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.

We’ve all been hearing more and more about HPV infections; that they cause cervical cancer, vaginal cancer, anal cancer, throat cancer, mouth cancer and venereal warts. I’ve written several articles about the need to immunize girls and boys with the HPV vaccine. The most common vaccine, Gardasil is given in 3 doses, it is a quadravalent vaccine, which means it gives immunity to 4 types of HPV (6,11,16 and 18). These are the ones that cause 70% of cervical cancers, many of the other above mentioned cancers as well as venereal warts. But alas, despite the multiple direct to consumer ads in the media, recommendations by most doctors and the studies in peer-reviewed journals, only one third of adolescents are currently being immunized.

We would certainly expect the prevalence of these infections to be significantly diminished in those whose parents had the clinical acumen to have their children immunized. But they represent just 30% of their peers. So it was pleasantly surprising to find that a study published online in the Journal of Infectious Diseases reported that the prevalence of infections with the human papilloma virus types included in the Gardasil vaccine dropped by almost 60% among females aged 14 to 19 years during the four-year period after the vaccine became available and was recommended. Dr. Thomas Frieden, the CDC director, said during a press conference held to announce the results of the study, that increasing the vaccination rate to 80% would prevent about 50,000 cases of cervical cancer among girls alive today. “We owe it to the next generation- our sisters, our daughters, our nieces and to protect them against cervical cancer.”

Just to remind you, a three dose series of the quarivalent HPV vaccine was recommended in 2006 by the CDC as a routine vaccination for females age 11 to 12 years and for females aged 13 to 26 years who had not been previously vaccinated. In 2011, the recommendation for the vaccine was expanded to include boys aged 11 and 12 years and for non vaccinated males up to 26 years. No data is yet available on the proportion of males who have been vaccinated and/or the impact of vaccination on their infection rates.

The nearly 60% drop in HPV infection is greater than expected but can be due to “herd immunity” from vaccination (nothing to do with animals, it means that those who got the vaccination were unable to infect those who did not).

Remember, HPV is the most common STD in United States. The estimate is that 14 million people becoming infected with HPV every year. According to the CDC, 79 million of the those who have become infected with HPV are in their late teens and early 20s. Every year, about 19,000 cancers in women are caused by HPV; most are cervical cancer. And of 8,000 cancers caused by HPV that occur in men in the United States, most of them are oropharyngeal (mouth and throat).

Wow, this vaccine can make a huge difference. It may be too late for many of us who are over the age of 26 but we certainly can make sure that the younger (and youngest) generation are vaccinated… Not to do so is malparenting!

Like many gynecologists, I no longer deliver babies. (I do miss it, although I don’t miss the hours.) And I realize that most of my patients are not going to have to deal with decisions about delivery. But their friends, daughters, daughters-in-laws and even granddaughters may. There was a prominent article that came out in the May 8 issue of JAMA about elective cesarean delivery on maternal request (CDMR) and I thought that if this topic was important enough to warrant publication in this journal, it was worth bringing to your attention.

The prevalence of CDMR in the United States is not precisely known. In order to gather statistics about it, there has to be a diagnostic code which is used as an official indication for the procedure in order to record it as well as to bill insurance; unfortunately there is none. The author of the article stated that the prevalence of CDMR is probably less than 3% of all deliveries.. But what I felt was fascinating was that 18% of obstetricians responding to a 2006 survey from the American College of Obstetricians and Gynecologists indicated that they would prefer CDMR if they or their spouses were delivering an uncomplicated cephalic (headfirst) singleton (one baby) pregnancy at term. There was similar data from Britain that describe preference for CDMR in 10% of midwives, 21% of obstetricians, 50% of urogynecologists, and 50% of colorectal surgeons. The reasons that were cited included fear of labor, prior poor experiences with labor, concern about specific outcomes including anal and urinary incontinence, fetal injury, and need for emergency cesarean or operative vaginal delivery.

There can be complications for both methods of delivery…who said having a baby was easy or uncomplicated. After all, I and all other Ob-Gyns spent years training to help women do so. One source of concern is late term pregnancies, i..e. not going into labor at 40 weeks gestation. Data from an examination of California birth certificate recorded that 1284 stillbirths occurred among 1,653,809 pregnancies delivered between 39 and 42 weeks of gestation or 0.07764%. This suggests that 1288 CDMRs at or just before term might have prevented one stillbirth in this group.

Difficult vaginal deliveries can, as we all know, result in birth trauma, lack of oxygen to the infant’s brain and infection. But with modern obstetrics and monitoring, this has become increasingly rare. There may be a slight increase in bladder and rectal prolapse after vaginal delivery. But when it comes to urinary incontinence, a trial from Baltimore showed that although there were initial increased rates for urinary incontinence with planned vaginal delivery vs planned cesareans delivery (7.3% versus 4.5%), there were no differences between those who planned cesarean delivery and those who planned vaginal delivery when patients were questioned about symptoms two years after delivery.

On the negative side for CDMR, cesarean delivery without labor is associated with an increased risk of newborn’s respiratory complications and overly rapid heartbeat. If this occurs, the infant may have to be transferred to the NICU. The differences in respiratory outcomes between vaginal delivery and CDMR may actually be due to gestational age of birth. Often a planned cesarean section is scheduled before 39 weeks in order to make sure that the date is set and that labor doesn’t ensue before the elective schedule. There is a reason that the term “term” is so important. Prior to 39 or 40 weeks gestation, the infant’s lungs may not be completely mature. That means that although a women may want to “get it over” or choose a date that is convenient for her and her doctor’s schedules… She could delivery a premature infant (from the perspective of its lungs) and this should never be electively done before 39 weeks of gestation.

There is also a concern that cesarean section can result in a decreased chance for bonding between mother and infant especially if the baby ends up in the NICU. Studies have shown that, in general, after elective cesarean section there is less likelihood that there will be immediate breast feeding as well as decreased duration of breast feeding.

Finally, there is a concern about complications for future pregnancies in women who initially have CDMR. Results from a large NIH funded observational study show that the risks of placenta accreta (growth and invasion of placental cells into the underlying uterine wall that prevents the usual separation and delivery of the placenta) and gravid hysterectomy (hysterectomy performed at the time of delivery or in the immediate post partum stage when the uterus is still large and receiving much greater blood supply than the nonpregnant uterus) along with maternal blood loss and surgical complications, increase with increasing number of cesarean sections. Complication rates rise from 0.2% to 2.1% for placenta accreta and 0.7% to 2.4% for gravid hysterectomy in a first compared with a fourth cesarean delivery.

The current recommendations from the National Institutes of Health and the American Congress of Obstetricians and Gynecologists for planning Cesarean Delivery on Maternal Request (CDMR) are:
1. CDMR should not be planned before a gestational age of 39 weeks has been accurately determined.
2. CDMR should not be motivated by the availability of effective pain medication and management.
3. CDMR is not recommended for women desiring several children given the risks of placenta previa, placenta accreta, and gravid hysterectomy that accumulate with each cesarean delivery.

A major concern for the majority of women in their late 40′s and early 50′s has been whether and when to start hormone therapy. (Note it used to be called hormone replacement therapy, but the experts now agree that this term suggests that the menopause transition is an endocrine deficiency disorder and not a natural change in our hormonal and reproductive status, so the word “replacement” is out.)  I concur with the current PC terminology, but should point out that 80% of women experience symptoms related to this menopause transition as their estrogen levels plummet. The most common symptoms are hot flashes and night sweats (called vasomotor symptoms or VMS).  Add vaginal dryness, sleep problems (either due to the hormonal transition or to the stresses we face in mid life), mood changes and even a sense of diminished focus and quality of life and it’s clear that for many women, lack of estrogen production in the menopause creates sufficient physiologic and psychological havoc that they want to do something about it. That most effective something has been hormone therapy; estrogen (as pills, patches, creams, sprays. vaginal tablets and rings) and if a uterus is present (i.e. no hysterectomy) some form of progesterone (again as pills, patches, creams, drops or vaginal gels).

Since the Women’s Health Initiative was publicized, women have been encouraged by the FDA and just about every other official agency that reviews the research on hormone therapy, that if they chose to take hormones, they take the smallest effective dose for the shortest duration, preferably no more than 5 years. That “magic|” 5 year mark has been suggested because it’s felt that menopausal symptoms resolve in most women after 5 years. (Much of the “this-won’t last” data comes from women who have chosen not to take HT and have been followed for years to see what happened to their symptoms.)

Many women don’t want to wait for symptoms to resolve, especially if they are not guaranteed a finish date. Indeed some research has shown that 15% of women continue to have symptoms in their 70′s. Twenty five to 50% of women who stopped hormone therapy after the Women’s Health Initiative resumed therapy. Those most likely to do so had severe symptoms before they started HT, were obese, younger at time of menopause, African American, smokers or physically inactive.

When it comes to “it’s time to stop your hormones” advice I generally suggest that quality of life vs. risk be considered: will you feel lousy enough without hormone therapy to counter the possibility of an increase in your risk for breast cancer with long term (probably more than those 5 years) use of HT?  I also explain that estrogen has positive effects on bone mass and in the first years of use is probably heart protective. |But as the years pass and other factors affect our cardiovascular system, estrogen may no longer afford the same cardiovascular protection.

So what is a woman (who has been happy on her hormone therapy) to do? Should she try to “wean off” or just stop after that arbitrary 5 years?  A new article in the Journal Menopause tried to address this in a scientific fashion.  A study was conducted in Sweden in which the researchers recruited women to stop their hormone therapy “cold turkey” or do so gradually by taking it every other day. They wanted 200 women for the study, but when faced with the idea of stopping their hormones, many refused and they could only find 87 volunteers!  At the end of 4 weeks there was no difference in the symptoms of the women who abruptly stopped and those who tapered and then discontinued.  And because vasomotor symptoms came back for many, within 4 months 30% of the participants resumed their hormone therapy and after 1 year that number had risen to 50%!

Now to my clinical experience… I try to lower the dose of HT for most of my patients after they have taken it for 5 years. (This necessitates a discussion of the possible risks associated with long term use). If a patient is amenable, I prescribe a dose that is lower than that which she has taken and suggest she try it for 4 to 6 weeks. Some of my patients can then keep lowering their dose until they successfully stop and have no symptoms. Others state that although their symptoms resumed “they were not that bad” and they try to stop HT for good. But I do have patients (about 30%) who feel pretty awful, either on a lower dose or once they stop. I then suggest that they continue at the very lowest dose that allows them to keep their symptoms under control.  (And in their next visit I will revisit the risks and benefits of long term hormone therapy. Basically we are agreeing to procrastinate.) As long as we have a frank discussion about the pros and cons of long term HT, the final decision should be made on an individual basis.  Unless there is a truly health threatening reason that dictates that she stop, issues regarding her quality of life (and life style) have to be considered.

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.

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