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

As expected, the Trump administration is planning to roll back the contraceptive mandate. The contraceptive mandate requires that insurers cover costs for contraception without copay. The proposed change in regulation would allow employers to refuse to cover contraception because of religious or moral objections. This change will not go unchallenged, Numerous lawsuits will likely be initiated if this change takes place. 

Those objecting to the contraceptive mandate often cite their objection to certain birth control methods which prevent implantation. However, mainstream authorities focus on the fact that increased contraceptive availability is associated with plummeting incidence of abortion and unplanned pregnacy. 

In other policy news Texas plans to continue funding their task force to determine the causes of their alarming rate of maternal mortality. It is really a shame that Texan’s don’t just save their money and acknowledge the obvious: that increased maternal mortality is directly related to their gutting of health care services to women. At this time, one quarter of Texas women lack health insurance. Data from many quarters tells us that this is a sure fire way to ensure poverty and high maternal mortality for many generations to come. 

Arkansas is racing to the bottom as well. A Federal Appellate court in St. Louis has ruled that Arkansas can block Medicaid funding to Planned Parenthood. 

Winning the race to the bottom, is of course the the Trump administration, who has resolved to cut Teen Pregnancy Prevention program funding. The American College of Obstetricians and Gynecologists (ACOG) came out with a swift condemnation of this plan. The current administration supports abstinence only programs, and yet asserts they favor “ evidence based” programs. Sling that medical jargon. 

Lawmakers have prevailed upon the Trump administration to make the Federal Government insurance subsidy payment for August. In fact, it is Republican members of Congress together with Democrats who have convinced the administration to continue payments, fearing a collapse of insurance markets. They believe this will buy time for a bipartisan solution to stabilize the markets. The CBO (Congressional Budget Office ) continues to warn that ending subsidies with cause premiums to rise by 20% by 2018. 

In encouraging news, Oregon has passed law budgeting half a million dollars to expand comprehensive reproductive health care coverage for all its citizens. The law also requires insurers to cover such services with no out of pocket cost. Available evidence tells us that, as a direct result, they should expect decreased rates of unplanned pregnancy and abortion, with increased levels of educational attainment among women, decreasing unemployment statewide, and increased standards of living. 

https://www.cdc.gov/obesity/data/prevalence-maps.html

On to the medical news. 

It is time for us to start thinking about obesity in more sophisticated ways. Obesity is a devastating and widespread medical problem. It is also very personal and for that reason it is challenging to discuss and treat. We are now beginning to understand that the causes of obesity include but are not limited to individual habits. For example, poverty and its many causes factor in strongly. We can graph the incidence of obesity on maps and thus understand obesity is part of culture as culture spreads across geography. New research out of the National Institute of Health has revealed that the “ origins of obesity lie as much in early childhood - even prenatally and intergenerational- as it does in an individual’s current behavior. “ Obesity is closely tied to many forms of human suffering and disease, from heart disease and diabetes, hypertension and cancer, to poor self esteem and depression. Further research is necessary, by all means. However to effectively address this serious problem, both patients and physicians are going to have to do better at mustering their courage and talk about obesity in frank and accurate terms. 

You might have noticed my mention of obesity as having a role in increasing cancer risk. Maybe you were not aware of this, since there is not an obvious connection. However, we have always know that obesity is associated with many types of cancers. However, new research from the Journal of the Academy of Nutrition and Dietetics sheds more light on the subject. It turns out that “ women who eat a lot of high calorie foods may face a slightly higher risk of obesity related cancers - even if they remain thin” The study went on to elaborate that “ women who favored low nutrient high calorie foods had a 10% higher risk of cancer linked to obesity. “ Cancers related to obesity include cancer of breast, colon, ovary, kidney, and endometrium (uterine lining). 

A new study from the Canadian Medical Association has shown that oral cancers related to the HPV are on the rise. Between 2000 and 2012 it is believed that the incidence of such cancers has risen by 50 %. 

Smoking in pregnancy is still a big problem. It turns out that depression in pregnancy makes smoking more likely. This tendency of smoking during depression in pregnancy is on the rise, according to new research published online in the October issue of Drug and Alcohol Dependence. 

HPV and smoking are a bad combination. Did you know smoking greatly accelerates the progress of HPV related disease ? 

HPV has an effective vaccine against it. However, new research indicates that less than half of girls and a quarter of boys are vaccinated. HPV ( Human papilloma virus ) has a vaccine. Humans papilloma virus causes genital warts, precancerous and cancerous lesions of the genitalia and mouth. Vaccines are available for young people from the ages of 9-26 years of age. They have little in the way of known side effects. 

In other virus news, there have been no locally transmitted cases of Zika viruses in Florida yet this year. The same encouraging trend has also been seen in Latin America and the Caribbean. Authorities now believe that those infected develop immunity to reinfection. However, authorities are also concerned that Zika may now be getting transmitted sexually. Work on a Zika vaccine is underway. 

Again, I encourage you all to contact your elected officials about your views on women’s health. Tell them the American people are willing to shoulder their collective responsibility for people's health care and the good of the future. 

Medical Monday: Part Two

Medical Monday: Medical News Section 

Pregnancy related death continues to rise in at a fairly steady rate in the US. As of 2013, we sit at 17.3 women per 100,000 live births with a rage of about 12 per 100,000 for whites and 40 per 100,000 for blacks. Cardiovascular diseases of various kinds accounts for about 40% if these deaths. About 9% are due to pulmonary embolism, and 7% are related to high blood pressure and preeclampsia. The rest pertain to infection, hemorrhage and rare disorders like amniotic fluid embolism. 

Teen births are statistically high risk. It turns out that high teen birth rates cluster in certain cities. Analysis of the data shows these clusterings are not random and are not related to poverty to education. Most generally, the clusters are in the southern states, but they also exist in Denver, Fresno, and Yakima. San Antonio has the distinction of being the number one urban center with a teen pregnancy cluster. These findings my begin to help shed light on what is no doubt at least partly a cultural phenomenon. 

Breastfeeding has been touted has having numerous benefits, including health benefits to the mother. It turns out that prevention of uterus (endometrial) cancer is one of those benefits. Breastfeeding EVER confers an 11% reduction of risk. The longer the breastfeeding the more the risk was reduced, until risk reduction peaked at somewhere around 6-9 months of breastfeeding. 

Polycystic Ovary Syndrome (See PCO section HERE) is a complex of problems which include problems with ovulation (producing an egg), as well as obesity, excess male hormone, and difficulty metabolizing carbohydrate. A given patient may have one, all, or just a selection of the features of this varied disease. Generally, doctors have assumed that obesity and carbohydrate intolerance goes together. However new research has shown that even normal weight patients with PCO have have significant insulin resistance. This points for the need to counsel normal weight patients to eat a very high quality diet rich in protein, vegetables and fruit, and healthy fats. 

The overall incidence of depression in teens in higher than once previously believed, coming in at about 14% for those between 12-17. Of note, by 17, girls had a three fold higher incidence than boys. 

In the vice department, the news is sobering. New research from the Journal of Drug and Alcohol Dependence has shown that children born to women who smoke as few as 10 cigarettes per day have problems later in life. In particular, they have increased problems “learning and thinking”. 

The British Medical Journal has published research showing that even small amounts of alcohol produces changes in brain function which play out as poorer performance on language related tests. This data comes from research on 550 men and women over a 30 year period of time. 

Hard data is in from last year’s mosquito season in America (including Puerto Rico). Zika virus, which is transmitted by mosquito, produced birth defects in about 5% of babies who’s mothers became infected in pregnancy. This number was higher for those infected early, and lower for those infected late. We should learn even more this  year, and hopefully get one season closer to a vaccine for this dreaded disease. 

For those in Zika- vulnerable states: Remember, DEET is safe in pregnancy. Zika is not. 

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

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

In this week’s policy news, focus is on The Contraceptive Mandate. This is the part of the Affordable Care Act (ACA) which requires all insurance companies to cover birth control at no cost to the insured. The New York Times has reported that the Trump administration is working on broadening the criteria through which employers and insurers may refuse to provide contraception as a benefit within their health insurance.

Initially, one company, Hobby Lobby, went all the way to the Supreme Court to argue that based on their religious principles, they had a right to decline to provide insurance which covered contraception for their employees . They argued that contraception is against their religious principles. The Trump administration would like to expand the criteria for which companies can claim a moral or religious objection to the provision of contraception.

The President of the American College of Obstetricians and Gynecologists has spoken out in multiple ways against this trend and has added his objection to discussions pertaining to the elimination of the necessity to cover maternity care. Can you believe it? Attorneys at the American Civil Liberties Union have begun to elucidate a very powerful argument that these policy trends violates the separation of church and state. Moreover they constitute discrimination based on sex.

At the present time approximately 55,000,000 women receive contraception through this no cost benefit. The scientific data supports the Democratic assertion that there is a clear and evidence-based correlation between The Contraceptive Mandate of the Affordable Care Act and the historically low unintended pregnancy rates, teen pregnancy rates, and abortion rates.

Women are not the only target in the latest round of discussions on healthcare policy. A certain group of GOP senators I'm working on a revision of the Affordable Care Act which will no longer classify employer purchased health insurance as a tax deductible expense. This appalling antibusiness and anti-healthcare piece of legislation threatens the 177 million Americans who have their health care coverage through their employers. Additionally anybody who has a pre-existing condition or who has to watch their health care expenses is at risk if any of these GOP draft revisions to the health care bill are enacted. 

On to the medical news. Did you know that there is no safe level of alcohol consumption pregnancy? People widely assumes that the rule of moderation applies to alcohol and pregnancy but this is not at all the case according to the CDC, (the Centers for Disease Control and Prevention), the National Institute of health, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics. No alcohol should be consumed in pregnancy. Not a popular message. 

An increasing number of states have legalized the use of marijuana. Accordingly pregnant women have gotten the skewed message that this sends and have been using marijuana in record numbers. No one seems to be listening to the repeated messages coming out of scientific circles such as the American College of Obstetrics and Gynecology indicating that marijuana use in pregnancy is associated with brain development problems in the fetus. A whopping 14% of pregnant teenagers ages 12-17 use marijuana. Dumb and Dumber. That is my fear. Also not a popular message. 

It is Zika virus season again in North America. To date 64 babies have been born in the US with Zika related birth defects. Diagnosing infections and tracking the spread of the virus is of paramount importance, together with enacting virus prevention measures such as spraying and education. All this costs money, and funding is tighter than ever this year, pursuant to the policies of the current administration. Zika virus, when contracted by pregnant women, produces a high risk of severe brain damage in the baby. Zika virus is spread by certain species of mosquitoes which live in the southern portion of the United States and points further south, most notably Central and South America. Florida already has 43 documented cases of Zika virus infection in pregnant women. 

Finally, in the good news department, women who breast feed their children for at least six months reduce their risk of endometrial cancer by over 10%. Of course they do their babies an infinite number of goods from improving their teeth to improving their brain development, but who knew there could be such tangible and profound effects on the health of the mother. 

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

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 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. 

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

Two weeks worth of news will be covered this week !

Nearly two third of infected Zika patients are women. This has been determined recently in Puerto Rico, but also widely across South and Central America. Experts are not sure about the origins of this number, stating this might be because women are more likely to seek care and be diagnosed. 

In the good news department, an experimental vaccine has been shown to protect mice against Zika. This is a promising step, but still many steps from a human vaccine. And in the reminds-me-of-science-fiction department, antibodies from the blood of recently recovered Zika infected mice can be injected into other Zika infected pregnant mice. This causes the levels of Zika virus to drop in the unrecovered mice.  This novel treatment is to be tested next on non-human primates. 

A Zika “ syndrome” is coming into definition. It has five cardinal features: 

1. severe microcephaly
2. decreased brain tissue with  specific pattern of calcium deposits indicating brain damage
3. damage to the back of the eyewash a specific pattern of scarring and increased pigment. 
4. joints with limited range of motion
5. too much muscle tone. 

The very first baby born in Puerto Rico remains hospitalized. This baby and all other Zika affected babies will be followed until age 3 in a registry called the "Zika Active Pregnancy Surveillance System”. 

In non-Zika news, a recent study indicated those who give birth in winter may need extra vitamin D supplementation. Our recent experience substantiates this. We have yet to quantify this, but in our obstetric population, it is not uncommon for us to uncover vitamin D deficiency. Good news: prescription supplementation is easy and works well. 

Did you know that long acting reversible contraceptives such as IUDs can be placed immediately post partum ? This is a breastfeeding compatible way of providing women with reliable contraception especially if they are unlikely to follow up at later visits. 

Preliminary reports on a herpes vaccine in humans are encouraging. This new vaccines reduces lesions and viral shedding for several months. It consists of three shots three weeks apart. 

Rates of preterm birth are increasing in the US. This is especially true among black and native women. 

Antenatal steroids for lung maturity were, until recently used only until 34 weeks. Now, they have found to have been useful for late preterm births between 34 and 36 weeks, and even for women undergoing planned C section 37 weeks and later. Steroids reduce the rate of neonatal distress syndrome these babies. 

In the we-already-knew-this-department, researcher have now shown that low carb meals reduce insulin resistance. Insulin resistance is bad; it means your cells don’t respond normally to insulin and do not transport sugar from the bloodstream into the cells well a they should. Eating low carb restores the cells responsiveness to insulin. 

The World Health Organization (WHO) has issued revised recommendations for antenatal care. This includes double the number of recommended prenatal visits compared to before. (Surprise ! Prenatal visits help ! )

There is yet more good news. When Kenyan women are provided with HIV self test kits, partner and couple testing increases to more than 90%. As they say, knowledge is power. 

Stay tuned for next week, when we will cover more news from the world of Obstetrics and Gynecology, and doubtless, reactions to the election from those in health care. 

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

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.  

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

Zika again dominates the news in Ob/Gyn. As of Friday, a storm system was approaching the subtropical state of Florida, where 43 are confirmed infected with the Zika Virus. Authorities think the storm may help spread the virus which is transmitted by mosquitos and sex. Meanwhile, the CDC (Centers for Disease Control) does not have enough Zika testing resources. I myself experienced this last week when I was told a specimen we sent to the CDC would take “weeks” to result. We Ob/Gyns are not able to effectively work in time frames like this, and so this week we will have being having some words with the powers that be. 

A new study published in Radiology has shown that Zika can cause many other brain defects besides microcephaly. They have thus far identified 8 major defects. One of the most common was ventriculomegaly, or enlarged ventricles and thinning cortex. 

Thus far the Florida outbreak has been clustered around Miami. However Thursday, an isolated case showed up some 250 miles to the north in Tampa Bay, Pinellas county. It is still unclear how this occurred. On the bright side, modeling done by researchers at the University of Florida has indicated that the total outbreak should limited to under 400 individuals or less, considering all the southern states. They also believe winter will stop the outbreak, which would then recur next summer the same way. It is estimated that 20,000 pregnant women in the Miami area are taking extreme measures such as confinement indoors or moving to avoid Zika infection. 

NewYork officials are noting that travel restrictions to Zika affected area not being properly observed by pregnant or pre conceptual women. How do they expect people to take these restrictions seriously when they gave full sanction to people traveling to the Olympics in Rio? 

Dr. Kristyn Brandi writes that Zika is spreading more rapidly than anticipated in Puerto Rico, and that resources of information and contraception are not adequately available. 

The chair of ACOG (American College of Obstetricians and Gynecologists) has written a strongly worded piece which has criticized how politics has prevented the funding of an adequate Zika response. He and co author, Dr. Didi Saint Louis of Morehouse School of Medicine have called for the full funding of comprehensive reproductive health care to allow women to avoid or delay pregnancy. They have called on Congress to reconvene to deal with this. 

In the non-Zika news, HPV virus is in the spotlight. This virus is responsible for abnormal paps, and cervical cancer, among other things. It has an effective vaccine which is meant for young people between the ages of 9 and 26. However parents remain wary to give it to their children. Research is being done regarding the prospect of putting it on the list of already mandatory vaccines which must be done before school entry. Surveys show that parents would accept this as long as there was an opt out provision. As of 2014, only 40% of girls and 20% of boys were vaccinated. It will be interesting to see if there will be those who decline the Zika vaccine once it gets developed. 

Breastfeeding is practiced by about 80% of all American women when they leave the hospital. However less than a third keep it up for the recommended time. The American Academy of Pediatrics has recommended that infants should get nothing but breast milk for six months, and that breastfeeding should continue one year. 

Co-sleeping beyond six  months has been shown to produce significant stress on women. Researchers at Penn State note this may be related to fragmented sleep and less time with partner. Perhaps this is related to the falloff in breastfeeding. 

In the everyone-already-knows-this department, researchers at UCLA have discovered that menopause accelerates aging. In all fairness, what they have determined is that methylation increases in menopause, accelerating cellular aging about 6 %.

And in the we-should-have-known department, the “ baby simulator” program in high schools designed to deter teen pregnancy may actually be encouraging it. Graduates of the program with over third more like to have a teen pregnancy. 

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

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

In sobering news, results from a study using mice as a model indicate that children's and adult's brain cells which are critical to learning and memory might be susceptible to the Zika virus. Zika may be able to infect neural progenitor cells which serve to replenish normal neurons over the course of a lifetime.

Meanwhile, a second local Zika out break may be beginning in Miami Beach Florida. Louisiana is bracing for Zika in the wake of recent flooding since flooding affords more mosquito breeding grounds. Finally Puerto Rico has declared a state of emergency due to the Zika outbreak. Zika has infected about 10 thousand people there including over 1000 pregnant women. The CDC (Centers for Disease Control) estimates that 10,000 pregnant women could be affected before the end of the season. 

The head of ACOG (American College of Obstetricians and Gynecologists) has written a piece highlighting Florida as the worst place to be a pregnant woman. He cited the combination of three things: the threat of Zika, restrictive abortion laws, and the lack of funding to fight the virus. 

CDC director Tom Frieden has indicated that there is now thought to creating a $300 million dollar “ rapid response reserve fund” to combat infections disease such as Zika. 

The CDC is becoming concerned that sexual transmission of the virus can spread beyond its natural geography beyond the territory of the Aedes mosquito. The CDC estimates that the public underestimates the risks of transmitting Zika sexually. 

Brazil has been on the leading edge of the Zika epidemic. Fifty years ago they once combatted this virus. However, they fear this time it will not be so easy. They do believe their mosquito control efforts are yielding results. However, they are beginning to discover the long term medical consequences of Zika. 

According to researchers a the University of Kansas, Zika is unlikely to spread the the majority of North America, however is could plausibly spread to Africa and Southeast Asia. 

In other news, OB/GYNs are in short supply and the supply is due to become even shorter incoming years. Although the field is rewarding in many ways, there are also many disincentives associated with it as well, such as risk of lawsuit and grueling hours. 

The US fertility rate has plummeted to the lowest point on record. Some factors are that women are delaying pregnancy, teens are having fewer pregnancies, and more women are choosing to have no children at all. The first quarter of 2016 saw 60 births per 1000 women, half that of the 1950s. Forty years ago, women had their first baby at 21, on average. In year 2000 it was about 25. Now it is over 26 years of age. It is speculated that the economic downturn may bear on this. It is also speculated that women are increasingly concerned with stability, turning attention to being financially solvent, with adequate education, good jobs, and lower debt. 

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

We continue to learn more about the way Zika virus affects babies.  It turns out Zika can affect babies late in pregnancy. In fact, Zika related brain changes may not become apparent until months after they are born. The reason for this is that the baby continues to grow all except the brain, which does not. 

Zika also appears to produce joint deformities. This may take the form of curved or crooked legs or arms. 

We are also learning more about the sexual spread of Zika. Men may be able to spread Zika for longer than six months, longer than previously reported. The Obama administration has shifted another $81 million dollars from the Department of Health and Human Services to continue development of a Zika vaccine.

Florida officials continue to deal with more local spread of Zika in the Miami area. Aggressive spraying programs are underway to reduce mosquito populations. Additionally there are plans to release genetically modified mosquitos which will mate with the natural Aedes Aegypti and render their offspring sterile. This has reportedly reduced the Aedes populations in Brazil, Panama and the Cayman islands by 90%. 

Various commentators are now starting to focus on how abortion politics played a role in the Congressional failure to develop a funding plan for Zika. It continues to play a role. Since Zika produces grave birth defects in babies which usually live, it is a condition for which some women might chose abortion. Marc Rubio (Republican from Florida)  has come out this week saying that he “doesn’t believe a pregnant woman infected with the Zika virus should have the right to an abortion-even if she had reason to believe the child would be born with severe microcephaly. “ A recent STAT Harvard poll indicates that 59% of Americans believe that a women should have a right to end a pregnancy after 24 weeks of testing showed a serious possibility that the fetus had microcephaly caused by the mother’s Zika infection. The same poll also showed most Americans are unaware that Congress left for vacation without securing Zika funding. Meanwhile women and health care workers in Puerto Rico are trying to overcome historical cultural barriers to contraception in a territory at very high risk for Zika. 

The Obama administration has shifted another $81 million dollars from the Department of Health and Human Services to continue development of a Zika vaccine in Phase 2 trials. Stage 1 is preclinical development, in labs and on animals. Stage 2 is when the vaccine is first tested on humans. This second stage proceeds first to study safety and then, if it passes, to effectiveness. 

In other news, ACOG (The American College of Obstetricians and Gynecologists) has updated its opinion on home births. New data has prompted the revision. The new Committee Opinion Document states that babies are twice as likely to die and more than three times as likely to have seizures soon after birth, compared to hospitals. I would point out that this is case even when most home birth attendants chose low risk patients to deliver at home. I would also point out that the literature on which this is based only reported on two of the worst outcomes, death and seizures. The many lesser but still significant complications like subsequent learning disability remain unquantified. 

In other sobering news, the US maternal death rate has increased. Between 2000 and 2014, the death rate increased from 19 per 100,000 to 24 per 100,000. It is unclear as to why though more thorough reporting methods are believed to account for much of the increase. However some of the increase is real, and authorities speculate that it is because women having babies are older and more likely to be obese than in the past. This gives rise to more complications such as maternal hypertension and diabetes. 

Many including me are cheering the relaxation of rules surrounding marijuana research. It is currently being used legally in several states without evidence of its effectiveness. New studies should be able to “ weed” out the legitimate from the bogus uses of which I suspect there are many. 

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

Zika funding. It comes down to this. Even as Congress has reached its planned seven week summer break, there is still no Zika budget, the United States faces its first couple deaths from Zika virus, one in Utah, and the other in Puerto Rico. The AP ( Associated Press) reports that the main hang up was Democratic objections to GOP language which would block Planned Parenthood clinics in Puerto Rico from receiving money to fight the virus. Shame on them all. 

The Imperial College in London has presented a bad news/good news scenario. Their modeling has indicated that Zika will likely last in Latin America for another two to three years. At that stage, herd immunity will hopefully develop. 

The CDC (Centers for Disease Control) is working on preparing a protocol for the first locally transmitted cases of Zika. One of the biggest challenges is that 80 percent of Zika infections area symptomatic. Almost all stars of the Union are at risk including the northernmost United States of Michigan, New Hampshire, Washington state and Minnesota. There are currently 346 pregnant women with Zika in the United States. 

Half a million people are excepted to travel to Brasil this year for the Olympics. However experts at the CDC are projecting that this will not spread Zika internationally. They have explained their position by saying that this half million represents only about 1% of all international travel to Brasil. 

HERE is the link to the excellent CDC pages on Zika. 

http://www.cdc.gov/zika/index.html

Happily much of the other news this week is good, though a fair amount of it falls in the "we already knew this" category. 

One thing we did not even suspect was that a mouse could have a menstrual cycle. The spiny mouse has a tiny nine day menstrual cycle. Researcher hope the mouse will provide a model to study the reproductive cycle in women. 

Moderate exercise in pregnancy has been shown to benefit both mother and baby. In particular, mothers who do moderate regular exercise in pregnancy have lower rates of hypertension, gestational diabetes, and C section. 

Both mothers and fathers weight during  pregnancy affect the weight of children later in life. This is believed to be true not only by virtue of lifestyle but by genetics. It appears that both mothers and fathers weight influence gene expression in the unborn, which postnatally can affect weight. This knowledge may help us counsel prospective parents and spare their children unnecessary risk and struggle from obesity. 

The Journal of Pediatrics has published research indicating that breastfeeding reduces the incidence of diarrhea and otitis media (ear infections) in infants. At the same time, the USPSTF (US Preventive Services Task Force) used US taxpayer dollars to create recommendations which support but no longer promote breastfeeding. ACOG (The American College of Obstetricians and Gynecologists) has sent their objections in writing regarding this important change. The breastfeeding discussion needs to be continued, and very publicly, since we all have a stake in the outcomes. 

Stay cool this week, and take precautions from mosquitos. Remember, DEET is safe, and safe in pregnancy. 

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

Good Monday. This week the news is again dominated by the specter of Zika. I reported earlier that the Puerto Rican chapter of ACOG (American College of Obstetricians and Gynecologists)  is working hard to deliver donated contraceptives to women in this vulnerable population. However, IUDS are not common there due to cost, and as a result, few doctors know how to insert them. Approximately 60,000 IUDS and 80,000 packs of birth control pill packs have been donated by Bayer, Allergen and Medicines 360. The donor companies have also started training physicians to use and presumably teach the use of IUDS. However, their dispensation is held up since the CDC has yet to line up a licensed distributor in Puerto Rico.

This sounds like a problem that can be solved. IUDs are not that hard to put in. I cannot help but think that telemedicine, i.e. videoconferencing, could not help train doctors to put in IUDs. By some accounts there are about 150 Ob/Gyns in Puerto Rico, and about 138,000 women there who are vulnerable to pregnancy.

A little more Googling on my part indicated that the Puerto Rico Obstetrics and Gynecology is holding a “ Sunshine Seminar”  August 4-7 this year at the Wyndham Grande Rio Mar Beach Resort and Spa. Really ? Instead of studying morcellators and bioidentical hormones, maybe conference attendees should put some gloves on and start seeing as many patients as they can. 

I am going to contact the chair of the Department of Obstetrics and Gynecology Dr. Sharee Umpierre at the University of Puerto Rico and see what she has to say about the situation. 

The New England Journal of Medicine reports an increase in abortion medication in Zika affected South American countries. 

In some good news, the FDA has given the go ahead on human clinical trials on a Zika vaccine known as GLS-5700. The safety and immune response will be studied in about 40 subjects. Thank you very much you brave souls. 

In more good news, the NIH ( National Institute of Health) have started a massive study on Zika in affected countries. 

The House has approved $1.1 B to fight Zika. This would come from $750M in savings, $107M unused Ebola funds, $100M in cuts to the Department of Health and Human Services (Medicaid and Medicare) and $534M from Obamacare in the US territories. This does not add up. And, it will not pass the Senate or the President’s Desk. 

Ten cases of Zika were confirmed in Dallas County, Texas as of Friday. So it begins. 

In other breaking research news, there is quite a bit of what we already knew or suspected: Cranberry juice may help prevent UTI (urinary tract infection). Physical inactivity increases risk of ovary cancer and healthy lifestyle reduces cancer risk. Leading oncologists push for greater use of the HPV (Human Papilloma Virus) vaccine. Healthcare is more affordable since Obamacare. Age of puberty for girls is going down. Soy isoflavones reduces menopause symptoms. Women who work long hours face more chronic disease. 

Why are studies done on matters that already seem established ? One reason is that prior studies may have been done to get a rough indication of a cause or pattern. Later, better designed studies can establish something closer to proof. However, some of these things are just common sense. If we took full advantage of the knowledge we already have and actually put it into clinical use with our patients, there would be so much more health and so much less disease. Case in point: HPV vaccines usage. 

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

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

Good Monday.

First the Zika news. Dr. Anne Schuchat, the principal deputy director of the CDC (Centers for Disease Control) has stated that "everything we look at with this virus seems to be a bit scarier than we initially thought”, noting that "the virus has been linked to a broader array of birth defects throughout a longer period of pregnancy, including premature birth and blindness in addition to the smaller brain size caused by microcephaly”. Additionally, she announced that "the mosquito that carries the Zika virus is present in 30 states, more than twice what officials originally thought. The maps at right indicated the territory of these mosquitos. Click on the image to take you to the CDC site on the subject. 

The White House has shifted nearly $589 million or over half a billion dollars in leftover Ebola funds in order to fight the Zika virus. This comes well short of the $1.9 billion that has been requested by the National Institute on Allergy and Infectious Diseases. Dr. Anthony Fauci, the Director of this organization has announced that he will also be diverting funds from other areas in order to close the gap on funding what he views as critical efforts.

Florida leads the nation in number of Zika cases which last week totaled 84. Zika cases in Florida account for 23% of all cases in the states. Mosquito activity is of course greater in warm climates. It is expected that when the rest of the southern part of the country achieves these temperatures that Zika transmission will increase. The CDC has reiterated that insect repellent containing DEET are safe to use at any stage of pregnancy.

Zika is now associated a third clearcut disease entity. We already know a fair amount about microcephaly which is incurred by the fetus when a pregnant woman acquires a Zika infection during pregnancy. We also know about Guillain-Barré syndrome, post viral paralysis, which can effect of minority of people after a Zika infection. Researchers in Brazil are now reporting that the virus may be linked to "an autoimmune disorder known as acute disseminated encephalomyelitis or ADEM. In this syndrome neurological symptoms could start right away or as long as two weeks later. 

New research from the CDC indicates that white women between the ages of 30s and 50s are dying at increasing rates. This is been attributed to poor access to healthcare in rural America. In related news, a new study from Delaware has indicated that women enrollees in their state Medicaid program outnumber men to 2 to 1. State officials are interpreting this as an indication of increased poverty among women.

California has expanded the care that pharmacists are able to give. Perhaps most significantly, they are now able to prescribe contraceptives without the patient having to visit to another caregiver. While three quarters of physicians in one poll do not support the dispensing of birth control by a pharmacist, the American Congress of Obstetricians and Gynecologists support this legislation wholeheartedly.

Delaware has modified its Medicaid policy to require that contraceptive costs be bundled with the hospital’s charge for obstetric care. The Governor of the state, Jack Markell, recently wrote an op-ed for the New York Times describing this change and indicating his belief that it would allow for better family planning. He also went on to argue that contraception is vital to prosperity. 

The Guttmacher Institute recently released a study showing that teen abortion and pregnancy rates have dropped to historic lows. Teen pregnancy rates in particular have been cut in half between the years 1990 and 2011. The teen pregnancy rate in 2011 was 52.4 per thousand and, also of interest, is nearly 25% lower than the rate in 2008.

That seems like plenty to think about this week. Stay tuned next week for more news from the amazing world of Ob/Gyn. 

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

The CDC has finally given some time bound recommendations to prevent the spread of Zika virus. In particular, they are advising women to wait 8 weeks after Zika infection to attempt pregnancy. Men are advised to wait 6 months before having unprotected sex. Imagine, there is nearly an entire continent of people who are being asked to strictly observe these rules. 

Knowledge about Zika is diffusing northward. Nonetheless, about 1 in 3 people in the US think Zika is spread like a cold. Furthermore, 42% do not realize it is sexually transmitted, and 29% do not realize it can be spread through blood transfusions. Seventy five precent do not know of its association with Guillaine Barre syndrome, post viral paralysis. They have obviously not been reading this blog. You know that it can be acquired through a bite from the Aedes Aegyptae mosquito, from sexual contact with an infected person, vertically from mother to child, and also in any manner that is blood borne. 

The CDC is working hard to get sources of contraception to Puerto Rico, which is under dire threat from the Zika virus. The CDC has recently ramped up their presence on the island and estimates that 138,000 women there do NOT wish to become pregnant but do NOT have access to birth control. 

Democrats in the Colorado House have moved to take away copays for birth control in their state. It still has to pass the House where the GOP holds a one seat majority. 

The Governor of Virginia Terry McAuliffe has vetoed a bill which would have blocked Planned Parenthood Funding in his state. Apparently the bill as written would not affect the ability to provide abortions but would have blocked small state grants for health services like cancer screening and sexually transmitted infections. 

The FDA is altering the labelling for the use of “ Mifeprex” the so called abortion pill. It can now be used for up to 70 days after a missed period rather than 49. The new criteria have been approved by the WHO ( World Health Organization), the AMA ( American Medical Association) and ACOG ( American College of Obstetricians and Gynecologists.) These governing bodies have all cited the need to bring legislative practice into line with available scientific evidence, and this meets this requirement.

I can not help but wonder if this change was hastened by the Zika crisis plaguing the Americas. Because of the specter of the complication of microcephaly in babies born to Zika infected mothers, abortion is under more consideration there than ever before. 

Smoking is has been a scourge to all, but it is arguably harder on women than it is on men. Many people do not realize it’s role in fostering cervical cancer. The reason for this is that HPV ( human papilloma Virus) causes cervical cancer by inserting its DNA into the DNA of our cervical cells. Chemicals from smoking makes DNA fragile so that it breaks ( and admits the virus) easily and makes more errors in replication. That is one of the main ways it causes disease including cancer all over the body. A shocking new report has found that smoking while pregnant produces the same DNA mutations in babies as it does in adult smokers. This study was large and considered very authoritative. 

New research published in the Journal Circulation has indicated an association between endometriosis and cardiovascular disease. This was an observational study with large numbers, so it does not speak to causality or mechanism. It is nonetheless useful information in that it may prompt more investigation, and even at this early junction, prompt more targeted screening of possibly at risk patients. 

Wow this week’s news is rather sobering and somehow all connected. Here’s hoping the week will bring some good news to the world of Women’s Health.