October, 2012

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Infertile? It Might be Time to Go Gluten-Free

Monday, October 29th, 2012

The gluten-free lifestyle is gaining popularity in American culture. Even at some of the most mainstream cafes and grocery stores, you can find gluten-free alternatives to your favorite breads and baked goods. Many people are giving up gluten because of the known health benefits associated with cutting it out of your diet. However, some people avoid gluten for a different reason. People with celiac disease suffer from abdominal pain, diarrhea, and weight gain when they eat gluten. The disease is actually fairly common, as 1 in every 133 people in the United States are afflicted with it. Unfortunately, negative reactions to gluten are not the only side effects of the disease.

Women with celiac disease are often infertile. Infertility is defined as the inability to get pregnant within a year after discontinuing contraception. So, while you could get pregnant eventually with celiac, it will be much more difficult. If you have celiac disease, you’ve probably noticed that your periods are sometimes irregular because your body cannot spare any resources, particularly iron. This is because your body has trouble absorbing certain minerals and nutrients, especially if you’re undiagnosed and still eating gluten. In fact, women who seem to be infertile are often tested for celiac disease because the two problems are so closely related. You ovulate less frequently when you have untreated celiac disease because you are malnourished.

Luckily, diagnosing celiac is the first step in recovery. If you have been infertile for a while and realize that you have celiac disease, cutting gluten from your diet might make fertilization of your eggs easier, and you will increase your chances of getting pregnant.

If you’re having trouble getting pregnant and you’ve been experiencing abdominal pain, diarrhea, weight loss, and a general ill feeling, it’s time to get tested for celiac disease. Cutting gluten out of your diet will be difficult at first, but the benefits will be well worth the sacrifice. Besides, giving up gluten is easier now than it ever has been before. Twenty years ago, people with celiac couldn’t even think about eating anything remotely close to bread or wheat. Now, gluten-free options are bountiful. People with celiac can eat everything from cupcakes to foot-long subs thanks to the popularity of alternative baking.

– Yvonne S. Thornton, M. D., M. P. H.

Apgar Scores May Predict ADHD

Thursday, October 25th, 2012

As you’re nearing the end of your pregnancy, you’ll probably be relieved in some ways. You’ll be able to lift your own ban on caffeine, start working back towards your normal body weight, and say goodbye to the relentless back pain. At the same time, you might be nervous about entering motherhood. There are many questions you’ll need to know the answers to upon your baby’s birth, and motherhood will become your new unpaid – albeit wonderful – full time job. One concern many mothers have as their baby starts to develop is the risk for attention deficit hyperactivity disorder (ADHD).

Many kids are prescribed with different medications for ADHD, and there is endless controversy surrounding it. Unfortunately, the disorder affects many children and their ability to learn in a classroom setting, so it can be detrimental if left untreated. The worst part is that we as physicians are unable to find the cause for the condition. However, one recent study suggests that you might get a clue about your child’s susceptibility to ADHD right after birth.

After you’ve given birth, your doctor will perform an Apgar examination. The test measures your baby’s vital signs such as his or her heart rate, muscle tone, and breathing. Essentially, it is a score that measures the health of your baby immediately after birth at 1 and 5 minutes.   It tells the pediatrician whether or not your newborn needs to be resuscitated because it doesn’t demonstrate the essential hallmarks.  Your baby will be ranked on a scale of 1-10, and babies with a score under 7 need additional medical attention. Amazingly, the results of the recent ADHD study show that children with a low Apgar score immediately after birth are more likely to develop the disorder later in life. Even in children with a score of five or six, their risk was 63% higher than those with a score above seven.

If your baby is born with an Apgar score below seven, you shouldn’t immediately assume that he or she will suffer from ADHD. Instead, you should be prepared and look for signs as your child grows up that he or she might need some assistance in school. Being a good mom is tough, but knowing in advance that your child is at risk makes your job a little easier. The low Apgar score could be a sign that there were some developmental problems in the womb, and you should assist your child accordingly should any learning disabilities present themselves.

– Yvonne S. Thornton, M. D., M. P. H.

Is the Media Affecting Your Appetite?

Monday, October 22nd, 2012

When you hear someone mention eating disorders, you probably think of anorexia or bulimia right away. These are more commonly discussed in the media, but in reality, an eating disorder is any type of distorted relationship with food that negatively affects our behavior. Compulsive overeating is a type of eating disorder, even though it is essentially the opposite of anorexia. Many of us have a distorted relationship with food—I myself am guilty of such a relationship. However, I’m at one end of the spectrum where it doesn’t necessarily interfere with my life. Many women, especially in the Western world, suffer from eating disorders, and numerous studies show that it is directly a cause of skinny role models in the media. Before discussing that cause though, let’s first examine the different types of eating disorders people commonly develop.

Anorexia affects one in every 200 women in America. Studies show that the cause might be linked to traumatic situations. Peer pressure is a major factor, and some studies even show that genetic factors and posttraumatic stress might contribute to a person’s likelihood of developing anorexia. It is the refusal to maintain a healthy body weight and a fear of gaining weight. People with anorexia have an unrealistic body image.

Bulimia is characterized by recurrent binge eating following by compensatory behaviors. Diuretics, vomiting, and excessive exercise often follow binge eating. Binge eating is also a disorder of its own when it is not followed by compensatory behavior, which is considered compulsive overeating. Many studies suggest binge eating is triggered by stress.

So, why do people, especially women in the United States, feel that their bodies are not good enough? In addition to the stress and trauma often behind the disorders, studies suggest that the media might have a large role in the problem. Dr. Anne E. Becker, a professor of Global Health at Harvard Medical School, completed studies to determine the relationship between figures in the media and people with eating disorders. Not surprisingly, the impossibly skinny role models currently in the media heavily influence women and their self-image.

It’s hard to ignore the beautiful women on TV and in the magazines, but it is our duty as mothers and healthy citizens to do so as best we can. Try to maintain a healthy body weight with proper nutrition, and never let the airbrushed women in the media affect your view of yourself.

– Yvonne S. Thornton, M. D., M. P. H.


A Short Cervix May Equal a Short Pregnancy

Thursday, October 18th, 2012

Taking care of yourself during pregnancy, has always been a trusted form of prevention for preterm births, so avoiding habits such as smoking and overeating are recommended. Sometimes, even women who stay healthy deliver preterm with no reasonable explanation. However, studies show that there could be a very obvious and physical predictor as to whether or not you will deliver your baby preterm.

Although controversial, there have been new recommendations that the cervix should be measured (transvaginally) in the midtrimester of every pregnancy in order to assess the possibility of a preterm birth.  Critics of universal screening have cited a concern that facilities for transvaginal ultrasound screening are not widely enough available. There also is concern about the potential misuse or overuse of technology, and concern that many women will undergo treatment unnecessarily.

A recent review was published by one of the investigators of the study promoting the use of a hormone gel (progesterone) intravaginally to treat such shortened cervices. This investigator was also a paid consultant for the company who manufactured the progesterone gel and therefore, had a serious conflict of interest in her recommendations.  Nevertheless, there is mounting evidence that a cervical length measuring between 10-20 mm places the pregnancy at increased risk for early delivery.  It has long been known that  women with a shorter cervix are more likely to give birth preterm.  However, the best management  approach eluded clinicians until several studies demonstrated that women who had a history of preterm birth fared better when they were given weekly injections of progesterone (17a-OH progesterone caproate).  In patients without a history of preterm birth, the treatment was not given; that is, until recent studies demonstrated shortened cervices, identified at midterm, had better outcomes when the patient was treated with a progesterone gel intravaginally.

Preterm labor, defined as birth before 37-weeks of pregnancy.  Cervical insufficiency results when the cervix dilates (without labor contractions) leading to a preterm birth.   Shortened cervices are more likely to have cervical insufficiency.  With that said, ACOG (American College of Obstetricians and Gynecologists), a governing body for OB/GYNs) fell short of mandating routine transvaginal cervical length screening in women without prior preterm birth.

When you become pregnant, it will be up to your physician or midwife to request a midtrimester ultrasound, which looks at the cervix as well as the fetus for anomalies.  If your cervix is abnormally short, you and your physician can be prepared for preterm labor and intravaginal progesterone can be offered.  Another form of management also sounds good in the form of a cervical cerclage, or a stitching of the cervix to prevent labor before the 37th week.  However, this plan of management remains controversial with several studies showing no improvement in outcomes for preterm fetuses.  Also, the downside of a cervical cerclage is rupture of membranes and infection, which may ultimately lead to hysterectomy.  With a shortened cervix, patients may be advised to take bed rest in your last trimester to prevent any unnecessary pressure on the birth canal.

A short cervix is probably not a feature you’ve ever included in a physical description of yourself, but when you become pregnant, it could become the difference between a preterm infant and a baby that has grown to term.

– Yvonne S. Thornton, M. D., M. P. H.


Alfirevic Z, Owen J, Carreras Moratonas E, Sharp AN, Szychowski JM, Goya M. Vaginal progesterone, cerclage or cervical pessary for preventing preterm birth in asymptomatic singleton pregnant women with history of preterm birth and a sonographic short cervix. Ultrasound Obstet Gynecol. 2012 Sep 18. doi: 10.1002/uog.12300. [Epub ahead of print]

Cerclage for the prevention of preterm birth in high risk women receiving intramuscular 17-α-hydroxyprogesterone caproate.Szychowski JM, Berghella V, Owen J, Hankins G, Iams JD, Sheffield JS, Perez-Delboy A, Wing DA, Guzman ER; for the Vaginal Ultrasound Trial Consortium.J Matern Fetal Neonatal Med. 2012 Aug 24.

Found a Lump? Stay Calm.

Monday, October 15th, 2012

October is breast cancer awareness month, and it reminds us every year to practice good breast health and receive regular mammograms to protect ourselves. Early detection is always best when it comes to any type of cancer, and a simple mammogram is all we need to detect cancer in our breasts. All women are also encouraged to perform regular self-examinations to look for irregularities. If you find something unusual during one of these self-examinations or even just by chance when you look in the mirror, you’ll probably automatically assume it’s breast cancer. The truth is, it could be a number of different things, so don’t panic.

Don’t get me wrong – any changes in your breasts should be examined by your doctor immediately. However, there is no reason to get worked up over breast pain, nipple discharge, or even a palpable bump. Yes, any of these symptoms could be caused by breast cancer, but you won’t know for sure until you’ve had a diagnostic mammogram, physical exam, and ultrasound. Until then, remember that our breasts are complex and unpredictable organs.

Surprisingly, the Canadian Task Force on Preventive Health Carefound fair evidence that breast self-examination had no benefit and good evidence that it was harmful because it increased anxiety, physician visits and resulted in higher breast biopsies for benign disease. This group concluded that among women aged 40-69 years, routine teaching of breast self-examination should be excluded from breast cancer screening. However, I believe that breast self-examination has the potential to detect breast cancer that you can feel and still should be recommended.

It’s easy to forget that breasts are not simply sitting on our chest unchanging. They are constantly active, and they are easily affected by our body’s hormonal changes at any given moment. Your breasts will change during your menstrual cycle, during pregnancy, and even during menopause.

Especially in women younger than 40 years of age, changes in your breasts could be caused by benign cysts, mastitis, abscesses, breast hematoma, or a wide variety of non-cancerous tumors that can form in the many areas of such a complex organ. Breast tissue changes will always be alarming, but you should try to stay calm until the results of the test come back. Breast cancer can be fatal, but the many other possible conditions are harmless and will sometimes even go away on their own.

When you notice any changes in your breast, your reaction should should not be to panic and apathy will only kill you. You should certainly call your doctor and set up an appointment right away, but you should not start calling your family members frantically without knowing the entire story. Breast cancer awareness month should remind you to stay on top of your breast health, but it should also remind you to be grateful for all of the time you’ve remained happy and healthy.

 – Yvonne S. Thornton, M. D., M. P. H.

Why Pregnancy Will Leave You Breathless

Thursday, October 11th, 2012

Especially if you were fit before your pregnancy, losing your breath when performing simple tasks seems like a reasonable cause for concern. Running a half marathon before you became pregnant was easier than going up a flight stairs with your baby bump because you become winded at the third step. While losing your breath can be frightening at times, it is actually a common side effect of pregnancy. Many women experience it, and unless you’re really having trouble breathing and there are other side effects, you don’t need to rush to the doctor. There are a few harmless reasons you might be losing your breath.

You might experience breathlessness even in your first few weeks of pregnancy. While this seems outrageous because you have very few other symptoms, it’s actually because your body is sending more oxygen to the fetus. The hormone progesterone is doing its job and increasing your lung capacity so that you can take in more oxygen. That extra oxygen is then sent down to assist in the development of your baby. So, you might feel like you’re not getting enough because your body and breathing patterns are not adjusted to this newly added space in your lungs.

Later in your pregnancy, your growing uterus will more likely cause your breathlessness. Your baby bump will begin to push up against the surrounding organs, including your lungs. You might feel like you can’t get a full breath in because, frankly, you can’t. Most women experience this most at 31 weeks and later when the uterus begins pushing against the diaphragm.

If you start feeling short of breath during your pregnancy, your first instinct will be to panic. Instead, you should relax, as panicking will only make it harder to breathe. Stop what you’re doing and breathe slowly and deeply, and soon you’ll catch your breath. You should also try improving your posture so that your lungs can easily reach full capacity. If you find it difficult to breathe through the night and upon waking up, try sleeping in an upright position, as it could be a sign that you sleep in a way that restricts the lungs.  Amazingly, you might notice that your breath returns to normal in your last few weeks of pregnancy because your baby will drop down to the birth canal. Breathe deeply and start getting ready, because you’ll be a mom in no time.

– Yvonne S. Thornton, M. D., M. P. H.

A Simple Survey Could Determine Your Risk for Ovarian Cancer

Monday, October 8th, 2012

As women, we have to go through countless medical tests throughout our lives. Mammograms, pregnancy tests, HIV tests, and bone-mineral density tests are all par for the course when you become an adult. In fact, few women haven’t gotten all of these tests and more. Don’t get me wrong- as a physician, I genuinely appreciate our ability to screen for life-threatening conditions, and I wouldn’t have it any other way. However, as a woman, I understand the patient side of it as well.  Wouldn’t it be easier if medical screening tests were simpler? According to a new study, simplicity might just be attainable.

Researchers have developed a new screening tool for ovarian cancer that can be completed in minutes by a simple survey. That’s right, no heavy machinery, foul-tasting chemicals, or drafty hospital gowns required, just a simple pen and paper.  The study questionnaire that was tested was based on a symptom-screening index developed in 2006 by M. Robyn Andersen, Ph.D and co-author Barbara Goff, M.D., professor and director of Gynecologic Oncology at the University of Washington School of Medicine.   The survey asks women three questions about their current symptoms that have been most commonly associated with women that screened positive for ovarian cancer. A few of the symptoms might be passed off as menopause or menstruation symptoms, so the key in early diagnoses is recognizing the symptoms as they are happening. Some of these symptoms include abdominal or pelvic pain, a sensation of feeling full too quickly, and abdominal bloating. You have to admit, you’d never attribute any of these symptoms to cancer.

Traditionally, ovarian cancer is thought to have no early warning signs, such as bleeding or an abnormal Pap smear, as one sees in uterine cancer or cervical cancer, respectively.  In comparison to breast cancer, which is the most frequent cancer in women, with about 212,000 new cases a year, ovarian cancer has only 25,000 new cases a year. But, because there are no early warning signs or tests to detect ovarian cancer, and the cancer has progressed to a more advanced stage prior to diagnosis, the death rate is higher—about 62 percent in ovarian cancer, as opposed to 18 percent in breast cancer and 32 percent in cervical cancer.  With that said, this new study takes into consideration symptoms, which are commonly dismissed by many patients and by combining them together, have proven to be significant factor in trying to diagnose ovarian cancer at an earlier stage.

Of course, these symptoms are minor and can easily be associated with other issues. However, the results are proving the survey effective so far. Of 60 women who submitted the survey with positive indication, one was diagnosed with ovarian cancer. Of the 1,140 women who did not claim to have the symptoms, none tested positive for ovarian cancer over the course of the following year.


The survey will also serve as a research tool for doctors. Women who take the short survey and indicate that they have all of the symptoms will also be asked to write any additional symptoms. If those women screen positive for ovarian cancer, those additional symptoms will be analyzed, and common additional symptoms might be added to the survey to further screen patients.

Early detection is extremely important in treating ovarian cancer.  If you have these symptoms, talk to your physician about ovarian cancer to rule out the possibility that you might have it. If he or she thinks you should get tested, do so, as it could save your life.

 – Yvonne S. Thornton, M. D., M. P. H.

Drink Up Ladies!

Thursday, October 4th, 2012

If you were lost on a desert island, you would probably die from dehydration before you died of starvation. This is surprising for many people, since we all know how hungry we can get when we accidentally skip even one or two meals. The symptoms of dehydration are harder to pinpoint, but it’s extremely important that you get enough water every day. If hydration is so vital to our wellbeing on a regular basis, imagine the importance of it during pregnancy.

Women who are pregnant should be diligent in staying hydrated for the duration of their gestation. It is easier to become dehydrated when you are pregnant. For one thing, you are probably experiencing more nausea and vomiting than you ever have. Morning sickness is common, and every time you lose your lunch, you could become seriously dehydrated. The worst part is that you won’t have the desire to drink fluids after you’re sick, so the problem is not always remedied.

I recommend to my patients that they should drink, at least, two quarts of pure water per day.  Not soda, not tea, not coffee, but good old-fashioned water.  In the summer months, that amount should increase by a quart in order to compensate for the increase in perspiration and insensible loss.  With the recommended quart of skimmed milk per day, I really don’t understand why there is a need for any more fluids in the form of soft drinks, etc.  Becoming dehydrated during your pregnancy, even temporarily, puts your baby at risk for serious complications. When a pregnant women is dehydrated, that fluid restriction is thought to decrease the production of amniotic fluid in your womb.  Particularly, in the second or third trimesters, dehydration can lead to premature labor because it triggers the same hormone that causes uterine contractions (oxytocin), not to mention the typical pains of dehydration such as headaches and muscle cramping.

The best way to prevent dehydration during your pregnancy is to drink more than enough water and stay out of the extreme heat and direct sunlight. If you experience symptoms such as dark urine, infrequent urination, headaches, dry mouth, chapped lips, and dry skin, contact your doctor immediately. It might be too late for water to solve the problem, and hospitalization might be required.

In a perfect world, we could all relax during our pregnancy and focus only on our health. Unfortunately, we are all busy people and our daily lives are often full of other concerns. If you find it difficult to keep track of how much water you’re drinking, consider keeping a log to make sure you’re always getting enough.  Dehydration can be serious, so make sure avoiding it becomes one of your top priorities.

– Yvonne S. Thornton, M. D., M. P. H.

Ditch the Itch——Are You at Risk for Obstetric Cholestasis?

Monday, October 1st, 2012

There are many reasons why you might feel itchy during your pregnancy. You might start to itch around your midsection because your skin is stretched. You also might itch because of your prenatal vitamins. The hormones released during gestation also make your skin more sensitive, so even something as simple as your perfume or fabric choices might have you scratching incessantly. However, if you’re experiencing severe, generalized itching (pruritus) all over your body (especially the soles of your feet) that won’t go away, it’s time to talk to your doctor. It could be a sign of a serious condition known as obstetric cholestasis.

Obstetric cholestasis (OC) or intrahepatic cholestasis of pregnancy is a disorder that affects the liver and develops during pregnancy. Ten percent of the affected women will develop jaundice.  Essentially, it is caused by a buildup of bile salts that are supposed to be flowing to and from your liver in the digestion of food. You’re at a higher risk of OC if it runs in your family. So, if your mom had OC while she was pregnant with you, there’s a good chance you’ll get it, too. It is also more common in women in Pakistan, Sweden and Chile. Unfortunately, there is no cure for OC. Itching usually resolves within a few days of delivery, and subsequent liver problems are uncommon — although cholestasis is likely to recur with other pregnancies.   Because the liver is involved and the liver is responsible for clotting factors, blood tests to check your clotting factors are done throughout the pregnancy and you may need to take Vitamin K supplements, depending on the test results.  Although the condition may seem to be just a nuisance and annoying to the mother, it can lead to stillbirth. So, it is a very serious condition.  Because most fetal surveillance studies, such as electronic antepartum fetal testing (nonstress test) are very poor at predicting stillbirth in this disorder, doctors recommend that women with OC with elevated bile salts need to have their labor  induced at 37 weeks (after fetal lung maturity has been established) to make sure the baby makes it out healthy and happy.

If your physician determines that the cause of your itching is in fact OC, you’ll need to get regular tests to make sure your liver is functioning properly. For some women, the itching is unbearable, so you should talk with your physician if the itchiness is interfering with your daily activities.  A medication, known as Actigall (ursodeoxycholic acid ) helps regulate cholesterol by reducing the rate at which the intestine absorbs cholesterol and consequently is effective in alleviating the itching.  Aveeno®  oatmeal baths, topical steroid creams  and other steroids have been used with some success.  . You should also try to scratch your skin as infrequently as possible, as open cuts from scratches could become infected.  Although, when you’ve got the pregnancy itch, not scratching is obviously easier said than done!

– Yvonne S. Thornton, M. D., M. P. H.