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

This Monday the world has become a different place. A new Administration has taken office in the United States. But more importantly, women across the country and across the world have become galvanized. Many marches of hundreds of thousands each took place on Saturday. These were largely demonstrations by and for women to make a statement against sexism, misogyny and against the loss of health benefits in the US. I’m not sure the world has ever seen political activism for one goal on such a large scale. 

Democratic lawmakers made a last ditch appeal on Friday, urging that the GOP halt the repeal. They cited the many clauses of the ACA which prohibit practices which are discriminatory to women, such as denying coverage of contraception and coverage for women-only health screenings such as mammograms. They cautioned that this, along with defunding Planned Parenthood, would harm women in every state. 

It is becoming clearer and clearer that many Republican governors do not favor a wholesale repeal of the ACA. They know that repeal would cause chaos in health care, as well as increasing costs for their state programs. 

In the shocking numbers department, it has been determined that HALF of all men have genital infections caused by HPV. One in four of those have viral strains which can cause cervical cancer. 

Meanwhile, New York State is reporting a 50% decline in cervical cancer deaths since 1976. This is attributed to women obtaining regular paps to detect precancerous conditions and the introduction of the HPV (human papilloma virus) vaccine Gardisil. 

It is interesting to note that abortions are at a new low since the institution of Roe versus Wade case law in 1973. Researchers attribute this new low to the increased availability of affordable and longer lasting contraceptives. 

If the ACA is repealed, both these important gains might likely be lost since the ACA has covered contraception and health screening for women. 

As if to add insult to injury, repeal of the ACA would also strip breastfeeding protections from the workplace. These protections are in place through the ACA. 

The ACA deals with more than women’s health issues. The ACA contained provisions to authorize a fund to combat the costliest of our chronic diseases: diabetes and heart disease. Repeal of the ACA could eliminate this fund, which is for state public health programs.

Americans may be divided, but 40% across both sides of the aisle agree that health care should be a top priority for the new administration. Meanwhile, the popularity of the ACA is steadily climbing in the polls. Forty eight percent of Americans strongly approve of the ACA. Of those 22% of respondents who want it repealed, half want to do so only when a replacement is in place. The Congressional Budget Office itself has calculated that if the ACA is repealed, 18 million people will lose their insurance in the first year. Over a decade, 32 million would lose insurance. They also estimate that individual premiums would double. 

In Zika news, officials have been debriefing from the season. They feel the greatest failure has been of prevention in the areas most affected by Zika. They have emphasized that the toll taken has scarcely been counted. 

Fetal alcohol syndrome (FAS)  is still a scourge. Over a hundred thousand babies are born yearly with this condition. Britain has one of the highest rates of FAS in the world, with 40% of British pregnant women drinking during pregnancy. 

The American College of Obstetricians and Gynecologists has continued to take issue with the FDA on their overly conservative and out of context warnings on anesthetics in pregnancy. Their concern is that caregivers and patients will be reluctant to have critical procedures such as appendectomies and gall bladder removals in pregnancy should they become necessary. Surgical illnesses such are these are very much threats to both mother and babies in pregnancy and should be dealt with in the standard fashion. To put theoretical concerns from animal studies ahead of clear and present dangers is missing the forest for the trees. 

Contact your elected officials with your concerns. It is not enough to march. 

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

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

Research on Zika continues at an accelerated pace. This last week Zika news includes the release of a new three-in-one test to test for Zika, Chickengunya and Dengue. Researchers say this cannot keep up though without an emergency spending bill from Congress. 

Puerto Rico has become a strong cause for concern. The director of the CDC has visited recently and expects “ hundreds of thousands” to be infected by Zika, among whom are thousands of pregnant women. Puerto Rico is believed to be an important route of infection to the United States. 

In Brazil, newest numbers show 29 % of Ultrasounds on babies born to Zika infected mothers show fetal anomalies with “ grave outcomes”. The newest research shows the prevalence much publicized defect called misrocephaly, but it is also becoming clear that other kinds of problems are likely Zika-related. These would include: lack of amniotic fluid, other forms of fetal brain damage, blindness,and stillbirth. 

There are 273 cases of Zika in the US States and 282 cases in the US territories including Puerto Rico. 

A small randomized controlled trial published in March of this year studied 78 first time mothers and their second stage of labor. The second stage is the time from becoming completely dilated to pushing the baby out. The old guidelines allow first timers pushing well to take 2 hours without epidural or three hours with epidural. Study subjects were allowed to push for one hour greater than current guidelines. In this study, when they did, C sections rates were cut in half without any other adverse effects noted  in either mother or baby. The authors remarked that the study was underpowered to detect small but clinically important differences. It does however, suggest that first timers were being “cut” as we say, too soon. 

As an Obstetrician, I would note that I have seen this study reported in the press. Many assumed that this meant that caregivers should now let patients push longer. Finally I got at look at the study itself. Nowhere in the press did it mention that all of the women in this study have epidurals. This makes it more difficult for many people to push effectively. Now it makes sense to me that more time made for more safe vaginal births. Certainly in many cases,  second stages with low quality epidural-influenced pushing should not be expected to make as much progress as second stages in women with strong epidural-free pushing. More time should be given for these patients. Normally, in a real labor population, some people have epidurals and some do not. Labor length averages are going to be influenced by his. However, If every single patient in a small study has an epidural, result swill skew toward the effect of the epidural-ized labor. Obviously. 

The old labor guidelines were made in the days before epidurals. In those cases, the women were probably unmedicated and thus pushing for all they were worth. In such cases, the old time allowances were probably appropriate. The idea is that, if your patient was going to deliver vaginally  safely, she should be able to do so within the old time allotments. Furthermore, if you persist in pushing her longer, you set yourself up for a variety of bad situations like stuck shoulders, a traumatized baby, or a traumatized mother, or a very late and thus risky C section. Hard coordinated pushing should result in continued progress of some degree. If it does not, the safety of vaginal birth should be questioned.

There are various signs we watch for during labor to tell if the baby can safely be delivered vaginally. It is so much more than the time duration of pushing. We watch the fetal heart tones, the evolving shape of the baby's head, the movement of the baby in response to the mother’s particular push in whatever particular position she is in. We factor all this in. I may know someone is stuck after only one hour, and I may let someone else safely go for four. It is a matter of not only knowing the labor guidelines, but but knowing the reasons behind them and knowing your particular patient very well. 

In the way cool department, researchers are using an iPhone app to begin a study of postpartum depression. They will be looking at a possible genetic predisposition for PPD. Using the iPhone will allow them to more easily get the enormous numbers (100K) they need to produce quality conclusions. 

In the good news department, Vox report that several more states, Missouri, Hawaii, Washington, South Carolina and Tennessee are considering bills to allow pharmacists to prescribe birth control pills. Ob/gyns support these bills because of the well established safety of these medications. 

The Supreme Court is hearing arguments about the ACA’s (Affordable Care Act) contraception mandate. A religious group called “ Little Sisters of the Poor”, one of the plaintiffs, are nuns, and they argue “ the birth control provision violates the laws of God.”

Governor Mike Pence of Indiana has signed a bill prohibiting abortions even for birth defects. He did this despite opposition from several of his female pro-life Republican colleagues in the House. Has he heard of the Zika virus ?

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

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

The CDC (Centers for Disease Control) predicts Zika will spread along the Gulf States of the US this Summer. The CDC has also said that since mosquito control in Florida is good, the risk there should be relatively low. As with regard to South America, and in particular Mexico, the CDC has noted that the Aedes mosquito, vector for the virus, is rarely seen above 6500 feet. 

Researchers studying a Zika outbreak in French Polynesia have identified a 1% risk of microcephaly among children born to mothers infected in the first trimester. Observers of the Brasil outbreak think the figure is too low given what they are seeing. It will take several more months to draw any conclusions.

As of Friday, there are 450 people in the United States who are infected by Zika. This does include Puerto Rico, where the Puerto Rican section of ACOG ( American College of Obstetricians and Gynecologists) are providing IUDS free of charge. (So proud of my brothers and sisters in ACOG ! )

In other news, concerns have been raised in an opinion piece in the journal Obstetrics and Gynecology that media coverage of controversial medical technologies may prevent certain women from getting the best treatment for their particular needs. They site the recent reluctance of doctors to use mesh implants, morcellators, or Essure sterilization even in patients for whom they are well suited. 

In the no-good-reason department, new research shows that sexually active teens with LARCs ( Long acting reversible contraceptives such as IUDs) are 60 percent less likely to use condoms that similar girls taking the pill. Birth control use in teens is distributed as follows: 2% use LARCs, 6% use Depo Provera injection, patch or ring. 22% use the pill. 

Also in the no-good-reason department, new research indicated 50% of pregnant women who quit smoking start again after childbirth. What percent of smokers quit during pregnancy ? 13 %. 

What about smoking pot in pregnancy ? One thing’s for sure, Ob care givers are not consistently counseling patients about it. These are the findings of new research published in the journal Obstetrics and Gynecology. I will say that as a caregiver, It is challenging to counsel against something that is so widely used, and for which people will rally. Neither the popular media and the research community  give us much in the way of support here. In fact, the facts on MJ use in pregnancy are not encouraging. If you are interested you can read the definitive information HERE, which is a summary document from the American College of Obstetricians and Gynecologists to its members. This is an area needing further attention. That is, if we value the brain power of the next generation. 

Steroids are given to mothers at high risk for preterm delivery. At this time, we give them from 24-34 weeks of gestation. However, new evidence indicates they may be helpful given even as early as 22 weeks. Hopefully the demand for this will be small. 

A new study published in JAMA ( Journal of the American Medical Association) reveals that vaccine aversion may be beginning to manifest in increasingly rates s measles and pertussis (whooping cough) in the United States.  No surprise here. 

Also In the vaccine department, there is good news. Chicken pox, also called Varicella, is now nearly 100% preventable. Think that’s no big deal ? Try telling that to someone like me who got it at the age of 24 ( and got seriously ill) or someone with a terrible case of shingles, which is reactivated chicken pox. New data says getting two shots instead one, one at age one, and the second around 4-6 years of age, confers near 100% protection. 

Stay tuned for more breaking news from the world of Obstetrics and Gynecology, here, (or hopefully in your inbox) next week, on Medical Mondays. 

Medical Monday: Breaking News from the World of Obstetrics, Gynecology and Women’s Health

ZIka virus news continues to be front and center. Zika virus causes an illness which is usually mild or moderate but is strongly associated with the development of a severe birth defect known as microcephaly. It is also associated with a post illness paralysis called Guillaine Barre.

This weeks changes include new mandatory reporting of confirmed case for all states in the US. Calls for Zikus virus research funding are being made. The WHO ( World Health Organization) has declared that the virus is spreading explosively. They have convened an emergency meeting, and in a rare move, has declared the virus a global health emergency. Brazil is the worst affected, the over 4000 cases of microcephalic babies born through the end of January.  Additionally Brazilian health authorities are fearing a wave of illegal and unsafe abortions among women who have no access to contraception or insecticide. Florida has declared a health emergency over Zika. Health workers in Texas have confirmed the sexual transmission of the virus. 

Brazil is using the military to spread insecticide.Two vaccine approaches are underway but will not likely be ready this year. Additionally genetically engineered mosquitos are being released into the wild, to sharply reduce the mosquito population. The US Senate plans to meet about the outbreak and plans to work closely with ACOG ( The American College of Obstetricians and Gynecologists) to address the problem. 

In other news, ACOG has issued a statement urging Ob/Gyns to support new mothers whether they breastfeed or not. In the same brief, it continued to advocate for policies that support a working woman’s right to breastfeeding. 

In more breastfeeding news, the Lancet has reported research indicating that if “nearly every new mother breastfed, that more than 800,000 children’s lives would be saved each year and that thousands of future breast cancer deaths would be avoided." Compelling ! 

Stay tuned for more breaking news from the world of Ob/Gyn. Thanks for reading !

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

The Zika virus continues to spread. There is increasing evidence that Zika infection causes microcephaly in the unborn as well as post viral paralysis Guillaine Barre syndrome. Every day there is new information about the outbreak, and the CDC ( Centers for Disease Control) is the best place to learn about it.

Unfortunately, there is yet no hint about treatment, and a vaccine is 1-2 years the making at best. The WHO ( World Health Organization )has warned that ZIka is likely to spread to every country in the Americas except Canada and continental Chile. As of this last Friday, January 29th,  the World Health Organization has reported 31 cases in 11 United States states and 1.5 million cases in Brazil alone. The WHO estimates that the virus could affect 4 million people by the end of 2016. About half of those will be women and an unknown percentage of those women will be pregnant.

In other news ACOG, the American College of Obstetricians and Gynecologists, has updated a “ Committee Opinion” which it distributes to all of its physician members. According to lead author, Dr. Allison Stuabe, "the goal is for OB/GYN's to own breast-feeding as a part of reproductive physiology”. The paper advocates that breast-feeding support should begin during prenatal care when breast-feeding can be discussed in clinic. Breast-feeding is still underutilized in this country and the world over. 

The American Heart Assoication has issued a report saying that “heart disease remains undertreated and under diagnosed in women”. It goes on to explain that "The causes and symptoms of heart attacks can differ markedly different between the sexes". Compounding problems is that “ women are under represented in clinical trials for heart disease ", occupying only about 1/5 of the slots. Moreover the report indicates,"even when women are included in trials, researchers do not often parse out the gender specific data that could deepen scientists understanding of how the disease affects women”

Last year the Gynecology community was startled by the revelation that ovarian cancer is now thought to originate in the Fallopian tubes. Accordingly, ACOG made a recommendation that they be removed in the course of surgery for other benign indications. However, a new study through Yale indicates that only slightly more than 5% of eligible surgeries utilize this recommendation. In all fairness, this is relatively new information and the efforts to disseminate it were fairly modest. Additionally taking the tubes out takes extra time at surgery and entails a certain amount of extra surgical risk. I was once told by an old professor of mine that it was not good to be either the first one on the block or the last one on the block to adopt a certain new surgical technique. 

This time the USPSTF (The US Preventive Services Task Force) has done something right. They have come out with a strongly worded recommendation to screen all adults for depression. They have gone on to particularly mention the need to screen all pregnant women and new mothers. They are basing this recommendation on new data indicating that maternal mental illness is more common than previously thought. New research indicates what has been called postpartum depression may actually begin during pregnancy and that left untreated these mood disorders can be "detrimental to the well-being of children". It is interesting that in the past the USPSTF has required proof of benefit to recommend any given intervention. Maybe today's announcement is a sign they will also begin using common sense.

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

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

Good Monday. We start out with good news, noting findings reported at the World Diabetic Congress that those who breastfeed have a substantially lower risk of developing type two diabetes later in life. 

Northern hemisphere readers will note that the CDC ( Centers for Disease Control) has reported that this year's flu activity, so far, is relatively low. They also note that slow starts aren't unusual and those that haven’t yet gotten a flu shot should get one, especially since this year’s vaccine is good match. 

USPTF (The United States Preventive Services Task Force) has once again released it’s version of guidelines for breast cancer screening. They are, predictably, lax, and recommend individualization for women of average risk before age of 50, and every other year between 50 and 74. They have chosen this age range of screening since they state their data show this is the age range “ of greatest benefit” from mammograms. This is no doubt true since this is when most cancers are diagnosed. However, what they cannot seem to understand is that women want ALL the benefit that mammograms can confer. Think about it. Their recommendations would condemn any woman below 50 of average risk to having her cancer detected only when it became palpable. Of course mammograms detect them far earlier, when they are more curable. 

Women want ALL the benefits mammograms can confer, and yes, they understand all such diagnostic tests must be weighed against their risks. But in this case, the risks are so small. They are the risks of biopsies for concerning findings which come back negative for cancer. They are also, according to the USPTF, the risks of fear and discomfort of the procedure. I have seen two and a half decades of patients and I have never heard one patient cite these risks as even coming close to outweighing the benefit of screening for cancer. Where does the USPTF get the idea that these particular risks are so important or that women even care that much about them ?

The good news is that the controversy has hit the airwaves and the blogosphere. NBC, the Washington Post, the NY Times, and Newsweek, among others, all covered it. ACOG (The American College of Obstetricians and Gynecologists) maintains a recommendation of annual mammograms after 40, and the American Cancer Society recommends annual mammograms from 45 on. ACOG plans to convene a conference to sort out the issue once and for all. 

Group B strep is an important pathogen for moms and newborns. A new vaccine against it is under development. 

Big news: Ovarian cancer actually seems to arise in the tubes. The data for this is sufficiently compelling that ACOG is recommending removal of the tubes with preservation of the ovaries when applicable. 

The CDC reports that the average age of first time mom’s is at an all time high, being 26 years and 4 months. This can be attributed, at least in part, to fewer teen pregnancies. 

In sobering news, a new virus called Zika is causing birth defects in the Caribbean and South America. It is spread through mosquitos. The CDC may warn pregnant women not to travel in that region. I’m sure we’ll hear more about efforts to deal with this in the near future. 

The effort to develop personalized vaccines to treat ovarian cancer is in the early stages. This work is on the desk of the FDA as we speak. 

Wow, so much happening ! Stay tuned for more breaking news from the world of Obstetrics and Gynecology next week on medical Monday. 

Medical Monday: Breaking News from the World of Ob/Gyn

2016 brings in some good news for women’s health. Physicians are starting to weigh in on the new over the counter contraceptives available in Oregon and California, and they are overwhelmingly applauding it. 

A recent article in the Los Angeles Times also indicates physicians are also weighing in on the controversy on mammogram frequency recommendations, and many support annual screening from the age of 40. This view is supported by the American College of Obstetricians and Gynecologists, the American College of Radiology and the National Comprehensive Cancer Care Network. 

The National Public Radio Health Blog Shots has indication that 2015 was the year “ menstruation came out of the closet. They cite the care of Kiran Gandhi who finished the New York Marathon on her period,without pads, drawing publicity to the idea that #PeriodsAreNotAnInsult. They cite other instances where menstruation entered polite public conversation, thereby beginning to erode long held taboos. 

The FDA now classifies mesh for prolapse as a "high risk device". Given the complication rates, I think this is a good thing. Also good is that the FDA excluded mesh for incontinence which is a different device entirely and works rather well, without the same high complication rate. 

You may hear of a retrospective observational study has picked up an association between the use of oral fluconazole (Diflucan) in the first 6 months of pregnancy with a 50% increased risk of miscarriage. From this data, it is not at all possible to say whether the diflucan is causing these miscarriages. Think about it…. maybe it is the yeast itself, or a diet high in sugar. More study is needed to figure this out. 

A new blood test may help physicians sort out those at risk for preeclampsia. This is most welcome since it is sometimes difficult to discern preeclampsia from chronic hypertension. 

Finally, in some really fantastic news, the Journal of the American Medical Association (JAMA) has published research indicating that even “ older women” i.e. 69 or older, who get regular mammograms have a lower likelihood of dying from breast cancer during the ages of 75-84 compared to their counterparts who did not get regular mammograms. Currently we are permitted to stop screening around 70 and the US Preventive Services Task Force says mammograms should not be done after 75. This has to do with supposedly having an expectation of living less that another ten years. You know, something tells me this whole line of thinking is going to evolve as women live longer and more vital lives. I wonder what Betty White, Angela Lansbury, Sandra O’Connor, Ruth Bader Ginsburg or Dame Maggie Smith would have to say about all this. 

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

Good Monday and Happy New Year. ACOG (The American College of Obstetricians and Gynecologists) has once again reiterated the newer recommendations regarding cervical cancer screening. They have stated that “ Women ages 30 to 65 at "average risk" for cervical cancer should receive co-testing with cytology and HPV testing every five years or screening with cytology every three years”. ( Cytology just means sending cells with a pap and co-testing means DNA testing for HPV, Human Papilloma Virus via the same sample.) I would like to emphasize a couple of aspects of this statement: the phrase “ average risk”, and the idea that they are talking about sending specimens to the lab. 

Average risk is not precisely defined, and this is ok, since it gives clinicians room for applying clinical judgement to individual patient cases. Average risk does not certainly include those patients, who are by virtue of disease or medication, immunocompromised. It does not include those who have recently had precancerous cells in the cervix, vagina or vulva. In my opinion it does not include those who have a significant smoking habit, since smoking is tightly associated with accelerating the progress of HPV disease. I do not believe average risk includes those with alcohol or drug problems since these patients can have poor immune function and struggle with satisfying recommended follow up protocols. In my opinion, average risk also should not include those with high risk sexual habits, such as having unprotected sex or large numbers of partners. But does the media ever highlight any of these things ? I have not seen it. 

These ACOG recommendations are about the recommended sampling frequency for cells on the cervix. They are not a statement about the frequency of annual exams or even pelvic exams. Those proceed on their own schedules for their own separate indications. The media has not done a good job at highlighting this important distinction. After all, a woman is more than just her cervix. 

The Journal of the American Medical Association (JAMA) has received a request from a group of researchers to retract their own study from the Journal on the grounds that they have discovered that the lead researcher has falsified data about the usefulness of nitroglycerin for improving bone density.  Kudos to those whistleblower researchers. 

South Carolina Department of Health and Environmental Control (DHEC) will revise its regulations concerning the practices of licensed midwives, what we call lay midwives, meaning those who are not Certified Nurse Midwives. The DHEC was picketed by about 50 midwives. ACOG has said that while women deserve the right to chose where they deliver, they should be informed of the risks and benefits of the choices, including the two to threefold risk of neonatal death while delivering outside the hospital. (This data came from a study reported in the New England Journal of Medicine (NEJM) and involved a study of 80,000 pregnancies in Oregon.)

Let’s think a little more about that statistic on neonatal death. Neonatal death is defined as the baby dying in labor or in the first month after birth. Why would such a terrible thing happen in the hospital ? High risk pregnant patients come to the hospital. High risk mothers may have very early labor, ruptured membranes, or severe preeclampsia, all resulting in deliveries so early that babies are far more apt to die or have serious morbidities. This is the source of neonatal death in the hospital, not the average pregnant women who comes in for labor or induction.  On the other hand, most licensed lay midwives restrict their practice to low risk patients, with none of these aforementioned problems. And yet many more of their patients end up with dead babies, despite the fact that hospital caregivers are dealing with these sometimes insurmountable obstacles. Problems which are solved by a simple medication in the IV, or the use of forceps, or even a C Section in the hospital, result in death when the same problems occur outside the hospital.

Speaking of neonatal death being two to three times more prevalent among those who birth at home, did you ever consider that this is a group average ? What happens when you unpack that group ? It turns out that first timers delivering at home have a 14 fold increase risk of first apgar score of ZERO, which is tantamount to neonatal death. And while the multiparous patients (women with multiple prior births) may do better with labor, they are much more prone to hemorrhages and other maternal complications, which are not even addressed in this statistic. 

So beware of the medical reporting in the popular media. Don’t take those statistics at face value. Remember the actual human realities behind them. 

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

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

This weeks news is all about the facts and figures. Statistics is like pie. It is all about how you cut it. That is to say, the real meaning of raw data is challenging to correctly interpret. A great deal of the message from a study depends on how the data is presented. Be wary about drawing conclusions from studies where none can be drawn. 

The CDC report indicates that the number of abortions in the United States has hit a record low compared to 1990. This is true for all ethnic groups.

A new study has hit the press indicating that use of SSRIs, common antidepressants, in the first trimester is NOT associated with increased risk of autism spectrum disorders. Nonetheless the study also showed babies whose mother’s took SSRIs were 75% more likely to get autism than than their peers. Whether this is related to the mom’s condition, the medication or something else is totally unknown and cannot be known from this study. 

In the strange, counterintuitive and questionable department, a new observational study published in the Journal of the American Medical Association shows more complications among those with a planned C section compared to those with an emergency C section done after labor. This is against what has been show before, and against common sense. Authors at the NYT Blog Well speculate that somehow the labor is “ good” for babies. You just as well might speculate that people who chose elective C sections are less healthy to begin with. No conclusions can be drawn, although many will be. 

New findings in the Journal Cancer Epidemiology show that while cancer rates are declining in developed countries, they are increasing in the developing parts of the world. With development comes smoking, and more obesity, which increase the risk for certain cancers. 

The now ancient Women’s Health Initiative, which gathered data on a great many things, has been mined once again. This time it has revealed an association between smoking and infertility. No surprises there. 

I guess I am not the only one who doubts the work of the USPTSF on the issue of breast cancer screening and mammograms. Over 60 lawmakers, headed by Representative Debbie Schultz of Florida, have included a provision in the new budget requiring that the US government officially recommends breast cancer screenings at age 40 rather than 50 as the UPTSF does. Looks like they feel American women are willing to undergo some increased anxiety and discomfort in exchange for earlier detection, longer life, and less mortality. 

A new study out of Britain once again raises the question as to whether the use of the Ca 125 blood test can help detect ovary cancer and save lives. The results are by no means conclusive, but they will provide an impetus for much needed additional study. 

Back to pie. This week I hope you have several kinds, pumpkin, cherry and whatever is your favorite. Merry Christmas week ! 

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

There is some sobering news in this week's collection. 

Findings from Sweden published in the Lancet indicate that babies from women who gained a large amount of weight in pregnancy are at increased risk of stillbirth and infant death compared to others. This work is an impetus to study the issue in more depth, since there is no clear indication of why this is it the case. 

A study presented at the World Diabetic Congress has shown that about 10 % of teens with type 2 diabetes in the study got pregnant over at 6.5 year period. Any women with diabetes in pregnancy are at high risk for complications. Pregnant teens with diabetes are at especially high risk. It was noted that these pregnancies frequently have poor outcomes. 

A study published in the Journal of Clinical Electrophysiology has indicated that women who were overweight at age 18 have a greater risk of sudden cardiac death. This persists irrespective of later weight loss. Those with a body mass index (BMI) in the high 20s have a 33% greater risk.. Those with  BMI over 35 quadruple their risk. 

New research indicated that 62% of all Ob/Gyns are now women ! That even counts the old ones : )  

Speaking of doctors, new research published in JAMA, the Journal of the American Medical Association indicates that about 29 % of all medical residents have depressive symptoms or depression during their training. The general population comes innate about 6.7 %. Of course this is all about long stressful work, sleep deprivation but also about hierarchical structures and bullying. In my opinion, a lot would have to change for this to be different. 

Omigosh this post is so dismal it is sounding like a parody but I kid you not, researchers from Oxford, namely statisticians and medical epidemiologists, have now asserted that happiness has no direct effect on mortality. They say the idea that unhappiness causes illness is a really a case of illness causing unhappiness. 

Data crunching at the CDC has concluded for 2010 and from 1976 until 2010 pregnancy and abortion rates have fallen to record lows. 

Dame Sally Davies (Yes, ladies she is a Knight of the British Empire ), the Chief Medical Officer in England, has declared obesity the greatest threat to women’s health and to that of future generations. She has declared it a national priority. 

Finally, in a bit of progress, the FDA has updated the required pregnancy and breastfeeding labelling for prescription medications. 

Maybe the world's researchers wanted to get all the bad news out of the way before the holidays. I can't wait for next week. Stay tuned. You can't make this stuff up. 

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

Until recently, the only treatment for preeclampsia is delivery. However, a new study is underway to test Recombinant Human Antithrombin to manage early onset ( 23-30 weeks) preeclampsia. As the same suggests, this medication acts by inhibiting abnormal blood clotting and inflammation, two components of preeclampsia. If this helps, this will be the first medication to directly address this common and serious disease. 

In the unbelievable department, The Government Accountability Department (GAO) has discovered something concerning at the National Institute of Health (NIH) . They have discovered that the NIH does not, in their research, always keep data on sex, thereby making it impossible to determine whether or not an intervention or exposure affects men and women differently. Those of us from the world of Ob/Gyn can tell you that rather often, the same factor will affect men quite differently than it will affect women. 

Here’s your reference http://www.gao.gov/products/GAO-16-13

The Radiologic Society of North America heard research results indicating that the recent Medicaid Expansion has boosted rates of breast cancer screening in low income women. Assuming these and other women do not pay too much attention to the USPSTF ( US Preventive Services Task Force) recommendations of later and less frequent mammograms, we may soon see increased rates of early detection and eventually, longer survival. 

ACOG (The American College of Obstetricians and Gynecologists) has made its strongest statement yet on pregnancy, stating not only that it is safe, but that it is recommended on a daily basis and should be the norm. 

OB/GYNS all over the world are nodding on this one. The Journal of the American Medical association has indicated the WHO's (World Health Organization) optimal rate of C section at 10% is too low. As C section rates rise to 15%, the study shows maternal and infant deaths decrease. In fact, maternal and infant deaths continue to decline through about 19%. This is the sweet spot, meaning where maternal and infant well being are at their highest. In the US about 33% of births happen by C section. This probably has to do with many things, including our culture, patient preference, doctor’s risk tolerance, the medico-legal climate, and the obesity epidemic. We can improve. 

Sobering : False positive mammograms may be linked to a higher risk of breast cancer later in life. The group in question is those whose mammograms indicate the need for a biopsy but then whose biopsies are negative. These women, despite negative biopsies, have a 39 % higher risk of breast cancer in their future that women who didn’t require a biopsy. I wonder how this finding will factor in to the recommended frequency of mammograms. So many authorities are weighing in on how frequently they should be done. ACOG still says every 1-2 years after 40. 

It turns out that giving flu vaccine to pregnant women in the second and third trimester benefits not only the mom but at least have of the unborn babies as well. Bonus ! 

Stay tuned next week for more breaking news from the world of Ob/Gyn ! 

Medical Monday: Breaking News from the World of Obstetrics, Gynecology and Women’s Health

The HPV vaccine has recently been vetted at the European Medicines Agency (EMA, the equivalent of the FDA). The EMA concluded that the benefits of Cervarix and Gardisil outweigh the risks. CDC (Center for Disease Control) Director Tom Frieden estimates that increasing the HPV vaccination rate to 80% would prevent 50,000 cases of cervical cancer in women.

Echoing results from last week, a study published in the Journal Hypertension has shown that those who had high blood pressure in pregnancy double their risk to develop the condition later in life. For diabetes, the risk quadruples.

Our largest and most foundational study on postmenopausal hormone therapy, the Women's Health initiative, (2002) was noteworthy for the fact that overall “estrogen plus progestin hormone replacement therapy" increased risk of "heart disease and breast cancer”.

Well the devil is always in the details, and sometimes angels too. It turns out that age makes a big difference the development of heart disease risk. If you “unpack" the data, you will see that women between the ages of 50 and 59 actually had a protective benefit to using hormone therapy, while women over 60 did not have the same advantage. Is interesting to remember that in this study all study participants  had never before taken any postmenopausal hormone replacement therapy. Therefore those who were 60 and older entering the study were beginning their hormone therapy approximately 10 years after the onset of menopause. Some researchers believe that it is that block of time after menopause but before initiation of hormone therapy in which silent atherosclerotic developed. If this is true then cardiovascular disease manifesting during the course the study would not really have been caused by the hormone replacement under study. Optimistic speculation leads us to wonder if women over 60 would do as well as their younger counterparts if they're hormone therapy has been started at the onset of menopause. It would be nice to know whether or not it is the youth of the women that caused them to do well with hormone therapy in their 50s or the fact that they started their hormone therapy immediately after the beginning of menopause.

It is interesting to note that age at the beginning of the study did not affect a woman's risk of breast cancer. Use of "estrogen plus progestin hormone replacement therapy” was and is clearly associated with increasing risk of breast cancer. (The same cannot be said for those who are able to use estrogen alone as their hormone therapy.) The lead investigator in this most recent study, Dr. Joanne Manson, indicated that "for every 1000 women per year not using hormone therapy, about 3 develop breast cancer” versus 4 out of “every 1000 women” using combined estrogen plus progestin hormone therapy.

A recent study has shown that only about half of women visited the dentist during pregnancy. Dental care in pregnancy is critical since many oral and tooth diseases have a direct impact on the pregnancy including increased risk of preterm labor.

Former Republican representative from Georgia Phil Gingrey has criticized the recent US Preventive Services Task Force (USPSTF)  recommendations on mammography citing the differing recommendations of the USPSTF, the American Cancer Society, and the American College of Obstetricians and Gynecologists. He has urged for more time to study the basis of these differing recommendations, so that we can "analyze the research and arrive at a medical consensus”. He has introduced a bill entitled “Protect Access to Life-saving Screenings”, (PALS). This bill would place a two year moratorium on the USPSTF recommendations.

I am all for this and I dare say a great deal of unpacking the data will be necessary here. What will be important in the conversation is identifying the “harms" of screening. And please don't talk to me or the breast cancer survivors in my life about fear of and pain from mammograms, which have been cited by the USPSTF as harms. Besides this, it will also be imperative to study endpoints, not only survival, meaning and lack of death, but years of life. It seems like a subtle distinction but it seems to have been lost on the US Preventive Services Task Force thus far.

Support has come out for treatment of subclinical hypothyroidism (low thyroid) in pregnancy. A new study presented at the International Thyroid Congress has shown that treatment with synthroid or Levothyroxine in pregnancy for those with subclinical hypothyroidism “was associated with decreased low birth weight and Apgar scores". It was not however associated with a significant decrease in miscarriage. This will probably tip the wobbling scales in favor of universal thyroid testing in pregnancy. 

Any study recently published in the December issue of Obstetrics and Gynecology has shown that yoga is safe even late in pregnancy. Study participants were put through various yoga postures and measurements were taken of heart rate, blood pressure and other vital signs for mother and or baby. Although mothers often opted for various modifications of their poses, no ill effects were found.

In more happy news, the United Nations and the World Bank jointly issued a report Thursday noting that maternal death rates have dropped 43% worldwide since 1990. This is attributed to better access to higher quality health and sex education services.

Stay tuned for more news from the world of OB/GYN and women's health, next week on Medical Monday.

Medical Monday: Breaking News from the World of Obstetrics, Gynecology and Women’s Health

Happy Monday ! This week, in addition to reading the news and doing your normal workweek, you get to start seriously preparing for the holidays.  Enjoy the process !

Postpartum depression is in the news again, and this is a good thing. “ Shots” blog by NPR ( National Public Radio ) has run a story about a woman, Paige Bellenbaum,  who went through this. She has since recovered and has become an activist on the subject, and helped to write a bill in New York “ aimed at educating more families on the symptoms of maternal depression.” The bill also promotes screening through the Pediatrician's office. Early treatment for postpartum depression is, of course, more effective. 

Research findings presented at the NCI ( National Cancer Institute’s) annual conference underscored that increasing parity ( the more children you have ) reduces risk of ovarian cancer. The first child reduces the change of this cancer10% and each subsequent birth reduces it 8% more. While no one would decide the number of children they wanted based on this, it is interesting and may spur further research about how ovarian cancer comes into being the first place. Hopefully this will ultimately yield clues on how to prevent and treat this awful disease. 

New research published in the Journal of Diabetes Care indicates that women with central obesity (higher levels of abdominal fat) are more likely to develop pregnancy associated diabetes here. Of course it is also known that women who get gestational ( pregnancy associated diabetes) are more likely to get Type 2 Diabetes later in life. Moral of the story: Get in good shape and at your correct weight before pregnancy and in-between each delivery. 

Also hot on the trail of gestational diabetes (GDM), s study presented at the Conference of the Society for Endocrinology indicates that women who are sedentary in the first trimester are more likely to get GDM. They defined sedentary as sitting more than 6.5 hours per day. Has anyone ever tried a standing desk ? Personally I think the best thing at work is to alternate siting and walking about at frequent intervals. Also naps, mid afternoon. Wouldn’t that be cool ? 

The CDC ( Center for Disease Control) reports that half of pregnant women are gaining too much weight in their pregnancy. IOM ( Institute of Medicine ) recommendations indicate women with a normal BMI ( body mass index) gain about 18.5 an 24.9pounds. Smaller women should gain more and larger women should gain less. 

Wow this week's news sure had some common themes. 

To help you stay in the know very quickly, don’t miss Medical Monday.

Medical Monday: ACOG weekly news

What's an Ob/Gyn site without a little OB/Gyn news ? I like reading the Ob/Gyn News and I like translating science information into clear non medical language. So I'm going to give Medical Monday's another go. 

A large Finnish study has show that those who have depression and who are treated for it in pregnancy have lower rates of preterm labor than those who have it and are not treated for it. 

Most everyone has heard of BRCA1 and BRCA2, the genes conferring increased of breast cancer. Unfortunately there are many more gene mutations which are associated with the development of breast cancer. Fortunately, testing for 20 more of these genes may soon become available for select patients with strong family histories of breast cancer. 

Fully one quarter of American women 65 and older have osteoporosis. Thank our marginal diet, heredity, Big Soda, Big Tobacco, alcohol and our sedentary lifestyle. 

One third of ovary cancer patients are living in excess of 10 years. This is a substantial improvement over the last several decades. 

Finally, stats are in through 2013 and infant mortality in the US has dropped to a record low. Wow, finally ! I'm going to try to end on a good note, so with that, stay tuned until next week. 

Medical Monday: ACOG weekly news

I have noticed that this is not the most popular column. I thought hard about reducing to three posts per week, eliminating this one. For now I have decided to keep it since it helps me keep up to the minute on news pertinent to the field of Obstetrics and Gynecology. Please let me know what you think.

The state of Delaware has banned the dispensation of formula from the hospital to new moms in an effort to promote breastfeeding. Some mothers have weighed in with opposition saying that many workplaces stigmatize breastfeeding making formula feeding necessary. Two comments: those little sample from the hospital aren't enough to make or break your formula supply. Buy your own formula if you want to. And, wouldn't it be better to help the whole situation by introducing some sort of " Freedom to Breastfeed" program in the workplace ?

An entirely useless article came out about a number of mortalities among those who experienced complications during Robot surgery. Non medical media didn't bother to compare these numbers with the numbers of mortalities in those with complications from non Robot surgeries. Also, it is unclear whether or not attention was restricted to new resident doctors, of whom a greater percent use the robot, seasoned surgeons, or both. It would obviously make a difference. 

Recent studies indicate breast cancer survival is aided by aromatase inhibitors, as well as good old fashioned bisphosphonates like fosamax. Cheap help ! 

Republicans want to defund Planned Parenthood in the wake of the recent videos discussion the disposition of the products of conception after abortion. Some say the videos are controversial, some say they aren't. The republican House speaker, John Boehner, has stated he wants the " facts first". FYI Planned Parenthood also does routine check-ups, cancer screening and provides birth control at low cost. 

Breast cancer death rates have declined 33.5 %  from 1988 to 2010 !  Good news. I bet it has decreased more since then. 

Finally, 60% of women over 60 are sexually active. Stereotypes be gone ! 

Stay tuned for next week's Medical Monday ! 

adolescent misogyny

I felt very done with posting about the recent shootings, until, another one happened and until I saw this article: 

Your Princess Is in Another Castle: Misogyny, Entitlement, and Nerds

I thought I had a grasp of two of the most important factors in play: guns and bullying. This article let me in on a whole other aspect of the situation of which I was unaware. It is a shocking but well written and heartfelt article. I am passing it on because I think these ideas need more exposure. 

It discusses a virulent strain of geek culture wherein young adolescent men alternatively idolize and revile the attractive and popular women who don't date them. The narrative broadens to describe " rape culture "  as it has been portrayed in the popular media and online. It is an eye opener. So I pass it on to you, with one caveat: Do not extrapolate and apply these observations to everyone in this social group. Nerd and geek culture is evolving and more and more it includes women.

And speaking of rape culture, can someone explain to me how so many people can tolerate watching Game of Thrones ?