Preventing Unintended Pregnancy
Our expert is Jeffrey F. Peipert, MD, PhD, Professor of Obstetrics and Gynecology at Washington University School of Medicine. He is Vice Chair of Clinical Research for the Department of Obstetrics and Gynecology and is a recognized expert in reproductive epidemiology, sexually transmitted diseases, and family planning.
Please don’t hesitate to let me know if there is a topic relating to women’s health that you would like to see explored in this blog.
THE CONSEQUENCES OF UNINTENDED PREGNANCIES ARE SEVERE
In the United States, of the 6.4 million pregnancies each year, 49% are unplanned and, of these, 40% will end in abortion. In this country $11 billion is allocated to unplanned pregnancies and abortions. In addition, unintended pregnancies often carry higher risks, and the outcomes for the neonates are often poorer. There is also a higher risk of partner violenceand, for the individual woman, an unintended pregnancy can disrupt her education and her career plans.
MORE EFFECTIVE FAMILY PLANNING WOULD SAVE LIVES
Effective family planning could prevent as many as one in every three maternal deaths. It would prevent unintended pregnancies and abortions, enable the healthy spacing of births, and it would prevent the risks to mothers and to the children of very young mothers. It would also stop childbearing when the desired family size has been reached.
LARC METHODS ARE THE MOST EFFECTIVE REVERSIBLE CONTRACEPTION
Long-acting reversible contraception (LARC) methods include IUDs and implants. They are 20 times more effective than pills, patches, and rings, and even though they are reversible, they rival sterilization in their effectiveness. They have high satisfaction and continuation rates and, of major importance, these methods are not dependent on compliance or adherence. They are immediately effective and, when removed, there is a rapid return to fertility. These methods work by preventing fertilization, either by preventing ovulation and/or thickening the cervical mucus and making it difficult for sperm to ascend to meet the egg. The subdermal implant provides protection for up to 3 years, the LNG-IUS lasts up to 5 years, and the copper T IUD, is effective for up to 10 years.
PROVIDERS AND PATIENTS ARE INSUFFICIENTLY AWARE OF LARC CHOICES
Given the very high satisfaction rates for existing users, coupled with the high effectiveness rates for LARC methods, more women would be expected to choose these methods if they were made aware of them. The use of IUDs declined drastically in 1971 when the Dalkon Shield was the subject of litigation and people worried about disease and possible infertility. However, we know, today, that the fears of disease, as long as the woman doesn’t already have an STD, are ungrounded. In addition, the return to fertility is rapid after the IUD has been removed.
LARC METHODS ARE VALUABLE FOR MOST WOMEN OF REPRODUCTIVE AGE
LARC methods are useful to women during their reproductive years. However, LARC methods are not suitable for everyone. The best method for an individual is the one that she is most likely to use consistently and correctly and that is compatible with her reproductive life plan, including her desire for pregnancy and her preferred spacing of pregnancies. Although fertility declines significantly after age 35, LARC methods are important in the premenopausal period because pregnancies that do occur in this age group are at higher risk for genetic anomalies such as Down syndrome and other pregnancy risks.
SOME WOMEN ARE NOT GOOD CANDIDATES FOR INTRAUTERINE CONTRACEPTION
Women with the following conditions are poor candidates for IUDs:
Known or suspected pregnancy
Immediate post-septic abortion
Cervical or endometrial cancer
Uterine fibroids that interfere with placement
Current purulent cervicitis, chlamydia, or gonorrhea
INFORMATION AND RESOURCES
The following two websites provide useful information, materials, and resources related to LARC methods and their use and the Contraceptive CHOICE Project: www.larcfirst.com andwww.choiceproject.wustl.edu
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Protein Consumption, Exercise, and the Elderly
Our expert is Wayne Campbell, PhD, Professor of Nutrition Science at Purdue University. He is a member of the 2015 Dietary Guidelines for Americans Advisory Committee appointed by the USDA and the HHS. An important focus of Dr. Campbell’s current research is changes in older people relating to protein metabolism, body composition, and glucose metabolism.
As always, if there is a topic that you would like to see covered in the MP Post, please e-mail me.
THE ELDERLY, PARTICULARLY WOMEN, MAY NOT BE GETTING ADEQUATE PROTEIN
Protein intake is remarkably stable throughout our lives and constitutes approximately 15% of total calories. However, as we become older, the number of calories needed to maintain body weight decreases, so if protein intake remains at 15% the absolute number of grams of protein consumed decreases. This means that older adults may not be getting enough protein to maintain muscles and internal organs. Data from a 2013 study of 1,768 adults, by Louise A. Berner, PhD, and colleagues, suggest that approximately 12% of older men and 24% of women over the age of 70 do not consume enough protein.
WHEN REDUCING CALORIES, THE ELDERLY SHOULD CUT BACK ON PROTEIN-POOR AND NUTRIENT-POOR FOODS
Physiologically, and metabolically, most adults are in the elderly category by age 75. If you have an elderly patient who is consuming fewer calories, recommend that she not cut back on protein-rich foods as much as on protein-poor foods. However, it is important to clarify what this means. The protein-poor foods that are candidates for cutting back are desserts or foods made from bleached flour such as white breads. Nutrient-rich foods, such as fruits and vegetables, are still a valuable part of the diet even if protein poor. The protein-rich foods to emphasize are lean cuts of meat, low-fat or fat-free dairy, fish, and eggs, including egg whites. In addition, all the plant-based proteins, such as legumes and soybeans, are good sources of protein, but a variety of these foods should be eaten to obtain all of the amino acids necessary to form a complete protein.
ADEQUATE PROTEIN AND EXERCISE ARE NECESSARY TO SLOW PROGRESSION OF SARCOPENIA
Sarcopenia is age-associated loss of muscle that occurs in everyone. However, it occurs faster in people who do not consume enough protein. Unlike fat and carbohydrates, our bodies do not have a large store of readily available protein. Most of the body’s protein is in lean tissues such as organs and skeletal muscles. When we don’t consume enough protein, the body will take it from somewhere, and muscles will be sacrificed before organs. Anyone who does not eat enough protein will have muscles that shrink in size and decrease in functionality. The good news is that, with a combination of a diet that includes adequate protein and a program of strength training, the progression of sarcopenia can be slowed and even reversed. With adequate protein, combined with strength training exercises, increases in muscle strength of up to 50% are seen, typically, within three months. The increase in strength isn’t entirely from muscle growth as it also includes improvement in the neuromuscular control which in itself results in improved strength.
GET ENOUGH EXERCISE
A minimum of 30 minutes a day of moderately vigorous physical activity or 20 minutes a day of vigorous activity is recommended. For improved physical fitness, 45 minutes to an hour of moderate physical activity is recommended. The exercise does not have to be continuous. Intermittent sessions of fifteen minutes of exercise are still valuable. The goal should be 200 to 300 minutes of exercise per week.
FOR THOSE WHO HAVEN’T BEEN EXERCISING, CREATE SMALL, REALISTIC GOALS
It is important for patients not to be discouraged by their current level of physical activity. Any improvement is good. Often an individual will go to the gym and be intimidated by the fact that others have higher levels of physical activity. The result is that they get discouraged and don’t go back. Tell these individuals that, wherever they are in their goal of improved fitness, they are doing something really positive for themselves as long as they keep trying and set small, achievable goals. Encourage them to feel a sense of accomplishment if, for example, over a couple of weeks they are able to walk for ten minutes instead of the five minutes that had been their previous limit. Any improvement counts and will improve their health. In many cases, elderly patients may want to consult with and work with dietitians and certified strength trainers.
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Our expert is JoAnn V. Pinkerton, MD, Professor of Obstetrics and Gynecology at the University of Virginia and Director for the Midlife Division and the Midlife Health Center, a nationally recognized multidisciplinary center for women’s midlife health. She is a Past President of the Board of Trustees for The North American Menopause Society (menopause.org) and serves as Vice Chair of the Board of Directors for the National Women’s Health Resource Center (healthywomen.org).
The topic, as with most of those that you will read about in this blog, was suggested by a reader of the MP Post. If there is a topic that you would like to be covered in the blog, please let me know. I enjoy hearing from you.
HOT FLASHES AFFECT A LARGE NUMBER OF WOMEN
Approximately seventy-five percent of menopausal women in the United States will have hot flashes, although only about 25% of women will have symptoms severe enough for them to seek medical help. The flashes usually begin during peri-menopause and they peak within the first 4 years of menopause. However, for some women they can continue for as long as 13 years.
WOMEN WITH SIGNIFICANT HOT FLASH PROBLEMS CAN USUALLY BE HELPED
If a woman has significant problems with hot flashes, such as seven or more a day or 50 a week, or if they cause her to stop her normal activities, she may want to explore treatment options. The gold standard for treatment is hormone therapy. Traditional hormone therapy is comprised of estrogen and progesterone. There is good evidence that if it is used within 10 years of menopause, hormone therapy is probably safe, but it is important to keep in mind that the goal of therapy is to prescribe the lowest dose for the shortest time.
NEW HORMONE THERAPY
In large, randomized clinical trials, bazedoxifene (BZA) 20 mg/ conjugated estrogens (CE) 0.45mg and CE 0.625 mg, reduced menopausal symptoms and prevented bone loss in postmenopausal women. The therapy demonstrated a favorable safety profile on the breast, endometrium, and ovary, and with cardiovascular and venous thrombosis events, that was similar to a placebo. Using these treatments, there were also improvements in sleep, health-related quality of life, and treatment satisfaction. Compared with traditional, progestogen-containing hormone therapy, BZA/CE had higher rates of amenorrhea and reduced breast pain, with changes in breast density from baseline that were similar to a placebo. The therapy (conjugated estrogens 0.45mg/ bazedoxifene (SERM) 20 mg) is FDA approved.
A NEW NON-HORMONAL TREATMENT FOR HOT FLASHES
There is a new non-hormonal treatment for hot flashes—low dose paroxetine salt 7.5 mg—which improves hot flashes at 4 and 12 weeks with continued improvement at one year. It also reduces nighttime awakenings and improves sleep duration, and these results are achieved without weight gain or loss of libido.
NON-TRADITIONAL THERAPY FOR HOT FLASHES
Helping women who cannot use traditional hormone therapy is a major unmet need. For mild hot flashes, women may find it beneficial to try non-traditional therapies, although in general most of these have not been proven to be more effective than a placebo. The good news is that even placebos work 50% of the time, and any of the following may help with a woman’s symptoms: black cohosh, phytoestrogens, acupuncture, hypnosis, yoga, and paced breathing. Paced breathing includes the kind of deep breathing techniques sometimes practiced in yoga and it is done when a hot flash is coming on. Paced breathing includes inhaling for six seconds and then exhaling for six seconds, and it is usually done for twenty minutes. Women should avoid triggers such as spicy foods, hot drinks, caffeine, and alcohol. In addition, they should exercise regularly and try to avoid stress.
NON-HORMONAL TREATMENT FOR DYSPAREUNIA
Ospemifene is new non-hormonal treatment for dyspareunia (painful intercourse). It is an oral estrogen agonist taken daily for the prevention of vaginal atrophy. It may help preserve bone density. However, taking ospemifene can lead to a slight increase in hot flashes, possible stimulation of the uterus, and an increase in blood clot risk. It has not been tested in patients with breast or uterine cancer.
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Our expert is Joel S. Finkelstein, MD, Associate Professor of Medicine at Harvard Medical School and Associate Director of the Massachusetts General Hospital Bone Density Center. His clinical interests include bone and mineral metabolism, neuroendocrinology, and reproductive endocrinology.
If there is a medical topic that you would like to see explored in the MP Post, please let me know!
OSTEOPOROSIS SCREENING IS UNDERUTILIZED
The U.S. Preventive Services Task Force (USPSTF) screening guidelines for osteoporosis recommend universal screening at age 65 for postmenopausal women, or earlier if there are additional risk factors such as a family history of osteoporosis; smoking; small body frame; drinking more than three glasses of alcohol a day; long-term use of corticosteroid medications; or a sedentary lifestyle. However, Medicare data indicate that only about half of eligible women have had a bone density test. As half of postmenopausal women older than 50 years, in the United States, will experience an osteoporotic fracture in their lifetime, this underutilization means that millions of women will develop a disorder that could have been prevented easily.
EARLIER AND MORE FREQUENT SCREENING IS ADVISABLE
The cost-effectiveness models, on which the USPSTF guidelines were based, were made before alendronate became a generic drug in 2011. The cost of treatment for an individual has dropped from approximately $1000 a year, to approximately $50 a year. In addition, screening and treatment are likely to be most beneficial if they are begun around the time of menopause, which is a time when bone loss is exacerbated. The problem is that, by the time a woman is 55, she may already have experienced bone loss. The DXA screening is simple, safe, cheap, well-tolerated, and it predicts consequences better than any other screening test for any major disease.
A SHORTCOMING IN THE CURRENT MEDICAL GUIDELINES
Current Medicare guidelines allow for screening once at age 65 and then they do not allow for re-screening unless the woman’s T-score is -2.5, in which case she already has the disease. Many women may have a borderline score, such as -2.4, which is very different from someone who is a -1, and yet a woman with a score of -2.4 would not qualify for monitoring. In other words, the current guidelines don’t permit screening until it is already too late, and many women will develop the disorder unnecessarily.
VITAMIN D SUPPLEMENTATION CONSIDERATIONS
In June, in most of the United States, you can get the vitamin D you need by having a square foot of skin exposed to direct sunlight for 15 minutes. On the other hand, in mid-winter in a northern area such as Boston, the sunlight is so weak that all day exposure to sunlight would not be sufficient. Unfortunately, there are almost no natural sources of vitamin D in the diet except some fish oils. However, milk is generally fortified with vitamin D as are some grains and breads. In addition, vitamin D supplementation may be needed. It is not known what levels of Vitamin D are ideal, but in recent years the acceptable limits for what constitutes the normal range have become lower.
CALCIUM SUPPLEMENTATION AND THE RISK OF CARDIOVASCULAR DISEASE
There are conflicting studies on the safety of calcium supplementation and cardiovascular events. Because this is a potentially major public health issue, until we can prove that it is safe, it makes sense to limit the risk. The safest option is to get the needed calcium through diet and if that isn’t sufficient, women can take supplements. However, they should take care not to exceed the upper safe limit.
BISPHOSPHONATES ARE ONLY RARELY ASSOCIATED WITH FRACTURES
There has been concern about people getting fractures while being treated for osteoporosis with bisphosphonates. However, in 90% of the cases, the fracture resulted from the underlying osteoporosis and not the medication. Bisphosphonates are among the most commonly prescribed and carefully studied drugs in the world. Overall, bisphosphonates are very safe, effective, and well-tolerated. Only about 5-15% of subtrochanteric or femoral shaft fractures are “atypical” and associated with bisphosphonates. For women who have received oral bisphosphonates for 5 years or more I recommend the following:
• Consider a drug “holiday” if the risk of fracture seems reasonably low (e.g. T score > -2.0).
• Continue therapy if the risk of fracture seems reasonably high (e.g. T score < -2.5).
• Monitor bone mineral density after stopping bisphosphonates and resume therapy if rapid bone loss ensues.
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Thyroid Dysfunction and Pregnancy
David F. Gardner, MD, is Professor of Medicine in the Division of Endocrinology at Virginia Commonwealth University School of Medicine. He specializes in endocrinology and thyroid disorders and has been a popular speaker at the Women’s Health Annual Congress. As always, if you have topics that you would like to see covered in the blog, please let us know. This blog post on thyroid disease comes at the request of a reader in California.
THYROID DYSFUNCTION DURING PREGNANCY REQUIRES IMMEDIATE INTERVENTION
Untreated hypo- or hyperthyroidism is a threat to the health of a pregnant woman, to the health of her fetus, and to the health of her future baby. This is true for overt hypo- or hyperthyroidism, but it is also a factor in subclinical hypo- or hyperthyroidism. For hypothyroidism, these risks include spontaneous abortion, hypertension, placental abruption, low birth weight and preterm deliveries, plus neurocognitive development problems for the baby and growing child. In the case of hyperthyroidism, the risks include spontaneous abortion, hypertension, preterm labor, low birth weight babies, and stillbirths. Fortunately, all of these risks can be mitigated with proper treatment, but the treatment should be started immediately. In the case of a woman known to have thyroid dysfunction who learns that she is pregnant, I would advise her, not entirely joking, “Tell your husband first, then your mom, and then your doctor.” She needs to have access to treatment immediately.
THYROID HORMONE DOSE ADJUSTMENT DURING PREGNANCY
If a woman is taking medication for hypothyroidism, she needs to increase the dose by 28% even before seeing her doctor. The need for medication is immediate and this is something that a woman can, and should do, even before her next appointment, which should be soon. Ideally, a strategy for managing her hypothyroidism should be discussed with her physician prior to conception.
USE THE SAME CRITERIA FOR TSH SCREENING FOR PREGNANT WOMEN AS FOR NON-PREGNANT WOMEN
Currently there is no consensus on recommending universal screening for thyroid disorders in all pregnant women. However, if a woman has a strong family history of thyroid disorders, if she has symptoms of the disease, or if she has a goiter, she should be tested. In general, test a pregnant woman for thyroid dysfunction using the same criteria you would use for a non-pregnant woman. However, be aware that what is normal in a non-pregnant woman is different from what is normal for a pregnant woman. A non-pregnant woman may have a TSH result of 4 or 5 and that would be considered to be in the normal range, but the upper limit of normal for a woman in her first trimester is 2.5. This TSH level of 2.5 should be maintained throughout the first trimester, but slightly higher values are acceptable in the latter stages of pregnancy.
TREATMENTS FOR HYPO- OR HYPERTHYROIDISM DURING PREGNANCY
A pregnant woman with hypothyroidism is very likely going to need an adjustment in her medication. As many as 70% of pregnant women will need higher doses of thyroid supplementation, with dose increases in the range of 25-50%. In the case of a woman with hyperthyroidism, the anti-thyroid drugs methimazole (MMI) and propylthiouracil (PTU) are the treatments of choice. When, as rarely happens, a women with hyperthyroidism has a reaction to these drugs, a thyroidectomy may be necessary.
The Thyroid Journal Program, published by Mary Ann Liebert, Inc., is comprised of Thyroid, Clinical Thyroidology®, and VideoEndocrinology™ and provides comprehensive coverage of thyroid related disease, care, and research: www.liebertpub.com/thy
Thyroid, Clinical Thyroidology®, and VideoEndocrinology™ are official journals of the American Thyroid Association (ATA). The ATA is the leading organization devoted to thyroid biology and to the prevention and treatment of thyroid disease through excellence in research, clinical care, education, and public health: www.thyroid.org
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