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