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

We will start off with novel and beneficial new research. A think tank called “Center for American Progress” has released an analysis of the current state of "sex ed” in America. They found the states to be, as a whole, deficient in teaching about issues of healthy relationships, consent and sexual assault. Only a handful (10) of states programs even mentioned these things at all. 

Backlash continues across states and the nation. Last week, Iowa passed a law which bans abortion once a heartbeat is detected. This contradicts the law on the books at this time, Roe VS. Wade. Iowa is being sued by the ACLU and various abortion providers. 

The Trump administration intends to cut all Title X funding to any clinic which even counsels about or refers for abortion. Eighty-five separate groups have signed a letter to HHS Secretary (Health and Human Services) Alex Azar to restore Reagan era regulations. 

The Trump administration has shown political and financial preference toward family planning clinics who promote only abstinence for birth control, even though it is neither effective nor evidence-based. Since family planning clinics have been organized and staffed by those who endorse evidence-based effective contraception not including abstinence only, this effectively defunds all family planning clinics. The States have a serious interest in this since they realize the health and prosperity of their populace depends on such services. In that light, the States Attorneys General have come together to back family planning clinics nationwide to sue the Department of Health and Human Services over its policy. They argue that the current policy violates the terms of Title X enacted in 1970 with bipartisan support. 

Should Medicaid recipients have a lifetime limit on benefits? Certain states, in cost-cutting bids, have been lobbying for this. However, the Fed, via the Center for Medicaid Services (CMS) has rejected these requests. In doing so, the Fed has broken rank with party conservatives. 

Care for women, pregnant women and postpartum women is not just germane to women. The health of women extends to others in the way that the health of men simply does not. Pre-pregnancy health, we are learning, is more germane to a child’s health than we previously realized. During pregnancy our opportunities to intervene to prevent morbidity and mortality are obvious. Less obvious are the manifold opportunities in the postpartum period. New recommendations from ACOG (American College of Obstetricians and Gynecologists) the Society for Maternal Fetal Medicine, and the Academy of Breastfeeding Medicine reflect a growing understanding that support in the extended postpartum period reaps many benefits. They now recommend that postpartum care should extend to 12 weeks and become a sustained period of support for the new mother and infant. It has come to light that for every 10 weeks pf paid job protected leave, infant mortality decreases about 5 percentage points. 

With the legalization of marijuana all around the country, more and more pregnant and breastfeeding women are using. Until recently, we had only vague warnings for these women. However, now new data indicate that using during pregnancy leads to a 50% increased chance of low birth weight. Use during breastfeeding is associated with decreased motor development in babies. 

The nation is indeed split on the issue of women and children. Part of the country is set on shifting away from collective responsibility toward women and children as they actually live. The current administration is intent on solidifying its base through supporting the explicit ideology of its voters, which gives women certain constraints in society:  abstaining from sex before marriage, using abstinence only for birth control, and rejecting abortion. The administration has combined these emblematic stipulations with their advertisement to cut taxes, and the result is that healthcare budgets for women have been slashed. And as if to add insult to injury, it is not at all clear if the money lost to the health care system will actually end up back in the hands of the taxpayer. 

The other part of the country is looking at the real problems of maternal morbidity and mortality. They are trying to solve problems with the best available science, rather than with ideology. States are beginning to realize that the lack of good routine health care, prenatal care, and postpartum care is expensive. It is expensive in the emergency room and in the workplace. Professional, scientific and legal groups are starting to fight back. 

ABC has just done what amounts to an exposé on the poor quality of pregnant and postpartum care in the US. This column has dealt extensively with the percentage statistics and trends on maternal morbidity and mortality. However, I have rarely included raw numbers. Here they are. In the US seven hundred women die each year in childbirth. Sixty five thousand more almost die. In a response to this program, ACOG has publicized its coordinated initiative to reduce maternal morbidity and mortality state by state. It is called AIM, Alliance for Innovation in Maternal Health. It has already been implemented in 18 states. 

Science marches on. 

New research indicates low levels of free t4 in pregnancy are associated with lower non-verbal IQ in children ages 5-8. Most caregivers are now including thyroid labs in their prenatal panels. Ask your doctor to be checked. 

BRCA genes are not the only genes pertaining to breast cancer. Newer multi-gene testing panels are now available for selected patients. Ask your doctor to speak with a geneticist if you are uncertain. 

Common sexually transmitted diseases are on the rise in California.  New data indicate that chlamydia is most increased in women in their 30s, while men account for the majority of new syphilis and gonorrhea cases. 

Fertility rates in the US have fallen to record lows for the second straight year. The same is true for several other developed countries. What are we to think? We know that at present, 50% of births are unplanned. As women become more educated and have more autonomy, birth rates naturally decline. You hear environmentalists’ concern about overpopulation, and politicians bemoan declining birth rates. The devil is, as always in the details. Certain subgroups in our population are decreasing and others are increasing. All of this will add up to social and economic change. I have one main concern: that growth be sustainable. Since my life’s work is mainly done one woman at a time, I am concerned that my patient's health habits and healthcare are sustainable. I am concerned that she have the means to grow her family or finish her family's growth in a sustainable way. I am concerned that my town and my countryside have sustainable growth. However, for me, growth is not the right word. I’d rather my community mature, or flourish. We shouldn’t always need more people, more buildings or a larger economy. What we need is for the family size to be ideal as determined by the parents. We need our towns to function optimally and to improve the space we have until it is optimized. The same is true for our nation. But our financial institutions are geared toward growth: more consumers, more goods, more profit. But this comes a human, societal, economic and ecologic cost. When we think about family size, birth control, population statistics, and even prosperity in general, we have to think about what we want our future to look like. When women lack access to health care, we cannot craft our futures. 

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

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

Health and Political concerns for women have merged into one. Many of you have appreciated this for some time, but now the topic is mainstream. 

Last Wednesday leaders representing over half a million medical students and doctors gathered to lobby Senators against the so-called BCRA (Better Care Reconciliation Act).Among the leaders were the Presidents of The American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists (ACOG). They validated and reiterated widespread concerns that without the ACA (Affordable Care Act) or similar, people will delay or forgo care. For example, under the new proposal, older patients will have cost sharing reductions curtailed in 2 year. The leaders also voiced concern about allowing individual States to determine what constitutes essential benefits. Dr. Munger of the American Academy of Family Physicians indicated this compromising essential benefits would constitute a special threat to people with chronic, rather than acute conditions, since their essential health needs are ongoing. The President of the American Academy of Pediatrics indicated that there will be a calculable “ body count” associated with this proposed law. 

Dr. Haywood Brown, President of ACOG, stated the legislation represented an “ assault on women’s health”. He elaborated, saying BCRA could result in women and men paying differently for health care. It would end the guarantees on preventive care, i.e screening tests like paps and mammograms. Dr. Haywood also noted that fully 50% of pregnancies are unplanned. The BCRA bill would end guaranteed coverage of contraception and maternity services. These changes would worsen the already terrible trends in maternal mortality in the United states. He states he feared going back to the time when having a baby could lead to bankruptcy, and when treatments for cancer were not always within reach. Indeed, the Journal Cancer has published a study containing projections of the numbers of increased cases of late-stage breast cancer that will be diagnosed during to loss of access to screening mammograms. As if to drive home the point ,the Journal Cancer Epidemiology contains new research indicating that breast cancers appear to have been diagnosed earlier after the ACA was implemented. 

California has its own contraceptive requirement, a goal that many States are now have accomplished or are working toward. The California policy, in place since the first of the year, requires that insurers cover contraception. It also requires that they cover 12 months of it at a time. It is estimated that in California, it will reduce the number of unintended pregnancies by 15,000, the number of miscarriages by 2000, and the number of abortions by 7000. Health care costs will be reduced by 43 million dollars annually. 

Low income women are at particular risk if the BRCA goes through, since it would phase out the Medicaid expansion in a more permanent way than the ACA would. Of note, half of all births in the US are covered by Medicaid. One fifth of all American women use Medicaid. 

Many observers have noted that BCRA healthcare bill disproportionately affects women, since it targets maternity, screening, and contraception. Bill Cassidy (R-LA) has come forward to say that the law should include provisions for all insurance plans to include prenatal care and for laws that require employers to grant maternity leave for both parents. Hooray for Republicans standing up for women’s health ! I did a little research and found that Senator Cassidy and his wife are physicians who feel this aligns with their Christian values. Why is this so rare ? 

Another group is at risk of losing affordable insurance: Those who obtain their health insurance through their work. The Affordable Care Act currently mandates that businesses of a certain size offer their employees health insurance. That requirement is due to go, all or in part, by the wayside. 

Modifications to the BCRA plan are under consideration. GOP senators had considered scrapping the “ wealth tax” on those families making more than $275,000, but now they are considering keeping it to help pay for extra funds to combat the opioid epidemic. Furthermore, GOP senators have conceded, at the urging of insurance officials, that the individual mandate be kept indirectly in that a penalty fee will be levied against all those who do not maintain health insurance at all times. Insurance industry representatives have asked for this to help stabilize the insurance market. Personally, I think it is an important part of any health care plan, since it requires people to prioritize their health, it enables people to comPlanned Parenthoode in for care especially screenings, and it protects patients, caregivers, hospitals and the rest of us paying insurance against direct or indirect financial loss due to health mishaps. 

Two GOP Senators, both women, have criticized the BCRA over its defunding of Planned Parenthood. 

Personally I think it would be just fine if the GOP scraps the ACA then puts it all back together piece by piece, gives it a different name, and takes full credit for it. I just hope that, being Republicans, they find a fiscally responsible and sustainable way to fund it. I favor heavy vice taxes. Why ? Because they discourage vices ( true and documented !) and they make lots of money for the public coffers. Cigarettes are heavily taxed, but they could get taxed even more. Alcohol could be further taxed. Soda taxes could be tried but have not been popular… too bad !  Finally, in my opinion, marijuana should be taxed in those States where it is legal, for all but those with legitimate cards. FaIling these, I favor increased gas taxes and increased sale taxes on luxury items. 

On to the medical news. 

Zika precautions for pregnant and potentially pregnant women are still in place. Travelers heading anywhere south of the Mason Dixon line should inquire on the CDC.gov website about regional risk. 

Opioids. These are the pain pills or IV drugs, the morphine derived compounds that are so addictive. It turns out they are not really that much help with actual pain. It turns out they work less and less well over time, and that eventually, they need to be taken just to feel “ok”.  Patients often begin them for legitimate reasons, but then end up taking them just to cope. They may not even realize they are addicted. Doctors give them for legitimate reasons, but also because they are lazy. It is hard to say no, especially when you think that saying no will cause your patient to leave your practice and medical care altogether. A new study has found that about half of opioids are given for mental health disorders rather than pain. Physicians and patients need to be educated. It is estimated that half a million people will die in the next decade due to opioid abuse, unwitting or otherwise. 

Flu vaccine may be delivered by a painless patch in the future. A new study published in The Lancet reports on this research. I wonder if this will enhance vaccination rates. 

Increased rates of air pollution are associated with shortened life spans. A new study published in the New England Journal of Medicine indicates that “ safe” levels may be lower than previously imagined. Indeed, there may be no “safe” level at all. 

ACOG recently held its annual meeting. New research presented there focused on media representations of female genitalia. Dr. Cheryl Iglesia noted that images of female genitalia are “highly-curated, and extensively retouched” before being presented on the internet, “ leaving men and women little idea of the real range of normal efface genitalia”. She has suggested that this distortion is associated with a sharp rise in labioplasty surgery in the last year. Ten thousand such surgeries were done in the past year, a rise of 23% compared to the previous year. ACOG has issued a Committee Opinion document “...expressing concern about the lack of data and deceptive marketing practices surrounding a number of cosmetic vaginal surgeries”.

So much news ! Stay tuned here next week … for Medical Monday. 

Meanwhile contact your elected officials at Congress.gov !! It's Independence Day ! Exercise your freedom !! 

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

By now the whole world knows that Trumpcare version 1.0, the American Healthcare Act (ACHA) has failed. For now, Obamacare, the Affordable Care Act (ACA), remains the law of the land.

This last Friday, the ACHA bill went to the floor of the House for a vote. However, all day negotiations proved fruitless to bring over Democrats or close the deep divisions between House Republicans. House Republicans broke rank with the President, but did so in two camps. First those on the far right “ The Freedom Caucus”, withdrew support because they felt the bill was still too costly and still too much like Obamacare. Moderate Republicans withdrew support because the ACHA gutted federally funded Medicaid and is widely believed to lead to the loss of insurance for a great many people, putting that burden on the States. Paul Ryan, recognizing the tally, pulled the bill before the vote. 

House Speaker Paul Ryan has indicated the GOP will keep working on heath care. One little publicized option is for the Whitehouse to sue to stop the Fed from paying insurers for work done under the Affordable Care Act. This tact was going on before the ACHA was brought to the House. Their argument is that these contractual payments from the Fed to insurance are invalid and illegal. 

One of Trump’s major campaign promises was to reform healthcare, indeed to provide “universal coverage”. Progressives favoring Universal Coverage may attempt an uneasy alliance in the service of this goal. Senator Bernie Sanders plans to unveil such a proposal entitled “ Medicare for All “. 

Policy news is moving at light speed and I recommend everyone start reading it from various reliable sources. I also recommend people familiarize themselves with their elected representatives and give them and their staff regular meaningful input. 

On to actual medicine. 

A new study from the Journal of the Academy of Nutrition and Dietetics indicates that most American women do not eat a healthy diet when they are pregnant. This is something we see in clinic on a regular basis. It is worth noting however the many women believe that they are eating healthy diet, even though they are not. These are well-intentioned people who have been taken in by advertising or who are victims of their busy schedules. Unless the physician or nurse midwife takes a detailed dietary history they will not know how their patient is really eating. Merely asking the person whether or not they eat healthy is not enough. People generally say they eat healthy and people generally say they are active or fit. That is because they believe it to be the case. Until people have objective definitions in front of them they cannot reliably answer these questions. Doctors take important shortcuts if they do not delve into a reasonable amount of history taking detail. When patients get specific explanations of exactly what we mean when we say "eat healthy", they're much more likely to do so. One of the problems of course, is that many doctors do not know precisely what it means to "eat healthy”. 

Four prior commissioners of the Food and Drug Administration (FDA) have produced a joint letter warning Congress about the legalization of importing drugs from other countries. Certain members of Congress have indicated that they would support this in an effort to reduce drug costs. In particular, the commissioners emeriti have warned against counterfeit, substandard and contaminated medications, since standards from other countries may not be adequate.

Pregnant women with HIV have a better chance than ever of avoiding transmission of their virus to their children. Preventive treatment including retroviral drugs given in pregnancy account for this progress.

In other viral news, a new gel treatment for genital and perianal warts is under study. These are caused by the human papilloma virus. The treatment is based on nitric oxide. Stay tuned for more on this nascent therapy.

Also regarding human papilloma virus, the American Society of Clinical Oncology has issued global statement regarding the primary prevention of cervical cancer. They recommend that all girls ages 9 to 14 receive two doses of the human papilloma virus vaccine also known as Gardisil. In the last few years there has been definitive evidence that Pap smears combined with this vaccination reduced the incidence of cervical cancer. The vaccine is also available for boys of the same age group.

Yet another study has demonstrated that exercise during pregnancy is safe and beneficial. This most recent study published in the Journal of the American Medical Association is meta-analysis of studies with more than twenty five hundred pregnant women. This is in line with ACOG (American College of Obstetricians and Gynecologists) recommendations which indicate "women without major medical or obstetric complication should get at least 20 to 30 minutes of moderate intensity aerobic exercise… on most days of the week."

In the concerning department, the FDA (Food and Drug Administration) has now linked anaplastic large cell lymphoma (ALCL)  to breast implants. This disease is a rare malignancy in the immune system which is statistically linked to breast implants, particularly those which have a rough versus smooth surfaces. The FDA has issued a statement indicating that women with breast implants have a very low but increased risk of developing ALCL compared to those who do not have breast implants. It is worth remembering that a statistical link does not prove causality. Concerned patients should speak to their plastic surgeon about this matter.

In other cancer news,  new research indicates that breast cancer gene testing is underutilized in America. A simple history in the caregiver’s office can identify whether or not a patient is at high risk of having abnormal genes, i.e. breast cancer gene mutation, or BRCA. Women with two first degree relatives such as a mother or sister are at high risk for having an abnormal gene and should explore the possibility of testing. Those patients with close relatives with any cancer should make sure their caregiver is aware of it. 

New research coming out of the Cancer Genome Atlas Project and the Cancer Research UK Database have indicated that only about a third of cancers are due to a special inherited genetic mutation. This means that two thirds of cancer-causing mutations arise spontaneously and are not able to be inherited by one's children.

We conclude with the good news department. A new device called the Alexis retractor is being tested across the world. Preliminary indications in Europe show reduced infection rates and reduced post operative pain after Cesarean section. 

Finally, many States are following another European lead and introducing baby boxes. Currently Americans put their newborn babies to bed in a wide variety of ways. However, clear research shows that the incidence of SIDS (sudden infant death syndrome) can be significantly reduced if babies are placed on a flat surface on their backs, head uncovered, in a special sleep sac or a one piece sleeper, and WITHOUT any blankets, swaddling, bumpers, padding or or toys. The sheet on the firm mattress should be fitted. The baby box programs are designed to provide all this teaching as well as an actual  baby box and mattress. For those who are not aware, the baby sacs are like insulated zip overalls with a closed bottom, which allow babies to move. They are not to be confused with swaddle wraps, which are also associated with SIDS. Babies typically wear a shirt and a diaper with it. Very cute inexpensive ones can be obtained at Ikea, Target and online. 

Here is an authoritative link from the NIH for those who want to learn more: 

https://www.nichd.nih.gov/sts/about/environment/Pages/look.aspx

Our photo for today's post was brazenly lifted from the pages of the National Institute of Health linked above. 

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