Hyperemesis Gravidarum, or super vomiting  of pregnancy. 

Right now our beloved Princess Kate is hospitalized with Hyperemesis Gravidarum. 

The royal spokesperson has said that she is less than 12 weeks pregnant, but has not given us her due date yet. We can assume that she is past 8 weeks or so, or the HG would not be at this stage. So she is between 8 and 12 weeks. That means she is due near July 1st 2013. 

HG happens when the pregnant women is so nauseous that she vomits nearly continuously. 

Nausea and Vomiting are completely normal parts of the first trimester of pregnancy. Most women will experience some of this. In fact, most women will lose some weight the first trimester of pregnancy, just because they cannot eat a lot of food. 

But, when a women suddenly gets so sick that she cannot tolerate fluids, and what fluid she does have vomits back up, two bad things will happen. First, she will get severely dehydrated. And that will make her very very weak. Her blood pressure will be low, and she may not have the stamina to even get out of bed. The second bad thing that happens is that she will lose electrolytes, such as sodium, potassium, and chloride. Losing the electrolytes is worse than plain dehydration because it can make the heart beat irregular, or worse. 

We can detect this severe dehydration by weighing the patient. If she loses 10 pounds over a few days, then she has certainly lost enough fluids to go to the hospital. There, we can replace the fluids and check the electrolytes. 

Obstetricians don't really know what causes such a severe intestinal problem. We know that progesterone, which is a hormone that the ovary and placenta makes in abundance, can make people sick. Some women get really bad PMS from the natural progesterone of a normal menstrual cycle. The progesterone peaks about day 23 or so of a normal 28 day cycle. A lot of women feel awful from that peak of progesterone. It makes their breasts sore. It retains fluid. It makes them crabby. It makes them gain a few pounds of fluid. It makes their intestines fill with gas, and they get really bloated. They really hate it. The peak progesterone level of a normal cycle is about 12 or so, according to my lab.  In pregnancy it may go up to several hundred, as the placenta makes a ton of it. The natural purpose of the progesterone seems to be to keep the uterus from having a menstrual period, and thereby pushing the baby out. The uterine muscle responds to the progesterone by getting very soft and dilated. Unfortunately, that same kind of muscle is in human intestines.  Under the influence of that much progesterone the intestinal muscles seem to dilate and get soft. This prevents peristalsis and makes the women nauseous as the food backs up into the stomach and esophagus. 

There is also a strong belief among some people that the nausea has an evolutionary purpose. 

What I mean is that the vomiting may be a defense mechanism to protect the fetus from noxious foods and exposures. This is because the first trimester has an importance unlike any other time in human events. It is the phase of organogenesis. 

The first trimester of pregnancy lasts from about 2 weeks of pregnancy (that is before the pregnancy is even known about) until about 13 weeks. The first trimester has an unbelievably important function for the fetus. It is the phase of "organogenesis". This means that the baby is actually forming it's own anatomy. The heart is being built into chambers, the kidneys are being made, all the tissue layers are folding into final position, the basic brain structure is starting up, and all of the events that create a human being are happening. After 14 weeks, all of this complicated tissue construction is done. The only thing left is to grow and fine tune the functions of the organs. 

What is the last organ to be completed? I like to tell my patients it is the brain. That is done, in some people, around the 40th year of life or so. There is a bit of humor and a bit of truth in that statement. It is my belief that the human brain never stops developing. Since we can all learn new things, and do new activities, it seems to me that the brain never stops growing. For this reason I believe in lifelong "effortful" learning. Effortful is the opposite of Effortless. For this reason, I like to say that people should push to learn and do and experience new things all the time. For me, my recent activities include learning to play the guitar, learning languages, and learning new computer processes. Such as learning how to write a blog on Google, learning the Java programming language, expanding my knowledge of Pascal, keeping up with the latest Basic compiler from Microsoft, and things like that. 

And to grow the brain we have to nourish it. That is why I recommend everyone including myself to take DHA omega three supplements. This is an essential fatty acid component of human brains, that no one gets enough of, that cannot be created inside of a human. I take and recommend 300 mg a day of DHA. 

Probably the second to last organ to be finished is the lungs. I don't know why, but the human lung has a lot of trouble oxygenating a human being until about 36 weeks of pregnancy or so. There are multiple issues with the function of an immature human lung, but one of the last factors to be created is Surfactant. The NICU now uses artificial surfactant and that helps the premees quite a bit. It helps them breath. 

But, until all of this complicated organogenesis is done, there is a very delicate fetus. If there is some unfortunate exposure to a toxin of any sort, it may have a disastrous effect on the organogenesis. The heart may not form right. The cover over the spine may fail to fuse, causing anything from a spina bifida to anencephaly. There may be entire limbs missing. There may be a tiny imperfection, like a cleft lip. There may be a huge central failure, like syrinomelia, where the legs are fused. This is why most physicians are loath to prescribe any medicines in the first trimester. We will, if possible, defer any medical treatments to the second trimester. Sometimes, we will defer treatments of minor infections. We will push hard to defer X-rays, if possible. We will certainly advise against smoking, drinking, and illegal drugs. We do not advise refraining from exercise or sex, unless there is a specific reason to do so. 

So, some people believe that Hyperemesis is Mother Natures way of protecting the fetus from noxious exposures. Most pregnant women will run away from any noxious fumes, because it makes them extremely nauseous. This serves a very important purpose of keeping those toxic fumes away from the baby. 

As an obstetrician, my job is to keep the baby safe. Keeping the baby safe means keeping the mother comfortable.  

If a pregnant women has more vomiting than is safe for the baby, then we need to take action. The first thing to do is to see if dietary modifications will help. I will ask the women to start taking a tiny sip of Gatorade every 20 minutes. This will replace the electrolytes and the fluid slowly, and prevent there from being too much fluid in the stomach as to make her vomit it back up. I will ask her to stop all spicy and greasy foods. I might ask her to have one salty cracker (called a saltine her in the USA) every  twenty minutes. Sometimes the saltines and Gatorade diet does the trick. 

Sometimes we try the BRAT diet. This is bananas, rice, apples, and toast. This diet is explained on Wikipedia page here: http://en.wikipedia.org/wiki/BRAT_diet. 

If the women needs medications to stay hydrated, then we usually start with phenergan and or odansetron (Zofran). If pills get vomited, then go to suppositories. Women don't like that of course. If that doesn't work, then go to IV or Subcutaneus pumps of these meds. Plenty of women are maintained on these meds, sometimes they need them for most of the pregnancy, if the situation is really bad. 

If nothing else works, then the women needs both IV fluids and IV nutrition. These IV's can save both the mother and the fetus, and I have managed this many times. Most of the time I will ask for the help of a specialist in IV nutrition. Our hospital has several of these specialists available. I call them into the case, and their help is very much appreciated.  

Sometimes, in bad cases, such as if the gallbladder goes bad at the same time as Hyperemesis, these women will need IV nutrition for the whole pregnancy. It is certainly possible. These women are really suffering, though. 

If the vomiting is not managed well enough, then the stomach acids can inflame the esophagus  This can get really painful, and needs to be managed as well. These stomach acids are really bad for the teeth, too. Just like in a bulimic patient. 

Let's hope that Princess Kate doesn't need this kind of service, but if she does need it, I am sure that it can be provided. 

Thanks once again for reading. 

Dr John W Marcus MD FACOG 

89 North Maple Ave 

Ridgewood NJ 07450 

phone 201-447-0077 

fax 201-447-3560 

blog at doctorjohnmarcus.blogspot.com 

comments below are very much appreciated. 

Stem Cells


Everybody asks, "Should I have my umbilical cord blood stem cells frozen and stored?" Usually, by the time patient is asking me this question, she has been bombarded with advertisements from the stem cells storage companies. But, even if the patient doesn't ask me, I will ask the patient at about 20 weeks. In my practice, it  is a prenatal care checklist item for 20 weeks, along with the 20 week genetic and anatomy sonogram. So, I will make sure that the patient has the information that she needs to make a good decision.

First of all, everybody should be aware that umbilical cord stem cell storage has not been endorsed by any professional group other than the stem cell companies themselves. My ACOG states that this procedure is unnecessary. Anything that is unnecessary is not going to be a covered benefit under the health insurance. So, anyone who does it is going to have to find a way to pay for it.

It costs anywhere from $1350 to $9000 or so to get the process started. The price varies from company to company. There is also variance on what exact services you have contracted for. There are some companies that will take the whole placenta and use it to get more of the stem cells. Other companies will take a short segment of the umbilical cord itself. All of these things are added cost.

Once the stem cells are frozen and kept under liquid nitrogen, the companies that do this work will charge you once a year to keep the cells frozen. The yearly charge is something on the order of 150 to 250 dollars a  year. I suppose that if you don't pay, they would throw out the stem cells. Or maybe donate them to science, or a public stem cell bank.

What is the benefit of doing this?

The stem cells that are retrieved from the umbilical cord, fetal blood, and placenta, are processed and examined by the cord blood storage companies. Then they are deep frozen under liquid nitrogen. This does not kill the cells. It preserves them for future use. If, in the future, this baby has some kind of medical problem that can be cured with an infusion of stem cells, then the stem cells are there for the baby to use. These problems are usually some kind of leukemia or cancer. In that case, the future oncologist has the option of removing this victims bone marrow cells, curing the cancer, then thawing out the stem cells, and then restoring the immune system with those stem cells. This is all only theoretical, because the successful cases done like this are rare.

The stem cell companies claim that about one out of 200 stored units are eventually put to use. I have not seen an independent validation of this claim. If this is so, then I think that everybody should do the stem cell storage. I think it is more likely that there is a small number of stem cell units that are used. The rest will stay frozen indefinitely.

There is a ton of ongoing research right now to see if stem cells can be used to treat a bunch of other conditions. There is some some studies being done for heart disease, and some even on autism. So the applications for stem cells seem to be widening. It may be that the future for stem cells is very wide indeed.

On the other hand, biotechnology marches on. It seems now, that many times, the biologists can get stem cells retrieved even from grown ups. If this is so, then there is no reason to store the fetal cells, as everyone has stem cells. We can use the adult stem cells to do the job of the fetal stem cells. If that is true, then no one needs to freeze the fetal stem cells, we have our adult cells and that will be good enough.

So, in the final decision making, a family needs to decide the odds of using these stem cells, versus the odds of not using them or not needing them because the body makes it's own. I also tell my patients that if they need the stem cells years later, and they didn't store them, they may be very sorry.

And then the decision is affected by how much you value the 2000 dollars or so you invest in it.

I tell a family, "if you have a lot of money, then you can spend a lot on the stem cell fees". On the other hand, "If you don't have a lot of money, and 2000 dollars will break the bank, then don't do it. Either way, I will help you both figure out the right thing to do is, and I will help you do it. You need to make your decision some time before the placenta comes out."  I will then note in the chart that we had the discussion, and I will note whatever they seem to be deciding at the moment. We will revisit this discussion throughout the rest of the pregnancy and I will offer to help decision making.

The majority of the people in Bergen County will decide that they do not want to pay for it.

If they do, there are a couple of good choices available.

Viacord is the biggest company. They are based in Ohio. They will not let you visit your unit of blood. They generally will not negotiate with you. They will provide my office with 500 dollar coupons that people can use to lower the price from 2300 to 1700 dollars.

Neostem is the best local company. They are based in the next town, Allendale New Jersey. I personally have met some of the people, and I like them. They will let you visit your unit of blood. They have good prices. They will talk to you on the phone. They also have a coupon available in my office.

CBR is another big company.

There are a hundred others.

The local blood bank still does it as well. I don't know why more people don't use them. Maybe they are being out marketed by the commercial providers? I don't think the blood bank markets the service at all. They used to have an open donation program that was free to donors. I sent a lot of donors their way. The donor program is now closed due to lack of money. As you can imagine, the donor program was quite expensive to administer. If it ever opens again, I will send a lot of patients to the blood bank for stem cell donations. It was a very very popular program with my patients when it was still open.

Ultimately, the decision to store the stem cells is difficult for most people. It is an assessment of risks, potential benefits, and costs.

Sometimes, the grandparents have a very strong opinion, and take action. It's great watching them when they do this. It becomes a parent taking care of a child, but the parent is the new grandparent, and the child is the pregnant women and her husband. The grandparents say, "where doing this, that's all their is to say about it". They will allow no dissent. And then the stem cells are stored.

I don't know how the stem cell companies find the pregnant women to market to, but they seem to use some kind of internet magic. There was a story of a 17 year old girl who got pregnant, and did some looking around the internet on Google. Pretty soon, there were items in her mail box to help her with the pregnancy, and try to sell her things. This, despite nobody but her knowing about the pregnancy. Her Father read the mail, and found out she was pregnant. I don't know the outcome of that story. There is a strong lesson there, though. The lesson is, almost nothing one does is the modern world is completely private. I think, for the sake of safety, always assume there is a camera watching you, and there is someone who knows what you do on the internet. There are technical ways to block that snooping, but I am pretty sure they are not completely successful at blocking your trail.

I think the next post will be about Hyperemesis Gravidarum, as that is what our beloved princess Kate is hospitalized with right now.

Thank you sincerely,

John W Marcus MD FACOG
89 North Maple Ave
Ridgewood NJ 07450

phone 201-447-0077
fax 201-447-3560
blog at doctorjohnmarcus.blogspot.com

Pre-eclampsia or Toxemia

Toxemia is a big problem.

Toxemia strikes about one in twenty pregnant women. It is usually mild, but sometimes is severe. Occasionally it will become life threatening. When it gets really bad, it develops into eclampsia (instead of pre-eclampsia). When it is super bad, it leads to a failure of the blood systems, then we call it HELLP syndrome. HELLP is an acronym for "Hemolysis, Elevated Liver Functions, and Low Platelets". About one out of 75,000 pregnant women will get toxemia so bad that they die of it. 

The professors of Ob all call this pre-eclampsia. The old folks will likely call it toxemia. Personally, I like to call it toxemia. I think the name toxemia better reflects an understanding of what the disease process is. The old latin name of pre-eclampsia just doesn't create any useful meaning to me. In any case, all physicians know both meanings. 

To put the mortality rate into perspective, there are about 5000 hospitals in the USA. This means that about 1 in 15 hospitals can be expected to lose a patient to toxemia in one year. And about one in 20 Obstetricians will lose one patient in his or her's entire career. This is assuming an Ob career involves about 5000 babies. Personally, I have already delivered more than 5000 babies, but I believe I have more experience than most. 

Some hospitals have more high risk cases. Those high risk hospitals will obviously have a much higher count of the risky cases. 

My hospital, The Valley Hospital in Ridgewood NJ, attracts these extremely high risk cases. We have one of the best Neonatal Intensive Care Units in existence. Our chief neonatologist is Dr Frank Manginello. He is a noted author of one of the best NICU reference books in existence. His best selling book is called Your Premature Baby. The book is available on Amazon. Here is the Amazon link: http://amzn.com/0471239968 . 

We also have a superb IVF program, and a wonderful Maternal Fetal Medicine team, not to mention a medical staff in the thousands, most of which were trained in New York City. Many of them maintain privileges at University hospitals. 

For instance, my favorite fetal cardiologist is Dr Zvi Maran. He has privileges at both Valley and at Columbia University. Columbia is about 20 minutes away just over the George Washington Bridge. Dr. Maran took care of my daughter when she had a very frightening cardiac arrhythmia. He and his excellent partners got her through this and eventually her heart healed itself. 

So, hospitals with a higher risk population is going to see a lot more of the riskier cases, and their experience is going to be higher than just the numbers will show. 

What is Toxemia? 

Nobody really knows for sure. But, even though we aren't sure what it is, we do know an awful lot about what it does. The body of the pregnant women is behaving as if there were a really bad toxin in the blood stream. No toxin has ever been found. But all of the organs start to fail. First, the blood pressure starts going up. This is due to the arteries feeding these organs squeezing down on the blood flow, leading to less flow to these organs. Early on, the kidneys start to malfunction. The kidneys start making less urine. This leads to fluid retention and severe swelling, and usually 10 pounds or more of fluid is retained all throughout the body.  The kidneys start to "spill" protein into the urine. There is usually no protein in urine because the kidneys are good at making clear urine and keeping the valuable protein in the body. In toxemia the protein spills out. 

So a lot of prenatal care is designed to check for these things. In a prenatal visit, the blood pressure will be checked, the patient will be weighed to see if there is this sudden severe fluid retention, and the urine will be checked for protein. All of these checks are to test for the signs of toxemia. 

Officially, the diagnosis of toxemia requires an elevated blood pressure, and some protein in the urine. 

The brain will eventually be affected. Some of the signs of toxemia affecting the brain are: a bad headache, visual changes including dark spots, sparkles, blurry vision, loss of vision, or more rarely, personality changes. 

The liver will be affected some times. This will lead to an elevation of the "liver enzymes" on a comprehensive panel of blood tests. If the liver gets too swollen, it can cause pain in the liver area of the abdomen. This is considered the right upper quadrant of the abdomen, just under the lower edge of lowest rib. A very swollen liver can actually rupture. If this happens, the patient may die from the blood loss into her abdominal cavity. I have never seen a liver rupture, but I have seen many many painful tender livers, with elevations of the liver blood tests. This is all quite common if toxemia gets to the HELLP stage. 

In the blood, the red cells can rupture. This can lead to severe anemia, and elevations of bilirubin in the blood on tests, and bilirubin in the urine as well. Also, in the blood, the platelets can get used up by the toxemia, leaving the platelet count perilously low. These women may need platelet transfusions.  Platelet transfusions are easy to order from the blood bank, and can be lifesaving If the platelet count gets too low, a life threatening hemorhage becomes likely, especially at the time of delivery. At delivery a woman needs all the platelets she has to shut off the blood flow to the placenta. Without that, there will be a hemorrhage. 

The blood flow to the heart muscle can be compromised, leading to heart failure, or a heart attack. 

All of the organs can be compromised. 

None of the toxemia directly affects the baby. Only to the extent that toxemia affects the mom or the placenta. 

If the blood flow to the placenta is compromised, then the baby may become short on oxygen, or may be short on nutrition. The baby may stop growing. The babies blood pressure may become very low. 

The placenta might even disconnect from the mother. If this disconnection is more than a mild case, then the baby will be distressed or even die. We call these placental disconnections Abruptions. Placental abruptions are much more common with hypertension, than will normal blood pressure. Abruptions can also happen from some kind of trauma to the pregnant uterus. Car accidents, falling over on ice or on the stairs, or physical assault on the fetus, can all cause the placenta to abrupt. A complete abruption when a woman is far away from the hospital will almost certainly end the babies life, and will very much risk the mothers as well. Sometime the blood just pours out of the vagina like a hose. If this happens there are only a few minutes, perhaps 10 but maybe up to 30 minutes, to try to save the baby and the mom. I have seen many abruptions. If it happens in the hospital it is almost certain that we can save the mom and the bay. If the private obstetrician is not there with the patient, then we have the on call ob. The "doc in box". In my years doing the on call, I have saved maybe 4 or 5 or more from a placental abruption. Mostly by doing a really fast C-Section. 

After the baby is delivered the nurses will sometimes come up to me and say, "thank you for coming right away when I called you. You saved this baby". My answer to that is, "no, you saved the baby by being there, recognizing the problem, and calling me without delay. You saved the baby, I was just doing my job". In the end, doing our jobs requires a lot of teamwork. Everyone becomes a link in this chain of human events. And when it all works out, we can all be really proud of what we do. 

But not all abruptions are complete. Many are partial. It is easier to save those babies. 

How to diagnose it? 

If the blood pressure is elevated, then we know there is a problem. It might be "gestational hypertension", which used to be called PIH, or pregnancy induced hypertension. Or, it might be toxemia. We will look for protein in the urine, either on a urine dip strip or on a 24 hour urine collection. We will order blood tests to look for hemolysis, low platelets, and liver function tests. We will likely need to do these tests in the hospital. The patient may be formally admitted, or she may be kept as an outpatient for up to 24 hours. 

We will ask her if she has a headache, or visual changes, or sudden fluid retention and swelling, We will ask her about nausea, and pain in the liver area. 

We will weigh her, examine her lungs, heart, liver, and uterus. We will check the reflexes. If they are elevated, that is a sign of toxemia. 

If the blood pressure is below 160/100, and there is no hemolysis and the platelets are normal, and there is no liver involvement, and no brain involvement, then we call it mild toxemia. Mild toxemia remote from full term can be observed, usually in the hospital, but sometimes at home. Mild toxemia at term should be delivered without delay. 

Delivery cures toxemia 100 percent of the time. If the women has permanent damage to her kidneys, or heart, or anything else, as result of a terrible toxemia, then those problems can last forever. But the toxemia itself will be gone. usually it fades away from hours or days after delivery, and is completely gone in 6 weeks time after delivery of the baby. 

A patient with severe toxemia will need to be delivered regardless of the gestational age. Even if it means losing the baby. We have to deliver the woman, even at 22 weeks, and sometimes deliver a non-viable baby. If we do not deliver the baby, then the mother may die or be permanently damaged from the multiple pathways of pathology I described above. We do not want to have a maternal mortality. 

Even having said all of that, ACOG (American College of Ob/Gyn) has written a recommendation that some milder cases of severe preeclampsia, if they are remote from term, may be allowed to stay pregnant a little bit longer if it means the difference between life and death for the fetus. ACOG will only allow this protocol under certain circumstances. Among them are an experienced facility with very experienced Obstetricians, perhaps with Maternal Fetal Medicine specialists available. Our facility fulfills all of those criteria. Therefore I am comfortable managing a "moderately" preeclamptic patient without immediate delivery. But in most cases, immediate delivery is necessary. 

Who is at risk? 

Some women are much more likely than others to get toxemia. Hypertensive patients, diabetics, older pregnant women, over stressed women, women who have had it before, women who use drugs like cocaine, women without prenatal care, women who suffer from poverty or who don't have a family or husband to help, women with anxiety disorder. 

But even so, it can happen to anybody at any time. 

Prevention? 

Many things have been tried to prevent toxemia. Nothing has worked. We can certainly prevent some of the risk factors, though. We can provide proper prenatal care, proper nutrition, prevention of diabetes, lower lifestyle stress issues, prevent drug abuse, and engage the family into a social support group. 

Aspirin has been tried and it doesn't work. 

Calcium, magnesium, vitamins, none of them work. 

We usually advise some moderate bedrest to lower the blood pressure, but most Obs don't believe that bedrest will actually prevent it. And bedrest itself has a number of severe risks, especially including lethal embolisms from DVTs, but also including severe decondioning, which may require physical therapy to overcome. 

Someday, someone may actually find the toxin of toxemia. If they do, there will surely be a Nobel prize to that individual. 

Thanks for reading. 

John Marcus MD Ob/Gyn 

89 North Maple Ave 

Ridgewood NJ  07450 

201-447-0077 

blog at doctorjohnmarcus.blogspot.com 

Influenza after Hurricane Sandy

It is now Saturday November 10th, and it's my first weekend off since Hurricane Sandy came through. When I woke up today I was struck by the thought that I haven't had any phone calls for influenza yet this season. We are well into flu season. Usually, by now, there are a ton of calls. I wondered "what was up with that?" Why no calls for influenza? So I did what I usually do with these kinds of influenza questions. I opened my iPhone and surfed over to Google's flu tracking tool at http://www.google.org/flutrends/  Immediately I discovered that the United States is having a bad flu year. Here is a screen shot of my iPhone page: (Hint: If you click on this picture, it gets much bigger and more readable):

The line for the present year is a darker blue than prior years. This years line ends at about November first, because that is the most current data.  You can see that the present incidence of influenza is well into the moderate range, and it it well above prior years. This years line is above all prior years, with the exception of the really high H1N1 year. That tall peak was the year that H1N1 happened. Google's web service tracks influenza by analyzing search terms that people type into Google. Google's flu tracking technique is statistically validated, and their results are published in the scientific journals. It turns out that Google's technique gives us flu data about two weeks sooner than the old way. The old way was just collecting case results from emergency rooms, and things like that.

So, if the US is having a bad flu year, why am I getting no calls? I decided to look at New Jersey's results. When I clicked on New Jersey on the map, I got this:

You can see that New Jersey's incidence is not only low, but has dropped off quite a bit over the last week. So Google's flu tracker seems to confirm my suspicion that we are having an anomalously mild flu season. Either that, or people with influenza are neither calling me about it, nor are they searching Google for answers. It seems to me that we are actually having a mild year.

Could it be hurricane related? Maybe so. There was no bus or train service for a very long time. Maybe no one is spreading flu on the bus, so the incidence is very low and dropping. It could be that no one was going to work, and therefore not spreading the flu at work. Or, a big factor might be that the kids are out of school for more than a week. If the kids cannot spread influenza at school, that might be enough to lower the incidence of influenza. Are there any other factors? Maybe all of the houses without heat were inhospitable to the influenza virus.

So, you heard it here first. This is headline news. Catastrophic Hurricanes during flu season causes a reduction in influenza incidence. The evidence is the strong dip in the dark blue line on the second screen shot above. This is a tiny silver lining in the cloud over our heads. If no one has noticed this effect before, maybe I can get the hurricane effect named after me, :). The Marcus effect, maybe? If it hasn't been named before?

If this reduction is real, then I would like all of you to consider the lethal nature of influenza. Every year, 25 to 50 thousand Americans die of influenza. Please compare that number to the 200 or so people who died in Hurricane Sandy. Maybe the silver lining isn't so small after all. If these statistics hold true, it may be that Hurricane Sandy saved more people from influenza than died from the storm. If you look at the yellow picture of the United States in the above two web pages, you can clearly see that the northeast states have a much lighter shade of yellow, compared to, say, the south from Florida to Texas. The northeast may have been affected by the hurricane, whereas the south is having a normal flu season. Maybe someone can compare this with prior years to see if the effect is real.

In my office I try to immunize all of my pregnant patients against influenza. All of the professional groups, such as the American Congress of Obstetrics and Gynecology, recommend  that pregnant women get a flu shot ASAP. In fact, pregnant women should be first on the list if there is a shortage of vaccine. When H1N1 happened a few years ago, there was a severe shortage of that vaccine. Who was offered the vaccine first? Those most at risk were offered first. And that meant pregnant women were offered the vaccine first.

When the power went out in my office I took my boxes of vaccines home. I did that so I could keep them in a fridge at home, and keep them safe in the power outage. But I missed a box in the dark office. It warmed up and I had to throw out the whole box. That was a shame  because I had the single dose vials. These have no preservatives and are better for pregnant women.

Back in 2009 I was a speaker at an influenza symposium given by our hospital, The Valley Hospital. At that time, influenza type H1N1 was running it's course. H1N1 is unbelievably evil. There were two giant epidemics last century that each killed millions of people. H1N1 came back again in the year 2009, and there were worries that we would once again have millions of people die. Well, that didn't happen. Our public health measures were very successful at averting the mortality rate of prior pandemics.

What is influenza? It is a virus that infects humans via microscopic airborne droplets. It doesn't just infect the lungs though, it gets loose into the blood stream as well. The major signs that one has influenza is high fevers and muscle aches. There is usually profound fatigue, some respirator illness such as a sore throat and cough, and maybe some intestinal discomforts.

Whenever a person has high fevers and muscle aches, we call that illness an Influenza Like Illness, or ILI. An ILI does not require a visit to the doctor or the emergency room, but a phone call to the doctor would be a great idea. The doctor can phone in a prescription for an antiviral medicine. One such medicine is called Tamiflu. Pregnant women with an ILI really should take the Tamiflu. In my experience the Tamiflu sometimes stops the virus in it's tracks. A persons energy then pops right back. The Tamiflu really avoids the prolonged fatigue that one gets while recovering from this nasty virus. Also, when one is recovering from an ILI, one should be resting and drinking plenty of fluids. This is especially true of pregnant women. Pregnant women simply don't have the reserve energy that non-pregnant adults do. Some of them cannot possibly recover from the profound fatigue unless they take the time to rest.

So the lesson for influenza is this:

Get vaccinated to prevent it.
If you get an ILI, then push fluids, rest, and maybe take Tamiflu.
If you are pregnant, then you must stop working, rest, push fluids, and take Tamiflu.
Call your doctor.
You won't need to go to the doctor unless there are other complications.

Once again, thanks very much for reading my blog. Please post links to my blog. It is really great to see all the people who are reading this from all over the world.

Sincerely,

Doctor John Marcus MD
89 North Maple Ave
Ridgewood NJ, 07450

phone 201-447-0077
fax 201-447-3560
blog at doctorjohnmarcus.blogspot.com

I am soon to start twitter as well, as it was one of the only services that actually worked during the height of the storm. I do have an account, I just never really used it. I am still not sure if I tweet to other people, or if they tweet to me. In any case I just tweeted that I have a new blog post up. Where that tweet goes, I have no idea.

Hurricane Sandy Recovery, and more yeast infections. Some photos of tree damage in my town. 

Today is Monday November 5th. Hurricane Sandy came through here exactly one week ago. Power came back at my house about 36 hours ago, and electrical power came to my office about 24 hours ago. This morning we went in to the office and restarted our business equipment. The phone system has completely lost it's mind. The programming is gone. This means that every phone in the office rings for every call. My staff was extremely busy all day taking phone calls and arranging  new schedules. And they did it with our malfunctioning phone system. It sounds funny, but the fax machine started to answer every call. I am sure that was frustrating to callers who were answered by a fax tone. We unplugged the fax and forwarded those calls to a Lifeline fax server. And when we tried to send faxes, the receiving fax machine was putting our fax machine on hold, complete with music. Our fax machine does not need, or even like, music, so that obviously blew up our communications systems. Once, when I got tired of the phones ringing nonstop in the exam room, I pulled the phone off the wall and unplugged it. I think I moved much too fast. Besides alarming my patient, I banged my head into the corner of the cabinet by the phone. Ouch. That hurt. But I had a good laugh about it. Probably everyone's phone and fax system is deprogrammed by now.  If it wasn't so serious it would be funny. Today, I had a women who needed to know a vaginal biopsy report to decide if she was going to have a C Section or not. But the lab couldn't get the test done, so now we have to decide without that information. That's kind of stressful. We will take good care of her anyway, and I think she will be satisfied with what we have done.

I think Halloween is cancelled now. It was rescheduled by Governor Christie, if you can believe that. First to Saturday, then to today, Monday. This, despite Halloween not being any kind of official holiday. But, since the streets are full of fallen trees, fallen power lines, piles of leaves, and piles of branches, there is just nowhere safe for the kids to go around trick or treating.

Most of my town is still without power, and the gas lines are still very long. Most of the gas stations are closed due to either running out of gas, or no electric. I called the Governor myself and was utterly surprised when a women answered the phone. I asked her to relay a message to the Governor that I thought the gas stations should get generators. Now, everyone must realize that Generators are dangerous machines. Our military has a spate of soldiers who died in war zones because of improperly wired generators. The press uses the term "faulty wiring". Faulty wiring means that electricity flows were it doesn't belong. Generators are only safe if they are operated within codes. That means that "electrical ground" is grounded, and "electrical neutral" is "bonded". If that is so, and connections are secure, than there is no danger. So, I asked the Governor to make sure that every local code official inspects the gas station generators, but not deny it due to permits. The other generator safety factor is that the generator must not "backfeed" into the power mains. If it does that, then there will be dangerous electricity where the power company thinks there isn't, and power line workers can get hurt, or worse. Worse, when the electrical mains come back, the generator cannot fight the strength of the power company, and the generator burns up in a ball of fire, especially including the gas tank on top of the generator. In an emergency, the best way to safely prevent backfeeding, is to pull the electrical meter. This completely prevents backfeeding. But, pulling the meter is illegal. I urged Governor Christie to explicity alllow pulling the meter at gas stations, by qualified electricians, so generators can be hooked up safely.  Pulling the meter reduces the electricians job to just a few minutes. We know that generators are scary dangerous. We in Jersey know that. But, here in New Jersey, we are facing a killing freeze tonight, and many folks have no power. And many folks cannot get gas due to the lines (lines are called queues in other countries). Something has to be done. It is my belief that the legal electrical codes need to be modified to suit the emergency. Pulling the meter is a no brainer, and allows safe electrical supply to Gas Stations.  The Gas Stations need to get electricity, and to start pumping gas. If generators are properly operated, then they do their function very safely. The electrical code officials are the best troops on the front lines of getting everyone the gas they need.

I don't see any gas stations on generators around here, with the one exception being the gas station that is owned by the mayor. That one has a nice generator hooked up, and at least our town can get gas there. But, there is still a giant line of waiting people queued up. I am sure that the mayor had no problem with proper hookup, or with the towns electrical inspector.

So, it is my opinion that getting the gas stations on generators is a priority. Moreover  it is an easy job for an electrician. It will save lives and prevent misery over the next few days.

Unbelievably, we have a Nor'Easter coming in two days. These storms are "winter hurricanes" centered out over the Atlantic Ocean, which blow strong winds and rain inland. Usually there is a lot of wind damage and power lines down. We only get one every few years. It will only add to the misery, especially to those without power. I hope no more lives are lost.

I have lent my generator out to a local family without power. I hope it helps them, and it keeps their pipes from freezing.

What was the most common Gyne problem I saw in the office today? Yeast Infections. True to form, on Halloween and Easter, there were a ton of yeast infections. I carried my bottle of diflucan around in the office. And handed them out. I think the yeasts were worse than usual today. It is possible that the stress of the hurricane is worsening the situation, but it seems to me there is something more. My theory is that all of the veggies were gone from the grocery store and the peoples fridges, so people were compensating with lower quality food, with more carbos. Obviously that would include Halloween candy. But it would also include donuts, chips, and other junk food. Personally, I bought a box of donuts and brought it home, and no  one at home complained there were too many donuts. How could I resist? The store had them out at the front. And everyone was stressed. The donuts were great.

I have a stack of photos of the tree damage done a week ago. There were trees snapped off at the trunk, and uprooted, some onto cars and houses. I have heard of no one in my town getting directly hurt by the hurricane.

Here are some of my photos. They are all within a two minute drive of my house:

The above tree snapped off at the main trunk.

This tree was uprooted and fell over next to a stop sign. The stop sign was turned upside down by the winds.  That root ball is 7 feet tall.

This big healthy tree was snapped off. 

This tree was uprooted and landed on the car in the background. The car has a tarp on it. 

These folks got a car smashed, and their house. 

1, A power line in the foreground 2. A Gen running in the garage! They are lucky to outlive this severe generator error. I informed a fireman around the corner, but he said he could do nothing. This is a lethal error. Never run a combustion engine inside, ever.  

This is a nice Honda Accord smashed by a tree. Obviously the driver would have died if it hit with him in it. 

This uprooted tree barely missed the house. 

This area was spared, but look at the power lines. Buried power lines look better and are safer. 

A different view of an undamaged lot. 

Another undamaged Wyckoff lot? look in the back yard. A tree is down there. 

This nice Mercedes Benz sacrificed itself to save the driveway. Obviously passengers in that car would have been killed. Look at the size of that tree trunk. It is as wide as the Mercedes. Only a part of the tree fell. it was a twin oak, or maybe a triplet oak. 

This is a short 30 minute line just for gas cans, for generators. Notice the police keeping the peace? They all did a really great job. They came around, asking questions, and making sure everyone was ok. The guy behind me in this line had a tree branch come through his roof. The branch penetrated his bed where his legs would have been, had he been sleeping there. Thankfully, he wasn't in bed. But if he was in bed, he was ignoring the towns advice to stay on lower floors. To my knowledge, no one in my town got hurt in an upstairs room of their house. And there were no floods. 

That's it for today, 

Thanks, 

Doctor John Marcus 

Ob/Gyn 

Ridgewood NJ 07450 

Office number 201-447-0077 

Blog is at doctorjohnmarcus.blogspot.com 

I corrected a few typos on November 10th. My editor must have been taking a break. 

Hurricane Sandy

   The hurricane passed us last Monday. Today is Thursday. It was a historical storm, doing things that have never been done before. The radar and satellite images of Sandy at the time it hit southern New Jersey stretched from the arctic circle to South Carolina. The eye hit New Jersey, and that means that the storm surge on the right side of the storm, hit northern New Jersey and New York. This is where I live. Right at about 11 PM the remains of the eye of the hurricane passed just to the south and west of where I live and work, near Ridgewood New Jersey. Actually this hurricane briefly had a double wall, and it was the outer wall that hit us. Since then the power has been out, the phones were out, the cells were out, and the phone texts were delayed by hours. I am right now running on a generator at home. That is keeping some of the lights and the heat on. The TV's are working and the internet is back now. The answering service that I use is based at the hospital, and they are swamped. If you need to call me via the service just wait on the line and call back if necessary.
   I like to tell my patients that if they cannot get me on the phone, and they may be in labor, or the baby is not moving well, or they have some emergency, then they should just go to the hospital. We always have an Obstetrician physically present in the hospital, 24/7. We call that the Valley On Call Ob Service, or informally, we call it the Doc in Box. We do 12 or 24 hour shifts. It is voluntary for us Ob's to be part of that service. Personally, I am part of that service. I have been since the start. We only allow experienced Obs to do the On Call Ob service. The hospital pays us for this service, but it is not enough to cover the business expenses, especially the malpractice insurance costs, of providing the service. I do it because it is great to stay part of the system, it is really great to save lives, and the money is welcome. Right now there is about 14 of us that share in that service.
   I was on duty for Hurricane Irene last year. It was a busy shift. Many of the Obs could not make it in to the hospital, so I covered their needs while they were away. I was on duty when the power went out in the great power outage a few years ago. We made do with various generators, and backups to generators. We kept everyone safe, and the power came back eventually. We definitely deferred some elective procedures, such as labor inductions and C-Sections. Our hospital now has really giant generators, the kind that are built on  Semi Truck trailers. They are permanently installed.  When the power goes out now, there is just a brief flash of the lights, and everything seems perfectly normal. We still try to defer elective cases while on the generators, though.
   Around my town, and in all of northern New Jersey, there are trees down. Some came down on houses. There are about 30 houses smashed by trees in my town. Many cars are smashed. Many of the trees came down on power lines. Many of the trees were uprooted and toppled. A lot of the trees just broke off on the main trunk. During the hurricane we could hear trees cracking all over town. It makes an unbelievable sound. Usually there are about 3 or 4 cracks over a few seconds, and then the tree falls. When the power lines fall, the transformers near the fall are overloaded and explode, creating a huge flash. If the transformer doesn't explode, then the power lines that make it to the ground start sparking an electrical fire. The brightness and the colors of those fires are amazing. At 11 pm there were giant sparks of these fires all over town. It went on for hours like that. It was a like a lightening storm with continuous flashes all over town. The fire department and police just didn't stop working keeping everyone safe. They cordoned off the wires, used heavy equipment and chain saws to keep some of the roads open, and rushed all over the place. They told the entire town with a reverse 911 call to stay out of the upstairs of the houses. Personally, I saw a tree lifted up into the air about twice it's height, spinning around, leaves and dirt flying everywhere, the air so dense with debris I couldn't see through it, and then the tree was ripped apart and the branches dropped about a hundred feet (30 meters) in front of my car. That was a sight I will never forget. It was like slow motion watching it in my mind.
   During the storm I sometimes would stand at my front door. The wind was not steady, but gusty. I could hear the wind, but then would come a really loud gust just howling out of the north. It would really roar. Then the trees would start cracking and falling. My town has millions of trees. I think if it wasn't for the trees, the houses would have lost many of their roofs.
   Oddly, my town never got a lot of rain. I was watching the rain bands on radar, and the rain just skipped us most of the time. We never got it heavy. This storm was really wide. There were rain bands up to Toronto, and down to South Carolina, and it mostly skipped us. Then, the mountains west of us got several feet of snow, and the ski resorts had their earliest opening ever.
   It is now Thursday. There is no power in my office yet. The power is restored within a few blocks of my building, but not up to my building yet. So, I cannot see my patients. Originally, when we cancelled Mondays hours, we scheduled a lot of them for Wednesday. But Wednesday came and went without power, and still barely with phones. So we have been trying to communicate with them via my phone calling service. But that is really problematic. For instance, the phone calling service called all of my Mondays patients to remind them of their appointment, but they also got a message that the hours were cancelled. The reminder was automatic, and we didn't stop the automatic reminders. I can't blame people for being confused. I just hope they aren't too upset. My phone calling service is called SecureReach, and they are based in Ohio. During the emergency, it was difficult to get everything perfectly right.
   Most of the people around here are taking these problems in a good mood. I have seen these situations before, when everyone comes together to help each other out, and everyone tries to do all the right things. That especially happened after 9/11. But sometimes trying too hard to be nice backfires.
   There are lines for gasoline throughout New Jersey. The lines are hours long. The stations that have power to pump gas run out of that gas in a matter of hours, and the stations that have no electricity have their gas locked up underground. Last night I waited for Gas at a Hess station. One guy was done pumping, but couldn't get out and make room for the next guy, because he was blocked by another car. So we tried to help guide him out so other people could get their gas, but he wouldn't move. People started yelling at him, people who already had their gas. They wanted to help the people behind. Nobody from behind came up to yell; they were being patient. Eventually, the guy blocking him moved and everything got back to normal. So, the only stress there was that everyone was trying to help each other, but one guy didn't want to help enough by moving out of the way. So he got yelled at.
   My power company has about 1700 workers on the power line repairs, and some more tree workers to move the fallen trees. Even so, there are millions of trees down and it will take weeks to get it all fixed. Usually, with a natural disaster, neighboring states will send their power line workers to help. After last years freak October blizzard brought down a bunch of trees (because the leaves were still on), the crew that fixed my neighborhood was from North Carolina. They were prowling around in a pack of about 10 large trucks just looking for the problems and fixing them as they went. This time, the damage covers such a wide area, that if the North Carolina workers are not working in North Carolina, they will be in Maryland or Delaware, where they need just as much help. This time, the news reports that crews are coming in from as far as Texas and California. That would mean that the entire country has mobilized to help repair from the storm. I don't think this has happened before, except maybe with Katrina. But the width of destruction this time goes from Canada to Cuba. So the mobilization will have to be very very wide.
  Meanwhile, my patients will need to just go to the hospital if they cannot get me on the phone. And there is a good chance they cannot, as the cell service is very weak. And the phone lines are dependent on fickle generators. The phone company has a generator running right now, but who knows how long their gas will last. When they run out, if they do, there will be no internet for me to post a blog.
  The food stores are mostly open, but they are completely out of perishables. Most of the perishables were thrown away, because there was no power to keep them cold. And many people, especially the ones without a generator, have lost all of their perishable food.
  Me and my family are doing fine. I wish you all well. Send your prayers for the more than two hundred people that have died, from Canada to Cuba. People have died from drowning in floods, from being washed away in rushing water, from live electrical wires, and by being trapped by falling trees.
  On a lighter note, there will be a baby boom in 9 months. There certainly was one 9 months after last years freak blizzard. All the local hospitals Ob units were quite busy. So, look for lots of new babies next summer.
  Once again, thanks for reading my blog.

Dr John Marcus
Ridgewood NJ 07450.
Phone 201-447-0077
blog at http://doctorjohnmarcus.blogspot.com

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