Mammogram or not to mammogram

For years women have been taught the great importance of doing a breast exam on a monthly basis and the need for annual mammograms >40 years old. Well, the USPSTF (U.S. Preventative Service Task Force) just recently recommended a drastic change from the norm. The new recommendations are as follows:

• The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. (grade C recommendation)
  


• The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. (grade B recommendation)
  


• The USPSTF recommends against teaching breast self-examination (BSE). (grade D recommendation)

So let me throw in my two point five, two, seven, five cents :) The argument for / against mammograms has been an issue for years. The major issue is that the number of women that need to be screened to save one life is around 2000. In addition along the way several women will have to deal with the scare of breast cancer and may have an unnecessary breast biopsy. The question... is the scare worth the life of one woman? I am convinced that if it is my wife, mother, aunt, grandmother, sister it is worth the scare.

Now it is beyond me why I, as a medical professional (in particular an OB/GYN), would choose to not teach a woman how to do her own breast exam. The fact that you have the knowledge base and are aware of what to bring to a physician's attention is key to early detection in my eyes.

Of course I will take a second to educate. Remember that the breast tissue is shaped like a tear drop. The tail points toward the arm pit (this is called the tail of Spence). The tail region and directly underneath the nipple are the high risk areas for breast cancer.

So here are my recommendations

1. Learn how to do a breast exam and do it on a monthly basis
2. In agreement with ACOG ( http://www.acog.org/from_home/Misc/uspstfResponse.cfm ) continue having your mammogram every 1-2 yrs age 40 - 49 and annually 50+ yrs

As always feel free to ask any questions.

I'm Pregnant with H1N1....Help!!

This has probably been the craziest flu season in a long time for patients and practitioners alike. In April 2009, when the first reported cases of the H1N1 novel virus hit the news I'm sure that no one could have anticipated how wide spread this problem would be.

I thought that I would make my comeback blog one that would dealt with a specific question concerning H1N1. What do you do if you are pregnant and have a confirmed diagnosis of H1N1? First lets establish the ground rules. As a physician I will suspect that a patient has the flu if they have:

• fever
• chills
• headache
• upper respiratory symptoms (cough, sore throat, running nose)
• muscle aches
• joint aches
• fatigue
• Nausea/Vomiting/Diarrhea (these symptoms are not very common with the seasonal flu)

After you have raised my suspicion I will swab your nose and send it for Influenza A &B. You may not know that the H1N1 is a variant of the Influenza A. The whole swine flu thing came from the fact that pigs can be infected by several different strains of influenza (bird, human, ducks, etc...). When you have a single host with several different viral strains a NEW (or NOVEL) strain can emerge that has not been seen before. This is part of the theory behind or 2009 flu virus.

If you are sick (see the above symptoms) the first thing to do is C A L L your OB doc. Right now ER's and Urgent care facilities are becoming a melding pot for sick patients. If your symptoms are mild and you don't have the following problems:

• Difficulty breathing
  
• Chest pain
• Persistent vomiting
  
• High fever not responding to Tylenol
• Baby moving much less or no movement

then the best thing to do is stay at home. You will need to be started on Tamiflu (this will help you fight the infection). Stay hydrated, get rest, and use Tylenol for symptom relief. If symptoms worsen and you experience the above then you must be seen quickly. We are trying to avoid pneumonia or other complications of the flu.

Handwashing is key. And if you are sneezing and coughing a lot then a face mask will probably be helpful for you to wear to decrease exposure to your family.

Breastfeeding (for the mom who has delivered) is a toss up. Thus far no one has brought any definitive proof showing that you should not breast feed your baby. The risk is that you could pass the virus to your newborn because of having an active infection. But we know that sooooo many good things are available in breast milk that not passing that on to the baby would be a crime. You can also use Tamiflu while you are breastfeeding.

Lastly, please...please...please get the H1N1 flu vaccine (the injection NOT the flu mist).

Would I give my daughter Gardasil?

Ok. This is a hot topic right now and getting plenty of press so I might as well jump on the bandwagon and throw out my two and a half cents.

Just as a little background, Gardasil hit the market in 2006 with much fanfare. The idea of vaccinating little girls and potentially little boys against high risk HPV (human papilloma virus) subtypes to prevent the sexually transmitted infection that causes cervical cancer. At one point the state of Texas had legislation heading to the books that would have made the vaccine mandatory for school-aged children.

The vaccine is effective against subtypes of the virus 6, 11, 16, 18. The first two are responsible for genital warts primarily whereas the last two are the major culprits behind agressive dysplasia (abnormally growing cells) and cervical cancer (the outcome if left unchecked). In 2008 there was approx. 11,000 new cases of cervical cancer. The pap smear has become one of the single most effective screening tools in modern medicine and has moved cervical cancer out of the top 3 causes of cancer related deaths for women. So the most natural step would be to try and prevent the known culprit from even getting a head start.

Now if you read my last blog about Herpes you know that it is very easy to spread STDs. It could not be any easier than with HPV. There is currently no testing for HPV in men and therefore no way to find out who is carrying the aggressive strain of the virus and stay away from him. The best way is to stay abstinent until marriage and then stay faithful to your spouse but of course this is not the way our free society views sex (sorry about the soap box...I'll put it away now).

------------------------------------------------------------------
According to the package insert from Merck:

Serious Adverse Reactions in the Entire Study Population
A total of 237 subjects out of 25,274 total subjects (9- through 45-year-old girls and women; and 9-through 15-year-old boys) who received both GARDASIL (N = 13,686) and AAHS control (N = 11,004) orsaline placebo (N = 584) reported a serious systemic adverse reaction following any vaccination visit during the clinical trials for GARDASIL.
Out of the entire study population (25,274 subjects), only 0.05% of the reported serious systemic
adverse reactions were judged to be vaccine related by the study investigator. The most frequently reportedserious systemic adverse reactions for GARDASIL compared to AAHS control or saline placebo and regardless of causality were:
Headache [0.02% GARDASIL (3 cases) vs. 0.02% AAHS Control (2 cases)],
Gastroenteritis [0.02% GARDASIL (3 cases) vs. 0.02% AAHS Control (2 cases)],
Appendicitis [0.03% GARDASIL (4 cases) vs. 0.01% AAHS Control (1 case)],
Pelvic inflammatory disease [0.02% GARDASIL (3 cases) vs. 0.04% AAHS Control (4 cases)],
Urinary tract infection [0.02% GARDASIL (2 cases) vs. 0.02% AAHS Control (2 cases)],
Pneumonia [0.02% GARDASIL (2 cases) vs. 0.02% AAHS Control (2 cases)],
Pyelonephritis [0.02% GARDASIL (2 cases) vs. 0.03% AAHS Control (3 cases)],
Pulmonary embolism [0.02% GARDASIL (2 cases) vs. 0.02% AAHS Control (2 cases)].

Deaths in the Entire Study Population
Across the clinical studies, 24 deaths were reported in 25,274 (GARDASIL N = 13,686; AAHS Control N= 11,004, saline placebo N = 584) subjects (9- through 45-year-old girls and women; and 9- through 15-year-old boys). The events reported were consistent with events expected in healthy adolescent and adult populations. The most common cause of death was motor vehicle accident (4 subjects who received GARDASIL and 3 AAHS Control subjects), followed by overdose/suicide (2 subjects who received GARDASIL and 2 subjects who received AAHS Control), and pulmonary embolus/deep vein thrombosis (1 subject who received GARDASIL and 1 AAHS Control subject). In addition, there were 2 cases of sepsis, 1 case of pancreatic cancer, 1 case of arrhythmia, 1 case of pulmonary tuberculosis, 1 case of hyperthyroidism, 1 case of post-operative pulmonary embolism and acute renal failure, and 1 case of systemic lupus erythematosus in the group that received GARDASIL; 1 case of asphyxia, and 1 case of
acute lymphocytic leukemia in the AAHS Control; and 1 case of medulloblastoma in the saline placebo group.
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In the past year there has been much horrible press for Merck. Gardasil has been "associated with" several adverse events from painful injection sites, neurologic issues, immune disease, blood clots, pulmonary embolism, and death. I used the "quotes" because there has not been any 1:1 correlation between the vaccine and death. The CDC is standing by the statement that Gardasil is safe and the risk outweigh the benefits. To date there are approx 12,000 adverse events reported of which a few deaths have been included.

The question is does the overall good that the vaccine can bring to millions outweigh the small percentage of bad outcomes?

Well if it were my daughter I would say.... NO! Even though I truly believe that this is a giant leap forward for prevention of cervical cancer I can't, in good conscience, tell my daughter or my patients to get the vaccine.

A quiet epidemic

First of all, sorry for the delay in posting. I've been a little busy and haven't had the time to post. I thought that this would be a good topic and will definitely get you thinking.



Genital herpes is probably one of the most quiet epidemics in the U.S. to date. CDC states that that approx. 1:4 women are positive for herpes (1:8 for the men). One of the reasons that I believe that this disease continues to propagate is because there is no mandate to screen patients.



The disease is one that takes about 2 weeks to present itself after initial exposure. The problem is that only about 25% of infected patients will have the classic painful ulceration that will drive them to the doctor's office. The remainder of the patients will not have a single classic symptom. As a matter of fact the symptoms that most patients will have are similar to that of a yeast infection (women) or jock itch (men). What I have found in my office is that this is exactly what is happening on a daily basis. We have, in the past year to year and a half, started offering a full STD screening that includes herpes (Gonorrhea, Chlamydia, Trichomonas, Syphillis, Hepatitis, HIV, and Herpes). Just as an aside, if you haven't had blood testing for STD screening you probably haven't been tested for the last four diseases.



Now, the problem with offering testing for herpes is not the patient that comes in with problems but it is the patient who is asymptomatic. My problem has been telling a 43 year woman with no symptoms that she is positive for herpes. How does she tell her significant other, lover, husband that she is positive? When I have posed the question to some of my medical colleagues about screening the response has been, "Why open a can of worms?" For the asymptomatic patient why should she be screened for a disease process that may never cause her a single problem in her life (remember that the majority of patients will be asymptomatic)? The answer is HIV. Wait, wait, wait... I thought that we were talking about HSV (herpes)! HSV can increase any patient's susceptibility being infected with HIV. The thought is that because of the lesions the virus has a easier access.



Let's throw another wrench in the thinking. Herpes is classically understood to be classified as HSV-1 (oral) and HSV-2 (genital). It does not take a rocket scientist to understand this concept: anyone who participates in oral sex makes theirself a candidate for a outbreak of HSV-1 on their genitals. I bring this thought up because most would consider a new outbreak of herpes as a sign of infidelity of their partner. The truth is that the outbreak may be a HSV-1 or HSV-2. I adamantly oppose telling any patient that their partner has been unfaithful based on a positive test or symptoms pointing towards herpes. The reality is that the patient could have been infected with their first sexual experience.



So what's my recommendation? If you have been with one partner for the past several years and have never had a single outbreak don't run to the doctor to try and find out your status. Why?... Ignorance can be bliss in this situation. If you are positive more than likely your partner is positive and neither one of you can get more positive. What I have seen more than once is strife and fear being brought into a situtation that need not happen. Now if you are planning to hit the dating scene it would behoove you to know what you are bringing to the bedroom. For my patient's that either practice serial monogamy or that ... well don't I want them to know where they stand.



[At the risk of sounding preachy I must fall back to the biblical principal of one husband and wife concept. It's old fashioned but if you have a true covenant between the two this won't be a concern.]

New Guidelines for Pap Smears

Ok, I know that getting a pap smear is about as exciting as a root canal (personally I've never had either :), but when you go to your local gynecologist there is something new you should ask for if you are 30 or older. Ask for HPV genotyping with your pap.

HPV (human papilloma virus) made a big splash on the marketing venues with the release of the vaccine Gardasil (if you haven't been to the web site click on the link...very interactive and informative). Up until March 2009 when the FDA approve a new test the only thing that we as physicians were concerned about was the entire group of high risk strains of HPV. It is well established that the most virulent strains are 16 and 18.

The FDA approved Cervista:

Descriptions of New FDA-approved HPV DNA Tests

In March 2009 the FDA announced approval for clinical use in the U.S. of two new HPV DNA diagnostic
tests.

• One of these tests is designed to identify 14 high risk types of HPV. These include the 13 types detected by the Hybrid Capture® 2 HPV DNA Assay (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68) as well as HPV 66. This test will be marketed under the name Cervista™ HPV HR. The other test is designed to specifically detect HPV 16 and HPV 18 and will be marketed under the name Cervista™ HPV 16/18. Both tests utilize an isothermal enzymatic DNA amplification process with a fluorescent read out and both are approved for use with ThinPrep® samples. They were developed by Third Wave Technologies which was acquired in 2008 by Hologic Inc., the manufacturer of the ThinPrep® Pap test.
  

FDA Approved Indications

• The FDA-approved clinical indications for Cervista™ HPV HR are similar to those of the Hybrid Capture® 2HPV DNA Assay. These are:
  

1. To screen patients with ASC-US cervical cytology results to determine the need for referral to colposcopy.
2. Used adjunctively with cervical cytology to screen women 30 years and older to assess the presence or absence of high-risk HPV types.
   

The FDA-approved indications for the Cervista™ HPV 16/18 test are:

1. In women 30 years and older the test may be used adjunctively with the Cervista™ HPV HR test in combination with cervical cytology to assess the presence or absence of specific high-risk HPV types.
2. Used adjunctively with the Cervista™ HPV HR test in patients with ASC-US cervical cytology results, to assess the presence or absence of specific high-risk HPV types. The results of this test are not intended to prevent women from proceeding to colposcopy

Succintly put: In a low risk 30+ y/o female the new guidelines are to perform a thin prep pap accompanied by Cervista. If the patient has a negative pap and a +screening for cervista (i.e. the presence of 16 or 18) then she should have a colposcopy done to look for cervical dysplasia. Because of the genotyping we are able to pick out the women that will be at highest risk for cervical dysplasia and/or cancer.

So when you go back for your ANNUAL (put it big letters so you don't forget to call for an appointment) ask for HPV typing if you are 30 or over.

Polycystic Ovarian Syndrome ??

I've gotten a couple questions about this one topic of polycystic ovarian syndrome (PCOS) and decided to blog on the topic.

PCOS is a grouping of problems under one name. The average patient with PCOS usually presents to the doc with the c/o infertility. The (textbook) patient is usually overweight (BMI >30), hairy (in the sense that she has more male pattern hair distribution (see woman on

the left), has an ultrasound showing polycystic ovaries (see the image)

and the hallmark is the fact that she has very irregular periods. The irregularity of the cycles is what is the central visible problem that the patient notices. She will have complaints that she misses several monthly cycles at a time.

Behind the scenes the patient has the following problems

• Borderline diabetic state (if not fully diabetic): high insulin levels
• Increased levels of male hormones (i.e. Testosterone and it precursors)
• And the possibility of leading to other health issues: increased cholesterol and hypertension (take a look at Metabolic syndrome)

Now although the goal of most of the patients is either to: get pregnant or have a regular cycle there are several goals that the gynecologist would have.

1. Weight loss (obesity is the cornerstone of several preventable diseases)
2. Diagnosis and then the subsequent control of diabetes
3. Blood pressure control if it has become a problem
4. Monitoring of lipids
5. Testing for pre-cancerous (hyperplasia) endometrium (the lining on the inside of the uterus, this is what sloughs off each month and becomes the menstrual cycle) because the patient can have several months of anovulatory bleeding (basically bleeding that is not controlled by a normal cycle: these patients are not releasing an egg each month and will subsequently have an overgrowth of the endometrium) that can lead to endometrial cancer.

PCOS is a complex but yet conquerable disease process that you and your GYN should talk about if you feel I'm describing you.

Induction of Labor

Induction of Labor (IOL)

Many times I have heard and seen my birthing community cringe at the mention of the IOL as if it is some type of @#!@# word. Induction of labor is a very useful tool in the hands of the gentle OB. I will admit that the use of IOL has definitely gotten OB's in trouble several times but I want to give my guidelines for the usuage.

Indications: simply put, a solid medical reason. Whether my mom has Pre-Eclampsia, the scare of it via elevated BP's (150's+ SBP or 100+ DBP), uncontrolled diabetes (gestational or pre-exsiting), cardiac disease, IUGR, oligohydramnios, too mention a few off the top of my head. I feel as though under circumstances where the potential is harm to mom and/or baby this is a no-brainer. As with the process of Pre-E the outcome can be so devastating (Hypertensive disease is the #1 cause of maternal mortality) that anything less than delivery would constitute mal practice.

Now where the argument arises in the community is the idea of elective IOL. Here is where I will expose myself (cover your eyes :). I have yielded to the crying, sobbing, and pitful mom who is begging to be done with the pregnancy. The times when I have done so the following criteria have been met:

1. 39+ wks gestation by solid dating (LMP c/w a 1st trimester sono)
2. Favorable cvx (as determined by a Bishop score of >8)
3. Vertex fetus
4. Counselled mom explaining that she will be at an increased risk of c-section

My method of induction will fluctuate.

Unfavorable, Medically indicated IOL:
I have used cytotec before in the past but prefer cervidil (can pull the medication if any signs of tachysystole or hyperstimulation). Most times I will place a foley bulb. The foley bulb is almost always very effective and by the time it comes out the patient is usually around 4 cm dilated so pitocin can be increased. Will use 2-4 mu of pitocin with the foley bulb to provide the starter contractions (the pitocin is not increased until the foley bulb comes out).

Elective, Favorable cvx IOL
Because I have gotten away from doing these types of inductions on a regular basis I will mostly perform a membrane stripping for patients who are anxious to get started and don't want to wait and let their body do what it should naturally. I usually will strip a cervix that is 3-4 cm dilated and > 50% effaced. If the patient's cervix is very favorable and she is not in active labor I have found the membrane stripping to be very effective in starting the laboring process. Most of these moms will not need a milliunit of pitocin.

The patients that I am particularly hands off with are my first time moms. I explain to them that they should be given every opportunity to go into labor on their own. Some are crying to me by 41 weeks. My postdates cut off is 41 1/2 wks to 42 wks. I will intervene and do an IOL by that point. I'm sure that I will hear plenty on that point but that is what I do.

As always I love the discussion. Fire away.

Free Birth

Free Birth

Should you climb this mountain alone?

At the risk of sounding paternalistic

As a physician (OB/GYN) I do not believe that any woman should be without professional support at the time of birth. Whether a Midwife or Physician you need a safety net. You need someone to Birth Assist.

At the risk of sounding paternalistic I decided to pen this blog. Hopefully after reading this you will not look at me as a money hungry, self absorbed, OB/GYN but someone who sees the need for everyone excelling in what they are trained to do.

For those who are not familiar the concept of “free birth” or “unassisted birth” is that a mom will deliver her child without the help of a Birth Assistant . My concept of a birth assistant is anyone (Midwife or Physician) that has been trained to assist in the birth of a child. I coin this thought of birth assistant because I believe that too many times patients do not educate themselves enough to actually take charge of the birth of their child and count on me as a OB/GYN to deliver their child.

Partnership in birth

is the key to placing patients in a healthy relationship with their birth assistant

The extreme of this birthing experience is the idea that a patient can spend 7 - 8 months reading text books, blogs, or looking at videos and become proficient enough to become their own safety net during a problematic birthing experience. Now I am quite aware that themajority of births are normal, natural experiences. Yet for the paucity of births that need a birth assistant I believe that a new mom does herself a disservice to not avail herself of this expertise.

Now I believe that the reason that patients turn to free birth is because of a traumatic experience under the hands of a medical professional not listening to the desires of the patient. Janet Fraser who coined “birth rape” is a prime example. Read: http://ecochildsplay.com/2009/05/... You hear in Janet’s experience a patient who felt helpless in a situation where her birthing freedom was taken away. I will not second guess the management of the Midwife but it is obvious that Janet’s experience was one that scarred her for life.

Medical education in OB/GYN focuses solely around the concept of preparing for disasters. This is why the majority of Dulas, Midwives, and birth activist look at OB/GYNs as a hurdle to having a natural birthing experience. In practice I see that the majority of patients only want to have a healthy baby and do not spend much time thinking about how their baby will be born. They count on me to deliver their baby rather than assist in the birth. From my prospective I am prepared to do both. Whether the patient will accept the responsibility to educate themselves on the experience and take control of their birth is something that I await. My job is to educate patients, prepare for the problems, but ultimately sit back and watch the glory that God intended to happen at the birth of a child.

My hope is that less and less patients will be put in the place where they feel that they are better off without the support of a birth assistant when their child is born.

A. Harris Sr., MD

Dayton, OH

I am sure that this will generate conversation. I welcome your thoughts.

Which birth control is right for me?

When thinking about birth control methods it is important to find something that fits your personality. Are you the meticulous person that will remember to take a pill every day. Or are you the person who needs an implantable device because you would lose your fingers if they weren't attached to your body?

Key things to remember when talking to your health provider:

• Discuss your health issues with the provider; He or she should already be probing into that issue BUT you take control of your healthcare by making sure. In particular, a personal history of blood clots (i.e. deep vein thrombosis), uncontrolled hypertension, stroke, severe migraines with any type of neurologic component, smoker over the age of 35, history of breast or endometrial cancer means stay away from OCP's (oral contraceptive pills)

• Have the provider discuss the full range of birth control options

• Have the provider discuss failure rates of the particular birth control method with you

Here is a quick list of the the more popular birth control types and my preference when it comes to prescribing them to my patients. This is based on failure rate. Failure rate is greatly influenced by how much work the patient has to do.

For the FAILURE rate: the number represents the how many pregnancies will happen in 100 women per year.

IUD (intrauterine device) [Mirena and Paraguard]: These are 5 and 10 year birth control devices (respectively). The Mirena is coated with a type of progesterone and the Paraguard is a cooper based mechanism. The IUD is inserted by your provider in the office. It can be crampy for the first 24 -48 hrs. In addition the device can cause irregular bleeding for about 6wks (on average) but up to 3 -4 mos. FAILURE rate <1

Nuva Ring: This is a contraceptive ring that is inserted by you once a month. The ring stays in the vagina for 3 weeks and then comes out for 1 week to start your menses. The issue I see with some patients is getting over the idea of having something in the vagina. The ring is to be worn at all times (most importantly during sex). If the ring is in the vagina comfortable then it is in correctly. The medicine is released by heat and moisture both of which the vagina has plenty. FAILURE rate 1-2

The patch (Ortho Evra): This a patch much like the smokers wear. It is placed on the skin (avoiding the breasts and waist) and the medication is absorbed through the skin. It needs to be changed weekly for 3 weeks and the fourth week is patch free and when your menses should start. The main complaint with the patch is that of skin irritation. FAILURE rate 1-2

OCP’s: The number of birth control pills available is enormous. The key is finding a pill that doesn’t cause you much breakthrough bleeding. ALL birth control pills help with acne so don’t let that influence your choice. Most women let the provider choose for them which is o.k. FAILURE rate: 1-2

Depo Provera: This is a 3 month injection of progesterone. Patient either hate this or love it. The love it group doesn’t have any side effects and no cycle while on the shot. The hate it group has hair loss, weight gain, and 3 months of irregular/constant vaginal bleeding. FAILURE rate <1>

Male condoms: Well, the condom is only affective as the man using it. The plus side is that condoms reduce your risk of STD exposure. The downside is that the FAILURE rate is 11.

Spermicides: Any of the foams, gels, creams. FAILURE rate is 20 - 50

Pull and pray: Need I say more FAILURE rate 20

Just getting started with the blog thing. If you have questions go to my web site www.horizonswomens.com and drop it off there.