Fertility and Health News

Protecting You and Your Family from Harmful Sun Damage
April 2012

As the days grow longer and warmer, many of us look forward to spending more time outdoors. Whether it’s time with family at the beach or getting some time to do those outdoor chores, everyone needs to make sure they take time to guard against the damage caused by the sun. When I was growing up, sunscreen was hardly ever used and was often promoted as a way to get an even darker tan. Fast forward more than a few decades and most of us  recognize that “tan” is a euphemism for sun damage. Unfortunately wrinkled skin is not the only eventuality of over-exposure to the sun’s damaging rays. Skin cancer in all its various forms can be directly linked to exposure to the sun’s UVA and UVB rays.

Learning the steps to take to prevent you and your family from the damaging effects of the sun can help ensure that you enjoy your spring and summer months while maintaining good skin health.  The National Council on Skin Cancer Prevention has named the Friday before Memorial Day as “Don’t Fry Day” to increase awareness about sun safety. They have a simple message to take steps to minimize the damage the sun can cause. These steps include avoiding tanning and burning, staying in the shade when possible, using liberal amounts of sunscreen, and wearing protective clothing if you cannot avoid sun exposure. They even have a catchy phrase to help us remember the steps: Slip!Slop!Slap! and Wrap. When outside, both on sunny and cloudy days, slip on a tight woven shirt, slop on broad spectrum sunshine with at least a SPF of 30, slap on sun shading wide brimmed hat and wrap on UVA and UVB resistant sunglasses to protect your eyes from sun damage.

Each of these steps will help ensure that you minimize your risk of developing skin cancer in your lifetime. Sadly skin cancer is on the rise in the United States and it is estimated that over two million cases of basal cell and squamous cell skin cancers will be diagnosed this year. In addition, over 76,000 Americans will be diagnosed with the more serious malignant melanoma. Many of these diagnoses can be avoided if we take steps to limit our over-exposure to sun.  One effective way is to avoid time outdoors when the sun’s UVA and UVB are most potent between the hours of 10 am and 4pm. If this is not possible, try to cover up sufficiently with clothing and hats that block out the sun’s rays. Be sure to wear hats that cover sensitive areas that are often missed like ears and the back of necks. When possible try to find shade and always provide shade for children. Children are particularly vulnerable to sunburns and burns they get today can be the underlying cause of skin cancers they may develop in adulthood.

Sunscreens are great for helping to reduce the impact of the harmful effects of the sun’s UVA and UVB rays but they are vastly limited. The key to successful sunscreen use it to use one with at least a SPF 30 which will block UVB rays which cause you to burn. An SPF 30 product will block 97% of UVB, however that does not mean that SPF 60 blocks twice as much or last twice as long. All sunscreen needs to be reapplied at least every two hours and more often is you sweat or get wet. It is best to apply sunscreen 30 minutes before sun exposure. SPF ratings have no impact on the sun’s UVA rays which can be even more damaging. These are the rays that don’t cause your skin to burn but rather reach into the deeper layers of your skin and can cause more long term damage like wrinkles and skin cancer.  So when looking for sunscreen be sure to look for ones that also protect against UVA damage. Sunscreen makers can use both chemicals and barrier type compounds to protect against UVA. Some makers use zinc oxide and titanium to block UVA while others include chemicals like Parsol 1789 and Mexoryl. Another key to using sunscreen successfully is to use adequate amounts. You should apply 1 ounce of sunscreen during every application. It’s estimated that most people apply far less and many do not reapply appropriately. Remember sunscreen is only as effective as it is properly used.

Hopefully you will heed the advice and try to limit overexposure to the sun’s harmful rays. Everyone wants to be able to enjoy the great outdoors and all it has to offer. Just be prudent when spending your time outside and your skin will thank you today and in the years to come.

 

Folate Facts March 2012

We can all recount our mothers’ admonition to eat all our fruits and vegetables. Truth is, mom was certainly on to something. A diet laden with fruits and vegetables can ensure that we get the proper nutrients to keep our bodies strong and prevent disease. Unfortunately, the typical American diet of highly processed foods does not always include the proper amounts of key vitamins and minerals needed to sustain good health. As an obstetrician, I am particularly concerned about the diets and nutritional health of young women in their child-bearing years.  Eating foods rich in iron, calcium and folic acid can help get a woman maintain optimum health now and help secure good health in the future.  In the case of folic acid or folate, that future might be that of her unborn child.

Folate is found naturally in foods such as liver, beans and legumes , leafy green vegetables and citrus fruits. A diet which includes healthy portions of romaine lettuce, spinach, asparagus, broccoli, cauliflower, beets and lentils will give you a good amount of folate which is a water-soluble B vitamin .  Folate is instrumental in helping the body synthesize and repair DNA. It is also used by the body to produce red blood cells, aid with rapid cell division and growth and helps to prevent anemia.  All of these are especially important during pregnancy, particularly during the first 28 days when the fetus is developing key neurological structures.  Folic acid is a synthetic compound that is used in vitamin supplements and fortified foods.  Since its discovery in 1931, folate has long been recognized as an important component to diets and most developed countries have instituted fortifying foods with folic acid to help improve the nutritional needs of their citizens.  It is easy to find many products that will include folic acid as an added ingredient including cereals, breads, and juices among others.

Numerous studies have shown that proper amounts of folate help minimize several complications of pregnancy including miscarriages and neural tube birth defects, such as spina bifida and anencephaly.  Anencephaly is a defect where a child is born without parts of the brain and skull and infant death usually occurs shortly after birth. Spina bifida is a defect in the formation of the spinal column and can affect the spinal cord and nerves. Babies born with this defect can have a wide range of symptoms including physical and mental disabilities. Some born with spina bifida will only have mild symptoms while others may have more severe symptoms like paralysis and neurological deficiency. Clinical trials have also concluded that folic acid intake may also decrease the incidence of other birth defects related to heart, urinary tract, orofacial (cleft lip and palate) and limbs. Further studies are necessary to replicate and substantiate these findings. In an effort to reduce the risks of these birth defects, all women in their child bearing years are highly encouraged to increase their folate levels through diet and supplements.  While some women will meet or exceed the Recommended Dietary Allowance (RDA) of 400 mcg per day with foods in their diets, many will not. The U.S. Food and Drug Administration mandated in 1996 that folic acid be introduced to grains and cereal products and food labeling will show folate as a percentage of daily value or DV.  So for instance, some healthy cereals actually provide 400 mcg of folic acid per serving and the label will indicated that the DV value for folic acid is 100%.

If label reading and keeping track of all your nutritional DVs is not for you; taking a multi-vitamin which includes a minimum of 400mcg or 0.4milligrams (mg) is a great way to ensure that you are getting the essential folic acid your body needs. Vitamin makers have become very proficient at marketing vitamins to particular consumers based on gender, age, and health needs.  Choosing a multi-vitamin formulated specifically for women will most likely include the recommended minimum. The important message is for all girls and women to have 400 mcg of folate daily through diet or supplements to minimize the risks of having a pregnancy that could result in a birth defect.  It is estimated that around 50 percent of pregnancies are unplanned so even women who are not actively trying to become pregnant should be getting folate.

Some women may need to have additional amounts of folate in their diet depending on their health and pregnancy history. Consulting with your healthcare provider is the best way to find out if your personal needs may be different from the average recommendation.  For instance, women on certain medications like certain antibiotics should not take folic acid as it may interfere with the absorption and efficacy of the medication. Similarly, some medications may interfere with the proper absorption of folic acid and dosage may need to be adjusted.  Women who have medical conditions which may compromise their ability to absorb nutrients will also require different recommendations.

The exciting news about folate is that it is now being studied to see if it can help with a myriad of medical conditions including heart disease, cancer prevention, Alzheimer’s disease and hearing loss among others. Every day, we learn more about how vitamins and minerals help improve health.  However it is important to always be prudent about medications and supplements. Check with your healthcare provider if you have any questions or concerns about what is right for you.

 

Super Bones Diet Guidelines
Choosing foods that help prevent Osteoporosis January 2012

Osteoporosis is a disease of the bones; it literally means “porous bones.” Our bones are strong throughout our 20s and reach their maximum strength at age 30. By the time we go through menopause, whether it is early or around the average age of 50, our bones start to thin at a faster rate. There are many ways to help put on the brakes. One of the best ways is through our diet. There are certain foods that can help increase our bone thickness at any age.

The cornerstone of strong bones is calcium. Every woman should get 1,000 milligrams per day through age 50. Once they turn 51, they will need to get 1,200 milligrams every day. Milk is the best source of calcium: a single eight-ounce cup of milk has 300 milligrams on its own. However, there are many people who do not drink milk at all. In this case, a cup of yogurt has just as much calcium as a glass of milk. Also one ounce of Swiss cheese has nearly as much calcium as both yogurt and milk. Many people avoid yogurt and cheese due to being lactose intolerant, but swiss cheese is actually very low in lactose. There are also products available that are completely lactose-free.

If milk and dairy products are not in your diet, there are other ways of getting calcium, such as orange juice fortified with calcium. One serving has up to 240 milligrams of calcium. Breakfast cereal may contain as much as 1,000 milligrams of calcium in each serving. Another excellent source of calcium is sardines. Eating three ounces of canned sardines delivers a little more calcium than a cup of milk. Salmon is another fish that is high in calcium. This fish not only contains calcium, but another important vitamin for your bones, Vitamin D. Vitamin D is best thought of as the key that allows the Calcium to get into your bones. Every woman should have at least 600 IU of Vitamin D per day.

For those women who are not fish eaters, you might be surprised to discover that many vegetables offer a good source of calcium. These vegetables are of the dark, leafy, and green variety. Examples of these are Chinese cabbage, kale, bok choy, collards, and turnip greens. One cup of these vegetables contain 200 milligrams of calcium. Tofu is another great source of calcium. A half of a cup contains as much as 861 milligrams.
If dairy and fish are not in your diet, supplements are an easy way to boost your calcium intake. To get the most bang for your buck, you should not take more than 500 milligrams at one time. This usually is equivalent to 1 pill. In order to get the daily 1,200 milligrams, you should take one pill in the morning and one pill in the evening. Many calcium supplements are better absorbed when taken with food.

The last item on the list for super bones is performing regular weight-bearing exercises. I know that this is not a food but it is equally important. This includes any activity that uses your own weight or outside weights as resistance; such as walking, running, dancing, tennis, weight lifting, and yoga. These activities allow your bones to actually create more bone material, which increases your bone strength. So think twice when you are at the grocery store or eating at a restaurant and choose the foods that will help keep your bones nice and strong. If you add regular exercise to a healthy diet, you can help prevent osteoporosis and its impact on your health.

 

National Breast Cancer Awareness Month October 2011

October 2011 will mark the 25th anniversary of the National Breast Cancer Awareness Month organization.  Over the past quarter of a century, millions of organizations, companies, healthcare providers, patients, cancer survivors and supporters have raised funds and most importantly awareness about breast cancer. A great deal has changed over these last 25 years. Mammography has improved to detect even earlier cases of breast cancer when treatments can lead to higher survival rates.

All those pink ribbons help to raise much needed research funds and critical awareness about the benefits of early detection and possible risk factors that may increase your chance of developing breast cancer. Knowledge is powerful and when women know what their risk factors are they can be proactive about ensuring they stay as healthy as possible. A risk factor is simply a condition or set of conditions that may increase your likelihood of acquiring a disease. Risk factors do not mean that you will get breast cancer and most women who get breast cancer have no known risk factors.

Some women are at higher risk than others of developing breast cancer in their life time. Women who have had a previous breast cancer are at higher risk of developing a subsequent breast cancer. All women are at increased risk of developing breast cancer as they age and the majority of breast cancers occur in women over the age of 50.  Family history, heritage, race and genetics all are factors that may increase a woman’s chance of developing breast cancer. Obesity and alcohol consumption can be a risk factor. Environmental factors like exposures to radiation and hormones can also increase the risk of getting breast cancer. There are many excellent resources to find out more in depth information about what your risk factors might be, including the American Cancer Society’s website: www.cancer.org.

Women who find that they are among the highest risk factor group may want to discuss with their health care provider the topic of chemoprevention for breast cancer. Over the last several years, a few medications that have historically been used in the treatment of breast cancer are now being investigated for their possible preventative qualities. These drugs fall into a few different categories and work in unique ways to lower breast cancer risk. Tamoxifen and raloxifene are called selective estrogen-receptor modulators or SERMs and as the name suggests, modulates or interferes with the estrogen in the body. Researchers believe that estrogen can stimulate the growth of breast cancer cells. Both of these drugs are used to treat specific types of breast cancers which are estrogen receptor positive. Tamoxifen has been studied for several decades and has been shown to reduce the incidence of estrogen-receptor positive cancers by as much as 48% in women who took it as a preventive therapy. However, as with any medication, there are known side effects, some of which are significant. Women taking tamoxifen are at increased risk of developing some gynecological cancers and major blood clots. Raloxifene works similarly to tamoxifene in interrupting the estrogen path that is critical for the growth of certain breast cancers. Raloxifene is a newer drug and has not been shown to be associated with the gynecological cancers but so far does not seem to have the same success rate as tamoxifene. Raloxifene also increases the risk of significant blood clots which can become life threatening.

The Federal Drug Administration has approved both tamoxifene and raloxifene for use as a medication to reduce breast cancer based on evidence from various studies conducted over many years. Women with an elevated risk of breast cancer need to work closely with their health care providers to calculate both their risk factors for breast cancer as well as their likelihood of developing health conditions from the side effects of these potent medications. Your health care provider will use many indices to determine your risk/benefit analysis including age, menopausal status, gynecological history and health including your Body Mass Index. Not all women with a high breast cancer risk will be good candidates for either drug.

Just as SERMs have changed how breast cancer is treated and prevented, newer drugs called aromatase inhibitors, such as exemestane, letrozole and anastrozole are currently being used to treat breast cancer and are being studied for possible chemoprevention uses. These drugs work to stop aromatase which is an enzyme used by the body to convert other hormones into estrogen. Early studies show that these agents may have less detrimental sides effect like gynecological cancers and blood clots. Currently these drugs are just used as chemotherapy following surgery for breast cancer and the FDA is awaiting results from a couple of studies to decide whether they will be approved for chemoprevention use.

Americans are well acquainted with chemoprevention. Think of the millions who are prescribed hypertension medicines or cholesterol lowering medications to prevent the chance of having a heart attack or stroke. We have long known what causes cardiovascular disease and have prescribed medicines to help minimize an eventual event. Thanks to many Octobers of fund raising and research, we now have better ideas about what might cause some types of breast cancer and can prescribe medications that just might prevent this disease too.


Asthma In Pregnancy August 2010

Asthma is one of the most common conditions that can complicate a pregnancy. It complicates 8 percent of pregnancies. Asthma is a lung condition that includes a myriad of symptoms including shortness of breath, persistent cough, wheezing and tightness in the chest. Symptoms can be mild to severe and can occur intermittently or up to several times per day. Breathing is difficult because of swelling to the airways in the lungs, secretion of mucus or muscle spasms of airways.

Proper diagnosis of asthma in pregnancy is critical for appropriate treatment. Left untreated, asthma can lead to complications in pregnancy including premature birth and low birth weight and all the problems that accompany premature delivery including life long disabilities.

Women who are asthmatic before pregnancy should consult with their health care provider to discuss their current asthma treatment plan and how the demands of pregnancy may alter both their asthma and treatment. Statistics show that about one third of women with asthma will actually have less asthma symptoms in pregnancy, while a third will experience no change in symptoms and the final third will experience worsening of symptoms. Understanding the nature of your asthma before you become pregnant will greatly reduce the problems that may arise in pregnancy.

Asthma sufferers are well acquainted with "triggers" for an asthma attack. Nearly 70 percent of asthma patients also are allergic to many common allergens in the environment including pollen, dust mites, animal dander, and mold, among others. Avoiding these contaminants can spare many asthmatics an attack. Women who have more severe allergies may receive allergy shots on a routine basis. Pregnant women may continue getting their allergy shots if their regimen was started before they became pregnant. However it is not advisable for pregnant women to begin allergy shots for the first time during pregnancy because of the slight risk of anaphylaxis, which is a serious allergic reaction.

Besides common allergens, many asthma patients will find that their condition is exacerbated by other factors like smoke, air pollution, infections, and cold air. Obviously asthmatics and pregnant women should not smoke tobacco and should try to avoid second-hand smoke and other air pollutants. During flu season, asthmatic women should receive a flu shot to avoid illness which may worsen asthma symptoms. Exercise during pregnancy is encouraged to stay healthy and avoid excessive weight gain. Pregnant women with asthma should consult with their health care provider to see if they should take asthma medication before exercising to prevent worsening of their symptoms.

Pregnant women are encouraged to take the appropriate amounts of asthma medications that relieve their symptoms. Pregnant women should never stop taking previously prescribed asthma medication for fear of risk to the fetus. Experts agree that the greatest risk to baby is for a woman to not get adequate oxygen during pregnancy. While many women worry that their medications can harm their unborn baby, most specialists agree that poorly controlled asthma is a much greater risk than the risk of taking medication for asthma. Medications traditionally prescribed for asthma should be continued during pregnancy including inhalers and bronchodilator sprays like albuterol. This medication is known as a rescue medication because it is quick acting and is used to open airways; generally this medicine is used on an as needed basis. Asthma patients with more persistent symptoms may need steroid medications like budesonide (brand name Advair), salmeterol (brand name Serevent) or prednisone which are used in various strengths and doses to keep symptoms at bay. Some of these medicines are inhaled and others are taken orally.

Your health care provider will be able to monitor and adjust medications as needed throughout your pregnancy by regularly monitoring lung function with physical exam and sometimes with a hand held machine called a peak flow meter. Often times, care for pregnant women with asthma is shared between an obstetrical provider and an asthma specialist. Evaluating your pulmonary function on a regular basis will help your health care provider make adjustments to your medications. Always be sure to let your provider know if you experience an improvement or worsening of symptoms. Pregnant women with asthma who experience mild symptoms and are well controlled with medication will require routine monitoring. However pregnant women with more severe asthma and those whose symptoms are not well controlled will require more monitoring to follow the development of their fetus. Ultrasounds are routine in pregnancy but asthmatics usually need additional ultrasounds particularly after 32 weeks of pregnancy to monitor fetal well being and growth. Fetal heart rate testing also known as a non-stress test may be required on a scheduled basis.

Asthma therapy in pregnancy is important and improves the odds of having a healthy pregnancy. Therapy is most successful when the pregnant woman follows the treatment plan closely and receives regular medical care. Pregnant women with asthma can breathe a sigh of relief that with close monitoring by a qualified medical professional, they can enjoy a healthy and successful pregnancy.

Staying Healthy During Pregnancy July 2010

The announcement of a first time pregnancy is often followed with a barrage of questions about what is safe and healthy for a women's growing fetus. Most women are aware that drinking alcohol and smoking should definitely be halted during pregnancy. There are several other caveats that should be heeded while pregnant. Pregnant women should avoid certain foods and preparation methods. Likewise, certain chemicals and medications should also be avoided. Additionally pregnant women should avoid certain activities throughout their pregnancy.

Your obstetrician or health care provider will give you a thorough idea of what he or she thinks is best to avoid during your pregnancy. Many providers will discuss these issues when you come for one of your first trimester visits and some may provide printed materials to refer to if you have questions.

Many studies have shown the adverse affects of alcohol on the growing fetus and health warnings are provided on many alcoholic beverages. Alcohol has been associated with several complications of pregnancy including low birth weight, premature births, and delayed mental development of the fetus. Similarly cigarette smoking has been associated with low birth weight. Besides compromising a women's health, illicit drugs also can be endanger the health of a developing fetus. If you have a problem eliminating alcohol, smoking or other unhealthy behaviors while pregnant, immediately consult your health care provider who can offer advice about cessation programs preferably before you become pregnant.

Less harmful chemicals like caffeine and artificial sweeteners may also affect your fetus. Often these substances are not well studied in pregnancy so many health care providers will advise moderation. One or two caffeinated beverages per day will probably not cause any ill effects and limited use of artificial sweetener is also a good idea. Herbal products and supplements should also be eliminated as some herbs can be harmful in pregnancy. Always consult with your health care provider before taking any herbal or homeopathic agents.

Certain foods should be avoided during pregnancy as they may be harmful to pregnant women and their fetuses. Women should avoid unpastuerized dairy products including cheeses like feta, blue-veined, and certain Mexican styles cheeses. These products can cause listeriosis which can cause premature birth, miscarriage and serious health problems for newborns. Pregnant women should only eat deli meat and hotdogs which have been thoroughly cooked. Raw fish, like sushi, and raw shellfish should also be avoided because these foods may contain parasites or bacteria which could be harmful to mother and baby. Even cooked fish should be eaten with caution as many of the larger body fish like tuna, swordfish, mackerel and tilefish may contain high levels of mercury which has been shown to be harmful to a fetus in high doses. These types of fish should be avoided however other smaller fish, like flounder, tilapia, and salmon among others are safe to eat during pregnancy. If you have any dietary concerns, be sure to discuss them with your health care provider.

We know that most things a pregnant woman ingests can cross over the placenta and affect the fetus that's why it's important to carefully monitor the foods, beverages and medications you take. Typically your health care provider will let you know what he or she feels comfortable with you taking during pregnancy. Acetaminophen such as Tylenol and antacids like Tums are usually safe to take in moderation but if you have a need to take these medications frequently make your provider aware. Certain medications will be stopped during pregnancy because of their known side effects in pregnancy. These medications include but are not limited to: Accutane and Tetracycline which are used for acne, ace inhibitors like Lisinopril which is an anti-hypertensive medication, and Coumadin which is a blood thinner. It is always best to disclose all medications you are taking including prescription, over-the-counter, supplements and homeopathic agents. It is also important to continue taking prescribed medications for underlying health conditions like diabetes, hypertension, and depression among others. Your health care provider will advise you about what to take and any substitutions that may be necessary. Women should also avoid certain environmental situations. Generally speaking, pregnant women should avoid having x-rays unless the mother's health is at risk. Chemical exposure to hair dyes and phthalates which are found in nail polish remover, skin care products and air fresheners have recently received attention, however with the exception of one very small study there is no evidence that exposure to these agents is harmful to a fetus. Likewise there is no study to support that these agents are safe for fetuses. Therefore many women feel better avoiding these agents particularly in the first trimester. Pregnant women should also avoid toxoplasmosis which is an infection caused by a parasite called toxoplasmosis gondii. Toxoplasmosis is spread several ways including through cat feces and food borne pathways. It is important for pregnant women to take precautions. Pregnant women should not clean cat litter boxes. They should also wash hands after gardening. Food preparation should include thoroughly washing fruits and vegetables before eating and eliminating under-cooked or raw meats from your diet. Infants exposed to toxoplasmosis may not exhibit signs initially but may suffer from mental retardation and blindness later in life.

Pregnancy does not have to change your lifestyle drastically. Modifying your diet and behaviors will give you the piece of mind that you are doing everything to ensure the safety of your baby. Pregnancy can be a time to alter your diet for the better, eliminate some unhealthy habits like smoking and enjoy the best health of your life.

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Pregnancy Over Thirty-Five

Over the generations, many women have decided that delaying pregnancy and childbearing is a good decision for them. Some will pursue educational and career advancements that make marriage and family come later than was traditional several decades ago. Putting off pregnancy until your thirties or even forties is now commonplace and can result in healthy pregnancies. However, women who delay having a child need to consider several factors.

Women who are healthy can expect to enjoy a healthy pregnancy but should know that age does raise risk factors during pregnancy including the success rate of becoming pregnant. As women age, their fertility declines. Women over thirty-five who have tried to become pregnant for six months without success should seek medical advice because of the increased risk of infertility. In fact pre-conception counseling is always a good idea for all women considering pregnancy but is especially important for women over thirty-five.

Women over thirty-five who conceive are at increased risk of developing several conditions throughout their pregnancy including hypertension and gestational diabetes. Older mothers are also more likely to conceive multiples like twins or even higher numbers of infants which increases the risk of that pregnancy. Miscarriages and genetic disorders are also more common in women over thirty-five. Pregnant women in their thirties and forties are also more likely to experience placenta previa, where the placenta attaches to the lower part of the uterine wall and can partially or completely cover the cervix. Placenta previa can complicate delivery. Women over thirty-five are also more likely to have a cesarean birth.

Good prenatal care is essential for every pregnant woman but is even more critical for an older mom who may already have an underlying medical condition like hypertension or type II diabetes that comes with age. Women who are on medications for certain health conditions may require closer monitoring. Ultrasounds are routine for most pregnancies but pregnant women over thirty-five may need more done throughout her pregnancy.

Additional testing such as an amniocentesis may be recommended to women over thirty-five to test for chromosomal abnormalities like Downs syndrome. Downs syndrome is the most common chromosomal birth defect and the risk increases with age; a mother at twenty-five has a 1 in 1,250 change of conceiving a child with Downs, at thirty-five the chances increased to 1 in 385, and at age forty, the chance is 1 in 100. Mothers over thirty-five may also require genetic counseling because other births defects may increase with age.

Besides the increase risk for baby, mothers over thirty-five are at increased risk of experiencing any one or several of the following complications of pregnancy including: gestational diabetes, hypertension in pregnancy or pre-eclampsia, placental previa, premature birth and increase risk of stillbirth. Pregnant women over thirty-five are twice as likely to develop gestational diabetes as there younger counterparts. Gestational diabetes is usually temporary diabetes that you first acquire during pregnancy. Babies born to diabetic moms tend to be larger and may suffer from complicated births. Diabetes in pregnancy can be closely monitored to reduce risks for both mother and baby.

Pregnancy-induced high blood pressure or hypertension in pregnancy is also more common in women over thirty-five and can complicate both pregnancy and delivery. Pre-eclampsia is the most severe form of hypertension and can be life threatening so your health care provider will be very diligent in monitoring your blood pressure during pregnancy.

Qualified health care providers can usually address all the increased risk associated with advance maternal age. In some instances, women over thirty-five may have to be seen by a high risk specialist if they are experiencing certain high risk conditions. Usually women are referred to these specialists by their obstetrician and may work in concert with them to deliver specialized care.

Starting a family over the age of thirty-five is a trend that is probably going to continue as women take full advantage of educational and career opportunities afforded to them. In fact, 1 in 5 women in the United States has her first child after age thirty-five.

Good prenatal care is the key to any successful pregnancy but is essential for the older mom to be. Close monitoring by a qualified health care provider can help ensure a positive outcome for both mom and baby.

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Polycystic Ovarian Syndrome

Polycystic ovarian syndrome or PCOS for short is the most common hormonal condition in women of child-bearing age. It is also the most common cause of infertility and affects 5-10% of all women. Recognizing the signs and symptoms of PCOS and understanding its causes and treatments can help women more fully understand their choices should they suffer from this relatively common disorder.

Polycystic ovarian syndrome, as the name suggest, is not just one condition but rather a constellation of symptoms which together can be categorized as a syndrome. Women with PCOS will have several if not all of the following symptoms:

• Menstrual irregularities caused by a hormonal imbalance which causes erratic ovulation.
• Excessive production of male hormones or androgens. Testosterone is the most common. Too much androgen in a woman's body can lead to unwanted facial and body hair in a male distribution.
• Polycystic ovaries that can be diagnosed with pelvic ultrasound.

PCOS is thought to be caused by a signaling disorder at the cellular level.

Women's bodies with PCOS become less sensitive to insulin thereby causing the body to produce more insulin so the signal to the cells is stronger. This higher level of insulin acts on the ovaries to produce more androgens or male hormones. A medication such as Metformin, a diabetic medication, can improve insulin resistance and may be recommended for some women with PCOS. More androgen can lead to androgen side effects such as acne, excess facial and body hair and male patterned baldness. The excess insulin is thought to encourage weight gain which overtime can lead to obesity.

Diagnosing PCOS can be confusing because no one test can determine PCOS. The diagnosis is made with a gynecological exam, laboratory tests and a pelvic ultrasound. A physician or healthcare provider can guide women with symptoms of PCOS to the right diagnosis.

Women with PCOS need specialized treatment and follow-up. PCOS can lead to obesity, high blood pressure, diabetes and elevated cholesterol. Women with PCOS can prevent these late consequences of PCOS with medication and lifestyle changes. Particular attention should be paid to diet and exercise for women with PCOS, as healthy weight control can help stave off some of these more troublesome side effects. Additionally, irregular menstrual cycles associated with PCOS, can lead to uterine cancer. Therefore women with PCOS should receive routine gynecological care to monitor their health.

Treatment of polycystic ovarian syndrome can begin after a firm diagnosis is made. Confirming a diagnosis includes ruling out other possible causes of symptoms. Once made, treatment will vary according to a woman's age and severity of symptoms. Most women in their reproductive years will need medication to correct the hormone imbalance. Many women choose the birth control pill to regulate their menstrual cycles. Birth control pills decrease androgens which usually improve acne and decreases excess facial hair when present and regulate menstrual cycles. Women attempting pregnancy may need fertility medication to cause the ovary to ovulate or release an egg on a more regular basis. Weight loss in obese women with PCOS is associated with improved fertility.

After menstrual cycles are regulated, it is extremely important for women with PCOS to exercise regularly and eat a well-balanced diet. Women who are already overweight when PCOS is diagnosed will be encouraged to lose weight to lessen worsening of symptoms.

PCOS can be a confusing disorder that can affect many aspects of a woman's life. However women with PCOS in collaboration with their doctor or health care provider can make a plan to chart a course for a healthier life.

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Oocyte Preservation "Egg Freezing"

Over the course of the last fifty years, women's reproductive lives have changed dramatically. The advent of the birth control pill in the early 1960's, gave women greater freedom to choice if and when they might become pregnant. It was a great departure from the previous methods of contraception available up until then because it chiefly gave women, themselves, control over the time and number of pregnancies they would have.

Fast forward three decades and a new scientific advance is promising to take women to a new frontier of reproductive freedom. Oocyte cryopreservation or egg freezing is being touted as the latest opportunity for women to have control over their reproductive lives.

Companies are springing up all over the country offering a woman the chance to preserve her fertility until she is ready to embark into motherhood. Women hoping to beat the proverbial "biological clock" should thoroughly understand what this new technology is all about.

Egg freezing began back in the late 1980's and the first report of a successful pregnancy from a frozen egg was in 1986 as reported in the journal Lancet. Since that time, this technology has been mostly employed to help preserve eggs from women with particular health problems and diseases, most notably women who are going to undergo chemotherapy or radiation treatments for cancer. Many chemotherapy treatments have the potential of destroying eggs in a woman's ovaries. Some younger women may choose to have eggs extracted before treatment begins, so that she may conceive through in vitro fertilization following her cancer treatments. Egg freezing can also be beneficial for women who are at risk of undergoing early menopause; eggs can be extracted in the event that menopause begins before they are ready for pregnancy. A third category is women who are infertile and could benefit from IVF but may object to freezing embryos for either ethical or religious beliefs. Only recently has the notion of oocyte cryopreservation been introduced as way to delay pregnancy for personal or social reasons. Advances in the technology are probably the biggest reason for the promotion and commercialization of egg freezing.

Egg freezing begins by extracting eggs from a woman's ovaries after she has undergone several weeks of hormone injections. These series of hormones stimulate the ovaries to produce eggs. Once the eggs mature, they are extracted and frozen. Unlike, sperm cells which are small and easily frozen, eggs are relatively large cells and are made of a significant percentage of water. It is the water content that makes freezing particularly tricky. Ice crystals can form, compromising the integrity of the cell. Traditional methods include dehydrating the cell and introducing a cryprotectant which can help minimize the formation of ice crystals. Eggs are then frozen using a controlled rate and slow freezing method which gradually reduces temperature with liquid nitrogen.

A newer freezing method called vitrification or ultrarapid freezing involves freezing eggs rapidly by immersing the collection vial directly into liquid nitrogen in almost a "flash-freezing" technique. Vitrification is so rapid that ice crystals do not have time to form. This new process is reported to yield far better results with approximately 10 babies born for every 100 eggs preserved. The controlled and slow freezing method yields are far less with 1 birth per 100 eggs. While these rates sound very impressive, the real numbers to date are less substantial. To date, only two hundred babies have been born using previously frozen eggs. Dr.Raffaella Fabbri of Bologna Italy is a leader in the field of oocyte cryopreservation and is responsible for seventy of these world-wide births. This relative low number has made it difficult to quantify other statistics regarding the health of babies born from previously frozen eggs. The rate of birth defects among children conceived the old fashion way is comparable to rates for children conceived through assisted reproductive technology or ART which includes in vitro fertilization, oocyte cryopreservation and other assisted methods.

All of this technology, of course, comes with a price tag which may be significant to many. The total cost from egg retrieval through the embryo transfer can range anywhere from $12,000 to $20,000. The annual cost of storing eggs usually runs around $200.

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Forty and Healthy

Well before your AARP card comes in the mail, a woman in her forties should begin to take a good look at her health care needs. Most women spend a huge investment of time and care in monitoring and maintaining the health of their families. Whether its children, spouses or parents; women have developed great skill at attending to the needs of others before themselves. Your forties is a great time to evaluate where you are health-wise and start preparing for a healthy future. Your health care provider is a great resource for helping you assess your current health picture and letting you know what tests are appropriate for your forth decade.

Forty is also a great age to begin changing some unhealthy habits you were able to "get away with" in your twenties and thirties. It's also a good time to cultivate healthy new habits like better nutrition and getting proper amounts of exercise into your life. A good first step is to make an appointment for a complete physical. Many women see their health care provider often during their twenties and thirties as they explore birth control options or receive obstetrical care. Some women feel that after their reproductive years are over that they really don't need annual healthcare. However, your medical visits are just as important after your childbearing years.

As we age, gynecological health changes and other health concerns begin to develop. For instance, diabetes and hypertension begin to develop for some women in their forties and early detection is paramount to maintaining good health. Likewise, high cholesterol becomes more prevalent as we age. Additionally, it is easier to gain weight as we enter our forties because our metabolism begins to slow.

Health care providers will check your blood pressure, weight, blood sugar, and cholesterol profile. Breast exam and pelvic exam, along with a check for moles and other skin irregularities are also part of a routine health exam. Many providers will also recommend follow up with an ophthalmologist to check for common eyes problems that can develop as we age including glaucoma and other eye diseases. Routine gynecological check ups will include a Pap test to screen for and prevent cervical cancer. Some providers will also recommend an HIV test depending on sexual history. Breast exams by a provider check for cancer and a mammogram is first performed when a woman turns forty. Women who are genetically predisposed to certain conditions such as breast and ovarian cancers will need to be assessed and screened earlier than forty. Changes in menstrual cycles during your forties can be an indicator of perimenopause which is the time when the ovaries gradually start to produce less estrogen. Sometime perimenopause can be associated with irregular periods, decreased sex drive, mood swings, difficulty with sleep and other symptoms usually linked with menopause. Your health care provider can discuss these symptoms with you and offer suggestions for handling them.

Besides the gynecological exam, health care providers can order blood tests that let you and them know critical details about your overall health including your cardiac health. A lipid profile includes testing blood for high density lipoprotein or HDL-C and low density lipoprotein or LDL-C and triglycerides. This test is often done following a fast to ensure accurate results. Total cholesterol optimally should be under 200 and not greater than 240.LDL should be less than 100 and not greater than 160 while HDL cholesterol should be greater than 60 and not less than 35. Triglycerides should be less than 150 and not greater than 200.Sometimes dietary changes and increasing exercise can help get your cholesterol numbers where they should be. Cholesterol lowering medications like statins can be prescribed to help with your lifestyle changes to bring cholesterol to an acceptable level.

Blood pressure is another factor that your health care provider can monitor to make sure that you stay heart healthy. As we age, blood pressure usually increases. Lifestyle choices like smoking and caffeine intake may affect blood pressure as will extra weight and the onset of menopause. Women with a family history of high blood pressure may also be prone to hypertension.

Your health care provider can counsel you on how to manage your blood pressure with dietary choices and exercise regimens. Medications can also help you achieve an acceptable blood pressure. Finally your provider will want to test you for diabetes or prediabetes. Several different tests can be offered including fasting plasma glucose (FPG) or an oral glucose tolerance test (OGTT) or a random plasma glucose test. Both the FPG and OGTT can be used to detect both prediabetes and diabetes. If you are symptom free, most providers will begin routine testing at age 45 unless you have certain risk factors to include: family history, being physically inactive, history of gestational diabetes (during pregnancy), polycystic ovary syndrome, or have symptoms of cardiovascular disease like hypertension, high cholesterol, or obesity. In the case of any risk factors, your health care provider may want to test for diabetes well before forty. Additionally if you exhibit any common symptoms of diabetes like increased thirst and urination, fatigue, increased hunger, blurred vision, unexplained weight loss or wounds that will not heal easily, testing will be done immediately.

As young adults, good health can be taken for granted but as we age we need to be more deliberate in thinking about maintaining good health. Proper diet and exercise become more important as we enter our forties. Routine physical exams can help us monitor where we are and what we need to do to ensure we stay healthy for many more years to come.

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Adenomyosis is a Common Condition in Women Occurring Later in Their Childbearing Years - March '09

Adenomyosis is a common condition in women occurring later in their childbearing years. Around 60% of women over 30 may have adenomyosis but many never suffer from any symptoms. For those who do, treatment with medications and or surgery is available. Adenomyosis is a thickening of the uterine lining which occurs when endometrial tissue moves to the outer muscular walls of the uterus. Endometriosis is a different condition where endometrial tissue becomes implanted outside of the uterus. However many women who suffer from adenomyosis also have endometriosis and many of the symptoms are similar.

The most typical symptoms of adenomyosis include heavy or prolonged menstrual bleeding sometimes with clots, painful periods (dysmenorrhea), cramping throughout menstruation, painful intercourse, and bleeding between periods. The uterus may also be enlarged or tender. Although some women may suffer from all of these symptoms, others will only have a few and still others may experience no symptoms at all. Treatments will vary depending on the symptoms that are present.

Experts are not certain about the exact cause of adenomyosis but there are several theories. Some think endometrial cells invade the muscles of the uterine wall particularly during uterine surgery like a caesarian section. Still others believe that adenomyosis begins in utero when the uterine lining is being formed and there occurs an overlap of the myometrium (uterine wall) and the endometrial tissue. Some experts speculate that adenomyosis involves postpartum (after childbirth) inflammation of the endometrium that may break down the normal boundaries of the uterus and its muscle walls.

Further research may one day resolve these various explanations but all are in agreement that estrogen in a woman's body will affect the growth of adenomyosis which is why it is most often resolved following the decrease of estrogen during menopause. A woman's proximity to menopause will be considered in treatment methods. Women with adenomyosis will be diagnosed through evaluation of their symptoms. Health care providers may also order several tests to confirm a diagnosis including a pelvic exam to feel for tenderness or enlargement of the uterus. Your provider may also order an ultrasound and or MRI (magnetic resonance imaging) of the uterus. In some instances, a biopsy of the uterine lining may also be done to rule out any other cause for the abnormal bleeding. A biopsy is a tool to rule out other conditions but will not confirm a diagnosis of adenomyosis. The only conclusive test for adenomyosis is examination of the endometrium after a hysterectomy has been preformed.

Hysterectomy is the definitive cure for adenomyosis but is by no means the only treatment for the condition. Treatments options include use of anti-inflammatory drugs like ibuprofen which may lessen pain and decrease blood flow during menstruation. Additionally, hormone therapies like the birth control pills, IUDs, patches and vaginal rings which contain either estrogen, progestin or both may be used to lessen menstrual symptoms which can affect adenomyosis. Which treatment option is right for you will depend on several factors, including the severity of your symptoms, your age and menopause status and your risk factors for surgery or medication options.

While adenomyosis is not the easiest gynecological condition to diagnose, it is usually very treatable and most women have complete resolution of their symptoms from the treatment options available. Seek advice from your health care professional if you suffer from any of these troubling symptoms.

Prenatal Genetic Screening: The Next Chapter? - February 09

Currently the most common treatment for a child with sickle-cell anemia is frequent blood transfusions. Sickle-cell anemia is a genetic disorder in which the blood cells are sickle, or C-shaped, rather than disc-shaped. The abnormal shape of the blood cells causes them to move poorly through the blood vessels. They are stiffer than normal blood cells and their shape causes them to clump together, blocking blood flow. Although transfusions are effective, they are painful and are merely a treatment to this disease, not a cure. Bone marrow transplants are the ideal cure for this disease; however it is very rare to find a perfect transplant match for the patient.

By combining the recent technologies of preimplantation genetic screening and directed cord blood banking, there is now a greater chance of finding a suitable transplant match for a child suffering from sickle-cell anemia, or other genetic disorders.

Cord blood is the blood found in the umbilical cord and the placenta that remains after delivery. This blood contains stem cells that are genetically matched to your child.

Stem cells are cells that can transform into different types of cells that grow and develop inside the body. These cells are often used in treatment of leukemia and other genetic disorders. Cord blood stem cells work similarly in treating conditions as a bone marrow transplant; however, there is a lower chance of rejection.

After delivery, the cord blood can be easily collected either with a syringe or through draining the blood from the umbilical cord into a bag. Both methods are safe and painless. Once the blood is collected it is simply stored in a cord blood bank, and can be accessed if your child, or a sibling, is ever affected by a disorder. The use of cord blood is especially effective because it is an exact match to your child's DNA. It is much easier to use the child's own blood than to find a match from another person. Unfortunately, if a child has a genetic disorder, their cord blood will also be affected by the disease and will be unable to be used.

Preimplantation genetic screening is the process of screening embryos before implanting them after in vitro fertilization. During in vitro fertilization, sperm and egg are combined in a laboratory to create an embryo that is implanted into the uterus of the woman. Generally during in vitro fertilization, several embryos are created and the most viable embryos are selected to be implanted. Each of these embryos is screened, and this technology has been able to detect abnormal chromosomes or genetic defects to increase the likelihood that the embryo selected will produce a healthy child. Using one cell from the embryo, the cell is probed with a DNA marker to identify the desired embryos.

The two technologies mentioned are becoming more widely used and effective in their uses. However, combining the two technologies could be further used to treat children with current medical conditions, like sickle-cell anemia. If a parent decides to have a second child, preimplantation genetics can increase the chance of conceiving a donor match to their ill child. As it is rare to find an exact match for a bone marrow transplant, parents may now be able to use preimplantation genetic screening along with cord blood banking in order to have a second child who will be able to cure his older sibling. Even if parents are able to conceive naturally they may choose to use in vitro fertilization so that they will be able to prescreen the embryos and choose the embryo that will increase the odds of a transplant match for their older child, while also screening to make sure the younger sibling will not have the disease. Once this child is born, he will be a very close transplant match to his older sibling. After delivery the baby's cord blood can be collected, and this blood can be used to cure his older sibling. If the cord blood treatment does not work, a later bone marrow transplant from the younger sibling may be successful in curing the older sibling. By being a match, the chance of rejecting the new grafted cord blood cells will be much lower.

While preimplantation genetic screening of in vitro fertilization pregnancies is becoming more routine, combining this technology with the option of cord blood banking still remains controversial. Families, along with their healthcare providers, will need to consider medical and ethical ramifications of these newer life-saving options.

New Guidelines for HIV testing in Women - September '08

Today women represent the fastest growing population of individuals acquiring human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). The World Health Organization estimated that 17.5 million women were infected with HIV worldwide in 2005. In the United States the CDC reported that between 2000 and 2004, AIDS increased 10% among females. African-American and Hispanic women are disproportionately affected by HIV and AIDS.

These unsettling statistics have prompted the American College of Obstetricians and Gynecologists (ACOG) to issue the recommendation that all women, regardless of their risk factor, between the ages of 19 and 64 be screened for HIV. The target population will also include teenagers under 19 who are sexually active and women over 64 who have had multiple partners. This represents a significant departure from the usual protocol of most practicing OB-Gyns. Previously, HIV testing was usually reserved for pregnant women, women with high risk factors and women who requested such testing. These new guidelines are a direct reaction to the ever rising cases of HIV and AIDS among women in the United States. The hope is that women will become more informed about their HIV status and the status of their sexual partners since heterosexual transmission has increased greatly over the decades.

It is estimated that about 25% of HIV positive Americans do not know they have the condition which is probably contributing to the spread of the disease. Previously the following women fell into a higher risk category and included the following: women who had unprotected sex with many partners, women with a sexually transmitted infection, women who used injected drugs, women who received blood transfusions or blood products before 1985. Additionally women who had a sexual partner with any of the above mentioned conditions were also at higher risk of developing HIV. Children born to infected mothers are also considered at higher risk.

ACOG's departure from the traditional testing criteria stresses the importance of knowing your HIV status. This organization is promoting an "opt-out" model of testing. This type of testing occurs when patients are notified that they will be tested for HIV as part of a routine obstetric or gynecological visit and must "opt-out" if they do not wish to be tested. Testing is usually a blood test where results will be sent back to your provider's office from the testing laboratory. You will be notified about your status by your health care provider who can offer counseling and necessary medical information.

ACOG's recommendation has only been released in August, 2008 and it may take time for insurance companies and medical practices to review and evaluate it. It is customary for professional organizations to make recommendations which may or may not be adopted by the greater medical communities. Certainly, other organizations will weigh in on this very important epidemic over the next months. If you have questions about HIV or AIDS, seek the advice of your health care provider. The Center for Disease Control has a comprehensive website which can answer just about any question you might have about HIV and AIDS at www.cdc.gov/hiv/. You can also get information from our website: www.atlanticobgyn.com.

Women should not fear finding out about their HIV status because effective and reliable treatments are available for treating this once untreatable condition. Knowing your status will help stop the spread of this serious medical condition. Presently only 40% of the United States population knows their HIV status and this number must increase if we are to help reverse the trends of this dangerous epidemic.

Article for August '08

As we age, our muscles lose their tone and elasticity and our outward appearance can change. So too, does the tone of our interior muscles that hold our internal organs in place deteriorate. Uterine prolapse occurs when the muscles and ligaments of the pelvic floor weaken and are unable to sustain the placement of the uterus. An evaluation by your health care provider can provide insight into the symptoms, causes and treatment options available if you suffer from uterine or other pelvic organ prolapse.

Pelvic organ prolapse is common among older women who have completed menopause. As women age muscle tone of the pelvic floor is lost because of age and decreased estrogen. This weakness coupled with previous strains of pregnancy can cause the muscles to give way, one organ is the uterus. Women who have had several pregnancies or delivered larger babies, as well as women who may have had long or difficult labors may be more likely to develop uterine prolapse. Women of Northern European descent, because of their collagen properties may also be at greater risk of pelvic organ prolapses.

Symptoms of uterine prolapse vary from mild to severe. Some women may not even be aware of their prolapse and only discover them after a pelvic exam. While others, have more obvious symptoms. Bulging, or tissue protruding from the vagina is one telling sign. Some women feel a heaviness or pulling of the pelvic muscles. Some will experience less evident symptoms like lower back pain or trouble with constipation.

Many women will have symptoms that occur constantly and consistently and others will experience symptoms that worsen throughout the day. Discussing your symptoms with your health care provider will help you decide what treatment option might work best for you.

Asymptomatic patients may wish to simply monitor their condition and avoid situations that may exacerbate their prolapse. For instance, obesity may worsen your prolapse so maintain a health weight or loss weight if necessary. Likewise avoid smoking and treat any underlining conditions that are associated with coughing as coughing will cause undue strain on pelvic muscles. Women with mild prolapse should also consider performing Kegel exercises which strengthen the pelvic floor. Kegels are performed by identifying and isolating the pelvic floor muscles. Tightening and releasing the muscles that control urine flow is a good way to strengthen these muscles. Your health care professional can set you up with a routine. Pelvic floor rehabilitation can be aided with physical therapy.

Women with more profound cases of uterine prolapse may want to seek alternative therapies. These range from use of vaginal devices to surgical alternatives. Some women may choose to be fitted for a vaginal pessary which can be temporary or permanent depending on your lifestyle. This device holds or supports the uterus inside the vagina. Limitations of the pessary are that they may not be enough support for women with more severe prolapse and can be irritating to the vaginal walls. For women who have more pronounced prolapse or do not want to deal with the maintenance of the pessary, surgery may be a good solution.

Surgery options for uterine prolapse include both vaginal and abdominal hysterectomy as well as surgical repair. A gynecological surgeon will determine which method is preferable based on your age, symptoms and overall general health. Hysterectomy involves the removal of the uterus and can be performed laparoscopically as well as the more traditional method. Women who wish to have children would of course want to avoid a hysterectomy and may be a suitable candidate for surgical repair of a prolapse called a uterine suspension procedure. Uterine suspension can be performed by reattaching the pelvic support tissue or by augmenting the tissue with graft material.

Uterine prolapse is in most incidences a condition that can be remedied before it results in more serious complications such as ulcers and prolapse of other organs like the bladder or rectum. Seeking medical care early is important to avoid these further complications. Uterine prolapse is treatable and you should not hesitate to seek advice if you think you may have the symptoms of this condition.

News in Women's Health by Dr. Timothy Hardy

Each month, Dr. Hardy contributes a column to a local magazine, Tidewater Women. He writes on a variety of topics related to women's health as well as on new developments in the field of gynecology. These articles can be viewed in the magazine or here on our website. We encourage our patients to stay up-to-date with issues that affect their health and medical care. If you have any questions about the topics discussed here or other gynecological issues, please contact our office.

Please click here to read more articles written by Dr. Hardy in Tidewater Women Magazine.

The Do's and Don'ts of Pregnancy - May 08'

The news of pregnancy can be both exhilarating and worrisome for many women. A first pregnancy is fraught with excitement, anticipation and questions, questions and more questions. Many women will read extensively about their new condition and others will consult with their family, friends and co-workers. Many women will seek advice while others will have advice thrust upon them. Conflicting and confusing information from well-meaning friends and relations can add another level of stress to an already perplexing period. The best source of advice for pregnancy begins with your health care provider. Hopefully you will begin a relationship with this provider well in advance of becoming pregnant. Pre-pregnancy counseling allows a health care provider to advice about nutritional health, avoidance of chemicals including alcohol, drug and nicotine and increasing folic acid intake before pregnancy.

Once pregnant, your health care provider can recommend resources like books, websites and printed materials that can answer all those "little" questions about your pregnancy. Monthly visits will allow your health care provider to keep you up to date on your baby's development and monitor your health.

While no list can be exhaustive of all the questions you might have, the following are general guidelines to pregnancy; what to do and what to avoid during pregnancy. Many of these items are outlined on an excellent governmental website: www.4woman.gov/pregnancy/pregnancy/ published by the Department of Health and Human Services.

Beginning with the positive; all pregnant women should take a pre-natal vitamin which includes iron. Modern diets do not always have the essential nutrients for a pregnant body and a developing fetus. Women should also take 1mg of folic acid every day. Folic acid helps to minimize the risk of developing certain neural tube defects in the fetus.

Women should also eat a well-balanced diet to include plenty of fruits, vegetables and whole-grains. Calcium intake is also important during pregnancy for the fetal development of strong bones and teeth. The adage that you are now eating for two is true in as far as the food choices you make. Healthy eating will sustain a healthy pregnancy. Women should also establish a healthy pattern of weight gain during pregnancy. A weight gain of twenty-five to thirty pounds is considered normal during the duration of pregnancy. Your health care provider can help you monitor your weight throughout your pregnancy.

Getting enough exercise during pregnancy will help you keep your weight gain in check and will help give you more energy for your pregnancy. Your health care provider can give you some good ideas about the types of exercise that are appropriate during pregnancy. Extra strenuous exercise where you may become overheated may need to be avoided during later pregnancy. If you are eating right and getting enough exercise you will probably have no problem with sleep but pregnancy can affect your normal sleep patterns. Getting between seven and nine hours of sleep per night will go along way in helping you deal with the normal aches and pain of pregnancy.

Women should also consult with their health care providers about any medical conditions they may have had prior to pregnancy. Diabetes, hypertension, and obesity are all conditions that will be closely monitored by your provider, ideally before you become pregnant. Diabetes control is especially important at the very beginning of pregnancy to reduce the chance of birth defects. You should consult with your provider before taking any medications including over the counter or herbal supplements.

Women should take all the normal health and safety precautions as they would have before becoming pregnant. Flu shots can be given to all women after 12 weeks of pregnancy. Check with your health care provider about other immunizations. Pregnant women should wear their three point seat belts (including harness strap) while in a car and should wear their belts low on their laps beneath their stomachs.

While many women know about the positive steps they should take during pregnancy, many women are more concerned about those things they should avoid. Whether it's maternal instinct or a learned behavior, many women are concerned about their environment and its effect on their developing fetus. "Is this safe for my baby" is the most asked question from my pregnant patients. Here is a short list of things to avoid during pregnancy. Alcohol, illicit drugs, and tobacco should all be avoided. Studies have shown various complications for fetuses when these substances are used including low birth weight, neurodevelopment problems and premature birth. Consult with your health care provider if you use or abuse any of these substances for help.

Pregnant women should also avoid certain foods like certain types of cold water fish like swordfish, shark, king mackerel, albacore tuna and tile fish which may contain mercury. Likewise any fish or meat should be properly handled and cooked to avoid any food-borne illness which can be especially harmful for developing babies.

Exposure to chemicals like those found in pesticides, paints, cleaning products and other items should be avoided as it is often unknown whether these agents can be harmful for developing fetuses. Similarly women should avoid changing cat litter boxes during pregnancy as cat feces may contain a parasite that can cause an infection called toxoplasmosis which can be harmful to a fetus.

Pregnant women should avoid chemicals contained in scented feminine hygiene products as they may increase the risk of developing a yeast or urinary tract infection. Likewise pregnant women should not douche, take very hot bathes, use hot tubs or use saunas.

Your health care provider can guide you and answer any questions you may have about exposure to other environmental agents including radiation (like x-rays), radon, lead and other substances found in our homes and work environments.

Following a few dos and don'ts can help you stay healthy during your pregnancy and assure that you're taking all the right steps for your growing baby. The bad news is, you might have to skip the sushi for a few months; but the good news is someone else has to clean out the litter box.

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Preventing Breast Cancer - April 08'

The FDA recently approved a new drug to prevent invasive breast cancer. The drug called Evista also known as raloxifene is a member of a class of drugs called SERMs short for selective estrogen receptor modulators. These drugs have estrogenic and anti-estrogenic properties depending upon which tissue they are acting on. Several recent studies on women who were at high risk for developing invasive breast cancer were conducted with Evista to persuade the FDA that prevention of invasive breast cancer was possible and had acceptable side effects and risks.

The Study of Tamoxifen and Raloxifene (STAR) trial compared two SERMs head to head to gauge which one was better at preventing invasive breast cancer. The study showed Evista was as effective at reducing invasive breast cancer as tamoxifen.

Tamoxifen has been used for over 20 years for the treatment of women with advance breast cancer and more recently has been given to women with an increase risk of developing breast cancer. A woman's risk factor for developing breast cancer is assessed by evaluating a number of key data to include: her age, personal history of breast abnormalities, age of menarche (first period), age of 1st live birth of a child, family history of breast cancer, and race. Women at high risk for developing breast cancer using these variables were put on tamoxifen and were followed in a study. There was a 50 percent reduction in the number of diagnoses of invasive breast cancers among the women who took tamoxifen. Fifty percent of these women also had fewer diagnoses of noninvasive breast tumors. However this good news is accompanied by some common side effects. Typical menopausal symptoms like hot flashes, vaginal dryness, and irregular periods are a few worth mentioning. Additionally women taking tamoxifen have an increased risk of developing uterine cancers. There are also higher rates than average of women who develop blood clots and cataracts.

Raloxifene has been shown to be as effective as tamoxifen in preventing estrogen receptor positive breast cancer in high risk post-menopausal populations. The main difference between the two drugs was that those taking raloxifene experienced 30 percent fewer blood clots and 36 percent fewer uterine cancers than those taking tamoxifen. Both medications were associated with the menopausal-like symptoms. Cataracts and cataracts surgeries were less common in the group taking Evista (raloxifene). The incidences of stroke and heart disease were about the same for both the tamoxifen and raloxifene. Women who took the Evista in the trial were more likely to have higher rates of noninvasive breast cancer such as ductal and lobular carcinoma in situ. These cancers are sometimes referred to as pre-cancerous tumors.

Women with high risk factors for developing breast cancer will need to discuss with their health care providers their various options. Chemoprevention options include tamoxifen and raloxifene. Both of these medications have anti-estrogenic effects on the breast which reduces invasive breast cancer by 50 percent. Since Evista has less of a risk of for uterine cancer and a more favorable short term side effect profile, it is recommended in post-menopausal women who are at high risk for invasive breast cancer. However, tamoxifen is recommended for pre-menopausal women who are at high risk since it has been studied longer.

All women should take steps to understand their risk for breast cancer. Monthly breast self- exams, routine physical exams and mammograms are important for every woman. Women with a high risk for breast cancer should consult with their health care provider to discuss if chemoprevention of breast cancer is an option for them.

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The Future of the Pap Smear

by Timothy J. Hardy, M.D.

A little over a month ago, news headlines and reports declared another "significant" finding related to women's healthcare. Recent studies, one in Canada and one in Denmark, revealed that HPV or human papillomavirus testing is more effective for identifying cervical cancer risk in a certain population of women. Big headlines gave the impression that the longstanding Pap smear would soon be a thing of the past. Most cervical cancer occurs in women who have never been screened or who have had sporadic screening, further proving that Pap smear screening is a critical tool in preventing cervical cancers.

Broad statements make good headlines but lack the in-depth understanding to convey what was really discovered in a study. Researchers often perform studies on a limited subset of subjects, and the results can be limited in their scope. For instance, in the Danish Cancer Society study, two separate groups of women were followed. 8656 women between the ages of 22 and 32 and 1578 women between the ages of 40 and 50 were followed for a 10-year period. These women were tested for HPV and had several Pap smears performed in the same time period. In the older population of women, 21% of women with positive HPV tests but negative&