June 2009 -  

An Overview of Contraception

     Control of reproduction is the essence of women’s empowerment.  In the Third World 4,500 women die from childbirth related complications EVERY THREE MINUTES.  In most Western countries contraceptive choice is readily available, relatively inexpensive, effective, and reversible in most cases when sterilization is not the option.

     In ancient times it was not immediately known that sexual union was the cause of conception.  Eventually when, what now seems obvious, became widely known to cause pregnancy, the actual mechanism was unclear.  There was a theory known as “Ex Ovum Omnia” that roughly translated “from the egg comes everything” and held that the female egg only needed to be touched by a sperm for conception.  The idea of genetics was not born yet.  A competing idea was the “homunculus theory” that maintained that inside a sperm cell was a little person that only needed to gain entry into the uterus to expand and grow.  In any event feeble attempts to prevent conception began to take shape. The Romans fashioned condoms out of lambskin and the ladies of the time made a roll of elephant dung and honey to be inserted vaginally.  This was copied after an ancient Egyptian recipe using crocodile dung and camphor.  How infection was avoided remains a mystery but the likely odor of these devices would seem to have precluded sexual union.  Arab traders crossing the Sahara and Mongols crossing the Gobi desert along the Silk Road inserted stones into the uteri of camels to prevent pregnancy- a prelude to the modern intrauterine device (iud).  Through the middle ages there were vague tales of contraceptive potions and unguents of uncertain efficacy.  Plain old abstinence, while not popular, was effective.  So, big families were the rule for centuries but children were needed to till the field and work in the guild halls and many succumbed to childhood diseases that have been eliminated today. Hence contraception was not much in demand and, in fact, was proscribed by the Church.

     The biggest breakthrough in contraception came in the late 1950’s with the invention of the birth control pill (“the pill”).  Taken daily it prevented pregnancy 96% of the time, had few side effects and when ceased, fertility returned.  Then, as now, it prevents pregnancy by blocking ovulation and thickening the cervical mucus. The side effects are minimal: occasional weight gain, moodiness, change in sexual urges, and rarely increase in the tendency of blood to clot resulting in heart disease and/or stroke.  Collectively the risks from the pill are less than the risks of pregnancy.  The pill is thought to reduce breast and uterine cancer, neutral to ovarian cancer and widely regarded as having drastically reduced cervical cancer because women need to come to the office every year for an exam before the pill can be renewed and this exam includes a pap smear that is still the best screen for cervical cancer.  Today, the dosage of the pill is much less thanks to newer hormones so the side effects are reduced but is still contraindicated for women who are over 35 and smoke.  Some pills are even used to reduce heavy periods, decrease premenstrual dysphoric disorder.  Other pills can be taken to allow periods every three months and there are now new ones that allow a yearly period. For those that have trouble swallowing pills, there is even a chewable variety.

     The Intrauterine Device (iud) has been around since the previously mentioned Arabs and the camels but has only been used for human contraception since the early twentieth century.  They come in different sizes and shapes and are inserted into the uterus through the cervix by a physician in the office.  The exact mechanism of action is unclear but probably prevents the sperm from reaching the egg.  The early devices were large and caused cramping and bleeding but the newer ones today are good for ten or five years respectively and can actually reduce menstrual flow.  For those who cannot remember to take a pill it is an ideal method of contraception but is ill advised for a woman who has not had children since there is a risk of infection that could result in sterility.  Once removed by having the doctor pull on the string, fertility returns within two months.

     Depo-Provera is a shot given every three months that contains only progesterone so is convenient and safe even for women who smoke but can cause weight gain and osteoporosis if taken long enough.

     There is a relatively new method in which a hormonal implant is inserted into the upper arm and fertility returns upon removal. The side effects are minimal and are as effective as the pill.

     Most other methods are known as “barrier methods” that involve a device that holds a spermicide against the cervix.  The diaphragm, now rarely used, held contraceptive gel against the cervix and then a list of sponges, foams, and inserts that roughly did the same thing.  As with condoms, the efficacy is dependent upon the user following the manufacturer’s guidelines.

    A word here about a new male contraceptive that uses a shot of testosterone that is in early testing and promises to have few side effects and promises to be reversible.  More to come as this appears on the market.

     Lastly, permanent contraception is available to couples who are 100% sure that they do not want more children as there are no reversals of these procedures.  Males can opt for a vasectomy that cuts the tube that carries sperm under a general anesthetic or under local anesthesia as an outpatient.  Women generally have two choices when considering a tubal ligation: a laparoscopic procedure done under general anesthesia  as an outpatient: a camera is inserted into the belly button and another instrument through an abdominal puncture wound  used to either burn the tubes closed or to place a ring or clip on the tubes.  Both procedures have a 1/2,000 failure rate.  A new method utilizes a small coil that is placed in the fallopian tubes utilizing a scope inserted into the uterus visualizing the tubal opening.  No incisions are necessary.   However, a conventional contraceptive must be used for three months before an x-ray is taken to insure that the tubes have been blocked.  There is a movement underway to do this procedure in a doctor’s office but it must be as well equipped as a hospital operating room to deal with any potential complications.

     In conclusion, the choices are many and should be discussed in detail with your doctor.  A hasty decision is usually regretted especially concerning sterilization and this decision should be made after much thought and careful weighing of the pros and cons.

May 2009 - PREGNANCY ETIQUETTE

     A pregnant woman is the epitome of the “Empowered Woman”.  For the sake of this column and of American readers, pregnancy related problems of the Third World will be left to a future article.  Whether a woman chose to become pregnant or not is irrelevant to the body changes that she will undergo.  Let us get some definitions straight:  pregnancy is a forty week period from the date of the last period or  thirty eight weeks from the day of conception.  Since most couples do not know when the exact day of conception was it is conventional to date a pregnancy from the day of the last menstrual period.  Doctors date the pregnancy in terms of weeks not months because each month has a different number of days.  However, for those who insist on talking in terms of months, pregnancy lasts ten lunar months—a lunar month defined as 28 days.  Delivery is at the end of the tenth lunar month.  Furthermore, the forty week pregnancy is divided into trimesters: the first from day of last period to twelve weeks; the second from twelve weeks to twenty eight weeks and the last trimester from twenty eight weeks to delivery.  Each trimester is characterized by specific body changes in the woman that reflect her hormonal status and that of the growing fetus and placenta.  In the first trimester, hormones produced from the ovary from which ovulation occurred cause the initial nausea and vomiting, fatigue, breast tenderness and bowel changes.  The fetus is in a growth spurt as organs are being formed and consumes huge amounts of sugars that cross over directly from the placenta.  Hence, most women at this stage are ravenously hungry even if they throwing up frequently.  In the second trimester, the growing uterus causes a decrease in hunger as the stomach of the woman is compressed, heartburn from this compression and from calcium deprivation, abdominal aches and pains from ligaments being stretched and possibly gall bladder problems from compression and cholesterol imbalances.  Sore and leaking breasts, periods of faintness are common.  In the final trimester, fatigue sets in from rising hormones, inability to sleep because of positional difficulties, frequent urination, wild dreams, achy legs, and fetal motion .  If the first pregnancy, worry over the delivery process itself and, if not the first, worry over the other kids, the house, finances, marital relationships, etc. take a huge toll.

     Now the point of all this and hence the title “Pregnancy Etiquette” is that most pregnant woman do not feel very well.  They are thrilled with the little life being created within and  overwhelmed by the very miracle of it BUT  their noses are stuffy, they are nauseous, their breasts grow tender, they might have trouble eating, can’t sleep, legs hurt, are constipated, and very very concerned with body image.  Most women are concerned that  they either look too big or too small.  Modern obstetrics relies not just upon the physician’s measurements of the uterus to determine size but ultrasound as well which  correlates the date of delivery with the size of the fetus and determines without error the number of  babies within the uterus.  So, imagine if you will, a pregnant woman who goes to the grocery store or to the YMCA or to the gym and is told by well meaning people (some of which may have never met her):  “my God, you are huge- you are having twins- the doctor is wrong- the baby will weigh twelve pounds, etc. etc..”  These comments will usually provoked tears and worries about looking “whale like” and might even contribute to unrecommended binge dieting.  Then there is the tall thin pregnant woman who hears the comment: “ are you sure you are pregnant?  The doctor must be wrong—maybe you just have gas”.  The woman might just be carrying that way and might indeed have just undergone a long period of infertility and has conceived  by advanced technology so she too goes home crying and panicked that something is wrong.  In years of practice I have heard these stories thousands of times. In most cases, she is exactly the size she should be when measured by an experienced and well trained person.  Now I know that it is true that the people that make these comments are well intentioned and mean no harm and  are authentically thrilled to see the creation of life before them.  Some even lament that their very own reproductive days are behind them.  So, a few words of advice: never ever touch a pregnant woman,unless invited to and  especially not at the grocery store—it is offensive to most and an invasion of privacy and if you must say something just say “my you look lovely, pregnancy becomes you.”  Then you have not only empowered the pregnant woman but yourself as well.

April 2009 -WOMEN’S HEALTH IS TOO IMPORTANT TO IGNORE

On March 3, 2009 eleven hundred physicians gathered on the Capital steps in Albany in an attempt to convince legislators to enact legislation that would preserve and conserve health care to all New Yorkers.  I am obstetrician/gynecologist and Chair of the Legislative Committee for the New York State Chapter of the American College of Obstetricians and Gynecologists—also known as ACOG.  We represent more than four thousand members who provide health care to New York’s women.  Similarly on December 19, 2008 I spoke at a legislative forum at SUNY Oswego before Senators Aubertine and Valesky on the same issues.

I have been selected as the spokesman for ACOG because I have delivered well over 6500 babies in 30 years of practice.  As a practicing ob-gyn I feel that I am uniquely qualified to speak on the subject of women’s health care.  I was born and educated In New York State, received an Oswego County scholarship for medical school and I have helped my community by providing care to the very large underserved population of Oswego County since 1980.

One of the biggest issues that New Yorkers face is universal maternity care—an area where the delivery of services is sorely lacking.  ACOG has a program entitled: “Health Care for Women, Health Care for All”.  It is widely recognized that women who have access to comprehensive maternity care have healthier babies, are less likely to deliver prematurely and are less likely to experience serious complications during pregnancy.  That is why the need for universal maternity care is so great in New York State.  Over the past several years, the percentage of pregnant women in New York State receiving adequate prenatal care has remained persistently low.  In a 2005 state-by-state analysis, only 63.8 percent of pregnant women in New York received adequate prenatal care, ranking New York State 48 among the 50 states!  New York State is also far behind in the Health People 2010 goal which strives for 90 percent of live births to be delivered to women who received early and adequate prenatal care.  A change in fragmented prenatal care delivery system is needed.  Any consideration of programmatic health care enhancements for children and families must start with the provision of a comprehensive maternity benefit package.  It is ACOG’s hope that our universal maternity care proposal is ultimately incorporated into the larger discussion of a universal health care system in New York.  We envision a program that will offer women more comprehensive and clinically appropriate  health care services, strengthen public education and the utilization of prenatal care and raise provider reimbursements.

Access to care is being severely challenged in New York State.  A combination of low reimbursements to providers and escalating costs of practicing (salaries, utilities, equipment and malpractice insurance) are creating a situation where physicians are retiring early, relocating to other states, restricting their practices to low risk procedures, and finding trouble recruiting new physicians to come to their area.  My very own practice has had and still has trouble recruiting to our county and the reasons cited are always the same: “the reimbursement is low, the malpractice rates are high”.  The legislature has ignored ACOG’s statistics and arguments and now is considering new laws that would actually raise our rates by 20%--if enacted would  effectively drive many obstetricians out of practice.  If our practice were driven out women would have to travel 40 miles to Syracuse in a potential blizzard to deliver.  Despite years of lobbying in Albany and in Washington, no changes or suggestions have been enacted.  Call your legislator and ask: “what have YOU done for women’s health care?”  ACOG has proposed a system (similar to worker’s compensation) that quickly, equitably and fairly rewards neurologically impaired infants the services they need.  Such a system would provide medical care, case management and process for the review of the negligence or the standard of care.  Our proposed system will help families to navigate a confusing system of medical benefits and services already available and would provide the child with lifelong care.  This program would increase patient safety through comprehensive reviews and would reduce legal system costs throughout New York.

    According the latest report issued by the U.S. Senate Finance Committee on health care reform, medical liability reform is not just a state issue but a national one as well.  It is noted that “alternatives to civil litigation need to be utilized so that administrative costs associated with litigation can be reduced.  Helping patients and providers to cooperate rather than participate in time consuming and expensive legal battles may help to shift America’s health care system away from the costly practice of defensive medicine and toward the best quality care and adherence to standards of care”.

Because WOMENS HEALTH IS TOO IMPORTANT TO IGNORE, I hope that the New York Legislature is able to arrive at some comprehensive reforms and cost saving measures in the area of health care.