They Are Beating Us, About 5 To One, or Maybe It's Ten to One

In this era of contraception we might occasionally think about mothers of very large families, and we may even know a few people who have a half a dozen or a dozen siblings. But rarely do we think about  the "record holders" of birthing. Since ultrasounds, heal prints, and formal hall of record documents do not necessarily exist for some of these 'record holders' the skeptics may question the lore as just lore!The record setting mother is Mrs. Vassilyev who had birthed 69 children between 1725 until about 1765. This is however significantly less than the famed King of Poland, Fredrich Augustus Elector of Saxony who fathered 300 around the same time between 1696 to 1750. Now we have the absurd case of a British fertility specialist who claims to have fathered 600 children. Of course we are more interested in quality not quantity(no aspersions to the offspring of any of these illustrious parents intended!), but it's interesting to mull over the idea of such reproductive commitment!

Now That You are Pregnant, Did You Forget To Check Your Testosterone Levels?

During fertility treatments and with patients having early pregnancy problems it’s very common to check progesterone levels, and occasionally we do use estrogen level checks. But checking testosterone or other male hormone levels has been typically reserved for the woman who is having irregular cycles, extra hair growth, changes in sexual function or acne problems. A group of Stanford University research physicians working in their department of Reproductive Endocrinology and Infertility began to wonder about the birthing problems they saw in their most infertile patient population: patients getting in vitro fertilization (IVF). In these patients babies that had more stillbirths, and early infant deaths, more preterm deliveries and more low and small birth weight babies than the group that did not have trouble getting pregnant. These findings have been known, but why IVF pregnancies are more at risk just hasn’t been completely understood, so the researchers asked if there were variations in the hormone testosterone in early pregnancy that could account for some of these pregnancy problems. Most think that these pregnancy problems are due to problems with implantation. Interestingly, they did find changes in testosterone when women get fertility treatments; the fertility treatments caused patients to have higher testosterone. But in their group they couldn’t specifically link the higher testosterone to problems with the pregnancies. So you may not need a testosterone test, but maybe it can explain some of those hormonal feelings, the sex drive, the acne, the nausea? Just saying.

Who Can, Who May, and Who Cannot Use the Contraceptive Implants

Long term contraception is better at what the name implies: preventing pregnancy. Once you have an implant, you don’t have to remember or repeat or re-do anything. It is there and it works, and it works very well. The implants contain no estrogen, and within the first 8 hours of use they begin to leak enough medication that a woman gets a blood level of the progesterone etonogestrel for her to be protected against ovulation. The rate that the Implanon implant, the currently available single rod (or it’s slightly newer sister Nexplanon which has identical hormone) leaks hormone is about 60 mcg/day when it’s first inserted. This is only a bit less than the 85 mcg of the progesterone leaked by the old 6 rod Norplant system. It’s best then to think about the reasons that some women may not be able to use the contraceptive implant. Absolute contraindications to getting a contraceptive implant like Implanon or Nexplanon include an active case of blood clots, undiagnosed abnormal bleeding, active liver disease or liver cancer, and breast cancer. For women with severe acne, severe migraine or vascular headaches, severe depression or medicines that strain liver enzyme systems the contraceptive implants can be used, but gynos think you would benefit from other methods. For women who are heavy smokers over than 35, who have high cholesterol or high blood pressure, gall bladder disease, or diabetes, the implants can be used, but it is important to get a consultation with your gyno to be sure this is an appropriate method for you. Otherwise, if you want to wait at least 2-3 years to have your next baby it just might be the best method for you. But for STD protection, still, don’t forget to use your condoms!

Gynuity Health Projects Weighs in Venous Blood Clots and Hormonal Contraceptive

Gynuity Health Projects and other researchers have summarized the current studies on venous thromboembolism (blood clots, primarily deep vein) and the newest hormonal contraceptives. They point out that the risks of blood clots for the average user is very low. Most women will have a riskof blood clotting before ormonal contraceptives of 1/10,000 and after their is will rise on bontraceptives, but even with the newest generation progesterones the risks will only riske in the 5-10/10,000 range. The studies varied in the risks they showed. It is important for women with signs or symptoms of deep vein clots, whether on hormonal contraceptives or not, to promptly see their health care provider, and only accurate testing can help us get a firm diagnosis. Many of the studies quoted suffered from incomplete informaiton on some patients. If a woman has trauma or surgery this many increase her risk, whether or not she is on hormonal contraception, and it's also important for health care providers to be able to separate out the impact of the other risk factors so we can understand how to best help our patients minimize their risks of blood clots. The studies of pills containing the 4th generation progesterone drospirenone (this is in Yasmin) have only studied the 21 day stronger estrogen regimens. The new study points out that the most commonly used formulations use 24 day regimens (like with the pill Yaz), but lower amounts of estrogen, about two thirds as much estrogen, so it is not really known if those risks are equal or, as suspected, slightly less. In 1995 in the UK there was a "pill scare" whereby the risks of the contraceptive pill was highlighted by the Committee on Safety of Medicines in the United Kingdom; and the benefits or oral contraceptives were not higlighted, nor were the risks put into perspective. After that 'pill scare' many women discontinued their contraceptive methodes and ther was a dramatic spike in conceptions, both wanted and unwanted. Pregnancy planning with your gyno makes for successful contracpting, and successful pregnancy. Accurate information about the hormonal contraceptive method that is right for you, in consultation with your gyno is important.

Saving Your Life: But It Takes Time Why You Have To Stick with Mammograms

Breast cancer begins with a single cancer cell. Because of this small cancers (very very small cancers) are unlikely to cause the death of a patient, and larger, more persistent cluster of cancer cells cause increased patient mortality. Every trial in the world that has ever been done shows that mammograms save lives: after ten or 20 or 30 years of screening. In the first 5 years that you get mammograms, the group is not going to show prevention of mortality: it takes time for a population of women to have lives saved with mammograms. Mammography is a screening test: it is meant to sort a group of women that will get more evaluation. By definition, the group will include those very likely to have disease as those somewhat likely to have the disease, and it will exclude those patients very unlikely to have disease. Thus, the bar has been set to capture almost all the cancers, miss very few (BUT MISS SOME CANCERS) and capture some normal women who may have appeared likely to have disease but who did not. Mammography testing guidelines have been improved, and the technologies have improved, and they should continue to improve. Until we find the prevention for the disease of breast cancer we have to continue to support getting regular mammogram screening as an excellent long term strategy to save your life.

Cramping And Pregnancy: Lots Can Happen in these 280 Days

If a patient calls and says she has cramping or pain and a positive pregnancy test, we want to see that patient promptly to get a diagnosis of why she is in pain. Early pregnancy tests are so widely available and so accurate, most women today know they are pregnant when hardly a period day has been missed. Due to the fact that women find out they are pregnant so early, it is not uncommon to feel slight cramping in early pregnancy. Cramping or pain with bleeding is a more significant sign of possible miscarriage, but you cannot tell on the amount of bleeding alone. Later in pregnancy the cramping a woman experiences is probably just the on and off contractions called Braxton Hicks contractions and yet they may actually be labor pains. In general women are asked to have a plan as to when to call their physician if they have cramping. Full term is between 259 and 293 days of pregnancy, and the average is 280, in truth the uterus contracts during most of those days, but mostly we cannot notice. When the cramps become noticable, even when you are getting closer to term some gynos may tell you to rest, to drink fluids and to then call after a couple of hours. It is not real labor unless the cervix is opening up in additon to the cramping. Most gynos will caution to call if you are leaking fluid or bleeding, especially if you are past the first trimester of pregnancy. But most women will report a bit of cramping, and mostly you will  be able to be reassured that it is normal.  

Show Me Your Hands

Why would a gynecologist look at your hands? Actually there has always been a lot we can tell from a hand evaluation. Skin tone, skin turgor or thickness, your nail health, the presence of arthritis, sun damage just to name a few things your physician can tell with a glance. But one thing you may not know is that this is a window on your sexuality as well. Look at your flattened hand on the table. Then observe your index finger (digit 2 or 2D in the short hand for this test) in relationship to your ring finger (digit 4 or 4D). The relationship between these two digits, called the 2D:4D ratio is tied to some of our basic genetics and the amount of hormone receptors we have to male hormones. We can then use this 2D:4D ratio measurement to study how it is linked to our patient's sexual behavior. There maybe a large number of variables that this measure is actually related to, but what has interested some Canadian gynecologic researchers is that this seems to be a marker of how sensitive a woman is to the male hormone. When we measure how sensitive to the male hormones, or androgens, we are, we can get a window on the likelihood that a woman is going to suffer sexuality side effects of  oral contraceptives. If the Index finger is no longer or even shorter than the ring finger, which it often is in men, then you have what is determined to be a “low 2D:4D ratio." And in women with the lower ratios they might be more sensitive to a change in sexuality secondary to oral contraceptives. Its a field that is just being studied, and until we can tie real genetic studies to these behaviors it will not be a very useful test, but still interesting!

Operating On a Uterine Fibroid: The Inside Out Technique

Fibroids that hang from the inside of the uterus are called submucus myomas. They have a typical appearance when seen by your gyno when she is peering inside the uterus with her high tech camera. The appearance is very white tissue, often round or roughly specifically shaped and covered with a network of very tiny blood vessels. Fibroids that grow quite large and hand off the back wall of the uterus or are completely encassed in the wall of the uterus often produce no symptoms at all. But these tiny lining fibroids can cause heaps of trouble. Because of that operating from the inside and working our way a bit into the wall of the uterus when necessary is both more effective and less invasive for a woman seeking to treat her fibroids quickly and effectively. This can be done with an operative loop on a hysteroscope, or a device called a Myosure. It's often done under local anesthesia, or sedation, but can be done under general anesthesia as well. Most women will return to work in a day or after a relaxing weekend. An ultrasound can help determine if you are a candidate for this type of treatment.

The Aging of the Adrenal Gland

The famous Dr. Addison discovered that tuberculosis, in addition to runing one's lungs could destroy the adrenal gland. And from this, the name of adrenal insufficiency, became Addison's disease. Immune causes, tumors, and infections are all associated with weaking of our adrenal gland that can have profound affects on our health. Medicaitons like steroids can cause adrenal gland problems, but so can other medications, and there is an entire list of medications. For women remaining on long term treatments, it may be a consideration to look at the levels of adrenal gland hormones if you are getting inexplicable side effects. Genetic family diseases cause adrenal gland problems, and can be associated with other problems such as parathyroid gland conditions and chronic yeast infections! Aging itself is not necessarily a problem, although it can be for the adrenal gland as well as other prts of our body. Interestingly the highest amount of DHEA is produced in the third decade of our lives. There is a lot for us to know about how the adrenal gland ages, we will be following this research closely!

Should Women Over 26 Get Gardasil Shots?

HPV vaccination has the ability to virtually eliminate cervical cancer, and many of the diseases that HPV causes. In the USA we know that we should vaccinate girls and boys around age 9-12. By the time they are teens, the vaccine is still recommended, but this is late to begin the shot. For individuals over the age of 26 there is no FDA recommendation regarding the shot, but you and your own gyno (or a young man and his physician) can determine if you would benefit by spending your own money on getting the vaccine. Gardasil, the HPV prevention vaccine for types 6,11,16,18 has been studied in about 3200 women from ages 26 to 45 to judge the effectiveness in preventing the acquisition of these types of HPV and the diseases they cause. On the surface it was a disappointing as there was no difference is the numbers of cervical cancers, cervical dysplasia of high grade (CIN 2/3) no any difference in the rats of adenocarcinoma in situ (early cervical gland cancers). The women given the vaccine did develop some immunity to this vaccine, but it is not known how strong an immune response would be required, because a few of these women who did not test positive to the HPV types did break through and acquire the virus or developed disease. These may have been patients who had HPV in the past, and this was just not able to be detected in this study. In general it was about 80% effective in preventing HPV + tests for the vaccine HPV types, it was about 85% effective at preventing any dysplasia, and it was about 87% effective at preventing warts caused by the HPV types in the vaccine. These are very good numbers. If you had not been sexually active prior to getting the vaccine, you would probably anticipate being in the successful group. If you want to get tested for the presence of the virus before making your decision, it's also something you could discuss with your provider, but this is not a standard approach to vaccinations. As we said, lets get the girls and boys vaccinated in their youth for effective and long lasting protection.

Has Your G Sopt Been Found

Medical news is bustling with a story that a physician working on dissecting a cadaver has found proof of the size, the shape and the anatomy of the ever elusive G-spot! A lone working physician has found this spot and reported his findings on line. The topic has been discussed in several prior posts if you'd like to look back a bit.  Actually, it's still not completely clear if this is enough proof that all women have a G spot, but more and more it is reported that the area can be improved, and that this will help some women combat the decrease in sexuality that they are sometimes reporting.

Holding the Baby In



A Device To Hold the Cervix Closed in Pregnancy



A new pessary invented by Arabin, called the Arabin Pessary has been studied as a non-hormonal method of securing a woman's cervix and preventing the cervix from opening prematurely during pregnancy. The use of this rubber cone was studied in Spain PECEP, and headed up by Dr Maria Goya. They used women who were found to have a short cervix by ultrasound. The pessary placed around the cervix in pregnancy only used once the cervix was found to be short, did reduce the numbers of babies born prematurely. This device is not yet approved for use, and other treatments, such as progesterone vaginal gel is used for this purpose in the US. The study being discussed is registered with ClinicalTrials.gov, number NCT00706264.