I know we have all heard the admonitions not to text or use hand-held cell phones while driving. Oprah even wrote an editorial in the New York Times. I installed a hands free device in my car several years ago in order to comply with California laws as well as to assume my role in assuring road safety to those in my car (mostly my dog) as well as on the road. A commentary in the April 15th issue of JAMA caught my attention and pointed out my inattention to the statistics that warn that even hands free devices result in accidents.

So here are the distracting statistics:

  • 5,870 persons died (16% of all fatalities) in crashes involving driver distraction due to texting or use of mobile phones in 2009
  • 515,000 individuals were injured in what are now called “distracted crashes”.
  • 21% of all reported injury crashes involved distracted driving
  • While dialing a mobile phone, drivers of light vehicles (cars, vans and pickup trucks) were 2.8 times more likely to crash or near crash than non-distracted drivers. (If they were commercial truck drivers this number rose to 5.9.)
  • Texting is a disaster waiting to happen….the average person who texts while driving takes her eyes off the road for 4.6 to 6 seconds and is 23.2 times as likely to have a serious vehicular crash compared to a non-texting driver.

And here is what really got my attention:

Analysis of 125 studies confirmed that cell phone conversations while driving were associated with impaired reaction time and that there was NO difference in risk between hands-free and handheld phones! And according to the Highway Loss Data Institute (yes there is an institute for everything) the benefits of banning the use of hand-free phones are outweighed by the increased use of similarly distracting hands-free devices. They found no decrease in crashes in states that enacted handheld cellular phone bans when compared to states that did not.

As I and my family update our cars, we are bestowed with more and more electronic gadgets. I can now do everything but write this column while driving… but I guess I won’t try. The good news is that using a GPS (with verbal instructions) is safer than trying to read a map. So I can tell my husband (who always gets lost) that his GPS is relatively safe. But the bad news is that I will not try to save time and answer patient queries while driving but instead will instruct you to call back once I have reached my destination.

Our cars should be declared no phone or messaging zones. For your sake, mine and all the other drivers and pedestrians on the road, I hope you will consider the above stats and turn your i-phones, blackberries, droids and i-pads off while driving.

Although ovarian cancer is “just” the 9th most common malignancy in women, it is the most common cause of death from a gynecologic malignancy. This is due to the fact that it is usually not diagnosed until it has reached an advanced stage. According to The American Cancer Society, 21,550 new cases of ovarian cancer were diagnosed in the U.S. last year and 14,600 women died of the disease. We now warn women to pay attention to symptoms such as an increase in abdominal girth, bloating, urinary frequency and urgency, pelvic pain, back pain, trouble eating or feeling full quickly and unexplained weight loss. (Studies have shown that if we look back and inquire if women diagnosed with ovarian cancer had any of these symptoms months before their diagnosis, they did….) So before I begin to discuss a new test to help monitor treatment of ovarian cancer, let me emphasize the need to see your gynecologist if you experience these symptoms.

It would be great if I could state that there is a single test that will declare “here it is” and herald the diagnosis of early ovarian cancer… while it is confined to one ovary and has not invaded adjacent tissues (Stage 1). Unfortunately, we are not there yet. Most women know about a blood test for CA 125, a protein that may be produced by malignant tumors of the ovary, stomach and intestines but is also produced in excess in diseases such as endometriosis (in which cells that normally line the endometrium of the uterus implant outside the confines of the lining) and fibroid tumors. CA 125 is not elevated in 50% of early (non metastatic) ovarian tumors and hence it has “failed” as a diagnostic screen for early ovarian cancer. We now use it only in patients in whom we have found a mass on the ovary and want to delineate whether it could possibly be malignant. It is also used to monitor progress in treating ovarian cancer. Levels should decrease if surgery and chemotherapy are successful. If levels increase, a new regimen of chemotherapy is usually warranted.

So what does the new blood test I promised to discuss detect? It measures the level of a glycoprotein called human epididymis protein 4 or HE4 which is produced by normal female and male reproductive tract cells as well as cells in the lung. This protein may inhibit a certain enzyme called trypsin. In 1999, researchers found that HR4 was “over expressed” in ovarian cancer tissue. The normal range of HE4 is less than 150 picomoles. (This is a number you really don’t have to know, but I might as well be thorough.) In the most common types of ovarian cancer, the level of HE4 rises to over a thousand picomoles.

The test for HE4 has been approved by the FDA to aid in monitoring the recurrence and the progression of ovarian cancer. However, THE TEST IS NOT CURRENTLY FDA APPROVED FOR MAKING A DIAGNOSIS OF OVARIAN CANCER. So I can’t yet offer it as a screening blood test. But I will use it to follow patients who have had the disease and together with CA125 levels, it will help improve the accuracy of diagnosis of recurrence or remission.

It may turn out that the HE4 test (as well as other markers that are currently being investigated) is more accurate than CA125, especially if the latter is elevated due to benign disorders such as fibroids or endometriosis. Measuring both CA125 and HE4 in women who are found to have a pelvic mass or ovarian cyst might better allow us to determine whether ovarian cancer is present. This constitutes one more step in finding a blood test that will hasten early diagnosis and successful therapy of this dreaded malignancy. I await more good (and scientific) news. I’ll keep you posted.

As a fellow of ACOG (The American College of Obstetricians and Gynecologist, the term “fellow” has no gender significance)….I recently received a survey to complete with questions about my age, number of hours I teach, see patients, percent of patients who are on Medicare, languages I speak, etc….the usual questions that one would expect them to ask in order to keep their census up to date. But this time they included a second page of questions that asked about my knowledge of a specific infection. When I realized my knowledge was minimal (actually I didn’t know anything about it), I quickly looked it up so that I could mark their queries in other than the column “I don’t know”. (The survey was multiple choice).

I’d like to share the information I learned with you….not because you too will be “tested” but because general knowledge about this water borne infection in not well known (even by doctors) and there are warnings that should be issued to help protect many of us.

The infection is due to a parasite called Cryptosporidium. It causes (you guessed it) cryptosporidiosis (nick name Crypto) …which usually manifests itself as diarrhea. It’s a fascinating organism. It thrives in cattle, sheep and pigs as well as wild animals such as deer, elk and moose, especially their young offspring (calves and lamb) and, unfortunately, in humans. Once a parasite gets to the small intestine (the gut) though ingestion, it can multiply and recycle indefinitely. In a fascinating process, once in the gut, this microscopic parasite actually undergoes a sort of fertilization to form a zygote, and this ends up having 4 offspring called sporozoites. (Sorry if I am getting too detailed, but it’s the biologist in me.) Some sporozoites remain in the gut and infect new cells. Others that get surrounded by a cyst wall become oocysts, and these are passed in the feces and into the environment. All this happens astoundingly quickly…each generation can develop and mature in 12 to 14 hours. During the last 2 decades, “Crypto” has become one of the most common causes of waterborne disease in humans in the US and through out the world!

The usual source of infection is water that has been contaminated by the feces of animals or infected humans. If a person drinks the water or involuntarily swallows it while swimming, they then “catch” cryptosporidiosis. Crypto has been found in swimming pools, hot tubs, Jacuzzis, fountains, lakes, springs, rivers, and ponds which can be contaminated with sewage or feces from humans or animals. It can be spread by eating uncooked food that is contaminated, by touching your mouth with contaminated hands…which could have “picked up” the parasite from touching surfaces (and this includes diapers) that have been contaminated by stool from an infected person or handling an infected cow or calf. (We do the latter infrequently in LA.)

Symptoms of the infection usually appear within 2 to 10 days of exposure and include diarrhea, abdominal cramping, nausea, vomiting, low grade fever and weight loss. In persons who are immunocompromised (due to diseases such as AIDS or cancer), the infection may become life threatening. The good news is that the immune system in healthy individuals is able to stop the infection, although symptoms may last for one to two weeks. But even after symptoms subside, sporozoites can be excreted in the feces and if that person swims, he or she can pass them into the water from spores that are present in the outer part of the anus or even on the thighs (ugh!). Here is where physician advice should include sanitary precautions to wash hands, use separate towels and not go swimming for 2 weeks after all the symptoms have resolved. The other rather concerning information that I discovered was that chlorine disinfection of the organism is ineffective; even one oocyst can withstand pure bleach for 24 hours and still cause infection .Most water filters today do remove small particles including cryptosporidium from our drinking water…but this may not occur in home wells (or swimming pools).

According to the CDC, the best way to protect yourself and others from this cause of diarrhea is to:

  • Wash your hands after using the toilet and before handling food (especially for persons with diarrhea).
  • Wash hands after every diaper change, especially if you work with diaper-aged children.
  • Do not swim if you are experiencing diarrhea (essential for children in diapers) and stop for 2 weeks after diarrhea subsides
  • Avoid water that might be contaminated.
  • Do not swallow recreational water.
  • Do not drink untreated water from shallow wells (or boil it first).
  • Do not consume untreated ice or drinking water when traveling in countries where the water supply may not be safe.
  • Use safe uncontaminated water to wash all food that is to be eaten raw (and if there is a chance that the food might be contaminated, peel it).
  • Avoid eating uncooked foods while traveling in countries with poor water treatment and food sanitation
  • You’ll love this one….avoid fecal exposure during sexual activity.

The diagnosis can only be made if stool samples are tested for the parasite, and frankly the test is not always positive the first time so several samples may be necessary.

The only FDA approved treatment is through a prescription of a medication called nitazoxanide (brand name Alinia). Most people with healthy immune systems will recover without treatment. Diarrhea should be managed with fluids to prevent dehydration.

So now you know and could “pass” the survey put out by ACOG. If I include a bottom line, as I usually do in my newsletter, it would probably include the phrase “Don’t swallow” (at least while swimming), know your drinking water source and wash your hands!

As the days grow longer and the sun brighter, we increase our outdoor activities. I thought this would be a good time to go over the risk factors for melanoma, the seventh most common cancer in women and cause of most skin cancer deaths. This skin malignancy arises from atypical or dysplastic moles, which are clusters of pigmented cells that lie in the outer layer of skin or epidermis. Think of them as a “confused” group of melanocytes (cells with pigment) whose DNA can easily undergo mutations which lead to abnormal and invasive growth.

I read a recent account of a lecture presented at the Hawaii Dermatology Seminar by the director of the melanoma program at the University of Miami. (Both locales are of course, among the top US locations for sun exposure, sunburns and skin cancer.) Here are some facts that were pointed out. Consider them as you look in the mirror at your moles and blemishes, check your supply of sunscreen, and contemplate whether you are due for a visit to your dermatologist.

Mole (nevi) count: The more you have the greater your risk. Nevi are associated with UV exposure and can be a marker for sun damage to your skin. Melanoma risk increases 46% with 16 to 40 common moles on your body and rises 7 fold (700%) with mole counts of 101 and higher.
Phenotype (coloring): If you have light-colored skin and hair (we’re talking true blond without the help of a colorist) and blue eyes, your melanoma risk is twice that of a dark or olive skinned individual with dark hair and brown eyes. Melanoma risk is 3 times higher if you have red hair compared to dark hair.

UV exposure: We all know that sun exposure and sunburn lead to skin cancer. Melanoma risk is higher in people who have experienced short intense episodes of burning sun exposure — especially during childhood. (This is the time when I should insert a public health warning… always protect children from the sun with appropriate clothes even if it makes then look dorky!) Studies have also shown that three or more outdoor jobs as a teen and three or more blistering sunburns before the age of 20 quadruple your risk of melanoma. But did you know that tanning beds increase melanoma risk by 75% if the first exposure occurs before the age of 35?

Occupation: Airline crews, especially pilots have been found to have a higher-than-expected incidence of melanoma. The lecturer speculated that this might have been due to their travels to high sun-exposure areas where they enjoyed outdoor, unprotected activities. (The latter phrase sounds a bit like sex without condoms — we don’t have statistics on that; here we postulate that that they failed to cover up with appropriate clothing or use sufficient sunscreen!)

Socioeconomics: Higher socioeconomic level is a risk factor for melanoma…maybe because a higher income allows one to travel to sunny climates in the winter or engage in sun exposed recreational activities.
Family history: Melanoma is twice as common if you have a parent with a history of melanoma, three times as common if a sibling had melanoma and nine times as common if both a parent and a sibling have had melanoma compared to individuals with no family history of melanoma.

The need for self skin checks: I always remind patients that this is one cancer that doesn’t require X-rays, blood tests or other invasive procedures for initial diagnosis. Just use your mirror and remember to look at the skin between your fingers and toes and at the hairline. (You can certainly ask your hair dresser to do the latter) Pay attention to any pigmented mark or mole on your body and know your ABCD’s.

A = asymmetry
B = a ragged, blurred or irregular border or a mole that bleeds
C = color variations within a mole or moles that are tan, brown, black, red, white or blue
D = diameter larger than a pencil eraser

I also add G for growth of a new lesion or increase in size of an existing lesion.\I should point out that from a skin cancer perspective, there is no such thing as a healthy tan. Any color change in the skin that is due to UV rays, even if it’s from a mild pink to a dark brown, is an indication of the their biologic effects which may go on to instigate the DNA changes and immune suppression that result in cancer. So as you venture out in peak sun hours (from 10AM to 3PM) wear a hat and if possible long sleeves and pants. And if your daytime activities call for short sleeves, shorts or bathing suits slather on sun block, and repeat the application frequently, especially if you swim or sweat.

Having listed all these risks and sun warnings, I guess I should mention that sun exposure does benefit our Vitamin D levels. But we can always take Vitamin D supplements (at least 1,000 units a day) to get this health vital vitamin.

I am on my way to the dermatologist for a mole check the week I write this…As one raised on the North Jersey Shore, I had those potentially skin damaging childhood sunburns. Too bad we didn’t know then what we know now. Shade and sun blocking clothes, gels and creams are our skin’s best friends. And of course (at least yearly) skin checks.

As I sat down to write this newsletter, I felt that I did not have a favorite new article to use for an update. So rather than leave a blank newsletter this week, I thought I might re-issue one that I wrote for MSNBC several years ago. (There is nothing like quoting oneself!) It dealt with ways to cope with breakthrough bleeding while on birth control pills. Here it is (with just a few changes):

I often get calls from patients who have started taking birth control pills and have experienced bleeding at the wrong time. They wonder if this means they should change their particular pill or whether they should consider another mode of contraception.

Bleeding at the wrong time does not necessarily mean that a woman is a “pill failure”. Breakthrough bleeding is very common in the first few months after starting combined oral contraceptives. (“Combined” means the pill contain both an estrogen and a progestin… progestin- only pills are notorious for breakthrough bleeding and hence are less commonly prescribed.) The bleeding usually decreases within three months of pill use and should stop by the fourth month with correct and consistent use.
Before you decide if breakthrough bleeding is the pill’s fault or your own consider the following:

Are you taking the pill at the same time every day? Missing one pill or taking it late could affect the integrity of the uterine lining (built up by the daily, consistent levels of hormone achieved with on-time pill use). If the hormone level drops, even momentarily, “bits and pieces” of the lining can shed causing spotting or bleeding.

Are you taking any medications that could affect the absorption of the pill? These include antacids, antibiotics, some over-the-counter digestive medications and herbal remedies such as St John’s wort. Also, medications that induce a liver enzyme system called P450 can increase the metabolism of birth control pills. These include anticonvulsants, anti-tuberculosis and antifungal medication. Steroids in pill form (prednisone) or shots (even joint or epidural injections) can also have a hormone changing effect.

Do you smoke? If you take the pill and smoke, you increase your risk of heart attack and stroke, especially if you’re 35 or older. I’ve always said that the pill be should be available over the counter and smoking should be by prescription only. Smoking decreases the absorption and effectiveness of the hormones in the pill, possibly leading to more breakthrough bleeding. Smokers have a 30 percent increased risk of bleeding irregularities in their first cycle of pill use, and this rises to 86 percent by the sixth cycle. Smoking also has anti-estrogenic effects, and increases the metabolism and breakdown of estrogen in the liver. (This is important to know when we give hormones to menopausal women … but I digress in my anti-smoking tirade!)

Now let’s look at other potential pill issues that may require professional consultation… If you’re taking a very low-dose pill (20 micrograms of estrogen) and have consistent breakthrough bleeding switching to a higher (but still low-dose) pill containing 35 micrograms of estrogen might help prevent shedding of the uterine lining . Some progestins may be more potent than others and also help prevent “lining breakdown” and bleeding.  This is where pill changes (and your physician or health care provider’s understanding of what is contained in the multiple pill formulations currently on the market) may help. There are monophasic pills (the same dose of progestin and estrogen in each active pill), biphasic pills (the amount of estrogen and progestin changes once during the cycle) and triphasic (the amount of estrogen and progestin changes three times) formulations of the pill. If you routinely experience breakthrough bleeding during a change of the estrogen-progestin ratio with a biphasic or triphasic pill, you may want to switch to a monophasic pill where the estrogen and progestin levels remain the same throughout the cycle. Or if you consistently have bleeding late in the cycle, a pill that increases the amount of progestin in that second half may correct this form of breakthrough.

Finally, if you’re trying an extended cycle pill (one without the placebo) so you go without a period and attendant side effects for three months or even longer, you’re more likely to have breakthrough bleeding. It may be worth going back on a monthly pill, or — if you want to keep trying to extend the time between periods — at the time of the breakthrough bleeding, simply stop the active pill for five days (you’ll have your “period”) and then start over again. The bleeding should cease and you can keep going on the active pills until this happens again.

After four months and/ or changing your pills, you still continue to have breakthrough bleeding, your doctor may want to run some tests. These should include a blood count (to make sure you’re not anemic from all of the bleeding), a thyroid blood test, and if the breakthrough bleeding is severe, a blood test for clotting abnormalities.  I also suggest you get an ultrasound to check for internal polyps, fibroids or ovarian masses. And of course, your doctor should make sure your cervix shows no irritations, polyps or tumors.

Bottom Line: If you have breakthrough bleeding and you’ve just started the pill, make sure you’re taking the pill at the same time every day and that its absorption isn’t being affected by medications or smoking. If it’s not heavy, wait three to four months and the bleeding should subside. If not consult your physician.

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