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

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

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

So by now all of your know that the Republican Tax bill passed. Most of you also know the tax bill is not just about taxes. With it’s passage, the Individual Mandate of Obamacare has been repealed. Therefore it is now no longer incumbent upon people to hold any health insurance. So, like an uninsured driver in a bad accident, someone else will foot the big bill when fit hits the shan. 

Those of us in medicine realize that in the short term this will save the Fed money. However in the medium and longer term, it will cost far more than was saved in both monetary, productivity and human terms. I only hope that this resultant data will be kept properly so that can see the true results of our lawmaking and course corrections in policy can be made accordingly. I am beginning to consider all such bills on taxes and health insurance as politically charged estimates, and how costs and benefits actually turn out are another matter. How costs and benefits are actually tallied and reported are yet a third concern, and I daresay I will view all reports with skepticism unless their methods are sources are clearly declared. Transparency in reckoning will be critical, and in this climate of alternative facts, something fundamental will have to change. 

The Congressional Budget Office estimates that premiums will go up about 10% for all policies through Obamacare simply because of the loss of the Individual Mandate. The CBO also estimates about 4 million people will either lose or forgo health insurance because of the change. 

The current administration is also trying to roll back in the Contraceptive Mandate. This is the part of Obamacare which requires all health insurance to provide coverage for birth control without copay. The Democratic States Attorneys General have banded together to prevent this from happening. Their argument is that the planned rollback of the Contraceptive Mandate "for employers to include birth control in their health insurance plans is an unconstitutional endorsement of religion” and "violates the constitutional separation of church and state and encourages illegal discrimination against women.” 

In science there is a phenomenon called a natural experiment. This occurs when happenstance set up a comparison between one set of circumstance and another, allowing a later comparison. For example, there have been instances of twins separated at birth and raised under different conditions. The resulting differences can then be studied. 

What if there were a modern country where birth control was not readily available ? What might that be like ? While considering that Venezuela and the United States are very different, one can still view the situation in Venezuela a cautionary tale. Venezuela is experiencing a shortage of birth control. Women are using the “ counting method” otherwise known as rhythm, and using unproven folk remedies. Venezuelan health officials are noting spikes in unplanned pregnancies, sexually transmitted diseases, and unsafe abortions. Data in the United States while the contraceptive mandate was in place show abortion has hit an all time low. 

In the nobody-saw-this-coming department, Ob/Gyn residency training programs in Wisconsin and perhaps across the nation might be at risk of de-accreditation. At present, the Accreditation Council for Graduate Medical Education requires that abortion training be part of residency in Obstetrics and Gynecology. Two Wisconsin state representatives have introduced legislation that would eliminate resident’s  ability to complete this training, thereby putting the program out of compliance with the accrediting body. As it is, a national shortage of Obstetricians and Gynecologists is looming; it is already the case in rural areas, and will be so everywhere if trends continue. 

CMS, the Center for Medicaid Services is floating a proposal to allow individual States to determine what constitutes “ essential benefits”. These are things which insurers MUST cover.  As of right now, under Obamacare, things like annual exams, cancer screening, like paps mammograms and colonoscopies, and prenatal care are covered. Medically necessary surgery is covered. Emergency room visits are covered. However, with this proposal, this might change, and it might vary widely between individual states. Health care providers are worried this will leave many necessities uncovered, and insurers are worried States will want to keep insurers providing benefits, which will cost them more money. 

The deadline to sign up for the ACA is December 15th. As of last week, about a million more people are signed up than at this time last year. That's what I call an endorsement. 

On to the Medical News. 

A new study has shown us something we have always suspected. We have known for some time that obesity is a risk factor for uterine, or more specifically endometrial cancer. (Endometrium is the lining of the uterus. ) The reality is even more stark. It turns out that fat cells drive the growth of endometrial cancer cells. In particular, a protein produced by fat cells “tells” endometrial cels to proliferate. It’s one more powerful reason to make sure your weight is optimized

In the we-already-knew-this department, robotic assisted laparoscopic hysterectomy is looking good. In particular, a recently published study compared robot hysterectomies with “open”  hysterectomies, meaning the ones using a large incision similar to the incision used for Cesarean Sections. Guess what ? The robot cases with the tiny incisions, precise instrumentation and excellent visualization had better results than the open cases with large incisions, manual instrumentation, and variable visualization. In particular, this study shows  they had fewer complications across the board and shorter hospital stays compared to the open cases. I should add that literature and the prevailing experience is that patients having robot cases also have less post op pain. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

First, the policy news. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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