Mammograms, Evidence Based Medicine, Media, Politics,...

In 2002 the researchers of the WHI (Women's Health Initiative) held a press conference to announce to the world the results of their study. This was before any of their peers had a chance to review their results. They told us that they had prematurely halted the study on Hormone Replacement Therapy (HRT) because they had found a significant increase in the risk of heart disease, breast cancer and stroke in the treatment group.
The radio, TV and the internet were ablaze with outraged women that felt betrayed by their physicians who had obviously given them these poisonous pills for years. Many of my patients called our office to inform us that they were stopping their HRT. More than a few however called back a couple of months later to tell me that they were restarting them as life was unbearable with constant hot flushes, night sweats and mood swings.
Fast forward a few years and now these wonderful and informative studies have had a chance to be peer reviewed and a consensus has emerged.
There is no increased risk of the conditions mentioned above for about the first five years after menopause starts. The recommendation now is to only prescribe HRT to alleviate menopausal symptoms and at the lowest dose and for the shortest period of time (usually three to five years). These guidelines for some reason did not grab any headlines. If only we could convince a celebrity to say you could have wonderful sex, all day long if you take HRT according to these recommendations.
It appears that the history is repeating itself. The U.S Preventive Services Task Force (USPSTF) has recently issued its recommendations for screening for breast cancer. You cannot escape the headlines on TV, radio and newspapers. Blogs are also of course full of opinions on the matter. The fact that the American Cancer Society, American College of Obstetricians and Gynecologists and surprisingly! American Society of Radiologists have come out against these recommendations has only added fuel to the fire.
The major changes to the current practice are;

1. For women aged 40-49 individualize decision to begin biennial (every two years) screening according to the patient's context and values (family history, other risk factors, patient's desire, ...)
2. For women aged 50-74 screen every two years.

Again, as was the case with the WHI study the USPSTF have done a great job in studying the merits, risks and benefits of a very common screening program. Where this effort has failed, through no fault of its own is that it never had a chance to be appropriately peer reviewed and a consensus to be reached. This should have been done before the media had a chance to make a mockery of it and the Congress to feel obliged to step in.
A screening program must meet the following criteria;

1. The disease in question should constitute a significant public health problem, meaning that it is a common condition with significant morbidity and mortality.
2. The disease should have a readily available treatment with a potential for cure that increases with early detection.
3. The test for the disease must be capable of detecting a high proportion of disease in its preclinical state, be safe to administer, be reasonable in cost, lead to demonstrated improved health outcomes, be widely available, as must the interventions that follow a positive result.

Adequacy of a screening test should not be based on anecdotal evidence or questionable expert opinions. Everyone can remember an uncle or a grandfather that lived to be ninety despite smoking a pack a day. It doesn't make smoking safe. This brings me to my favorite Hippocrates quote;
"There are in fact two things, science and opinion the former begets knowledge, the latter ignorance."
My patients have started asking me about these new recommendations and for now I'm telling them that I'll wait for the dust to settle and for knowledge to overcome ignorance.

How Can I Get Pregnant?...NOW!

The glint in the husband’s eyes is unmistakable as I explain the frequency with which the couple needs to have sex to increase the likelihood of getting pregnant. My patient on the other hand looks a little more skeptical. It is as though she wants to make sure this is not the result of some male conspiracy or that her spouse didn’t call me before the appointment to arrange for this advice!

For numerous patients, planning a pregnancy is a conscious decision that usually leads to behavior and lifestyle modifications. It is however unlike most other conscious decisions in our lives in that we have less control over when it may happen.

“Finish college at 21. Take a year out and travel before graduate school. Get married at 26. Get stabilized at work and married life for one to two years. Get pregnant around August so can have baby in Spring and not be pregnant when it is too hot outside!” This is how many of us try to plan our lives and for the most part we manage to stick with the agenda until it comes to the last item on the list. This lack of control can lead to anxiety and feelings that something must be wrong.

The scenario can be a familiar one. The first month is all very exciting. The couple have sex as they are advised. They both try to delay doing the home pregnancy test until at least an hour after she would have expected her period to come. Most however can’t even wait that long. They start a day or two before. Squinting their eyes as they look closer at the test strip for any faint positive signs. Then they reassure each other that they tested too early. I bet one or both of them later goes and retrieves the test strip from the garbage can just to make sure. The disappointment is clear when her period starts.

By the third month, the excitement of having sex prescribed by your doctor is all but gone. Instead, having sex is about achieving results. It is about ovulation kits, temperature spikes and the consistency of cervical mucus. All of which are, no doubt, very well known aphrodisiacs!

Anxious thoughts and insecurities begin to creep in. She feels less of a woman and him less of a man. “Maybe you need to relax. You’re too stressed.” “Maybe you need to take this more seriously". "What if something’s wrong?"

Most pregnancies happen during the first six months of trying to get pregnant. Overall, after 12 months of unprotected sex, approximately 85 percent of couples will become pregnant. Over the next 36 months, approximately 50 percent of remaining couples will go on to conceive spontaneously. This entire group is considered to have “normal fertility”. The approximately 10% that are remaining may need evaluation for decreased fertility.

Having this knowledge doesn’t necessarily make dealing with disappointments any easier. It is important for a couple to sit down before they start and discuss their approach and their goals. Having a strong foundation built on communication and mutual support will certainly help. It is important to include your healthcare provider in your discussions. He or she can make sure that you are in optimal physical and emotional health before starting on this very exciting journey.

Miscarriage- Tragedy of Now...Hope for the Future

My heart sinks almost immediately after I start the trans-vaginal ultrasound. I desperately look for a flicker or a movement where the heart beat would be.

At the same time my mind is rehearsing what I may have to say. “I’m sorry but the pregnancy has stopped growing”. No, that doesn’t make sense. “I’m sorry but the baby has passed away”. Don’t like that either.

What do I say? She should be about 7 weeks pregnant. Just missed her period a couple of weeks ago. Like most couples they didn’t want to allow themselves to get too excited. I am sure however, that like most couples from the moment the home pregnancy test gave them the positive signal, the cautious day dreaming began. What names for boys and girls? Which color for the baby’s room? Daycare or babysitter at home?

“I am very sorry but I don’t see a heart beat on ultrasound today”. I then explain the miscarriage process but mainly try to listen.

This is not something that is usually taught very well in medical schools. I made mistakes at the beginning of my career and placed my foot several times in my mouth before settling into what I know now.

What I have learned over the years is to separate the tragedy of the moment from the hope for the future. Too many people resort to minimizing the emotional effects of an early miscarriage as a way to comfort the grieving couple.

All the stages of grief apply to an early pregnancy loss, from denial and guilt through to acceptance and hope. It is not unusual to feel isolated with these emotions because the couple may not know anyone else who has had a miscarriage. It is not exactly a topic that comes up often during dinner parties and family gatherings.

Unfortunately miscarriages are very common. Approximately 15% of known pregnancies will end up in a miscarriage. However if you include all the pregnancies that are lost before a woman even misses a period, the number is a staggering 50%. Most of these are due to chromosomal abnormalities which are sporadic in nature. This means that in most cases it appears to be a chance event.

“Is it because of something that I did or didn’t do, maybe something I ate?” The feeling of guilt is inevitable. You cannot cause a miscarriage by lifting something heavy or having sex and no it wasn’t that second glass of wine you had before you knew you were pregnant. The list goes on.

As reassuring as it is to know that the woman did not cause this miscarriage, it is disturbing to live with the lack of control. “How can I make sure that this does not happen again?”

There are a few things that can help minimize the risk of having a miscarriage. The most important thing is to be in an optimal state of health. If you have chronic illnesses such as diabetes they should be well controlled. With the help of your provider you can identify any environmental factors such as excess alcohol and cigarette smoking. You will probably need practical help to manage both of these habits.

There are some suggestions that moderate consumption of caffeine may increase the risk of miscarriage in the first trimester.  One cup of coffee a day should not pose an increased risk, as long as you take into account your entire intake of caffeine (including that in caffeinated sodas).

Guess what?! Exercise is good for you! As long as your provider has not identified any reason why you cannot exercise, it has been shown that not only is it safe but it may lower the risk of miscarriages.

Despite all of these adjustments there are a minority of women that experience recurrent early pregnancy losses. The guidelines at this time recommend starting to look for potential reasons after two to three consecutive miscarriages. I’ll leave this topic for another day.

I have been present and shared this emotionally devastating time with a few of my patients. I have also been privileged and have had the pleasure to deliver their healthy newborns sometime later. I cannot help but wish that I had the power to show them the future as a way to ease their pain. But I can't. I know that for now we should mourn the loss.

Labor Pains- Natural Birth? I Hope Nobody Reads This!

If nobody reads this, maybe we can continue to label those women that say they want to have natural birth as a bunch of hippies and wierdos. Then when we fail to provide them with resources to maximize their chances of achieving what they want, we won't feel as bad. Great idea!
If nobody reads this, maybe we can continue to smile knowingly everytime we meet someone who wants to try labor without an epidural.We can continue to make mental bets on how long they will last. After all, what else is there to offer them?
If nobody reads this, maybe when our patients say they want to try natural birth we can go on telling them, "sure just come in on the day and we'll see how you manage!".
Perhaps many of those that want to have a natural birth like the idea of it but don't want to put much time and effort into preparing for it anyway. I tried this philosophy on running the marathon once. It didn't work out too well!
The question is, who has time for all of this when things seem to be working just fine? How can change happen?

If we really wanted to make a change, we would initially create a sense of urgency. Then we would put together a guiding team that would include patients, physicians, midwives, nurses, hospitals etc. (if you can't tell, I've just read "Our Iceberg is Melting" by John Kotter!). The solutions would be decided upon as a TEAM.
Since no one will hopefully reads this, I can be honest and say that many women who choose a non-pharmacologic approach to pain management are often ill-prepared. Some of the ones that succeed look at the pain as a side-effect of a normal process (labor). They may even say crazy things like they felt "able to transcend their pain and experience a sense of strength and profound psychological and spiritual comfort during labor". Yeah! Whatever!
So what are some of the things that we do know about this option?
In contrast to epidurals, the primary goal is not to make the pain disappear. Instead, the woman is educated and assisted by her caregivers, childbirth educators, and support people to take an active role in decision-making and using self-comforting techniques and nonpharmacologic methods to relieve pain and enhance labor experience. If a woman after a few hours in labor decides to get an epidural it is not a sign of failure. For some, just the ability to walk around for a period of time and feel more in control can be very satisfying.
The birth environment and continuous labor support from the father, family member or doula are very important aspects of this approach. A doula that is familiar with the family and the physician can provide tremendous support. A prior meeting or discussion will make sure that everyone shares the same mental model of what to expect when the time comes.
These are some of the options for non-pharmacologic pain management in labor even with the system that we have in place now;
Water Immersion: Many women find the feeling of being immersed in warm water very comforting and relaxing especially in the beginning phases of labor. It has been shown that in "low risk" pregnancies this is a safe practice.
Sterile Water Injection: Also called a "water block", usually involves four small injections in the skin of the back to primarily relieve pain in that area. The injections can be painful but the relief can last 45 to 120 minutes.
Touch and Massage: Women clearly appreciate these and they appear to reduce pain and enhance feelings of well-being.
Acupuncture and Acupressure: As long as this approach is performed by trained practitioners it seems to be safe and provides a great deal of satisfaction to those that have tried it. It remains to be seen how it can be integrated in healthcare institutions.
Hypnosis: Hypnosis used for childbirth is almost always self-hypnosis; the hypnotherapist teaches the woman to induce the hypnotic state in herself during labor. Sometimes her partner is taught to signal her into the hypnotic state. I have seen the positive effects of this technique in my patients that I have referred to Dr Jay Stone. He makes his materials available on line at http://www.drjaystone.com/ .

There are many techniques that can help decrease the pain of labor and sometimes eliminate the need for epidurals and medications. Not all of them may be available or appropriate depending on the risk level of the pregnancy. Most of these methods need a good deal of preparation and time investment by the woman and everyone involved in her care. Although our current system is not fully set up to support these approaches it doesn't mean that they are completely out of reach.

It does seem like a lot of work though! Like I said I'm glad nobody's gonna read this.

Labor Pains- Epidural, Neither Demon Nor Savior

A knight in shining armor, the anesthesiologist gallops away on his white horse after saving yet another lady from the throes of pain!

When the epidural works as it is supposed to this or a similar scene is what comes to mind. The fact that the anesthesiologist is the hero in this scenario doesn't bother me. Really, I'm not jealous! Even though un-scientific polls (conducted by me) show that most women would prefer to see their dentist rather than their gynecologist. I know that I will never experience a gyne exam but less popular than dental work? When I see my dentist I have what seems like a large and noisy Black & Decker drill excavating my tooth, shaking me to the core while flying debris land on my face and glasses. This all as I'm trying to watch Oprah on the tiny sized TV mounted high in the corner. It may be my only opportunity to learn what she is telling my patients to ask me. I'm not angry. I'm just sayin'!

Please ignore my digression. This post is not about exulting the virtues of epidurals but hopefully giving you an idea of what we know of it's benefits and disadvantages and perhaps dispelling some myths.


Lets start with benefits:

Epidurals have been shown to be more effective in relieving pain and have less of an effect on the baby than some of the intravenous medications. Their placement is usually easy and despite some women's fears not very painful. Depending on availability some may be able to walk with the epidural in place but in practice most women rest in bed. There is also the possibility of patient controlled epidurals where you control the amount of medication flowing through the pump.


Now disadvantages:

You may have heard that epidurals slow down the process of labor. This indeed appears to be true. Studies show that it can prolong labor by 40-90 minutes. There are also some conflicting data about the fact that it may increase the need for instrumental (vacuum or forceps) delivery.
A more common but usually minor risk is that epidurals can cause a headache. This commonly resolves within days and rarely requires an intervention called a "blood patch".

There are times that epidurals are ineffective or only partially effective. This does not happen very often but understandably can create a great deal of anxiety and panic. Some of my patients say that they want to be "drugged up" so they won't feel any pain. It is important to emphasize the other options for pain relief and provide tremendous coaching and support in case the epidural is unavailable or is ineffective.


How about myths:

Some of my patients make their minds up very early on that they will not consider an epidural under any circumstances. Unfortunately many times this is not a choice based on accurate information but rather myths perpetuated by friends and family members. One of the most prevalent is that epidurals cause chronic back pain. This has been shown not to be the case. The risk of developing back pain is the same whether you receive an epidural or not.

Another common but erroneous perception is that an epidural may not be placed until cervical dilatation has reached four centimeters. The view of ACOG (American College of Obstetricians and Gynecologists) is that "women in labor should not be required to reach 4–5 cm of cervical dilatation before receiving epidural analgesia".



Epidural analgesia is a safe and effective option for pain relief in labor. You need to approach this choice as you would any other medical procedure. Ask questions, discuss with your physician or midwife and consider the risks, benefits and other alternatives. This post is certainly not meant to be comprehensive but only to provide an overview and a starting point for discussion. In subsequent posts we will look at some other options to consider and they probably will not involve anesthesiologists or dentists!

To look at the ACOG patient education pamphlet on "Pain Relief During Labor and Delivery" go to:
http://www.acog.org/publications/patient_education/bp086.cfm

Labor Pains-Regain Control

"A large number of women want to avoid pain. Some just don't fancy the pain [of childbirth]. More women should be prepared to withstand pain… pain in labour is a purposeful, useful thing…such as preparing a mother for the responsibility of nurturing a newborn baby," (Dr Denis Walsh-Associate Professor of Midwifery, United Kingdom, July 2009).
OMG! (Oh my god!) WITRMBSATITDAA?! (Who in their right mind believes such a thing in this day and age?)
I feel a little nervous starting a series of blogs about labor pain management. The discussion many times becomes overwhelmed by extremes of beliefs that accuse each other of often untrue and imagined practices. On one side are those that passionately advocate for natural, unmedicated labor and on the other those that believe medicalized pain relief is often the best choice for most women. The former at its extremes paints a picture of scalpel wielding, episiotomy cutting physicians who want to expedite delivery in time for the first “tee-off”. The latter on the other hand portrays an image of incense burning, oil rubbing midwives who would go beyond the boundaries of safety to achieve natural birth.
In my experience neither of these portrayals is anywhere near accurate. However it’s the extremes that grab the headlines and leave pregnant women confused and sometimes forced to choose sides.
Forgive my slight detour but this is very similar to our current debate on healthcare reform. If one listens to the loudest voices the choices are either granny killing death panels on one side or gun toting poor people haters on the other. The majority of us want to hear a reasonable mature discussion where all sides are heard and acknowledged, (I know people tell me I’m naive!).
Over the next couple of blogs I will discuss what options may be available to manage pain during labor. From medications and epidurals to meditation and guided imagery. Whatever pain management technique you may be drawn to, knowledge is empowering.
Some of my patients tell me that they are used to being in control and are fearful that they have none when it comes to pain in childbirth. In my opinion, control is a function of knowledge and together with your readings (but not googling at random!) and discussions with your healthcare provider team you will feel in charge. It is important for you and your healthcare provider team to have a “shared mental model”. This means that all of you agree on a common goal: a healthy baby with a healthy and happy mom.

Weight loss after childbirth

We were two weeks away from her due date when my patient asked me how soon after the delivery she could start exercising again. It came as a bit of a surprise since up until that point my efforts to encourage physical activity had for the most part been ignored. She was concerned about losing her pregnancy weight.
We discussed that exercise after childbirth is safe and is important. The timing to some extent depends on the mode of delivery. That means whether the delivery was vaginal or through a cesarean section. Most physicians recommend six to eight weeks of recovery time after a cesarean section. After a vaginal delivery the timing depends on how the mother feels but probably two to four weeks after delivery would be reasonable. If the delivery happened to be complicated by tears or episiotomies then a discussion with the physician or the midwife is warranted.
Many women enjoy and relish the transformation that their bodies go through during pregnancy. Most of them however cannot wait to get back to their pre-pregnancy or even lower weight. That’s why I am asked a similar question quite a lot.
According to the Cochrane library review of the literature, weight retention after pregnancy can contribute to obesity. It is suggested that women who return to their pre-pregnancy weight by about six months have a lower risk of being overweight ten years later.
This review also indicates that probably a sensible approach would be to achieve this weight loss through a combination of diet and exercise.
Diet in this case does not mean severe calorie restriction. In order to see a sensible approach go to http://womenshealth.about.com/cs/breastfeeding/a/nursingdiet.htm .
Since my children were born I have tried to do something that doesn’t always come naturally. I have tried to exercise regularly and with a smile on my face! This is for the hope that they will see this as a normal part of daily living and not a torture to be endured either for health or weight loss.
I am a firm believer that starting your exercise routine in the postpartum period will help you reach your pre-pregnancy weight as well as act as a life lesson for your newborn.

Life after baby

Our son was born on September 5th 2001 at 10pm and the next six weeks seemed much tougher than either one of us had expected.
I am an obstetrician and therefore used to being up at all times of the night. Prior to the arrival of my son I would dismiss comments such as “you better catch up on your sleep while you can”. After all I had been through a tough obstetric residency and how much worse could this really be.
My wife had to be induced and so we didn’t really sleep much the night before the delivery. We were just too excited. This would eventually add to our feeling of total exhaustion by the time our son was born. I clearly could not have been nearly as tired as my wife (before anybody comments that I wasn’t the one who carried and pushed the baby out!).
Our son was 8lbs 11oz and because of his size needed some supplementation with formula immediately after delivery. This was so that his blood sugar wouldn’t drop. My wife wanted to breast feed and I told her that this shouldn’t cause any problems. I was categorically contradicted in the morning by our nurse who told us that she could not breast feed since our son was used to the bottle now. Our son had “nipple confusion”. My wife burst into tears since we had clearly failed as parents and he wasn’t even a day old.
I was recruited to clear my son’s confusion. I had a syringe full of milk draped over my shoulder which was attached to capillary tubing. This tube rested on my pinky which was meant to imitate a nipple. Perhaps if I wasn’t as tired I would have protested a little more emphatically. As it was we kept trying and eventually were sent home.
The constant attention that the little person needed was shocking. Days and nights blended into each other and for the first couple of days neither one of us wanted to admit how overwhelmed we were. Then we felt guilty if we did acknowledge how hard this was. This would mean we were unfit parents. After all when you have your baby you are supposed to be overjoyed and walking around with a constant smile on your face. You know like the ones on the cover of magazines.
Thankfully at the same time I found a support group. Not an official one but a group of wonderful physicians who used to supervise residents with me one afternoon a week. They all had children of different ages and told me that neither our experience nor our feelings were unique. It was just unbelievable that no one talks more openly about how overwhelming being a new parent can be.
Since then I try not to forget to have a talk with first time parents before they deliver. I still see that look in the faces of many women when they come back to see me after the delivery. That pale and sleepy look. They tell me how tired and overwhelmed they feel but after every sentence remind me that they love their child. As if to make sure that I don’t judge them for complaining. I tell them our story and that they are not alone. I also recommend mom and baby support groups.
Sometimes the feelings of anxiety and sadness last beyond the first few days and weeks and that is the time to call your doctor or midwife to make sure you are not suffering from postpartum depression.
Our son is soon to be eight and we have a daughter who is five. It would be silly to try and find a word that describes how much we love them. We gladly work hard to take care of them and appreciate everyday what they have added to our lives. We also make sure to tell expecting parents that the first few weeks can be tough.

HPV: To be or not to be tested

What is HPV?
In the United States, the most commonly diagnosed sexually transmitted infection is human papillomavirus (HPV). An estimated 80 percent of sexually active adults in the U.S. will acquire HPV infection prior to the age of 50 (Reichman, 2009). The source of transmission is usually without symptoms and is unaware that he/she has been infected. There are many different types of HPV. Certain types can cause genital warts, and others can lead to cervical cancer.

Risk factors
The following predisposes one to infection with HPV: early onset of intercourse, multiple sex partners over time, and having sexual partners who have had multiple partners (Sirovich, B., Feldman, S., & Goodman, A., 2009). Cigarette smoking and immunosuppression increases the risk of cervical cancer (Sirovich et al, 2009).

Screening
The Pap smear is a screening test that can identify changes in your cervical cells that are caused by HPV infection. It is estimated that more than half of women who develop cervical cancer either have never had a pap smear, have been screened on an irregular basis, or have not been screened within the previous five years (Sirovich et al, 2009). The current recommendation is for women to initiate annual pap smears beginning three years after the onset of intercourse or at the age of 21, whichever comes first. “The effectiveness of Pap smear screening also hinges on adequate follow-up and treatment for abnormal results” (Sirovich et al, 2009, p. 11).

What can you do to prevent HPV?
A vaccine has been approved for girls, age 9-26. This vaccine protects against four different types of HPV, two of which put a woman at increased risk for cervical cancer and two that cause genital warts.
The only way to prevent HPV is to abstain from intercourse. Utilization of condoms with intercourse, if used all of the time and in the correct manner, may lower the risk of developing HPV.
Limit the number of sex partners.
Cervical cancer can be prevented with routine screening (pap smears) and prompt follow-up of abnormal results.
Avoid cigarette smoking.
Lead a healthy lifestyle w/ diet rich in fruits, vegetables, lean meats and exercise.

Should I tell my partner?
Talking to your sexual partner about HPV is a personal decision. If you do, recall that:
-By the time your infection with HPV was found, your partner was already exposed.
-Once a particular virus has been shared through sexual contact, the risk of passing the infection back and forth is gone.
-It is nearly impossible to determine who gave you HPV or when you were first infected. -The HPV infection could have been from your current partner or any of your past partners.
-If your partner is male, at this time there is no approved testing for HPV in men.

Should I be tested for HPV?
I am sure you have seen plenty of ads for HPV vaccine and HPV testing. You must be wondering if your doctor is testing you or not. At this time there are two options in the American College of Obstetricians and Gynecologists guidelines for women over the age of 30;
1-Continue annual pap smears and perform HPV only if pap smear shows ASCUS which means it is hard to determine if there is definitely an abnormality present or not.
2-Perform HPV with every pap smear. If they are both normal you don't need a pap smear for 3 years(even though you need a pelvic exam every year). If pap smear is normal but high risk HPV is positive you need anther pap smear in 1 year.
Are you confused?!
As you can see there are different ways of making sure we reduce the risk of developing cervical cancer. You and your physician should collaborate and make sure that you are being followed by one of these approved guidelines.

Eden Takhsh M.D.
Elizabeth Torres APN
Kimberly Alton APN