I was elated to see the very thoughtful editorial in the January 2 issue of The New England Journal of Medicine. Like many of you, I have relied on the news to get information about the cases being brought to the Supreme Court in which for-profit corporations argue that their “religious rights” are being infringed upon if they are required to provide coverage for contraceptive services to their employees. And I wondered how a for-profit corporation could have religious rights…

In this issue, the entire editorial group of the most prestigious medical journal in the US (and perhaps the world) asked the same question and then give their informed opinion… In the first of the two cases to be argued in March 2014 (Sibelius, the United States Secretary of Health and Human Services versus Hobby Lobby Stores, Inc.) the court is asked to consider whether contraceptive services meet a compelling public health need. The editors as well as the Institute of Medicine proclaim it does. They site the numerous studies that demonstrate that prescribed contraceptive services prevent unintended pregnancies, more than half of which are currently terminated. Although it seems obvious, planned pregnancies give women and their children a better quality of life; younger women have the opportunity to complete school, start careers and establish stable relationships. Ultimately a full panel of contraceptive services saves money for every state and the country. The editors go on to say that “In working with women to prevent unwanted pregnancy, physicians need the full panel of FDA approved contraceptive methods. If that panel is limited by a woman’s inability to pay – if the method deemed optimal for her is unavailable because her health insurance does not cover it – then the religious freedom of her employer will have interfered with the provision of high-quality medical care to her… After all it is the woman, not her employer whose health is at risk.”

A second case that will be brought to the court argues that contraception services insurance should be excluded by health insurance from “religiously concerned” for-profit corporations. The case is titled Conestoga Wood Specialties Corp. versus Sibelius. That corporation “feels” it is unacceptable to provide contraception because of its religious beliefs. The editors of the New England Journal of Medicine point out that this is absurd and give examples to bolster the absurdity. They ask, would it be acceptable if an employer who was opposed to blood transfusions offered employees a health insurance policy that did not cover transfusions, or if they did not believe in vaccination, not cover vaccination, or deny mental health services or cancer chemotherapy? Obviously if the employee does not want to receive covered services she’s free to make that choice for herself. They go on to write that “the arguments of Conestoga puts the religious beliefs of an inanimate corporation ahead of the primary health needs of its employees.”

Their final editorial statement is so eloquent that again I have to quote: “To deny coverage for these vital public health services to women who want them but cannot afford them outside their employer-sponsored insurance would be a personal and public health tragedy.”

I certainly hope the justices of the Supreme Court who will be deciding these cases read the New England Journal of Medicine.

Every once in a while you’ll see a “how awful” media story about a young woman who had a stroke or clot in her lungs that was ostensibly caused by oral contraceptive pills (OCPs). Lawyers are suing, OCP users are scared and I get lots of calls from concerned patients and parents. And then there are those ads that come on at night, often on non-network channels, that ask you to call a specific law firm if you have had “fill-in the blank” complications after taking Yaz or Yasmin or for that matter, any birth control pills. So although I have tried over the years to both reassure and address the pros and cons of birth-control pills to patients and concerned family members, unfounded and founded concerns remain. Hence I was delighted to see a new review in The Journal of Obstetrics and Gynecology titled ” Risk of Acute Thromboembolic Events With Oral Contraceptive Use”. The authors reviewed 6476 citations that reported on an association between exposure to oral contraception and outcomes of venous clots (thromboembolism), stroke and heart attack. They looked at every study’s design and quality as well the number of women who took OCPs and control women (who did not) and the number of years in which the women and controls were followed. In the end they found that 50 of the studies included the data that made them appropriate for their review.

Having given you ” the how they got to their conclusions”, I will skip the 7 dense pages of data and charts in the article… They found that there was a threefold increase in the odds of a venous thromboembolism diagnosis among current users of oral contraceptive pills compared to women who did not use OCPs. There was no evidence that the pills that had the progestin drosperinone ( found in Yaz, Yasmin and the generic equivalents) or other pills that had new second- generation progestins where associated with an increased risk of venous thromboembolism in many of the studies. Altogether, they did not find evidence for a difference in risk among the four types of progestins used in birth control pills. They also found a twofold increased risk of stroke from clot obstruction to cerebral vessels among current oral contraceptive pill users. But as they pointed out, the risk of a clot or stroke in pregnant and postpartum women is increased much more, threefold to eightfold that of non pregnant women. (In other words, a woman is far more likely to get a clot during pregnancy then she is using the pill to prevent pregnancy.) Additionally, there was no increase in heart attacks in women who took the pill when compared to women who did not.

The issue of whether OCPs that contain 20 ug of ethinyl estradiol or less (very low-dose pills) versus those that contain 35 ug (low dose pills) was not resolved because many of the studies did not distinguish between these two doses of birth control pills. The authors also pointed out that women who were high risk for clot formation because of heredity, obesity, previous clots or cardiovascular problems were less likely to get prescriptions for OCPs and hence the complication stats could be skewed.

So now when I’m asked, I can say yes, there is a slight increase in risk of clots with birth control pills but that risk of this complication is far greater during pregnancy. And I also want to remind women that birth control pills can regulate cycles, decrease cramps and heavy menstrual bleeding, treat acne, help overcome hormonal changes, reduce the risk of endometrial and ovarian cancer and of course prevent unwanted pregnancy. (But I should now add that there are other forms of contraception that are highly effective and for certain patients may be more appropriate, this is not an ad paid for by Ortho!)

The choice of OCP brand, amount of estrogen or type of progestin depends on a woman’s symptoms, side effects from previous use and her physician’s prescribing habits. This new analysis of multiple studies has shown that there is no difference between OCP types with regards to risk of thromboembolism. I hope the malpractice attorneys pay heed.

I know this is the Fourth of July weekend and many of my patients and readers will be busy with family, barbecues and hopefully celebrating the independence of the fabulous country we live in. (And, of course, there are those wonderful sales!). But if you happen to be glancing at this website, I want to take this opportunity to indulge in a modicum of self-congratulation; a committee opinion from the American College of Obstetricians and Gynecologists was just released and it supports what I’ve been telling my patients for years; that hormone therapy does not increase coronary heart disease risk for healthy women who have recently become menopausal. What also makes this committee opinion novel is that it states that if a woman’s quality of life is diminished by menopausal symptoms past the age of 65, extended therapy may be considered. Let me repeat: The American College of Obstetricians and Gynecologists now recommends against routine discontinuation of systemic estrogen at age 65 for women who need HT to manage their vasomotor symptoms (hot flashes and night sweats).

So that’s the summary. And you can go back to your holiday celebrations. But if you want to read further here are some of the studies and facts that the committee used in its announcement:

Much of the controversy about the impact of hormone therapy (HT) on cardiovascular disease came out of the Women’ Health Initiative (WHI) and the Heart and Estrogen/progestin Study (HERS) which seemed to show an increase in heart attack and stroke in women who took hormone therapy. But more recent studies have cast doubt on some of the methodologies used. Many of the women who were in the those two studies were over the age of 63 when they started hormone therapy and already had underlying coronary heart disease, hence they had an underlying increased risk for developing heart attack and stroke, which perhaps was augmented by hormone therapy. But newer studies indicate that when hormone therapy is started at a younger age, in women aged 50 to 59, the opposite occurs. An important study used CT scans to examine the distribution of calcification (plaque) in the coronary arteries in 1064 women who were in that 50 to 59 year range. Those who took estrogen had calcium scores that were lower than women who took a placebo, moreover, those who stayed on estrogen for more than five years had a significant reduction of 40% in their calcification scores.

The committee also looked at other variables of hormone therapy that could affect cardiovascular disease. They stated that synthetic medroxyprogesterone acetate (Provera) causes constriction of blood vessels whereas natural progesterone causes the vessels to relax and therefore may have a positive effect on blood pressure. In addition, unlike synthetic progestins, natural progesterone causes little or no reduction in high density lipoprotein. (Remember, high density lipoprotein is the good cholesterol and works like a rotor router to protect vessels from plaque formation). The committee doesn’t go so far as to state that ET or HT improve cardiovascular outcomes, they simply state that the evidence is as yet insufficient. But they do say that recent evidence suggests that women in early menopause who are in good cardiovascular health are at low risk of adverse cardiovascular outcomes and should be considered candidates for estrogen therapy or combined estrogen and progesterone therapy for relief of their menopausal symptoms. And women over 65 should talk to their doctor. If their symptoms are persistent, it’s OK to consider continuing their hormone therapy.

My final summation: If you develop symptoms that make you miserable – start hormone therapy in the early years of menopause, there is no increased risk of CHD if you are healthy… and continuation beyond age 65 may be an appropriate option if your quality of life is significantly reduced by these symptoms. We still have to discuss risk- benefits (most specifically breast cancer risk…) There is no free lunch or hormone!

I have obsessively discussed the positive health aspects of the various forms of contraception in my newsletters over the past few years. (Clearly a part of my Planned Parenthood background!) I have also proclaimed gender health success when the Affordable Care Act (ACA) stated that after August 1, 2012, preventive health services recommended by the Institute of Medicine and endorsed by the Department of Health and Human Services would be covered by insurance companies. These services are meant to promote the development of a health system that sustains health rather than merely treats illness. The services include all FDA approved forms of contraception, the morning after pill as well as sterilization procedures. And women will now be afforded health mandated services for cervical cancer screening, screening for sexually transmitted infections, mammograms and maternity care. But as we all know, some religious organizations and private employers have demanded exemptions from providing contraception stating that this violates their religious beliefs. Many of us have been outraged. Our umbrage was beautifully voiced in a “viewpoint” article published in the May 15th Journal of JAMA. Three physicians from the Northwestern University Feinberg School of Medicine in Chicago, Illinois contributed to the article and I would like to share their arguments with you.

As I leave for a brief vacation over the holiday, I wonder (as do most Americans) what’s going to happen to that impending fiscal cliff. Somehow, I reassure myself our divided congress will get this settled. But I am less complacent about the outcome for healthcare in the year and years to come. Just before I got on a plane, I glanced at the New England Journal of Medicine (my reading choices are not as literate as they should be) and came across a special report titled: “Implications of the 2012 Election for Health Care- The Voters’ Perspective.”  So as we go into the new year, I thought it might be appropriate to share the results of this report with you…

Obama won! (Excuse the exclamation point.) We also now know how those who voted for him felt about health care. Here are the stats: Obama voters were three times as likely to say that healthcare was the most important problems facing the country as those who voted for Romney. Obama voters want the Affordable Care Act  (ACA, also known as Obama care) implemented and not repealed. Obama voters want a more activist federal government intervening in the US healthcare system over the next four years. Seventy eight percent of Obama voters favor implementing or expanding the ACA and having the federal government continue its efforts to ensure that most Americans have health insurance coverage. And 85% of Obama voters support having the government try to fix the healthcare system, including 55% who believe that the federal government should have more responsibility than state governments for fixing it. And, (just a few more statistics) the majority of Obama voters upholds changing the structures of the current Medicare program ( 83%) and Medicaid program (78%). Finally 8 in 10 Obama voters believe abortion should be legal in all or most cases.

Yes, we live in a democracy but that doesn’t mean that what the majority of voters favor will, indeed, be accomplished. Thirty of the nation’s 50 states will have Republican governors in 2013, many of whom may not consider the establishment of state health insurance exchanges and Medicaid expansion as their state’s mandate. It’s clear that this may become a contentious year for many reasons and healthcare may lead the “it’s not for us” list.

Meanwhile, back to the personal, each of us should do what we can to ensure our individual health. And I will try to continue to help you do this with timely information about prevention, diagnosis and health care innovations in the year to come.

I and my staff wish you a happy and healthy New Year!

Recently, a mother brought her adolescent daughter to my office for advice about  menstrual migraine therapy. After I made my suggestions, I thought it might be timely to give a few “notes” (I sound like a producer) for the website regarding the causes of and treatments for this debilitating disorder. Migraine headaches are unfortunately very common; they affect nearly 28 million Americans including 18% of all women and 6 % of all men. A migraine is defined as a one sided, severe, pulsating headache aggravated by physical activity together with sensitivity to light (photophobia) and sound (photophonia). The true migraine usually manifests itself in 4 phases. (This is not a simple come and go headache).

The Premonitory Phase (Prodrome): This phase is due to neurochemical alterations in the brain and is most commonly associated with fatigue, difficulty concentrating, stiff neck and light sensitivity. It can also include mood swings, food cravings, yawning, change in vision, nausea and vomiting.

The Aura Phase: This occurs in 15% t 20% of migraine attacks. The ends of the 5th  facial nerve ( the trigeminal nerve) are activated causing symptoms that include scintillating lights, distorted vision and numbness and tingling in the hands or face. These sensations are usually followed within 60 minutes by the headache. Rarely an aura can occur and not be followed by pain; it’s then aptly called a migraine aura without headache. This may be a final neurological diagnosis (by exclusion) once a full work up for symptoms of stroke is negative.

The Headache Phase: The trigeminal nerve that gives us our sensory perception from our face also provides a pain pathway from the meninges (the capsule around our brain). Though a complex system called the trigeminovascular system, the nerve can become activated by many triggers. This trigeminal activation then instigates the transmission of impulses in the brainstem and causes a release of substances called vasoactive neuropeptides. They, in turn, cause dilation of blood vessels and inflammation in the meninges. The activated trigeminal nerve fibers become abnormally sensitive and any stimulus, such as light, sound or even gentle touch can increase pain. (This explains why most migraine sufferers want to be left alone in a dark room without human contact once the migraine occurs.)

The Post Headache Phase (Postdrome): Migraine symptoms can last for up to 2 days. This “post” seems to go on forever!

More than half of the women who suffer from migraines have them in association with their menstrual cycles; moreover, the migraines that occur with their periods are worse than all others. There are 2 kinds of cycle associated migraines… (Medicine is chock full of nomenclature.) Pure menstrual migraines occur without aura 2 to 3 days after the start of menstruation but do not occur at any other time during the menstrual cycle. Menstrual related migraines include menstrual migraines but attacks can also occur at other times in the menstrual cycle (often days before the onset of the period, or right after ovulation). It is thought that change in hormones, especially the decline of estrogen before and during the period, play a role. Also as an added insult, when we menstruate, pain stimulating substances called prostaglandins are released and can trigger headache, nausea, vomiting and diarrhea even in women who do not have true migraines!

OK, now that I have given you a synopsis of Migraine 101, let me get to therapies. First … those that are nonphamacologic: This is where we try to limit migraine triggers, use relaxation training and biofeedback. Although I can’t teach you how to do the latter two in this summary, I can at least acquaint you with triggers that you can avoid. They fall into 4 categories:

  • Diet: Alcohol, chocolate, aged cheese, monosodium glutamate artificial sweeteners, caffeine, nuts, nitrates and nitrites and citrus fruit. Not all these affect the same person and clearly there are other foods that can less frequently act as triggers.
  • Changes: weather, seasons (maybe we should all live in San Diego or Hawaii), travel, altitude, schedule changes, sleeping patterns, diet changes, skipping meals.
  • Sensory Stimuli: Strong lights, flickering lights, odors
  • Stress: Let-down periods, intense activity, loss (death, separation, divorce); relationship difficulties, job loss/change and anything that causes emotional or physical crisis.

The above includes much of what we do or experience in life! But I would be remiss if I didn’t give you this list. (In case you want to know my reference it’s from The New England Center for Headaches… it should also be applicable to those of us residing in the West Coast).

Now let’s get to pharmacologic therapy:

  • Nonsteroidal Anti-Inflammatory Drugs (NSAID’s): These interfere with those pain promulgating substances, the prostaglandins. They include ibuprophen, aspirin and naproxen. Some of these OTCs also include caffeine. If they don’t work after 4 to 6 hours or result in “bounce back” of the migraine once stopped and/or they need to be used continuously for several days, you are probably better off with a prescription medication.
  • Triptans: These are prescription medications that bind to and activate specific receptors called 5-HT which are expressed on the smooth muscle cells in the walls of blood vessels. They induce constriction of those dilated vessels in the meninges of the brain that caused the migraine in the first place. The good news is that they usually work within 20 to 30 minutes and don’t cause sedation so you can continue your normal activities. There are at least seven triptans. One type is combined with an NSAID. The best way to use them is at the very onset of the migraine.
  • Ergots: These have been used since the 1930’s. They constrict blood vessels and activate 5-HT. They are less “in vogue” for migraine therapy because of their potential side effects (such as an elevation of blood pressure).

Preventive Treatment: This requires daily use and includes medications that are used to treat hypertension (beta-blockers, calcium channel blockers), certain antidepressants that decrease the conduction of pain stimuli (tricyclics) as well as anticonvulsants. I would include hormonal therapy as a mode of migraine protection for many women. I frequently prescribe oral contraceptives to my younger patients who are migrainers in order to stop the ebb and flow of hormones during their cycle. (Remember that hormonal contraception signals the pituitary to NOT send signals to the ovaries to develop follicles and ovulate.)  I suggest using the active pills or a contraceptive vaginal ring continuously so that there in no break in the hormone level it provides. (No you don’t NEED to stop and get your period.) If there is a break in active contraceptive hormone use (some patients prefer to take it for  3 months at a time, or experience bleeding after a few months and “take a short break” from the Pill or ring), I prescribe an estrogen patch to “cover” the time off so that the decline of estrogen does not instigate a migraine.

At this point, I should add a warning: The occurrence of migraines without aura has been shown to increase the risk for stroke by a factor of 3, whereas if aura is present this increases to a factor of 6.  The use of oral contraceptives in women with stroke is considered an independent risk factor for stroke. So ACOG (the American College of Obstetricians and Gynecologists) discourages use of oral contraceptives in women who have migraines with aura.

Now, let’s consider migraines in menopausal women. They often improve. (Finally, something to look forward to as we age!) Once we stop the vacillations of our hormones in our reproductive years, the migraines may lessen. However (sorry, but there is often a “however” in medicine), some menopausal women begin to experience migraines once they no longer produce estrogen. If they want to reinstate their premenopausal estrogen status, I then prescribe transdermal estrogen….usually a patch so that they achieve a “steady state” of estrogen with no ups and downs.

This has been a longer website article than most. But since so many of my patients, friends, staff and relatives (my daughter) suffer from migraines; I felt I owed it to them to give a fairly complete summary. I hope it didn’t give you a headache!

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.

We could ask our kids (rarely works), speak to the school administrators (they are probably the last to know),  read Seventeen and Cosmo or just look with despair at the promiscuous styles offered to and requested by young girls (and boys).

In my perusal of journals, I found a fascinating study which addresses this question. It comes from the National Youth Risk Behavior Survey conducted from 1999 though 2007. (Remember it takes a year or two to collect, analyze and publish information of this sort, hence it did not include ‘08 and ‘09.) Researches analyzed data from this survey to determine age at first intercourse in 66,882 black, Latino and Latina, white and Asian students in grades 9 though 12. According to the students’ anonymous self reports, the probability for “coital debut” by their 17th birthday (I’m assuming they meant vaginal intercourse, the use of euphemisms in medical reportage is astounding!) was: 82% for black males, 74% for black females, 69% for Latinos, 59% for Latinas, 53% for white males, 58% for white females, 33% for Asian males and 28% for Asian females

Now before we take this report and approach our children or grandchildren with queries as to whether they fall into the above listed statistics (“did you or didn’t you?”), I should point out that the survey was based on self-reported data. Girls are more likely to underreport sexual activity, whereas boys tend to over report. The survey did not stratify the groups by parental income or educational level, nor did it differentiate between public or private school attendance. And the study did not include youths who had dropped out of school (who would, most likely, skew early coital debut to higher probability).

I realize that parents don’t always like to look at gross statistics when it comes to their own progeny. But this large study does show us that a majority of teens self report that they were sexually active before the age of 17. It’s way better than rumors… and should help parents decide when to make sure that their daughters have access to appropriate contraception. (This may have the appearance of a plug for Planned Parenthood and I should disclose that in the past I was on the board of the LA chapter of this organization). We know that timing is important for HPV vaccination. The best results will be achieved if the vaccine is given before a girl becomes sexually active. Hence most pediatricians now discuss this with parents at a time when they are not quite ready to consider that their “little girl” will engage in sexual activity. But they will… Finally this survey emphasizes what we already know; all young teens should be taught about STD’s and the need for protection before they have that first, often too early, sexual encounter.

Your daughter comes to see me…she has a boyfriend or perhaps already had one (or, and I know this is hard, several). She may be going off to college and she (or you) want to make sure she is prepared, not just with books or the latest in fashion, but with birth control. You probably want me to sternly reiterate those warnings about STD’s and the need to use condoms if (oi) she should become sexually active. This admonition may sound more authoritative from me than from either her teachers or you.

But should I do a Pap smear to “make sure everything is alright?” Or when she comes back from school and sees me a year later, and admits to sexual experiences, should I do it then?

We have heard a lot about cervical cancer and its cause, the human papilloma virus (HPV). To be succinct….there is no cervical cancer if there was no prior and usually ongoing HPV infection. (Remember when we were told that women who had never had sex would not get cervical cancer….we just didn’t know why, now we do; they were not exposed to HPV.) Well most of us have been exposed….the current estimate is that 50% of sexually active women in the United States will have a positive test result for HPV within 36 months of the onset of sexual activity. And because recurrent infections are also common, 57% of sexually active female adolescents (defined as a teens up to the age of 20) are infected with HPV at any one time. There are at least 30 types of HPV but thankfully, only some of them are high risk instigators of cervical cancer.

Here comes the good news… Eight months after initial infection the HPV usually becomes undetectable and in most adolescents with an intact immune system the infection resolves within 24 months.

Based on these facts, the American College of Obstetricians and Gynecologists (ACOG) does not recommend the use of HPV testing in this young population. (But they do recommend that adolescent girls and women up to the age of 26 receive the currently available HPV vaccine that builds immunity to 4 types of HPV….see my post on Gardasil). Moreover, there is no rush to do a Pap smear on these adolescents. Once more ACOG has come out with the recommendation that “the first Pap be done 3 years after the onset of vaginal intercourse and no later than age 21 and annually thereafter until age 30”

If perchance a PAP or HPV test was done before that and the HPV was positive, it should be ignored! If the Pap shows minimal abnormal cells (in technical terms ASC-US and LSIL) it should simply be followed since in most cases these changes will simply go away within 2 to 3 years. To make sure, ACOG s recommends doing a repeat Pap every 12 months for a 2 year period. Further testing with colposcopy and possible biopsy should be done only if these mild changes (termed CIN1 and CIN2) persist for 2 years or the Pap indicates more advanced “high grade” lesion (HSIL).

As with any STD diagnosis, the adolescent becomes an “immancipated minor” and parental consent for diagnosis and treatment, although preferred may not be required. (I generally ask my adolescent patients if I am “allowed” to talk to her parents, but will keep her privacy if she insists…especially if the test or therapy is not a threat to her health. Since most parents see the bill from the lab, complete confidentiality may be difficult).

So if you ask me to see your adolescent daughter, I, like most clinicians will sternly advise her about STD’s, the need for birth control and condoms. I probably will not do a Pap or HPV testing…until she is 21. And even at that age, I will “forgive” an HPV infection and/or mild changes in the cervical cells, but not ignore them. The plan will be to follow her with future Pap smears, HPV and STD testing.

Once upon a time most of us moved here, to LA, from other states or countries. And we love it!  As veteran Los Angelinos we live, work and of course, look at others in this, our youth and media oriented city. The inevitable follows: we would like to look like a celebrity worthy of an appearance on Oprah or at least appear younger than our chronologic age. So when we see ads politely inquiring whether we are developing a bulge above our jeans, flushing, flashing (from heat, not exhibitionism), sleeping poorly, loosing our libido or worse… wrinkling; we go on the alert. Who can resist that spiel? : Step right up and spit here; we’ll see what you’re missing and order you a very special, made- just- for- you therapy. Rub this cream on, swallow these capsules, put these drops under your tongue and don’t worry, these “bioidentical” hormones are chockfull of health, not like the ones made by those big, bad pharmaceutical companies.

Many of my tenured (note I refrain form using the adjective “old”) and new patients want to know if they should start these “bioidentical” hormones or switch to them.  To quote Shakespeare, who was hormonally clueless but recognized some distressing female symptoms:  Here’s the rub.

“Bioidentical” is a marketing term. It’s as ingenious as the word natural when it comes to selling a product; both appeal to consumers’ aversion to artificial ingredients. But remember, hemlock is natural.

When the term “bioidentical” is used by compounding pharmacies and celebrities who are often selling their products or touting their own books, it refers to formulations of various types of estrogens, progesterone, adrenal hormones, and androgens (male hormones) compounded within creams, gels, lotions, capsules, drops, capsules, and even suppositories.  The compounded estrogens are often a combination of weak forms of estrogen (estrone or estriol) as well as the stronger  estradiol. In order to get significant relief of menopausal symptoms, large doses of the estriol or estrone   have to be used and there is no evidence that this is safer than the lower dose of estradiol which, by the way, was produced by our ovaries and accepted by nearly every cell in our bodies during our reproductive years. Estradiol is the estrogen contained in many of the FDA approved hormone therapy medications, and/or the metabolite (the end result after processing in the body) of these medications.  Nearly all plant derived estrogen therapy, both individually compounded formulations and pharmaceutical products come from the same soy and yam precursors. They all undergo chemical conversion to become hormones. ( The concept of plant gathering followed by stomping created a great “I Love Lucy” sketch and will work for grape juice and ultimately wine, but will not result in a biologically active hormone product, no matter how skillful the stomping and crushing.) Compounding pharmacies may claim that the combination of their estrogens is either safer or more natural than any of the products that are commercially prepared by pharmaceutical companies. No clinical studies published in reputable peer review journals have shown this to be true. As for the claim that estriol may reduce the risk of breast cancer; this is pure speculation based on old studies that were usually carried out on animals. The FDA has unequivocally stated that it is not aware of any credible scientific evidence to support claims made regarding the safety and effectiveness of compounded “bioidentical” hormone replacement drugs. They have taken action against seven pharmacy operations that claim their compounded “bioidentical drugs” which contain hormones such as estrogen, progesterone and estriol are superior to FDA-approved menopausal hormone therapy medications. The American College of Obstetricians and Gynecologists (my professional entity) has the same concerns stating that “most compounded products have not undergone rigorous clinical tasting for safety or efficacy and issues regarding purity, potency and quality”.

Doctors who prescribe these “bioidentical” hormones often use salivary (spit) testing to tailor the amount of hormones they prescribe. But salivary hormone levels vary tremendously throughout the day and differ from woman to woman. Moreover we don’t have studies that demonstrate a correlation between the levels of spit hormones and a woman’s clinical state or her response to hormone preparations. The major mavens on menopause (we have a society for everything), The North American Menopause Society, does not recommend saliva testing to determine hormone levels, nor do they recommend custom compounded products over “well tested, government approved products for the majority of women”. All these institutions are concerned that patients do not see the black box warnings that are prominently displayed with FDA approved medications…the ones that state that hormones should not be used if you have had certain conditions that include estrogen related cancers and blood clots and the concerns about risks for long term use.

Finally who pays? Sometimes insurance companies do, but often the patient is stuck with a bill that is higher than the one she would pay (or co-pay) for commercially prepared hormones. Moreover if the practitioner who prescribes “bioidentical” hormones also sells them from her or his office, there is a potential conflict of interest.

Some hormones including testosterone and DHEA (used for low libido or specific deficiency disorders) may not be available in pharmaceutical products and will have to be compounded. As a matter of full disclosure, I do prescribe compounded hormones when the latter are needed or when a patient becomes allergic to standard therapy. But I advise all my patients that there are no free hormones, no matter how they are made. There is an indication and contraindication to every medication and it’s imperative that your physician use appropriate, up-to-date studies in order to inform you of both.

Unfortunately, no hormone will provide you with that lost fountain of youth. But when prescribed for significant symptoms in appropriate doses, hormone therapy will help you feel better. Exercise, proper nutrition, weight control, hair color, make-up, and the right lighting are the only proven (and risk free) ways to help you feel and look your best.

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