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

These Summer days are very busy for me and my family. So I am going to keep to an abbreviated or bullet version this summer. A little later, I’ll let you in on a fun little secret about why I am so busy. 

The biggest policy new has to do with the need to fill the vacancy in the Supreme Court created by the resignation of Justice Kennedy. The most contentious issue thus far has been abortion, Thus, all conceivable candidates are being scrutinized for their views the subject. Justice Kennedy had been a more liberal justice, and Trump has promised to install an anti abortion justice who would then contribute to the making of law for the rest of their tenure. At present, under Roe V. Wade, abortion is legal. Prior to that it was not, yet many many women and caregivers defied the law, often at great peril. My late father in law, an Obstetrician Gynecologist minted in the early 1960s remembered the days before legal abortion, and while no friend of abortion, told us cautionary tales about the complications that illegal abortions could produce. 

The ACA (Affordable Care Act) has more users now than it did last year. As of this last February, 3% more people paid for ACA plans than the prior year. This is especially noteworthy since the Fed decreased funding for outreach about the plan by 90% and halved the enrollment period. 

Starting in 2019 the Joint Commission ( a chief governing body for hospitals) will require accredited hospitals to have a newborn identification protocol. Details to follow, though we know it will require “ two factor authentication”. 

The Senate has approved 50 million dollars in funding to reduce maternal mortality. Most of this will go to the Federal Maternal and child Health Bureau to expand life saving evidence based programs. Some will also go to the CDC and some will go to Healthy Start programs for mothers and babies. 

The Senate also has approved three new bills pertaining to maternal and child well being. In particular the money will be used to reopen closed programs which aim to prevent preterm birth. 

One major piece of the maternal mortality puzzle is the lack of Obstetricians and Gynecologists. It is tough job with tough call and its pay lags behind that of similar surgical specialists. It is estimated that there will be a shortage of nearly 8800 Ob/Gyn in just TWO YEARs, in 2020. The shortage is very likely to keep growing. 

Medical News

Non-European women with ovary cancer seek genetic testing less than their peers. Genetic testing after ovary cancer may help identify risk factors for other members of the family dn may define the patient’s tumor type in such a way as to tailer its treatment and make it more effective. 

Flight attendants have been found to have a higher incidence of many various types of cancers. The findings were published in the Journal Environmental Health. It is unclear why this is the case. Theories include increased exposure to ionizing radiation, circadian rhythm disruption , or to other carcinogens. More study is needed. 

Many older women or their caregivers begin to lessen the frequency of their bone density screenings after about 65 years of age. I have never liked this approach as it smacks of marginalizing older women. Many older women begin their final decline with a hip fracture that could’ve been prevented. Now, new recommendations from the USPTF, US Preventive Services Task Force has produced evidence saying it could be worthwhile. This is true because there are many meaningful potential treatments, which when instituted, could help prevent bone fractures and the debility that those entail. 

Probiotics. They are for gut health, right ? Turns out a new study has shown that probiotics given to women protect against the loss of bone density. See the Journal of Internal Medicine. 

There are nine vaccine which pregnant women may receive. ACOg has recently released a single page list of these and his encouraging all pregnant women to speak with their physician about these. 

Smoking. It’s bad. How bad ? Well its bad enough to increase your risk of miscarriage…. even if it is just your partner who smokes ! Yes, second hand smoke from a partner is associated with an increased risk of miscarriage. 

In separate research, smoking also appears to double your child’s chances of having hearing loss. 

In clinic, most people report being active. And yet, the CDC report s that fewer than 23 % of US adults are meeting federal standards for time spent exercising. 

In rather disturbing news, over 1 in 4 girls have harmed herself in the past year, often by cutting or burning, compared to 1 in 10 boys. 

There is more good news about vitamin D. It turns about high levels of vitamin D may help prevent breast cancer. Vitamin D levels in our lab should sit between 30 and 80 to be considered normal. However, there is more and more evidence that sitting on the higher end of that spectrum may have benefits. New research has indicated that having a level near 60 confers 80% lower risk of breast cancer compared to a level near 20. Associated risk factors were depression, suicidal thoughts, buying and substance abuse were risk factors. See the recent edition os American Journal of Public Health. 

Oh… my fun little secret ? I am starting a traditional French Bakery and Bistro. No, I will not be baking. Yes, I will continue full time Obstetrics and Gynecology. It has always been a dream, and, along with a great team of people, I am getting to realize it. Stay tuned. We will open in late August. Visit me at 

bonjourbakeryandbistro.com 

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

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

Policy News

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

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

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

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

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

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

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

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

Medical News 

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

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

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

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

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

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

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

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.

Food Friday: Vitamin D

Vitamin D is in the spotlight. Is this celebrity justified ? 

Vitamin D is a fat soluble compound that is necessary to human health.Interestingly, it is not widely available in our diet. It is however, manufactured in our skin when the skin is exposed to UV rays from sunshine. It is of course available in supplements, supplemented foods, and a few foods naturally. 

You might wonder how we developed to need something that seems so hard for modern people to obtain naturally. I think it is a good bet that pre-agricultural people especially those along the coast got more sun and UV exposure than we do today. I suspect that plus their intake of vitamin D rich fish supplied their needs. Then as people began to move inland, wear more clothes, eat less fish and live long enough to have to protect against skin cancer, their vitamin D requirements became harder to meet. 

 Vitamin D is historically most “ famous” for its role in enhancing Calcium absorption. Calcium is critical for bone mineralization. Deficiency of Vitamin D leads to rickets and osteomalacia, which are failures of the bones to properly form. 

Those at risk for vitamin D deficiency are breastfed infants who aren't supplemented, dark skinned people, people who wear occlusive clothing, the home bound, the elderly, the obese, vegans, and those whose gastrointestinal tracts are inflamed or cannot absorb properly. 

It seems odd to me that breastfeeding does not supply all the necessary vitamin D a newborn needs. This is simply because the Vitamin D content of human milk is related to the mother’s vitamin D status. The infant cannot get vitamin D though UV exposure since it is not appropriate to expose infants to direct sunlight. There has been a big recent campaign to educate breastfeeding mothers about the need to supplement with vitamin D. 

Vitamin D also affects the general functions of cell growth, neuromuscular function, immune function, and the control of inflammation. These features are why there is more than the average amount of buzz around this mild mannered vitamin. Two hundred and fifty studies on vitamin D and various health parameters were done between 2009 and 2013. These were systematically reviewed by the Agency for Healthcare Research and Quality, and to date, it concluded that it is still not possible to specify a relationship between vitamin D and specific health outcomes other than bone health. As the number of studies indicates, there is widespread interest, or even hope that vitamin D therapy will prove useful for a wide variety of conditions, especially those involving autoimmunity. 

Adults need between 600 and 800 IU of vitamin D per day. It is best not to take more than about 4000 IU per day from all sources, unless specifically instructed to do so by your physician. Vitamin D is fat soluble, can be stored in the body and can, in excess, lead to toxicity. 

It is best to get your vitamin D from a combination of foods, fortified foods, and supplements. The best dietary sources of food are fatty cold water fish such as salmon, cod, tuna and swordfish. (As a side note, pregnant women should restrict their intake to salmon and cod, since tuna and swordfish may theoretically have increased levels of heavy metals. ) Besides these, egg yolks, fortified orange juice and fortified dairy products are the best sources. 

If you are concerned your vitamin D levels are low, ask your doctor about testing your levels. We have been screening patients more proactively lately, and have found some astounding deficiencies. The good news is, they are quite easy to fix. 

Here’s my favorite go-to recipe for a great blast of vitamin D and protein: 

Salmon Salad

Simply mix one drained can of coho salmon with 1-2 tablespoons of olive oil based mayonnaise ( My favorite is called “Lemonnaise”.), Add a table spoon of dill relish, a couple Tablespoons of sliced olives, some capers, finely chopped celery, chopped sun dried tomatoes, and whatever else suits your taste. Mix. Do not feel compelled to put it on anything. Enjoy. 

Refererence: 

National Institute of Health Office of Dietary Supplements