Healthy Pregnancy

Plan B

2006-08-25T09:19:00.001-04:00

After stalling for years, the FDA has finally approved Plan B, a form of emergency contraception, for over-the-counter sales. That means that a woman will be able to step up to the drugstore counter and purchase it without a prescription and without a pharmacist's blessing, if she can prove that she's at least 18 years old. Younger women will continue to need a prescription.

The policy to restrict the sales to adults in drugstores seems arbitrary, especially in the face of all the unplanned teen pregnancies. It seems to me that any policy that would make the medication conveniently available, even in gas stations and convenience markets to anyone who thinks she might need it would have been more prudent. The only downside to taking it "incorrectly" seems to be decreased efficacy, and the easier it is to get, the better it might be utilized.

There are arguments that making emergency contraception more available will increase promiscuity and unsafe sex. But research shows that more than half of the pregnancies in the US are unplanned, which means there's a lot of unintentional unprotected intercourse going on anyway. If EC provides an option to reduce unintended pregnancies after the act, it makes sense to me to have it readily available when it is needed.

Emergency contraception, when used properly, decreases the chance of pregnancy from 8% to 1%, which is a significant reduction. But, it must be taken within 72 hours of unprotected intercourse, and, the sooner the better. It does not protect against sexually transmitted disease, and, it should not be used for routine contraception.

When it comes to how Plan B's availability, it seems that politics prevailed, but at least approval is here in some form.

-RW, MD

Related Topics: Many Teens Use Condoms Incorrectly, Teens Still Look to Parents for Sex Info

Technorati Tags: Plan B, emergency contraception, unplanned pregnancy

HPV Vaccine is FDA Approved - What's Next?

2006-06-09T17:28:00.000-04:00

Yesterday the FDA gave final approval for Gardasil, Merck's new HPV vaccine that promises to significantly reduce the risk of cervix cancer, precancerous lesions of the cervix, and genital warts.

Here are the facts and answers to FAQs as I see them:

The vaccine is currently approved for use in girls and women ages 9 to 26.
Women, and the parents of girls should consider the vaccine before sexual activity is initiated, but it may be given to any age-appropriate woman regardless of prior HPV exposure because it offers protection for four-subtypes of HPV virus.
The vaccine offered 100% protection against high-grade precancerous lesions, cervical cancer, and genital warts in women who had no prior HPV exposure in pre-release studies.
The vaccine will not prevent progression or expression of HPV-related disease that is caused by a virus type that a woman has already been exposed to.
The usefulness in older women, and in men and boys is currently being studied. At this point, they are not candidates for vaccination.
The vaccine will not reduce the importance of regular gyn exams and Pap smears.
The vaccine schedule consists of three doses, given over a six-month period.
It is not recommended for pregnant women, or for women who are trying for a pregnancy during the vaccination period.
The vaccine is produced from highly-purified "virus-like particles" that are part of a protein that's found in the wall of HPV. There is no active or intact virus in the vaccine; it is made from yeast that has been genetically modified to produce the particles.
Follow-up studies in more than 20,000 women for up to four years indicates that the vaccine is extremely safe. Adverse reactions and side-effects are very rare.
The vaccine is $120 per dose, so the series costs $360. Insurance coverage for the vaccine is yet to be worked out, but it should be covered as are other preventive care measures.
Details may be found in the Patient Education Pamphlet.

The opportunity to significantly lower the amount of HPV-related disease is HUGE, and I think this is great news for women and for parents of young women or women-to-be. I know that I am going to recommend in favor of vaccination for my patients, their daughters, and, specifically, for my daughter.

I hope that the third-party payors will quickly pave the way for this to become universally available. And, most of all, I hope that the current government, with its sometimes anti-women, anti-progress politics, won't try to stall or block the availability of public funding for the large numbers of uninsured women who probably need it most. We'll see......

RW, MD

Related Topics: WebMD Video: Cervical Cancer - Hear from Experts and Patients, Cervical Cancer Vaccine Approved

Technorati Tags: gardasil, HPV, HPV vaccine, cervical cancer

Mucous describes Mucus

2006-06-06T15:20:00.000-04:00

This is just a playful little spelling lesson post...

I notice, almost daily, that many of our posters on the WebMD message boards misspell (or misuse) the words mucus and mucous when they're describing the uniquely feminine qualities of cervical and vaginal secretions. There's so much variation in the posts, everyone gets confused. (And, I have to admit, it took a medical education and a specialty certification before I finally got the terms right!)

Here's how they should be used:

Mucus is a noun - it's the stuff we're always talking about.

Mucous is an adjective that describes the qualities of mucus.

Mucas isn't a word.

Hope that helps!

RW, MD

Related Topics: Pregnancy Calendar, Getting Pregnant

Technorati Tags: women

HPV Vaccine Nearly Ready to Roll

2006-05-30T07:23:00.000-04:00

Last week brought the much awaited news that the FDA has cleared the path for approval of Gardasil, Merck's HPV vaccine that promises to significantly reduce the risks of cervical cancer to women who are vaccinated before exposure to the virus. The studies reported that none of the women who received the vaccine developed precancerous lesions of the cervix during the study period! And, that's great news!

Not only will the vaccine most likely significantly lower the rates of cervical cancer, but there are other great benefits as well: there will be way-fewer rates of genital warts (condylomata), because the vaccine also protects against some of the "low-risk" HPV subtypes. And, there will be significant cost savings by reducing the numbers of colposcopies, treatments, and follow-ups of these problems. Many of our young patients will be spared the sometimes traumatic first experiences with a gynecologist that these problems sometimes dictate, and they'll avoid the potentially fertility-risking treatment procedures such as LEEP and conization.

There's a lot that will need to be worked out and perfected with this in the years to come, like how to effectively vaccinate adolescents before they're sexually active, whether to vaccinate boys (the vectors) or not, and whether to include additional less prevalent viral subtypes in the vaccines. But this is a great start.

Gynecologists see enough HPV-related disease to understand the importance of vaccination, but the problem is that we frequently don't see young women until after they've become sexually active. (See my previous blog entry about new thoughts about timing the first visit with a gynecologist.)

We need to be sure to do what it takes to educate and get buy-in from pediatricians, family-practitioners, and parents to make this work.

The big picture is that 75% of high school students admit to having premarital sex, and that's where these problems frequently start. As with most things, we tend not to address issues unless they're right in front of our noses. The prospect of near-future sexual activity is something that most parents don't want to think about with their young teenagers, but we're going to have to get over that hump and make this vaccination a standard of care if we want to prevent this disease.

A couple of disclaimers: The availability of the vaccine in no way sends the message that having sex may be taken lightly. Abstinence and safe-sex programs still have their roles in pregnancy prevention, disease prevention, and psycho-social indications. And, the vaccine will not eradicate the need for a yearly gyn checkup and cervical cancer screening. Just because there will (hopefully) be far fewer abnormalities, doesn't mean we'll quit screening for cervix cancer and other problems.

RW, MD

Related Topics: WebMD Video: Will a Cervical Cancer Vaccine Soon Be a Reality?, How Long will the Cervical Cancer Vaccine Last?

Technorati Tags: gardasil, cervical cancer vaccine

Are Periods Passe?

2006-05-26T13:09:00.000-04:00

The Choice to "Opt-Out" of Menses....

There's a lot of discussion these days about taking oral contraceptives in unconventional ways to delay or avoid menstruation. Seasonale, a birth control pill that's been available since 2003, extends a woman's cycle length to three months, so she only has withdrawal bleeding (a "period") quarterly. Now, there's news that Wyeth is seeking FDA approval for Lybrel, which is taken daily, continuously without monthly or quarterly breaks, and will optimally eliminate withdrawal bleeding altogether!

When the pill was developed, the 21-on, 7-off formulas were instituted in order to mimic normal cyclic menstruation. But, the timing is arbitrary - who's to say that bimonthly, quarterly, semiannually, or no periods at all aren't just as good? For years we've presecribed oral contraceptives continuously for women with endometriosis. And, we have frequently recommended short-term variations in pill-taking strategies for women who want to avoid their periods during their weddings, or vacations. It usually works....but not always.

Hormonal contraception has been around for a long time, and there's plenty of information and experience that says it's relatively safe and efficacious for large numbers of women. It even prevents problems for some women, or keeps them from worsening, as with ovarian cysts, endometriosis, and ovarian cancer. But, some women choose not to take them due to hormonal side-effects or intuition...

There are probably not different health risks or danger to fertility by taking oral contraceptives in creative ways to control or eliminate menstruation vs. conventional formulations. But, there are not any long-term studies of large numbers of women that prove this safety. (We thought that postmenopausal women could take continuous progestin to avoid withdrawal bleeding - a supposition that turned out not to be the safest choice...) Intuitively, I believe that if a woman chooses to take oral contraception, there are probably not significantly different risks no matter how she takes it, but I can't say that with authority.

I predict that the acceptance rates of the new formulations will be determined by the efficacy they have in eliminating unwanted bleeding. Wyeth claims that Lybrel stopped 71% of women's bleeding after seven months...but what did it take to get through those seven months? Was there unexpected and nagging breakthrough bleeding? And, what about the other 29% - how long should they tolerate unexpected bleeding in hopes that they'll eventually stop?

My experience is that women would rather know when to expect bleeding than be surprised by it. They're unlikely to put up with random breakthrough bleeding for more than two or three months, even if they're reassured that it's to be expected and it's safe. And, I know that I can't predict which women are good candidates for extended or continuous hormonal therapy.

So, unless these newer formulations are better than conventional OCs at preventing breakthrough bleeding, they're probably not going to work for a majority of women, unless we're able to create a paradigm shift in their thinking that it's worth putting up with unwanted bleeding for six months or longer in order to achieve no-menses nirvana.

RW, MD

Related Topics: Message Board: Birth Control Options, Birth Control Overview

Technorati Tags: Seasonale, Seasonique, Lybrel, birth control

First Ob-Gyn Appointment for Girls

2006-05-15T14:30:00.000-04:00

I just attended the Annual Clinical meeting of the American College of Obstetricians & Gynecologists in Washington, DC last week. I was interested to hear that a recommendation of an ACOG Task Force is that adolescent women (girls?) between the ages of 12 and 14 are now encouraged to have an appointment with an ob-gyn physician before they become sexually active. I mention this because many of my patients have asked me over the years, "when should my daughter have her first visit?"

The purpose of the early visit is not necessarily to perform an examination or Pap smear. Unless she is having problems with her periods, an exam really isn't necessary. It is merely a chance to have a conversation during which reproductive health topics may be discussed, and questions answered.

It is the opinion of the task force that these subjects are not being adequately covered by school programs, pediatricians, and family physicians, and that early education and familiarization with ob-gyns will help decrease unplanned pregnancy and sexually transmitted disease in this vulnerable population. Providing a link to an ob-gyn practice will hopefully improve access to birth control and emergency contraception, as well as STD information and screening, and abstinence support. And, with the new HPV vaccine that will be available this year, it seems prudent to get the word out there about cervical cancer prevention.

I think this is a great idea. Since 75% of high-school students now admit to having sexual intercourse, it seems the earlier the better to initiate these conversations.

Related Topics: Media May Prompt Teen Sex, Teen Virginity Pledges: Can They Work?

Technorati Tags: teens, ob-gyn, reproductive health, sex education

Ethics, Rape and Emergency Contraception

2006-04-19T13:55:00.000-04:00

Even though I am not adverse to controversy (I like spicy arguments now and again..."), I really wanted to avoid abortion and emergency contraception for awhile. But, I just can't...

Last weekend I was involved in a case that was an opportunity for further reflection. I performed a cesarean section on a newly-turned fourteen-year-old. Unfortunately, her pregnancy was the result of a rape by a "family friend" when she was 13 years old.

In this particular case, the rape was not revealed until well after the time that emergency contraception was an option. And, abortion was never an option.

But, as I sat with this patient and her family over the weekend and helped them deal with the unarguably far-reaching consequences of life's events, which included major surgery, adoption vs. parenting, etc., etc., I couldn't help but reflect on the following:

What if I were in the emergency room responding to a similar case of the rape of a thirteen year-old? The gathering of evidence and the recommendations around STD prevention are fairly straightforward.

But what about the potential of pregnancy and the choice to offer her emergency contraception? I find myself wondering whether any physician, no matter his or her beliefs about abortion or the mode of action of "emergency contraception" or practice setting, would or could ethically withhold the choice to take the "morning after pill" under such circumstances. I would like to believe that no physician would put his or her "morals" in the path of such a patient choice. It seems clear to me that at least offering the prescription is the right thing to do, and I believe that most, if not all of the physicians with whom I have worked would offer that choice.

I am left feeling kind of numb with the whole conversation about the legalities of abortion and emergency conversation. I feel that legislating what patients may or may not do, or what doctors or clinics or hospitals must or must not do is polarizing, and only gets in the way of doing the right things for patients. I'm tired of arguing.

RW, MD

Related Topics: Syphillis Rising in the US, Protecting Your Child from Sex Abuse

Technorati Tags: birth control, morning after pill, sexual abuse, medical ethics

Ethics and Teens

2006-04-18T14:30:00.000-04:00

I recently wrote a blog entry about new guidelines for managing abnormal Pap smears in young women.

At the end of the ACOG Committee Opinion, there's an interesting aside that deserves comment: the fine line about confidentiality issues and informed consent when evaluating and treating adolescents with these problems.

This is an issue that has come up more than once in our practice. Frequently, young women have Paps done as part of STD screening, or in order to get prescriptions for birth control pills. When their Paps occasionally come back abnormal, they're called in for further work-up and possible treatment.

Historically, adolescents are allowed by state laws to obtain contraception and STD screening without parental consent. But, when a problem is uncovered, and further testing and treatment are necessary, the ethical and consent issues become cloudy.

For example, we recently had a 17-year-old woman with an abnormal Pap smear. When she came back for colposcopy, she insisted that the workup be kept confidential or she would not undergo the evaluation. We went ahead and did the evaluation without parental notification or consent under the assumption that we were managing STD. But, when a high-grade lesion that required excisional biopsy was uncovered, some of us questioned the wisdom of proceeding with the procedure without parental involvement.

This was a tough case. The patient clearly did not want her parents to know anything about this. But, we were recommending therapy with potential cervix-damaging consequences, and one could argue that a 17-year-old shouldn't be responsible for such decisions on her own. And there were insurance issues here as well: her insurance coverage was as a minor under her parents' policy, and we couldn't guarantee that billing confidentiality could be maintained. She again threatened to avoid further care for her problem if that involved notifying her parents. So, we were faced with several ethical dilemmas...

As a patient advocate, I can make the argument that this condition is the result of STD exposure and that the patient should have the right to make adult decisions about adult problems. But as a parent, I would expect to be notified if my minor child needed a surgical procedure, especially if it had such far-reaching consequences as potentially threatening her fertility, or my pocketbook!

The obvious superficial best choice here would be for the adolescent to come out about this to her parents and receive their support, despite the consequences. But, that's not always easy in all circumstances. And, it's surely not easy being caught in these situations where we're trying to provide the best overall support for our patients.

RW, MD

Related Topics: New Healthcare for Teens, Teens Look to Parents for Sex Info

Technorati Tags: teenhealth, sexuallytransmitteddiseases, HPV

What's Wrong with Silence and Birth?

2006-04-17T06:31:00.000-04:00

With the birth of Tom Cruise and Katie Holmes' baby girl, Suri, it's worth taking a look at the controversy about their intention to have a "silent birth." According to their religion, the birth and the immediate postpartum period should be conducted as silently as possible in order to provide the "best possible environment for the birthing mother and her new baby." I'm not sure why this upset anyone. That sounds like noble intent, to me.

I am not very familiar with Scientology and its tenets, but I do know that the idea of welcoming a newborn into the world in a calm, quiet, peaceful environment seems intuitively appropriate to me. I'm familiar with similar practices employed by my patients over the years, like the "Leboyer Method," which was popularized by the French obstetrician Frederick Leboyer in his classic Birth Without Violence. The practice of "gentle birth" appeals to many segments of the world's population without regard to religious practices.

It appears there's a misconception that's been spread in the media that women are discouraged from making a sound during birth, and that's understandably produced an uproar among womens' advocates and birth experts. But, all the accounts I've read of "silent" births indicate that womens' choices are supported in the process including birth location, position, provider / birth attendant choice, anesthesia options, and even noise-making! And, I don't think that Tom's appropriately paternalistic intentions to support his idea of a nurturing environment for his beloved newborn necessarily infringe upon Katie's birth choice and experience...

So, I ask, "what's wrong with a little silence?" Surely no one would argue that silence might be more welcoming to a newborn's acute senses than a blaring TV or Nintendo - whether it has long-lasting effects or not. I don't think it takes medical research to make that case. And, to put it in perspective: why not cut Tom and Katie a little slack, if this is the experience they wanted for themselves and their family? This is, after all, America: the land of "Cesarean Birth on Maternal Demand" and elective newborn circumcision - neither of which is supported by sound medical research.

RW, MD

Related Topics: Elective C-Section Under Spotlight, Few Would Choose Their Babies' Sex

Technorati Tags: silent birth, tom cruise, katie holmes

Abnormal Paps and HPV in Young Women

2006-04-13T13:50:00.000-04:00

I know this isn't about pregnancy, but every now and then I feel the need to comment on noteworthy news for the vast majority of women who are not pregnant...

This month, the American College of Obstetricians and Gynecologists released a Committee Opinion on the Evaluation and Management of Abnormal Cervical Cytology and Histology in the Adolescent. In plain English, that means that there are new guidelines about how to deal with abnormal Pap smears and cervix biopsies in young women.

The new guidelines have come about because of improved understanding of the natural history and cancer-causing potential of human papilloma virus (HPV), and because we have improved Pap smears (liquid-based) and high-risk HPV DNA testing available to us now. The net result is that we are finally able to say that most HPV-related problems in young women are unlikely to cause cancer, and we are comfortable using the new tools to follow the abnormalities conservatively rather than treat them aggressively unnecessarily.

This is good news, because most HPV infections and their resulting abnormalities will resolve on their own without treatment. The treatments (cryotherapy, laser, and LEEP) are known to increase the risk of damage to the cervix, and it seems prudent to limit these procedures in the relatively young.

The bottom line here is that if you or your young daughter's Pap smear is abnormal, it is now reasonable to take a more conservative approach to managing these lesions without a fear of cancer developing. Such observation requires good compliance with follow-up, however, and only well-informed, reliable young women should take advantage of these relaxed guidelines.

RW, MD

Related Topics: WebMD Video: Cervical Cancer Vaccine, New Guidelines for Cancer Screening

Technorati Tags: papsmear, guidelinesforpaptests, HPV

Episiotomy is Out - Finally!

2006-04-12T12:53:00.000-04:00

Last week the American College of Obstetricians and Gynecologists released a Practice Bulletin that effectively condemns the routine practice of episiotomy. I found the recommendations unusually blunt for ACOG; normally these guidelines are more politically correct.

Now there's good evidence to confirm what most midwives and conscientious doctors have understood for years: that in most cases, women will give birth with less trauma to the perineum without episiotomy than they sustain when one is cut.

I do believe that very experienced practitioners sometimes make the wise call that an appropriately chosen episiotomy might be preferable to severe lacerations, but those instances are rare, and the call is mostly subjective rather than objective. These instances should be exceptions rather than the rule, and ACOG wisely states that practitioner's track record could be used as an indicator of quality.

And, it goes without saying, that a patient who wishes to avoid episiotomy should have her request respected, no matter what the potential outcome seems to be.

RW, MD

Related Topics: Episiotomy May Not Help Most Mothers, Labor and Delivery

Cesarean on Request: NIH Review Lacks Conviction

2006-03-31T18:02:00.000-05:00

The NIH spent a whole lot of money to convene a panel of experts to discuss Cesarean Delivery on Maternal Request. Only one definite thing appears to have come out of the conference: it now has an acronym, CDMR. The panel announced yesterday "that the available information comparing the risks and benefits of Caesarean delivery on maternal request (CDMR) versus planned vaginal birth do not provide the basis for a recommendation in either direction."

Their recommendations are that more time and resources be utilized to study and document the outcomes of these elective c-sections. In the meantime, doctors are encouraged to counsel patients who request elective cesarean section individually, taking into account "societal and cultural conventions, ethical issues, available resources, and other factors pertaining to the individual patient."

The recommendations do caution against CDMR in women who want large families, because there is evidence of increased risk of serious complications with each additional Cesarean delivery. And, c-sections shouldn't be done prior to 39 weeks unless an amniocentesis confirms fetal lung maturity prior to delivery.

So, what's next - amniocentesis and premature birth on request?

Related Topics: Typical Pregnancy 39 Weeks, Not 40, Can You Time Your Pregnancy?

Technorati Tags: CDMR, caesarean delivery, pregnancy, childbirth

My Experience with Integrated Medicine

2006-03-22T16:17:00.000-05:00

I guess I am a pioneer in Integrative Medicine. When I was a "young"
obstetrician-gynecologist, newly in practice in the late 1980s, I found allies early on in "alternative" practitioners such as lay-midwives, nurse-midwives, doulas, childbirth educators, La Leche League, chiropractors, accupuncturists, yoga instructors, massage therapists, naturopaths, herbalists, Bradley Childbirth instructors, etc., etc.

I was open to the support that these disciplines offered my patients that complemented the "allopathic" practice that I was trained to provide. I don't know why I was more supportive of these practices and less threatened by them than my colleagues, except to say that I was open-minded to what worked for my patients, and I realzed that "Western" medicine did not have all the answers.

In the early 1990s I had the privilege of meeting Dr. Andrew Weil in Tucson. One principle that he elaborated stuck with me: that medical treatments and healing practices do not work miracles: they only support an individual to heal.

Dr. Weil's assertion is that Western medicine might be at the end of a spectrum of choices that people have to support their healing, and that while surgeries, medications, and invasive procedures might sometimes be necessary, "alternative" or complementary therapies that are more attractive and more gentle to patients only make sense in many cases.

I've come to trust the intuitive wisdom that my patients have in charting their courses for healing. And, I believe it is my duty to offer my expertise and experience, but to stay out of the way of a patient's process as she discovers her healing course. I am reassured by the cumulative success of my practice style, and by feedback from patients about what makes for an ideal doctor.

In 2003, I joined the medical staff of North Hawaii Community Hospital on the island of Hawaii. This relatively young, but ten-year-old hospital was founded from a vision of Integrative Medicine, and it remains a pioneer in state-of-the-art care for "treating the whole individual - mind, body, and spirit - through a team approach to patient-centered care..." I am proud to remain a member of the medical staff here, and I have found the process supportive of my professional approach to holistic medicine.

I have also become aware of the challenges in the evolution of the "New Medicine." These are primarily political and financial challenges.

Until allopathic physicians embrace the potential that "alternative" medical practices have to offer, there will be a smugness and resistance from traditional hospital medical staffs to facilitate other practitioners' integration into plans of care for patients. Medical doctors need to gain trust and experience with integrating alternative therapies into therapeutic plans to the point that they are proactive towards (and even suggestive of) their inclusion rather than simply tolerated upon a patient's insistence.

And, the financing of healthcare services must be expanded and revamped to more fairly support the integration of all healing modalities. There are pluses and minuses to third-party vs. patient payment for medical services, but it is clear to me that the decisions around what are covered and not covered are mostly arbitrary at present. The delicate debate of healthcare expenditures must include a sensitivity to the expansion of covered services.

The good news is that the movement towards "integrated medicine" is patient-driven. I think that's reinforcement of what I learned long ago, that patients, not doctors, know best what's right for themselves.

RW, MD

Related Topics: Choosing and Using Alternative Medicine, Complementary Therapies

Technorati Tags: integrative medicine, pregnancy, childbirth

Curious Choices

2006-03-09T11:08:00.000-05:00

Wal-Mart Changes Its Mind & South Dakota Restricts Abortion

Pharmacists - 1 Doctors & Patients - 0

The news this week includes two stories of interest in the fields of reproductive health and women's rights. First, Wal-Mart has changed its mind and has decided to sell Plan B Emergency Contraception in its pharmacies nationwide. Second, there's a new law in South Dakota that outlaws virtually all abortions.

Wal-Mart's decision, according to its "Wal-Mart Pharmacies to sell emergency contraception"press release, is based on the company's realization that it will most likely face further challenges in states other than Illinois and Massachusetts to its previous national policy not to sell emergency contraception. And, according to the Wal-Mart Vice President of Pharmacy, they "feel it is difficult to justify being the nation's only major pharmacy chain not selling it." The press release made no mention of any commitment to women's reproductive choice, and, quite importantly, the point was made that the company will maintain a conscientious objection policy, in which a pharmacy associate will be allowed to refuse to sell emergency contraception if he or she does not "feel comfortable" doing so. I wonder how this will play out in the politics at Wal-Mart: will an employee's "choice" be noted somewhere in a database or personnel file where the information will be used when considering which associates are eligible for promotion, raises, or service recognition? If I were a pharmacist at Wal-Mart I would wonder...

Contrast that to the new law in South Dakota that strips doctors of the right to choose to participate in abortion services by making it a felony offense. Most physicians who choose to perform abortions were thoroughly trained to do the procedures in residency programs, and they provide these services legally within the standard scope of practice of obstetrics and gynecology. I don't know a single physician who "enjoys" doing abortions, and I don't know any doctor who has done one against his or her will, or against a patient's choice. They do these procedures because they believe that reproductive freedom for women includes the right to choose a safe pregnancy termination, and because they choose to make their skills and expertise available in these situations. The new law drastically restricts the choices that doctors and patients can make - at least in South Dakota. Some conservative purists in the South Dakota legislature and Governor's office pushed ahead with this extreme legislation that is designed to spark a US Supreme Court challenge despite the fact that seventy to eighty percent of the Nation's population supports some access to legal abortion.

I find it curious that pharmacists' choice is being preserved at Wal-Mart while doctors' and patients' choice is being radically stripped elsewhere. This seems way out of sync with the beliefs of mainstream America, and I think it's time for women (and men) to voice their opposition to such attempts at puritanical control.

RW, MD

Related Links: Women's Health: State Rankings, Sex Habits and the 'Morning After' Pill

Technorati Tags: Plan B, Emergency Contraception, Morning After Pill, Abortion

Close Watch on "The Patch" for Now

2006-02-22T10:22:00.000-05:00

Ortho Evra, a.k.a. the "birth control patch," has become a popular birth control method that is used by about four million women in the United States. Recent reports in the news media have suggested that there may be higher rates of serious complications in patch users than in women using low-dose birth control pills.

Preliminary data from studies that were supported by Orth Evra's manufacturer produced conflicting results. Both studies failed to show an increased risk in heart attack, stroke, and death, but one of the studies did show an twice the risk of non-fatal "thromboembolic events," presumably deep venous thrombosis and/or pulmonary embolus.

The FDA is closely monitoring the studies, but is currently only recommending that patients be made aware that there are conflicting results in the preliminary studies that compare the rates of side effects in patch users vs. pill users.

I think it's important for patients to realize that although the components and methods of action of the patch and the pill are very similar, the pharmacokinetics of transdermal vs. oral administration are different, and there could be differences in safety profiles. The good news is that although there is risk with any hormonal contraception, the risks are extraordinarily low in young, healthy, non-smokers. And twice a very small risk is still very small. Clearly, further study is warranted, but for now, a well-educated consumer could logically decide that the benefits of using the patch outweigh the unknown, but apparently small risks associated with its use.

RW, MD

Related Topics: Birth Control: Which Choice is Right for You, Condom Quiz

Technorati Tags: orthoevra, thepatch, birthcontrol, hormonalbirthcontrol, fda

Rethinking Prozac and Pregnancy

2006-02-15T12:33:00.000-05:00

Researchers from the University of California published a study last week in the New England Journal of Medicine that appears to put a damper on the long-held belief that today's most popular antidepressant medications are really safe in pregnancy. Selective Serotonin Reuptake Inhibitors (SSRIs) are the mainstay of today's medical therapy for depression, because they usually work, and their safety and side-effect profiles are attractive. This class of medications includes the popular brand-names Prozac, Zoloft, Paxil, Celexa and Lexapro.

Although the usual warnings about unknown risks are always given to pregnant patients on these medications, until now, we've had little reason to worry about serious consequences of taking these commonly prescribed antidepressants while pregnant. This study suggests that women who take SSRIs after the 20th week of pregnancy have s sixfold increased risk of giving birth to a newborn with persistent pulmonary hypertension. Also known as persistent fetal circulation, this condition is a rare life-threatening lung condition that affects newborn infants immediately after birth. It is so rare, in fact, that a sixfold increase in risk only translates to about a 1% risk for women who take these medications in the last half of pregnancy.

The good news is that women who become pregnant while taking these medicines need not worry: the risk is only increased if they take them beyond twenty weeks. They will have plenty of time to get off the meds if they can. But, making that decision is tricky business. Some women might be just fine if they stop them, but many need these prescriptions to function. And, probably every woman who has a history of depression is at risk for postpartum depression, so stopping the medications mid-pregnancy might not be in their best interest.

I believe that this knowledge calls for even closer coordination of care among the patient, her ob team, and a psychiatrist. Each patient needs to be carefully and timely counseled, and if a decision is made to stop the meds, she should be monitored carefully for deterioration of her mental health status. The recommendation of whether to stop the medication or stay on it must be individualized and taken seriously, because clearly, the benefits of the medications do outweigh the risk in some patients. And, I agree with the authors: we need to know more about the management of depression during pregnancy in order to provide expert care for these patients.

RW, MD

Related Topics: Facing Depression During Pregnancy, Infants and Antidepressant Withdrawal

Technorati Tags: pregnancy, depression

Obesity and Pregnancy Risks

2006-02-13T13:38:00.000-05:00

All the recent news about obesity and health seems to support what we corpulent ones already intuitively know: that being overweight just isn't healthy. And, now the word is that obesity is not only unhealthy for pregnant women, it's not a good thing for their babies, either.

Overweight women are at higher risk for infertility, high blood pressure, strokes, and heart attacks. And, in pregnancy, high blood pressure, blood clots, and gestational diabetes risks are increased. Rapid weight gain during pregnancy can cause large babies (fetal macrosomia), and it increases the risks of cesarean section. The latest news on obesity and pregnancy, based on a position paper from the Public Affairs Committee of the Teratology Society is that obese women have twice the risk of having infants with neural tube defects.

The authors suggest that preconceptual counseling for obese women should include a discussion that includes the risks of obesity along with smoking, drinking alcohol, and an insufficient intake of folic acid. Women should be informed of the risks that their obesity poses to their unborn children, and they should be supported with nutritional counseling and exercise programs that encourage them to lose weight before they become pregnant.

Dieting to lose weight during pregnancy is not healthy; it's best to shed that avoirdupois and develop a healthy lifestyle prior to conception. Easier said than done, I know, but it's worth it.

RW, MD

Related Topics: Eating For Two: Pregnancy Nutrition for Expectant Moms, (WebMD Video) Weight Loss 101: Snacking Secrets

Emergency Contraception: NOT at Wal-Mart

2006-02-03T13:20:00.000-05:00

Don't go to WAL*MART on the "morning after"...

I read on CNN.com that WAL*MART is being sued in Massachussetts over a decision not to carry Emergency Contraception pills in its pharmacies. Massachussetts state law requires pharmacies to stock all "commonly prescribed" medications to meet the "usual needs" of the community. WAL*MART has apparently decided that emergency contraception is neither commonly prescribed nor a usual need of the community.

Emergency contraception, also known as the "morning after pill," will never be a regular purchase for consumers. Hopefully, WAL*MART's regular customers will not need to buy it more than once or twice during their reproductive years. But, for emergency contraception to be effective, it must be immediately available. It seems to me that women should rightly expect their "neighborhood pharmacy" to stock it.

I do not want to debate whether or not government ought to require businesses to carry particular merchandise. Even the Massachussetts laws does not require pharmacies to carry EC. But I do believe that this high-volume, low-cost retail giant is hiding its conservative anti-women agenda behind a thinly veiled business policy. Once again, WAL*MART is falling short as a community player - leaving choice only to the high-and-mighty few back in Arkansas.

RW, MD

Related Topics:Emergency Contraception, Guide to Birth Control

Technorati Tags: emergencycontraception, morningafterpill

Birth Defects: Sobering News

2006-01-30T21:38:00.000-05:00

CNN reported today a March of Dimes report on the global toll of birth defects. The report emphasizes the disparities in the birth rates, mortality and disability among children with birth defects who are born in wealthy vs. medium or low-income countries.

There are opportunities for reductions in the prevalences of these conditions, via improved education and increased availabitity of genetic counseling and testing and through nutritional programs. And, there are hopes for improving the plights of affected children via better diagnosis and treatment of the condition.

There's a sobering point about congenital anomalies that's confirmed in the report: that every mother-to-be has a five percent chance of having a child with a serious birth defect.

This background rate holds true even in wealthy countries, including the U.S. and France. That's a one in twenty chance that any couple will have a baby with a serious anomaly. To me, that's a strong dose of realism. We tend to forget that detail in our quest for perfection these days. Parents-to-be worry so much about taking an aspirin inadvertently during early pregnancy or about having a margarita, but they don't acknowledge that they've signed up for much greater risk than these insults could ever cause just by choosing to have a baby!

We have a long way to go before we put a dent in that 5% figure. Reducing that rate will be possible, but it will require even more sophisticated and more costly screening tests, and more compassion about individual choices around testing and prevention. Reproduction is risky business, but, as I've said before, there's never been a safer time to be a newborn or a pregnant woman. I guess we should celebrate that and say the Serenity Prayer.

RW, MD

Related Topics: Preparing For Pregnancy, WebMD Daily Video: Baby Noor

Technorati Tags: birth defects, prenatal screening

C-Section By Choice?

2006-01-25T17:58:00.000-05:00

Today I received an interesting invitation. It was to the NIH Conference on Cesarean Delivery on Maternal Request. Also called elective c-sections and patient-choice cesareans, cesarean birth without a traditional indication is a hot topic these days. It's in the medical news, on the CBS News, and it's being blogged about. A colleague of mine (who hasn't delivered a baby in about twenty years), jokingly has referred to c-section as the "vaginal bypass" operation. Unfortunately, that thinking seems to be catching on without careful consideration.

The subject is alarming to me on a gut level. I am objective enough to believe that an elective c-section might carry a low enough risk to justify a patient's request for whatever reason. She may desire the convenience of planning her delivery date, she may find the idea of labor "horrendous," or she might believe that by having a c-section she'll reduce the risk to her baby or of damage to her pelvic floor. It's also possible that if elective cesarean birth became routine, the cost would be equal to or lower than the average cost of labor and vaginal birth. But, the truth is, we just don't know if these are reasonable considerations. We don't know the true benefits and risks of isolated elective cesarean delivery to mothers and babies. In fact, right now, there's an ACOG front page press release that vaginal birth is not associated with urinary incontinence later in life. And, there are several studies that suggest that mothers and babies bond and breastfeed better following vaginal birth. It seems to me we need to know a lot more before such choice becomes routine standard practice in this country.

Apparently I am not alone in my misgivings. I find it interesting that although almost two-thirds of obstetricians in the US and in other countries say they would give careful consideration to a patient's request for elective cesarean section, only about fifteen percent of them would recommend it for themselves or their family members. And, I think I know why: It's because of the frequently forgotten interface between the normal life functions of pregnancy and birth, and the best-intentioned but interventive practice of modern obstetrics. My long-held belief is that pregnancy and birth are far from disease and surgery, and that just because we can do something doesn't mean we should do it. And, my experience is that vaginal birth is an empowering feat for most women. Apparently, deep down, my colleagues around the world share these beliefs on some level.

I applaud the NIH for convening this conference. I just hope those in attendance represent all the important issues regarding this important subject.

Regards,

RW, MD

Related Topics: C-Sections: Necessity or Choice Issue?, Preterm Birth and C-Section Rates Up

Technorati Tags: pregnancy, childbirth, c-section

Screening for Anomalies: Choice is Good

2006-01-16T12:54:00.000-05:00

I came upon an interesting thread about first trimester screening and antenatal diagnosis of congenital anomalies in general on another blog this week.

I find the conversation an appropriately unemotionally charged discussion that covers the challenges that patients, doctors, counselors, midwives, and society face as technology advances and we have the ability to diagnose conditions before birth.

Although I find the discussion interesting, I am weary of the complexity that others impose on the issues. For me, it's simple: information is good, and anything I can do to offer information to parents about the condition of their unborn son or daughter is good and seems the right thing to do. Worrying about whether or not they choose to have the information, what they might legally choose to do with the information, or whether I have the authority or responsibility to facilitate their access to the information seems paternalistic to me.

There are plenty of couples who want screening information, but who are not committed to pregnancy termination. Either they are undecided about abortion, and will make their decision when the need arises, or they will not choose abortion, but want information for reassurance or preparation.

I have not found it difficult to remain impartial but compassionate during these conversations. Empathetic counseling is an art of medicine. Maybe some of us are better at it than others?

RW, MD

Related Topics: To Test or Not To Test?, Down Syndrome: Exams and Tests

Pregnancy and Work

2006-01-02T12:33:00.000-05:00

An article in the December issue of Obstetrics and Gynecology brings attention to a common concern of many pregnant women: What effects could my job have on my pregnancy and how will being pregnant affect my ability to do my job?

I've become more interested in this subject of late, because our practice in Hawaii includes many hotel workers who face significant challenges among their jobs, their supervisors, and their pregnancies. I am frequently frustrated by the lack of flexibility these pregnant workers face. My experience is that most women want to work during pregnancy, but they do not want to experience undue risk and strain, and they don't want the burden of bureaucratic hassle every time something comes up that limits or prevents their abilities to work.

The study by Lisa A. Pompeii, PhD, COHN-S, et al., from the University of North Carolina at Chapel Hill, studied 1908 women during pregnancy. The results suggest that working long hours, heavy lifting, and prolonged standing do not contribute increased risk of preterm or small-for-gestational-age (SGA) birth. There was a statistically significant increase in the risk (50% increase) of preterm delivery in women who work the night shift, however.

The correlation between night work and preterm birth was a surprise, and this information made the news in a big way. The authors caution, however, that further study is necessary to confirm these findings before any definite conclusions about this are made.

The information that work activity during pregnancy (lifting and standing) does not increase the risk of premature or SGA birth is good news. It will be useful information for women who are doing fine and want reassurance that their work activities are not likely to negatively affect their pregnancies.

But this great study did not address some of the more complex issues around pregnancy and work. What about common discomforts of pregnancy and the effect that work may have on them? Many women complain of fatigue, weakness, back pain, leg pain, abdominal pain, etc., and most believe that work worsens these complaints. While it may be true that these serious complications of pregnancy are not increased by working, it is my belief that many of these complaints are exacerbated by prolonged standing, lifting, exertion, and staying too long in one position.

And what about women who experience preterm contractions at work? This study does not suggest that pregnant patients and obstetricians should disregard these complaints and tell women to keep doing what they're doing that seems to increase uterine activity. Standard practice is to evaluate these patients for preterm labor and put them to rest. Most women with preterm contractions won't deliver prematurely, but right now, there's no effective way to tell who will deliver early and who won't. What we need is a study that compares our standard "go to bed and observe" policy with continued activity, but such a study will probably not be done because we always think we have to do something...

I'm not suggesting that this study should or could have answered all the questions about pregnancy, work, activity, and preterm birth. I'm grateful for the insight that this paper does provide. And I am also inspired by this opportunity to address the very real challenges that working women face when they're also pregnant. I believe that women need to face reality when it comes to their jobs and their pregnancies, and they need to put themselves in positions that allow flexibility and understanding of their potential needs. And, if more than two-thirds of pregnant women work these days, there is a huge opportunity for change in our workplace expectations, laws, disability policies, and compassion for pregnant women. Pregnancy is not an illness, it is a normal part of life, and it's challenges should be supported and celebrated - not stressed over.

RW, MD

Related Topics: Pregnancy Fitness, Preparing for Pregnancy Emotionally

Finding a Good OB for Your Pregnancy

2005-12-26T11:11:00.000-05:00

Pregnant women are always asking me how to find the best obstetrician to go to for their pregnancies and births. It's a great question, and the decision shouldn't be made lightly. The good news is that by doing a little homework and soul-searching early on, you'll be able to find the obstetrician who is right for you.

First, you'll need to get clear about what characteristics of a doctor are important to you. There are many personality types, philosophies, and styles of practice, and one doctor doesn't fit all. Many of today's obstetric practices are collaborative groups that include obstetricians (MDs or DOs), certified nurse-midwives, and nurse practitioners, and you may or may not be interested in the increased personal attention that midlevel providers (midwives) typically provide. And, you'll need to speak up and let your preferences be known, so your sources may point you in the right direction.

Before you get too far in your quest, you'll need to pay attention to your health plan's benefits and provider network. Some plans allow you to choose your practice among all those in your area; others may restrict your choices to a subset of participating providers. You'll need to check your benefits and network provider list. Depending on your circumstances, this might narrow down your search at the start. But, don't let these lists restrict you too much - sometimes it is worth a little extra out-of-pocket expense to go to a provider who is not on the list if the network can't meet your needs...

You might want to start by checking the referral sources that are available locally and on the Internet. Most ob groups only deliver at one hospital these days, so hospital affiliations are important. Call your local hospital(s) physician-finder line and ask for a list of obstetricians that use the hospital. Don't be satisfied with just one name: get the whole list of practices. You may also visit the American College of Obstetricians and Gynecologists or the American College of Nurse-Midwives websites to find OB practitioners in your area.

One of the best ways to find an obstetrician is to ask nurses. If you have any personal access to labor and delivery nurses, ask one or more of them off the record who she'd recommend. It has to be a private one-on-one conversation, though; simply calling the hospital and asking for a nurse will not result in a candid recommendation.

If nurses aren't available, you could get the names of childbirth educators, lactation consultants, or La Leche League leaders in your area. These women are usually well connected, and should have insight into the styles of practices in your area.

You may also rely on the recommendations of friends, family, or acquaintances, but be careful to be as objective as possible in evaluating these referrals to be sure the practices fit your needs. Many people are charged by birth stories, and, unfortunately, their referrals may be clouded by their own personal agendas. I do not mean to discount anyone's experience; it's just that their ideas may or may not be of value to you.

However easy or hard the process seems, know that, ultimately, the choice is yours. If you find yourself in a situation where your first doesn't choice doesn't meet your needs, don't hesitate to explore the option of switching practices during your pregnancy. You'll want to make the change as early as possible, though, so you'll have plenty of time to develop a relationship with your new doctor before your birth.

Most practices in this country are composed of doctors and other practitioners who practice "good medicine," so it's hard to go wrong as far as safety issues are concerned. But the important thing here is that you find a practice that suits your needs so that you feel well supported during your pregnancy and birth. I hope these words help you find the best doctor for yourself.

Best wishes for a healthy and happy pregnancy!

RW,MD

Related Topics: Choosing a Caregiver and Place to Give Birth, Questions to Ask Your Doctor or Midwife

What's Natural About Menopause?

2005-12-20T11:32:00.000-05:00

Several times a week I find myself sitting face-to-face with a patient who is experiencing menopausal symptoms and who is trying to decide what the right decision is to make regarding hormone therapy. Very frequently, the conversation centers around figuring out the most natural approach. I have realized that natural is open to interpretation, and that each woman must decide what's natural for her.

It's true: it's natural for a woman's fertility to end and for her ovaries to drastically reduce the amount of estrogen, progesterone, and other hormones when her ovulation stops. But, it's also natural to die shortly after menopause, because, let's face it, until the last century most women didn't make it much beyond the age of fifty if they managed to live that long.

So, the real decision becomes more a philosophical than a medical one, because, believe me, there is no good medical evidence out there to help a woman decide whether it's helpful or harmful to take natural human-equivalent hormone replacement. Of course it's natural to go through menopause and deal with the consequences of living without estrogen. But, how natural is it to live another forty or fifty years without the some of the good stuff that (arguably) makes a woman a woman? One could argue effectively, I believe, that it's unnatural to live up to half a life without hormones!

So, there's probably not a right answer for everyone regarding what to do about hormones. A woman has to get the facts that are available, evaluate her own experience and family history, and sometimes reach deep inside to find the answer to this challenge and to feel good about her decision.

I'm going to write a lot more here about human-equivalent hormone restoration and all the options that are available to women. It's a subject that I am passionate about, and I believe I offer a relatively unique refreshing enlightened approach for managing the challenges that women sometimes face in the menopausal and perimenopausal years.

All the best!

RW, MD

Related Topics: Hormone Replacement Q&A, Nutrition for Menopause

Pregnancy and Worry

2005-12-14T00:18:00.000-05:00

One of the challenges of my profession is dealing with the anxieties that naturally come up for women during their pregnancies. Sure, there are plenty of concerns that are natural for parents-to-be, and it is appropriate for us to address all issues sincerely and honestly without cynicism and with only the best intentions. But sometimes it seems that we are obsessed today with a compulsive perfectionism that is inappropriate under early-21st-century circumstances, and it seems that a good reality-check might be appropriate.

I have contemplated writing about this for quite some time. But I was challenged by the complexity of producing something readable that was both light-hearted and sincerely poignant. Needless to say, I was elated to find that MSNBC's Victoria Clayton was up to the task. She has done an excellent job in her article, The pregnancy panic attack, and I refer you to her for a wonderful discussion of the stress surrounding pregnancy.

There are a couple of points that I want to emphasize that may help to put prenatal anxiety into perspective:

There has never been a safer time for newborns and pregnant women in the history of the human race despite our concerns about stress, hard work, partying, obesity, environmental toxins, food additives, medical interventions, etc., etc., yet ...
Despite the relative safety surrounding pregnancy and childbirth today, 3% of babies are still affected with major congenital anomalies. This is a sobering fact that ought to serve to bring into perspective all the worrying we do about sometimes seemingly silly scenarios and unlikely outcomes. What's obvious is that most of the concerns that parents have about unwise or unintentional exposures to this and that, or whether they make the right choice about this test or that procedure, pale in comparison to the significant risk inherent in the decision to reproduce.

What I'm suggesting is that women (and their partners) should realize that they are choosing to accept some risks when they choose to become pregnant and continue a pregnancy, and that reproduction is not nearly a perfect exercise. Yet they should be powerfully optimistic about the probable outcome this day and age and not fall victim to needless preoccupation with unproductive worry. I believe that our consciousness does shape our experiences, and that couples who have positive outlooks will have wonderful families despite the details.

Now that I've managed to ramble on in seriousness, please re-read Victoria's column, and have a great day!

Happy Pregnancy and Happy Holidays!

RW, MD

Related Topics: Yoga in Pregnancy, Make the Best Choices for Your Baby