Yeast Infections: 

I see yeast infections every day in my office. Most women have at least some experience with this problem. Yeast is a huge problem on a global scale. I am going to spend quite a bit of time discussing it here because there are women who really suffer. Until the problem is resolved, it wrecks their life.

The symptoms could include vaginal or vulvar itching, some kind of discharge, maybe some swelling, sometimes there is burning to various degrees, and sometimes there is discomfort with sex. Sometimes the skin becomes so soft from inflammation that the skin actually cracks open from the minimal stress on it from daily activities, such as sitting or walking. When it gets that inflamed, the burning can become mind bending in severity. Usually, women won't let it get that bad. But sometimes, they have no choice and it becomes severe before they can do anything to fix it. Then, if the skin gets cracked, there can be bacterial infections on top of the yeast infections. Then, we need to get really serious about it and do everything we can, including admit patients to the hospital or even the ICU. I have seen all of this.

But sometimes, there are no symptoms at all. If a women has no symptoms but she clearly has a small or moderate amount of yeast in the vagina, we may choose to not call it an infection. We would only do this if there was no inflammation and no other problems.

Sometimes, the infection looks exactly like a jock itch that men get. Jock itch is a yeast infection that men get around their genitals, on their skin. Women can get the very same infection around their own genitals, even if it is not in the vagina, and the treatment may be the same as men. Jock itch is treated with jock itch spray that one can buy at the local pharmacy.  If a women has a jock itch, then vaginal treatments will be mostly unhelpful. If a woman tries a vaginal treatment, she will certainly wonder why the itch is not getting better. Technically, a jock itch in a women is not a vaginitis at all, but a vulvitis. Either way, many times they wind up in my office for consultation and advice and treatment options.

Interestingly, there are yeast infections that people get on other areas of the body. If a yeast germ somehow gets under the skin it will start growing in an expanding ring. The center might clear a bit. This ring is called, believe it or not, a "ringworm". It is most certainly not a worm. Ringworm is just like a jock itch, but in other areas of the body. In my practice I see ringworm type rings, centered on the vagina, sometimes going around the front all the way past the rectum. This infection is a yeast, not a worm. At this point, the infection could be called a "yeast infection", a "ringworm", or a "jock itch". All of them point to the same process. And the treatment is the same. It will be some oral meds, usually Diflucan, and some topical treatment including antifungals and antinflammatories.

Yeast organisms live in our environment. They are a natural and important part of our ecosystem. It is not possible to completely eliminate them from our environment. What we can do, though, is help our bodies defend ourselves from an attack by these germs. How do we defend ourselves?

First of all, stay healthy. A healthy body will have a healthy immune system, and that will help to fight off these germs. Healthy means eating a simple, safe, and balance diet, with minimal unnatural chemicals. In my mind, unnatural chemicals include preservatives, fake sugars, fake fats (like margarine or shortening), or overly processed carbohydrates. Too much sugar is bad for a human. What does it do? High blood sugars only feed the yeasts. Yeasts love the sugar and go nuts.  So diabetics, who have naturally high blood sugars, are much more likely to get yeast infections. But you don't have to be a diabetic to get a high blood sugar level if you eat a whole pecan pie, or have a 32 ounce soda. In my practice, we always see an abundance of yeast infections after Halloween and Easter. These two holidays usually include lots of candy in the revelry, and women get yeast infections quite a bit when they eat too much candy.

Try to lose weight. I know that sounds like empty advice when a person simply cannot lose weight no matter how they try. Believe me, I know. I am not skinny myself. But, I have to say it, because it might work.

Take your vitamins. In my opinion, a person cannot eat such a perfectly balanced diet that one would get all of the essential nutrients every single day. It is just not technically possible. My personal vitamin D level was very low, despite having evidence of too much sun on my skin. So, now I will have to supplement D for the rest of my life. I try to take my vitamins every day, but remembering it is a challenge. Try to leave the vitamins out, on the counter. They are much easier to remember that way.

Another important nutrient is Probiotics. These are the healthy bacteria that need to live in a human to assist them in living a normal life. There are thousands of bacteria that a human needs to live. This would include for instance staph epi (epidermidis),  and acidophilus, and thousands of other types. Our hospital now has a standing order to give our patients probiotics under certain circumstances. This would include antibiotic treatment. Bacterial antibiotic treatment is completely indiscriminate in its mission. It kills many of the good bacteria, while it is working to kill the bad ones. The end result of antibiotic treatment is, in may cases, not only a severe diarrhea, but an awful yeast infection. This is because the antibiotics have killed off the healthy bacteria that live in a normal vagina. Mainly, the healthy vaginal bacteria is acidophilus. A good acidiphilus will keep a vagina healthy by crowding out the yeasts, attacking the yeasts, creating the acid that keeps the vaginal pH very low, and actually making hydrogen peroxide. This kills all the invading germs. A woman that loses her vaginal acidophilus may be in for quite a lot of vaginal discomforts, until we can get her recolonized or at the very least replace the function of the acidophilus. If acidophilus just won't grow no matter what, then we can replace most of it's function with Boric Acid.  Boric Acid has just the right pH for a vagina, and can make a woman comfortable, but it is a long term treatment, and it is not a cure. Most of the "compounding" pharmacies around here are very skillful at making vaginal boric acid suppositories. They do it all the time for my patients. If a women is somewhat technical, she may be able to help herself with this. She has to remember to not take it orally. It will not help.

I have a microscope in my office and very frequently I will look at the vaginal fluids. It is easy to see acidophilus. They are non motile gently curved rods. If there are none, that is a problem. If the bacteria move, there is a problem. Of course, the yeasts are thick walled clumps, buds, or strands. they are easy to see. Bacteria stuck all over the epithelial cells are called "clue" cells. I don't have a clue why anyone named them that. But if they are there, that is a problem.  A women should have at least 80 percent of her epithelial cells clear of "clue" bacteria. Trichomonas are sometimes easy to see. That is a separate problem. They have a "flagella" that whips around really fast, and moves the Trich all over the place.

I also check vaginal pH. It should be very acidic, around 2-4. Any higher than that, and the abnormal uncomfortable germs can have a field day. We see elevated Ph's all the time. Sometimes, when nothing else works, it is time to get the Boric Acid to get the pH down.

A vagina should also be free of a certain kind of odor. For the sake of decency, I don't want to get too graphical with my metaphors. But, there are some odors that don't belong.

A pure yeast infection will mostly be free of bad odors. But, if there is a yeast odor, it may smell like beer, or fresh bread, from the obvious uses that humans have for the yeasts in our world.

There was an interesting study done about 10 years ago. What the investigators did was set up an exam room very near a pharmacies check out counter. When they saw a women buying a yeast treatment product, they asked the women if she wanted a professional exam. The exam was free, and she was told it was an investigational study. Most of the women agreed to have the exam. About a third of the women did not have a yeast infection at all. Many had a vaginitis, but of a different type such a bacterial, or trichomonas. Some had other very serious problems. There were even a few ectopic pregnancies, or appendicitis. These can be life threatening. There were some ovarian cysts, too. These are common, and only rarely a severe problem.

The bottom line is, if you are in any way unsure if it is a yeast infection, don't treat it without a professional opinion first. Or, if you do treat it with over the counter meds, and you don't get better in a day or two, you better come in for an exam. If it is the weekend, then strongly consider doing a pregnancy test. Even if you are menstruating right this very minute, it does not mean that you are not pregnant. Many pregnancies, and especially ectopics, have bleeding that is indistinguishable from a normal period. And ectopics are doubly risky if the mentruation is not like a typical period. And pregnancies can occur despite almost any kind of contraception. I like to tell my patients that even abstinence and virginity cannot totally prevent pregnancy. [I deleted a crummy Virgin Mary joke here, on the advice of someone I trust]. But, the reality is, plans for abstinence sometimes go awry.  And some women even forget that they have had intercourse. Or, are reluctant to admit it to themselves or their family. So a pregnancy test should be strongly considered if there is any doubt.

What do I do in my office? I keep a bottle of Fluconazole oral yeast treatment in my office. If it looks like a simple yeast infection I might just give her a single dose out of my office stock. I buy it in bulk and it is much cheaper. I give it away as a free sample. One dose can cure. The drug companies obviously don't give free samples of a drug that works in one dose, but there is no reason that I cannot give it away. If the yeast comes back, I will ask her to try some Monistat over the counter meds. If that is not enough. I will need to rule out other problems, like a lost acidophilus. I think the best monistat is the single day treatment. It has the most ingredients and it will likely work in one dose. There is no reason to use a vaginal cream for days on end. Women dislike the extended courses. It is uncomfortable and messy.

I also might ask their husbands to use some jock itch spray on their relevant body parts. This can help the woman if it is going back and forth. It might help the man a bit too. At least I don't think it would hurt him.

In the old days, the Gynecologists would paint the vagina with some "gentian blue". I have never done that. But I understand that it would really stain everything in sight a bright blue. I don't think women would like that.

This post is just the beginning of the microbiology of the vagina. What would you guys think of a series of photos of vaginal microscopy? Post below if anyone thinks it might be interesting, or if it is unneccessary and too icky.

More posts are coming. I have a ton of ideas. I have a number of requests for Toxemia, so that will come soon. 1 in 20 pregnant women get Toxemia. I will try to make some sense of it.

Thanks sincerely.

Please don't copy this article without my consent.

But links to here are appreciated.

Sincerely,

John Marcus MD FACOG
blog at doctorjohnmarcus.blogspot.com
89 North Maple Ave
Ridgewood NJ, 07450
Phone number 201-447-0077.

Ovarian Cancer Screening

You may notice that I haven't posted in awhile. I have certainly not stopped my blog, I have just been very busy. Even so, there are thousands of people who read this blog from all over the world. And it is still growing. Google is linking in from Ob/Gyn kinds of searches. Many of these blog posts have information that will not change much over time, so the search engines keep linking in here.

I have been a bit busy to blog much. I had to do my yearly boards exam. That is about 35 hours of open book testing, done in "free time". So it always takes me a long time. I score very well on these tests, but I am very careful to read the questions and the reading material. Also, we had summer vacations to deal with. My covering doctor, Fred Rezvani, took some time off, and that leaves me with covering his patients as well. I like doing it, but it does take up a lot of time.

Today's blog post is about Ovarian Cancer Screening. This is a contentious subject. It is certainly not a hopeless subject, but we can certainly do a lot better than random screenings.

Occasionally I will get a request from a patient to do some kind of medically unnecessary testing. This might include some unnecessary testing for ovarian cancer. Similarly, sometimes a patient or her family will want to have an obstetrical sonogram that is not on the list of traditionally accepted indications. I have seen instances where the patient's family is in from overseas and they have not seen the baby yet.  They would like to see the baby before they leave to go back home.  And in a situation like that I will sometimes do a so-called unofficial sonogram and show the baby to the family. Also, there are situations where the patient does not feel the baby moving.  It may be too early in the pregnancy to expect such fetal movements.  But even so, the stress level can get so high, a quick peek at the baby with the sonogram is valuable to convince the woman that she and her baby are fine.  The stress reduction is so gigantic, that it is a very worth while sonogram to do.  Sometimes, if the sonogram is not available, just checking the fetal heartbeat with the Doppler is rewarding.

Ovarian cancer screening, however, is very murky.  The scientific evidence at this time seems to be that the usual screening methods do more harm than good. There is a recurrent ovarian cancer e-mail that goes around on the Internet.  It is extremely common.  This email advises woman to take control of the own destiny and demand a sonogram and a CA 125 test. If the patient asks me about this situation, this is what I usually try to do:

I will not utterly deny her the testing.  If she is completely convinced she needs the test, and I don't do it, I will have likely lost this patient for good.  This means that I will be unable to give her good medical care in the future, and she may not get any good medical care at all. I think this scenario is even riskier then doing the scientifically unproven ovarian cancer screening.

But, I will explain to the patient that the scientific evidence is at best murky, and that at worse shows actual harm to the patient.

A smart person might legitimately ask "how can a simple blood test and a simple sonogram harm a person?".  The answer lies in the fact that no lives are saved by this set of testing.  Sure, we find many ovarian cysts, many ovarian tumors, and even a few cancers.  But the comparison group between screened and the non screened   individuals shows no difference or worse for the screened group. This was originally proven by the Gilda Radner study. Gilda was a famous and wonderful comedian who died when she was young. She died of ovarian cancer.  Her husband, the famous Gene Wilder (the first Willy Wonka), sponsored a medical study to try to help save women from ovarian cancer.  This study, and several since, showed harm to the screening group, or at least no benefit.  I am told that the Gene Wilder study cost $7 million dollars.  And it was a good study.

Why is the screened group harmed?  Because, among other things, they are exposed to a lot of unnecessary surgery.  This surgery has a lot of risks.  Surgery, if unnecessary, still leads to the risks of infections, bleeding, scarring, and damage to adjacent organs.  These risks are high enough to lead to more harm to the screened group then to the non-screened group.  But the situation is worse than that. The women who get the screening tests done become very reluctant to really come in when it actually becomes necessary.

What I mean is, that a patient who has an ovarian sonogram, will have a feeling that she is so healthy that she will refuse to come for medical care even when it is necessary, when her ovaries are painful or bloated. When a woman has painful or bloated ovaries,she must come in for an evaluation.  But, not for a screening evaluation, it is now a medically necessary diagnostic intervention. The scientific analysis that these tests are valuable is indisputable. The problem with the screened group of women, is that they will not come back for these tests.  I have had women say, "but I just had a sonogram and it was normal!"  I will tell them, that I don't care if the sonogram was done last month, she needs another one. People can certainly get a clinically evident ovarian tumor in the space of the single day.  It is a mathematical and  medical certainty for any given person who has a tumor, that it was undetectable prior to becoming detectable, and since we have no control over when that transition to detectability occurs, we must start a new evaluation every time there are new symptoms of problems. The woman who have been screened for ovarian cancer will sometimes not come back for years despite the new onset of problems. they seem to forget that every cancer is undetectable before it is detectable. When a woman says to me "but I just had it done...", I will look in the chart and sometimes see that it was years ago. That doesn't surprise me at all, because I certainly cannot remember the last time I had an EKG, or anything else. I feel like my colonoscopy was 2 days ago, but it was years ago, and I certainly cannot remember which year. Who wants to remember those things? That's what medical records are for.

Of course there are grey areas in between non detectable and detectable tumors, and there is a fuzzy kind of logic in between the two situations, but that doesn't change the fact that all tumors are not detected before they are in fact detected. And we don't know when that transition happens.

So, we have a situation where we have screening tests done, but in general do more harm than good. But Diagnostic Testing does more good than harm. All women should strive for diagnostic testing instead of screening testing.

But, women should think about this: How often does a women get a screening test? Since there is no science that screening helps women, we have no idea how often to do it. This is like the mathematical equivalent of dividing by zero, the result is not defined. So, we can guess that maybe yearly screens are a good idea. Or, if a woman has a lot of time and money, she could get screened twice a year. There is no good answer.

But, Diagnostic testing is different. Diagnostic testing for ovarian pain and bloating can be done more often than once a year, if it is necessary.   Diagnostic testing has been indisputably proven to help women better than screening.  And, it can be done more frequently, if and when it is necessary.

What happens when we follow this diagnostic protocol? It seems to me that something magical happens. Women themselves become an integral part of the chain of events that are necessary to save their lives from cancer. Think of how empowering that is for women. Think of one woman, who says, "I demand a sonogram and CA125 blood test, even though I feel good". The science shows that that woman is harming herself, under the misguiding thought that these tests might help save her. And, she may wind up paying for these harmful procedures, since they are not medically necessary. That is quite expensive. But, another women, a bit smarter maybe, will get yearly checkups of course, but will reserve her ovarian cancer testing for the one unfortunate day when she is bloated, or in pain. Her diagnosis may be dramatically sooner in the disease process than a previously screened women. So, the second women is empowered to become part of the system. She is, herself, by force of will alone, becoming a link in the ever important chain of human events that create an early detection system for ovarian cancer. This is so much better than a dumb and blind stab in the dark at a random screening for ovarian cancer.

Despite these proven the advantages of diagnostic testing done when indicated, some women still want to be screened.  If I explain the harm proven in the above studies, and the patient still wants screening, I will do it for them.  But I will emphasize for them, that they still need to come back if they ever get ovarian pain and bloating.

There are physicians who dispute the above science.  They will screen either every woman who comes through the door, or every woman who asks. These physicians will of course be doing a lot of surgery on healthy women.  These surgeries can become the most lucrative part of their practice. They may make a very good living by doing this style of practice.  And they are making a lot of women very happy by telling them they don't have cancer in the postoperative recovery room. They will say it with a big dramatic sigh of relief.

Don't get me wrong, I don't think that ovarian cancer screening is impossible.  I just don't think it is ready for prime time. There is lots of cancer screening that has been proven beneficial.  The Pap smear is great. The Pap smear is so great that we are probably overusing it. Colonoscopies most definitely save lives. I have had mine done. One day, we will get a protocol that works. It might involve proteomics, or it might involve MRI's.

Like I said before, when woman understands the above, and she still wants her ovarian cancer screening, I will do it. You would all be surprised, however, how many women believe the above scientific analysis.  Most women agree to follow the scientific protocols.  Most women agree to hurry back to the office if her ovaries become sore or bloated.  Then I can do the indicated testing, and maybe help save her life.  This is more successful than any screening protocol yet devised. And maybe I will get to see her more often than once a year.  This is fine by me.  I know that, without a doubt, I am providing better care by doing this.

Thank you sincerely.

I hope I have explained the above two groups of women adequately. Those two groups being the unscreened women and the screened women. And you may notice that this post is nonscientific. It is just my thoughts. There are no peer reviewed references. If I did that, this blog would be very different.

Please feel free to forward this note on to other people. Maybe we can get it to go viral. Just be sure to include the following lines:

John Marcus MD Obstetrician and Gynecologist.
Ridgewood, NJ, USA
Phone number 201-447-0077
Member of The Lifeline Group at www.lma-llc.com
Blog at doctorjohnmarcus.blogspot.com

Contraception 

   Why should people contracept? Is it so they can have free and easy sex? Maybe that is so, but in my mind it is not the most important reason. The most important reason people should contracept is so that every baby is desired, wanted, and tried for. 

   There are many couples who have free and easy sex, but are not contracepting. They may or may not want a baby, but maybe making a baby is not their goal. I am not sure if this is a good lifestyle. When they do get pregnant, it is not something that they were planning for or hoping for. In my mind, pregnancy is something that is so important that they should be planned for. And every baby should have the courtesy of being wanted from the time of conception. Sure, there are many surprise babies that are wanted and loved, that were not attempted for, but it is not the same as hoping for conception at the time the conception happens. 

   I think there is something magical that happens between a man and a women when they attempt to have a conception. I think the feelings go very deep. I think that people can feel the "conception connection" from the beginning to the end of time, when they conceive together. And that is a beautiful thing. People should really try to enjoy that deep spiritual connection. If they try to enjoy that feeling and connection, it feels really good. So, what does contraception do? It enables all babies to be wanted. Inadequate contraception means that all babies are surprises, and are not planned for, prepared for, or cared for in an ideal manner, from the moment of conception.  

   When I do checkups on women, as a gynecologist, I have to ask women, are you contracepting? It is an unbelievably  important part of medical and reproductive care, to make sure that the contraception is understood. Many times, when I ask that question either verbally, or on a questionnaire, the answer is no. This seems to be the answer that many people give. 

   So, as a thought experiment, I would like to put you in my shoes. I am facing a 32 year old women who has sex, who is heterosexual, and in for a checkup. She states she is not contracepting. She has never been pregnant. Yet she appears to be unworried that she is not pregnant. In fact, she is not asking questions about pregnancy at all. Whether she is married or not is irrelevant right now, because she is having sex. Perhaps she may not know that conception and contraception are part of my job. 

   From here forward, I may gently ask some questions about sex. Ultimately, most women like this are either using condoms or withdrawal as a method of contraception. They are not concerned about infertility, because  they are not trying for pregnancy. But there are so many misconceptions about fertility and infertility and contraception that they don't even realize that they are or are not contracepting.  They may not be doing it properly, and may not be doing it optimally. Many people make suboptimal choices based on bad information. I try to give good information, and good counselling. This at least attempts to make all babies wanted, and can make marriages and relationships much better. 

   My goal is to help my patients achieve their life goals, whatever that may be. One life goal is a good marriage. Another life goal is to not get pregnant if they don't want to be, get pregnant if they do want to be, and have a normal sex life if they want to contracept. 

   And, as a said before, a normal sex life is good, but wanting a baby when the time is right is even better. contraception can help that. And then, when the time is right to concieve, the sex can be the best ever, because of the deep connection and meaning of the union between the man and the women. 

   So, how can I help a women achieve her goals of contraception? 

   If a patient wishes to, I will go through the methods available and help her decide if she is doing the best method for her. 

   I will first describe for her that there are barrier methods, and hormonal methods. 

  Barrier methods are: 

• withdrawal
• abstinence
• calendar method 
• spermicides
• condoms
• female condoms
• cervical caps
• sponges
• diaphragms
• IUDs or Intrauterine Devices, copper vs hormonal 
• vasectomy - surgery on men
• tubal ligation - surgery on women
• tubal blockade, Essure 

Hormonal methods are: 

• Oral Contraceptive pills 
• Minpills, or progesterone only pills 
• Morning After Pills, emergency contaception
• Hormonal Implants 
• lactational
• Nuvaring - Same as oral contraceptives but via the vagina  
• Contraceptive shots : progesterone every three months, or monthly "oral contraceptive" shots
• Patches - Same as oral contraceptives but via a skin patch 

Abortion: 

• This needs it's own article. It is legal, but it should be rare

Contraceptive Methods: 

   Some methods are much better than others. Some methods are lousy. Some methods are common even though they are lousy. All methods have a failure rate. Actually, there are two failure rates, the perfect use rate, and the actual use rate. Failure rates are given as the pregnancy rate per 100 women per year. If there are three pregnancies in 100 women in a year, the failure rate is 3 percent. This percentage is called the Pearl index. The Pearl Index of noncontracepted intercourse is 80 to 85 percent. It is not 100 percent because many people are infertile. I blogged about infertility last month. 

   Birth Control Pills have a failure rate, or Pearl index, of 3 percent, with perfect use. That means that 3 in 100 women will get pregnant every year. This is about 1 in 30 women. Most women are surprised when they learn that Oral Contraceptives will allow one pregnancy every 30 years. This means that an average women who uses Oral Contraceptives from 18 to 48 years of age, will have one pregnancy on the pill. The actual pregnancy rate is much higher, because no one on Earth can remember to take a pill every day for 30 years. There will be forgotten days, and there will be days on antibiotics. If there are a lot of those, then the pill is useless and not only will the women get pregnant, but she will have uncomfortable side effects of incorrect use. If she forgets pills she will likely get break thru bleeding. Women really hate break thru bleeding.

   Birth control pills are available as monthly cycles, three monthly cycles, and noncyclic.

   Most women will experience break thru bleeding. Women get so annoyed that they frequently quit the pill. If they stay with it a few months the break thru bleeding usually stops. 

   Perfect use of OCP's, along with perfect use of condoms, make the Pearl index about one in a thousand. Pregnancy is very very unlikely in that case. Women who absolutely cannot get pregnant should use a double method like this. Then they can be secure in their method. 

   Most couples use withdrawal as their method at some time or another. It is  also called coitus interruptus. That is a Latin word. Don't ask me why anyone would want to use Latin, but there is is. Latin is perfectly appropriate in the Vatican, where even the bank machines use Latin, but probably nowhere else outside the medical journals. 

   Withdrawal really sucks as a method. First of all, a couple is asking a man to actually stop having sex right at the moment when it feels really good to continue. Right when it feels the best, you are asking him to stop. That is kind of like making dinner, putting it on the table when your hungry, putting it up to your lips, smelling it, tasting it a bit, and then throwing dinner away. Mother Nature will fight you on that. I can guarantee that the guy will stretch the interruptus part to the very last second, and then pull it out. There will usually be some sperm in the vagina. The guy might say this is ok with him because interrupted sex is much much better than no sex at all. The woman might even say that this is ok, she is ok with getting pregnant. She might say this vigorously, and defend her method. But, as I said before, this deprives the couple of the joy of the actual attempt at conception, which is my mind is a rare and beautiful thing, and it will once again deprive the baby of the courtesy of being wanted from the first moment. 

   In my mind, couples shouldn't just be OK with getting pregnant. They should actually want it. That is much more spiritually satisfying. And a real joy. So actual and true family planning really matters to me. 

   So, I would hardly ever agree with someone that withdrawal is a good choice. It almost never is. Nonetheless, it is extremely common. \

   When a woman tells me that is her method, I will counsel her that the method doesn't work very well, and that the couple didn't even get to enjoy to process of conception properly. Sometimes she agrees and sometimes she doesn't.

   If she asks me what is a better method I will describe barriers vs hormones. If she is young I will advocate Oral Contraceptives, with or without condoms. OCP's have the advantage of lightening the menstrual flow, nearly eliminating cramps, nearly eliminating the problem of ovarian cysts, preventing some infections, controlling the onset of endometriosis, and blunting PMS. The risk of OCP's is that there will be thicker blood. Blood can clot in the leg veins, causing a Deep Vein Thrombosis, which can travel to the heart, block up the heart (as a pulmonary embolism), and kill the women. DVT's happen commonly, and there are hundreds of thousands of cases a year in the USA. Many people die. But DVT's are more common in pregnancy than on the pill, so the pill can actually lower the risk of DVT because it prevents the pregnancies that actually cause more of them. And, a woman can control the risk by staying hydrated and active, and calling right away if she has leg pain or chest pain. In that case we can detect the DVT and the PE before it is too late. So OCP's have many desirable side effects, and some significant risks. Oral Contraceptives work by making the body think it is already pregnant, therefore it will not ovulate, the cervical mucous will be very thick, and the uterine lining should not grow enough to support the embryo. It does this because oral contraceptives are really just pregnancy hormones. OCP's do not cause any sort of cancer. They are just pregnancy hormones, and have some of the hormonal benefits of pregnancy itself, such as much stronger bones.

   The Catholic Church does not support OCP's because there will be at least some embryo's that are created that cannot implant because the uterine lining is too thin. In that sense the OCP's are at least a little bit of an abortion pill. Most religions, but not all, allow the OCP's. Even the Catholic Church, however, will allow the OCP's for a medical diagnosis such as treating chronic pain, or preserving fertility from the damages of endometriosis. So, for Catholics, if they need the OCP's for some medical reason, then the contraception becomes a side effect and the Catholic Theologians will, in my experience, usually allow it.

   In fact, there is only one method of contraception in the entire list above, that the Catholic Church will allow. And that is the Calendar Method. In other words, couples can refrain from sex when the woman is near ovulation, and she can have full intercourse when she is near or in menstruation. This is allowed. Note that Catholics are not allowed even the simple method of withdrawal, as the Catholic Theologians do not want the sperm to be wasted outside the body.

   Interestingly, sometimes Orthodox and Conservative Jewish women are not allowed sex for seven days after menses. After the seven days they need to ritually purify in a special bath called a Mikvah, usually in a temple, before they can have sex again. Since seven days after menses is the time of ovulation, they also cannot do the calendar method, unless they limit sex to the last few days of the menstual month, right before the period. This is highly limiting, the calendar method really sucks for sexually active conservative Jewish couples. They should come up with something else. Usually the pill, because it significantly shortens the period, and makes the Mikvah that much closer so the couple can get together again.

  If a woman is postpartum and breast feeding, she really shouldn't use a hormonal method. Some of the hormones will get to the baby. They should use condoms. I advocate for "lambskin" condoms because they are very slippery, and a postpartum vagina can be very dry, especially if breast feeding. Sponges will work ok too. The only brand available is the Today Sponge. It is hard to find, but you can get it on Amazon.com. The combination of a lactational state plus a barrier method such as condoms or sponges will make contraception very effective, with a Pearl Index of less than one percent.

   If a women is done having children then there are a few choices that are better than any other. An IUD can make it so a women has no periods, no pregnancies, no worries, no contraceptive duties for 5 years, and can be placed in a few minutes and removed in seconds. This is hands down the best method for a lot of women. There are no hormonal risks or side effects, and the reversibility is highly advantageous. The Mirena IUD has a tiny bit of hormones, but those hormones are stretched out over 5 years, and they are at a negligible level in the blood. Those hormones are contained in the uterine cavity, where they are most needed. They do not cause DVT's and pulmonary embolisms as the OCP's do.  In my experience, women who have an IUD really really like it. There are a few where it has to come out due to cramps or infections. These cases are rare, and in my experience they only need a few days of oral antibiotics to get better. The IUD obviously needs to be removed as well. There is a risk of more serious infections and destruction of the uterus. Those women may need surgery or removal of the uterus. I have only seen maybe four pregnancies with an IUD in place in my entire career. The failure rate is very very low.

   The biggest problem with an IUD is getting women past the fear of a foreign device inside their uterus. I try to tell them that foreign devices in humans are very common, and usually ok. But there was a dangerous IUD in the 70's called the Dalkon Shield that caused a lot of infections. Since then women are reluctant to use it. The advantages are profound,  and especially so for conservative Jews who don't have to worry about the Mikva for years. Their husbands are very grateful.

  IUD's are not so great for my business because women feel so good that they forget to come for checkups. But even so, I like the method. It does a lot of good.

   Two other methods that are good for women who are done having kids is either a vasectomy, which men rarely agree to, or a tubal ligation. This is very common. Tubals are done because they are highly reliable and women will never have to worry about pregnancy again. There is a surgical risk. But once healed, there is no more hormonal or method related risks. And no pregnancies.

  A properly done tubal ligation will have no effect on menstrual flow. The women will have completely natural cycles. This is both an advantage and a disadvantage. Natural cycles increase the risk of both endometriosis, as well as ovarian cysts, at a much higher rate than pregnancies themselves would. But if natural cycles are what the woman wants, and many do, than the tubal is a great method. Pregnancies are very rare. If any of my tubals have gotten pregnant, then I am unaware of them. It is possible they have, and have not told me, but I don't think so.

   There is a newer form of tubal called the Essure. This can be done with minimal anesthesia in the office, via the cervix. What happens is that an inflammatory device is screwed into the fallopian tube via the hysterscope. The device has inflammatory material, a stainless steel coil, and a  nickel titanium alloy cover. The tube then slowly inflames and blocks up. A few months later, someone attempts to push xray dye through the fallopian tubes to see if they are properly clogged. If so, the tubal is declared done.

   I still prefer a traditional tubal. I have had perfect success with it, it doesn't rely on any inflammation, it is instantly effective, it has been done forever without problems, and leaves no reactive material in the body. My tubal will usually be done with an inert plastic ring that has the effect of completely avoiding heat and it's risks within the body. I prefer it over the Essure. Women like the Essure because it uses less anesthesia, has no abdominal incisions, but remember that the dye x-ray still has to be done in a few months.

   There is the three month contraceptive shot. This is called Depot Provera. The advantage is that a women only has to think about it once every three months. After a woman's uterus gets use to it, there is frequently no menses at all. This is great for endometriosis, and women who need mikvas, but there will frequently be break thru bleeding for many months while her body gets used to it. Once the body gets used to it, it is great. There is no periods, and the failure rate is very low.

  All of the methods above have some advantages and some disadvantages. The female condom is best for preventing STD's, but it seems very awkward.

  There are women who really like their diaphragms. It needs to be filled with spermicide, and then placed in the vagina before sex. It works ok, but a women needs to stop to place it before she has sex. This can interfere with the mood, unless she placed it well before she was planning to have sex.

   The sponge was taken off the market sometime in the 90's, leading to a great episode on Seinfeld show where Elaine bought up all the remaining sponges, and then invented the word "spongeworthy" for her boyfriend. It has since come back on the market, but it is still hard to find. It is a great method for some people. It has no hormones, and the guy does not have to even know it is there. The only available brand is called the Today Sponge. It is easiest to order it on Amazon.

   So, the most common methods, in my practice and experience, is abstinence, withdrawal, Oral Contraceptives, condoms, surgery, and IUD. Of these, abstinence is great when neccessary, but problematic in a marriage. Withdrawal is unfortunately common but is terrible. OCPS' are great due to their good side effects, but need a second method for some women. Condoms are easy, but interfere with sex a bit. Surgery is great when it is needed and wanted. And IUD is wonderful and much loved by it's users. Unfortunately they are expensive and women have an unnecessary fear of them.  

   All of contraception is good because it enables pregnancies to be wanted, not loathed and feared.

   The Morning after pill, or emergency contraception, is over the counter now. Any women over 17 can just walk into a store and ask for it and get it without a prescription. The main brand is called Plan B. Just ask the pharmacist for it. It may make you nauseus, and it may give you an abnormal menstrual flow with break through bleeding, but it will really reduce the chance of getting pregnant. All women need to know this, but very few do. It is time we educated them.

   This is my take on contraception.

Thanks once again for reading my blog.
This one is much longer than I intended for it to be. There is still a lot more to say, but this can be a basic introduction to contraceptive options. I hope many of you find it useful.

Comments are appreciated.

Dr John Marcus Ob/Gyn
Ridgewood, New Jersey
Phone 201-447-0077
blog at doctorjohnmarcus.blogspot.com

July First in Medicine, and Work Fatigue

   It is now Friday, and the holiday has passed. The new academic year has started as of July First. July First is a crazy workweek in medicine in General. First of all, the Senior Physicians are mostly off duty for the holiday. Then, in the teaching hospitals, the new med students come into clinical rotations. They are brand new, and slow on the uptake of the fast pace of clinical work. At the same time, the new interns come. This is their first day on the job. Moreover, many of the chief residents supervising them are also supervising for the first time. There may be a newly graduated "attending" physician, again, first day on the job as a supervising attending. So, we have a situation where there are many people in their new role on the first day. And remember, the senior physicians are away for the holidays. What this means is that there is going to be stress as everyone gets used to their new roles. While all this is happening in the teaching hospitals, community hospitals are not immune to the stress. Everybody is connected one way or another, in a multitude of ways.
   In community hospitals, the Senior Physicians are still going to take a holiday, leaving the more junior members working. And many physicians are on staff at multiple places. My hospital, The Valley Hospital in Ridgewood New Jersey, has many staff members on staff at teaching hospitals. We are an affiliate of Columbia University hospital just over the George Washington Bridge about 20 minutes away. That is one of the best teaching hospitals in the world. Many of our physicians go to Columbia. Columbia is not immune to July First issues. Nowhere is. We are also about 20 minutes away from Hackensack University Medical Center, and that is a teaching hospital. Many of our staff go there as well. And my hospital still has to take on the newly minted physicians graduating from residency and fellowship programs. They will be new on the job at The Valley Hospital.
   So, altogether, July First is a stressful time in the field of medicine. I worked through this holiday on call myself. And I did it last year as well. We can't all go away on holiday. Someone has to stay and do the work. 


   Here is a link describing this problem in the AARP: 
http://www.aarp.org/health/doctors-hospitals/info-06-2010/why_you_should_avoid_the_hospital_in_july.html

   Here is a link to another blog about it:
   http://neilbaum.wordpress.com/2011/07/23/dont-want-to-die-avoid-july/
 
   I don't think you need to avoid hospitals in July and August. That is a bit extreme. But, personally, if I was admitted, I would check out my medical team. If everyone was new on the job, from the students to the interns to the chief to the attending, I would leave that hospital and go to a community hospital. And I would make sure that my attending at that hospital had more than a few years under their belt. If, on the other had, everyone was new except for the attending, and the attending made a commitment to stay on the unit, then I wouldn't worry. If the attending was supervising from the mall or the golf course, then I would leave. If the chief was in their second year, then I wouldn't worry. Don't forget the night shift. That may be staffed by beginners, especially in the era of reduced work hours for residents. There are few places left where residents can stay for 36 hours to make sure their patients are safe. Most training programs have reduced work hours to make residents leave either at 12 or at 24 hours. This is so they can get some sleep and rest.
   Many neurocognitive studies show that being on the job after 24 hours is as disabling as being under the influence of alcoholic drinks. And many people without stamina are dizzy with fatigue sooner than that.
   My residency program had me working 36 hours on and 12 hours off for four years, not counting vacations.
   I think that some residents in training did very well under those conditions, and some did not. We knew the ones who did not, and they either washed out or we supported them through the tough days.
 
   Generally, to be a busy Ob/Gyn in the real world, a person needs to have the stamina to work days and nights. There may come a time when there will not be an excuse that "I'm sorry, I am too tired to take care of you." On the other hand, when a doctor reaches their fatigue limit, then the physician needs to take advantage of backup, cancel hours, and try to get some sleep. I have done this myself. Patients understand this need very well indeed.

   Thanks for reading my blog.

John W Marcus MD
Obstetrics and Gynecology
Ridgewood, NJ
Phone 201-447-0077
blog is at doctorjohnmarcus.blogspot.com