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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.