Menopause and Hormone Therapy – What’s New?

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estrogen replacementIt was only about 100 years ago that the average woman’s life expectancy increased to the extent she would live past the time of menopause. Now with the average life expectancy into the 80’s, a woman may live more than 1/3 of her life in the menopause. The number of women in the menopause is increasing and expected to go up even more. The consequences of menopause include hot flashes, night sweats, insomnia, skin changes, mood changes, depression, anxiety, irritability, loss of libido, vaginal atrophy, cardiovascular disease and weakened bones. How can hormone therapy be safely used to help treat this problem affecting so many women?

We need to put hormone therapy in perspective, and also consider risks and benefits of treatment. Although there is a lot of controversy in the media, patients look to their doctors to be their advocates and give good advice about treatment. It’s our duty as doctors to be informed and advocate for our patients. We need to treat disease in a preventive way, rather than wait for the damage to be done. Disease often starts off in a pre-clinical way, and with some diseases it can be difficult to detect early on. Many diseases that occur have their roots decades before they can be detected, and similarly their treatment may take time to demonstrate a benefit.

Menopausal symptoms

Hot flashes are one of the most bothersome symptoms of menopause. 50% of women have them longer than 4 years, 23% more than 13 years. Temperature regulation helps your body maintain the proper temperature by causing sweating when you are hot and chills when you are cold, thus maintaining a neutral zone of comfort. Hot flashes are a disturbance of this system which are thought to be due to a change in the temperature regulatory system where a decrease in estrogen causes a decrease in the size of the normal thermo-neutral zone in-between sweating and shivering. The end result can interfere with your sleep and your comfort.

Benefits and risks of treatment

Combination estrogen and progestin therapy is FDA approved to treat menopausal hot flashes, prevent osteoporosis, treat vaginal atrophy, and provide other benefits to reduce insomnia, irritability and short-term memory loss. Hormone therapy is highly effective to relieve hot flashes, both their amount and intensity. In women who have a uterus, estrogen alone therapy can increase the risk of uterine cancer, but the increased risk is removed once progesterone therapy is added to estrogen. In 2002 the Women’s Health Initiative study came out and revealed risks of this treatment, including an increased risk of heart disease, stroke, blood clots and breast cancer when both estrogen with progesterone are taken. This had the effect of scaring women into avoiding estrogen therapy even though the absolute risk was only 8 per 10,000 women and the study was based on doses higher than are in use today. This risk is roughly equivalent to the risk of dying in a car accident, and is relatively rare. Rather than being misled by percentages of change, it’s more scientific to consider the absolute risk, and when the risk is less than 1 per 1000 you must weigh that small risk against the improvement in relieving symptoms you get with the right treatment. Other variables to consider include age and method of treatment. Women receiving hormones in the age group of 50-59 have a much less risk of coronary heart disease, stroke, and breast cancer than those in the 70-79 age group. Also women who receive estrogen through a transdermal patch have a significantly reduced risk of a blood clot compared with oral treatment, possibly due to a more stable delivery system and avoiding metabolism by the liver where clotting proteins are made.

Having a uterus makes a difference

Having had a hysterectomy means that hormone replacement therapy need only include estrogen, which is the hormone that conveys most all of the benefits and very little risk. This good hormone decreases the risk of heart disease, protects against breast cancer, and reduces damage to blood vessels with benefits in the brain leading to less risk of Alzheimer’s disease. Women who don’t have a uterus are in a much better position because the only major risks to consider are those related to blood clots and much of this risk can be reduced by getting estrogen through transdermal medications that don’t affect the liver where clotting proteins are made. There are benefits in vaginal lubrication, increased vaginal thickness, better sexual function, better support of the bladder, improved bone strength and decreased cancer of the colon.

Having a uterus makes treatment more complex, because an progestin needs to be added to treatment to decrease the risk of uterine cancer. But what if there were a medication available that can still provide estrogen benefits without the progesterone risk? Well, there is a new type of estrogen now available called a SERM, or selective estrogen receptor modulator, and when combined with a traditional estrogen, its called a TSEC, or tissue selective estrogen complex. The new estrogen has been designed to have some progesterone-like beneficial effects on the uterus (but without a progestin) and also when combined with a traditional estrogen conveys an improved quality of life, more satisfaction with treatment, improved vaginal health, improved sleep, improved bone density, significantly less hot flashes, with less breast pain and less bleeding. The new medication, Duavee, combines an estrogen with a synthetic “designer” estrogen called Bazedoxifene and represents an improved hormone therapy for those women who have a uterus.

While combined traditional hormone replacement therapy can still be used for the majority of women being treated, there are groups of women who are particularly good candidates for this new approach, including women with a family history of breast cancer, women who have had a problem with combined therapy such as tender breasts, those with increased breast density, or if they have had bleeding issues.

Conclusions 

We need safe and effective treatment for menopausal symptoms. The risk of breast cancer is slightly increased with hormone therapies that combine estrogen with progesterone, but not with estrogen alone or in combination with a new estrogen (called a SERM). TSECS combine an estrogen with a SERM to provide relief of menopausal symptoms without the increased risks caused by progestins and offer a new, safer treatment for menopause. These new developments in hormone therapy are just the beginning of designing new safe treatments that provide more benefit at less risk.

This information is from a course “Menopause and Hormone Therapy” given at the 2015 ACOG Annual Clinical Meeting and was presented by Drs Hugh Taylor and JoAnn Pinkerton.

Apps for Pregnancy, 2015

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Apps can be useful and fun. I’m always asking my patients which apps they like for pregnancy. These are some apps that have been recommended to me:

  1. My Days – Period and OvulationIMG_3685

This free, accurate app has is very helpful for determining the best days of fertility and improving your chances of becoming pregnant more quickly. It tracks periods and uses this information to predict fertility in the upcoming month.

Or… it can be used as a birth control rhythm method by knowing which are the most important fertile days and avoiding intercourse at that time.

  1. Perfect OB WheelIMG_3686

Comprehensive pregnancy wheel contains information about conception, length of pregnancy, due date.   It’s simple, fast, free, and has input flexibility, allowing you to put in the last menstrual period, the conception date, the estimated date of confinement, or the number of weeks and days of gestation based on ultrasound dating.

 

 

  1. IMG_3678What to Expect Pregnancy

This very popular app includes a due date calculator, week-by-week details on your baby’s development, weekly baby illustrations, updates on your changing body, and countdown to your due date. You get daily tidbits of advice and it also includes helpful information for dads. It’s from the popular book “What to Expect When You’re Expecting” and works on the iPhone, iPad and even the Apple Watch!

 

  1. IMG_3679Contraction Timer by iBirth

The value of a contraction timer is in its simplicity and ease of use. This app makes timing of contractions during labor easy. It has a simple interface, tracks the duration of each contraction, tracks the intervals between contractions, and has a history report for tracking labor progress over time. It’s great for tracking information that your doctor will want to know in assessing if labor has begun.

  1. IMG_3680Baby Names!!

For people who would like some help in choosing a name, this app will show you the name’s meaning, pronunciation, gender and origin. It also includes graphs of a name’s popularity over time. For example, the most popular girls names now are Sophia, Isabella, Emma, Olivia, Ava and Emily! You can search by name, gender, origin or initial. It links to Wikipedia and gives you oodles of information of more than 30,000 names. It also has a feature that chooses names that fit with those of the parents.

  1. IMG_3684Sex Life – 100+ Positions

This fun guide to sex positions may add some variety to your life!   This app has a contemporary style and can help you try different positions, rate them, keep track of what you have tried, and choose favorites. You can unlock one position free every day and over time build up your amount of visual illustrations.

A score board gives you an overview of your progress.

 

  1. IMG_3681First Aid.                                                                 A useful guide to quick treatment of many different medical emergencies from the American Red Cross, including allergic reaction, burns, poisoning, broken bones, choking, heart attack, heat stroke, seizures, shock, insect bites, unconscious and not breathing.                                                         The app has much useful information that can help you take care of an emergency by yourself or while waiting for help to come. It helps you to be prepared for the unexpected problem.
  2. Lactmed.IMG_3682

LactMed is part of the National Library of Medicine (NLM) Toxicology Data Network and is a database of drugs and dietary supplements that may affect breastfeeding. It includes information of the levels of substances in breast milk and how they could adversely affect the nursing infant. This app can help you know which medicines are safe to take when you are breastfeeding your baby.

 

 

These apps can be very helpful.  But you have to be careful when getting health related apps because some of them may superficially appear reliable but actually are not based on medicine or science. A recent article “Identification of iPhone and iPad applications for obstetrics and gynecology providers” performed a scientific search for quality ob/gyn apps with results described as “finding a needle in a haystack.”

The good news is that more apps are being written every day. As time goes on, I’ll report back on other apps I have found useful and based on reliable information.

United Healthcare changes coverage for hysterectomy.

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UnitedHealth bulletinUnited Health, the nation’s largest health insurer, is changing rules on coverage for hysterectomy. As of April, 2015, UnitedHealth Group will require doctors to obtain additional authorization before performing most types of hysterectomies. Only vaginal hysterectomy performed as an outpatient basis won’t require additional prior approval. Hysterectomy, a procedure done in the U.S. more than 500,000 times per year, is a gynecologic treatment commonly used for heavy bleeding or persistent pelvic pain.

The preferred method for performing a hysterectomy is through the vagina. Vaginal hysterectomy is done by a technique where there are no abdominal incisions, and neither the laparoscope nor the robot is used. According to ACOG, the American Congress of Obstetricians and Gynecologists, vaginal hysterectomy is associated with better outcomes, quicker recovery, and fewer complications than laparoscopic, robotic, or abdominal hysterectomy. With no abdominal incision we would expect less postoperative pain, and a quicker return to normal activity. Yet today vaginal hysterectomy is used in only 22% of cases.

An article published last year cited the experience at a Philadelphia hospital, and concluded that the average hospital costs for the procedures were $7903 for vaginal hysterectomy, $11,558 for total laparoscopic hysterectomy (TLH), and $13,429 for robotic-assisted hysterectomy (RH). The net hospital income was $1260 for vaginal hysterectomy, with losses of -$4049 for TLH and -$4564 for RH. Why would surgeons choose a more expensive method for surgery, one that is not better by any medical metric?

Some surgeons haven’t mastered the skills of vaginal surgery because in residency programs it is not taught as often as laparoscopic and robotic surgeries. Some hospitals push robotic surgery because they have to pay for the expensive equipment it requires. It is thought to be good for marketing the “modern” image the hospital wants to portray. One of our local hospitals had “the robot” on display in their lobby for weeks for marketing purposes.

When a vaginal hysterectomy is performed the cervix is removed, and along with that removal the major risk of cervical cancer is also removed. The cervix is left behind in most laparoscopic or robotic hysterectomies. Some surgeons erroneously think leaving behind the cervix is a good thing for the patient. A review of nine studies showed “no evidence of a difference in the rates of multiple outcomes that assessed urinary, bowel, or sexual function between TH or STH (leaving the cervix behind) either in the short term or the long term.” Leaving the cervix behind also increases the likelihood of cyclical bleeding up to two years after surgery.

Part of the reasoning for United Healthcare limiting the use of laparoscopic and robotic hysterectomy comes as a backlash against power morcellators. Morcellators, a tool used during laparoscopic hysterectomy, recently had their use restricted by the FDA after information about their association with spreading undetected uterine cancer was revealed.laparoscopic worries A series of articles recently described the hidden dangers of using this surgery. Despite the new information about the risk of spreading cancer, changing surgical skills to promote vaginal hysterectomy is going very slowly.

Whatever the reason for not being able to do recommend a vaginal hysterectomy for their patients, be it lack of training of surgical skills, or the lure of cool surgical toys or fancy marketing, some surgeons don’t want to refer their patients to surgeons who have the skill to do a vaginal hysterectomy because of lost money or perceived loss of prestige.

United Healthcare’s notice, affecting their 40 million female members covered by the insurer, said that physicians who don’t get preauthorization for the procedure (anything except vaginal hysterectomy) will have their claim for compensation denied. If gynecologists can’t do the right thing for their patients, and their professional society (ACOG) can’t persuade them, it’s not surprising that insurance companies are stepping in to point them in the right direction.

Our group of gynecologists, Doctors Seigel, Gottlieb and Cannon are glad we can offer vaginal hysterectomy for our patients, and encourage other gynecologists to also recommend this preferred procedure whenever appropriate.

Vaccinations are good for you.

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From December 28, 2014 through January 21, 2015 more than 50 people from six states were reported to have measles, mostly from an outbreak linked to Disneyland in California.

Measles is a highly contagious, acute viral illness. It begins with fever, cough, runny nose, and pink eye 2-4 days prior to developing a rash. It can cause severe health complications including pneumonia, encephalitis and death. Measles is transmitted by contact with an infected person through coughing and sneezing. Infected people are contagious from 4 days before their rash starts through 4 days afterwards. After an infected person leaves a location, the virus remains viable for up to 2 hours on surfaces and in the air.

Measles was declared eliminated in the United States in 2000 because of high population immunity brought about by a safe, highly effective measles vaccine (MMR). However, measles is still present in many parts of the world and outbreaks still occur in the U.S. when unvaccinated people become infected. Disney and other theme parks are international attractions, and visitors come from many parts of the world where the measles vaccine is not readily available.

More disturbing though, are people who refuse to vaccinate their children due to a “philosophical” objection. As it turns out, there is no medical support for theory that vaccines are harmful. There is no evidence that the MMR vaccine causes any chronic illness. The question about vaccine safety started with a bogus report published in the British Medical Journal in 1998 claiming the vaccine caused autism. By the time that scientists determined that the data had been falsified so the author could collect hundreds of thousands of dollars from a lawyer suing vaccine companies, the damage had been done: many people believed that the MMR vaccine was harmful. The BMJ retracted the article in 2010 when the pattern of falsified data to support a lawsuit was found out. However, a damaging public health scare that associated MMR with autism had been falsely created.

Vaccine facts include that more than 100 million diseases have been prevented by vaccinations in the US alone. The HPV vaccine (Gardasil) is safe and is nearly 100% effective in preventing cervical cancer produced by certain HPV strains. Gardasil coverage has been strengthened and an even better version (Gardasil 9) will be available soon. The flu vaccine does not cause the flu and is safe for pregnant women to take. TDAP vaccine has been found to be safe during pregnancy and should be given to all pregnant women between 27 and 36 weeks of gestation to decrease the risk of pertussis (whooping cough) in newborn babies.

Giant PeachThe famous author Roald Dahl dedicated his book “James and the Giant Peach” to his daughter Olivia, who died of measles. He hoped that telling people about her death would serve to protect others from illness and death from this disease. He wrote: “Here in Britain, because so many people refuse, either out of obstinacy or ignorance or fear, to allow their children to be immunized, we still have 100,000 cases of measles a year. More than 10,000 will suffer side effects and about 20 will die.“

The exponential rise of the latest measles epidemic in California due to large numbers of unvaccinated people should serve as a warning about the dangers of giving people the right to not vaccinate their children based only on “personal beliefs.” Vaccines are good for you and we encourage our patients to receive them to improve their health and the health of their children.

Most Popular Baby Names of 2014

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Your newborns Sophia and Jackson have some company this year. They’re the most popular girl and boy names of 2014, according to BabyCenter, a pregnancy and parenting online resource.baby

It’s Jackson’s second year as No. 1, and the name Sophia has reigned supreme as the No. 1 girl name for five years.

“This year’s list shows Jackson has staying power and is not a one-hit wonder, and Sophia is arguably the Jennifer of its generation with five consecutive No. 1 spots. It’s clearly entered the baby name hall of fame,” said Linda Murray, BabyCenter’s editor-in-chief, in a statement.

But the most pervasive baby trend? TV-inspired names. According to BabyCenter, 20% of moms found naming inspiration from TV-show characters and 16% got names from celebrities, leading Murray to call this the year of the “binge-watching baby name.” Cited in the “Netflix effect”:

• House of Cards character names were up since 2013: Garrett (up 16%), Claire (up 14%), Zoe (up 13%), Remy (up 11%), Frank (up 19%) and Francis (up 5%).

• Orange is the New Black characters were up since 2013: Galina (up 67%), Nicky (up 35%), Piper (up 28%), Larry (up 28%), and Dayanara (up 19%).

Other shows with name-inspiration power: Nashville and Shonda Rhimes-helmed shows including Grey’s Anatomy, Scandal and How to Get Away with Murder.

And in the year where the famed baseball player announced his retirement, the name Jeter increased 82% and Derek moved up 4%.

Here are the top 10 names for each gender. The site’s listings come from about 406,000 parents registered on the BabyCenter website who shared their baby names. Different spellings of names have been combined.

10 most popular girl names of 2014:

  1. Sophia
  2. Emma
  3. Olivia
  4. Ava
  5. Isabella
  6. Mia
  7. Zoe
  8. Lily
  9. Emily
  10. Madelyn

10 most popular boy names of 2014:

  1. Jackson
  2. Aiden
  3. Liam
  4. Lucas
  5. Noah
  6. Mason
  7. Ethan
  8. Caden
  9. Jacob
  10. Logan

BabyCenter has also listed the most “unique and surprising” baby names of the year, which is worth a bemused perusal. The names include Amore, Rhythm, Finnick (hello, Hunger Games) and Zeppelin.

The survey also found that 94% of parents used social media/technology to announce the name (58% used Facebook).

FDA warns about using morcellation to remove uterine fibroids

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The FDA on April 17, 2014 took a rate step of advising doctors to not remove uterine fibroids by a technique known as open power morcellation. This technique had become very popular as a tool used during minimally invasive gynecologic surgery as tumors can be removed during small abdominal incisions, reducing the pain of surgery and decreasing the time needed for the patient’s recovery. It is estimated that in the U.S. approximately 55,000 to 70,000 women have morcellation-aided hysterectomies every year. Gynecologists knew from the beginning that morcellators can drop bits of tissue. It was also suspected that in rare cases that a fibroid tumor can contain a hidden cancer. A study from South Korea in 2011 raised interest in this issue by showing how morcellating these tumors was more likely to spread cancer and worsen survival rates. The issue got even more attention in December when a 41 year old anesthesiologist at Boston’s Brigham and Women’s Hospital, Dr. Amy Reed, had inadvertent morcellation of a malignant tumor that resulted in a worse prognosis.Dr. Amy Reed

The FDA’s statement says it “discourages the use of laparoscopic power morcellation for the removal of the uterus (hysterectomy) or uterine fibroids (myomectomy) in women … because it poses a risk of spreading unsuspected cancerous tissue.”
“Based on currently available data, approximately 1 in 350 women who are undergoing hysterectomy or myomectomy for fibroids have an unsuspected type of uterine cancer called uterine sarcoma. … A number of additional treatment options are available for women with symptomatic uterine fibroids, including traditional surgical hysterectomy (performed either vaginally or abdominally) and myomectomy … performed without morcellation.“

The morcellation debate has sparked a big change: several hospitals including Brigham, Temple and Massachusetts General now say they require doctors for the first time to advise women about the cancer-spreading risk. What women do with that information is up to them. But, compared with a few months ago, they have a better chance to weigh the consequences as well as the benefits of less invasive surgery.

Hereditary Cancer Risk

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The field of medicine is changing rapidly through the advances made by genomic technology. We are on the verge of an exciting era where we will be able to have personalized medical care and treat each person based on his or her individual risks. For example, every woman fits into one of three risk categories for breast cancer. A person may face only a sporadic risk with the same risk as the general population, or their risk may be increased due to a positive family history, or increased even more if they are discovered to have an inherited genetic risk.  Focusing on a person’s family history gives us the opportunity to detect those people who face a significantly increased danger of developing cancer and then use proven successful strategies to reduce that risk.Geneticsmutations

Cancer screening depends on risk. Women who face only the sporadic risk of breast cancer do not need additional screening beyond that for the general population: regular mammography starting at age 40. Those who have an increased risk due to family history or who have dense breasts would benefit from more frequent screening with mammography, breast ultrasound or breast magnetic resonance imaging starting at least 10 years prior to the age of cancer diagnosed in their youngest affected relative. A small number of women carry the highest risk for gynecologic cancer due to having a defective gene. BRCA gene carriers, for example, should have testing started 15 years earlier than average, and usually benefit from oral contraceptives to decrease the risk of ovarian cancer. They also benefit from surgery to reduce their risk such as preventative removal of the ovaries, as otherwise the risk of ovarian cancer can be as high as 44% by age 70.

There are about 1 million people in the United States carrying genes for the most common hereditary gynecologic cancers: BRCA and Lynch syndrome. Hereditary Breast and Ovarian Cancer syndrome (HBOC) is seen in approximately 10% of breast and ovarian cancer patients. This autosomal dominant genetic disorder is caused by mutations in tumor suppressor genes BRCA1 and BRCA2. Red flags for HBOC syndrome include a three generation family history positive for breast cancer prior to age 50, bilateral, triple negative or male breast cancer, ovarian cancer at any age, prostate, pancreatic or melanoma cancer under age 50, Ashkenazi Jewish population, or a known BRCA mutation in the family.

About 20% of colon and endometrial cancers are associated with a strong family history of cancer. 5% occur in autosomal dominant genetically defined high-risk syndromes such as Lynch syndrome. Risk factors for Lynch syndrome include colorectal or endometrial cancer before age 50, colorectal cancer in 2 generations on the same side of the family, ovarian or gastric cancer at any age, and 2 or more individuals with colon, endometrial, ovarian, gastric, brain, biliary, pancreatic, or small bowel cancers.Geneticsreduce

Cancer risk assessment is one of the key parts of the annual well woman exam. Standard pap testing has been successful in reducing cervical cancer, and so too can screening for hereditary cancers result in cancer prevention and early detection. Knowing one’s cancer risk can guide lifestyle choices and the choice of medications that can safely decrease cancer risk. 10% of people carry increased cancer risk, and approximately 6% of people have increased genetic family risk that makes them eligible for testing to determine if their risk is greatly higher than was previously thought. If positive, this result can have a positive impact on not only the patient, but also their relatives and their descendants.

With our understanding of cancer genetics progressing rapidly, knowing one’s detailed family history and then determining who is at increased cancer risk can be of great value in having a safer, healthier life.

Morning Sickness of Pregnancy

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Some of my patients have nausea and vomiting of pregnancy to such an extent that they have the severe symptoms of persistent vomiting, acute starvation (with ketones in the urine) and weight loss more than 5 per cent of their usual pre-pregnancy weight. We call this hyperemesis gravidarum but most people call it pregnancy morning sickness.

50% of pregnant women have nausea/vomiting in early pregnancy. It usually peaks at 9 weeks of gestation and in most cases will resolve by the end of the first trimester. It is associated with a decreased risk of spontaneous miscarriage.Charlotte Bronte 1854

A number of famous English women have suffered from it. Charlotte Bronte, the novelist and poet who wrote Jane Eyre, died at age 38 in the 4th month of her pregnancy of severe nausea and vomiting.  Queen Victoria had 9 children, hated being pregnant, viewed breast-feeding with disgust and thought babies were ugly. She used marijuana to treat her morning sickness and also for childbirth pain. Kate Middleton, Duchess of Cambridge was hospitalized due to acute morning sickness. Her hospital stay was marred by invasion of privacy and suicide of one of her nurses.

 

Queen Victoria

Queen Victoria

In the 1950s and 1960s the most widely prescribed drug for treatment was Bendectin, a combination of Vitamin B6 and doxylamine, an antihistamine. It was a safe and effective treatment. The manufacturer, Merrill Dow Pharmaceuticals was bombarded with lawsuits that claimed it caused birth defects. Despite clear scientific evidence that Bendectin did not cause birth defects, lawyers prevailed over science and in 1982 the drug was withdrawn from the U.S. market to avoid further litigation expenses. A similar medication, Diclectin continued to be prescribed in Canada and its increased use there was found to result in a decrease in hospitalizations for this condition.

Kate Middleton

Kate Middleton

There are many theories on the cause of nausea and vomiting in pregnancy. It is thought to be an evolutionary protective response against eating foods that could be harmful to pregnancy. Some believe that it is due to increased levels of the pregnancy hormone HCG as it is more often found in twin and molar pregnancies that usually have increased HCG levels.

Treatment of morning sickness starts with the proper diet: small frequent meals with avoidance of spicy, fatty or odorous foods. Meals and snacks should be eaten slowly and in small amounts every 1 to 2 hours to avoid a full stomach. Women who feel nauseous should eat as soon as they feel hungry to avoid an empty stomach. A snack before getting out of bed in the morning can help. Pretzels, nuts, crackers, cereal and toast are often tolerated well. Cold, clear, carbonated or sour fluids in small amounts can help. Ginger ale, lemonade, and popsicles are good. Fluids are sometimes better if taken in with a straw.

Avoidance of triggers is useful. Some triggers include stuffy rooms, strong odors, heat, humidity, noise, visual and physical motion. Brushing teeth after a meal can be helpful. Supplements containing iron should be avoided as they can cause gastric upset. Taking prenatal vitamins before bed with a snack is better than taking them in the morning on an empty stomach.

Treatment of morning sickness may sometimes require medications. The FDA has recently approved a new formulation Diclegis for treatment of pregnant women experiencing nausea and vomiting. The medication is similar to Bendectin but has the advantage of a delayed-release tablet that works overnight. The usual dose is 2 tablets taken at bedtime. It’s two ingredients are both rated Category A for pregnancy, the safest FDA rating. Another medication that is widely used is Zofran (Ondansetron). It is rated Category B, also considered safe, and may have minor side effects of constipation, diarrhea, and fatigue.

In some patients these medications are not successful and hospitalization may be needed to give i.v. fluid therapy and improved nutrition through gastric tube feeding. There can be severe complications of nausea/vomiting of pregnancy including maternal depression, damage to the esophagus, and kidney damage. The fetus has an increased risk of low birth weight, but actually a decreased risk of miscarriage.

Morning Sickness of pregnancy is a common condition that interferes with normal daily life and can cause serious consequences. Having the optimal diet, avoiding triggers, and taking medications when needed usually results in the symptoms improving over time and a healthy baby at the end.

Polycystic Ovary Syndrome (PCOS)

Polycystic Ovary Syndrome (PCOS) is thought to be one of the most common endocrine abnormalities in women, affecting between 6.5-8%. Clinical features include menstrual dysfunction, hyperandrogenism (increased amount of male hormones), polycystic ovaries, metabolic problems, and an increased cancer risk.

Diagnosis:

  • Menstrual dysfunction shows itself as infrequent or absent ovulation. This can result in infertility and need for ovulation treatment for those wanting to conceive. The menstrual pattern is typically fewer than 9 periods a year (oligoamenorrhea) or no periods for three months or more (amenorrhea).
  • Hyperandrogenism is characterized as acne, hirsutism and male-pattern hair loss. Depending on which androgens are measured, 50 to 90 % of women have elevated androgen levels such as total testosterone, free testosterone and DHEAS.
  • Polycystic ovaries are seen by ultrasound and usually show 8 to 10 small follicles in the periphery of the ovary revealing a “string of pearls” appearance.string of pearls
  • Metabolic issues can include resistance to the effects of insulin, greater insulin levels, obesity, and a greater risk of Type 2 Diabetes. If the condition is not treated over a long period of time the result of too much estrogen can cause an increased risk of endometrial hyperplasia, which can lead to uterine cancer.

PCOS treatments are very helpful at reducing the symptoms and risks of this condition. The right treatment can lead to a normal outcome.

Treatment:

  • Birth control pills are the most commonly used treatment for regulating periods in those women who are not ready for pregnancy yet, and also pills are effective at reducing extra hair growth.
  • Weight loss is very effective in restoring normal ovarian function. Many overweight women with PCOS who lose 5 to 10 % of their weight will notice their periods become more regular.
  • Metformin is a medication that improves the effectiveness of insulin produced by the body. It is a treatment for Type 2 Diabetes but can also improve menstrual function.
  • Clomid is the most effective medication for achieving pregnancy. It stimulates the ovaries to release eggs in a regular monthly cycle.

With proper diagnosis and the right treatment we can achieve excellent results in minimizing the problems of this condition and leading to a normal life with regular menstrual cycles, good birth control and fertility when it is desired.