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

Policy News 

People across the political spectrum continue to debate the merits of Brett Kavanaugh for the Supreme Court. Since we now know that the political and judicial systems play such a large role in the health care of women, we’d all best pay close attention to this debate. 

Drug Shortages. We did not used to have them. Now it is common place on routine drugs, even IV fluids. No slight to third world countries, but sometimes it feels like we are in a third world country. The FDA is forming a new task for to more critically and quickly investigate and solve this problem. 

Companies that make formula are multinational. The Trump administration is avowedly pro business and this is particularly evident in the international sphere where of late, this had unsavory consequences. In its zeal to unfetter corporate interests, The Trump administration has taken an anti breastfeeding stance. At present advertisements of formula is limited regionally in areas where it could be misused or hazardous. The Trump administration has desired to “ reopen” these markets, under the auspices of free trade, seemingly oblivious to the perils of selling formula  in places where literacy (ability to mix correctly) and clean water is unavailable . The entire medical and public health establishment has reacted, concerned that breastfeeding continue to be encouraged as the safe and superior method that it is. Many are pointing out that formula manufacturers have no place at the health policy table. This baby feeding battle resurfaced last year when Ecuador proposed a resolution to the WHO (World health organization)  to support breastfeeding. The Trump administration through the US delegation at the World Health Assembly, tried to water down the resolution. When this did not work they threatened Ecuador with a trade war. Can you say “evil empire” ? ACOG (American College of Obstetricians and Gynecologists) and AAP (American Academy of Pediatricians) have responded formally. 

Did you know as little as two months of breastfeeding reduces risk of SIDS ? 

Did you know breastfeeding reduces mom’s risk of breast and ovary cancer, heat disease, and endometriosis ? 

Did you know the US ranks 26th among industrialized countries in breastfeeding ? 

The Trump administration seems to want people off the ACA. They have reduced the “navigators” fund from 36 to 10 million per year. Navigators are those who help people enroll in the ACA. The Trump administration says private health insurance agent and brokers do a better job. Do private brokers and agents get a fee for this ? 

Medical News 

Abortion facts were highlighted by NBC this last week: 

Death by childbirth is 14 times greater than death by abortion. 

Banning abortion does not reduce its incidence. 

Free birth control reduces abortion rates. 

Before legal abortion, 5000 women per died through complications of illegal abortion. 

Depression is not the only feature of postpartum depression. A new review has highlighted the fact that anger is often a big component of post partum depression. 

Your microbiome is the population of microorganisms that you have on your body and in your gut. This is affected greatly by what you eat. In pregnant women this microbiome is passed to the baby. Thus, what pregnant women eat can influence the microbiome of their child, for better or for worse. Newer research in multiple fields are beginning to describe the role of a healthy microbiome to overall health. 

The US birth rate is at an all time low for the second year running. Some site child care expense, wanting to spend time with existing children and concerns about the economy as chief reasons to wait. Germany and Japan have addressed their falling birth rates by putting better child care policies in place. Falling birth rates are not necessarily a bad thing, as they are associated with greater savings and higher levels of educational attainment. It is certainly an oversimplified falsehood to think that a larger population means a better economy. 

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

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

Policy News

Under the ACA, the Affordable Care Act, all health insurance providers were required to cover the full range or reproductive health services including birth control and abortion. However, a suit filed by two Christian has succeeded in blocking the part of the mandate that pertains to coverage of the abortion pill. DHHS (Department of Health and Human Services ) will no longer be able to enforce this portion of the mandate against them. 

The US provides health care aid to many countries. In those health care systems, birth control and abortion services are provided. However the US Gag rule has prevented funds from continuing to go to countries which provide abortion services. . The Trump administration has created auspices under which exceptions to the gag rule may be obtained. This is because there are some such countries whose national law requires health care providers to include information about such services. Such countries may continue to receive US aid under what is being called the “ affirmative duty defense”. Theater loophole, the “passive duty” exception, the US may continue to supply funding if abortion is legal in that country. 

Texas continues to rally. Texas comes in at 47th in vaccination rates. A new group called the Texas HPV coalition aims to increase this rate to 80% before 2026, stemming a tide of HPV related diseases including cancer. 

As previously reported, Texas had shot itself in the foot by defunding and otherwise weakening primary health care for the poor, and reproductive health care in general. It has also been early in the race to defund Planned Parenthood and teen pregnancy prevention programs. Now its teen pregnancy rates, and more worryingly, the material morbidity and mortality rates are skyrocketing. Texans are now are trying to circle the wagons. In particular, the Dallas City Council has by itself resolved to spend $300,000 on a program to curb teen pregnancy rates. 

Nationally the same logic is at work. This coming week the Senate will vote on a bill which will create “Maternal Mortality Review Committees”  that track and investigate maternal mortality. 

Physician leadership is again voicing its defense of the Affordable Care Act (ACA). A recent article in Forbes has highlighted the uniform positions of the American Medical Association, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the American Psychiatric Association. How can this not give the administration pause ? 

An Oregon county has sued the Trump administration for their new guideline which give preferential funding to health care programs that promote abstinence. If they prevail, it could block these guidelines nationwide. 

Because contraception has now somewhat unexpectedly become such a controversial topic, the medical community is lobbying harder and harder for drug companies and the FDA (Food and Drug Administration to make birth control an over the counter medication. The American College of Obstetricians and Gynecologists have long advocated for this regard the oral contraceptive pill. Now the American Medical Association  was set to consider a resolution to this effect. 

Medical News 

Vitamin D is increasingly in the spotlight. This time,  new study has shown that adequate levels of vitamin D protect against miscarriage. Women at high latitudes in areas with little sunlight and little seafood are more prone to vitamin D deficiency. 

A new study out of Duke indicates that young women’s exercise rates drop off after high school. Additionally they drop off more quickly than do mens. More research is needed to understand and correct this phenomenon. 

Remember the Zika virus epidemic ? A new study shows that over half of Floridians took no precautions whatsoever against the virus. The report has shown that much more education is needed. 

Here is a sad commentary on out profession and on our relatively affluent population: Less than10 percent of our population get the recommended screening and counseling pertaining to preventive health care. This pertained to basics like measurements of vital signs and blood tests, but also to imaging studies like mammograms and colonoscopies for colon cancer screenings. Preventive health screening should also include counseling on weight, tobacco and alcohol use, screening for depression and currency on vaccinations. 

 Alcohol is harder on women than it is on men. This may be related mainly to weight. A new study indicates that young women who drink regularly and heavily ( 4-5 alcoholic drinks) are probably destined for low bone density such as osteoporosis. Women have little androgen (male hormone) compared to men, and androgen protect bone. Estrogen does too, but its production ceases after menopause, when osteoporosis is at its highest risk. Young women need to realize they are likely olive considerably longer than their mother and grandmothers. To do so in comfort and wellness, they need to take really good care of themselves. 

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

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

It is no secret by now that the Trump administration is systematically enacting policies to ban abortion and limit access to contraception. Medical experts have indicated their concern all along, saying these policies are likely to backfire, increasing unplanned pregnancies and abortions overall. 

Legal challenges to Trump administration policies are now coming from many quarters. Mississippi and Louisiana have pending legislation to ban abortion after 15 weeks. Both laws will now go to Federal court to be tested. Meanwhile, New Jersey is suing the Federal government against the exemption which permits corporations to purchase insurance without contraception coverage if they object to it on “moral” grounds. Since when can a corporation have morality ? People, owners, and board members can have morality or the lack of it.

The Federal Courts are going to have a big role in determining how much of this Trump era law stands. For example, a federal judge in Washington struck down the decision by the HHS (Department of Health and Human Services) to withhold funds for the teen pregnancy prevention program. The judge called the cancellation of funds “capricious”.  HHS actions have been struck down by federal courts four times to date. 

A survey of various health care groups has shown the 95% have strongly criticized the Trump administrations efforts to weaken the ACA (Affordable Care Act). The American College of Physicians has published a paper calling for recognition and addressing of the discrimination against women in health care. Health care disparities include those pertaining to reproduction, family and medical leave, domestic and sexual abuse and inclusion in clinical trials. 

Elsewhere in the world, Ireland has voted to repeal the countries ban on abortion. The popular vote passed by a margin of 2 to 1. To put things in perspective in this historically Catholic country, divorce was only legalized in 1995. Gay marriage has also been ratified in Ireland, and an openly gay man has served as Prime Minister. 

Medical News

We all know that genes influence our physical health. But they also influence our mental health. They are a number of genes which are associated with the development of Schizophrenia. However, even if they are present, the odds of actually developing schizophrenia are low. New research has indicated that pregnancy complications such as gestational diabetes and preeclampsia increase the risk of schizophrenia in susceptible individuals, as can smoking. This is all thought to take place via epigenetics and the placenta. More research is needed. 

A new study indicates what we have often observed; that those women who introduce a bottle in the hospital are much more likely to give up breastfeeding. Breastfeeding is recommended as the sole food source for babies for six months. 

The Nurses Health Study has produced data about nutrition and healing loss. Turns out those who had a diet most closely resembling a Mediterranean or DASH (Dietary Approaches to Stop Hypertension) diet were 30% less likely to experience moderate or severe hearing loss later in life. 

You will hear all kinds of unscientific reasons from patients about why they will not get a certain vaccine. We all know vaccines stimulate the immune systems and we all know they can make you feel a bit flu like in the process- no fun. New research has now proven that HPV ( human papilloma virus) vaccine does not cause increased autoimmune activity in girls. This confirms two prior large cohort studies. Despite all this, there is still a lot of push back against vaccines. It is hard for a caregiver to persist when a patient or a parent declines a needed vaccine. However new research indicates that physician persistent leads to 94% of children being vaccinated against HPV. 

Many times I hear talk to the affect that obesity alone is not a problem. There must be other factors such as diabetes or hypertension for obesity to be a threat to health. FALSE.. Newer date now tells us that having obesity ALONE makes you 39% more likely to have heart disease. 

We have been finding a lot of vitamin deficiency up here in the North Country. This has been true in pregnancy. We have undertaken supplementation regimens with the input of Endocrinology and are tailoring better maintenance regimens for both diet and supplements. New research has now show some good news : that those who take vitamin D in pregnancy are 28 % less likely to have low birth weight babies or stillbirth. 

In other vitamin D related news, new research also indicated that women with sufficient levels of vitamin D are 10% more like to get pregnant after a miscarriage, and 15% more likely to have a live birth after a miscarriage. 

Folic acid is also important in pregnancy and is known to prevent birth defects such as spina bifida. New research indicates that poorer women rarely takeout before it during pregnancy. This is something that should have a really easy fix. 

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

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

Policy News

The “Global Gag Rule” is a rule which prohibits international health care organizations from counseling about abortion lest they lose their aid money from the USA. More recently Title X funds are being withheld from groups in the US who perform abortion or mention it as a choice. Many feel this amounts to a domestic gag rule. However, the Trump administration is back peddling, saying it only relieves Title X recipient caregivers of the requirement to mention abortion as an option. These are two very different things. I wonder which is really the case. I wonder too, if this means the Title X grant givers will requests the medical records documenting patients' visits to see what caregivers and patients are discussing. ACOG (American College of Obstetricians and Gynecologists) has called this an “egregious intrusion” in the doctor patient relationship.  Analysts point out that, additionally, these new rules will give those “health clinics" which oppose abortion and birth control easier access to Title X funds.

Medical News 

The Chair of ACOG New York has produced a guide to the Gyn annual exam for the New York Times. In it, she has explained what to expect, including the holistic nature of the visit. Many people think of the annual Gyn exam as just a pap. However, it is wellness and preventive check that addresses the overall health of the patient. Pelvic exams are performed as indicated according to protocol. Patients are also reminded about what should not take place, such as more touching than is necessary. Patients are reassured that they are entitled to an explanation for everything that is done. 

Texas is starting to take the bull by the horns. Maternal mortality and morbidity in Texas has been egregious. Authorities are now honing in on the contributing factors, and devising strategies to address it. The Texas Medical association has drawn up a list of recommendations including statewide legislation to improve health care coverage for pregnancy women, to increase access to long acting reversible contraceptives (LARCS), and to increase the quality of record keeping on maternal complications. 

Tobacco smoke from a pregnant women damages the unborn baby’s lungs (among other things). New research indicates that vitamin C may mitigate this risk. The changes from smoking do not simply harm the baby in that time frame. In utero exposure to those chemicals induce changes in the baby's genes (epigenetic change) which may persist throughout life. 

SIDS (Sudden Infant Death Syndrome) has been a worry for some time. I remember when it was first defined. At that time, we had no clue about its cause. It remains incompletely understood. However we now understand that the odds of it are greatly reduced when the parents do not smoke, and also when the baby sleeps on their back. This knowledge has given rise to the “Back to Sleep” movement which promotes putting babies to sleep on their back. We have also since learn that avoidance of loose bedding and avoidance of co-sleeping is protective. This means newborns must not sleep in the same bed with parents, despite what may seem like convenience. Nonetheless, NPR has recently reported on the disconcerting trend of increasing co-sleeping. AAP the American Academy of Pediatrics has come out again against co-sleeping which iss highly the associated with an increased risk of sleep related deaths in babies under 4 months of age. 

The Institute of Clinical and Relational Science at UCSF (University of California San Francisco) has produced research indicating yoga may help incontinence and anxiety in older women. Findings were presented at the American Urological Association in San Francisco. 

Marijuana in pregnancy is again in the news, with yet more reports coming out about its disruption of fetal brain development. It is also linked to smaller birth weights and irritable behavior in infants. It is also linked to higher likelihood of still birth. And yet, 70% of Colorado dispensaries are recommending marijuana to pregnant women for nausea in pregnancy. Conflict of interest and flagrant irresponsibility, much ? 

Lung cancer in young women has now surpassed that in men. Lung cancer in men and women has decreased over the last two decades, however it is decreasing more rapidly in men. 

There is now good data that air pollution is related to infertility and preterm birth. A new study on the subject shows that the closure of oil and coal plants boosts fertility in nearby communities. 

There’s an app for that. Maybe. There are many apps pertaining to birth control. There may even be one that can help predict the risk of preeclampsia. However, before you go relying on one of these, Please check with your doctor about the validity of such an app. Quality varies, so buyer beware. 

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

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

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

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

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

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

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

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

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

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

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

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

Science marches on. 

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

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

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

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

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

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

Maternal mortality is a big topic nationwide. The rates are unacceptable in the US, and particularly bad in the South. Arkansas, in a reasonable move to triage women for eligibility for home birth, have established a screening process. That screening process for women helps the State determine who may legally delivery at home. Heretofore, this screening did not require a vaginal exam. Now it does, and this has brought fire from patients and home birth midwives. It has always been our position that a patient may decline anything for any reason. However, to qualify for certain program certain requirements must be met. My position would be that women who do not want vaginal exams will have to forgo participation in that particular program. And, I must ask, what is the problem with vaginal exams ? Women are not fragile and information is power. This type of overly precious attitude toward the female body, even by women, is counter to the interests of maternal and fetal health. It is case of putting philosophy over responsibility. 

Texas OB/Gyns are starting to speak out about what they see are the causes of excessive maternal mortality rates. They are identifying system errors such as failing to recognize risk, as well as more subtle phenomena, such as unconscious bias. Race is of course a factor as black women are four times more likely to die than white women. A rally in Boston highlighted the same cause of maternal mortality. The centerpiece of the rally was a billion the US Senate which will promote the formation of state review committees for maternal mortality. 

Pennsylvania is also taking measures to try to curb maternal mortality and has established a committee through the State Health Department to scrutinize the problem. 

In an effort to get more pregnancy women into prenatal care, Connecticut has approved a bill to make pregnancy a “ qualifying life event”. This means that pregnant patients in the state my enroll in insurance plans anytime, and need not enroll within the confines of the enrollment period. 

With all this talk on maternal mortality, one might take a moment and discuss maternal morbidity. Morbidity means serious complications short of death. The CDC (Centers for Disease Control) has indicated that for every 1 mother who dies, 70 nearly die. That is an astonishing statistic and goes a long way in my mind toward explaining why Obstetricians have such burn out, and why their numbers are decreasing. Maternal morbidity comes from all the same things maternal mortality: worsening maternal health, worsening access to evidence based care. poorly funded health care systems, unconscious bias, race, etc. 

The Trump Administration is considering implementing the so called “gag rule”domestically. This would prohibit the dispensation of Title X funding to any clinics which even mentioned abortion. I wonder how this reconciles with freedom of speech ? Can you imagine trying to enforce this ? All patient consultation and exam rooms would need to have audio recording equipment and someone would have to review the recordings. Dystopian much ? 

The Trump administration is reappropriating about $15 billion in unspent funds from CHIP (Children Health Insurance Program) and certain part of the ACA ( Affordable Care Act). Democrats feel this is not the time to cap these budgets or reduce rainy day funds. However the Trump administration budget is ballooning and they are trying to cut costs anywhere they can even for vulnerable groups. 

Iowa has banned abortion once a fetal heartbeat is detected, which is at around 6 weeks. However, similar measures have passed in North Dakota and Arkansas but they have both been struck down as being unconstitutional and inconsistent with Roe V. Wade. 

Louisiana has seen a quadrupling of the rate of neonatal abstinence syndrome (NAS). NAS describes the condition of infants who are born to opioid addicted women. A recent feature in teh New You Times has reported that about 90% of pregnancies among addicted women are unintended. The reasonable inference here is that addicted women have a hard time using birth control effectively. 

ACOG (American College of Obstetricians and Gynecologists ) advises pregnant and breastfeeding women not to use marijuana for concerns about developmental delays. Nonetheless, a new study has shown that 69% of Colorado Dispensaries phoned do recommend it to pregnant women for nausea. Dumb and dumber. 

New data is coming out that induction at 39 weeks may be associate with fewer risks and lower C section rates. More research is needed. 

A new study on genetic testing for breast cancer has shown that those who do not meet the criteria for testing have harmful mutations AS OFTEN as those who do meet the screening criteria. Sounds like the screening criteria need broadening. 

In other genetics related news, we find that the number of genetics tests available is increasing. A new study has shown that only a small subset of physicians order genetic testing, and even fewer know how to interpret them. This appears to be a case of the technology moving faster than our understanding. 

The Human Genome Research Institute is developing “ preconceptual screening” for couples. Right now screening is piecemeal, meaning only for a selection of known genes. However, they are developing  a whole genome sequencing program, which has been made possible by NGS, or next generation screening. 3.5 % of participants had a medically actionable finding. As of yet, the majority of the information acquired does not have a clinical application. 

Yet more data has come out of a large study on the HPV (human papilloma virus). In a study of 73,000, it has been shown not only to prevent cervical cancer, it also prevents precancerous lesion of the cervix. Additionally it did not show any increased risk of side effects compared to control. 

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

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

Correction 

We start first this week with a correction. The error was late in last week’s section on policy. In it I reported that ProPublica reported that the “ US is the most dangerous country in which to give birth”. That should have read, “the US is the most dangerous affluent country in which to give birth”. That’s still an awful distinction and one of the reasons why I write. 

Policy News

Title X funding has been denied to clinics in Nebraska who proved abortions. No surprise there. However, what is more noteworthy is that the new law restricts the speech of the caregivers in clinic. In particular, caregivers, when behind closed doors and under patient confidentiality, are prohibited to “ counsel in favor of or refer patients to abortion services”. Does it make anyone else nervous that a state government is attempting to restrict what is said in a private medical visit ? 

Enrollment in the ACA this year in 2018 did not plummet as was expected. Enrollment dipped slightly by 400,000 to 11.8 million Americans, which represents a drop of a little more than 3%. This was despite the fact that advertising and the time frame for enrollment were slashed. This drop was noted primarily in the 39 States who’s ACA is run but the Fed. The remaining 11 States manage their own ACA programs, and they did not see this drop in enrollment. Of note, among all enrollees, 27% were new enrollees. The average pre credit premium did go ip in 2018 compared to 2017, at $621 versus $476. 

In the latest turn of events regarding detained pregnant teen immigrants, a Federal Judge has ruled that HHS ( The Department of Health and Human Services) must allow pregnant detainees the right to obtain an abortion. The current policy of the the HHS Department of Refugee Resettlement has sought to block their right to do so. Under the Obama administration, such patients had the right to obtain elective abortion at their own expense, though they were able to get it paid for if it had been as a result of rape or incest or if was a threat to life. 

Medical News

Huffington Post interviewed physicians on the subject of hair dyeing during pregnancy. The panel’s conclusion was that “ there is just not enough conclusive evidence or research to suggest they dyeing …hair while pregnant will cause fetal harm”. While this statement is true, it bears examination. Insufficient evidence of harm does not constitute sufficient guarantee of safety. Insufficient evidence of harm does not even rule out the possibility of harm. It does not even rule out the probability of harm. It simply means that there is not enough evidence to say one way or another. The article goes on to says that there is a general consensus that it safe. While this too, is true, it is a weakly based consensus. It is based on the notion that a large number of pregnant women dye their hair and that no one has noticed any disturbing patterns emerging among their offspring. And yet, our notice has not been particularly attentive, since no one has bothered to do even an population based study of pregnant women who dye their hair complete with meaningful follow up of their offspring. I belabor this point to hone the readers' understanding of what the statements they read actually mean. 

Apparently younger patients typically like to pick younger doctors. This makes some sense to me in that the patient has someone to whom she can relate. However, there is also a shortage of Obstetricians and Gynecologists in many places in the country, especially rural areas. The older Ob/Gyns are still in place, with ever increasing work loads, especially in the underserved areas, while the younger docs want to be in the city with more partners, city lifestyle and higher pay. Services are strained in the areas least likely to bear it, and this may be impacting maternal mortality rates. 

Every generation thinks teens are worse than they were. Turns out they are wrong. By several metrics, todays teens are quantifiably different than the teens of yesteryear. The incidence of many high risk behaviors among teens have dropped considerably. For example, cigarette use and alcohol have dropped sharply compared to past generations. Teen pregnancy rate are at an all time low. Teens are delaying sex more and even teen driving fatalities are down. It is interesting to note that while most authorities are reassured by these changes, others point out that teens may be less mature, age for age, than their predecessors. In other words, perhaps teens are more immature than they used to be. I was initially dismayed by this assessment. But I suspect they do not mean immature in the sense of irresponsible or silly. I suspect they mean more dependent on parents and more risk averse.  This observation which point to kids behaving “younger” longer, may go along with what some have noted to be a modern extension of adolescence. In the “olden days” perhaps even  75 years ago, a 19 year old male was expected to have a job and a career direction. He could be thinking about marrying once he was settled. Certainly a 19 year old girl, which in those days was in fact, a young woman, would typically be thinking about marriage and independence from family. These days most families are concerned about thier 19 year olds continuing their education or training, for at least another 4 years. 

The extension of adolescence is a critical topic right now, and I am scarcely qualified to address it. However I am the mother of three grown children including two sons and have shepherded countless women into motherhood. That and the formal literature I have read indicates extended adolescence is real in biologically, developmentally and sociologically measurable terms. We may begin adolescence sooner in terms of menstruation and puberty, but our brains are remaining plastic much longer. Our health and nutrition are better. As implausible as it sounds, society is actually safer, our parenting is actually better, and children are kept from harsher stresses compared to the past. We are more affluent than before. The age of information has made its debut. There is far more novelty in our environment and with our added relative affluence we can extend education until the mid twenties and afford children the opportunity to travel, all of which keeps the brain in a far more plastic and youthful state. This brain “metaplasticity” is based in neurons and their activity and can be measured. As a side note, a new post mortem study published in Cell Stem Cell has confirmed that neurogenesis (the making of neurons) continues in older people, even through the 70s. However in most older folks, they tend to be more poorly vascularized. 

Extended adolescence can go wrong. It has been credited with the hapless directionless young adult, deadbeat dads, kids who drop out of college, the 40 year old gaming in his mom’s basement, etc. Some say this is related to changes in our economy with a shift more to information based work than labor based work. With extractive industries and jobs with manual labor on the wane, men are less likely to get a job not requiring years of higher education. Acknowledging the breadth of these factors can help us understand why the blame game is fruitless. The bottom line is that older adolescents need parental support which they tell me is a foundation of unconditional love combined with a clear set of reasonable expectations and consequences. 

All of this bears very much into the work of Obstetricians and Gynecologists as we help women through the phases of their lives. We counsel women on risks to their health everyday. We support them through pregnancies where they may be on their own or poorly supported. We encourage them to move forward with their lives even after their children are born. We support women as they struggle with parenting their own adolescents. 

Here is some more reading for those of you who are interested. 

https://www.nytimes.com/2018/03/30/well/family/teenagers-generation-stoneman-douglas-parkland-.html

https://www.theatlantic.com/health/archive/2016/11/metaplasticity/506390/

https://www.scientificamerican.com/article/extended-adolescence-when-25-is-the-new-181/

Whole genome DNA sequencing has become popular for adults. Antenatal genetic screening has become standard prenatal care. Now the two can be combined though amniocentesis and whole genome sequencing. I wonder how long it will be before this can be done with a single maternal blood draw. 

Mayo Clnic is studying a streamlined form of home based prenatal care. A pilot group of patients is using home monitoring for baby and vital signs. They also have 8 actual clinic visits which is fewer than standard. Motivation for this study is to determine a valid protocol for women in remote areas. 

Last week I reported that boys were receiving Gardisil vaccine against HPV at a fraction of the rate of girls. Good news this week: that these rates of vaccination for boys are increasing rapidly. from 8 to 26% between 2011 and 2016. Girls’ rates went from 38 to 46 percent in the same time interval. 

ACOG has created a document called a Committee Opinion and thereby formalized something that most of us have always done. Ob/Gyns play a role in ensuring that women are protected from workplace discrimination. They do so by writing notes for work as documentation for specific health related work restrictions. They can help enforce sick leave, postpartum leave or parental leave for fathers. They can also help patients identify workplace abuses and refer them to the correct authorities. This behooves all providers to familiarize themselves about local laws and local labor offices. Workplace stress is a real health hazard and it is part of the Obstetrician Gynecologists responsibility to help deal with it. 

Many PCO (polycystic ovary) patients need to take Metformin to get pregnant. They are also advised to stay on it or related medications to prevent gestational diabetes. However, some are concerned about taking it in pregnancy. The available evidence indicates it is safe. Newer research has shown it reduces miscarriage and preterm labor. 

Vices taxes work. The Lancet has reported that taxing known harmful substances like cigarettes alcohol and soda steers consumers toward healthier choices. This study was a meta-analysis of 5 internal national studies from around the world. Concerns have been raised that these taxes disproportionate burden the poor, but this study examined this question and found that there was no disproportionate harm to this group. Larry Summers, a former Treasury Secretary and emeritus professional at Harvard wrote an analysis for the study, confirming that “ taxes are an underused instrument for the prevention of premature death and disease….” and “ consistently raise prices, reduce consumption, and save lives, while generating additional revenue to support public services. 

Vegetables work too. A new study confirms that lots of vegetables help older women keep blood vessels healthy. Of note, the ones that worked the best were the cruciferous vegetables, aka the brassica family which include cabbage, brussels spouts, cauliflower, cabbage, kale and the like. On that note, for northerners, I will recommend purchasing and planting spring seed. Those of you in the southern hemisphere can cultivate and plant now for a prompt spring germination. 

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

Medical Monday : Two Week Catch Up

Happy Easter and Happy Passover. We have two weeks to cover. Thanks for reading ! 

Policy News

Much of the National Health Policy News this week deals with contraception and reproductive health. Can anyone remember any time in this or any other country when these private matters were ever so much on the national stage ? The politically conservative aspects of my nature questions why this degree of government intervention in private lives is necessary. My medical qualifications and medico-legal experience cause me to classify some of this meddling as practicing medicine without a license. 

Title X is a federal grant program whose purpose it is to promote positive birth outcomes and healthy families. It provides grants for family planning and health services. So here’s my first question: Why is it not run by health care professionals ? Trump administration officials are now contemplating new wording which would add additional criteria for clinics to receive Title X funding, namely the provision of primary preventive services. Sounds good right ? Well many clinics offer only reproductive health services. These clinics would have to expand or close. This measure seems like just another way of closing family planning clinics.  Now whether pap smears would qualify as preventive health is unclear, or whether paps would be classified as reproductive health, I don’t know. 

Texas is challenging the federal government’s withholding of funds for its family planning programs. They were withheld several years ago based on the fact that these providers, many of them through Planned Parenthood, also provided abortions.

Planned Parenthood itself is challenging the Federal Government on its withdraws of funds from the teen pregnancy program. Between this and two other plaintiffs, the Department of Health and Human Services has partially and temporarily restored some of the funding until litigation can be completed. 

Idaho has failed to solve the problem of insurance for those whose income falls between Medicaid and the Affordable Care Act coverage criteria. A proposal called Plan First Idaho would have funded family planing services for women in the gap. My question is, what rocket scientist designed the State’s the two programs such that their income qualifying criteria do not meet seamlessly ? This is a problem of their own making and it needs solving. Republicans in the Idaho House stalled this measure. 

Idaho Governor “ Butch” Otter has approved a measure by which prospective abortion patients must a told about “ abortion reversal” a procedure that does not exist. Additionally, he has signed legislation which will require abortion providers to collect personal and demographic information which, in de-identified form they intend to make public. I don't know what they think this will accomplish, but I have a feeling it may backfire, since they will be able to see how many and how diverse a group of women utilize the procedure.

The Supreme Court is hearing a case between the State of California and a group of "crisis pregnancy centers”, an actual chain of 130 outlets run by “ The National Institute of Family and Life Advocates”. These centers are anti-abortion counseling facilities, however they are licensed as family planning providers. California has a law requiring that all licensed family planning facilities to post notices of the availability of free or low cost birth control and abortion services and they are challenging it. They are arguing that this posting requirement violates their free speech.  So far the Court has expressed concern that these clinics not be singled out from other clinics. California has argued that their staff, many of whom are not medically qualified, present medical misinformation as truth, all to the end of dissuading patients from abortion. Apparently theses non-credentialed counselors actually wear white coats. 

Along with the opioid epidemic has come a hepatitis C epidemic. Kentucky, having seen a surge of the disease, has passed a law now requiring all pregnant women to be tested for it. Hepatitis C used to be very hard to treat. However, patients have much more hope nowadays due to the availability of effective therapy. 

Missouri has expanded Medicaid for pregnant women in drug abuse treatment. Their continued coverage will be contingent upon them staying in treatment, and could under those conditions, be continued up to 12 months.  

And now for more of a purple to blue state review:

Florida is considering a bill requiring HPV (human papilloma virus) vaccination to be required as part of the vaccinations required of children attending public school. Human papilloma virus causes multiple illnesses most notably cervical cancer and genital warts, and the vaccine has not demonstrated any conclusive evidence of harm.

It is interesting to note that physicians are not prescribing HPV vaccine equally for female and male children. Doctors recommend the vaccine twice as often for girls as they do for boys. This puts the boys at increased risk for HPV disease, and puts all their future partners at increased risk too. 

Mississippi passed a law banning abortion after 15 weeks Of course this is unconstitutional based on Roe V. Wade which is still on the books. A Federal Judge over turned Idaho's ban. 

New Hampshire has passed a bill which will allow pharmacist to prescribe birth control. No doctors visit will be necessary. The medical establishment has concluded that vast majority of the birth control methods are safe for the vast majority of women. They certainly are when compared to pregnancy for those same women. Authorities believe this will eliminate yet one more barrier to contraception. Utah signed a similar law into place earlier in the week. 

On the other coastline, the state of Washington now has a bill that will require insurance to cover contraception, abortion and maternity care. Additionally, after the first of the year, all contraception has to be co-pay and deductible free. This includes voluntary sterilization. 

The new budget has failed to shore up the ACA ( Affordable care Act) marketplaces. States will have to tighten their belts and work on their budgets one by one. 

ProPublica has reported that the “US is the most dangerous country in which to give birth”. States all over the US are creating programs to quantify and address the problem of maternal morbidity and mortality, even as the Federal government under Trump is dismantling reproductive and maternal health care piece by piece. 

Do you ever get the feeling that the various States in America are becoming like the countries of the European Union with different values, cultures budgets and laws ? 

Medical News: 

Obstetrics: 

Striking research findings presented at Lancet Global Health conference have shown that the death risk is double among pregnant women who are anemic compared with those who are not. The lead study author also found the correcting anemia is not a sufficiently high enough priority among physicians. 

Research presented at Diabetes UK conference has shown that excess weight gain incurred during pregnancy by  gestational diabetics is associated with greater risk of cesarean section.

Women who exercise in pregnancy have shorter labors. This interesting news was published in the May issue of European Journal of Obstetrics and Gynecology and Reproductive Biology. The study group attended a professionally led session of moderate exercise three days per week. Labor was shortened about one hour, mostly in the first stage, or dilating phase. ACTIONABLE ! 

Children who were breastfed exclusively for at least 6 mores were less likely to become overweight to obese than their counterparts. The conclusions were drawn by analyzing over 38,000 records from children South Korea. The finding were presented at the Endocrine Society Annual Meeting. 

Gynecology/General Medical News: 

There may be a male birth control pill on the horizon. Research at the Endocrine Society's annual conference has presented information on a new male birth control pill called DMAU. It contains androgen and progestin,  which is analogous to the contents of the female birth control pill, estrogen and progestin. Once daily tablets appear to be safe and effective. No period required. 

Menopause and aging in general is characterized by a loss of muscle mass and bone density as well as the deposition of fat. As suspected, the Mediterranean diet may have a positive impact on bone mineral density and muscle mass in postmenopausal women. The Mediterranean diet emphasizes the eating of high quality protein, large volumes of fruit and vegetables, healthy fats such as olive oil and a modest amount of complex carbohydrates such as whole grains. As a whole, the diet is lower in simple carbohydrates than the typical American diet and is also higher in protein and antioxidants.

There are now over 400 cases of a rare lymphoma which are linked, epidemiologically, to breast implants. Breast implants are not new. Lymphoma is not new. However our ability to collect and parse data is better than it has ever been. The FDA it's taken this ability and created a meaningful database for this type of information. While an association between breast implants and this rare lymphoma is being established through data collection, a causality between the two is not necessary implied. That said, nothing is more likely to lead us to understand the causes of this problem than amassing quality data about it. 

Federal funding support for cancers is disproportionately low for gynecologic cancers if you rank them by lethality. Cancer of the ovary and the uterus ranked near the bottom of the funding list. Contact your elected officials ! 

A new modification of the current device used for pap smears can identify cells from endometrial (uterine lining) and ovarian cancer. The investigational PapSEEK uses an analysis of 18 genes and analysis similar to that used in prenatal screening for Down’s syndrome to identical the genetically abnormal cancer cells. THIS IS SO COOL ! 

A new study on postmenopausal hormone therapy has shown that it does help maintain thinking and memory skills. This is the case IF it is initiated shortly after the onset of natural menopause. This study was presented in the Journal Neurology and was a high quality randomized controlled trial of 75 women between the ages of  42 and 56. 

In my mountain state, there is not a great deal of sunlight or seafood. As a result we have a high prevalence of vitamin D deficiency. New research indicates that vitamin D deficiency increases a post menopausal women’s risk of metabolic syndrome. Metabolic syndrome includes the unholy triad of diabetes, high blood pressure, and abnormal serum lipids ( cholesterol and triglycerides) which together increase cardiovascular risk. Vitamin D levels are checked by a simple blood test. Ask your doctor about this ! 

Stay tuned for more news from the exciting world of Obstetrics an Gynecology, next week, here on Medical Monday ! 

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

Policy News

The Trump administration has said that the patients displaced by closures of Planned Parenthood offices can be absorbed by community health centers. However, a new survey out by Kaiser has indicated that fewer than one in five community health center will be able to compensate in this manner. Planned Parenthood may be apt to close if they cannot receive Title X funding through Medicaid on account of including abortion in their counseling or practice. 

A new Ohio law due to take effect later this month would have criminalized abortions done for Down syndrome. However, a Federal Judge has blocked the law, calling unconstitutional. In particular, it has been determined to violate the 14th Amendment due to violations of both liberty and privacy. 

Certain crisis pregnancy centers have no medical credentials whatsoever. Instead, they are merely storefronts for anti-choice or religious advocacy. The Supreme Court will hear arguments this week about the nature of their obligation to disclose their credentials and their agenda. 

The Contraceptive mandate was rolled back in Massachusetts. The state has challenged this but initially has failed to show enough data on adverse effects on the people of the state. The State plans to also argue that the rollback challenges the First Amendment which contains a prohibition against the establishment of religion by the government. 

New fast track legislation for the FDA ( Food and Drug Administration) called “Right to Try” has been under consideration. This would have streamlined/abbreviated the testing and approval process for certain potentially beneficial drugs, thereby getting them to more patients sooner. Proponents cited potential benefit, while opponents cited potential harms of less than completely tested drugs. The House failed to pass the measure failing to meet a 2/3 majority. 

Medical News 

The problem of appalling and increasing Maternal Mortality in the United States is squarely on the table now. Researchers are now focusing on several factors which may have led to this perfect storm. In addition to funding cuts and clinic closures, a shortage of Obstetric providers and rural hospitals providing Obstetric care is now in the mix. 

Stepping back, I'd like to remind readers that Mortality means death. However, for every mother who dies a childbirth associated death, there are 70 others who are near death and critically ill. This is the “ Morbidity” part of the equation. A new study has shown that addressing maternal Morbidity and Mortality in the States would greatly bring down the cost of healthcare. 

I would add that since 50% of all pregnancies are unplanned, that the contraceptive mandate might be worth its weight in gold to decrease maternal Morbidity and Mortality in rural areas and in general. Case in point: Colorado, home of my residency alma mater, the University of Colorado, has made sure safe and effective birth control was available all across the state, rural areas included. As a direct result, rural teen pregnancy rates fell by over half between 2007 and 2014. 

New research on teen pregnancy indicates that childhood bullying and various forms of rejection seems to be a risk factor in teen pregnancy. It is even more so for lesbian and bisexual girls, something caregivers should bear in mind. 

The field of Obstetrics is beginning to grapple with gender issues in the field. In 1970, only 7% of ObGyns were women. Now, 59% are. Furthermore, only 17% of ObGyn residents are men, and residents are the future. What are the ramifications for women’s health? Will men be excluded from the field by patient preference or institutional customs? 

Everyone has hailed the balancing of the field as a good thing. However, is it good if Obstetrics and Gynecology becomes devoid of men? One recent meta-analysis says 8% of patients prefer men Ob/Gyns and 41% have no preference. Here are some factors in the debate: 

• Patients may legally discriminate regarding who sees them. 
• Assuming that a certain gender will be insensitive or unprofessional is unfair. 
• Male medical students going into any specialty may be denied important clinical experience in their training if they are excluded from rooms. 
• Both men and women can and have made significant contributions to Obstetrics and Gynecology. 
• Outside of Obstetrics and Gynecology, men dominate 37 of the 42 other specialties, and fewer than a third of other doctors are women. 
• People want caregivers that are relatable, but their most important priority is to have a good doctor. 
• Women Ob/Gyns are not good Ob/Gyns because of their biology. It is because of learning, skill, and experience. These are gender neutral. 
• How male caregivers are introduced has a great deal to do with how well they are accepted. 
• The healthcare and health status of women is something everyone in society should care about and be able to work on. 

What do you think? Have had both male and female Ob/Gyns and have liked them all. 

Marijuana in pregnancy is again in the news. A recent study presented at the Society for Maternal Fetal Medicine has found an association between MJ use in pregnancy and the following outcomes: increased risk for stillbirth, increased risk of preterm birth, increased incidence of hypertensive disorders in pregnancy. 

Predicting cardiac risk in women is different than predicting it in men. In women, central obesity is a particular concern. Increasing BMI predicts increased cardiovascular risk. However, large waist to hip ratio predicts it even better in women. 

Dr. Barbara Levy, vice president of health policy for ACOG, has stated that labioplasty for purely cosmetic reasons should be cautiously considered since it is the removal of sexually functional tissue. Labioplasty for cosmetic or supposedly performance-related purposes is becoming increasingly popular, even among young women. I would add that it is often a cash up front business that practices use to bolster their income. 

Zika virus infection in pregnancy produces discernible malformations of the brain and eyes 7% of the time, across the board. The rate is higher if the infection is contracted in the first trimester. There is some evidence that the rates of malformation varied by country. 

In the good news department, women who are “ highly fit” in midlife may be less likely to get dementia later in life. This study ran over 44 years on about 1500 women in Sweden. Those only moderately fit saw some delay of dementia as well. 

Also in the good news department is the following: Scott Gottlieb, FDA commissioner, has announced plans to impose new lower limits on nicotine in cigarettes to make them minimally or non-addictive. While certain people will still roll their own, it seems certain that the population as a whole will benefit. 

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

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

The American Civil Liberties Union (ACLU) and the HHS ORR ( Department of Health and Human Services Office of Refugee Resettlement) are battling out a constitutional question. The are debating whether or not unaccompanied undocumented immigrant minors in shelters have any rights to abortion under the Constitution. I am no constitutional scholar, and I am ignorant as to the extent that our Constitution applies to undocumented immigrants. Whether or not they are in shelters, or unaccompanied, seems immaterial. Their age could be germane, but again, perhaps could be handled under the terms of our own age laws. Any insights would be appreciated. For any women or girl, undocumented or otherwise, to give birth or to have an abortion is  a momentous and expensive event. Either one is also a medical event and that is the most important point. We already have medical policies in this country about such things, and I cannot understand why immigration status would alter the medical algorithm such an undocumented minor would follow. We need to remember that these questions are primarily medical, not political. 

New Hampshire has proposed a bill further reducing barriers to contraception. Currently, contraceptives may only be prescribed three months at a time. However, the state is considering a bill to increase this to a whole year. This seems logical to me as a Gynecologist since, at least with a patient who is established on the pill, I only need to see her once per year. If I am observing her on a new pill, or working to decrease side effects, special arrangements can made to see her sooner. The New Hampshire bill also specifies that insurers must continue to cover it entirely without copays. 

The very red State of Idaho is espousing contraception. Idaho House legislators are advocating a bill which would obtain a “waiver” ie. federal permission, to expand family planning services to women aged 19-44 who do not qualify for Medicaid, Medicare or other programs. 

Unlikely bedfellows in Connecticut are trying to secure prenatal care for the newly pregnant. Republican legislators are working with Planned Parenthood to offer health insurance to pregnancy women if they sign up within 30 days of finding out they are pregnant. 

The red state of Nebraska, on the other hand, is draining funds from Planned Parenthood in a move that will decrease family planning services in an already medically impoverished state. The may com through restriction of Title X grants. 

Dr. Haywood Brown the President of American College of Obstetricians and Gynecologists, has flatly called out the Trump administration and their “ continued move away from scientific evidence based policies and toward unscientific ideologies”. The particular context this time was the announcement of preferential Title X grant giving to organizations that teach “natural family planning” and abstinence for birth control. Where is the pussy grabbing now ?  This administration has such an on again off again relationship with sex I just cannot keep track. 

In medical news, culture seems to be playing a big role in smoking. Witness the great discrepancy in smoking rates among pregnant women by state. Worst is West Virginia, at 25%, whereas in California it is a little over 1%. The average across the US is about 7%. But, I am a splitter, not a lumper, and it seems our efforts to curtail smoking in pregnancy should vary state by state, perhaps even county by county, to be the most effective. 

You may have heard about all the problems and lawsuits having to do with vaginal mesh used in prolapse surgery. You may also have heard of more of a tape or ribbon procedure to fix stress urinary incontinence (SUI). They are different. Vaginal mesh is a large sheet of mesh, whereas the tape/ribbon is narrow like the name suggests. They are not in the same category for complications. A new study has shown what we all have expected and hoped, that the tension free vaginal tape is safe and effective for women with SUI. 

Probiotics are all the rage, and I mean in the hallowed halls of medicine, not the local vitamin store. A new study of very high quality (a meta-analysis) has found that probiotic and fish oil supplementation in pregnancy may reduce the risk of eczema and egg allergy in the offspring. That’s great, you say, no eczema or egg allergy. Actually, I am going speculate intelligently, and suggest to you that eczema and egg allergy are what I would call marker conditions, meaning conditions which are part of a greater category of tendencies that we call atopy, or the tendency to react to things. Atopic patients are those with troubles like asthma, rashiness, and lots of allergies. Their immune system is likely a little dysfunctional in vaguely defined ways. If simple nutritional interventions during pregnancy can help curtail such tendencies in children, that’s interesting and beneficial. 

A new document of WHO (World Health Organization) pregnancy recommendations for woman in childbirth strikes me as unwieldy. It seems to address such a wide range of women in a wide range of conditions that it becomes unusable. Yes, it highlights recent findings and recommendations about giving natural unaugmented labor longer to progress. Yes, it advocates for movement and positioning during labor, and the presence of a supportive environment and support people. It mentions delayed cord clamping. But these are already standards of care in the US. However the document gets an identity crisis when it states continuous monitoring is not recommended, and yet allows food in labor, does not mandate an IV, and yet allows pain relief like epidurals. (One cannot have an epidural without an IV). It is a document for caregivers of patients who in many cases have had little or no prenatal care, and so in a modern care environment they would be considered high risk until proven otherwise. In no state of this union would a high risk patient be permitted to go without IV or monitoring. Neither would they be permitted to eat if an epidural was under consideration. In any labor, C section is a real possibility, and to have food in the stomach ahead of that is a real risk. On the other hand, if there were no facilities for C section then perhaps it is fine to allow patients to eat and go without an IV. But one’s ability to allow these things would not, under those circumstance, be because they are safe. It would be because they would not matter. 

I am afraid this document will entirely confuse practitioners in a modern care environment. The WHO document recommends things which, in our environment, would be indefensible. The document almost needs to be cleaved into two documents, one for those in poorly equipped areas, and one for those unwell equipped area. This document appears to be written by people who would like to think that the rules should be the same for all women in the world, and that all laboring women in the world would have the same standard of care. I am one of those people. However, the authors of this WHO document are trying to torque this equality into being by sanctioning the labor care methods of minimally equipped facilities; in short, they achieve a unified standard of labor care by writing a  document recommending a much lower standard or care for all. We in the US already have enough trouble with our maternal morbidity and mortality without these recommendations. 

A new headline in “Health Day” covering an article  published in the Journal of Nursing has concluded that "food and drink in labor appear to be safe". ACOG currently sanctions only clear liquids in labor, and this is to avoid the risk of aspiration of solid food particles, something to which pregnant women are vulnerable, especially if they go to C section. When an apparent discrepancy in recommendations like this comes up, it is always good to unpack the details. Did I mention I was a splitter ? It turns out the study was case-control design, done at a smaller Port Jefferson, New York hospital over 4 years. The study was actually comparing just ice chips versus clear liquids like jello and italian ices, the so-called "food". We have known for some time that clear liquids, which is what jello and italian ices are, are safe. The “food”is not solid, the study's conclusion is not news, and the recommendations have not changed. However, I worry that laboring women around the country will be asking to see a menu to order food as they enter labor. 

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

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

MEDICAL POLICY NEWS 

The new budget has blown the top off the old budget, and this, from conservative lawmakers. It exceed prior spending caps, and suspended the debt limit for a year. As part of the package it did refund CHIP (Children’s Health Insurance Program) for four years. 

CMS is the Center for Medicaid Services. According to their actuaries, health spending in the nation will increase by about 5.5%per year to $ 5.5 trillion dollars, nearly a fifth of the economy. The fastest growing sector of health spending is prescription drugs, estimated to grow by over 6% per year in the next decade. Due to the Affordable Care Act, (ACA) personal spending for health care has been at historic lows, though it is projected to increase, even under the ACA, at over 2.2% per year, which is over the cost of inflation which is 1.9%. Whether or not this is good, bad or indifferent, I cannot say. As a mother and as a physician, I feel we undervalue our health care and its costs. We spend on electronics, vehicles and vacations, which are important, but forget that health is at the foundation of it all. 

The Trump Administration is disinclined to regulate drug prices. However, they propose “easing government regulations (read: protections) to “spur innovation” to “lower drug prices”. They also proposed expanding drug coverage and  placing a cap on out of pocket spending for Medicare recipients. While the federal government will not regulate drug prices, it will allow up to five states to band together to negotiate drug prices. 

The ACA has a dependent provision saying that children up through the age of 26 may stay on their parent’s health insurance policies. A study recently published in JAMA, the Journal of the American Medical Association, has revealed that this provision resulted in increased rates of prenatal care, early prenatal care, and reductions in preterm birth. As an Ob/Gyn I can tell you that one of our holy grails is finding a successful approach to preterm birth. Looks like having health insurance might help. 

Maternal Mortality is four times higher for black women than white women in our country. Access to prenatal care is believed to be part of this. A recent New York Times editorial  featured a free Obstetrics clinic in Florida who accepted clients regardless of ability to pay. They were able to document a 40% reduction in preterm labor and low birth weight in this group. 

I reported earlier on the Utah bill which will provide for the use of Medicaid funds to provide family planing services to low income women. Part of the genius of this is that these are not just any poor women. These are women who are below the poverty level, but who are not so poor that they qualify for Medicaid. They are the so called women in the gap. Lawmakers would save everyone money if they gathered data about the lowest income at which one can reasonably afford private insurance, and made that the same level at which one qualifies for the Affordable Care Act. From there, the ACA should cover straight down to incomes which qualify for Medicaid. Then there would be no gaps. Rocket Science. 

Health care is a case of pay now or pay later. By now, everyone including consumers and lawmakers should understand that attending to health and paying for it up front saves both money, productivity and suffering in the long run. This is the single most important message I can tell you. 

Planned Parenthood has been under scrutiny, defunded in parts, and under continuing threat of more defunding. Planned parenthood provides many primary health care services at very low cost, not just family planning services. Their services disproportionately benefit women. Many associate their defunding in certain states like Texas, with increased rates of Maternal Morbidity and Mortality. This last week, leadership of Planned Parenthood announced they will begin a campaign of legislative action in key states. 

West Virginia is attempting to supercede Federal Law. Their Senate has passed the “no constitutional right to abortion” amendment, and it now heads to their House. All this is despite the federal law Roe Versus Wade which guaruntees the right to abortion within various age parameters. One opposing Democratic senator, a physician, simply read ACOG’s (American College of Obstetricians and Gynecologists) statement of opposition to the measure as his response. 

The Trump Administration has developed a “Conscience and Freedom” division of the Department of Health and Human Services. Since when did a Government office dealing with health care need a “ Conscience and Freedom” division ? It sounds very "morality police" to me. Encompassed in this type of approach would be protections for physicians who withheld certain treatments, and punishments for physicians who administered them. This move has also raised concerns in the hallowed halls of academic medicine. Professors from the Bixby Center for Global Reproductive Health and the Department of Obstetrics and Gynecology at UCSF (University of California San Francisco) have written an op ed against the formation of this committee and its enforcers. They have asked the Administration “to stop politicizing medicine and interfering in the judgement of medical professionals.” 

Think all this sounds implausible ? Think again. The Iowa Senate has approved a bill to ban abortion after a heartbeat is detected. We routinely detect heartbeats at 5.5 to 6 weeks after the last menstrual period. The bill includes a provision to charge physicians who do such procedures non-emergently with a Class D felony. Opponents of the measure are many. The University of Iowa would lose it’s accreditation of it’s residency program in Obstetrics and Gynecology if this were to be the case. This is because,to comply with the state law, the Program's policies have to comply with medical science and recommendations. This would worsen the problem of the shortage of Obstetricians and Gynecologists. 

MEDICAL NEWS 

In the recent past, Betamethasone steroids were only given to women expected to deliver before 34 weeks. More recently, the recommendation is to expand the use up through just before 37 weeks., the so-called late preterm period. Steroid given in this way decreases pulmonary (Lung) problems in the premature newborn. New research presented at the Society for Maternal Fetal Medicine has concluded that up to $200 million in savings could be realized by following this new recommendation. 

Increasing evidence shows that ovary cancer starts in the tubes rather than the ovaries. You might know this already if you have recently been counseled about a tubal sterilization procedure. In the past, we performed sterilization by tying, clipping, or cauterizing the tubes. However now we offer patients removal of the tubes to confer additional cancer prevention. 

American “fertility rates” are falling. This could be misconstrued as meaning more American women are infertile. However, this is not what it means. It does mean our birth rate is decreasing. Researchers believe this is explained by later marriage, smaller families, better adoption of birth control and fewer births among the unmarried. Their are varying assessments of this trend. Some people believe economic prosperity is dependent upon ever increasing birth rate, but this is an outdated and flawed analysis. Some believe that decreased birth rate alone will rescue the environment. I wish it were that simple. Data shows that income, educational attainment, and savings all increase with smaller families. 

HPV vaccine rates are still low. They are rising, but are still low. It is effective and has nothing to do with the choice to become sexually active. It prevents cervical cancer and genital warts. The side effects are limited to the side effects of an injection. What’s not to like ? 

Juice is out. Juice has been out for some time but many people seemed to have missed the memo. Many people still think that drinking 100% pure (even organic) fruit juice is a healthy thing to do. It is not. It is too much fruit sugar, in too broken down a form, for people to metabolize without spiking their blood sugar and risking fat deposition. A calorie is not a calorie. The RATE at which sugar enters your bloodstream is key. The rate with juice is just higher than our physiology can handle. It is far better to eat the whole fruit itself. The fruit has structure, even once chewed or blended in a smoothie, and it will enter the bloodstream in a slow release fashion. New research has shown that postmenopausal women who have a single 6 ounce serving of fruit juice per day persistently gain weight over the years. Of course many factors probably go into this, but the juice drinking may be a marker for misconceptions they have about nutrition. 

New research shows that who who meet criteria for and get MRI for breast cancer screening get more “invasive” (meaning with a needle or some other sharp object) biopsies. They say it like its a bad thing. Of course they get more biopsies. We see more detail and raise more concerns. The research goes on… fewer of these biopsies result in a cancer diagnosis”. AGAIN they say this like its a bad thing ! It is good to have no cancer diagnosis. What we are seeing here is a natural expectation of increased sensitivity and decreased specificity in the testing. There are more false positives, which we as a society have decided to accept as the “cost” of earlier diagnosis and better cures. So we as a group trade more pokes with a big needle for many women in exchange for greater years of life for a few. Sounds like a bargain to me ! Read these sensational headlines with care people, and don’t be afraid of needles. Sharp objects are your friend. And by the way, they talk about “invasive biopsies” like there is even such a thing as non-invasive biopsies. Spin the headlines much ? 

It is still meaningful to get your flu vaccine. If it does not prevent flu, it still will decrease the severity. If you don’t want to do it for yourself, do it for the unwell, elderly, children or pregnant women about whom you care. They are especially vulnerable and the death toll nationwide is appalling. Anti-vaxxers, take notice. There is cost to what you say. 

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

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

Policy

The GOP appears to be giving up on repealing the Affordable Care Act (ACA). Those who support the patient care aspects of the ACA may cheer, but they should not breathe a sign of relief, since the funding mechanisms of this plan remain somewhat undetermined. Encouragingly, there is increasing GOP interest in crafting legislation which will make the plan more fiscally stable. The goals in this case would be to guarantee Federal subsidies to insurers, and to reduce patient premiums while keeping essential benefits.

Do you think that people realize that the more people sign up for the ACA, the more stable it will be ? Well, it's true. It's easy. Go to heathcare.gov to see if you qualify. 

South Carolina has argued that a “ human being is a person at fertilization”. They have created a legal category “preborn humans” which incidentally my spell check refuses to recognize, and they propose these preborn humans be afforded due process and all protections under the law. ACOG, the American College of Obstetricians and Gynecologists, opposes the bill since it is not based on science. 

A 20 week ban on abortion failed the Senate. The bill’s proponents advanced the bill on the basis of their belief that 20 week fetuses can feel pain. ACOG has gone on record saying “ the fetus does not have the physiological capacity to perceive pain until at least the 24th week of gestation.”. We as a medical culture have a great deal of experience with 24 week babies since they routinely come to any large newborn ICU. Had the bill passed, it would have been challenged under the standing Roe V. Wade. 

Idaho has introduced a bill which introduces misinformation into the informed consent language for medical (pill based) abortion. The bill’s language asserts that medical abortion can be halted after the first of two pills is taken. The bill further requires providers to provide a list of other providers who can advise about “ abortion reversals”. None of the bills assertions are based in fact. A patient contemplating a medically induced abortion should not proceed if she has any doubts, since there is no evidence reversal is possible. I feel angry on behalf of distraught women who may be told this misinformation and who try to rely on it. 

A group of private donors has bankrolled the provision of medical abortion services for all public universities in California. A bill is under debate which will require public universities to provide this service. 

Another bill proposed in California would require larger businesses with new construction to provide space for breastfeeding. The bill stipulates these areas need to be be in place by 2019. 

The Utah bill which will require the offering of IUDs through Medicaid has passed the House and is heading to the Utah Senate. Republican lawmaker Ray Ward, has proposed the measure to decrease unplanned pregnancies, teen pregnancies, and abortions. 

Medicaid expansions may be able to move forward in several traditionally red states if they are paired with work requirements. What do you think ?

Medicine

 

Researchers out of UC San Francisco have come out highlighting the adverse effect of marijuana on the unborn. Dr. Dana Gossett has cited several recent studies which indicate marijuana increases risk of still birth and adversely affects how the babies brain develops. ACOG has already come out formally warning pregnant women not to use. This could potentially turn out to be a huge generational problem if these children, as a generation, have significant delays. This research also raises the question of what is marijuana does to the brains of children and adults who use. This research also raises the issue that state policy on marijuana has been made without any reference whatsoever to available science. 

Preliminary date from a Dutch population based study indicate that women with implants may be somewhat more likely to develop anaplastic large cell lymphoma. Further studies are needed to clarify the risk. 

It has been well established that obese women have an increased incidence of breast cancer based on weight aone. However it is now becoming clear that even fat/skinny women are also at increased risk. This means even a woman of normal overall weight with a high body fat percentage has increased risk. 

TDAP stands for tetanus diphtheria and acellular pertussis. This vaccine is given to children and to pregnant women. It turns out that that protection is afforded to the baby through the mother no matter when mother gets the vaccine in her pregnancy. Upshot: It is never too late to get a TDAP in pregnancy. Babies first vaccinations are not until 2 months, so baby needs passively acquired immunity from mom getting her shot in pregnancy. 

This season’s flu is on tract to be the worst of the decade. already it has surpassed the 2009 “ swine flu” epidemic. As f this writing, flu has led to 37 pediatric deaths nationwide. You may have heard that this year’s vaccine is only partially effective. This is true, but some protection is better than none. Get you and your loved ones vaccinated. Do not go to work of you are sick. Ask sick co-workes to go home. Do not take sick children to day care. Wash you hands twitch soap when you arrive at home. Be assertive ! If you think you have been exposed to flu, call your health care provider. You may be eligible for preventive medication, and certainly are if you are pregnant or immunocompromised. 

A new Zika vaccine has been fast tracked by the FDA. It is called TAK-426 and is currently being tested on 240 people between the ages of 18 and 49. 

Women have autoimmune disease 9 times more often then men. I will therefore report on two news items of interest to those with autoimmunity. The first pertains to Rheumatoid Arthritis. A new study has shown that women with Rheumatoid Arthritis tend to deteriorate after menopause. This hints at a relationship between autoimmunity and reproductive hormones. Unfortunately the relationship is not yet clear. Meanwhile, those with these issues should talk to their Gynecologist about navigating through menopause in a way that minimizes difficulty and risk. 

The second has to do with lupus, a condition which I have. New research indicates that a gene called “ Toll Like Receptor 7 (TLR-7) ” may be involved. Normally, only one copy (allele) a gene is active in a given individual. However, in lupus patients the second copy of TLR-7 does not deactivate as it should. The normal role of TLR-7 involves activation of type 1 interferon signaling which is critical to antiviral immunity. However too much of this powerful immune response can be damaging. Lupus nerds stay tuned with cautious optimism. 

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

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

I’d like to take a moment to thank readers for their continued attention to this blog and this site. The Women’s March drove home the point of how important it is for all of us to be aware, and for us to make our voices heard. The beginning is simple: learning what is going on. 

Policy

Up to date policy includes one Alex Azar, who will be the new HHS ( Health and Human Services) secretary. As such he will be in charge of health policy in the nation. He has vowed to consider the interests of both parties. 

The legislature is gearing up to vote on a 20 week abortion ban. I’m not sure how much effect this will have since most elective abortions are far earlier than this. Since Roe versus Wade was based 45 years ago, making abortion legal, approximately, twelve hundred restrictive state laws have been passed. 

The Trump administration is crafting a program called “ Conscience Rights” which would allow a health care provide to deny a patient care based on their beliefs. This care would obviously include controversial procedures like abortions and assisted suicide, but would also extend to providing contraception and sterilization. Numerous physician groups including ACOG have raised substantial objections. I would not like to see health care devolve this way. I already know physicians who disapprove of people who get abortions, and physicians who disapprove of people who don’t practice birth control to have large families “ as many as God will give”, or people who drink, or people who smoke, or people who get fat or get sexually transmitted infections. Is there no end to our judgmental mentality ? I though we were in this to teach, comfort and cure. 

Utah is where I went to medical school. It is also the center of governance for the Church of Jesus Christ and the Latter Day Saints, aka the Mormon Church. In general I found the people there an attractive mix of family oriented, strictly religious, and yet interested in and respectful of science and the diverging views of others. So in this progressive atmosphere it comes as no surprise to me that a Republican legislator Representative Ray Ward, has proposed HB 12, which will enable Utah Medicaid to provide birth control, which it currently does not. He is proposing this to save money by decreasing unplanned pregnancies, abortions and reducing all costs associated with those. Brilliant ! 

Texas lost $35 million in federal funds which it voted to exclude Planned Parenthood from the recipients list. It basically lost $35 million worth of care to Texas women. Could this be related to the astounding increase in Texas Maternal Mortality ? Now Texas legislators are trying to get that money back. They are proposing their own program which will still exclude Planned Parenthood; They are calling it Healthy Texas Women. If they get their money back for their new program, there is concern that other states will similarly overhaul how federal money is delivered to women’s health clinics. 

Meanwhile, nationwide, women continue to flock to clinic to obtain long acting IUDs ( intrauterine devices) to give them birth control in case the contraceptive mandate of  Affordable Care Act is revoked. 

The Trump administration is trying to find more ways to “ excuse” people from the mandatory requirement to have health insurance, the so called “ individual Mandate” part of the ACA ( Affordable Care Act).  For all the world, you would think they want fewer people insured. Oh wait ! They do want fewer people using federally sponsored health insurance plans, since those cost the government money which they would prefer to keep for items on their own agenda. They justify this stating consumers should have freedom of choice, meaning the freedom to save for health care expenditures, as if that is common practice, or you could reasonably expect to do it for a large 5 figure expenditure. Last year, there were 3.2 million more people uninsured compared to the year before. Most of this is reckoned to be people who simply chose not to pay for health care. I cannot understand why it is not simply like car insurance. If you are on the road, you must have insurance. If you do not, and something happens, you will cost others a great deal of money and yourself a great deal of trouble. The same is true if people are too irresponsible to obtain health insurance. 

Medical News

Hip fractures among women are on the rise. This new study shows what I have considered inevitable. The women of the Diet Coke, Tab and too much coffee age are upon us. Many were smokers, and few drank milk, let alone ate leafy greens. No wonder bones are breaking. Here in Montana, where winter is 9 months long and there are 3 months of bad sledding, vitamin D deficiency is rampant. Vitamin D is crucial to bone metabolism and is manufactured in the skin by sunlight. Pacific Northwesterners and many of us in the Rocky Mountains inland should consider getting checked and supplemented. 

Breastfeeding may protect against type two diabetes in women. The longer the breastfeeding, the greater the reduction in risk. We have always advised that breastfeeding helps moms lose unwanted weight, and of course that in and of itself lowers risk for diabetes. 

Placental insufficiency is just what it sounds like it is. All placentas are not created equal. Placentas deliver oxygen and nutrients to a growing baby. However, various medical conditions or just bad luck will result in a poorly functioning placenta. Just about any pregnancy complication such as high blood pressure, poor nutrition, or smoking will result a placenta of  poor quality and a higher risk of complications for baby. The worst complication is of course stillbirth. A new study has suggested that nearly a quarter of stillbirths could be preventable. Placental insufficiency is usually the culprit, and with standard prenatal care it is not hard to diagnose. When we identify the problem, we increase the surveillance with monitoring and Ultrasound. Any problems with access to good prenatal care will interfere with identifying and treating complications that lead to stillbirth. 

Texas continues to be in the news as researchers and policy people probe the appalling maternal mortality figures. As of this writing we know that many factors are to blame including access to prenatal care, prevalence of black women in the data set, especially those who are underserved, or who have hypertension. Most interesting to me is the contribution of stress from chronic societal discrimination. 

The spotlight is now on my state, Montana. In the case of 14 child deaths in Montana this year, 3/4 of them took place when an infant slept in the same bed as a mother who was using drugs. Our hospital has addressed this by have an active department of Social Services, an Addiction Specialty service, and the Baby Box program. This is modeled after a common European practice wherein a family with a newborn is sent home with a baby box full of safe supplies. The box itself is made to evidence based standards, having a flat firm mattress , a fitted sheet, and no covers. Baby is kept warm in a sleep sack, a kind of gown in which they cannot get tangled or suffocate. In Finland, for example this has been done for over 75 years with good results. Some say it has helped Finland achieve one of the lowest infant mortality rates in the world. The Baby Box program also includes extensive education about safe separate sleeping practices, but it remains challenging to change people’s behavior of keeping baby with them in the bed. 

http://www.bbc.com/news/magazine-22751415

A County Attorney in Big Horn County, Montana has announced a crackdown on pregnancy women who use drugs or alcohol. That office plan to seek civil restraining orders and even incarceration to meet their goals. ACOG has come out against this, indicating it basically keeps high risk women away from prenatal care. Handmaid’s Tale, much ? 

When medicine and policy collide: More women received indicated mammograms when Obamacare, aka the Affordable Care Act, banned copays. If that does not tell you copays are a barrier to screening, I don’t know what does. 

Women skip mammograms for money. But, a new study says women skip paps for embarrassment. Young women in particular could identify embarrassment due to body shape, shape of vulva, or smell. We need to do more to help women and girls feel comfortable in their own bodies. 

A new study reveals that increased long use of oral contraceptive pills confers better and better protection agains endometrial (uterine) and ovary cancer. It also confirms that long term use does not seem to affect risk of colon or breast cancer. You may have in the past heard other studies which have contradicted this. The good news is that our methodologies improve and computing power increases every year, making the quality of our data better and better as time goes by. 

Not-so-fun-fact: New research incites that a women's risk of dying from childbirth is 14 times higher than her risk of dying from an abortion. 

Finishing today in the SUPER COOL department, we have two entries. 

First, those Scandinavians are once again on the forefront of progressive perinatal care, this time using the power of probiotics. A new study shows probiotics consumed in pregnancy lowers the risk of preeclampsia and preterm birth. These Scandinavian countries provide comprehensive prenatal care and keep thorough databases on all patients, enabling them to glean meaningful information of good quality. More research is needed on how to implement this finding. 

Lastly, Apple has roiled out a new feature in the Health App enabling users, meaning patients, to control and transfer their own medical records. Twelve large medical institutions have begun beta testing. This is great for patient empowerment. It is also partakes of the open data movement, which says that in an ideal world, data should be fully shared, without fear of discrimination. When patient and research data can be shared, we can expect a great acceleration of medical progress on the topics which matter most. 

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

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 News from the World of Obstetrics and Gynecology

Policy News this week is monumental. President Trump signed an “ executive order” which allows small businesses and individuals to buy cheaper less comprehensive policies which do not met the minimum ACA (Affordable Care Act) requirements. Critics have several issues with this legislation. First, it decreases money in the collective pot used to cover anyone with a catastrophic illness for which a large payout is required. Second, it will drive prices up disproportionately, hurting mostly older Americans. 

Perhaps more impactful is the Administration’s decision to stop making federal subsidy payments to insurers. It is effective immediately. The President has further said that it may continue subsidy payments if a bipartisan agreement is made on health care. This last bit may illuminate the whole issue. When I first heard this announcement about cutting of subsidies, I ascribed it to wholesale lunacy. However now I view it more as blackmail. Without subsidies, the insurers will either bail or fail. Then the economy will follow, according to many analysts. No administration wants this. A bipartisan agreement has been impossible to craft, thus far. However, opposition to this move, and even opposition to the President himself may cause a high degree of motivation to compromise. Leading Republicans have called for continuing payments to insurers. As you read this on Monday, I wager you will be hearing fierce objection from both sides of the aisle. 

Hot off the press is an announcement that the current Administration will allow health insurance sales across State lines. Many of us did not realize that health insurance is sold within a given state. Insurers and their plans must be approved within that State and must answer to that State's Insurance Commissioner. Trump and many other Republicans have endorsed this before. They have asserted that, through increased competition,  premium prices will drop across the board. However, the National Association of Insurance Commissioners has called this a "myth". They have warned that this will start a " race to the bottom" wherein Insurance Companies will choose more lenient State regulators. Such regulators would require less and less coverage to consumers in order to maximize profits. This would result in healthier people getting cheap policies that cover little, and everyone else needing standard coverage getting steep rate hikes to compensate for the insurance company's loss in revenue. 

Unbeknown to most of us, the insurance industry was the Wild West before the ACA came along. Most of us only knew about insurance in their own State. But, it turns out there were different levels of what was covered, different caps on out of pocket, and different limits to premium prices. That all got more standardized with the ACA. That standardization is now being deconstructed bit by bit by changes like this plan of selling across State lines. 

The Department of Health and Human Services has put forth a couple of deeply controversial issuances. They have issued new rules on contraception. Without data or authority they have stated that “ Imposing a coverage mandate on objecting entities whose plans cover many enrollee families who may share objections to contraception, among some populations, affect risky sexual behavior in a negative way.” Importantly, this sentence uses confusing syntax. The subject of the sentence is “ a coverage mandate”. The verb phrase is “would…affect” the object is “risky sexual behaviors”. Thus the gist of the sentence it, a coverage mandate would affect risky sexual behaviors. Perhaps they meant to say the following: contraception WHICH could, among some populations, affect risky sexual behavior in a negative way. I suggest this because they have taken this position before: that contraception promotes sexual activity, particularly teen sex activity. A mass of available up to date and well derived data indicate otherwise.  For example, no-cost contraception is associated with a decrease in the number of partners. Additionally, contraception is NOT associated in a rise in sexually transmitted infections. Available research data clearly show too that rates of abortion and pregnancy fell among teens, when no-cost birth control was provided. ACOG (American College and Obstetricians and Gynecologists) has voiced it’s objections to the weakening of the contraceptive mandate. They have shed light on the patently false claims of the Administration about contraception. Many States have sued the Administration over the weakening of the contraceptive mandate. 

The second controversial issuance by the Department of HHS, Health and Human Services, has been to define life as “beginning at conception”. It has done so through a strategic plan document. This draft reads “HHS accomplishes its mission through programs and initiative that cover a wide spectrum of activities serving and protecting Americans at every stage of life, beginning at conception.”. Defining life at conception is not arguable in scientific terms. That is because it is a belief. In fact, it is a religious belief. As such, one might ask whether including this language in the strategic plan document of the HHS violates the separation of church and state. Clearly this language was advanced by those whose religious beliefs preclude abortion. 

I do not believe there has ever been a time in history when government has been so intimately involved in matters pertaining to Obstetrics and Gynecology. 

Pap smear frequency is again becoming controversial. As usual, the minimalist and government funded USPTF ( US Preventive Services Task Force) has interpreted the available data to mean the need for less frequent screening. They seem to consistently overemphasize the harms of screening (extra false positives, extra office biopsies) and consistently underweight the harms, i.e. more cancer cases. ACOG, various other cancer organizations, and patient advocacy organizations, give less weight to extra false positives and biopsies, with more concern focus on catching cancer early. ACOG still states that paps and HPV testing should go together from 30 to at least 65 years of age, and that for an average risk patient. Smokers, for example, would be screened, even more often. 

In the we-already-knew-this department, a new study shows that epidurals do NOT prolong second stage (the pushing part) of labor. The study, published in Obstetrics and Gynecology, also show no adverse effects of epidural on mother or fetus. 

Also in the we-already-knew-this department, a new study shows that women who have their fibroids embolized may need additional procedures. In particular, they have a fair chance of still needing a hysterectomy later. These women who go from embolization to subsequent hysterectomy were still better off in terms of complications than those getting myomectomies (removal of the fibroids from the uterus) to begin with. 

Finally for a trifecta in we-already-knew-this department, we feature a new study which indicates that “intensive exercise may attenuate excessive gestational weight gain for obese pregnancy women”. Excessive weight gain in pregnancy increases the odds of gestational diabetes, large for gestational age babies, and need for C sections. Research elsewhere also indicates that exercise in pregnancy also produces many other good effects, such as increased likelihood of vaginal delivery. 

Somewhere between politics and medicine we find people and society, and society has a lot to do with health. This week those in the entertainment industry have been reeling from all the revelations of sexual abuse and misogynistic workplace bullying by Harvey Weinstein. It has been sickening and yet illuminating to read the accounts of the women involved. The victims were abused in various ways. Those that escaped unscathed, had career setbacks by failing to acquiesce. They all suffered the shame and anger associated with such encounters, and even now are having to answer for why they did not disclose sooner, why they acquiesced, why they did not have more sense to begin with, etc. etc. 

see: 

http://www.vulture.com/2017/10/the-harvey-weinstein-sexual-harassment-assault-accusations.html

It is widely believed that Harvey Weinstein is not the only such perpetrator in Hollywood. It is also well known that Hollywood is not the only industry where this occurs. Although Weinstein's victims were generally celebrities, most victims are not. Yet even these celebrity women were caught off guard and were made to feel powerless and vulnerable. How much more so must the average woman feel, working a standard paying job on which they depend. 

Harvey Weinstein’s methods were outrageous. The vaster number of abuses in the workplace today are far more subtle. They are microaggressions. They are just enough to make you uncomfortable, but not enough make you realize it is abuse, much less move forward to report it. All of this adds up over time, and it takes a toll professionally and personally, and on stress levels, which eventually impacts health. I had one patient who developed certain medical problems. In taking care of her and getting to know her better, it turned out she had an extremely hostile workplace environment. We encouraged her to speak to people at the local department of labor. After a lot of effort and gumption on her part, the case went to the courts, where she prevailed. She emerged empowered and eventually healthy. But it had been years that she had suffered before she understood what she had actually been dealing with and where it fit on the spectrum of normal social interactions. 

Sometimes we do not realize that what we live with may not be normative. Our standard for what is acceptable behavior may be skewed due to a rough upbringing, or a innate tendency to think that we ourselves are the problem. If you think you may be living or working in some kind of an abusive environment, reach out to a trusted physician, attorney, local social services agency, community health center or mental health professional. Life is too short to let your quality of life or health suffer. 

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

Please remember to contact your elected officials to tell them what you think about all of this. 

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: Delayed Edition

Deep in the backcountry of Montana I was able to almost forget about medical politics. However, now that I am back, the time has come to recap events of last week in both medicine and policy. 

Moderate Republicans had hoped to achieve passage of a rewrite of the Affordable Care Act by making scaling down their proposal, making the changes less extensive. However even this “ skinny ” rewrite failed to pass as three Republican Senators Collins of Maine, Murkowski of Arkansas, and John McCain of Arizona opposed the measure. If you ask me it is no coincidence that two of these maverick Republicans are women and the other, Senator McCain, is a cancer patient. Here are three people who understand what is at stake, i.e. health care for women and the seriously ill. 

Also during the week, 148 Democrats wrote to HHS ( Health and Human Services) Director Tom Price objecting to the decision to cut two years of funding from the TPPP (Teen Pregnancy Prevention Program). Again, if someone could explain to me why decisions of this magnitude can be made single handedly, I would be much obliged. 

Texas has passed a bill which requires women to obtain separate addition insurance coverage for non-emergency abortions. It seems to me that this could be a compromise solution in which everyone would get a chance to support what they espouse. Of all the health care controversies, it seems this one is the biggest, and thus the one to compromise on. 

On the other hand, insurance wold become useless as a tool to support the general health and prosperity of the population if we conceded to every anti-vaccine person who refused to pay for coverage which included vaccines, or a Jehovah’s Witness who refused to pay for insurance covering blood transfusions. You could imagine the list would go on, as there are folks who are anti-antibiotic, and anti-mammogram, and yes, those who are anti-birth control. And just as I would advocate compromising on abortion coverage, I would dig in just as firmly on the critical need for birth control coverage, which is I think essential to our stability and progress as a society, not to speak of essential to the health and well being of women and children. 

Here’s a brand new issue: Menstrual Leave. This is is policy which allows a worker to take a paid day off during her period. Such leaves are in place in several countries including Japan and Taiwan. However, many experts feel that this has the potential to retard women’s progress in the workplace. The notion that work performance suffers during menstruation is a fallacy, and this policy plays into it. If a women’s period is so heavy, painful or otherwise debilitating that she need stay home from work, then she should seek consultation with a Gynecologist. 

In medical news, it turns out that some perinatal exposures may last through several generations. A new study in mice has shown that exposure in pregnancy to environmental pollutants results in offspring with increased asthma risk for up to three generations. 

For your we-already knew-this report of the week, new research has demonstrated that a brief daily run helps protect bone mineral density in women. Indeed brief bursts of any high intensity exercise will do it, increasing bone by about 4 %, which may not sound like much but is considerable. 

In exhilarating and awe-inspiring news, we have CRISPR. If you do not know this acronym, you should. It stands for "clustered regularly interspaced short palindromic repeats”. Basically these are short segments of DNA which read the same way in one direction or the other. In nature, they are used as part of the immune system of various creatures. In technology, they are useful for editing genes. 

The MIT technology review has reported on original research at Oregon Health Sciences University where researchers have edited DNA in the viable human embryos as a way of preventing disease. It is interesting to note that while the federally funded National Institutes of Health does not support studies involving CRISPR in human embryos, the US National Academy of Sciences has “ opened the door to such research providing that the work would address serious inherited diseases.”

And with this momentous news we conclude this delayed edition of Medical Monday. See you next week. 

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. 

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

In policy news, things are moving at a slower, more measured pace. Moreover, the policy pendulum is swinging back to a more moderate place. In a move striking many as too little too late, the House GOP has proposed adding $15 billion to their now failed ACHA (American Health Care Act) making it more palatable to centrist republicans. This money would be pad to reimbursing health insurance companies for high cost patients. The intention is that this would help states reduce health insurance premiums for clients starting in 2018. The Kaiser Family Foundation has estimated that health insurance premiums will go up for the average ACA (Affordable Care Act) client by 19% if federal subsidies are withdrawn. Even with this 15 billion dollar amendment, the GOP did not have enough votes to pass their bill, and now Congress has adjourned for spring break recess. 

According to the Gallup poll, the majority of Americans now support the ACA. This is now the case for the first time since the ACA became law seven years ago. Though 55% of Americans now support it, many feel it could be improved. Centrist Democrats, calling themselves the “ New democrats”  and moderate Republicans,  “the Tuesday group”, are beginning to work with one another on small feasible improvements to the ACA which could benefit everyone.

Senator Bernie Sanders has promised to propose a bill for a single payor system, the so-called “ public option”, also known as “Medicare for all”  in 2018. 

Sixteen State’s Attorneys General have filed an Amicus brief against a new Ohio law which prevents health care providers who offer abortions from receiving any federal funds for any services. A US District Judge in Missouri has reversed a similar law in Missouri. 

In other abortion news, the 2013 Texas House Bill 2 required doctors to have admitting privileges in order to provide abortions. It also required them to do so in ambulatory surgical centers. Finally, it decreased the limit from 24 weeks to 20 weeks. The first two requirements put many midlevel providers in office settings out of business. About half of all abortion providers were put out of business. 

A new study in JAMA, the Journal of the American Medical Association, looked at the changes in practice since this law has taken effect. It turns out there were 20 % fewer abortions performed in that time frame. It also turns out that the abortions performed were done at a later gestational age. The researchers also calculated that an increased umber of abortions were performed illicitly. 

In medical news, the WHO (World Health Organization) has data indicating that fully 10% of all deaths worldwide are due to smoking. The number is believed to be underestimated since the effects of second hand smoke have not been accounted for. 

Death rates from the main types of cancer for all types of people have declined between 2010 and 2014. The decrease washout 2 %. 

In other good news, TDAP vaccine given in pregnancy is associated with lower rates of pertussis in babies later. (surprise ! ) 

Looking back at Zika, new data has shown us that 10% of women with Zika infection in pregnancy had a baby with a serious birth defect. The number may be higher since not all babies born to mothers with Zika have been given neuroimaging. Also in Zika news, a vaccine under development is progressing to phase two testing.  

In other vaccine news, according to the CDC, as of 2014, about 42% of all people carry the virus. A large new Scottish study of 20,000 women has shown that the HPV vaccine has been associated with a 90% fall in the prevalence of the virus.

Stay tuned for more breaking news from the exciting world of Ob/Gyn here, next week on Medical Monday. 

Thanks for your patience with my delay during Passover ! 

Here is may first ever angel food cake, made gluten free from scratch. It is served with a dairy free chocolate ganache, lemon curd, and cherry berry sauce. 

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

In the most important news of the week, the ACA replacement plan was unveiled this last Monday, March 6th. It’s official name is “The American Health Care Act”. 

The bullet points: 

• Federal insurance subsidies are replaced by individual tax credits and state grants. 
• The individual mandate to have insurance will be scrapped, and replaced by a 30% surcharge the next time you try to purchase insurance. 
• The Medicaid expansion would end. 
• Protection of those with preexisting conditions will stay.
• The ban on lifetime coverage caps will stay.
• The ability to insure children until age 26 will stay. 

Initial reactions were negative to tepid, even among Republicans.  Analysts have noted that the tax credits will range between $2000 and $4000 based on age, rather than income. Tax credits will, of course only materialize for those who pay taxes, and the full credit will be utilized only if the patient pays enough tax to use it. Assuming even that the whole credit is received, it is still not as much as current subsidies. In many cases it will not cover deductibles. In short, the ACA replacement plan lowers prices for the more well off and increases prices for the poor. 

The bill was strongly criticized by very conservative lawmakers based on budgetary concerns. Conservatives and moderates also voiced concerns regarding widespread loss of coverage that will occur. Assuming there are no Democrats who approve the bill, there can be no more than 22 Republicans who disapprove of it for it to fail. 

By the end of the week, two key House Committees, Ways and Means, and Energy and Commerce did approve the bill. Nonetheless, many Republicans are against it as is every doctor group, every health care group, and every consumer rights group. 

Trump is reaching across the aisle on the issue of prescription drugs. He, together with most Democrats, favor allowing Medicaid to negotiate with drug companies on prices. Republicans have long opposed this. Hopefully it will save costs but not detract from research. 

Many continue to worry about the loss of contraceptive benefits by one means or another. One nonprofit called “Child Trends” has come out with an estimate that keeping contraceptive access for all women would SAVE $12 billion yearly. They also estimate this strategy would be accompanied by drops in unintended pregnancies, unintended births and abortions by 63-67%. 

In #alternativemedicalfacts news, many authorities are decrying the Indiana law requiring that the “abortion reversal procedure “ be discussed with patients. Medical authorities including ACOG (American College of Obstetricians and Gynecologists) have been very vocal about the fact that the procedure simply does not work, does not exist, and is not real. Utah has passed a similar bill. 

In Pennsylvania, one bill is seeking to ban the abortion pill. This pill is used to effect very early abortions without surgery. However, it is also used to stop hemorrhages after deliveries or miscarriages. Difficulty getting this medication would be an unmitigated disaster. We use it every day on our Labor and Delivery unit and it literally saves lives there and the world over. 

Kentucky has passed a bill defunding Planned Parenthood even though Kentucky Planned Parenthood does not provide abortion. 

Maryland has devised a bill to fund Planned Parenthood on their own, should it otherwise be defunded. 

Nevada democrats are testing the judicial waters by introducing a bill which would require insurers in the state to cover contraception regardless of religious objections. Of course this would be in opposition to the Supreme Court decision prompted by Hobby Lobby which states that businesses “with religious objections”. supplying insurance do not have to cover contraception. Go to Michaels or Joannes instead but stop by Michaels to tell them what you think. #canabusinesshaveareligion ? 

New Mexico has installed state law requiring that all insurers cover contraception at no out of pocket costs. They have gone a step further and added Vasectomy to the list of covered services. 

The US Preventive Services Task Force (USPSTF) has again questioned the utility of the annual pelvic exam. This has happened  before. As before, ACOG has maintained its validity as a screening tool. I personally find all kinds on things on routine screening pelvic exams on asympmotmatic patients. Perhaps the devil is in the details. Perhaps the utility or sensitivity of the exam depends on the examiner. A general surgeon friend of mine one told me with a wry look, “the pelvic exam is not sensitive in my hands”, meaning he really does not know what he is feeling, even though he is an excellent general surgeon. Perhaps if the USPSTF compared the utility of the pelvic exam for ob/gyns to the pelvic exam for other caregivers, they would see a difference. 

Beyond that, I want to know why the routine pelvic exam is being so rigorously studied. Is it costing the taxpayer a disproportionate amount of money ? Is it harmful ? Is it generating false positive results ? Is there a problem ? Aren’t there more pressing problems in health care that deserve our attention ? Why are women’s health care procedures always first on the chopping block ? #waronwomenshealth

We have a new department in Medical Mondays. You’ll love it. It is called “Outrage of the Week”. Let’s hope we do not have one every week, but something tells me we will. You will not believe this, and I mean you all on both sides of the aisle will not believe this. Republican Representative John Shimkus of Illinois has questioned why men should have to pay for insurance covering prenatal care. The Washington Post has reported that, among critics of the ACA, this is not the first time this question has been posed. #waronwomenandchildrenshealth

In the human nature department we report the following: The percent of overweight and obese patients has increased from 53 to 66 % in the last 3 years. However, the percent trying to lose weight has decreased from 59 to 49 %. These patients are invariably very expensive, medically speaking.  Should insurance prices account for weight or other health habits ? Should insurance give breaks for those who do not have issues or those who show documented effort to resolve their issues ? 

In medical good news department, we report on easy cancer prevention. In a two decade study of 60,000 women, published in the International Journal of Cancer, the Mediterranean diet has been found to be of benefit. In particular, it is estimated that about a THIRD of estrogen receptor negative cases of breast cancer would never happen if women were to adhere to this particular diet. 

On that tasty note, we will conclude, and hope that you will have the stomach for next week’s Medical Monday.