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Monday, April 9, 2012

Smoke-free Workplace?

Public buildings in the United States are smoke-free for the most part because there is general consensus that exposure to the smoke from another person's tobacco product could cause respiratory problems in susceptible people such as asthmatics and children.  Hotel rooms have the smoke-free option, and even bars are mostly non-smoking these days.

But what if it's not enough?  Research has shown that so called "third-hand" smoke, the residue of exhaled second-hand smoke, is actually quite a health hazard that must be addressed.  So simple banning of smoking in buildings will not necessarily protect the rest of us from what comes in on a smoker's skin and clothing after they smoke outside or in their car.

In 2010, a study by a group of environmental scientists showed that when residual nicotine reacts with other chemicals (mainly nitrous acid), it forms cancer-causing agents known as TSNAs, or tobacco-specific nitrosamines.  Nitrous acid is found naturally in the environment as well as in association with gas appliances indoors.  This interaction has the effect of producing potent carcinogens.

All non-smokers are familiar with that stale odor in a house, hotel room or car where a smoker has preceded them even if it has been days, weeks or months since anyone has actually lit up.  It can be nauseating and annoying, but more importantly, it can contribute to disease with repeated exposure over time - this environmental science study confirms that potential.

Infants and toddlers are potentially more at risk for exposure to these toxins than the rest of us - we hold a baby close to our chest where the residue of a recently extinguished cigarette still clings to our clothing; we let our toddler crawl on the carpet that has years of toxic chemical one wants to cause harm to a child, and most smokers would have absolutely no idea that this silent exposure is happening.

The current policies of banning smoking within so many feet of a building are at least better than no policy at all, but unless there is some way to decontaminate clothing and objects that accompany the smoker through their day, the rest of us may not escape at least some exposure to the third-hand carcinogenic agents.

Sunday, March 18, 2012

DVT: Are you at risk?

Deep vein thrombosis, aka DVT, sounds as ominous as it is dangerous.  Women are at particular risk because of hormone factors, but it is really a risk for anyone who is overweight, diabetic, smokes, has had recent major surgery or is otherwise leading an immobile lifestyle.  There are actually many additional risks including family history of clotting disorders, chronic diseases of all types, and cancer.

The problem is a huge one that mostly affects the veins in the deep part of the lower legs.  A clot forming in that venous system initially causes pain and swelling because of the blockage of back flow of blood.  Later, all or part of that original clot can break free and travel to the lungs where it becomes a pulmonary embolus, a potentially deadly phenomenon. 

Birth control pills, patches and rings as well as hormone replacement therapies containing estrogen add to other risk factors in women to make DVT probability rise, and some risk factors, such as smoking and inactivity, are in our control.  I recently interviewed a woman who, at age 48, was placed on continuous oral contraceptive pills to help her heavy menstrual bleeding.  She didn't admit to the prescribing physician that she was continuing to smoke cigarettes because she knew the doctor would refuse to prescribe the pills for her....for a good reason. The doctor didn't want to be responsible for a major complication.  I had no idea that someone would purposefully put their own life at risk!

Needless to say, I educated her on the incredible risk of combining cigarettes with oral contraceptive pills in someone her age.  Women under the age of 35 are not at as great a risk for DVT if they smoke while using birth control pills, but I always recommend smoking cessation.  You can assess your risk for DVT at

Saturday, February 11, 2012

Myth Buster: Plan B is NOT an Abortion Pill!

I was catching up on the news headlines, and something struck me about the discussions surrounding the so-called "morning-after" pills including the brand name Plan B (there are a couple of other brands).  The commentators seemed to be telling us that these pills are the same as abortion-inducing pills like RU-486 (mifepristone).  This is a complete misrepresentation of the facts, so I felt the need to bust that myth.

The currently marketed formulations that are FDA-approved for use as emergency contraceptives contain only the hormone progesterone.  This is an important female hormone for regulation of the menstrual cycle, and it can inhibit/counteract the effects of estrogen.  Ovulation (the regular release of an egg from an ovary) depends upon a delicate balance between estrogen and progesterone during the month, and any disruption in that balance will inhibit the egg release and movement through the fallopian tube where it might meet sperm and be fertilized - i.e. conception.  This mechanism of action is significantly different from that of the abortion-inducing medication.

Mifepristone is an antagonist to progesterone, and it blocks the beneficial, pregnancy-preserving affects of that hormone.  It can disrupt an established pregnancy (one that has implanted on the uterine wall and is growing) simply by virtue of the fact that the developing pregnancy requires progesterone.  In contradistinction to that, the progesterone-containing "morning-after" pills cannot disrupt an established pregnancy and therefore cannot induce an abortion.

Emergency contraception is not a good substitute for regular use of any method of birth control because it is more unreliable at preventing the undesired pregnancy, and there may be more side-effects than standard birth control pills, patches, rings, injections, etc.  However, as a rescue method, and when taken within an optimal window of 72 hours following intercourse, these pills are an good option.  Women who are personally opposed to abortion need not fear that this is the way that these pills work.

Monday, January 2, 2012

Endometriosis and Chronic Pelvic Pain

If I had to give a single disease process besides cancer in women that I would like to see abolished, it would be endometriosis.  A chronic, non-lethal disease of the female pelvis, endometriosis is a process whereby the cells that usually are confined to the uterine lining (glandular cells) somehow grow and invade tissues outside the uterus.  The result over the course of years can be debilitating pain.

Retrograde Menstrual Flow
 No one really understands the actual cause of endometriosis, but there is speculation that there is some hereditary component because mothers/daughters sometimes follow a similar path in their reproductive years.  Retrograde menstruation (bleeding backward through the fallopian tubes) potentially plays a role in this disease.  The fact is, there aren't many facts about endometriosis other than it is a very common cause of chronic pelvic pain as well as a contributor to infertility. 

 Women who ultimately are diagnosed with endometriosis often can track their symptoms back as far as their teenage years.  Their menstrual flow may have perpetually been heavy and painful.  Later, the pain dissociates from the menstrual flow days so as to be more notable just before the period and reach a crescendo during the period.  The key is that the pain is cyclic in nature in the beginning.  As the process of endometrial implants progresses within the pelvis, there is progressive scarring often found behind the uterus and around the ovaries that causes painful intercourse.  Some women even notice the same pain when inserting tampons or when moving their bowels.

Endometriosis Nodules Behind the Uterus

The diagnosis of this process if best done with a surgical procedure known as laparoscopy.  The surgeon can view the pelvic tissues with a magnifying scope and take pictures to document the extent of the scar tissue.  Ultrasound and MRI can give clues to the presence of endometriosis, but the laparoscope remains the definitive way to know for sure.

Treatment consists of suppressing the ovaries, which are integral to this whole pathway of pain.  The ovarian estrogen stimulates the growth and spread of the endometrial implants, and by keeping the ovaries quiescent, the disease process is slowed.  Pregnancy does the same thing, but no one is advocating that women pursue having a baby as a means of battling their pain!  Medications that can stop the progression of endometriosis are available for that.

Depolupron, a gonadotropin (sex hormone) releasing hormone substance is often used to put the ovaries into a temporary menopause state such that active endometriosis is arrested and healing can take place.  This therapy can be followed by continuous birth control pills, patches, rings, etc. in an effort to continue to suppression of the ovaries and the menses.  Surgery to remove active endometriosis lesions in the pelvis, especially endometriosis cysts of the ovary (chocolate cysts) is very helpful but clearly a more invasive way to treat then simply using a medication.  A new indication for the class of drugs known as aromatase inhibitors may be for those patients who fail to respond to the usual therapies for this problem, but that is still being studied at this point.

The most invasive treatment of severe endometriosis causing debilitating pelvic pain is to remove not only the uterus to relieve the bleeding but also both ovaries to eliminate the chance of ongoing pain and scarring.  If even a portion of an ovary is left in place when endometriosis is present, the disease is technically still there.  There can be reactivation of the pain/scarring cycle at any time even when the uterus is absent.  So the decision to go for major surgery for endometriosis is a big decision indeed.  If  you have cyclical pelvic pain and particularly heavy, irregular or painful menstrual flow, please consult your health care provider to find the cause and explore your options.

Sunday, December 11, 2011

Herpes Vaccine? Maybe One Day...

People don't talk about it much because it has such a huge emotional impact, but herpes simplex virus (HSV) is also a huge health problem throughout the world.  As many as 1 in every 5 people has potentially been exposed to HSV, and their immune response to that exposure can be determined with a blood test.  But unfortunately, that immune response in the form of antibodies does not "cure" the virus.  The viral particles live on in the nerve roots and continue to reassert themselves in the form of blisters on the genital skin or cold sores on the lips or mouth off an on throughout that persons lifetime.  Genital herpes, generally caused by HSV type 2 (type 1 causes most fever blisters/cold sores), is clearly more stigmatized, and plenty of people who have this problem don't even realize what it is.  Thus, the cycle of spreading the virus via intimate contact goes on.

How can the cycle be broken?  Since protective barriers such as condoms fail to cover enough skin to do the job, and since many people shed viral particles from their skin even with no visible sores present, the clear choice of how to avoid the problem of HSV exposure would be a vaccination.  Vaccine development has been ongoing and is currently being evaluated as to actual effectiveness in disease prevention.  It appears that the vaccine has more potential effectiveness in women than in men, and the immunity it affords women seems to be we're not there yet.

Those who already suffer with HSV outbreaks would not benefit from a vaccine in any case.  They are left with managing their outbreaks by various measures including decreasing their stress levels and taking a daily dose of a suppressing prescription anti-viral medication.  There are several good choices on the market that have been used for years with success, but clearly, it would be better not to have to deal with this problem at all.

Saturday, December 3, 2011

Bacterial Vaginosis

Riddle me this: what is it that women get that is somewhat like a yeast infection, often confused with a bladder infection and scary for being a sexually transmitted disease?

Answer: Bacterial Vaginosis (BV)

Bacterial vaginosis is actually more commonly found on exam than yeast vaginitis, but the symptoms are distinct and the treatment is 180 degrees different for each.  Bladder infections are not even in the same ballpark, but when a woman gets symptoms in the vulvo-vaginal area, sometimes it's tough to make the call about where the problem resides.  Sometimes the only thing my patient can tell me is that something just isn't right in that area of the body!

But once a person realizes exactly which symptoms go with which problem, it's fairly straight-forward.  For yeast, the hallmark symptom beyond the presence of a discharge is irritation and/or itching.  With bacterial vaginosis, those are not nearly as much in the picture.  There is minimal inflammatory response from the vaginal lining cells (mucosa), and so one of the main symptoms is the volume of watery-gray/white drainage.  Usually, it has an odor that people describe as "fishy" because of the effects of the bacterial metabolism.  That's usually what brings them into my office.

Bacteria are normal in the vagina, but there is a certain type that is native - these are called lactobacilli - they literally are "good" bacteria and help maintain healthy vaginal acidity and prevent the overgrowth of "bad" or non-native bacteria.  Those "bad" ones are really usually from another part of the person's anatomy such as skin and anus/rectum....I know...yuck!  But still, at least they are one's own bacteria, for better or worse.  The trouble comes when there are just too many of the abnormal bacteria such that the lactobacilli can't keep cleaning up.

Some tactics to keep the vaginal pH on the acid side are to use over-the-counter vaginal acidifying products like "Rephresh" - I have no proof that this particular product works, but the concept is sound.  Also, using some type of antibacterial wet-wipe when toileting can reduce the overall bacterial load so close to the vaginal opening.  Some of these products can be irritating and overly drying to the delicate skin in that zone, so you have to be choosy about which product you would use.  Douching is a definite no-go...these "treatments" actually do more harm than good as far as promoting healthy pH and lactobacilli.

Intercourse does play a role in BV in that seminal fluid would potentially change the pH to less acidic and promote the conduction of a woman's own bacteria from a location outside the vagina to the inside.  But strictly speaking, BV is not a sexually transmitted infection like gonorrhea, trichomonas or chlamydia.  We really don't treat the male partner of a woman with even chronic or recurrent bouts of bacterial vaginosis, but we might tell the couple to try using condoms to see if that helps.

Diagnosis of BV happens in the doctor's office (not over the phone) where a simple preparation of cells from a vaginal swab can be analysed with a microscope.  This will reveal whether or not there is overgrowth of abnormal bacterial relative to a less than normal complement of lactobacilli, a mixed infection with yeast or the presence of those pesky (and very strange looking) trichomonads.  The acidity of the discharge can also be directly tested.

Treatment is in the form of cream, gel or tablet depending upon the patient's choice and any allergies to medication that might be present.  I lean toward topical vaginal gel because it tends to hit the problem right at the source without disturbing the whole intestinal tract with antibiotic insult (like diarrhea or nausea).  Also, the topical agent known as Metrogel is supposed to help preserve the "good" bacteria relative to the evil ones!

If BV is a recurrent issue month after month, I sometimes use a monthly regimen of medication timed for use around the menses since that seems to coincide with the onset of odor and discharge.  I have the person use the medication for about 5 days each month on a cyclic basis for several months in a row while they also try the other measures that I mentioned above.

BV is aggressively treated in pregnant women because it has a known association with preterm contractions/preterm labor, but in non-pregnant women (except for those undergoing a gynecological surgery such as hysterectomy), it tends to be more of a nuisance.  There is evidence that the presence of bacterial vaginosis can predispose women to sexually transmitted infections including it's best to treat rather than to simply hope for things to get better on their own.

Saturday, November 19, 2011

Early Pregnancy Loss

Pregnancy is an emotional roller-coaster under the best of circumstances, but when you add some problems with bleeding early on, every woman will wonder "am I having a miscarriage."  Sometimes, the person is already emotionally invested in the pregnancy and has told multiple friends and family, so if an early pregnancy loss occurs, that attachment and connection with family can double the pain.  
Pregnancy loss in the first trimester can happen in 20% of all recognized pregnancies. Most will occur before 13 weeks, and actually, the majority will happen prior to 8 weeks. Some women won't even recognize that they are pregnant, believing that their menses has just come a little late and is heavier than normal for them when in actuality, it is a very early pregnancy failure.  The cause of such early losses is thought to be largely due to chromosomal problems in the developing embryo.  This does not usually mean that the woman or her partner have a genetic disorder (although it can signify that such a problem exists in rare cases).  Typically, it is a random event in nature whereby the tissue was not going to develop properly into a baby that can survive, and miscarriage is nature's way of disallowing the pregnancy beyond a very early phase of life.  The chance of early miscarriage due to chromosomal problems increases with increasing age of the woman.
Other factors can put a woman more at risk for pregnancy loss prior to the second trimester including untreated thyroid disease, diabetes, high blood pressure, and rheumatologic or autoimmune diseases like lupus.  Clearly, most women who seek to have a baby despite having any of those diagnoses can do so without a miscarriage, but the risk does increase nevertheless.
The signs of early pregnancy loss include bleeding and cramping; but some women will have absolutely no clue that their pregnancy has arrested in development until long after the event occurs.  Typically, a woman will miss her regular menses, which will prompt her to do a urine pregnancy test at home.  She would then begin the process of initiating a doctor's visit to confirm the positive result and date the pregnancy.  The gestational age is based on the first day of the last menses, and there are online pregnancy calculators to help figure that out.  Usually at around the 8th to 10th week of gestation, the woman is having her first health provider visit including a physical exam to determine the uterine size and potentially listen for a fetal heartbeat with a Doppler device.  If the gestational age is supposed to be over 10 weeks, but no heart beat is located, an ultrasound can be done to look for a heartbeat in the developing embryo.

The hardest thing in the world is to be the one holding that ultrasound and having to tell an expectant mother and her partner that the pregnancy has ended...the tears might not come immediately, but the grief process for early miscarriage of pregnancy is exactly the same as for other losses of life for many couples.  It is important to offer grief counseling to couples going through this emotional time and to be sensitive to their issues.