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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

On to the medical news. 

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

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

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

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

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

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

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

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

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

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

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

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

Medical Monday: Breaking News from the World of Obsteterics an Gynecology

As I step back and look through my last year of posts I am astonished to the extent to which politicians are getting deeply involved in the particulars of my profession, Obstetrics and Gynecology. This week's post underscores this in no uncertain terms. Is this really where we want government and politicians, right in the middle of a very specialized medical field, and right in the middle of the doctor patient relationship ? 

The New York Times has reported the the Trump administration plans to expand exemptions to the so called “ contraceptive mandate”. They are not abolishing the contraceptive mandate at this time. However, they are allowing employers to chose plans that do not cover birth control. These employers or insurers must be exempted on basis of “sincerely held religious beliefs”. 

It is my assumption that it is employers’ assumption that such plans which do not cover contraception are less expensive. However I feel entirely comfortable asserting that insurance companies know precisely where their dollars go, and they will not, for one minute, pass the savings on to the employer. That is because in about nine months after institution of this policy, there will be no savings. Seriously, do people really think that pregnancies and miscarriages will cost less than contraceptives ? 

As far as religious objections go, there are ostensibly several considerations. First, social conservatives have argued that the use of contraception encourages what they view as illicit or teen sex. This has been proven not to be the case. Moreover, they may object saying that contraception causes abortion. IUDs do act in part by preventing implantation of fertilized eggs, but they also act by causing cervical mucous to become viscous and block the cervical canal, preventing fertilization in the first place. So in this sense, a few fertilizations may take place which cannot implant. However, and critically, without any IUD or other birth control in place, as many as  25 % of fertilizations which do occur simply do not implant naturally, or they implant and naturally fail. Thus, with an IUD, a very small percent of fertilizations occur and do not implant. Without an IUD or other birth control method, 25 % of fertilizations fail and are lost, most before the period is even missed. In the end, there are many more natural abortions that there are IUD related abortions. If an abortion is an abortion, and one wants to minimize their numbers, one would certainly want to provide as much contraception as possible. A true anti-abortion advocate should espouse both IUDS and other forms of birth control, especially pills which prevent ovulation. 

But it seems those who are anti-abortion are interested in more than just preventing abortion. They are interested in legislating a world view and lifestyle. They see a world  where there is only one right way to live, and that those who live this way should have power over those who don't. I can only conclude this because of the “don’t bother me with the details” approach of much of the GOP on numerous scientific and medical issues such as contraception. If the GOP really cared about strengthening families, preventing abortion, and the health of infants and children, they would choose policies scientifically proven to meet these goals. ACOG ( The American College of Obstetricians and Gynecologists) has already come out against the bill since it is at odds with those goals. 

It becomes somewhat misleading to write so much about abortion policy since there are so many other pressing medical policy issue of the day. However, so much is happening in this area that it behooves me to report on it. For example, the ACLU (American Civil Liberties Union) has sued in Federal court in Hawaii challenging restrictions on the use of Mifiprex, the so-called abortion pill. They have argued that it should be available by prescription in a pharmacy. At present, a clinic or hospital visit is necessary. Particularly in the Hawaiian islands, access to clinics is variable. Mifeprex has been determined safe and legal, so ACOG has supported this suit. My concerns with pharmacy dispensing is that patients with positive pregnancy tests should have a reasonable idea of their gestational age before they take the medication, and that ectopic or tubal pregnancy not be missed. 

The House just approved the “Pain Capable Unborn Child Protection Act” which bans all abortions after 20 weeks. ACOG’s position is that a fetus cannot feel pain until 24 weeks. You just have to continue asking yourself, how do organizations and people formulate their opinions ? What data do they use ? Do they use data ? Would they know bad data from good data ? 

Forget alt facts. This next report shows us how far certain members of the GOP are wiling to go in their separation of politics from reality. Former Congressman Tim Murphy, a Republican from Pennsylvania, was a staunch anti-choice politician. However, he was recently caught telling his mistress to get an abortion. Think this is this height of hypocrisy ? Think again. Mr. Murphy promptly recused himself and resigned. Not Scott Dejarlais. This physician and Republican Representative from Tennessee circa late 1990s, called himself “pro-life”. However, he had multiple affairs with 3 co-workers, a “drug rep” and at least 2 patients ! At his divorce, he testified that he had supported his then girlfriend and now ex-wife to get two abortions. You would have thought he too would leave politics. However he has since been re-elected twice. The people have spoken and will get what they deserve. 

Finally, in a surprising turn of events, the Republican Governor of Illinois, Bruce Rauner, has signed a bill allowing Medicaid to cover abortions. He has stated that he does not feel women of different means should face different options. He has gone on record as a pro-choice Republican. 

Meanwhile the entire hurricane belt suffers under a burden of destruction and disease. There is a shortage of just about everything, from basic needs, to power, to medicine, doctors, and means of transportation to get all of it where it needs to go.  Shortages of pharmaceuticals in particular may be felt all through the US based on the increased need in the South. 

In medical news, we shift our attention to yet another case where beliefs seem to supersede science. Witness the practice of certain women of a more "natural" bent taking their placenta home to consume. It’s meat, right ? It’s even your own tissue, so what’s the big deal ? Most mammals do it. Modern women can have it various ways, but the most refined way is to have it “ encapsulated”. It turns out that “placentophagy" can make you and even your baby infected and sick, through pathogens (bacteria) that would have been killed by your own immune system, but aren't since they are separated from it and encapsulated into little gelatin capsules for swallowing. Moreover, the hormones in the placenta are NOT what you want after birth. The whole mechanism of uterine involution (contracting to prevent bleeding) and nursing is triggered by the expulsion of the placenta and it’s hormones. It is the expulsion of the placenta that changes you from pregnant to non pregnant. If you had complications in pregnancy like hypertension, you won’t get better until all your placenta and it’s hormones are gone. 

A new study has shown that those who drink four cups of coffee per day have a 64% lower  risk of early death. I would like very much to see that stratified by sex and age. Men do not have to worry about osteoporosis ( bone thinning) as much as women. Caffeine does thin the bones, and bone fractures in old age are a tremendous source of morbidity in older women. Women who are pregnant certainly should not drink that much caffeine. We ask our pregnant patients to limit their caffeine intake to 200 mg per day which is alot less than four cups. More than 200 mg per day of caffeine is associated with poor fetal growth. Whenever hearing results of a research study, ask yourself several questions. To whom does it apply ? Did they include women in the study ? What does this mean for women, or for a person like me ? 

Once again we have new evidence linking obesity with more than just diabetes and heart disease. A new report from the CDC (Centers for Disease Control) has indicated that “excess body fat accounts for at least 13 different kinds of cancer.  This study looked at over 600,000 people in the US in 2014. Obesity rates have increased even more since then. Results like this should change the way we think and teach about obesity. 

We have already mentioned the Southern United States in this post - the Hurricane belt. That same area is also know as the fat belt, also the bible belt. New data also shows that those in the deep south and midwest have higher smoking rates than the national average. In that area 22% of adults smoke, compared with 15% in the rest of the US. Could there be cultural reasons for the smoking and obesity ? 

A few years ago there was a bit of a scandal pertaining to a drug to treat preterm labor. Sold as a name brand, it was exorbitantly expensive. Generic, or even compounded, it was very cheap. It came down to FDA approval as to whether it could be sold as generic. First it couldn’t, then it could due to public and medical outcry, then it couldn’t again due to concerns about safety efficacy. However, now a new study published in JAMA Internal Medicine has indicated that the two preparations are equivalent. It will be interesting to see how long this data takes to get translated into policy, and we can once again buy cheap generic and have it be covered by insurance. 

In the good news department, breast cancer rates are declining. The American Cancer Society reported that breast cancer deaths increased through 1989. Thereafter, they have been on a steady decreased, altogether down 40 % since 1989. This attributed to better treatments and medications. 

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

Medical Monday, Labor Day Version: Breaking News from the World of Obstetrics and Gynecology

The current administration continues to try to whittle away at the ACA (Affordable Care Act). This week, funding for the "advertising” for the ACA was cut. In particular, programs for health care enrollment were cut from 100 million to 10 million. 

At the same time, a bipartisan group of Governors has stepped up to craft and submit a proposal to stabilize existing insurance markets under the ACA. Their plan maintains several original ACA features, including the individual mandate, guaranteed subsidies payments, and funding to promote ACA enrollment. New features would include a 15 billion dollar fund to supplement the subsidies, as well as tax credits for insurance companies willing to enter markets with only one insurer. The bill also favors more State flexibility in the spending of their respective subsidies. 

The most interesting news in policy is the Love Ernst Bill, also known as the “Allowing Greater Access to Safe and Effective Contraception Act” . It has been introduced by two Senators and two Representatives, all Republican, and all women. They are  Congresswomen Barbara Comstock (R-VA) and Mia Love (R-UT), U.S. House of Representatives to Senators Joni Ernst (R-IA) and Cory Gardner's (R-CO), in case you want to give them a shout out. 

• It incentivizes oral contraceptives (OCPS) to be sold over the counter (OTC) in several ways. 1. It hastens the FDA approval process and waives the fees to do so. It would then provide for OTC OCPS for women 18 and older. 
• It has also repealed the ACA’s provisions on using health medical and flex savings accounts (FSAs) on OTC medications. 
• Finally it has repealed the ACA’s annual limits on flex contributions. 

This represents great progress in the national conversation, and I applaud these forward thinking brave Republican lawmakers. At the same time, I fully understand the position of ACOG, the American College of Obstetricians and Gynecologists, of which I am a card carrying member. ACOG does not support the Love Ernst Bill. That is not because it is wrong, but rather because it does not go far enough. 

ACOG has stated that the available evidence shows that cost is a significant barrier to contraception. They state that the ACA’s strategy of birth control without copay is therefore the best strategy. ACOG also objects to the artificial age restriction of 18, and rightly points to the need to continue to curb the teen pregnancy rate, especially among those under the age of 18. Finally ACOG supports the provision of all forms of birth control, not just the birth control pill. 

At the present time, the use of IUDs ( intrauterine devices) is on the upswing. The developers of IUDs have come out with more brands and more sizes to meet the current demand and the particular needs of those who have not yet borne children. Nonetheless IUD use in the US lags behind our cohorts globally at 8% prevalence, while Belgium,for example is at 20% and South Korea at 70%. 

Egypt’s government is taking steps which show understanding of the relationship of contraception to prosperity. The government would like to employ contraception to control overpopulation, which they consider a threat to national development. They are deploying 12,000 family planning advocates to 18 rural provinces to address conservative beliefs on the matter. Perhaps they can also visit the United States as well. 

It is once again time to highlight the significant prevalence of post partum mood disorders. Time with a new baby is hard. Moreover, immense hormone changes are not always well tolerated. A new study published in the Maternal and Child Health Journal has shown that 21% of new mothers who have post partum mood disorders do NOT tell their physician. 

It should not be surprising then that a 14 year study out of Ontario has revealed that suicide is one of the leading causes of death in the pregnant and recently pregnant women. The study revealed that 5 % of deaths in pregnancy or the first year of motherhood were due to suicide. The study shows a clear need for comprehensive prenatal and post natal care with assessment for mood disorders and suicide prevention included. 

Let us not forget that Houston after Hurricane Harvey is a medical disaster. Several hospitals were just lost, and many had to be evacuated for repairs.  Beyond that, ambulances could scarcely travel, and caregivers had trouble getting to work at all. Much of the floodwater is polluted and the water supply is unsafe. All this spells a second wave of potential disaster from the threat of infectious disease. 

Polycystic Ovarian syndrome (PCOS) is a actually a cluster of conditions that involve problem with ovulation (egg production) and with carbohydrate metabolism. It turns out that those with PCOS not only have trouble getting pregnant, they have a higher complication rates in pregnancy, especially for gestational diabetes. 

A new global study has shown that perhaps we should all be eating fewer carbohydrates. The PURE study, which was published in the Lancet and presented at the European Society of Cardiology, showed that people who eat a high quantity of carbohydrates have a 30% higher change of dying compared to those eating a low carb diet. 

And in the truly awesome department, we look to the FDA approval of Kymriah, a new therapy for childhood leukemia. This is not actually a drug, per se. It is a technique, whereby the patient’s own white cells are extracted, genetically modified to kill cancer cells, then re-injected to do their job. It is being called a “living drug”. It produces remission in 83 % of cases. 

Gentle readers, you have work to do. Keep giving feedback to your elected officials, and even to those exceptional ones outside your district. 

And consider doing what you can for the those affected by Hurricane Harvey. Click on the satellite photo of the hurricane to donate via the Red Cross. 

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

First, the policy news. 

Trump has tied tax reform to health care reform. He has stated that there cannot be tax reform unless there is health care reform. Those that stalled the last proposal, the “ Freedom Caucus", an ultraconservative branch of the GOP, are reportedly in negotiations to prevent a stalemate as before. 

Negotiating with Democrats is another matter. Trump has once again threatened to withhold health care subsidies that fund the ACA (Affordable Care Act) to get Dems to the table. This would entirely destabilize the health care insurance markets. At the same time, the new administration moved to finalize rules to stabilize the ACA marketplaces as they now currently exist. These rules were drawn up by CMS, (Center for Medicare and Medicaid Services) who oversees these and other Federal Health care programs. The intent of these rules is to ease the what insurance companies say is an undue burden placed on them by the ACA. It will shift some of the cost of care back to the consumer, ostensibly making insurers more likely to stay in the market, i.e offer health insurance at all. For example, these rule would allow higher deductibles, larger out of pockets, and increased prices for insurance. It is hard to conceive of health insurance companies needing a “break “more than the common consumer. However, they need to stay solvent in order to make sure there are enough such companies in the market to make it competitive. 

Trump has signed a law withholding Federal Funds from clinics that provide abortion. This of course will also take down those providers from providing the general medicare care, birth control visits and cancer screenings that they would normally provide on a regular basis. 

In good policy news, a bill has been introduced in Connecticut which would make pregnancy a “qualifying event”, meaning it would enable pregnant women to enroll in the ACA anytime, instead of just during the specified enrollment periods. 

Aren’t you grateful when your medication can be purchased as a generic ? I am since it saves lots of money. Drug companies trying to recoup their losses try to keep generics out of the market as long as possible. Regulators such as the FDA ( Food and Drug Administration) intervene when the need for the drug is great or the company is believed to have recouped their expenses, or the cost of the drugs is simply too high. A bipartisan effort is underway to ensure timely access to generics. This could save the public billions of dollars. 

Human Papilloma Virus (HPV) is on the rise in the US. Those who have been vaccinated are not part of this rise. Surprise ! 

A new study indicates that many primary care doctors and Ob/Gyns are continuing to recommend mammograms after 40 rather than begin them after 50 as the USPSTF (US preventive Services Task Force)  recommends. That is because the USPSTF gauges effectiveness by death rates, rather than years of life. Death rates from cancer or non-cancer are low for women in both the  40s and 50s, and comparisons to not yield adequate numerical differences. Furthermore their metrics do not incorporate the value of early detection on the reduction of MORBIDITY (complications short of death)  or the enhancement of quality of life. The USPSTF is comprised of epidemiologists and not clinicians. ACOG ( American College of Obstetricians and Gynecologists) recommends that screening mammograms begin at 40. 

According to the CDC ( Centers for Disease Control) Texas has the highest repeat teen pregnancy rate in the country. Numerous voices in the State are calling for a state based no-cost provision of birth control. Why does this not make sense to everyone ? 

On that front, it is not widely appreciate that long acting birth control such as IUDs can be places right after the baby is born. This is especially useful for patients who might not show up to their postpartum appointments. 

In perhaps the most most important opinion piece of the week, the Catholic Democrats President Steven Krueger has described a problem in the Democratic party. He has noted Democrats seem reluctant to talk about ways to reduce abortion since it may imply they do not believe access to it is a fundamental right. He believes Democrats should come to the table with proposals to reduce abortion, thereby gaining ground on issues like birth control and provision of health care in general. 

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

Medical Monday: Dramatic Results with Long Acting Birth Control

Did you know that fully half of all pregnancies are unplanned?  Something pretty dramatic would have to happen to slash the rate of abortions and the rate of unplanned pregnancies, right? Actually not.

Hot off the press:

Researchers at Children's Hospital Colorado, through a grant from the Susan Thompson Buffet Foundation, devised a study to see the effect of freely providing long acting reversible contraceptives (LARCS) to teens and women who could not afford them. They did this over a 6 year period. The birth rate for teenagers fell 40% percent! The rate of abortions in that group fell by 42% as well. The pregnancy rate for unmarried women under 25 fell similarly. 

What are LARCs? They are the subdermal (under the skin) implants like Nexplanon, or the IUDs (intrauterine devices) such as Skyla, Mirena and Paraguard. These are well established, well understood devices which have excellent safety profiles. For more information, check our section HERE. 

These LARCs are fairly expensive. This study showed the effects of eliminating expense as a factor. Interestingly, for every dollar of cost of the contraceptive, nearly $6 was saved in Colorado's Medicaid program.

Perhaps more importantly, there are as yet, unmeasured consequences. We know from global data that there is an inverse relationship between education and number of children. We know that women who have children early may postpone or forego their education. We also know that women who are educated have better access to contraception and choose to delay childbearing. Not surprisingly, as a women's number of children rises, her financial dependence increases. On a population basis, as numbers of children rise, so do income disparities between men and women. Finally, as number of children rise, standard of living goes down and rates of poverty go up. It will be interesting to see whether, in Colorado, rates of educational attainment and income go up among young women in this cohort. 

To learn more: 

http://www.nytimes.com/2014/10/02/science/teenage-pregnancy-and-abortion-rates-plummet-with-long-acting-female-contraception-study-says.html

http://www.nejm.org/doi/full/10.1056/NEJMoa1400506

http://www.brookings.edu/research/reports2/2014/09/generation-unbound