Most of us watched with amazement (at least I did) during the World Cup as the soccer players used their heads and feet to make goals. (I will not discuss the Brazil team.). We have also been bombarded with information about concussions, especially in male football players. I suppose that butting the ball with one’s head in soccer is not brain protective. An article in the clinical review of JAMA at the end of August caught my attention. It was titled “Concussion and Female Middle School Athletes”. There were definitions of concussion, a list of health implications of concussion and statistics that I thought were highly informative for many of us as we watch our daughters and the daughters of our friends and family engage in this “getting more popular” sport.

A concussion in sport is defined as a process that affects the brain as a result of traumatic forces. (Well that part is clear.)

There are five features that characterize a concussion:
1. A direct blow to the head a blow to the body that transmits and “impulsive” force to the head.
2. This results in a rapid onset of short lived neurologic impairment that resolves spontaneously.
3. The clinical symptoms may or may not include loss of consciousness.
4. No abnormalities are seen on imaging studies.
5. The symptoms may be prolonged in a small percentage of cases.

Among high school athletes, concussion rates are highest in boys football and girls soccer. And in similar sports girls have higher rates of concussions then boys. Apparently female sex is a risk factor, so is prior concussion, young age and a history of migraine headaches. Symptoms include headache, dizziness, mental fogginess, difficulty concentrating and remembering and fatigue. Loss of consciousness occurs in less than 10% of concussions and the typical recovery time for an adolescent athlete is 7 to 10 days. (But the article noted that for some individuals, recovery may take weeks or months.)

In a report that was published in JAMA Pediatric a study, was done between 2008 and 2012 for soccer clubs in Washington state that involved 351 elite female soccer players from 33 youth soccer teams age 11 to 14. Among these girls 59 concussions occurred within over 43,000 athletic exposure hours. This meant that the cumulative concussion incident was 13% per season and the incidence was 1.2 per 1000 athletic exposure hours. “Heading” the ball counted for 30.5% of the concussions and most players continued to play with symptoms!

Perhaps the most concerning part of the report pertained to potential long-term effects of concussion. These include persistent deficits in memory and visual processing, decline in academic performance, depression, dementia and postconcussion syndrome (the symptoms last longer than three months) as well as second impact syndrome. That means that if another concussion occurs it can cause rapid brain swelling and this can be fatal!

The good news is that there is now legislation in all 50 states requiring schools to have protocols in place for concussions. They are supposed to have educational materials and guidelines for athletes, coaches and parents and the parents and athletes have to sign informed consent acknowledging the dangers of concussion before participation in sports. Any student who shows signs of concussion must be evaluated and cleared by a healthcare professional before being allowed to return to practice. However, unlike many high schools where athletic trainers are trained (we hope) to evaluate and manage injuries, youth sports leagues rarely have any type of medical coverage on site.

Since I knew so little of this information, I thought it was worthy of being shared…my conclusion is that parents need to be aware of concussion risk and engage in discussions with their daughters’ coaches. And just perhaps, encouragement to play tennis, swim, dance or go out for track is in order…

This week passed quickly and before I knew it my Friday website was due. As I scanned the various medical journals, I found an interesting article in the Journal of the North American Menopause Society. The long but very comprehensive title of the article is “Calcium/vitamin D supplementation, serum 25-hydroxy vitamin D concentrations, and cholesterol profiles in the Women’s Health Initiative calcium/vitamin D randomized trial.”

The authors (17 of them in multiple centers in the US) wanted to evaluate whether increased levels of active vitamin D concentrations in the blood, the 25 hydroxy form (25OHD3), became elevated after calcium/Vitamin D supplementation and were associated with improved cholesterol levels in postmenopausal women.

The randomized, placebo-controlled trial included women already in the Women’s Health Initiative Study (WHI) and who had been enrolled in 1993 and 1998. The group they specifically studied included 300 white women, 200 African-American and 100 Hispanic women that were randomly selected from the larger WHI trial. They measured their serum (blood) vitamin D levels before starting the study as well as their lipid levels which included fasting triglycerides (TG), high density lipoprotein cholesterol (HDL- C) and calculated low density lipoprotein cholesterol (LDL- C) levels before and after calcium vitamin/D supplement.

After two years, they compared these blood tests for the women who took 1000 mg of elemental calcium and 400 units of vitamin D (CaD) and those who took a placebo. They found that those who took supplemental CaD significantly increased their vitamin D levels and decreased their LDL- C levels. The women with the higher vitamin D concentrations had more favorable lipid profiles including an increase in their HDL-C (the good cholesterol), lower LDL- C and lower TG.

If you want the numbers… In the study the women on CaD increased their vitamin D levels by 38% compared with those on placebo and those randomized to CaD decreased their LDL- C by 4.46 mg/DL. And if the serum concentrations of vitamin D increased significantly then all three parameters of the lipids improved.

They did add one thing… That many of the women were on hormone therapy and there is the possibility that there is a synergistic relationship between vitamin D and estrogen therapy which could have improved the impact of Vitamin D on lipid levels.

Bottom line: According to this study as well as many others, your vitamin D level is important to your health and improving it with supplements may have a positive impact on your lipid profile and ultimately (and I have to interject “a perhaps” here, since this has not been sufficiently studied) on coronary heart disease. I usually suggest that my patients follow “the one and one” rule. Make sure you get 1000 to 1200 mg of calcium through diet or supplements and take 1000 units of vitamin D.

I’ve been back from vacation this week and have diligently looked at the articles in most of the usual journals. Initially, I didn’t find one that I wanted to report.(Note one article, in the New England Journal of Medicine, dealt with a mutation in a gene in 154 families in Europe and their risk for breast cancer… but I think it was a bit too esoteric to cover in the website.)

I did download an article that appeared in Contemporary OB/GYN which I get online. Under the heading “expert advice” they reviewed an article published in the Journal Radiology (which I don’t read) and that I thought was interesting. This was a study of 1162 women who had primary breast cancer and were 75 or older. Information in their charts from the time of diagnosis was reviewed and accessed for stage, treatment, outcomes, and whether the disease was detected by the patient, her physician or with mammography. The women’s survival rates were then compared. During the study (between 1990 and 2011) mammography detection of cancer over time increased from 49% to 70% and was most common for early stage 1. Detection by a patient or her physician was more common when the disease was more advanced at stage II or stage III. The investigators found that lumpectomy and radiation were common and mastectomy and chemotherapy less common in women who had mammography-detected disease than those with cancers found by the patient or her physician. Additionally, five-year disease specific survival was better in women with invasive breast cancer detected by mammogram (97% versus 87%). The investigators concluded that women who have mammogram-detected cancer were diagnosed at earlier stages, required less overall treatment and had better survival rates than women with cancer detected by themselves or physicians.

Bottom line: Women older than 75 may still derive benefits from mammography screening. I will keep ordering them…

I have to admit that I’m writing this in the midst of feeling wide-awake, rested and in fabulous mountain air while vacationing with my family at Mammoth Lake. Amidst the hiking and biking, I relaxed by checking out recent medical articles on my iPad. (Yes, I know this is not a sign of great mental health.) And what I found were the new clinical guidelines from the American College of Physicians based on their review of the medical literature on obstructive sleep apnea (OSA). No, this did not cause a diminution of family worries, but I thought the guidelines were worth sharing…

A quick review of the subject: In individuals with obstructive sleep apnea, breathing slows or briefly stops because the airway becomes blocked during sleep. This is usually accompanied by snoring (which annoys or disrupts the sleep of anyone within 20 feet and certainly a bedmate). The clinical symptoms of sleep apnea include unintentionally falling asleep, daytime sleepiness, waking from sleep without feeling refreshed, fatigue, and cognitive impairment. OSA affects 10 to 17% of the US population! It’s not just an annoyance; it is a serious health condition and is associated with cardiovascular disease, hypertension, difficulty with cognition and type two diabetes. It is not gender specific and the most common risk factor is obesity. As women get older, go through the menopause transition and often gain weight they begin to equal men in their incidence of obstructive sleep apnea.

Clearly there are are other causes for day time sleepiness and fatigue. Too few hours devoted to sleep and chronic insomnia are, unfortunately, extremely common…. The National Sleep Foundation states that as many as 40% of the population may be sleep deprived! Other disorders that can cause these symptoms include thyroid disease, GERD (reflux), and respiratory conditions. Until they are ruled out, the ACP states that it’s important to diagnose excessive daytime sleepiness with a sleep study, preferably done overnight in a sleep lab. A special monitor called a polysomnograph is used to monitor breathing, airflow, brain activity, oxygen levels and certain muscle movements during sleep. The study is fairly expensive and not always available…the alternative is to have a physician prescribe testing with a portable sleep monitor that can be used at home or in the hospital.

The most common form of treatment for obstructive sleep apnea is with a CPAP or continuous airway pressure device which keeps the airway open while asleep. It consists of a mask or other device that fits over the nose or the mouth and nose. This is connected to a motor that blows air into a tube connected to the mask. Most CPAP machines are small, lightweight and fairly quiet. The noise they make is soft and rhythmic (sort of white noise) and often does not impede relaxation and sleep. According to the NIH most people who use a CPAP report feeling better almost immediately once they begin treatment; they feel more attentive and better able to work during the day. So do their partners. There are surgical therapies, but they’re usually not used unless the CPAP has failed. And because obesity is the most weighty factor for obstructive sleep apnea, weight loss is vitally important. Every expert will tell patients that the first thing they should do is to lose weight. That alone may suffice to treat OSA.

So instead of using the expression “good night, sleep tight” when we send loved ones off to bed, we should probably say “sleep silently and continuously”. Those eight hours (the ideal) mean as much to our health and well-being as our daytime behavior.

I was considering omitting a website article this week. It’s been a tough week… A very good friend died from virulent leukemia. But I am back in the office and seeing patients and yes, I did look at some of the articles. The one that I thought might be of interest was a report by the FDA and the Environmental Protection Agency encouraging pregnant women as well as women who may become pregnant or breast-feeding as well as young children to eat more fish.

In their draft guidance, the agencies are calling for women to consume 8 to 12 ounces of a variety of fish that are lower in mercury; that amounts to an average of 2 to 3 servings per week. The fish that have lower mercury levels include salmon, shrimp, pollock, tuna (light canned), tilapia, catfish and cod. The US Department of Agriculture suggests an amount of 3 to 5 ounces per week for children under the age of six and 4 to 6 ounces per week for children age 6 to 8. The agencies feel that there is “long standing evidence of nutritional value of fish in the diet. Fish contain high-quality protein, many vitamins and minerals, omega-3 fatty acid and are mostly low in saturated fat, and some fish even contain vitamin D. The nutritional value of fish is especially important during growth and development before birth, in early infancy for breast-fed infants, and in childhood.”

There have been long standing concerns about the mercury content of fish and as a result the FDA found that 21% of pregnant women consume no fish and 50% are eating fewer than 2 ounces per week. There are some types of fish that the FDA still suggest that women and children avoid: these include tilefish from the Gulf of Mexico, shark, swordfish, and king mackerel. They also recommend limiting white (albacore) tuna to 6 ounces per week for adults and even less for children.

So there you have it…as usual recommendations can be changed. And now those issued by the FDA/EPA in March 2004 have been replaced with a recommendation of simply consuming up to 12 ounces of a variety of fish per week (two average meals) avoiding the four types of fish I listed above because that have a high mercury content.

Hooray for salmon! Now I just have to figure out what gefilte fish is made of…

By now you have heard about the side effects of this commonly used both over-the-counter and prescription medication to raise HDL and lower LDL. But I finally got the article in the July 17 New England Journal of Medicine and wanted to give you a little more scientific information.

I almost didn’t write this segment because I’ve been overwhelmed with what’s happening in Israel. The good news is that my daughter and her young children came to Los Angeles two days ago. They literally got out on the last flight before the 24-hour closure of the Ben-Gurion airport. I think it’s open now to flights on all airlines and hopefully some of this conflict will be resolved. I can’t stop watching the news and despair over the fighting in Gaza that has destroyed the homes and lives of civilian population that could not or would not find refuge and the hourly bombardments of missiles sent by Hamas to Israel, intended to cause widespread killing of anyone in range. (Thankfully, the iron dome works.) I like everyone, hope that a valid cease fire will be negotiated. But how does one negotiate with a terrorist organization whose goals are to hold on to power and eliminate the country of Israel and it’s citizens from the face of the earth? They show no regard for their civilian population (other than to allow them to shield weapon stores) and take every opportunity to run with cameras to record their suffering, and mourning…and yes, we all have to be appalled. As many of you know, I am on the board of Save the Children. We have programs in Gaza and have tried over the years to improve the health care, education and hope for a better future for the children there. Children are never to blame for conflict and are always the ones who suffer. Unfortunately, it would seem that much of the millions of dollars sent there by so many NGO’s has been used to building tunnels and purchasing weapons rather than for infrastructure and care of the population.

I”ll stop now…I know I am not supposed to wax political, but it’s hard to always be the evidenced based doc.)

So on to niacin… Ever since I went to medical school we’ve been taught that high density lipoprotein or HDL particles help decrease coronary heart disease. The higher the HDL the lower the disease in the general population. Likewise LDL or low density lipoprotein cholesterol increases plaque formation and enhances heart disease. The question is, are these two types of cholesterol risk factors or signs of heart disease or do they indeed have an impact in causing heart disease? The articles published in the July 17 New England Journal of Medicine may have changed our assumption of causation. In the heart protection study two- treatment of HDL to reduce the incidence of vascular events (HPS 2-THRIVE), 25,673 adults ages 50 to 80 with underlying cardiovascular disease were given either an extended release niacin combined with laropiprant (an agent that helps prevent flushing) or placebo and were followed for four years. Prior to the randomization, they had been put on statin based therapy. During the trial, the participants who received niacin raised their HDL 6 mg/dL and lowered the LDL cholesterol 10 mg/dL as well as their trygliceride level 33 mg/dL compared to those receiving placebo. Despite these favorable responses there was no significant reduction in major vascular events. Moreover, there were significant side effects which included an increase in gastrointestinal complications, infections, muscular skeletal pain, development of diabetes and a 9% increase in the risk of death. The American Heart Association now gives a very limited and cautious recommendation regarding the use of niacin…They state that niacin may still have a role in patients with very high risk for cardiovascular events who truly have contraindications for taking statins and who have a high LDL-cholesterol level. They also suggest that there may also be a use for those who have very high triglycerides and for whom it could be used to prevent pancreatitis. In an editorial in the same journal the author suggests that “it is time to face the fact that increasing the HDL cholesterol level in isolation seems unlikely to offer cardiovascular benefit”.

So before you take niacin as a so-called easier way to deal with cholesterol problems, please consult your physician. Next week, I hope I can write an article that doesn’t also deal with the middle east conflict.

I have devoted several website articles about the importance of HPV vaccination to help prevent cervical cancer in women and genital and anal cancer in men. I now have another reason to promote this vaccine. It comes from news from the Centers for Disease Control and Prevention reported in last week’s JAMA. The journal summarized an article that was published in the Journal of Infectious Diseases on the correlation between HPV infection and oral and or throat cancers. (Note, there’s a medical journal on everything, I don’t get a chance to read most of them and depend on JAMA or the New England Journal of Medicine to bring important articles to my attention.)

A recent analysis showed that 72% of 557 invasive oral pharyngeal squamous cell carcinoma samples tested positive for human papilloma virus (HPV). In nearly 2/3 of the samples, the investigators detected HPV-16 and HPV-18, the strains most often linked with cervical cancer. The HPV vaccines that are currently available actually target HPV-16 and -18 and therefore should be highly effective against this type of cancer.

The current estimates indicate that worldwide there are about 85,000 cases of oropharyngeal cancers that are diagnosed annually and in the United States about 12,000 new diagnosis are made each year. Most are classified as this type of squamous cell carcinoma. Wouldn’t it be amazing if we could immunize all adolescents and young adults and prevent these often fatal cancers! One more reason to make sure that the vaccine is given.

As I sit here worrying about the Middle East and talk to my family in Israel, I’m experiencing hot flashes. Admittedly, they are from anxiety and not a hormonal imbalance, but they have made an editorial I read this week in the Journal Menopause more compelling. It’s titled “Hot flashes: is a hot flash just a hot flash?” The author, Dr. Lila Nachtigall a professor from New York University, has long been an advocate of hormone therapy and has written multiple articles and given many lectures on menopause. Her current editorial highlights issues that may be of interest to many of my patients.

Studies conducted in 1990 have shown that among untreated women, 80% of hot flashes will stop in three years and 90% of hot flashes will be over after six years. A few women, however, can have them for 40 years or more. In more recent studies of women who have hot flashes, 25% reported that the symptoms remained for more than five years and 10% reported that the symptoms continued for more than 10 years. Why? Well, we know it’s lack of estrogen that causes these vasomotor symptoms. The brain has an inner thermostat zone that impacts the body’s ability to heat or cool with minimal temperature changes. There is a hormone; norepinephrine (now aptly called brain norepinephrine) which is released from brain estrogen receptors when they are not receiving estrogen. This hormone sets off responses in the body to impose heat regulation and cool the body though dilation of superficial blood vessels (flushing) and evaporation of fluids (perspiration). Women who are recently or suddenly postmenopausal have more of these used-to-work-estrogen receptors. Estrogen deprivation together with what we call up-regulated receptors cause these women to have more frequent and more severe hot flashes. (I know this doesn’t explain why 10% continue to have significant hot flashes. We do know if the hot flashes were severe from the start they are more likely to continue…perhaps because the estrogen receptors remain robust.)

There have been studies that have shown that the severity of hot flashes is associated with lower levels of health and even work productivity. One study called The Study of Women’s Health Across the Nation has shown that hot flashes are associated with a higher incidence of insulin resistance. Other studies including the Women’s Health Initiative have shown that there are higher risks of cardiovascular disease in women with significant menopausal symptoms. Those experiencing severe hot flashes have an increased risk of coronary heart disease by a factor of five compared with their counterparts who had less or no symptoms. Similarly, the risk of stroke was elevated by a factor of almost 4. Brain PET scans have shown that there is a significant decrease in cerebral blood flow during a hot flash. The author goes on to state that this may explain a woman’s inability to continue her tasks during a severe hot flash.

As a result of some of this data the American College of Obstetricians and Gynecologists has added new clinical guidelines for the management of menopausal symptoms. This directive encourages physicians to treat vasomotor symptoms i.e. hot flashes and not use age as a guideline, stating that the decision to treat should be individualized and there is no need to discontinue medication if a woman is still symptomatic after age 65.

Although it’s clear that estrogen will indeed prevent those brain receptors from releasing vasomotor causing norepinephrine there are other pharmacologic medications that are available to help diminish or stop the hot flashes. One of these is a low-dose SSRI (Paxil) called Brisdelle. A new formulation of gabapentin was found in a recent phase 3 study to statistically reduce frequency and severity of hot flashes.

The pros and cons of hormone therapy, types of hormone therapies, and alternatives to hormones have become a major subspecialty in the treatment of women over the age of 50. It’s difficult to give an assessment of what can and should be done in one article or one exam. Like everything in medicine, symptoms, personal and family history, health risks and of course symptoms have to be properly assessed by both the patient and her physician. New studies and expert insights improve our ability to make more informed decisions. So I thought I would share …and no, I have no ready solutions, despite copious reading, that helps me cope with my Middle East anxiety.

I know most of you may not be reading this email on Friday because it’s the Fourth of July. I’ll try to send it out earlier or you might pick it up after the holiday. So Happy 4th and enjoy the barbecue, parades and fireworks.

I couldn’t let the week go by without reporting on an article in the June 25 issue of JAMA that reports on a study of breast cancer screening using a method called tomosynthesis. The efficacy of tomosynthesis combined with digital mammogram was compared to digital mammogram only for breast cancer screening. A debate about the utility of digital mammogram has once more been brought up by the recent publication of the 25 year follow-up results from the Canadian National Breast Screening Study. It showed that there was no difference in breast cancer-related mortality in screened women versus controls. Many physicians and organizations have however, countered that these results were not valid for current U.S.policy; that the study was based on mammograms that were of poor image quality and that there were significant problems in randomization. Indeed, 14 more recent studies published between 2001 and 2010 have indeed shown a 25 to 50% reduction in breast cancer related mortality for women aged 42 to 74 years who had modern (and presumably better) types of digital mammogram screening. The American Cancer Society, the American Congress of Obstetricians and Gynecologists and other organizations still recommend screening mammography annually for women older than 40 years. The American Cancer Society also recommends annual MRI for women with a 20 to 25% or higher lifetime risk of breast cancer.

The article in JAMA is a retrospective analysis of screening in 13 centers over two time periods. During the initial period more than 281,000 examinations were done with digital mammogram alone. The second period included more than 173,000 examinations during which patients underwent combined digital mammogram and tomosynthesis screening. I know the word “tomosynthesis” sounds very synthetic biology. It is high tech but but not a biological creation. Basically, it is composed of a set of low-dose images produced by x-rays as they moves across the breast. The images are then put together to form a picture by a computer algorithm (of course) that reconstructs the images as slices of the breast. The advantage is in the resolution and clarity of the final image. An area may look suspicious because tissue overlaps from the pressure of a simple mammogram procedure; tomosynthesis is meant to prevent this effect and hence reduce false densities while making a cancer appear more conspicuous.

So does adding tomosynthesis to usual breast screening make a clinical difference? In this study the authors found that the introduction of tomosynthesis was associated with a significant decrease in recall rate (i.e the. need to get additional films, ultrasound, MRI or even biopsy) of 1.6%. There was however, a significant increase in the biopsy rate (1.3%), but perhaps the biopsies were more likely to confirm a cancer. There was an increase in the cancer detection rate of 0.12%. The latter doesn’t sound like much, but it made a difference for the 1.2 women whose cancer was found per 1000 screenings… They might not have had that early diagnosis with standard mammograms. There is however, as always, a drawback in medical innovation and the one here is that tomosynthesis requires twice as much radiation as a regular digital mammogram. And it is too early to know if adding this procedure will impact mortality rates from breast cancer.

In an editorial in the same journal the authors state that “Recent work has suggested that tomosynthesis is likely to outperform mammogram in finding small invasive cancers and lobular cancers, the ones that are most likely to be lethal.”

This and other studies raise some major questions for both physicians and women. Should we seek screening with tomosynthesis over digital mammogram? Should breast cancer screening centers convert to tomosynthesis and abandoned digital mammography? (Which will be costly.) Right now there doesn’t seem to be enough data or financial incentive to do so. But, tomosynthesis may indeed be an advance over digital mammogram for breast cancer screening and one day may become the norm in breast screening. As usual, I’ll end with the off-stated refrain…More studies are needed.

Up to 20% of women experience at least one episode of clinical depression in their lifetime. Talking to my patients and surveying my family, I sometimes think it might be even more than that… But I will cheerfully tell you about an article that came out in the New England Journal of Medicine on June 19. (The day before my birthday, a somewhat depressing event although I kept telling myself that aging is a privilege.) The article was titled “Antidepressants on Pregnancy and Risk of Cardiac Defects”.

According to the authors from the Department of Medicine at the Brigham and Women’s Hospital and Harvard Medical School, clinical depression occurs in 10 to 15% of pregnant women. The use of antidepressant medications during pregnancy has increased and is now reported to be 8 to13% in United States.. The chief concern is use of these meds in the first trimester pregnancy when potential teratogenic effects are more likely to occur, especially cardiac malformations. There been many studies that tried to address this issue and indeed on the basis of early results of two epidemiological studies, the FDA warned physicians that early prenatal exposure to Paxil could increase the risk of congenital cardiac malformations. Since then, however, other studies have been done with conflicting results and there is still significant controversy regarding whether this is (as the authors put it) “a serious concern or much ado about little.”

The current study published last week used a large national database of women from 46 U.S. states and Washington D.C. who were insured through Medicaid and were pregnant and delivered during the period between 2000 and 2007. Apparently this included close to 950,000 pregnancies. (Just so you know, Medicaid covers the medical expenses for more than 40% of births in the United States!). During the first trimester, 64,389 women or 6.8% used an antidepressant. The most common were Zoloft, Paxil and Proxac. When the researchers restricted their study to women with a recorded diagnosis of depression, they found that there was no increase in the risk of cardiac malformations among infants born to women who took the antidepressants during the first trimester as compared with infants whose depressed mothers did not. Other studies had not done this, they simply compared women who took antidepressants in pregnancy to those who most likely were not depressed and didn’t need them. The authors pointed out that in restricting the study to women with a recorded diagnosis of depression they have corrected for the potential influence on pregnancy of underlying psychiatric illness and associated conditions and behaviors which could increase the risk of malformations. These include smoking, alcohol and illicit drug use, poor maternal diet, obesity, diabetes and hypertension all of which are more common in women with depression than in those without. They also pointed out that women with depression and anxiety are more likely to use health care resources and hence there’s a higher chance of detecting a cardiac malformation in an infant who has a minor malformation that might otherwise have remained undetected and even self-corrected in early childhood.

Their conclusion: the use of antidepressants during the first trimester does not substantially increase the risk of cardiac malformations. They then add the phrase that is applied to just about every medication used in pregnancy. “In making decisions about whether to continue or discontinue treatment during pregnancy, clinicians and women must balance the potential risks of treatment with the risk of not treating”… In this case severe depression.

Although many of my readers are not pregnant, they may have used antidepressants in past pregnancies and worry about potential consequences an/or they have friends and family who will need to consider using antidepressants in current or future pregnancies. This study gives reassurance.