Birth Control Pills Going Over the Counter?

The American College of Obstetrics and Gynecologists (ACOG) have released a committee opinion statement that they recommend over-the-counter access to oral contraceptive pills (OCs). ACOG believes that access and cost are the major barriers to women using contraception, and that OTC birth control pills will greatly reduce those barriers, thus lowering the unintended pregnancy rate. ACOG feels that there is no significant safety risk when OCs are compared with medications such as aspirin, which has been OTC for decades. (Note, however, aspirin would unlikely be approved if it were starting the whole FDA approval process in 2012! Great drug, very useful, but the side effect profile is much higher than tolerated in drug trials today.)

This issue will surely be open to widespread debate, pulling in religious and political arguments as well as medical. I'd like to share my thoughts on purely the medical front. As a family physician, I appreciate the value of an "annual" physical exam and know that OC prescriptions are usually a tiny portion of that visit. As a busy mom, however, I know that many women are only motivated to make time for that exam when that visit is a requirement to continue taking a prescription medication- which for many healthy women, is only an oral contraceptive. I worry that women will push aside their other often silent health issues such as weight, blood pressure, blood sugar, cholesterol if there is not another reason "forcing" them back in to see their physician. Additionally, there is significant counseling that we pair with birth control prescriptions- from logistics about the medication itself (taking it the same time every day; what to do if spotting or missed pills, etc.), discussions about the impact of OC's on other conditions such as depression or migraines,  and of course, education about sexually transmitted diseases. Additionally, I believe most clinicians and many OC users would agree that there is an art to choosing the correct OC that goes well beyond a basic flow chart. I shudder to think of the media war that will ensue as the drug companies ramp up their ads to try and capture their piece of the OC market. The pharmacists, though well-versed in OC pharmacology, simply will not have time to individually counsel women about these issues.

BOTTOM LINE: OTC OC's? Buyer beware. 

Texting Can Save Lives?

http://t.cdc.gov/ecards/message.aspx?cardid=573&category=157

Following up on yesterday's Great American Smokeout..., an interesting study was published this year looking at the effectiveness of TEXTING support to help people quit smoking. This was an analysis of several other studies, including over 9000 total participants. Text messages were used either exclusively or as a supplemental part of smoking cessation programs. Although the results were not fully consistent between the individual studies, ultimately the data is encouraging to support use of this ever-present appendage to aid people in quitting smoking.

In fact, the National Cancer Institute has a texting support program for smokers wanting to quit. Smokefree TXT is designed to be a 24/7 support system offering advice, encouragement and tips for tobacco users trying to kick their habit.

More and more, we are finding ways to use technology to help our health. This picture above is from the free e-card collection at the Center for Disease Control (CDC). Use the link above to check out the wide range of health reminders that you can share with your friends and family! Everything from flu shot reminders, to cancer screenings (think mammograms, pap tests and colonoscopies) to yes, quitting smoking.

BOTTOM LINE: Every bit of contact and support that we can give our friends to help them quit smoking is worthwhile- even texting!

Great American Smokeout!

TODAY, the third Thursday in November, is the annual GREAT AMERICAN SMOKEOUT sponsored by the American Cancer Society. Each year, smokers are encouraged to use this day as a QUIT date, or at least as a day to make a plan to quit. If you have a friend who still smokes, please reach out to them today and kindly encourage them with a reminder that today is a special day earmarked for their health. With this vice, there is NO amount that can be justified as being "good" for you.  Tobacco harms virtually every organ in the body. Everyone knows about the cause and effect of smoking and lung cancer, but cigarettes also greatly increase the risk of developing cancers of the bladder, kidney, pancreas, esophagus, throat, mouth, pancreas, stomach, ovaries, cervix and colon. Smoking directly increases your risk of heart disease- both heart attacks and strokes. Obviously it damages the lungs, causing chronic conditions with increasing shortness of breath and lack of energy.
Finally, appealing to your vanity (hey, whatever it takes!)- tobacco stains your teeth and gives you bad breath. And guys, smoking can lead to erectile dysfunction that evenViagra cannot "cure"...enough said.

Tobacco is one of the strongest addictions, and therefore often the most difficult to quit- if you are a smoker, I don't have to tell you that! The good news is that we have more ways to support you as you quit, and even if you have smoked for many years, quitting now still yields many benefits for your health! Blood pressure and carbon monoxide levels improve the first DAY you quit. In a couple months, both your circulation and lung function start to improve. In just one year after quitting, you will have cut in half your excess risk of heart disease compared to people still smoking. In a decade, your risk from dying of lung cancer falls to half that of a current smoker.

BOTTOM LINE: If you smoke- even "socially"- the SINGLE MOST IMPORTANT THING YOU CAN DO FOR YOUR HEALTH IS TO QUIT SMOKING!!! Talk to your doctor and make a plan TODAY.

Elect NOT To Gain Weight This Holiday Season

Happy November! In honor of election day tomorrow, let's ELECT NOT to gain the standard 7-10 pounds during the holidays this year. We have begun the eating trifecta...Halloween, Thanksgiving & Christmas/Hannukah. Americans love to celebrate these holidays with excessive amounts of high calorie foods- in large quantities. Can you enjoy the season and NOT gain weight? Of course! But yes, some discipline and primarily large doses of awareness are necessary.

Let's start with the Halloween candy. Most people have "leftovers" of snack-sized chocolates. We finish up our favorites (always the Reeses cups in our home) and then mindlessly polish off the less desired ones simply because they are THERE. Take a look right now at your candy bowl (if it is still sitting out). Grab a bag & toss the candy into it, and drop it off at your neighborhood food pantry if you don't want to "waste" it by throwing it away.

As we move into party season, be very mindful as you walk into each gathering. Often hosts are handing out a delicious alcoholic beverage as guests enter...which is a double whammy. Number one- high calories in sipping form. Number two- alcohol goes hand in hand with mindless munching, especially high fat or high calorie treats. SO- politely declare your thirst and ask if you can start with a glass of WATER, which will actually help fill you up and keep your head clear for healthier choices. Many studies have shown that simply drinking a full glass of water before meals cuts calories and promotes weight loss, so this is a win-win!

BOTTOM LINE: Be conscious of mindful eating (and drinking) as we begin holiday celebrations, and there will be one less New Year's Resolution on your list!

PS. Did you remember to change your air filter on November 1st?

Can't Swallow That?

Difficulty swallowing, known medically as "dysphagia", is a very common complaint. In fact, up to nearly a quarter of patients seen in primary care settings will suffer from this problem. Dysphagia is definitely more common in the older population, whether they are in nursing homes or living independently.

What causes dysphagia? The most common cause depends on the age. In small kids, there may be structural problems present from birth that may need surgical correction. In adults, however, the cause is often something that can be fixed more simply, with medications and/or behavior changes.

Smoking, excess alcohol, and obesity all tend to increase stomach acid refluxing back up into the esophagus, which can cause pain or difficulty in swallowing. Reflux, also known as GERD (Gastro Esophageal Reflux Disease) is a very common cause of dysphagia that is seen in otherwise healthy people. Quitting smoking, stopping excess alcohol and weight loss can all improve symptoms, as well as taking medications that reduce acid production.

Medications such as NSAIDS (like ibuprofen), potassium supplements, antibiotics and osteoporosis medications can all cause problems with swallowing, so both diagnosis and treatment of dysphagia in this case may involve stopping prescription medications.

• Let me take this opportunity to caution against "DRY SWALLOWING" pills. I cringe when I see people grab an ibuprofen and swallow it without a drink. Every time you take a pill or capsule, swallow it along with at least a half glass of liquid. Dry swallowing can essentially "scrape" or chemically irritate the lining of your esophagus. And please, let gravity help you get that pill all the way to your stomach- don't lie down for at least five or ten minutes after you take medications.

Less commonly, the more serious causes of dysphagia are to blame, including cancers, strokes, neurologic disorders such as Parkinson's Disease, advanced infections, or scarring from prior trauma or radiation.

BOTTOM LINE: Don't ignore trouble swallowing, especially if it persists or is getting worse. Schedule an appointment with your family doctor!

Hormones- Should We Take Them or Not?

Hormone replacement therapy (HRT) for menopausal women has been back in the news. In medicine, we've swung from placing virtually every post-menopausal woman on estrogen to barely allowing even the most miserable, hot-flashing, night-sweating woman to have any (after the Women's Health Initiative- WHI). What's the answer? Is estrogen safe or not?

As always, the devil is in the details. The WHI never said that we shouldn't be using estrogen (and progesterone) for women who had menopausal symptoms (such as hot flashes and night sweats). In fact, this is an excellent use of estrogen, and physicians and patients need not fear the short term (around five years) use of hormones to reduce symptoms as a woman's body adjusts to menopause.

The larger questions are those involving taking hormones as prevention for other issues, such as thinning bones (osteoporosis), heart disease, or dementia. Although earlier studies suggested estrogen helped protect against Alzheimers, there is not enough evidence to support taking HRT for this reason. Estrogen is one of the strongest protective factors for thinning bones, however, so for women at high risk for osteoporosis and bone fracture, there is data to support starting hormones around menopause in this group. Heart disease, however, is another story. The old thinking was that it was estrogen in women that allowed women to have lower rates of heart attacks than men, and therefore HRT might continue that benefit for menopausal women. The WHI study raised the alarm that women on HRT had a higher incidence of cardiovascular events (heart attack and stroke), and therefore confirmed other studies that suggested HRT is not appropriate if given only for prevention of heart disease. This was not new information, but it was magnified in the media and popular interpretation was that HRT is BAD and causes heart disease.

What do we know today? We shouldn't be starting hormone therapy on women who have gone through menopause many years ago. Hormone therapy is best used at the beginning of menopause, and is fully indicated for those women who are complaining of hot flashes, insomnia, night sweats, etc., during this transition time. How long should we use it? About five years. If symptoms flare as the woman tries to go off HRT, go back on for awhile longer and try to taper next year. There are many subtleties that need to be addressed (such as adding progesterone if the woman still has a uterus) but the take home message should be that women need not suffer through menopausal symptoms.

BOTTOM LINE: Estrogen is still the best medication to address menopausal symptoms such as hot flashes, insomnia, and night sweats- talk to your doctor about HRT if you are suffering!

Gardasil- Not for the FAINT,,,

Continuing my discussion this week about the HPV vaccine, Gardasil, I'd like to address side effects. At this point in the United States, there have been over 46 million doses of HPV vaccine administered (the vast majority Gardasil), which implies over 15 million people (since a series includes three shots.)
Unfortunately, when you start involving a population this large, within that group there will be uncommon diseases that occur in the general population. For example, a disease that occurs in only one out of 500,000 will have 30 cases in this group. Sorting out which of these rare occurrences are random and which are linked to a cause such as a vaccine can be challenging.

We have multiple organizations that closely follow adverse reactions to vaccines. The VAERS (Vaccine Adverse Event Reporting System) accepts reports from anyone- patients, family members, clinicians, etc. The Vaccine Safety Datalink coordinates the CDC- Center for Disease Control and Prevention- with managed care systems through electronic medical records. The Clinical Immunization Safety Assessment (CISA) network hooks up the CDC with our academic medical centers. All of these organizations collect and analyze adverse reactions to vaccines, from minor issues like transient pain, redness, swelling or headache, to fainting, blood clots and even death. What have they discovered from Gardasil?

Let's address what was not found first. Although there have been over forty deaths reported, there is no common pattern in these tragic events to link the cause to this vaccine. Some causes of death included diabetes, illicit drug use, heart failure and viral infections (not HPV).

There is an increased incidence of serious blood clots in this group, but only 10% did not have other obvious identifiable risk factors for clotting (such as obesity, smoking, or oral contraceptive use.)

FAINTING (medical term, syncope) IS a real possible side effect of this drug. The numbers are not staggering, but they are significant. Although fainting after vaccination is reported in significantly less than 1% of Gardasil recipients, Gardasil is the most frequently reported vaccine to cause fainting (as a single vaccine), accounting for over half of vaccine-related fainting episodes reported. The good news is that half of the fainting episodes occur within 5 minutes of receiving the shot, and 80% occur within 15 minutes.

BOTTOM LINE: Make sure to wait the full recommended 15 minutes after injection to minimize the risk of fainting, but be assured that Gardasil is a safe vaccine.