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Thursday, September 29, 2011

Pregnancy is a Great Time to Quit Smoking

She showed up on the labor and delivery unit one Saturday morning on my watch, and I will never forget that day.  The woman was young, and her mother was with her for what they thought would be an ordinary labor - they could not have been more tragically wrong. She reported that she was having contractions but really hadn't felt the baby move for quite some time.  I noted that the chart said she smoked cigarettes throughout the pregnancy despite repeated counseling to quit.  It didn't take long for me to figure out why her baby hadn't been kicking...thank God her mother was there to bring an element of emotional support because this was likely going to be the worst day of their lives.

How do you tell someone that the baby they were so eagerly awaiting will be stillborn?  You cry and find a way to get them through it.  Perhaps tragedies like this one can be avoided with better education of young mothers-to-be regarding the very real and devastating effects of using tobacco products while pregnant.

Quitting smoking is no easy task, but it turns out that pregnancy is not only the most important time of a woman's life to quit, but it is also one of the easiest of times.  Every woman wants a great pregnancy outcome, and therefore, the motivation to quit is built-in.  Motivation to put that pack down is a major hurdle, and even people who have had major health issues such as a heart attack or stroke don't necessarily find that internal drive to stop what is clearly exacerbating their disease and risk of death.

Pregnant women can feel that motivational force literally kicking them in the gut every day.  Statistics show that 46% of women who smoke before they realize that they are pregnant can quit successfully such that the overall rate of smoking during pregnancy has declined from 18% in 1990 to about 13% in 2006.  Optimally, this should be zero.

There are important fetal and maternal health risks that can be directly attributed to the use of tobacco products including smokeless tobacco.  Babies rely on the placental blood flow for oxygen exchange, but that blood flow is compromised when nicotine is on board because of nicotine's effects on blood vessels.  The constriction of flow through the vessels can ultimately lead to restricted growth of the baby as well as sudden death in-utero.  No one wants to hear that their baby could die if they smoke during pregnancy, and I never enjoy talking about it...but the truth must not be suppressed.  Tobacco products during pregnancy are dangerous for both mother and baby.

The young woman in my story had actually suffered what is known as placental abruption, which translates into at least a portion of the life-giving placenta separating from the wall of the womb.  This results in loss of blood flow directly to the baby and subsequent loss of life.   Placental abruption can be equally catastrophic for the mother since major hemorrhage to the point of requiring blood transfusions is sometimes associated with these events.  The chance of abruption is hugely increased by smoking as is the risk of a very low birthweight baby and even sudden infant death syndrome (SIDS).  It is well known that children born to mothers who smoke have a much higher risk of asthma, colic and childhood obesity.

So what is the best way to quit?  Smoking cessation methods of all kinds are used in pregnancy including occasional need for medication (use must be balanced against the potential medication risks to the baby) along with counseling, cognitive and behavioral therapy sessions, hypnosis, acupuncture - the non-pharmacological measures clearly have no adverse affects on the baby.  But none of these adjuncts to quitting will work well without the motivation of the mother to be successful.  Want to quit?  No better time than when a baby's life is on the line.

Thursday, September 22, 2011

Birth Control Pills take a bite out of Ovarian Cancer Risk

Who knew?  Those packs of pills you took for all those years before and between kids turn out to provide an amazing long-term health benefit.  Studies prove that a woman's risk of developing ovarian cancer in her lifetime is cut virtually in half by pill use for at least 5 years in her life.  I just think that's awesome.  Despite so many medical advances, there is still little or no way to predict which women will grow a cancerous tumor from their ovaries, so any news about prevention is welcome.  Hereditary ovarian cancer is not actually the most common cause despite what most people think.  Plus, it is not uncommon for women to mistake the fact that their close family member had benign cysts of the ovaries or endometriosis and not cancer.  Cancer of the cervix or having an abnormal Pap test have no bearing on ovarian disease at all.

Although oral contraceptives can have a downside or even be inadvisable for women with certain health problems, they are mostly without any significant drawbacks to daily, continuous use.  There is no need for, nor benefit of taking a "pill holiday."  Researchers feel that it is the continuous suppression of the normal ovarian cyclic function that accrues cancer risk.  The specific type of pill and dose of estrogen or progestin does not seem to make a difference.  The relationship between oral contraceptive use and breast cancer is muddy, and there are a few studies that show some increase in risk and others that show absolutely no change in overall risk.  The NIH published a nice fact-sheet on this.

For women who have a first degree relative with ovarian cancer (mother or sister), getting genetic testing for BRCA 1 and 2 gene mutation is an option.  The presence of this BRCA mutation greatly increases the risk of breast and ovarian malignancy in that woman's lifetime.  She may be recommended to have removal of both ovaries at a relatively young age (once childbearing is complete if desired) in an effort to reduce the risk.  Some of those at-risk women are placed on birth control pills until such time as they want to conceive because of the clear benefit for the rest of her life.

Women's Health Hub

Tuesday, September 20, 2011

Infertility 101

One of the most heartbreaking situations for a gynecologist is to have a patient who strongly wants to have a baby but who has not been able to either conceive or to carry a pregnancy to term.  After a time of trying, desperation sets in and couples tend to seek the care of a physician.  They can begin with a consultation with a general gynecologist for the basic initial evaluation, but if no results are realized after a reasonable amount of effort with the simple measures, couples may need to step up to specialty care with a reproductive endocrinologist (RE).

Infertility is defined as the inability to conceive despite at least a year of concerted effort, but older couples (35 years and up) might not want to wait that long before getting some medical assistance.  There is a subcategory for women who actually can conceive but who cannot continue the pregnancy beyond a certain point (i.e. repetitive miscarriages).  About 10% of couples have some sort of fertility issue, and approx. 20% of the time, it is actually a problem with the male partner.  Female infertility is divided into multiple potential causes including tubal factor (i.e. the fallopian tubes become blocked because of infection or injury), ovulatory factor (the ovaries fail to produce  or eject a viable egg), cervical factor (sperm can't get past that point of entry) and unknown causes.  The latter is unfortunately a rather common diagnosis at all.

It is for the more difficult cases that assisted reproductive techniques are most helpful.  But first, the doctor will explore the general health of the partners.  Issues like smoking, excessive drinking and use of drugs clearly are contributing factors to infertility.  The female exam consists of a general physical, updated Pap test, cultures of the cervix for infection, and blood tests for thyroid function among other things.  Male factor infertility should also include a good general physical, but the one key test is a semen analysis.  Sperm can be less than optimal in number and quality, and the semen test will help sort that out and point the way to the appropriate treatment.

In any given menstrual cycle, women have about a 20% chance of conceiving, but those odds get worse as she ages beyond her early 30's.  So waiting too long to start trying to have a baby is one of the most common reasons that women don't get to realize their dream of having a family.

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The Mayo Clinic Infertility Page

Monday, September 19, 2011

IUD for birth it safe?

Why would anyone want an intrauterine device?  Wasn’t there some big-deal lawsuit over IUDs-gone-wrong a while back?  I can answer in one sentence:  modern IUDs are safe, effective to protect against unwanted pregnancy, and they have advanced well beyond the old Dalkon Shield device that spawned a class-action suit. on.

The new IUDs come in two basic forms: hormone containing and non-hormone containing.  The former lasts a total of 5 years and the latter can stay in place for 10 years.  The infection rate is astonishingly low for both, as are the pregnancy rates.  But there are reasons to choose one above the other and reasons not to choose an IUD at all depending upon individual risk factors.  So you’ll have to ask your doctor if an IUD is right for you (I couldn’t resist putting that in).

Women with enlarged uteruses due to fibroids or other pathology, and women with undiagnosed irregular/abnormal uterine bleeding are not good candidates for an IUD.  But once their abnormal bleeding has been investigated and cancer ruled out, they could still consider using one of these devices.  A simple office procedure known as endometrial biopsy can help sort that out.

Those who have multiple sexual partners and who may therefore be more at risk for sexually transmitted infections are not advised to use an intrauterine device.  The device has an attached string that sits just outside the cervix at the top of the vagina, and if bacteria, particularly gonorrhea or chlamydia are introduced from a partner, the bacteria can travel directly into the uterine cavity and result in a major pelvic infection known as PID (pelvic inflammatory disease).

Women who have never had a baby might not want to go through the extra bit of discomfort with IUD insertion through their relatively narrow cervical canal, but they are certainly still considered viable candidates to use this method. 

And what about that discomfort?  Some people choose to take something containing ibuprofen (Motrin) prior to have an IUD inserted just to cut down on the cramping of the uterine wall as the device settles in the center of the cavity.  But in truth, the procedure can be very quick such that premedication is not necessary.  That’s an individual choice.

The hormonal IUD, commercially marketed as Mirena, is the most popular IUD right now.  It can actually stop menstrual flow altogether or at least significantly cut down on the total number of bleeding days.  The progesterone component in the center of this soft, flexible device inhibits the regrowth of the uterine lining each month such that there really isn’t much tissue to slough off in each cycle.  The drawback is that some women have very irregular spotting on this method, and this might be annoying enough to cause them to discontinue use.

The Parguard, a copper IUD, has absolutely no hormonal component.  Menses tend to be unaffected by the presence of the device although some women experience an overall increase in the flow.  The biggest plus for this one is the 10-year staying power.  At the end of that interval, the old one can be removed and replaced with a new IUD at the same time.

Now all these features sound good, but surely there is a drawback to using IUDs.  If I had to name one thing that bothers me the most, it would be the risk of perforation of the uterine wall (as can happen with a difficult insertion) that could land that IUD in the abdominal cavity where it can wreck havoc with the bowels, bladder and other innocent tissues residing in its path.  This is a rare occurrence, but it can happen to anyone.  The signs would be inability to feel the string protruding from the cervix shortly after the device has been placed in the doctor’s office.  Pain is another sign that the IUD is not in the right location; however, cramping is such a common event immediately following the procedure that it would be difficult to sort out what is happening without the benefit of an exam by a provider.

Overall, I believe the modern IUDs are worth looking into if you are searching for a more long-term birth control option and hate to have to deal with taking a pill every day.  The manufacturers have user-friendly websites with a lot of product information and testimonials to help make an informed choice.  Link to more information about contraceptive options.

Sunday, September 18, 2011

What about that HPV Vaccine?

The vaccine to protect against human papilloma virus (HPV) in girls and boys has recently been at the forefront of the news media for reasons that I won't comment on here.  But it reminds me to address the two vaccines that are currently FDA-approved for use against this common, multi-strained, skin virus to help lower the incidence of cervical cancer among women.

HPV comes in many forms (over 100 known strains), but only a select few actually cause dangerous health risks.  Plantar warts are a good example of how HPV can be annoying without being flat-out dangerous - HPV type 1, 2,4 and 63 are thought to cause these growths on the sole of the foot.  But for cervical cancer risk, there are 12 or 13 bad actors.  Of those dozen or so, two are notorious: HPV 16 and 18.  These two strains are the only "high risk" strains covered by either of the two commercially available HPV vaccines today.

The vaccine that was first marketed with FDA approval was Gardasil, by Merck & Company.  Gardasil covers not only HPV 16 and 18, but it also blocks types 6 and 11 of HPV - those latter two strains cause annoying, but not dangerous, genital warts.  The Gardasil vaccine requires three separate shots to be given over the course of 6 months for girls/women ages 9-26 (and now boys, too).  The second vaccine to come to market was Cervarix, by GlaxoSmithKline, which covers only HPV 16 and 18.  It also requires three separate doses at roughly the same intervals as its competitor.

Both of these vaccines are considered very safe and very effective, and time will be the judge regarding how many fewer cases of cervical cancer will result from aggressive vaccination now in the approved age-group.

One of the most concerning things that I have noticed recently is the emergence of "scare videos" and blogs that give inaccurate information about the risks of either of these vaccine series.  The actual number of adverse effects that can truly be attributed to the vaccines are few and far between.  There are a number of anti-vaccine groups and individuals whose sole purpose is seemingly to discredit ANY vaccine for any disease across the globe.

I felt strongly enough about the health benefits of administering the series of shots that I gave them to my own daughters.  HPV exposure at some point in a woman's life from her partner(s) is a virtual 100% reality - only those people who remain completely celibate for their entire lives can be certain that  they have no risk.

Women's Health Hubs

Friday, September 16, 2011

Get Off That Couch!

Any dieting activity goes only so far in improving general  fitness, and without the addition of REGULAR exercise ( by regular, I mean DAILY exercise) you are doomed to fail.  Sure, people can lose weight with just calorie-cutting, but that is only going to help up to a point.  Drastic calorie reduction will slow your metabolism and make it harder to burn fat over time.  The body’s metabolic rate depends on the overall activity level, and if you spend all day sitting down or barely moving in your job, you must find time to work out. 

How to find the time?  Look at what time you usually get up and what time you have to be at work.  If you normally rise at 6 am to be at work by 8, then get up at 5:30 instead.  Spend 30 minutes engaged in any sort of exercise routine, and be sure to add in a brief warm-up and cool-down.  The warm-up/cool-down for a limited 20-minute workout in front of an aerobics video doesn’t need more than 5 minutes for each.  You still have plenty of time to shower, dress and eat before you have to punch the clock.

The key is to do whatever it is that you decide is a good “exercise” activity for you everyday regardless of whether or not it’s a weekend day, a holiday or if you are out of town.  Once you program your brain to follow this pattern, it becomes ever easier to accomplish.  In fact, once this habit forms, you might actually feel remorse when you miss a day!

Women's Health Hub

Thursday, September 15, 2011

Living at Mosquito Junction

Itch/scratch, itch/scratch...everyday I find new places on my body where the mosquitoes have taken a bit of my DNA.  There are always hoards of these pests in the summer/fall in eastern North Carolina, but the past few weeks have been much worse than usual.  Likely, that is because of hurricane Irene's recent passage and the standing water in her wake.  As I scratched, I began to worry about the chances of getting West Nile Virus (WNV)...seems like it is always more of a problem after tropical systems move through.

The Center for Disease Control (CDC) noticed that the cases of WNV doubled after hurricane Katrina hit, and they highly recommend that communities spend some time and money spraying.  And the CDC definitely recommends that people liberally and regularly use insect repellent when working or playing outdoors.  They give DEET and Oil of Lemon Eucalyptus (sounds intriguing) as examples of safe and effective ingredients to look for in the products available.

So why bother to be aggressive at fighting the mosquito attack?  The answer is that WNV can be deadly.  Older people are more vulnerable to the severe manifestation of WNV, which affects only about 1 out of every 150 infected people.  Most people have NO symptoms at all (80%) and up to 20% have minor, flu-like symptoms including fever, aches, nausea and a rash.  It can take a couple of weeks after an encounter with an infected mosquito before noticing any symptoms, and there really isn't any treatment other than supportive care for the symptoms!  Bummer...

So prevention, as usual, is always best....spray on!

Women's Health Hub

Wednesday, September 14, 2011

Breast Cancer Awareness

A few years ago, I lost one of my cherished friends to breast cancer.  I watched her go through chemo regimens and even bone marrow transplant only to ultimately have the disease claim her life.  It was heartbreaking for her family and friends, and her light in this world is sorely missed.  As I remember her life and her friendship, I am inspired to remind all women to be proactive in their pursuit of breast health.  So are mammograms still the best way to find cancer?  Don't we have something better by now?  Well, not really.
Mammograms, MRIs, ultrasounds….with such a dizzying array of tests for breast disease from which to choose, how do we know what is best for early detection of breast cancer?  The short answer is that mammography remains the simplest, cheapest most effective breast screening tool in our medical arsenal.  But there are some situations that women should know about that might make additional testing appropriate for their particular situation.
An estimated one in eight women are diagnosed with breast cancer in their lifetime.  Screening for detection of the disease before it spreads to other parts of the body is the most effective way to beat breast cancer, and women must not become complacent in getting tested at the recommended intervals.   In addition to the mammogram, a breast examination by a health care provider (clinical breast exam) has traditionally been part of the well-woman’s annual exam along with breast self-exam.  
Magnetic resonance imaging (MRI) has come into more common use in detecting breast disease, but it is still not recommended for the average woman as a routine screening test.  It has issues of false positive results as well as the potential to miss an early lesion that mammogram would otherwise pick up.  MRI can be used in some cases as an adjunct to regular mammogram particularly in women who have already had breast cancer in one breast, women with breast implants and women with very high risk of breast cancer based on their history.
The American College of Obstetricians and Gynecologists has stated that they will continue to recommend the screening mammography every year for women beginning at age 40.  They also feel that breast self examination has potential benefit along with periodic clinical breast examinations starting at age 20.  When to initiate mammogram screening and how often should be a topic of discussion between a woman and her health care provider based on that woman’s individual risk factors and desires for testing.
Ultrasound technology can be used in conjunction with mammograms for further evaluating areas of concern, and needle biopsy of a solid tumor or sucking out fluid from a cystic mass can then be performed.  A good use of ultrasound is when a breast lump is actually able to be felt on clinical exam.
Even better than early detection would be prevention of breast cancer, and there are clearly steps that women can take to lower their overall risk.  Studies have shown that overweight women, women who consume two or more alcoholic beverages a day and those with diets containing a high amount of animal fat have a substantial increase in the baseline risk of breast cancer.  In overweight women who can decrease their weight by twenty or more pounds (and keep it off), there is a forty percent risk reduction for breast cancer…so go for it!

Women's Health Hub