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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. 

Saturday, November 5, 2011

New Treatment for Genital Warts


Dangerous? No...Unpleasant?  Yes!
External genital warts are common, but since they sometimes have no symptoms, people may not even notice them.  When someone IS symptomatic, they get just a little freaked out when their health care provider tells them "it's genital warts."  The nomenclature just sounds bad...but really, this is another skin manifestation of certain strains of the human papilloma virus (HPV) that is passed from one person to another by direct contact. 

Usually, the skin at the point of entry of the virus has had some trauma that opens the door for the virus to invade into the skin layers.  The viral particles can then set up shop with their DNA and replicate, replicate, replicate.  After a while, the host's immune system will overpower the virus and kick it out.  The process of becoming infected and realizing that there are warts can take weeks to months or even years if the virus is dormant for a time.  The process of immune elimination is at least 6 months.  Certain factors make people more susceptible to this viral invasion including having a history of herpes simplex virus, HIV, immune suppression from medications or chronic disease and the like.  Pregnancy is included in the relative immunosuppression category of people, so pregnant women can frequently see a dramatic increase in wart size.

The HPV vaccine Gardasil offers immunity to the two most commonly associated subtypes of HPV (type 6 and 11) such that exposure from an infected partner will not result in transmission of the virus.  This will help those young women who have been vaccinated (ages 9-26), but for older women, the warts are a source of embarrassment - they don't even want to talk to their gynecologist about it.  But there are several excellent treatments available to shorten the number of weeks of symptomatic warts.

The older tried and true therapies included chemical acid agents to literally burn the warts.  Also, super-freezing the lesions is effective (cryotherapy).  But those involve multiple office visits for treatment.  Most women prefer to self-treat in the privacy of their home.  Home therapy with application of an immune system stimulating cream known as Aldara is effective, and now there is a botanical cream that has emerged on the market.

The new agent goes by the trade name of Veregen, and the proprietary ingredient is green tea.  Yes, that's right, yet another use for green tea to improve health.  I was as surprised as anyone to see that this product has not only gained FDA approval for use against genital warts, but it also has the support of the CDC.  The sinecatechins topical 15% cream is applied three times a day to the affected skin lesions for up to 16 weeks (the usual duration is 12 weeks).  Regression of the warts is progressive over that time.  Like most things, there is always the potential for a side reaction, and in the case of Veregen, skin irritation, redness, swelling and ulceration have been seen.  Nevertheless, this new therapy offers a "natural" solution to HPV-induced warts.