February, 2014

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Folic Acid’s Role in Preventing Neural Tube Defects

Thursday, February 27th, 2014

Neural tube defects (NTDs) are common birth defects that present an elevated risk of serious disability and infant mortality. NTDs include spina bifida, anencephaly, and encephalocele, and occur in about 1 out of every 1000 US births. Many of these pregnancies are either terminated or spontaneously lost, resulting in about 2,500 babies born with NTDs each year.

Spina bifida occurs when the vertebra do not form properly around part of the spinal cord. The disease can be mild, with no symptoms, or it can be debilitating, affecting every aspect of a child’s life. People with a very mild form may never even know they have it until some other problem prompts a back x-ray. In more serious cases, fluid can leak out of the spine and push against the skin, forming a bulge, or spinal nerves can push out of the spinal canal and sustain damage. This can cause problems with walking, coordination, and bladder and bowel control.

Anencephaly is a birth defect in which an infant is born without parts of the brain and skull. Most babies with anencephaly die shortly after birth. Encephalocele is a rare NTD that also affects the brain. In encephalocele, the brain and the membranes that surround it protrude through an opening in the skull. This defect is often linked to nervous system problems, such as uncoordinated movement, vision problems, seizures, and developmental delays.

Folic Acid Key to Prevention

Studies such as this one show that folic acid is instrumental in preventing neural tube defects. Folic acid is a synthetic compound used to fortify foods and supplements. The term “folate” means any compound containing the same vitamin properties of folic acid, and includes both folic acid and the natural compounds found in many foods.

Folic acid is water-soluble and has no known toxicity. (However, certain vitamins found in many multivitamin supplements are toxic at high doses, so do not continue a vitamin regimen that your doctor has not approved when you are considering becoming or are pregnant.) Women of childbearing age should be getting 0.4 mg of folic acid each day. Folic acid is highly bioavailable and one of the important ingredients in prenatal vitamins, a key reason why you should be taking them if you are pregnant or thinking of becoming pregnant.

You can also up your intake by eating plenty of leafy green vegetables, citrus fruits, and whole grain breads, pastas, and other foods enriched with folic acid. And plant foods, in particular, contains many compounds that are essential for your health and which you can’t get from a pill, so don’t let your vitamin supplement be a substitute for a healthy diet. The bottom line is that when it comes to optimal prenatal nutrition, both prenatal vitamins and a healthy, balanced diet are essential.

– Yvonne S. Thornton, M. D., M. P. H.

Just How Important Is Calcium?

Monday, February 24th, 2014

Through every stage of life, calcium is an important component of a woman’s diet. Calcium is involved in many aspects of overall health. It is believed to be important for bone health, prevention of cardiovascular disease, blood pressure regulation, weight management, and prevention of some types of cancer.

How Much Calcium Do You Need?

The recommended daily allowance of calcium for women between 19 and 50 years of age is 1,000 mg. That recommendation does not change when you are pregnant, but meeting it does become even more important, because you are providing nutrition for your baby as well, and his or her bones and teeth need calcium for proper development. In addition, when you don’t get enough calcium for a long period of time, you are at risk for developing osteopenia, which can lead to osteoporosis.  What’s the difference? Osteoporosis is a disease that breaks down the tissue in our bones, making them fragile and more likely to break. Osteopenia is not a disease, but a term that describes low bone density. Both can lead to painful fractures.  While osteopenia is not considered a disease, being diagnosed with osteopenia requires further monitoring. Preventive measures should be taken since osteoporosis may develop if bone density loss increases.

Actually, the real protection against osteoporosis begins when one is a teenager, because porousness of the bones is the end stage of a long process. Continuing to drink milk after childhood through the teenage years is like putting calcium in the bank to be drawn on later. Unfortunately, teenagers favor sodas over milk and not many drink the two glasses of milk a day that would allow them to meet more than half their daily calcium needs.

Which food has more calcium?  A cup of collard greens or a cup of whole milk?  The answer is collard greens!  Eight ounces of skim milk contains almost 300 mg – even more than whole milk, and in a healthier, fat-free package. Yogurt and cheese are good sources of calcium too, but remember that dairy products are just one of many ways to get the calcium you need. Salmon, kale, broccoli, and calcium-fortified orange juice are just a few of the other many places to find calcium.  I don’t believe that my orange juice should be calcium-fortified, but the manufacturers are offering the option.  Just drink milk!

What about calcium supplements? Their safety is often called into question, although for now they appear to be harmless. The real issue is that supplements are not a stand-in for natural foods that contain calcium, because they lack the protein, vitamins, and minerals that you, and your growing baby if you are pregnant, both need. With just a little effort you can get all the calcium you need easily through a healthy diet.

Calcium need during menopause is 1200 milligrams per day. After menopause, it increases to 1500 milligrams per day.  We once thought that calcium and Vitamin D supplementation should be taken to prevent bone fractures in postmenopausal women.  However, the United States Preventive Services Task Force, an independent panel of experts in prevention and primary care, recently issued a draft statement in June, 2012, recommending that healthy postmenopausal women should NOT take low doses of calcium or Vitamin D supplements to prevent fractures.  Why?  Because the supplements were found NOT to prevent fractures and only increased the risk of other problems, such as kidney stones.  So the risks outweighed the benefits and taking these supplements may actually be harming you.


Lactose Intolerance

Lactose intolerance is a common condition in which unpleasant symptoms such as bloating or diarrhea occur after consuming lactose, milk’s natural sugar. This happens when an individual does not produce enough of the enzyme lactase to properly break down the lactose. Lactose intolerance can unsurprisingly make it more of a challenge to consume enough calcium. However, some individuals can consume a small amount of milk without issue. Yogurt is often a good alternative.  However, there are many products today designed for lactose-intolerant individuals. In addition, there are many non-dairy sources of calcium available such as kale, broccoli, collards, and foods fortified with calcium.

Can You Get Too Much Calcium?

Like anything other good thing, too much calcium can present potential problems. Hypercalcemia can cause renal and vascular problems, as well as kidney stones. It can also cause constipation. However, it’s important to realize that you would have to consume more than three times the recommended daily allowance of calcium for problems to begin to occur. Given the average American diet, this is just not a real concern. So drink plenty of skim milk and enjoy lots of other calcium-rich foods as part of your balanced nutritious diet, especially while you are pregnant, lactating or postmenopausal.

For more information about the risk factors associated with postmenopausal osteoporosis, I refer you to my health book, Inside Information for Women.

– Yvonne S. Thornton, M. D., M. P. H.

Gynecology Board Reverses Male Patient Ban

Thursday, February 20th, 2014

Back in December, I covered the issue of gynecologists treating male patients at high risk for certain types of cancer. At that time, the American Board of Obstetrics and Gynecologists had disallowed the practice. However, in response to protests from both patients and doctors, the board has lifted the ban and said that gynecologists who choose to do so are free to treat men.

The board’s executive director issued the following statement: “This change recognizes that in a few rare instances board certified diplomates were being called upon to treat men for certain conditions and to participate in research. This issue became a distraction from our mission to ensure that women receive high-quality and safe health care from certified obstetricians and gynecologists.”

This past fall, gynecologists who chose to treat male patients were ordered to stop and threatened with loss of certification for noncompliance. The board prohibited treatment of male patients with the exceptions of newborn circumcision, transgender patients, and men who were part of a couple undergoing fertility treatments.

The decision was made then in order to protect patients and uphold the integrity of the specialty of gynecology. This was due in large part to gynecologists who were branching out significantly into other areas, such as cosmetic surgery, for instance, and even advertising their services and identifying themselves as “board certified” without specifying that they were gynecologists. This practice could have misled patients who believed that they were being treated by board certified plastic surgeons, or other types of specialist.

However, one group of patients that the directive directly affected was men at high risk for anal cancer. The gynecologists who treated them said that not enough doctors had experience in this type of screening, and they feared the ban would interfere with patient care as well as government-funded studies aimed at determining the effectiveness of these cancer screenings.

In December, the board relented and agreed that gynecologists could continue to treat their current male patients, but not accept any new ones. And after further pressure, the board in January stated that the ban on treating male patients no longer existed. Gynecologists are now free to treat male patients as long as they devote “a majority” of their practice to gynecology – a change from the specific 75% that used to be the minimum portion of a gynecologist’s practice that must remain within the specialty.

Interesting, since the board’s own definition of what a gynecologist is includes, “Obstetricians and Gynecologists provide primary and preventive care for women and serve as consultant to other health professionals.”

Some are calling the board’s decision a victory for patients, but is it? As I stated back in December, “…there is no reason that I can see why the specialty of gynecology should expand into unrelated disciplines. The very reason why we have specialties is so that specific areas of medicine can be studied thoroughly and the treatments we are able to provide kept up to the minute. A gynecologist should specialize in gynecology – delivering babies, taking care of women. Other practices and treatments are important and helpful, but they aren’t gynecology.”

– Yvonne S. Thornton, M. D., M. P. H.

Should Birth Control Pills Be Available Over the Counter?

Monday, February 17th, 2014

It’s a hot debate topic: should women really be required to obtain a prescription for birth control pills? Shouldn’t the most popular form of birth control be available over the counter (OTC)?

Proponents of making oral contraceptives prescription-free say that more access to the pill would lead to fewer unintended pregnancies. To be sure, there are women who would take birth control pills if they didn’t have to see a physician to get them and if the overall cost were lower. Women commonly site access, convenience, and cost as reasons why they do not use a consistent contraception method.

Those in favor of OTC oral contraceptives also say that the benefits of making them more available outweigh the risks, as these pills are widely prescribed and generally safe. There is no argument that access to birth control is very important. Unintended pregnancy has devastating emotional and financial effects on a woman’s life, often ensuring poverty, inability to continue her education, and much more.

However, the risks of taking birth control pills without medical advice are substantial. If they were to start being sold without prescriptions, it’s a safe bet that many women would not receive important medical counseling. For example, one of the reasons birth controls require prescriptions is that they have known drug interactions and potentially dangerous side effects.

For example, antibiotics can interfere with the effectiveness of the pill. Physicians counsel women on drug interaction dangers like this when they dispense prescriptions. Women who buy the pill over the counter may not realize that if they also take an antibiotic, they need a backup method of birth control that month. In addition, birth controls pills are completely useless against sexually transmitted infections (STIs). They are not a replacement for condoms.

And if a woman doesn’t have to see her doctor to obtain a prescription for birth control pills, might she be more likely to skip seeing her doctor altogether for longer periods of time? This certainly would not be an issue for all women, but the ones who go to the doctor only because they must to get the pill would encounter the additional risks involved in not obtaining regular preventive checkups, which can reveal health problems such as STIs and some cancers in their early (and treatable) stages.

In addition, women who smoke and take birth control pills have a much higher risk of strokes, heart attacks, and death.

Birth control pills are a great option for contraception. They are easy to use, can’t be neglected in the heat of the moment (although they be forgotten earlier in the day), are noninvasive, and do not have lasting effects on fertility. However, the risks of using them and the need to use them properly call for medical advice before beginning them, at the very least.

You can find more information on birth control pills and other contraceptive methods in my book, Inside Information for Women.

– Yvonne S. Thornton, M. D., M. P. H.

Strenuous Exercise Temporarily Decreases Fertility

Thursday, February 13th, 2014

A study from NTNU (Norwegian University of Science and Technology) suggested that the combination of strenuous workouts and achieving pregnancy may be too much for the body to handle. Therefore, female athletes or heavy exercisers may want to ease up a little if they want to become pregnant.

It is well known that women who are involved in elite sports struggle with fertility more than others. Now it appears that women who participate in other types of extreme exercise may encounter more fertility problems as well. In a study that included 3,000 women, researchers at NTNU discovered that frequent and strenuous exercise may reduce fertility – but only temporarily, or while the hard training lasts.

None of the women in the study had experienced a history of problems with fertility, and all of them were of childbearing age and in good health. Two groups of women showed a higher risk of fertility problems: those who trained nearly every day, and the ones who exercised until they were completely exhausted. The ones who fell into both groups experienced the most fertility problems.

In addition, the effects of strenuous exercise on fertility appear to be transient, ending when the hard training slowed down.

The theory is that extremely demanding physical activity requires so much energy that the body can actually experience periods of a deficiency of energy, in which the amount of energy needed to maintain the mechanisms, hormonal and otherwise, to enable fertilization just isn’t there.

It is important to note that women who engaged in low to moderate activity had no fertility impairments, so there is no reason for women to stop exercising altogether while trying to conceive. In fact, exercise can reduce stress, which is good for fertility. Moderate exercise has been previously shown to improve insulin function and promote better fertility as compared to complete inactivity.

It appears that the worst choices for women trying to conceive fall at both ends of the spectrum: extreme physical activity and extreme sedentariness. Pinpointing what constitutes the perfect level of activity, however, can be tricky, because it can be unique to individual women. If your menstrual cycle is particularly long or nonexistent, this could be a sign that you are exercising enough to negatively affect your fertility.

A woman is considered to be infertile after a year of unprotected intercourse without a pregnancy occurring. In women older than 35, it makes sense to see a doctor sooner; perhaps after four to six months of trying unsuccessfully to conceive. There are many factors that can affect fertility in women, including problems with the fallopian tubes, the ovaries, or the uterus, problems with ovulation, and hormonal issues. Sometimes the reason for infertility cannot be pinpointed, and sometimes it may the male partner who has the fertility problem and not the woman. A doctor’s evaluation is the only way to find out for sure.

– Yvonne S. Thornton, M. D., M. P. H.

Can You Safely Buy Medications Online?

Monday, February 10th, 2014

In a study of internet users conducted recently by the FDA, researchers found that while 20 percent of the participants had used the Internet to buy prescription medications, 29 percent reported being unsure of how to buy medicines online safely.

Medications can be bought safely online, but the patient must be aware of the dangers and be able to determine which Internet pharmacies are legitimate and which ones are not. The stakes are high, since if you put your trust in the wrong website, you could end up with a medicine (over the counter or prescription) that isn’t safe to take.

Making this determination isn’t as easy as it seems. Websites that sell potentially dangerous drugs often have a very professional and legitimate look. However, no matter how professional a website looks, it could be run by an illegal operation, which may sell drugs that are unapproved, contain the wrong ingredients, contain too little or too much of the active ingredient, or even contain dangerous ingredients.

So how can you avoid these risks while taking advantage of the convenience of online shopping? For starters, the pharmacy you choose should be located within the United States. It should be licensed by the state pharmacy board in the state where the website is operating. You can find a list of boards here. A licensed pharmacist should be available to answer questions, and the pharmacy should not be willing to sell you prescription medicines without a prescription. Finally, the website should provide contact information and you should be able to contact a live person by phone if you need to.

Another way to protect yourself is by being sure to check the appearance of the medicine before you take it, including its shape, size, color, and packaging, as well as its smell and taste. Some medications found online may be too strong or weak, past their expiration dates, labelled incorrectly, shipped incorrectly, or outright counterfeit.

Counterfeit drugs present a special danger because they are often difficult to identify and there is often no way for the buyer to know what is in them. They may not be effective for their intended purpose, or they may contain the wrong amounts of ingredients or even the wrong ingredients, period. This can be extremely dangerous and lead to harmful side effects. The fake packaging on these types of products can look quite legitimate. This is why it is so important to make sure to buy medications online from a trustworthy source.

And if you need one more reason not to trust online pharmacies without thoroughly investigating them first, how about identity theft or credit card fraud? Never give any website your personal information, such as credit card information, medical history, or social security number, unless you are sure the website is legitimate and will protect your information.

The take-home message from this blog entry is that I strongly discourage buying ANY prescription medications online.  Your local pharmacist has your history and is aware of any potential interactions with other medications that you have been prescribed, which could be life-saving.   Are you willing to risk your life to save a few dollars?   Think about it.

– Yvonne S. Thornton, M. D., M. P. H.

What You Need to Know about Cervical Cancer

Thursday, February 6th, 2014

Cervical cancer, just as the name implies, forms in the tissues of the cervix, which connects the vagina and the uterus. Generally slow growing, cervical cancer usually does not cause any symptoms. This makes it extremely important to get regular pelvic exams, during which screening tests are done that can find early-stage cervical cancers and even precancerous cells.

Any women can get cervical cancer, but it is typically found in women over 35. There are about 12,000 new cases diagnosed in the United States each year. Almost all cervical cancers are caused by HPV (human papilloma virus), the virus that causes genital warts.

Who Is at Risk?

There are several risk factors that increase a woman’s chances of developing cervical cancer. If you have none of these risk factors, your odds of getting it are very low. These risks include HPV infection (which you may not be aware of, another reason why those pelvic exams are so important); smoking or exposure to secondhand smoke; HIV infection, which can significantly weaken the immune system; certain medications which weaken immune system response; and multiple sexual partners.   

Can Cervical Cancer Be Prevented?

The good news is that cervical cancer is highly preventable. The first step for younger women and girls is to get vaccinated against HPV. Gardasil, a vaccine that prevents HPV infection, protects against the four types of HPV that are responsible for most cervical cancers as well as genital warts (70% and 90% respectively). The vaccine is administered via a series of three simple injections and has very few and mild side effects.

An annual visit to your gynecologist is another excellent way to be sure that, should cervical cancer be present, it is caught in its early and easily treatable stage. It is important for women to realize that even if they haven’t been sexually active recently, they are still at risk for cervical cancer if they have ever had sex. For this reason, continued screening is vital and saves numerous lives every year.

Keep in mind that anyone can lower their risk of various types of cancers by living a healthful lifestyle. Eating plenty of fruits and vegetables, getting enough exercise and enough sleep, and avoiding smoking and other dangerous chemicals are all effective ways to protect yourself and your family.

While cancer cannot always be prevented, it can often be found early and treated. If you haven’t seen your gynecologist recently and it’s closing in on a year (or has been longer than that), make an appointment today. Ignorance is not bliss when it comes to cancer – it’s often a death sentence.

– Yvonne S. Thornton, M. D., M. P. H.

Cancer Deaths Down; More Progress Still Needed

Monday, February 3rd, 2014

Great news: the death rate from cancer is falling. Over the past 20 years, cancer deaths have decreased dramatically and steadily. After peaking in 1991, deaths from cancer have fallen 20%. That’s well over a million deaths prevented over 20 years!

The American Cancer Society’s research shows progress – for example, middle-aged black men are the group with the largest decline in cancer deaths – but also the need for continued research and improvements in care, as cancer deaths are still more common in black men than in white men. Experts estimate that there will be over 1.5 million new cases of cancer in the US in 2014, about 586,000 of which will result in death.

The divide in cancer cases and deaths between races and ethnicities is starkly evident when one considers that even though the rate of deaths has been effectively cut by half in middle-aged black men, their deaths from cancer are still significantly more common than those of white men. The lowest rate of cancer deaths is seen in Asian Americans. Even more deaths could be prevented if the knowledge we now have about fighting cancer were applied across all groups of people – including the poorest subset of the population.

Lung cancer continues to top the list of fatal cancers, along with breast, colon, and prostate cancers. These four cancers alone are responsible for almost half of all cancer deaths in the US, with lung cancer causing more than a quarter of cancer deaths. Researchers estimate that this year, these four cancers will be the most common cancers diagnosed.

Still, the rates of not only deaths but new cases of cancer are also falling. One reason is that more people are having regular colonoscopies, during which pre-cancerous polyps can be removed and full-blown cancer avoided. Lung cancer occurrence has also decreased, thanks in large part to declining numbers of smokers.

Doing Your Part

The number of new cancer cases as well as the number of deaths from cancer can be further reduced by individuals taking a proactive approach to preventing cancer – or catching it early. This is one reason why your annual appointment with your gynecologist is so important; cervical and other cancers can be detected and treated in the early stages, before metastasis complicates your prognosis. Screening for other types of cancers, such as breast cancer and colorectal cancer, is also highly effective at detecting cancer early on. Most cancers are highly treatable when caught early. Free and low-cost cancer screenings are available in many states.

You can further reduce your cancer risk by getting an HPV vaccine and/or a hepatitis B vaccine; ask your doctor if these are right for you. Besides getting regular preventive medical care, avoiding tobacco, limiting sun exposure and avoiding tanning beds, keeping alcohol use to a minimum, getting plenty of exercise, and eating lots of fruits and vegetables can all go a long way toward helping your prevent – and fight – cancer.

– Yvonne S. Thornton, M. D., M. P. H.