preventive Services Task Force. Were we unwilling to provide education and support to potentially breast-feeding mothers before the dawn of this research conclusion? I think not.

Secondly, scintillating new conclusions published in the Journal Menopause indicate that women experiencing menopause symptoms may do better in a comfortable workplace. They break this down and indicate that the workplace should be comfortable. Moreover the patient’s boss should be supportive. Another victory for common sense and human decency !

In the possibly actionable department, a new study finds that good pain relief during labor may be associated with lower postpartum depression scores. An observational study presented at the annual meeting of the American Society of Anesthesiologists has found this result after evaluating 201 postpartum women. Studies of this nature are suggestive but not conclusive.

Here are a couple Halloween party food pictures that I promised. Have a happy and safe Halloween.

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

As the northern hemisphere encounters fall and winter weather, mosquito activity and the risk of Zika infection by mosquito falls but does not go to zero. Of course, sexually and birth related (perinatal) transmission are not affected and can continue unabated. 

Researchers at the University of California, San Diego, have honed in on the mechanism of action of the Zika Virus on human cells. It appears that Zika virus alters our RNA directly. 

We now know that Zika can persist in vaginal secretions for two weeks after onset of infection. During this time, a woman can pass infection on to a partner. Additionally, it has been determined that Zika is detectable in serum ( the liquid portion of blood) for a week. However it is present in whole blood for at least 80 days. These insights have been made possible through the contribution of one particular patient infected with Zika since the beginning of the epidemic. Through frequent and repeated testing on her, we have been able to ascertain these findings. We use a debt of gratitude to this female Zika patient who has allowed herself to be the subject of invasive scientific study since the beginning of the crisis. 

Everyone has heard of menstrual migraines. Some happen right before the period and some happen during the period. Those preceding the period are believed to arise from sharply falling estrogen levels. It turns out that the late-cycle migraines may be related to low ferritin levels from the blood loss of the period. This could lend insight into prevention, which of course might involve ongoing iron supplementation. 

In the things-we-already-knew-but-had-not-yet-been-conclusively-documented department, research published on the Arthritis Care and Research site indicated that systemic lupus wanes during pregnancy and flares in the postpartum period. Nonetheless, the research is quite welcome in that it sheds concrete insight into the baseline mechanisms of lupus and autoimmunity in women. Autoimmune disease as a whole is prevalent and predominantly affects women. Most patients are on current treatment strategies which decades old and are rife with significant side effects. This lupus patient applauds any sound research into autoimmunity in general and lupus in particular. 

Also in this same journalistic department we are now assured that smoking and alcohol are linked to 11 of 15 of the worst cancers. By worst, we mean those cancers most "responsible for premature death and loss of healthy life years”. Any second year med student can assure you conclusively of this. 

Pediatricians are being encouraged to change their counseling of parents about the HPV (Human Papilloma Virus) vaccine. Instead of highlighting the prevention of sexually transmitted HPV infection which can lead to warts, they are being encourage to highlight the cancer prevention aspects of the vaccine. It would be nice if we could simply explain that the HPV virus causes genital warts, precancerous changes on the cervix, which can then develop into cervical, vaginal, penile and even oropharyngeal (mouth and throat) cancer. I am tempted to think that we oversimplify subjects too much for people. People are capable of understanding a great deal if someone takes the time to explain it to them. 

In related news, new data has demonstrated that those children who obtain the HPV vaccine before 15 years of age only need two shots rather than three. Even more incentive to gets your kids done ! 

New research from the Agency for Healthcare Research and Quality have show that the C section rate for low risk patients is about 16%, whereas the C section rate for high risk patients is about 76%. Intellectually, I am a splitter rather than a lumper. Consequently, thinking about C section rates in this way is much more useful that saying, the C section rate in the United States is about 32%. I think information presented in this way will help patients understand their own risk factors, and how to prospectively stack the deck in their favor in the future. 

Here is some sobering but critically important news that I suspect will be woefully underreported. Maternal body mass index (BMI) is inversely correlated with newborns’ telomere length. Whoa, what does that mean ? Basically, the heavier a mother is, the less robust her newborn’s DNA strands will be. DNA is protected at it’s ends by segments known as telomeres, and when they are short, DNA is more apt to be damaged. Shorter telomeres means shorter DNA lifespan, which most likely means shorter lifespan overall. 

We have all heard by now of the micro biome, which means the healthy or not so healthy populations of bacteria and other organisms that populate our body. Women mostly focus on the micro biome of the vagina, knowing that if it becomes disturbed, yeast or bacterial vaginosis can result. However, the vagina is not the only concern. It turns out that the breast has a micro biome. Moreover, it turns out that breasts sampled and found to have benign disease versus those with cancer have very different micro biomes. This could be a clue to something, I’m not sure what. But is is a new and interesting concept. 

In disappointing news, the CDC (Centers for Disease Control) reports that rates of common sexually transmitted diseases have reached all times highs. This include syphilis, gonorrhea, and chlamydia. I’m going to give a shout out to bad parenting and network TV here. Thanks so much, guys. Oddly, syphilis was at an all time low in 2001, and gonorrhea was as recently as 2009. 

In surprising news, 43% of those with no type of health insurance could qualify for either Medicaid or coverage through the Affordable Care Act exchange. The reasons for this are unclear. I will say that some people seem to have quite a bit of trouble filling out the forms online. I have joked to my office staff that the government  should outsource both health care and the elections to reliable companies like Amazon or Google who can design a nice reliable website. 

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

Wellness Wednesday: Being Proactive

I found myself a little out of my comfort zone this week. I was working on a little app for the App Store, and I am new to developing. I had done my due diligence, reading, and going through the tutorials. And yet, things were just not working out how they were supposed to. I got a little down about it. I got a little mad about it. Tech support sent me a lame email back not really addressing the questions I had clearly asked. I put the project aside for a couple days. I thought, maybe this is just not my thing. Then Monday morning rolled around, and thought, I am going to wend my way through the phone networks of Apple Computer and find someone who can help me. Three layers deep, I did. The person I reached was amazing. She agreed that I had done all that I should have; She took on my cause and bumped it up the chain of command. Ultimately the advice she gave me worked. I looked back on the incident and realized how silly I was to have gotten discouraged. Only when I got proactive and reached out, did things get better. 

Proactive is the opposite of reactive. To be proactive is to be psychologically healthy. It means being the one who takes the steps to make your life what it is. It means to be responsible for one’s self, one’s thoughts, actions and circumstances. It means to be self-determined. 

To be reactive, on the other hand, is to be a victim of life. You life is determined by other people and other factors. What you do is a reaction to other factors which have happened “to” you. You may feel out of control or like a victim. 

Wouldn’t anyone want to be proactive ? You may want to become a proactive person. And yet, until you adopt the mindset and behaviors of being proactive, it would be very difficult. 

How do you become a proactive person ?

Responsibility

The first step is to realize that you are responsible your own well being and success.  Life hands people circumstances which range from good, to bad to ugly, and yet, mindset is the main determinant of how people feel and how they do in life. Remind yourself you are empowered in your life. Pin a pin, put up a poster, or do what you need to do to train yourself to remember this. 

Honesty

Also central to the process of being proactive is to understand your starting point. This requires honesty with one’s self about one’s present state. It is like talking a good hard look at the balance sheet of your life. What are the assets, and what are the liabilities ? Only then can you realistically plan for going forward. Train yourself to honesty. 

Accountability

To be responsible is to be accountable for yourself. In literal terms, you are the accountant of your life. You have the ability to set a budget, or a goal, and work backward to meet it. You are more than dreams and talk. You have real steps to realize your plans. You may even use the so-called SMART goals. (Click HERE to learn more.)You are reliable to others and to yourself. Train yourself to take regular inventory or your life. Train yourself to use SMART goals. 

Action

When you use SMART goals, you will get used to the idea that big goals are achieved with small steps. Furthermore, you will get used to taking small steps. Many people who haven’t realized their goals are simply not used to taking steps outside their normal routine. Being proactive means training yourself to get used to taking new and different steps as part of a larger, realistic plan. It also means training yourself to get used to the fact that meeting goals proactively takes time.  

Resilience 

When you become proactive in your life and start to take steps toward realizing your life goals, you usually encounter obstacles. These may derail or discourage you temporarily. This is natural. However, the proactive person must have resilience. This is the trait which embodies the best response to adversity. With resilience, the problem is acknowledged, analyzed and the steps of the plan are reworked. They are iterated, and reiterated.  With resilience, one has to train oneself to keep a flexible positive attitude, along with the idea that continual reiteration is part of the process. 

Communication 

In everyday life, being proactive is easier said than done. Everyone feels pressured, angry or frustrated at times. These are small everyday examples of being reactive. Sometimes even bigger situations like peoples' jobs or relationships are the result of being reactive rather than proactive.  Learning the emotional and communication skills associated with being proactive is no easy task. 

During challenging encounters, the natural reaction is fight or flight. Proactive communication requires acknowledgement of these reactive feelings, but not acting on them. Simply pausing, and breathing is an essential first start. In that moment, the feelings of anger, frustration or sadness are acknowledged and set on the back burner. Then a constructive response can be proactively made in accordance with the speakers highest and best ideas.

A proactive person also knows she has the right to defer. She can take time to think about things, calm down, or gather more information. She knows how to say these things the right way. She uses responsible closed loop communication. Responsible communication uses "I statements”, i.e.“ I think”, ,”I feel”, or “I need” or “ I want”.  In this way, you speak for yourself. You may not be listened to, but at least you have spoken up for your self, and your statement has the weight of authenticity which may well continue to sink in after the conversation. 

Closed loop communication has to do with listening well. When you speak, you are obliged to listen. Listen with full attention until the speaker is finished. Then use another “ I statement” , which is “ I heard….” then repeat back a nutshell version of what you thought you heard the speaker say. This is especially useful for challenging or complex conversations. It honors both the speaker and the listener and greatly reduces the chances of misunderstanding. 

Train yourself to breathe, pause, use "I statements", and closed loop communication. 

So you see that being proactive is a training process. Nobody has a charmed life. But everyone can use the methods of responsibility, honesty, accountability, action, resilience and communication to be more proactive and move toward the life they want. 

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

The genome of the Zika virus has been isolated. This is an essential step in learning about the virus and how to stop it. 

Meanwhile Zika virus continues its spread in southern Florida with three Zika transmission zones identified. Readers would do well to remember that Florida is still recovering from Hurricane Matthew and all the floodwaters are still receding. Florida has called on the Federal Government to help fund their fight against Zika. 

In chilling news, a new study out of Brazil indicates that Zika can affect a baby’s brain even if the mother contracts the infection a week or two before giving birth. This begs the question of whether newborns or even toddlers or beyond can incur damage to the growth of the brain by becoming infected. 

Breast and ovary cancer, among the most dreaded female cancers, both have new and promising therapies on the horizon. In the case of ovarian cancer, a whole new class of drugs called PARB inhibitors is showing improvement for all women with recurrent ovarian cancer. For breast cancer, an investigational drug Ribociclib combined with the older Letrozole, is showing significant improvement in PFS (progression free survival) for those with hormone responsive cancers. Such drug “cocktails" are becoming increasingly useful in the fight against many difficult diseases such as those from viruses or cancer. 

Researchers at Johns Hopkins Kimmel Cancer Center have created a free web based app to guide clinicians in their treatment of breast cancer. In these days of precision medicine, tumors can be subjected to ever more detailed molecular and genetic analysis to determine the best possible therapy. These are costly, which hopefully will change. For now, this app helps clinicians decide whether or not these more detailed tests are necessary. 

Have you ever heard of de-prescribing ? Me neither. Apparently this is when a physician takes a patient off medications. Physicians are increasingly trying to help patients avoid medication interactions or unnecessary medications altogether. I can imagine this being important in an internal medicine practice where patients have medication lists a mile long. 

Once again the value of mammograms is being questioned. This time it is in an article in the New England Journal of Medicine. Once again the concern cited is “ ...needless anxiety, treatment and expense.” Let’s be clear here, by “ treatment”they are referring to biopsy. And now that I think of it, use of this language is really irresponsible. Biopsy is not treatment in the case of breast disease. The authors indicated that over half of breast cancers diagnosed on mammogram are a case of mistaken identity…”. First of all, breast cancer is not a radiographic diagnosis. It is a TISSUE diagnosis. So, they could rightfully say, over half of all mammograms which are suspicious for breast cancer, are actually not on biopsy. This, to me is a cause for relief. Understand that if they want to decrease the mammogram frequency, they will increase the number of women with cancer who are picked up late rather than early. How many inconvenienced women are worth one who gets an early and more curable diagnosis of breast cancer rather than a late one ? I’d say many. Very many. How much inconvenience and expense is worth a life ? 

We are continuing to expand our understanding of how maternal obesity affects babies in utero, newborns, and even children into adulthood. Four recently published studies are showing these risks, and they include increased risks of stillbirth, diabetes, and blood pressure disorders of pregnancy. More interestingly, risks for children born to obese mothers of these same types of diseases persist into adulthood. 

Our national increase in maternal mortality is of paramount concern. Poor maternal health and the conditions which produce poor maternal health are undoubtedly to blame. Accordingly, experts are increasingly beginning to teach that women should attain a healthy weight and attain control of all their medical conditions before attempting pregnancy. 

In that spirit, I will report on a relevant and encouraging story coming from the International Olympic Committee. They have found that “ ...strenuous exercise during pregnancy doesn’t appear to increase the risk of most pregnancy complications for mom or baby”. ACOG (The American College of Obstetrics and Gynecology) has recommend institution or continuation of “ moderately strenuous” exercise during pregnancy as well. 

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