January, 2014

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Why Aren’t IUDs More Popular?

Thursday, January 30th, 2014

The IUD is one contraceptive device that seems to not be getting a fair shake. Birth control pills, contraceptive implants, condoms, and surgical sterilization are all more popular, despite the fact that most of these methods are either permanent or require perfect usage by the woman – in other words, remembering to take the pill every day at the same time, or being able to consistently use a condom in the heat of the moment. (Disclaimer: you should always use a condom if you aren’t in a monogamous relationship, but if you are, and you know that you are both free of STIs, a contraceptive method that frees you from having to use condoms can be a welcome change.)

An IUD is a small device shaped like a T which your physician must insert into your uterus. There are copper IUDS available as well as hormonal IUDS which release progesterone; both kill sperm and make the lining of the uterus inhospitable to fertilized eggs. Once inserted, an IUD can be left in place and forgotten for five to 10 years, depending on the type of IUD used. (However, it can also be removed at any time the woman chooses.) The IUD’s string hangs out through the cervix to enable the woman and her doctor to occasionally check that the device is still in place correctly.

IUDs may be a great option for sexually active teens, because they don’t require the same level of attention that birth control pills do – you can’t forget to use your IUD. In fact, IUDs are an excellent choice for any woman who may want to become pregnant eventually, but who knows she is a long time away from being ready. In addition, IUDs are extremely cost-effective when used for a period of several years.

The use of IUDs does not interrupt foreplay the way some methods can; it also does not require the cooperation of your sexual partner. IUDs are perfectly safe for women who are breastfeeding, and when an IUD is removed, fertility returns immediately. The bottom line is that IUDs are extremely effective, extremely safe, and extremely easy to use.

In spite of these benefits, less than 4% of women choose IUDs as their birth control method. Why is that? Part of the issue may simply be that doctors are not recommending IUDs with great frequency, and therefore many women may not even be aware of the availability or the benefits of IUDs. Surveys show that many doctors (about 30%) have doubts concerning the safety of IUDs, such as the possibility that IUDs may increase the risk of infection or jeopardize fertility. These were common concerns when IUDs first appeared on the market, but it is now understood that these fears are unfounded and IUDs are safe for use.

– Yvonne S. Thornton, M. D., M. P. H.

Exercise May Spell Relief for Migraine Sufferers

Monday, January 27th, 2014

Some people who suffer from migraines say that exercise can bring on the severe headaches, but a recent study shows the opposite – that exercise may, in fact, help prevent them. In the study, three groups of participants were observed. One group took the drug topiramate, which is commonly prescribed for migraines; one group practiced relaxation exercises; and one group exercised for 40 minutes three times a week.

After three months, no significant difference was observed between the groups in terms of the presence of migraines. All three groups showed a decrease in the number of migraines they got, suggesting that exercise may be just as effective as drugs at preventing migraines.

For people who know all too well the pain and misery of a migraine, it’s worth a try. It’s probably true that there is no one “right” approach that works for everyone; different people will find that different approaches are effective for them and some trial and error is inevitable in most cases. What is true is that as long as you have no physical contraindications, exercise usually won’t hurt and is a safe and healthy activity for most people.

Migraines can be difficult to diagnose, as they have several variants. In general, they are severe and even disabling headaches affecting about 22% of women and about 10% of men. Migraines can affect a person’s ability to go about his or her daily routine for hours or even days at a time and can be difficult to treat, so the information that exercise may help prevent them is good news for those who haven’t had much success with drug treatments or relaxation exercises.

A typical migraine can produce severe, throbbing pain, visual disturbances, nausea, vomiting, and sensitivity to sound and/or light. Many people find that once they have a headache, physical activity can make it worse, so finding ways to prevent migraines is important. Migraines may occur anywhere from once a year to several times a month.

The exact cause of migraines is not well understood. There is no shortage of theories, however, and they range from changes in the trigeminal nerve (a main facial nerve) to serotonin imbalance. Food sensitivity may play a role in some individuals. Another factor, particularly in women, may be hormonal fluctuations. Stress and heredity are also suspects in some cases. Still other possible triggers include sleep disturbances, barometric pressure changes, altitude changes, bright flashing lights, and strong smells such as gasoline or paint.

There are two main types of drug treatment used by migraine patients: those that treat an existing migraine and those that aim to prevent migraines from occurring in the first place. In individuals who have found that they aren’t responsive to drug treatments, regular exercise just may provide a new avenue to explore for the prevention of the debilitating headaches.

– Yvonne S. Thornton, M. D., M. P. H.

How to Handle Mastitis when Breastfeeding

Thursday, January 23rd, 2014

Mastitis is, simply put, an inflammation of the breast. It can occur without apparent cause, but it often occurs during breastfeeding. In fact, about ten percent of breastfeeding women experience mastitis. Mastitis can be particularly problematic in women who wish to continue breastfeeding, because it is often painful and women suffering from mastitis are very likely to wean their infants during this time.

Mastitis is caused by infection by bacteria that enter the breast through the nipple; the cracked and sore nipples common in breastfeeding women make perfect pathways for the bacteria to get in through. Most commonly occurring during the first six months of breastfeeding, it can add to the already-considerable burden of caring for an infant and increase the mother’s fatigue and stress. It often leads to the cessation of breastfeeding, but breastfeeding with mastitis is safe, and it is usually cleared up easily with medication.

Symptoms and Treatment of Mastitis

Usually the first thing a woman with mastitis notices is a painful area in one of her breasts. The area may also be warm and red. She may also experience body aches, chills, and fever. Swollen and painful lymph nodes, flu-like symptoms, and a faster than normal heart rate are signs that the infection is getting worse.

Mastitis is usually easily diagnosed by observation of the symptoms; specific tests are not typically needed. If you have symptoms of mastitis, don’t hesitate to see your doctor; an antibiotic will usually cure it relatively quickly. It is safe to breastfeed while taking antibiotics, so feel free to continue to do so, unless your doctor directs you otherwise. During treatment, help your body heal and yourself feel better by resting more, drinking plenty of fluids, and using warm or cold compresses on the painful area. You can also take acetaminophen or ibuprofen for pain. If you think you have mastitis, get medical attention promptly; delaying treatment can lead to complications which can be harder to treat.

Breastfeeding (or Not) with Mastitis

If you are determined to continue breastfeeding, you can do so safely with mastitis. Make sure to empty the affected breast completely each time you breastfeed in order to prevent a dwindling milk supply. If it is too painful to breastfeed much on the affected side, use a breast pump to completely empty the breast on a regular basis.

However, for some women, mastitis presents either too difficult a situation in which to continue to breastfeed, or a good opportunity for weaning for those who were planning it soon anyway. Caring for an infant is extremely challenging, and formula presents a perfectly nutritious and healthy option for feeding your baby. I know that most women feel like they “should” breastfeed, but in fact, millions of completely healthy and well-adjusted people were never breastfed.

Don’t worry about “bonding,” either. Feeding your baby should be a time to interact closely with him or her, but it’s the physical contact and the attention that matter, not whether the milk being fed is coming from a breast or from a bottle.

For more information on this topic and others, see my book, Inside Information for Women.

– Yvonne S. Thornton, M. D., M. P. H.

Multiple Births on the Rise

Monday, January 20th, 2014

If you feel like there are more twins, triplets, and more around than ever before, you’re not imagining it. Multiple births have increased since 1980, when one in every 53 babies born was a twin; in 2009, that number had risen to one in every 30. That’s a 76% increase in twin births in roughly 30 years.

One (smaller) reason for the spike is older maternal age. Older women are more likely to release more than one egg at a time (with or without fertility drugs), making multiple gestation a possibility more often. Incidentally, this does not pertain to identical twins, who are formed from a single fertilized egg.

Another reason, one which is responsible for a larger share of the increase, is the use of fertility drugs in women trying to become pregnant. Fertility treatments have attracted some attention in recent years following the birth of eight babies by the so-called “Octomom.” In that case, 12 embryos made from an IFV treatment were implanted into the woman’s uterus and the result was eight viable fetuses.

This was a clear case of poor judgment. Most cases of infertility are not treated with IVF, but rather with drugs that stimulate the ovaries to produce eggs. These drugs encourage hormone production, which aids in conception but also increases the chances of multiple gestation.

When women are undergoing treatment via fertility drugs, their doctors routinely monitor, via ultrasound and blood tests, how many eggs are being produced so that the couple can avoid trying to conceive during a month when there are too many. However, in some cases the monitoring is not done, or the couples disregard the advice given to them. Often doctors who have been demonized for “allowing” a woman to become pregnant with more than one or two babies during fertility treatments have actually given the woman advice that would have prevented the multiple pregnancy, had it been followed.   

There are good reasons to avoid having twins (or other multiples) whenever possible. Twin pregnancies are considered higher-risk pregnancies, and are usually more difficult for the mother than singleton pregnancies – especially older mothers, who no longer have the energy they had in their 20s. In addition, caring for more than one newborn baby at a time is exhausting, even when plenty of help is available. The exhaustion and expense factors increase exponentially with each additional newborn. It’s also extremely difficult to maintain social and emotional health during those early years with twins or more.

If you do find yourself pregnant with twins or more, take steps as soon as possible to maximize your odds of a healthy pregnancy and delivery, and learn all you can about ways to make taking care of multiples – not just as newborns, but through the challenging toddler and preschool years as well – as simple as possible.

– Yvonne S. Thornton, M. D., M. P. H.

Doctors Not Spending Enough Time Talking to Teens about Sexual Health

Thursday, January 16th, 2014

The sex lives of adolescents is a topic which many parents – and, apparently, doctors – would often prefer to avoid. But since almost half of high school students have had sex, we can’t pretend the sex lives of teenagers are nonexistent, nor can we neglect to teach adolescents about being responsible for their sexual health. Unfortunately, a recent study showed that only about 65% of physicians are talking to teens about sex, and when they do, the conversation lasts only an average of 36 seconds.

None of the 253 teenage patients in the study brought up sex themselves during their office visits, meaning that if the doctor did not initiate the conversation, it did not take place. The doctors were more likely to raise the topic with female patients. It may be true that girls are the ones who get pregnant, and must learn to protect themselves, but adolescent boys also need to know that they share equal responsibility when it comes to safe sex. Besides unexpected pregnancy, both girls and boys must be taught how to avoid contracting and spreading sexually transmitted infections.

And teens can’t count on learning the information they need at home or at school, either. Many sex-ed classes in schools fall short of comprehensive, and the subject is never brought up at all by many parents. For this reason, it is important for doctors to realize the magnitude of this need and be sure to talk to their adolescent patients about sex.

Parents can assist by not being present in the room during the exam – unsurprisingly, the study showed that doctors were much more likely to bring up the topic of sexual health when parents were absent. Longer visits were also more likely to include conversations about sex, one of many reasons why taking enough time with each patient and giving them individual, personal attention is so important.

Whether the doctors were uncomfortable talking about sex with teenagers, were concerned about making conservative parents angry, or were just too rushed isn’t clear. What is clear is that we can’t expect teens to make good choices if we don’t make the effort (uncomfortable as it may be) to educate them and provide them with the tools to make those good choices.

And since teens don’t bring up sex on their own during doctor appointments, it’s vital that we open up the conversation and give them a chance to ask any pressing or embarrassing questions they may have. Otherwise they will likely turn to their friends or the Internet, and there is far too much incorrect and downright dangerous information out there to neglect the job of teaching kids the facts and giving them the opportunity to talk to a trusted, knowledgeable adult about sex.

– Yvonne S. Thornton, M. D., M. P. H.

Is It Safe to Get the Flu Shot During Pregnancy?

Monday, January 13th, 2014

If you are pregnant, chances are that you are questioning everything that goes into your body, and for good reason. It’s your job during pregnancy to nurture and protect your baby from a wide range of potential dangers. During the winter months, you may be wondering whether the flu vaccine is among those dangers.

It’s not. The fact is that it is completely safe for pregnant women to get the flu vaccine. In fact, getting vaccinated against the flu could make a big difference in your baby’s health; it could even be the difference between life and death. The CDC (Centers for Disease Control and Prevention), the American Academy of Pediatrics, the ACOG (American Congress of Obstetricians and Gynecologists), the American College of Nurse-Midwives, and numerous others all strongly recommend that pregnant women get flu shots.

Getting the flu while pregnant can cause serious complications. Pneumonia is one major concern. Pneumonia is potentially life-threatening and could be a risk factor for preterm labor. In addition, there is evidence that when you get the flu shot during pregnancy, your baby may continue to benefit from this protection after birth. Also, if you avoid catching the flu yourself postpartum, then your baby is less likely to be exposed to it at all. And protecting your newborn from the flu is important, because the flu is particularly dangerous for young babies, who can’t be vaccinated themselves before they are six months old. (Therefore, not only you but other family members as well should get flu shots.)

The flu vaccine may have no side effects at all, or you may notice mild side effects such as mild pain, tenderness, or redness at the site of the shot. Some people notice muscle aches, nausea, fever, or headaches after the shot, but these generally only last a day or two. Allergic reactions are extremely rare.

Anyone considering the flu shot, including pregnant women, should tell their doctors or anyone who is administering the shot if they have severe allergies to eggs or anything else that may be present in the shot. It is important to note that pregnant women should receive the flu shot, and not the nasal spray, which contains live flu virus.

Pregnant women can get flu shots at any point in their pregnancy. Getting vaccinated as early as possible to avoid being unprotected when flu season begins is best. However, if you have avoided getting the vaccine because you were concerned about safety during pregnancy, go ahead and get one even if it is later in the season. Flu season can last well into the spring, so even women getting vaccinated later on can still benefit.

Lately there has been some concern among people getting vaccinated about thimerosal, a preservative used in some flu shots. However, the CDC has uncovered no evidence that thimerosal presents any risk whatsoever. Besides, the benefits of getting a flu shot far outweigh even any theoretical risk. If you are worried, though, don’t let it stop you from getting a flu shot; ask your doctor about thimerosal-free vaccine. If it isn’t available in your area, go for the regular flu shot, and don’t worry – it’s much safer than not getting one at all.

– Yvonne S. Thornton, M. D., M. P. H.

Thyroid Problems and Pregnancy

Monday, January 6th, 2014

The thyroid gland is one that most people never give much thought to – until it causes problems. The gland itself is about two inches long and shaped like a butterfly. It sits in the front area of the neck just below the larynx with one lobe on each side of the windpipe. Along with the other components of the endocrine system, the thyroid’s job is to produce hormones. It can also store these hormones and release them into the bloodstream.

The hormones produced by the thyroid are very important, as they affect metabolism, weight, breathing, nervous system functions, muscle strength, body temperature, and menstrual cycles. If the thyroid produces too much or too little hormone, nearly every organ in the body can be affected. Hypothyroidism is underactivity of the thyroid; overactivity is called hyperthyroidism. Because the thyroid affects the menstrual cycle, a woman with a thyroid disorder may find it more difficult to get pregnant.

If a pregnant woman has a thyroid problem, there are special considerations to keep in mind. A woman with thyroid disease can certainly have a healthy, normal pregnancy and baby if she talks about this problem with her doctor, educates herself on the ways in which the thyroid is affected by pregnancy, stays up to date on her thyroid function testing, and takes the proper medications on the proper schedule.

How Is the Thyroid Affected by Pregnancy?

The thyroid gland is basically responsible for controlling our body’s metabolism.  It is regulated by a hormone known as thyroid-stimulating hormone or TSH, which is secreted by the pituitary gland. Pregnancy causes the production of many hormones, one of which is human chorionic gonadotropin (hCG).  In early pregnancy, the growing placenta makes human chorionic gonadotropin (hCG).  HCG increases the production of progesterone, which is crucial for the growing fetus and without it may increase the risk for miscarriage. What does hCG and TSH have in common?  Well, they are two different hormones;  one (hCG) plays an integral role in maintaining pregnancy while the other (TSH) regulates the thyroid gland.  However, hCG can mimic TSH , causing the thyroid gland to become hyperstimulated.  It turns out that the molecular structure of both of these “different” hormones are very similar. 

Both are composed of two different protein subunits. One of those protein subunits is called “alpha” and the other “beta.” The alpha subunits of hCG and TSH are identical but the beta subunits are different; but not by much.  The beta subunits of hCG and TSH are about 40 percent identical.  Given that mechanism, very high concentrations of hCG can actually stimulate the thyroid gland sending it a message to become hyperactive. In other words, hCG can sometimes act like TSH, which is the reason an elevated thyroid function test in the first trimester (which may be interpreted as an overactive thyroid), should be repeated in the second trimester when the levels of hCG have stabilized.

The fetal thyroid becomes active at 12 weeks. Until then, it depends on the mother’s supply for brain and nervous system development.

The thyroid also becomes slightly enlarged during pregnancy, but not enough to be viewed as abnormal during a physical exam. If a thyroid is noticeably enlarged, this could be a sign of thyroid disease. But again, thyroid problems are tricky to diagnose during pregnancy, because the thyroid hormones levels are higher than normal and also because fatigue and other symptoms of thyroid disease are often similar to normal pregnancy symptoms.  That is why subspecialists, like myself, known as maternal-fetal medicine specialists, may need to be called upon by the midwife or obstetrician when caring for a pregnant woman with suspected thyroid dysfunction.

How Is Pregnancy Affected by Thyroid Problems?

Depending on whether you are dealing with hyper- or hypothyroidism, uncontrolled thyroid disorders in pregnancy can cause a number of health risks to mother and baby, including congestive heart failure, thyroid storm, neurologic deficits in the fetus, miscarriage, fetal growth restriction or neonatal Graves disease (hyperactive thyroid function in the newborn).   Thyroid disease has an autoimmune component and other autoimmune diseases also need to be ruled out.  Antibodies (TSI—thyroid stimulating immunoglobulins) from a hyperactive, hyperthyroid patient can cross the placenta and cause fetal goiter.

For these reasons it is extremely important that a woman with a thyroid disorder optimize her health by eating a balanced diet with iodized salt, taking a prenatal multivitamin that contains iodine (which the thyroid uses to make hormones), and taking the appropriate medication to control symptoms and regulate hormone production.  Up to 10% of postpartum patients develop new-onset of Graves disease or autoimmune thyroid dysfunction.  In my practice, patients who were six weeks postpartum all underwent thyroid function testing.  It is not the standard, but, after diagnosing several patients with thyroid dysfunction, I did not want to miss an abnormally functioning thyroid gland in any of my postpartum patients.  Thyroid conditions often require lifelong monitoring, but with the right medical attention, are easily controlled.

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

What about Postpartum Depression?

Thursday, January 2nd, 2014

Regardless of how much you have looked forward to the birth of your baby or how happy you are about it, having a baby is extremely stressful. A range of emotional reactions are expected and normal, including sadness, “baby blues,” or some depression. However, if you find yourself with feelings of depression that don’t go away within a few weeks, you could have a condition called postpartum depression. This is a serious condition that requires that you see your doctor as soon as possible to discuss treatment and support options so that you are healthy and able to take optimal care of your new baby as well as yourself.

The baby blues are common and mild, and may include symptoms such as sadness, moodiness, irritability, and trouble sleeping. These symptoms appear within a few days of giving birth and improve within a couple of weeks. Postpartum depression, on the other hand, is more serious and the symptoms are more severe and last longer.

Symptoms such as a lack of interest in your baby, worrying that you might hurt your baby, lack of interest in personal hygiene, lack of motivation or energy, feeling worthless or guilty, or thoughts of death or suicide are examples of the types of symptoms that should alert you to the fact that you may be dealing with something beyond normal baby blues.

What Causes Postpartum Depression?

It is not well understood why postpartum depression affects some new mothers and not others. However, there are a number of causes and risk factors that may contribute. Changes in hormone levels after childbirth, physical pain, insecurity about your changed body, exhaustion, and the stress of taking care of a new baby can all play a role in the development of postpartum depression.

In addition, it is known that some women are more likely to get postpartum depression, such as those who have a history of depression, a history of severe PMS symptoms, medical complications with the pregnancy or delivery, and a lack of support from friends and family. In fact, this study shows the important role that peer support plays in preventing and lessening postpartum depression.

How to Treat Postpartum Depression

To start feeling better, it is very important to take care of yourself. Making sure you get enough sleep, which may sound impossible when you have a new baby, but being exhausted will worsen your depression. I was told from a wise mother of several children, “When your baby sleeps, you sleep.”  No vacuuming, washing clothes or paying bills. Enlist help if at all possible so that you can get enough rest. And when awake, do not spend every waking minute caring for your new baby, your other kids, or your house – take breaks from mommy duty to pamper yourself.  That may be easier said than done when you have a maternal sense of danger if your baby is not within your sight every minute.  Even taking a shower may be difficult for some new mothers.  Single mothers have the most difficult time of balancing their lifestyle with the arrival of a newborn.  Instead of meeting a friend for coffee, ask that friend if she (or he) can come over to spell you from the rigors of motherhood for a few hours.  And, when she’s there, take a long, hot bath and do whatever simple things you enjoy to recharge and relax.   It DOES “take a village” to raise a good kid without exhausting yourself trying to do it alone.

You can also get closer to feeling like yourself by eating a healthy diet, getting plenty of mood-enhancing sunshine, and easing back into a regular exercise routine. A 30-minute walk each day is a good way to start, and your baby will probably love it, too.

Finally, make sure and take advantage of the help and support others offer – or be proactive about asking for it. Stay in touch with your friends; make plans with them and do not let yourself become isolated. Talking about your feelings can help, too.

As stated in my blog back in 2010, “Everyone feels sad some of the time. It’s normal to have a bad day. But if your bad day stretches into weeks, for your own sake and the sake of your baby, you need to get help. If you don’t have a therapist, ask your ob-gyn for a referral if you experience feelings of hopelessness, sadness or despair. Don’t suffer needlessly. Help is available.”

Talk therapy, hormone therapy, and medications such as antidepressants can all be highly effective in relieving postpartum depression.

– Yvonne S. Thornton, M. D., M. P. H.