Perfect health eludes many women in their reproductive years. And those who have medical problems may be at risk for significant maternal as well as fetal complications if they become pregnant. This doesn’t mean that they shouldn’t plan a future pregnancy; however, their underlying condition should be appropriately treated and once pregnant these women should be monitored by the right medical and prenatal team. Writing a prescription for a birth control pill, deciding on “just” barrier methods or inserting a form of long term contraception should not simply be tailored to a woman’s personal goals of when and if to get pregnant; contraceptive planning should also address her medical problems.

I have a mental check list of the do’s and don’ts for contraceptive prescriptions which I thought I might share with you in this website article. I’ve listed the medical problems that many women encounter and under each heading, what can, cannot (or maybe should not) be used to prevent conception. Obviously, there are myriad medical problems that women can develop during their reproductive years, I’ve tried to stick to the most frequent. (This is where I put in the “proclaimer” and disclaimer….if you have a medical condition that could impact your birth control methods speak to your doctor!)

Diabetes
There are multiple studies about diabetes and contraception, which I won’t list ….but the general consensus is that oral contraceptive pills (OCP’s) or the vaginal contraceptive ring are safe for women with diabetes. This “go for it seal” does have a few conditions, namely age less than 35, no kidney or eye disease and no smoking (smoking with diagnosed diabetes is truly stupid, but then smoking in general is ….OK I won’t start on this again).  IUC’s (intrauterine contraception) such as the Paragard and Mirena, as well as progesterone-only-pills (POP’s), Depot Provera injections (DMPA) and progestin implants are  safe and indeed they may be better choices for a diabetic woman who has any of the above mentioned risk factors.

Obesity
Unfortunately, this includes 35% of adult women in the US. A recent review of all the evidence seems to indicate that the efficacy of OCP’s may be mildly reduced in overweight and obese women. They are, however, more effective than barrier methods. Obese women have a 3 fold increase in their risk for dangerous clot formation (venous thromboembolism or VTE) compared to their svelter counterparts. I know there are frequent claims of “class actions” for stroke and heart attack “due” to OCP’s. The risk of that VTE is still much less with OCP’s then with pregnancy. If an  obese woman is interested in long term contraception I suggest an IUC, either the Paragard or Mirena. Their safety and effectiveness are not compromised by weight.

There is concern that the efficacy of oral contraceptive pills may decrease after gastric bypass (bariatric) surgeries due to limited absorption.  For those patients, I suggest a contraceptive vaginal ring (NuvaRing) or an IUC.

Headaches
We all get headaches, especially tension headaches. (I have one now as I contemplate all I have to do before the holiday.) Tension headaches do not increase our risk for stroke and have no impact on the safety of any of the contraceptive methods….the real headache will occur if birth control is not used or fails!

Migraines are another story…Women with simple migraines have a 2.5 to 3 fold increase in their risk of stroke regardless of whether they use OCP’s or other forms of birth control. I do prescribe OCP’s to my patients who suffer from “simple” migraines. (I am not denigrating their headaches; the word “simple” means there is no concomitant aura). Studies have shown that OCP’s don’t make a difference to their risk of stroke.

Most women of reproductive age who are migrainers experience their headaches during their periods. The hormonal decline that occurs before the menses (especially estrogen) may instigate the migraine. For those women who have menstrual migraines, I prescribe the active birth control pills (containing estrogen and progestin) continuously.  If they experience frequent breakthrough bleeding I may suggest that they take the active pills just 3 weeks a month (which is the way most pills are packaged) and prescribe an estrogen patch for the days that they are on the placebo in their pill pack,when they get their “period”.

Migraine with aura carries a higher risk of stroke than a simple migraine. So in general, most physicians will not prescribe OCP’s if there is a history of aura and/or additional risk factors, such as smoking or age over 35. (Maybe this is the time to state that smokers are, in general, at risk for stroke and heart attack but even more so with OCP’s….and if a woman who smokes is also over 35, the Pill is a ‘No No”. I have often stated that OCP’s should be over-the-counter and cigarettes should be available by prescription only! I just can’t seem to stop my antismoking campaign.

There are no contraindications to using IUC’s, progestin-only methods and barrier methods in women with migraines.

Seizures
Many of the antiepileptic drugs (AED’s) induce a hepatic enzyme system called P-450 which can increase the clearance of contraceptive hormones, causing them to be less effective. It may be necessary to use a somewhat higher dose of the Pill if a woman takes an AED. Injections of Depo-Provera, or an IUC might be a more secure form of contraception. It’s extremely important that reliable contraception be used, since some of the AED’s can cause fetal malformations if an inadvertent pregnancy occurs.

Hypertension
Women younger than 35 with well controlled hypertension can use OCP’s as long as they don’t smoke and have no known kidney or heart disease. Progestin-only meds are also fine, as are IUC’s.

HIV
OCP’s do not increase HIV progression. However, once a woman begins antiretroviral therapy this medication may alter the blood level of the hormones in the Pill. Moreover, the OCP’s can impact the level of the medication. This is when a consult with an HIV expert is needed. IUC’s are felt to be safe. (I just noticed that I am using a lot of initials, sorry but they do shorten the text.)
There is always concern about the risk of transmission to uninfected partners. So no matter what a woman who is HIV positive uses, she should use condoms.

Bottom line: In most instances, a medical problem does not “disenfranchise” our usual types of contraception. On the contrary, it makes use of appropriate birth control more important than ever!

Have a wonderful holiday. I too am celebrating with a vacation in warmer weather. I’ll return with my weekly website articles on January 7th, 2011. I hope that in the upcoming year my website will provide you with the medical information and comments that help keep you medically savvy and healthy!

Much of my memory of those interminable high school lessons of 15th through 18th century English history; you know… who succeeded who, who killed who, who married who, what and when wars were waged, lost or won… has been tempered by my subsequent medical training. In truth, I am more interested in the prevailing diseases of that time.  Aside from the plague, death in childbirth and horrendous rates of child survival, I remember that many of the historic and (generally) obese kings and noblemen of that period spent an inordinate time feasting on meat and imbibing alcohol. They (the men) also seemed to have had one condition in common; they suffered from gout which most frequently occurred in their big toe. (Gout of the big toe is called podagra. I guess this esoteric knowledge would not suffice to give me more than an “F” in any legitimate history test but it might help my score in game of trivial pursuit.)

Just to refresh your memory: Gout is an excruciatingly painful inflammatory disease of the joints caused by high levels of uric acid in the blood stream. The excess uric acid crystallizes, causing swelling, redness and severe pain in the joint. As gout progresses, attacks of inflammation (usually lasting 5 to 7 days) become more frequent and ultimately deform the affected joint. Moreover, high levels of uric acid can lead to life-shortening medical conditions such as diabetes, coronary vascular disease and fatal heart attack.

In the past, gout was considered a disease of male nobility…But not so in the last few decades; it has unfortunately reached a more democratic and gender-blind distribution, doubling in frequency and occurring in “common” (not related to nobility) men AND women. It has become especially frequent in older women and is diagnosed in up to 5% of women over 70.

We thought that the cause of increased levels of uric acid was a diet rich in organ meats (there goes chopped liver) and alcohol. Recent data, however, has shown that the use of diuretics (which concentrates the uric acid) abets crystal formation and also bears “gout-responsibility”.

According to a study published in a recent issue of JAMA, there are other risk factors for the development of gout in women.  The authors used the Nurses Health Study that was established in 1976. At that time, 121,700 female registered nurses living in 11 states completed a mailed questionnaire providing detailed information about their medical history, lifestyle and presumed risk factors. In 1980, a food questionnaire was added and in 1984 they were asked specifically about their soda intake. By then, the number of women who successfully completed the questionnaire was down to 78,906. (Still an amazingly high number.) The participants were asked whether they drank sugar sweetened colas, diet sodas or various fruit juices as well as how much, on average, they consumed a month, a week and a day. They were also asked if they had a diagnosis of gout or if they had experienced 6 of the 11 criteria for the diagnosis of gout. (Just so you know what they are: More than 1 attack of acute arthritis, redness over joints, painful or swollen joints in the toes, foot, one sided toe joint attack, swelling within a joint, elevated uric acid levels and an attack that starts and stops within a period of time.) The participants were asked to update the questionnaire every two years.  The response rate for the gout questionnaire was 81%.

This was what the study found: Increasing the intake of sugar-sweetened soda was associated with an increasing risk of gout. The relative risk (RR) of gout was 1.74 (74% greater) for 1 daily serving of these sodas when compared to women who had less than 1 such soda a month and 2.39 (more than doubled) for those who had 2 sugar-sweetened sodas a day. Diet sodas did not have a “gouty” impact. Moreover, it was just as bad for orange juice! (Of note to those of us who like fruit juices, orange juice has the highest amount of free fructose when compared to apple juice, grapefruit juice, tomato juice and other fruit juices.) Compared to women who consumed less than one glass (6 oz) of orange juice a month, the RR for gout was 1.41 for one serving per day and 2.42 for 2 or more servings per day. No other fruit juices were significantly associated with risk of gout. (Thank goodness, I drink apple juice every morning.)

Studies have shown that within minutes of a fructose intravenous infusion, blood (and later urinary) uric acid concentrations are increased. Apparently, there is a smaller but significant long-term effect on uric acid levels from fructose when taken orally. The Nurse’s Study has now shown that the sugar sodas and orange juice we drink on a regular basis has a clinical impact on big toe disease and gout. It’s not such a noble (and male) disease anymore!

Bottom line: The fructose in sodas and orange juice may do more than increase your caloric intake; this sugar can increase uric acid levels and ultimately lead to an excruciatingly painful arthritis. You may want to quench your thirst with water… I know we can’t always have our juice and drink it with impunity, but I do bemoan any elimination of orange juice, it is a wonderful source of Vitamin C.

I recently saw a 42 year-an old woman who was having severe hormonal problems stemming from a “mistaken” removal of both of her ovaries during a hysterectomy. She and her surgeon had agreed that she needed a hysterectomy with removal of one ovary (which apparently had recurrent cysts). Post operatively, the surgeon told her that he had mistakenly taken out the “normal” ovary as well as the one that had the cyst. He apparently was very apologetic and admitted that it was a grievous mistake. (She has no intention of suing.) I’ve tried to right her missing hormones with appropriate therapy. Hopefully, this will reverse some of her severe menopausal symptoms.

Operating room “oops” happen, but all of us in the surgical fields are working to reduce and eliminate them. In the November 11 issue of the New England Medical Journal, a case report was published titled “A 65 year-old woman with an incorrect operation on the left hand”. It gave an account of a carpal tunnel surgery which was performed on a patient who was supposed to undergo a different surgery for trigger finger. (My husband will find this especially relevant as he too suffers from trigger finger, but so far has managed without surgery….after this report he may never have surgery!) There was a series of incidents leading up to the wrong surgery at the hospital in the report….delays in the OR, prior surgeries that were performed by the busy surgeon on the same day, a change in the assigned operating room and nursing staff in the room and mixed-up documentation. This all occurred and was reported by a surgeon at Massachusetts General Hospital. The report also reported that “a financial settlement was negotiated shortly after the event.”

Because of ongoing reports of wrong-site and even wrong-organ surgeries (They are more likely to appear in court records and the media then in prestigious medical journals.), the American College of Surgeons along with other professional organizations have held several summits to discuss and approve protocols to prevent future surgical mistakes. I thought it might be appropriate to share highlights of their recommendations with you. (And if you ever have to have surgery, these safety measures might reassure you.)

*Conduct a pre-procedure verification.
Verify the correct procedure, for the correct patient, at the correct site.
This should be documented, checked with the patient while she is awake, documented in the hospital scheduling list and the operating room.

*Mark the procedure site before the procedure is performed.
Best to do this while the patient can participate. The mark should be sufficiently permanent to be visible after skin preparation and draping.

*Perform a time-out.
This involves all of us in the OR room, the surgeon, anesthesiologist, nurses, technicians. We literally call “time out” before the incision and state the patient’s name, the intended procedure, the site of the procedure, allergies and any other important identifying information. We then document the completion of the time out…and finally start the actual surgery.

Adherence to this protocol (as well as careful and repeated instrument, needle and pad counts), helps ensure that surgery will be performed as safely as possible. “Oops” is not a word we want to ever hear in the operating room.