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

POLICY NEWS

As reported last week, many States are starting to push back against the defunding of teen pregnancy prevention programs in their states. The latest such example is Minnesota, where in Hennepin County, HHS (Department of Health and Human Services) terminated a $214 million teen pregnancy prevention program. The grant had originally been obtained to last through 2020 and was cut as of 2018, and the suit filed asks that it be reinstated until 2020 again. Texas’ Teen Pregnancy Prevention Program is called Healthy Futures of Texas, and its Title X funds are slated to be cut. However, This organization and other Texas grant recipients are filing lawsuits to discontinue the termination of their grants. 

Title X is a federal grant program dedicated solely to providing funds for birth control and family planning. The Trump administration governs the awarding of such grant money. Of late, they have shifted their funding criteria to favor those organizations which promote abstinence rather than evidence based birth control. Several chapters of Planned Parenthood and the National Family Planning and Reproductive Health Association have filed suit against the Trump administration alleging that this strategy violates the mission statement of Title X. 

During the recent years of the Trump administration, the number of uninsured Americans rose by 4 million. These are those who slip through the cracks between the Affordable Care Act plans and private insurance, with a single income of $30,000 and a joint family income of about $61,000. The data comes from the Commonwealth Fund who warned that this trend is likely to continue. 

MEDICAL NEWS

We have known for some time now that women have been concerned about contraceptive access ever since Trump was elected. Long acting reversible contraceptives (LARCs) have been the strategy for many women. In one particular study out of UCLA David Geffen School of Medicine, uptake of LARCs nearly doubled in the two weeks following the election. 

All kinds of stereotypes exist about older people. Some have to do with sexual activity. A new study has shown that 40% of people ages 65-80 are sexually active, and of those, 73% are satisfied with their sex lives. In the subgroup of those with spouses or partners, a little over half are sexually active. Caregivers need to continue to bear all this in mind. 

ACOG (American College of Obstetricians and Gynecologists) recently held its annual meeting. One presenter there highlighted the medical benefits of vibrators, and called upon Gynecologists to identify patients who might benefit from them, and initiate discussions which normalize their use. 

ACOG president Dr. Hal Lawrence has termed the current health care climate a “battle” and “ one that is not going to end anytime soon”. They have called it a “fight to protect women’s health care”. The ACOG president has highlight the advocacy efforts of the organization this past year, along with like minded others, the “Gang of Six” consisting of  internists, pediatricians, family doctors, psychiatrists, ob/gyns, and osteopaths. 

Menopause. It is the cessation of ovarian function and all that results from that. We cease to ovulate and become infertile. Then our hormone production quits, and we may have symptoms of estrogen deprivation, like hot flashes and vaginal dryness. The average age of menopause is 51, but the range is considerable and it takes about two years to get completely through. A new study has highlighted a little know fact, that women with a poor diet, i.e. diets high in refined carbohydrates, get menopause much sooner than those with high quality diets, such as those with lots of whole foods and fish. 

The postpartum period or so called fourth trimester, is getting some much needed attention. A new study has illuminated the prevalence of perinatal depression. Turns out it affects 1 in 7 women. Indeed, a related study found that maternal suicide takes more women than hemorrhage and hypertensive disorders combined, and accounts for 1 in 5 postpartum deaths. The study has also shown that only about a fourth of postpartum moms suffering from depression get treatment. Both the US Preventive Services Task Force and ACOG recommend mental health screening during pregnancy. Pregnant moms take note: Your postpartum visit should cover mood, emotions, infant care, sexuality , contraception, sleep, and health maintenance, to name a few. 

The opioid crisis has brought many problems for pregnant women and their children. However, one such problem can go under the radar: Hepatitis C.The opioid epidemic is driving an increase in Hepatitis C among mothers and children and neither the screening protocols for mothers or infants has kept up. Hepatitis C is transmitted by blood, and thus by needles, and infrequently, from mother to child. There is no vaccine, but just recently, there is a fairly good treatment. 

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

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

How stable are the ACA Affordable Care Act, aka Obamacare)  insurance plans? That remains to be seen. At present there is a bipartisan effort to shore up the so called ACA “marketplaces” . This means that certain lawmakers are trying to find a way to create a realistic budget to fund them. The Affordable Care Act was affordable since the Federal government supplied money to insurance companies to subsidize or pay for part of people’s premiums. 

Let’s roll back a second. Let’s make sure all this terminology is clear. 

Bipartisan= involving both Democrats and Republicans 

Marketplace = the system of insurance companies from which consumers buy health insurance 

Premium= the monthly amount consumers have to pay the insurance company to have insurance and to ensure that their insurance is in force 

Subsidies, aka insurance subsidies = payments from the Fed ( your tax dollars) to the insurance companies to defray (reduce) what consumers pay for their premiums. 

Republican concerns at the beginning of the administration change:

1. Obamacare cost the Fed too much and made taxes too high (via the payment of subsidies to insurance companies) 
2. Obamacare funded programs that powerful special interest groups opposed, i.e. birth control (via the Contraceptive Mandate) 
3. Obamacare took away the choice of not having to get health insurance at all. ( Via the Individual Mandate) In other words, Obamacare law via the Individual Mandate required everyone to hold health insurance. 

Democrat concerns at the beginning of the administration change:

1. Obamacare was not adequately funded and could run out of money if not addressed.
2. Obamacare needed to continue to fund birth control as a human right and for the social and fiscal improvements it confers, ie. increased education, job productivity, individual savings, better health, fewer teen and unplanned pregnancies, fewer abortions. 
3. Obamacare needed to continue to fund preventive care and cancer screening since in the long run it prevents serious disease and saves money 
4. Obamacare need to continue to retain the Individual Mandate since

• Each person is obligated to contribute to the insurance fund to make it stronger for everyone. The American Academy of Actuaries has gone on record saying that repeal of the Individual Mandate “... would lead to premium increases” and reduce the "incentive for healthy people to enroll and balance out the costs of the sick.”
• Each person is responsible for covering their own care even if their health takes a downward and expensive turn, and they can only realistically cover it with insurance.
• Persons who do not hold insurance and who end up getting emergency or unanticipated health care get care whether they can pay for it or not, and their bill is absorbed by everyone else. They are cheating the system. 
• The ethic of the greater good should inform the Individual Mandate since health coverage enables health care and health care enables broad social benefits of all kinds. 

The deadline to enroll for Obamacare this year has passed. The site for enrollment, healthcare.gov, was getting crushed right through until the end, and at one point, customers were instructed to simply leave contact information with the expectation of a call back. Many did not know the time frame for enrollment since the Trump administration cut funds for promotion of the program by 50%. Numbers on enrollment are not yet in. 

There is bad news and good news for CHIP, the children’s health insurance program. The bad new is that it will run out of money by the end of January. The good news is that there seems to be broad bipartisan support for refunding it. A bipartisan group of Governors has also come forwards and requested that the government renew finding for CHIP. The question is, what with all that lawmakers have left undone, and still need to do, will they get to it in time ? Remember, the Federal Government only has a budget through December 22nd, which is fast approaching. 

In medical news, we find a convergence of holistic medicine and technology. A new study published in the American Journal of Obstetrics and Gynecology uses app-guided acupressure to relieve menstrual cramps. The results compared this technique with medical therapy of oral contraceptive pills or typical analgesics and the results were significant. 

Sugar and inflammation. I do not know the exact relationship. Let’s talk about excessive sugar. In particular, a new study reveals that pregnant women who consume excess sugar in pregnancy are statistically more likely to bear babies who have asthma later in life. Asthma is an condition of the airways and is believed to be mediated by inflammation. Excess sugar in pregnancy is associated with many more problems, like excess weight gain, and gestational diabetes. 

It is well know that pregnant poorly controlled diabetics have increase risks of serious malformations including spina bifida and congenital heart defects.  In new research, pregnant women with high glucose levels in early pregnancy - even those who are not diabetic, are more likely to have babies with heart defects. The relationship is linear. 

Got your flu virus yet ? I hope so. There are TWICE as many cases of flu this year compared to last. Bottom line: the flu shot is safe and effective in and out of pregnancy. Talk to your doctor. It is particularly risky to skip it in pregnancy since influenza is much more dangerous in pregnant women. 

There is some expected fall out after last weeks publication about a small increase in breast cancer risk with long use of oral birth control pills. Authorities are hastening to point out that while this finding about breast cancer risk was noted, it has also been confirmed that oral birth control pills decrease the risk of uterus, ovary and colon cancer, stabilize bone density and obviously, prevent pregnancy and all of its potential complications. Risks need to be weighed with benefits. 

Stay tuned for more breaking news from the world of Obstetrics and Gynecology on the next episode of Medical Monday. I will have to decide what to do for Christmas week, most likely depending on the news at hand. Let's hope the researchers take a nice break for the holidays. The politicians, well, they can just keep working right on through as far as I am concerned. 

Happy Holidays. 

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

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

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

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

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

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

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

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

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

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

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

On to the medical news. 

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

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

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

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

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

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

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

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

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

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

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

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

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

On last Thursday afternoon June 22nd the Senate unveiled their draft of the ACHA the American Health Act, which they are calling the “Better Care Reconciliation Act". House Minority Leader Nancy Pelosi put it well: This is a “…tax bill disguised as a health care bill.” As readers begin thinking about it, they should consider that it does one main thing: it shifts the cost of health care away from the Federal Government. 

Most doctors understand that decent health is fundamental to all human happiness and prosperity. Indeed someone once said health is our only real wealth. Additionally, many social scientists and other bean counters have discovered that standards of living go up when the quality of a population's health rises. It has been conclusively demonstrated that particularly when the quality of the health and status of women rise, the entire society benefits, in both social and monetary terms. When there is good access to maternal and child health care, infant and childhood mortality decrease, maternal health increases, and family size shrinks. Earnings, savings, and educational status rise. These are well documented phenomena. 

So called Obamacare, aka the Affordable Care Act (ACA), made the health of women and children a priority. For example, the ACA included mandated insurance coverage of maternity care. Yes, this meant that the cost of giving maternity care to some was shouldered by all, since everyone contributed to a “pot” that paid out for maternity care expenses.  Implied is the notion that society as a whole has a vested interest in the welfare of pregnant women and the children that they bear. The idea is that it is our collective responsibility to ensure the well being and betterment of the next generation. 

Indeed the whole notion of insurance used to be that people could rest easy knowing that they had a way to deal with life’s unexpected or costly events. They could contribute to a pool for emergencies and other medical needs, and it would be there for them when the need arose. This was by mutual agreement between all the contributors and governed by certain pre-agree upon stipulations. Everyone knew that more people meant better benefits and more stability of the fund. 

Health insurance was viewed as a social and financial responsibility. Nonetheless, if you did not have heath insurance, you would still get emergency care, since the moral values of society and the medical profession would kick in. At the same time, people who could get health insurance but didn’t were viewed as irresponsible since they would simply take their chances or let others foot the bill if they did land up in the hospital. 

People in the US disagree about what constitutes the responsibility of government. They disagree about the role of government in health care. However, progressive and prosperous countries across the globe have examined the question from a data- based rather than political point of view. They have determined that the social and financial benefits of universal health care coverage are well worth the price. In developed countries, the government sees to the national security, and it sees to our infrastructure. These are examples of enormous and costly tasks that no one person, family, or even state could accomplish. But, a nation can. Health care is like that. A healthy prosperous nation requires massive collective input, both from a planning standpoint, and a financial standpoint. I can think of no better use for the collective monies obtained through our taxes. In this light we consider the new health bill draft. 

The new health plan draft basically proposes massive cuts in what the Fed spends on health care. Not only does the Fed currently spend on Medicaid and Medicare, under Obamacare it spends by paying private insurance companies "subsidies” so that the the insurance companies can charge more reasonable premiums to consumers. 

This great reduction in Federal expenditures toward health care would be accomplished in several ways. First it will reduce the number of enrollees.The mandate to have insurance would be eliminated. Fewer people will therefore obtain insurance. They will also curtail the number Medicaid enrollees by making requirements more stringent and by rolling back the Medicaid expansions. The assumption is that these uninsured folks will simply not cost the Fed money. However they will cost someone money over time as they end up in the Emergency Room with their unmet health care needs and emergencies. The health care system and the insured patients who pay into it will cover their bills, and health care costs will have to rise to compensate. 

Secondly, the Fed will save money by asking consumers to shoulder a higher percentage of their health insurance costs by paying higher premiums and having higher deductibles. In return the Fed plans to offer “ tax credits”. Tax credits are not money. They are a lower tax bill at the end of the year. But who can use tax credits ? Only people with appreciable taxes. Tax credits will do low income or even middle income people little to no good. These are the people who need the most help. 

Thirdly the Fed will save money by requiring States to pay more for health care. They have proposed cutting Medicaid money dispensed to states giving instead “ block grants” of lesser value. 

Fourth the Fed plans to make huge cuts to key health organizations such as the National Institute of Health and the Centers for Disease Control. 

Fifth and perhaps most importantly, the Fed will save money by cutting services. First on the chopping block is the contraceptive mandate. And if some of you say the Fed will only pay through the nose for increased unintended pregnancies, fear not, there is talking of cutting maternity services as well. Emergency services and mental health services will be cut, and Planned Parenthood is to be defunded. 

The anticipation is that millions would lose health insurance altogether. The related expectation is that costs for those that remain in the market will skyrocket. Millions of tax dollars will be saved, and this will be trumpeted as a great benefit. In fact it will be a benefit only to those with a significant tax burden. Those with bigger incomes will obviously benefit the most, since they pay the most taxes. So, in the final analysis, money for the general welfare of the nation, the care of pregnant women and children, and the care of the poor will be taken out of the public coffers and placed back in the hands of the well to do who currently pay large taxes. Make no mistake, these wealthy people will still pay high taxes. They will just be slightly less high. The degree of good done by the tax cut for the wealthy will not match the harm done to the poor by the loss of their insurance. 

This plan would most likely result in millions of uninsured. There will be less health screening. Thus there will be fewer pre-cancers and early cancers caught and treated. There will be more unintended pregnancies. There will be more abortions, and more STIs. There will be more unreimbursed emergency visits at hospitals. There will be more missed work, unemployment and disability. There will be more resentment. 

The betterment of society is a collective responsibility. There are some older senators who have complained that they do not want to foot the bill for birth control or maternity care since they themselves will never need any. How would they feel if I said I did not want my insurance premiums to encompass the burden of paying for those who smoke, drink, or do not stay fit ? Perhaps I should start an insurance pool for the young, fit and beautiful. That would be great except they would not let me in. 

A firestorm of objection has been lit. Among the incensed are Senate Democrats. Also objecting for different reasons are certain Republicans: Rand Paul (KY), Ted Cruse (TX), Ron Johnson WI) and Mike Lee (UT, and others, members of the so called “ Freedom Caucus".  Also expressing reluctance were other Republicans Toomey (PA) and Collins (ME). 

Top medical groups have criticized the bill, most notably and loudly, the American College of Obstetricians and Gynecologists (ACOG). It is worth repeating the College’s statement on the legislation: “ Despite numerous efforts to collaborate and provide input throughout this process, women’s health expertise was rejected. It is reckless for legislation that will have such an immense impact on American lives and the economy to proceed without the opportunity for public hearings or any external commentary.”. 

On Capitol Hill there were angry protesters demonstrated, many of whom were in wheelchairs. 43 were arrested. Elsewhere across the country, demonstrations have been taking place. It seems the whole country is worried and upset. 

What’s next ? The draft goes to the Congressional Budget Office. There they will attempt to assess the direct and indirect, short term and long terms costs of the proposal. From there it may make it to the Senate floor for debate. If even as few as two Republican Senators disapprove of the bill, it will not pass. 

The Year of Living Danishly: Uncovering the Secrets of the World's Happiest Country

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By Helen Russell

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My father in law was a conservative gentleman who practiced Obstetrics and Gynecology for over 40 years. He was a Republican and very active in medical politics, advocating for  better health care for pregnant women across the state. He passed on a couple of years ago. I am glad he has not witnessed the degeneration of the Republican party and the disregard with which health care, women, and children are being treated. 

Medical Monday, medical portion, will have to come in a subsequent post, since this is already a very long dispatch. 

Again, please accept this reminder to call your Senator and let them know what you think. 

And for something upbeat, take a look at a book I just finished. It is called The Year of Living Danishly. You will get some smiles, but also some understanding of how another very successful country runs the relationship between taxes, health care, and happiness. 

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

Historically a new President is evaluated at the 100th day in office. This day comes next week, and for this reason there is a special emphasis on trying to get a Republican health bill pushed through next week. The various key features of the new proposal must please not only moderate Republicans but hard line conservatives. 

Anxiety remains over whether or not the Trump administration will continue to pay health care subsidies to insurance companies. These government subsidies to insurance companies is what allows them to offer coverage to their ACA clients at such low rates. This last week, the National Association of Insurance Commissioners indicating that these are “ ...essential for keeping insurance markets stable next year”. Last Tuesday health insurance representatives met with Trump administration officials but received little assurance that the subsidies would continue. House speaker Paul Ryan indicted he would consider continuing the payments until the end of the year to avoid “…disruption”. 

In the common sense department, a new study has confirmed that paid medical leave is associated with higher breastfeeding rates. The ACA stipulation that businesses of a certain size provide time and space for breastfeeding has also been associated with increased breastfeeding rates. 

We have a new study on marijuana in pregnancy. According to a new large survey based study from the National Institute on Drug Abuse in Bethesda Maryland, US teen girls are more than twice as likely to smoke marijuana if they are pregnant. The rates are at 14% versus 6% in those aged 12-17. The ratio is reversed if all ages of pregnant women are considered. In that case, 4% of pregnant women smoke, versus 8% of non pregnant women. Researchers speculated that pregnant teens use marijuana medicinally to treat nausea. However, others have opined that risky behaviors such as marijuana use and teen pregnancy run together. 

Currently no specific pattern of malformation (anatomic or structural) has been uniquely associated with marijuana use. However, sustained use of marijuana has been associated with a trend toward decreased birth weight. Additionally, reported childhood effects of marijuana use in pregnancy include lower scoring on verbal and memory testing, and difficulty analyzing and integrating specific cognitive processes.

Some authorities believe that the use of pot by any kind of teen is more dangerous than use for adults. This is because there are more consequential impacts on the teen's still developing brain. According to Dr. Seth Ammerman at Stanford University and Lucile Packard Children’s Hospital,  just telling teens about the risk of pot may be enough to get them to quit. 

The Trump administration has announced they will follow through with the $485 million dollar grant approved last year to fight the opioid epidemic. 

The Trump administration has also extended the “Veteran’s Choice Program” which enables some veterans to receive care from local doctors and hospital rather than travel to VA hospitals for their care. 

Breast implant linked lymphoma is again in the news. The FDA (Food and Drug Administration) has identified 359 women with a rare cancer called ALCL or anaplastic large cell lymphoma. It seems to occur with women who have had textured rather than smooth implants. Though over 350 cases have been identified, the incidence is very low at about 1/30000 women with textured breast implants. Those with implants should seek regular annual exams and mammograms making sure that their caregiver knows about their implants. 

A recent review in the Annals of Internal Medicine revealed a problem. This is a problem that could be 100% solved, and that could help patients with any disease that they are treating. The problem is medication non-compliance. Studies show that 20-30% of medications are never filled, and that of the ones that are, 50% are not taken or not taken as prescribed. It goes a long way to explaining why some patients don’t get better or relapse. The reasons are many from cost, to wanting to “be natural”. Patients may believe need for medication reflects weakness. They may avoid it since they don’t want to be reminded of their disease. Solving the medication compliance problem would save over a hundred thousand deaths and hundreds of billions of dollars every year.

By now most of you know that Serena Williams is pregnant. Perhaps you don’t know she won the Australian Open while being so. A recent editorial in the American Journal of Obstetrics and Gynecology highlights the fact that healthy pregnant women need not curtail their exercise. This is in line with the ACOG Committee opinion document on physical activity and exercise in pregnancy. Recommendations are that pregnant women engage in aerobic exercise for 35-90 minutes 3-4 times each week. Those with any high risk factors should consult their doctors first. By the way, Serena wasn’t the only one to compete at this level; eighteen pregnant women have competed in the Olympics. 

Earth Day and March for Science have recently taken place. In an unprecedented move, 25 medical organizations including ACOG (American College of Obstetricians and Gynecologists) issued a joint statement for March for Science. They stated that they are issuing a “….nonpartisan call for the appreciation of scientific evidence, education and investment”. 

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

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

The health care policy package proposed by the new administration must pass through several committees before actually passing to the House and the Senate. One of these is the Budget Committee. This last week House Republicans brought the American Health Care Act (ACHA)  through this committee by vote of nineteen to seventeen. However three GOP lawmakers voted against it, showing a house divided. Centrist Republicans who approved the bill did so providing the tax credit system change to better benefit the working poor. Nonetheless it is the working poor and older workers who will experience a disproportionate rise in premiums. This is because of the substitution of tax credits for subsidies. Those who have low wages have low taxes and tax credits mean little to nothing to them. As previously reported, tax credits help those with substantial tax burdens, i.e., those with higher incomes.  

Analysts believe premiums will likely rise for a number of reasons. Principally the lack of the individual mandate will keep a lot of money from entering the pool, and this needs to made up somewhere. The premiums from 24 million consumers are likely to come out of the pool,as 24 million are likely to lose insurance with the repeal of the ACA.  This alone is believed to account for what is expected to be a 15-20 % hike in premiums. Those of us who obtain health insurance coverage will make up that staggering shortfall. Moreover, when the uninsured hit the hospital, we will also pay for them in rising medical costs, since the care providers will be left holding the bag. 

Despite all this Health and Human Services Secretary Tom Price still says that the ACHA is “ intended to make health insurance feasible for every single American.” He and others in the new administration insists no one will lose coverage with with transition from the ACA to the AHCA. 

The Department of Health and Human Services budget will be cut by 15 billion, 18 percent. And yet, there will be sizable block grants for the opioid crisis and a “ Federal Emergency Response Fund.” The President’s new budget will cut funding to the NIH by 5.8 billion dollars. 

President Trump wants to give the States ability to alter their own Medicaid. On the table are copays, work requirements an premiums. 

Readers will recall from last week that Representative John Shimkus cited a “War on Men” and decried the mandate that men must purchase insurance which covers prenatal care. He does not believe that men should have to contribute to a general insurance pool if it includes funds for the prenatal care of women who also purchase that insurance. He is the same man who has sponsored anti- abortion bills out of his concern for the well being of fetuses. Connect the dots much ? 

That place where the federal government buck always stops is the Congressional Budget Office or CBO. According to the CBO, defunding Planned Parenthood would increase the number of Medicaid births, decrease overall Medicaid spending, but increase unplanned pregnancies. As unplanned pregnancy rates rise, so do abortions. 

And now for the highlights in medical news. 

Gardisil, the vaccine against Human Papilloma virus, is effective. It turns out that two doses are affected as the currently recommended three, good news for everyone including those kids who failed to get their third dose. 

When I was in training there were no limitations on length of our shifts. We routinely worked 36 hours at a stretch, and in my big training center, most of the time, we have no sleep at all. Shortly after I finished residency in 1994, an 80 hour per week working standard was set. Additionally the limitation of 18 hours per shift was instituted. However now concerns about continuity of care have caused the number to swing back to 24 hour shifts. However, The 80 hour week per limit for residents at all levels remains in place.

Preterm birth remains a serious problem in this country. We've developed various methods to try to predict its likelihood including cervical length ultrasound and fetal fibronectin testing. It does have some utility, together with the clinical judgment. However, it turns out that, according to a recently published study in the Journal of the American Medical Association, they have limited utility in first-time mothers.

Over 400,000 physicians from various disciplines compose the Medical Society Consortium on Climate and Health. Associations who participate include the American College of Physicians, the American Academy of Allergy, Asthma, and Immunology, the American Academy of Family Physicians and American College of Obstetricians and Gynecologists. The group has identified eight threats whose increase is related to climate change which will doubtless have serious effects on human health. They are, extreme heat, extreme weather, air pollution, ticks and mosquitoes, contaminated water, contaminated food, mental-health, and nutrition.

On that sobering note, I would encourage you to get more active in political, social and environmental activities which concern you. Your elected officials are truly easy to reach by phone or email. 

Stay tuned for more important news from the world of Obstetrics and Gynecology next week on Medical Mondays.