Contraceptive Choices While Breast Feeding

February 25, 2019 By Deborah Leave a Comment

Breast feeding has documented benefits for both mother and baby (NEJM JW Women’s Health Jul 9 2014; [e-pub] and Am J Obstet Gynecol 2014; 211: 424.el). So when women are choosing birth control methods, it’s important to know the options regarding the effects of hormonal contraception on breast feeding performance, as well as ease of use and safety. The best time to talk about contraceptive options with your practitioner is during your pregnancy.

The CDC has recently updated the U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC), which provides guidelines on the safety of available birth control choices for women with specific health conditions. Updates for breast feeding women were included based on risk for venous thromboembolism (VTE) and postpartum days. For instance, using combined oral birth control pills is not recommended within 21 days of delivery (rated category 4) due to the excess risk of VTE. It’s best to wait beyond 12 weeks postpartum to reduce the mother’s risk for blood clots. On the other hand, all progestin-only contraceptive methods are rated category 1 (low risk/no restrictions) or category 2 (advantages of the method generally outweigh its theoretical or proven risks) for breast-feeding women.

Here are some of the best options for breastfeeding moms:

1. Lactational Amenorrhea- This offers an effective temporary method of contraception (until menses return or milk substitutes are introduced). When women do not menstruate, they (usually) do not ovulate and cannot get pregnant. Some women will choose an additional method of contraception even while breast feeding exclusively to make sure they are protected from pregnancy…which I think is a good idea.

2. IUDs- There are several types of IUD’s which are safe and very effective. Some contain copper and others contain a hormone known as progestin, which is a synthetic progesterone. They can be used for many years and all can be removed as soon as you are ready to get pregnant again. An IUD can be placed in the uterus within 10 minutes of placental delivery which is very convenient, but risk for expulsion is higher when inserted this early. Many women prefer to wait until their 6-week follow-up appointment.

3. Implant, Shot, and Progestin-Only Pill- All 3 of these methods use the synthetic hormone Progestin. You can use any of these methods immediately after delivery. The implant is the most effective birth control available; even more effective than sterilization!!. Pregnancy can be achieved after removal of the implant. The Depo shot is also very effective as long as you are able to get the injection (given in the arm or buttocks) every 3 months. The progestin-only pill is least effective than the implant or shot mainly because there is more room for human error. The pill needs to be taken the same time everyday, which can be difficult when you have a baby to care for. A new option for women outside the U.S. is a progestin-only vaginal ring that is effective for about 1 year.

4. Emergency Contraception (EC)-This contraception is used only if your regular method of birth control has failed (forgotten pill, broken condom). If you are 17 years or older, you can get EC pills (Levonorgestrel) at the pharmacy without a prescription. Take them within 3 days of unprotected sex. A prescription-only EC pill, ulipristal acetate can be used up to 5 days after unprotected sex. Ulipristal is more effective than nonprescription EC. Small amounts of ulipristal has been found in breast milk so pumping and discarding breast milk is advised for 24 hours after taking ulipristal EC.
The most effective EC is having a copper IUD placed within 5 days after unprotected sex. This also provides you with a continuing and effective birth control method.

There are many safe and effective contraceptives choices after childbirth and when breastfeeding. Talk to your practitioner before having your baby to discuss your preferences when the time comes.

References: Chen, M, Schwarz, E. New guidance on contraception while breast-feeding, JWatch.org October 2016. p.77.
Curtis KM et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep 2016 Jul 29;65:1.

Should Everyone Over 50 Be On Aspirin?

February 17, 2019 By Deborah Leave a Comment

It is not uncommon for me to see aspirin on the medication list of many of my older patients. It is most common with my well-controlled hypertensive or hyperlipidemia clients whom have no history of clinically evident cardiovascular (CV) disease. So when I ask them why they are on aspirin, the common reply is, “I read that it prevents heart attack and stroke so I started it on my own”, or “My husbands cardiologist suggested I take it after I took him in for a check up”. Two new studies in 2018 might shed some light on the subject.

In the ARRIVE trial, some 12,000 non-diabetic patients were randomized to 100mg of daily aspirin or placebo. Enrolled men were 55 years or older with 2 or more CV risk factors. Women in the study were at least 60 years old and had 3 or more CV risk factors. After a 5 year follow up aspirin had no CV benefit in reducing CV-related death, heart attack, unstable angina, stroke or transient ischemic events anymore than placebo. Those in the aspirin group had a slightly higher risk for gastrointestinal bleeding.

In the ASCEND trial, 15,000 middle aged or older diabetic patients were randomized to 100mg of aspirin daily or placebo. During average follow up of about 7 years, aspirin prevented 1 vascular event but caused 1 serious hemorrhage for every 100 treated patients.

So what does this mean…

Maybe we shouldn’t use aspirin as the magic prophylactic bullet for primary prevention that we once thought. Among diabetic patients, the trade off between a small benefit and harm are razor thin. And balancing one adverse event (CV event) against another adverse event (gastrointestinal bleed) is not straightforward. We cannot predict which of those outcomes would apply to any given patient. The other consideration is that a large proportion of patients in both studies were taking statins and antihypertensive drugs, and only a small proportion were current smokers. So you could conclude that these studies examined the incremental benefit of aspirin, added to other standard preventative treatments.

I like to individualize my healthcare with patients since outcomes in studies give us associations and not cause-and-effect results. One additional way to determine if a patient would benefit from aspirin is by performing a random urine test known as Aspirin Works. This measures 11-Dehydrothromboxane B2 in the urine which is produced from the breakdown of thromboxane A2. It is released by activated platelets (that cause our blood to clot) and urine levels can be used to monitor the response to aspirin therapy. This test may determine that you don’t need aspirin, or if on aspirin that your dose needs to be changed.

Ask your doctor or practitioner to perform this simple urine test to see if a daily aspirin would specifically benefit you.

Reference: Brett, A. Aspirin for primary prevention of cardiovascular events; JWatch.org, Oct 1, 2018, Vol. 38, No. 19.
NEJM JW Cardiol Oct 2018 and N Engl J Med 2018 Aug 26; [e-pub]

Plants and The Truth About NSAIDs for Pain Relief

February 2, 2019 By Deborah Leave a Comment

All medications have risks, whether they be a supplement or prescription drug. One example would be non-steroidal anti-inflammatory (NSAID) drugs such as Advil, Naproxen, Celebrex, or Diclofenac. Many people use these drugs long-term for menstrual cramps, headaches, aches and pains, arthritis or injuries. Long-term use can increase the risk for acute kidney injury or chronic kidney disease progression. They also raise the risk for cardiovascular events such as myocardial infarction (heart attack) and stroke. So it’s been suggested to avoid use of these medications for those with hypertension, heart failure or chronic kidney disease. This is difficult, especially for the elderly who typically have these health conditions but also need pain relief for treatment of osteoarthritis.

In a recent U.K. study, Diclofenac was associated with excess risk for myocardial infarction as opposed to Naproxen. Also, Ketorolac, another NSAID, can adversely affect kidney function more than other NSAIDs. Factor in dehydration, nausea, activity limitations especially after surgery, and acute kidney injury and you can see that the use of these meds can be a real danger.

With the opioid crisis in the forefront, nonnarcotic alternatives for pain control are in high demand. If you need to use an NSAID, there are some like Diclofenac that pose a higher risk for cardiovascular events and GI bleeding compared with other NSAIDs or Tylenol. There is little justification to use Diclofenac before trying other traditional NSAIDs. Better yet, it’s worth trying herbs such as Ginger, Curcumin and Boswellia (AKBA). Combining Boswellia’s activity with Curcumin and Tumeric can offer even higher levels of pain relief. CBD is also an amazing pain reliever if monitored well.
I always advocate plenty of fluids, avoiding food allergens and other inflammatory triggers and getting healthy sleep as the foundation for reducing pain and optimal wellness.

References: Dubreuil M et al. Risk of myocardial infarction with use of selected non-steroidal anti-inflammatory drugs in patients with spondyloarthritis and osteoarthritis. Ann Rheum Dis 2018 Aug; 77: 1137.
Schwenk, T. NSAID use in patients with hypertension, heart failure, or chronic kidney disease. Journal Watch 2018 Nov; Vol. 38 No. 22 p. 180.
Myers, C. Plants for pain relief. Health and Happiness 2019 Feb; p 12.

Ischemic and No Obstructive Coronary Artery Disease in Women

January 15, 2019 By Deborah Leave a Comment

Just about everything we know about heart disease in women was learned in the early 1990’s. This is when the National Institutes of Health began requiring that women be included in the studies it funds. Up until then, most medical research was conducted on men: male patients, male rats, male monkeys and male cells. Like most gender gaps, this one is closing slowly. We are seeing differences between men and women in the development of heart disease and starting to take note.

In arteriosclerosis, men and older women are likely to have a blockage in one or more of their coronary arteries from localized plaque. But new research is showing that younger women are more likely to have diffuse plaque that lines and narrows the entire artery. Even though this leaves the heart muscle with a lack of oxygen and blood supply, no specific blockage is detected on tests. Even though a woman may have symptoms of blocked vessels, such as chest pain or shortness of breath, testing with repeated angiograms would show open arteries and no blockage. The woman is told that she is “free of heart disease” even though she is at high risk of a fatal heart attack.

Fortunately more doctors are now recognizing that despite having open arteries, half of women with this pattern have ischemia…poor blood flow through the heart. This condition is now called, ischemia and no obstructive coronary artery disease (INOCA). It comprises 25-30% of ischemic heart disease in women and 10% in men. You wonder why and how the heart can be starved for blood if its main arteries are not blocked. The answer is that women have smaller capillaries and arterioles that deliver oxygen and nutrients to the heart muscle. The walls of these vessels become dysfunctional where they fail to contract and dilate as they should.

Why women are so much more susceptible is unknown. The typical suspects are smoking, diabetes, high blood pressure and high cholesterol. But a history of problems during pregnancy, such as elevated blood pressure, pre-eclampsia and diabetes, as well as depression and autoimmune diseases, which are more common in women, may also contribute.

Effective treatment is badly needed. The first large trial comparing an intensive drug regimen got underway in 2018 and we should have results by 2022 which should help set treatment standards for women with INOCA. Women with microvascular dysfunction often go on to develop heart failure. Women have a different type of heart failure than men but both types are rising in the U.S. because our population is getting older, heavier and more diabetic. Even if you have had a heart attack and survived, you have a higher risk of dying of heart failure down the road.

Heart disease is the number one killer of U.S. women, far exceeding deaths from all cancers put together including breast cancer. Younger women, in particular, often go undiagnosed because physicians do not consider the possibility of cardiac disease. Hopefully that will soon change as more research continues to emerge describing these gender differences.

Reference: Wallis, C. “What Ails a Woman’s Heart”. The Science of Health. Scientific America, January 2019.

Top 10 Health Breakthroughs in 2018

December 30, 2018 By Deborah Leave a Comment

Here are the top 10 Health Breakthroughs of 2018:

10. Synthesized Antibiotics- There is a real concern regarding drug-resistant bacteria strains such as MRSA. Researchers in Britains University of Lincoln discovered a synthesized form of the antibiotic texiobactin that has already been used to treat infections in mice. The next step could be commercial drug use for humans to battle the growing epidemic of drug resistance.
9. Senescence Drugs- Some drugs are now being tested to kill old cells called “senolytics”. This will help extend our quality of life, not just our years.
8. Semiconductor technology- This can read the bodies vital signs on the skin. A thin plastic material laid over the skin can check heart rate, blood sugars and other readings that can be displayed on your Smart phone or sent directly to your medical professional.
7. CRISPR genome- Targeting the RNA of diseased cells has become more accurate and safe. Salk Institute scientists tested their technology against dementia which effectively restored healthy levels of proteins to the neurons affected by the disease.
6. Cancer vaccine. Human trials have been underway to treat patients with lymphoma which could present an all new treatment for the eradication of cancer.
5. Brain implants- A pacemaker for the human brain, or deep-brain stimulator, creates electrical impulses that could boost the memory of sufferers of epilepsy, Parkinson’s, and Alzheimer’s disease.
4. Ingestible Sensors: Track your gut health. This ingestible sensor developed by Australia’s RMIT University can measure the gases in your intestine that could help to diagnose gastrointestinal issues way before patients are symptomatic.
3. Cloning Monkeys- It’s been over 20 years since researchers cloned Dolly the sheep. Now China has cloned 2 monkeys which is the first time this technique has been used in primates. DNA was taken from fetal cells into eggs that had had their DNA removed, stimulated the eggs to develop embryos, and implanted them in female surrogates. Two female identical-twin long-tailed macaques’s were born. This could revolutionize research on disease.
2. Treating Muscular Dystrophy- Scientists corrected a gene mutation behind a form of muscular dystrophy in dogs. Duchenne muscular dystrophy is caused by a gene mutation that prevents the body from producing dystrophin, a protein required for strong muscle fibers. By using gene-editing technology we hope the same can be done in humans very soon.
1. Helping Paraplegics Walk- Having worked in the Neuro ICU treating para and quadriplegics, this is such a huge discovery! Researchers implanted tiny electrodes between patients’ vertebrae of paraplegics below the injury and delivered a weak electrical current to help amplify signals to the brain. After months of intensive physical therapy, one patient Jered Chinnock, could walk the length of a football field with assistance. “It feels,” he said, “like science fiction.”

Wishing all of you a Healthy and Joyful 2019!

References: The Week, December21/December 28, 2018. Pages 28-29.
Interesting Engineering.com. The 16 Most Remarkable Healthcare Innovations, April 7, 2018.