Dr. Barry Dworkin » Women’s Health

Find the right birth-control method

Dr. Barry Dworkin — Tue, 31 Aug 2004 21:08:14 +0000

Originally published in The Ottawa Citizen August 31, 2004

Original Title: Stop that swimmer!

What do you think are the most effective contraceptive options aside from complete abstinence (no intercourse)?

The definition of the effectiveness or pregnancy-risk of a contraception method is the percentage of women experiencing an unintended pregnancy within the first year of use.

Some are more fastidious with certain methods than others. Indeed, the method’s effectiveness depends on proper compliance or use.

Unprotected intercourse has a pregnancy rate of 850 per 1,000 women, or 85 per cent.

The choice of birth-control method can depend on cost, lifestyle, age, ease of use, previous pregnancies and children, and effectiveness of pregnancy risk.

All birth-control pills are equally effective. The reason there are so many different brands reflects the fact that each woman’s response to potential side-effects is unique. If used perfectly, three women per 1,000 will become pregnant within one year. However, many will forget to take their pill or not take it at the same time each day, resulting in a typical rate of 80 women per 1,000 or eight per cent.

Spermicides, the withdrawal method and periodic abstinence have a typical pregnancy-risk rate of 25 per cent. Condoms clock in at 15 per cent; if used perfectly the rate drops to two per cent. Female condoms fare worse at 21 per cent.

Medroxyprogesterone (depo-provera) injections must be given every 13 weeks. This has a pregnancy risk of three per cent if this schedule is not followed or the patient is taking certain medications that affect the breakdown and metabolism of the hormone. If used perfectly, the rate drops to 0.3 per cent.

The effectiveness of emergency contraception (the morning-after pill) is dependent on timing after intercourse. It is most effective within 24 hours after intercourse but can be used up to 72 hours after.

The trend for new products and procedures is to shift the pregnancy risk towards the perfect-use side. Tubal ligation (“tying the tubes”) for women reduces the pregnancy risk to five women per 1,000. Vasectomy has a risk rate of 1.5 pregnancies per 1,000. (Ladies, this is another reason to put your foot down and cite the evidence that vasectomy is the way to go.)

Two new products recently brought to market are an evolutionary change of older methods. The birth-control patch (Evra) uses the same medication found in the birth-control pill. The patch is changed once a week. It is also more forgiving. It has enough birth-control hormones to last eight to nine days. Unlike the pill, changing the patch one or two days late will not result in an increased risk of pregnancy. The patch has a pregnancy rate of three women per 1,000.

The intrauterine device (IUD) is a safe and highly effective method of birth control. Today’s IUD should not be confused with older devices such as the Dalkon shield that caused harm and was removed from the market. The IUD used today is a small T-shaped device about five centimetres long. It is a simple five- to 15-minute procedure to insert the device into the uterine cavity. Depending on the version of IUD, it provides protection from 30 months to five years.

The copper-T (Nova-T) has fine copper filament wound around the stalk of the “T.” Once inserted, it may cause some bleeding and cramping for a few days to weeks, but thereafter subsides. Six women per 1,000 can become pregnant within one year with this device.

The other version (Mirena) exchanges the copper for levonorgestrel, a variant of the female hormone progesterone. Microgram quantities of levonorgestrel released into the uterine cavity exert a local influence on the tissue. It thickens the cervical mucus to prevent the passage of sperm and blocks the sperms’ mobility and function. It has negligible extra-uterine (outside the uterus) hormonal contraceptive side-effects.

Although usually used in women who have had children, the IUD is used also in nulliparous (never-had-children) women.

The IUD is a reversible process. A small string remains on the outer edge of the cervix. Your physician uses a small forceps to grab the string and painlessly remove the IUD.

Mirena has a pregnancy-risk rate of one woman per 1,000, less than tubal ligation and vasectomy.

Consult your doctor about the potential benefits and side-effects of each option. Although many of the side-effects are minor, complete disclosure of all the potential effects is necessary.

Medications can soothe menstrual cramps

Dr. Barry Dworkin — Wed, 24 Sep 2003 20:57:45 +0000

Originally published in The Ottawa Citizen September 24 , 2003

Original Title: Cramping my style

It is the most common gynecologic problem women face in their lives. Every month it can wreak havoc in a woman’s ability to function at work, interfere with social interactions and family life. Even after it passes it looms over her shoulder ready to inflict pain and suffering in a seemingly unending cycle.

Painful menstrual cramps (dysmenorrhea) affects up to 90 per cent of women. Although varying in degree, many can attest to the absolute misery they experience each month.

Two types of dysmenorrhea exist: primary and secondary. The former occurs in the absence of any demonstrable pelvic disease. Secondary dysmenorrhea can be caused by tumours, fibroids, sexually transmitted disease, intrauterine devices (IUDs) and endometriosis among other factors.

Primary dysmenorrhea usually begins within three years of the onset of the menstrual cycle (menarche). About 60 to 90 per cent of adolescent females report symptoms of dysmenorrhea. Why does this occur?

The body of evidence suggests a sequence of events that cause pain. During a normal menstrual cycle, estrogen and progesterone will stimulate the cells lining the inner uterine wall (endometrium) to buildup of a substance called arachidonic acid.

When bleeding begins, biochemical reactions within the disintegrating endometrium change arachidonic acid into prostaglandin F2alpha (PGF2alpha) and other substances. PGF2alpha levels are greatest in the first two days of the menstrual cycle.

This prostaglandin produces intense prolonged contractions of the uterus that will restrict blood flow into the uterine muscle (myometrium). The result is similar to an attack of angina; reduced blood flow starves the muscle tissue of oxygen. The muscle responds by using other energy sources that do not require oxygen in order to survive. The net result of this process is a buildup of metabolic byproducts that sensitize the nerve endings that cause uterine pain.

The pain usually coincides with bleeding and ends 12 to 72 hours thereafter. The pain can remain confined to the lower abdomen but for some women it will radiate to the back and legs. Nausea, vomiting, diarrhea, fatigue, headache and malaise can accompany the pain.

The diagnosis of dysmenorrhea requires a thorough medical history and physical examination. The physician needs to know whether the cause is due to gynecologic disease as mentioned earlier or is indeed primary dysmenorrhea.

The medical history should include the age of the woman when she first started her period, the number of days between the first day of each period, the dates of her last two periods, the amount of blood flow, the total number of bleeding days and whether she has any spotting between her periods.

Are there other symptoms with the pain? How severe is it and does it radiate to other regions? Does she experience painful intercourse? Are bowel movements painful? Is the pain unrelated to her period and does it prevent participation in normal daily activities and responsibilities?

What medications have been used to relive the symptoms? Did it work? Did the use of nonsteroidal anti-inflammatory medication (NSAIDs) like ibuprofen (Advil, Motrin) help relieve some or all of her pain? If it did provide pain relief, the diagnosis is more likely to be primary dysmenorrhea.

The pelvic exam is usually normal in women with primary dysmenorrhea. Women with gynecologic disease usually have some physical findings but some may also have a normal examination.

The mainstay of treatment is NSAIDs. This class of medications will block the synthesis of prostaglandins. Between 70 to 85 per cent of women will respond favourably to this treatment. A trial of naproxen (Naprosyn), mefenamic acid (Ponstan) or other NSAID follows if ibuprofen (800 milligrams every four hours) fails to work (NSAIDs can cause stomach upset and bleeding in some individuals. Please discuss dosing with your physician or pharmacist).

The birth control pill is an option for women if NSAIDs are ineffective. It will block the production of arachidonic acid thereby reducing uterine contractions and pain during her period.

Women who do not respond to NSAIDs and oral contraceptives may have a gynecologic disease such as endometriosis causing their pain.

There are some small clinical trials that show other methods relieved symptoms. One trial demonstrated that after a two-month low fat-vegetarian diet women reported a significant decrease in pain intensity.

Another study reported pain reduction using a fish oil supplement (1080 mg eicosapentanoic acid, 720 mg docosahexanoic acid).

The use of a TENS (transcutaneous electrical nerve stimulation) machine seemed to provide pain relief. Physiotherapists often use this device to treat muscle injuries.

These preliminary studies suggest that other modalities may be effective in treating primary dysmenorrhea. Evidence remains scant regarding the effectiveness of acupuncture, herbs and other treatments.

Women should not have to suffer with this condition. Consult your doctor about treatment options.

Safety with medication vital during pregnancy

Dr. Barry Dworkin — Tue, 19 Aug 2003 22:54:58 +0000

Originally published in The Ottawa Citizen August 19, 2003
Original Title: Medication safety during pregnancy

Moms-to-be should speak to their pharmacist and doctor about prescription medications and any other drugs they might be taking’ What medications are safe to use during pregnancy? Should I stop my prescription medications? How can I treat my heartburn? Can I drink coffee?”

Health care providers need accurate information to answer these questions. Some women have medical conditions that require ongoing treatment. If they stop, they could increase the potential risk to their baby and themselves.

Minor health problems might require medical therapy, and pregnant women may use over-the-counter medications (OTCs) to treat them.

There is understandable angst and concern about medication use during pregnancy. One or two per cent of birth defects are due to drug exposure during that time. Ninety five per cent of defects are due to random chance or genetics.

It is unethical to subject pregnant women to clinical trials to establish the safety of a particular medication. The risk to the fetus and mother outweigh any potential benefit of the research — a lesson learned from the use of thalidomide.

In 1975, the U.S. Food and Drug Administration defined pregnancy risk factors for all drugs, and Motherisk (www.motherisk.org) provides a similar service to the public and health care providers.

In June, the Centre for Addiction and Mental Health (CAMH) released a booklet called Is it Safe for My Baby? It offers assessment of risk and recommendations for the use of medication, alcohol, tobacco and other drugs during pregnancy and breastfeeding.

This excellent guide reviews the safety of more than 200 substances when pregnant or breastfeeding. It includes a host of information covering over-the-counter and prescription medications, illegal drugs, herbal preparations, cosmetics, household chemicals, solvents, paints and cleaners.

The booklet’s release comes at a time when some prescription-only medications are now reclassified as OTC medications.

Pregnancy is not a static situation. Certain medications might be safe in the last trimester but not in the first. The reverse is also true. Let us look at some common concerns during pregnancy: pain, heartburn, nausea, constipation, caffeine, tobacco, marijuana and herbal remedies.

Tylenol (acetaminophen) is present in many OTC cold and flu medications. There is no known link between it and birth defects. ASA-containing products such as Aspirin and non-steroidal anti-inflammatory (NSAID) medications seem to be safe in the first two trimesters of pregnancy but only in low doses. However, greater doses might cause bleeding in the newborn, decreased birth weight and prolonged pregnancy.

Therefore, ASA and NSAIDs should not be used in the last trimester (28 to 40 weeks).

Infrequent use of Tylenol with codeine or other prescription narcotics is safe, but daily use can increase the risk of miscarriage, premature delivery and complications during delivery. If possible, stick with acetaminophen alone to treat pain.

Heartburn can worsen as the size of the uterus increases. Increasing pressure within the abdominal cavity can cause stomach acid to splash up into the esophagus. Antacids such as Tums, Maalox, Rolaids and Gaviscon are generally safe to use throughout pregnancy. If these options fail, the use of Zantac or Pepcid would be the next safe step.

For nausea, Diclectin (pyridoxine/doxylamine) is the only medication approved by the Society of Obstetricians and Gynecologists of Canada for use during pregnancy. The society does not recommend Gravol (dimenhydrinate) for routine use, but it is used in its intravenous form for severe vomiting and dehydration (hyperemesis gravidarum).

Fibre laxatives such as Metamucil or Prodiem and stool softeners Soflax and Colace are safe to use. The stimulant laxatives such as Ex-Lax, cascara and castor oil might cause uterine contractions and should be a last resort.

Caffeine in excess of 300 milligrams per day (three regular cups of coffee) can increase the risk of miscarriage and low birth weight babies. Caffeine consumption in a combination of other products such as 500 millilitre energy drinks (50 to 125 milligrams), a 45-gram chocolate bar (50 milligrams), 355-millilitre colas (30 to 90 milligrams) and a cup of tea (20 to 90 milligrams) can easily exceed the maximum allowable daily limit.

The harm from tobacco is dose-dependent. The more you smoke, the greater the miscarriage risk, premature delivery and low birth weight babies. It is the carcinogenic compounds and other chemicals rather than the nicotine that increase the health risk to the fetus.

Cannabis (marijuana) poses the same risk to the fetus as tobacco with an extra caveat: Newborns might have more sleep disturbances and other cognitive difficulties.

While some clinical data exists for some herbal remedies, the effect of others remains unknown. Ginkgo biloba can cause bleeding, dong quai (ephedra) and feverfew can induce premature labour.

Discuss your concerns with your doctor or pharmacist before taking medication and review all your prescription medications during your pregnancy.

The information booklet is available from CAMH for $2.50 (1-800-661-1111 or by contacting marketing@camh.net).

© Dr. Barry Dworkin 2003

Women should worry more about cardiovascular risks

Dr. Barry Dworkin — Tue, 18 Mar 2003 23:39:35 +0000

Originally published in The Ottawa Citizen March 18, 2003
Original Title: The Truth About Women’s Hearts

Perception is everything. Not only does it apply to the political arena but to the public’s perception of health risks.

A survey by the American Heart Association done in 2000 asked women what disease they thought was the major threat to their lives. Eight per cent said heart disease compared to 50 per cent citing cancer. The reality is altogether different. Cardiovascular disease kills more women than the next 14 causes of death combined.

A woman’s lifetime risk of dying from breast cancer is one in 28 whereas one in two will die of cardiovascular disease.

This perception rings true in the office setting. It is uncommon for women to experience a heart attack at 40 or 50 years of age, but many know of someone suffering with breast cancer at this young age. This close-to-home event scares many women. Understandably, breast cancer prevention becomes a primary concern.

This skewing of risk perception leads to the difficult task of focusing preventive health and education on diseases that occur later in one’s life, such as cardiovascular disease. A woman’s risk of death from a heart attack occurs about 10 years later compared to men. Yet more women than men die from heart attack each year.

Studies done in the early ’90s indicate that women with the appearance of heart disease symptoms are less likely to be referred for evaluation and treatment. Further, sex-specific risk-factor differences exist for women. These include elevated cholesterol, high blood pressure (hypertension), diabetes, smoking and premature menopause.

For example, a low good-cholesterol level (HDL-cholesterol) below 1.05 millimoles per litre is more predictive of fatal heart disease for women over the age of 65 compared to men with the same level. In 1998, the U.S. National Health and Nutrition Examination Survey reported that more women than men had cholesterol levels above the desirable range.

Fifty-two per cent of women over the age of 45 have hypertension increasing the risk of heart disease and stroke.

Compared to a non-diabetic woman, a woman with diabetes has a threefold to sevenfold greater risk of heart disease. Compare this to a twofold to threefold greater risk for diabetic men.

More women than men smoke. Smoking rates among teenage girls exceeds those of boys. Smoking accounts for over 50 per cent of heart attack in middle-aged women and will likely increase given the smoking trends.

What can you do to prevent cardiovascular disease? The Web site familydoctor.org provides helpful information (http://familydoctor.org/handouts/667.html).

Consult your family doctor for a thorough medical examination. This includes a detailed family history (heart disease, diabetes, stroke and hypertension) and a personal medical history that reviews previous illnesses, alcohol and drug use, cigarette smoking, and diet.

Your doctor will order blood tests to check for diabetes and elevated cholesterol levels, among others. If the results are abnormal, he or she may order additional tests and offer treatment options.

Lifestyle modifications are the first treatment choice when cholesterol levels are elevated. Women should stop smoking and alter their diet to limit fat intake. Your doctor’s office should have many handouts of sample diets prepared by the Canadian Diabetes Association or log on to the Heart and Stroke Foundation of Canada Web page at http://ww2.heartandstroke.ca/Page.asp?PageID=1559&SubCategoryID=195&Src=&Type=Article.

Weight loss and exercise (30 minutes of moderate intensity exercise three to four times per week) are crucial to reduce the risk of heart disease. These components will increase the HDL-cholesterol, reduce blood pressure and decrease the risk of type 2 diabetes.

If six to 12 weeks of lifestyle changes do not sufficiently reduce cholesterol levels, medical therapy is the next step. The Heart Protection Study demonstrated a dramatic reduction in fatal heart disease and stroke risk equally in men and women using a cholesterol-lowering statin medication.

These medications (Zocor, Lipitor, Mevacor, Lescol, Pravachol) reduce the risk of coronary artery blockage caused by small clots or plaques that accumulate on the arterial walls.

Estrogen replacement therapy, once considered to reduce the risk of heart disease, is no longer a recommendation. The recent Heart and Estrogen/ progestin Replacement Study (HERS) did not show any reduction of fatal or nonfatal heart attack risk in women who had coronary heart disease.

If you have not had a recent heart disease risk assessment, book an appointment with your doctor. There is sufficient evidence-based information available to accurately assess your 10-year risk of heart disease. Women, justifiably vigilant about breast cancer, should be more so for heart disease.

Early intervention can save your life.

© Dr. Barry Dworkin 2002

Cervical cancer tests save women’s lives

Dr. Barry Dworkin — Tue, 26 Nov 2002 20:53:29 +0000

Originally published in The Ottawa Citizen November 26, 2002

Original Title: A Proven and Effective Means of Fighting Cervical Cancer

Medical research strives for the day when the diagnosis of cancer will no longer evoke fear. The goal to develop effective screening and treatment strategies to eradicate this disease continues to move forward. One of the ongoing success stories in this battle is the screening and early treatment of cervical cancer.

Cancer of the cervix is the third most common malignancy in the United States and the eleventh among Canadian women. Approximately 1300 Canadian women will develop cervical cancer and 400 will die this year. Worldwide, it is the second most common form of cancer in women and the leading cause of cancer death in developing countries. Why this discrepancy?

Cervical cancer is preventable through regular screening – simply put, having a pap smear. The data suggests that the Canadian primary health care system is better able to provide the screening resources to patients. Women who avoid screening or have no opportunity to do so are at increased risk.

Cervical cancer commonly peaks within two age groups; 35 to 39 years and 60 to 64 years. Since the introduction of Pap tests over 40 years ago, the incidence of cervical cancer decreased from 45 to eight per 100,000 women. Indeed, there has been an increase in detection and incidence of precancerous changes and invasive tumours over this same period.

Death from cervical cancer decreased from a rate of 11 per 100,000 in 1951 to 2.39 per 100,000 in 1995. The rate of decline in incidence and mortality was similar for all age groups. Women over 65 have the highest incidence and mortality rates.

Early detection improves survival; 92 percent of women survive cervical cancer that has not spread or metastasized while only 10 percent with metastatic disease live for five years.

Unlike other cancers, women have the means to minimize their risk of cervical cancer. Indeed other than low socioeconomic status and increasing age, most risk factors fall under individual lifestyle choices. These modifiable risk factors include early age at first intercourse, greater number of sexual partners, infection with human papilloma virus (HPV) and smoking.

The virus that causes genital warts, HPV, also infects the cervix. A majority of women with cervical cancer and precancerous changes have HPV infection. In the United States, 20 percent of teenagers and 40 percent of women 20 to 29 years of age harbour HPV. Canadian rates are similar.

It can take years for the infection to cause cancer. HPV represents a class of about 50 to 60 viruses (subtypes). Only some of these subtypes cause cancer. Many women with HPV infection do not develop malignancies. Some precancerous changes spontaneously improve. Careful monitoring of these changes is mandatory.

HPV infection alone is not enough to cause cancer in some situations. One U.S. study of 296 women compared nonsmoking women without HPV (the control group) to three other groups: smokers, HPV infection alone and both smoking and HPV infection. The relative risk of pre-invasive cancer was two, 15 and 66 times more than the control group respectively.

This significant relationship persisted after adjusting for age and number of sexual partners. The longer someone smokes the greater the risk. Breakdown products of cigarette smoke have been found to concentrate in cervical mucous. The evidence implicates cigarette smoking as a co-conspirator with HPV with direct cancer-causing (carcinogenic) effects on the cervix.

Condoms are not foolproof protection from HPV because genital warts are not restricted to the genitalia. They can spread to the scrotum, anus and pubic areas. Skin to skin contact will pass the virus from one person to another. Treatment for HPV exists but early detection and treatment can reduce the duration, cost and complexity of therapy.

Treatment of cervical cancer depends on the patient’s age, their overall health, the desire to have children, the stage of the disease and size of the tumour. Treatment of advanced disease usually requires invasive surgery and radiation therapy.

Primary prevention is the best means of controlling this disease. This includes the sexual history of a new partner, screening of sexually transmitted infections (STIs) prior to any sexual activity, smoking cessation, being vigilant and delaying the onset of sexual intercourse.

The Pap test is the best means to date to screen for cervical cancer. Many women come into the office resigning themselves to this examination often with gender specific comments about their boyfriends and husbands best left to one’s imagination. Men, you don’t have a clue! Despite the compromising yet painless examination, it saves lives.

The Canadian Task Force on the Periodic Health Examination recommends annual screening with the Pap smear after initiation of sexual activity. A Pap test should be done after intercourse with a new partner. Women in long-term monogamous relationships having had two previous normal annual Pap smears can be screened every three years until age 69. Although the bane of many women, the cost of avoidance is too high.

OHIP hinders therapy for uterine bleeding

Dr. Barry Dworkin — Tue, 13 Aug 2002 20:58:57 +0000

Originally published in The Ottawa Citizen August 13, 2002

Original Title: Only Women Bleed

Dysfunctional Uterine Bleeding (DUB) is the leading cause of low blood iron and red blood cell levels (iron-deficiency anemia), causes painful menstrual cramps (dysmennorhea) and has great impact on work, social, home and sex life. DUB is defined as abnormal bleeding from within the uterus that is not caused by any pelvic diseases such as cancers, infections, general medical disorders, noncancerous growths, anatomic abnormalities such as fibroids or abnormal hormonal conditions. It is most commonly seen at either end of a woman’s reproductive years.

The diagnosis of DUB is one of exclusion once all other possible causes are eliminated using specific blood tests, ultrasounds, biopsy of the uterine lining (endometrium) and hysteroscopy (a fibreoptic camera that peers inside the uterus). The key hormones that influence the endometrium are estrogen and progesterone. Conventional treatments focus on controlling their effect upon the uterus in order to reduce bleeding.

Once DUB is confirmed, various treatment regimens are available. Nonsteroidal anti-inflammatory drugs (NSAIDS) such as Ibuprofen (Advil, Motrin), Naproxen (Naprosyn, Anaprox) alone can reduce bleeding by about 30 percent. Cyklokapron reduces blood loss by a different mechanism.

Birth control pills can reduce flow by as much as 50 percent but cannot be used for smokers over age 35 because of the increased risk of developing blood clots. These women may benefit from Depo-Provera, a progesterone only injection given every 12 weeks. Intrauterine devices (IUDs) impregnated with progesterone can reduce blood flow by up to 97 percent.

The success rate of medical therapy is about 50 to 60 percent. Treatments can last years right up until menopause and have side effects in 40 percent of the time. In can be an expensive long-term proposition in terms of time and money requiring numerous visits to the physician’s office for monitoring.

Surgical options are the next step if medical therapy fails.

Surgical Endometrial Ablation (SEA) is highly skill dependent. Few gynecologists perform this procedure. Using a fibreoptic scope the surgeon removes the entire endometrial layer. Complications include hemorrhage, infection, perforation of the uterus and heart failure due to the amount of fluids used during the procedure.

The final option is hysterectomy with all its inherent post-operative, physical and psychological complications. These last two procedures are quite a drastic approach to the problem. Granted for some this may be the only option but reside in the last-resort category.

There is another procedure that could prevent the need for surgery. Thermal Endometrial Ablation using Uterine Balloon Therapy (UBT) works by applying heat directly against the endometrium.

The procedure is similar to an IUD insertion. A soft inflatable balloon attached to a thin catheter is inserted into the uterus. It is then filled with up to 30 millilitres (one ounce) of water. The water is heated to 87 °C and evenly distributes the heat within the uterine cavity. It takes 8 minutes and is done under local anesthesia. To date there have not been any intra-operative complications. Within seven to ten days the endometrium will slough off resulting in a small period. Like SEA, it is 80 to 90 percent effective after 6 months but without the associated complications. Women can usually return to work the next day. Most will have a pinkish and watery vaginal discharge for two to four weeks. UBT is safe, effective, inexpensive over the long term and restores quality of life with minimal discomfort.

UBT is not an option for women who want to have children. Pregnancies can be dangerous for both the fetus and mother after UBT.

Sonohysterography or Saline Infusion Sonography (SIS) is an essential specialized ultrasound that reveals the complete contours of the uterine cavity. The results of the SIS are superior to conventional ultrasounds in the decision making for UBT. The results determine if UBT can be performed safely. It is advisable to perform SIS prior to offering UBT.

However SIS is no longer an insured service. OHIP states that the existing billing codes were never meant for SIS. Until there is a code approved by the tariff committee for this procedure, they will no longer reimburse the clinic or physicians for it. So now the Ottawa General OB/GYN ultrasound department and the Civic campus no longer provide this service.

The Bank Street Ultrasound Centre will provide SIS for a fee. This fee has been set by the Ontario Radiology Society at $300 to cover the cost of the scan, consulting fee, and the equipment.

UBT is available only at the Ottawa Hospital, General campus by a number of gynecologists under general anesthesia. Drs. Guy d’Anjou and Douglas Black use local anesthesia in about 50 percent of selected patients. But it cannot be done as safely since OHIP will not allow SIS.

Drs. d’Anjou and Black hope to open a Menorrhagia clinic at the newly created Riverside Hospital Woman’s Centre. It is their hope that SIS can be incorporated into the Centre. People should not have to suffer because of bureaucratic roadblocks.

Premenstrual Syndrome

Dr. Barry Dworkin — Tue, 21 Aug 2001 21:02:27 +0000

Originally published in The Ottawa Citizen August 21, 2001

Every month it came. The anticipation of its coming slowly turned light into dark. A shroud of darkness gradually enveloping her. Each month she lost a part of herself. It was a demoralizing and humiliating experience. But she was told that this was just the way life is; you can’t change who you are. Live with it. Other do why can’t you?

There are many women who sufer with this condition. It does not matter whether you are a man or woman, suffering is a universal condition. How or what leads to it is irrelevant. The end result is the same; depression, mental anguish, marital strife, family breakdown and physical pain.

Yet with all this despair, the stigma remains a potent force restraining the sufferer from seeking help.

Premenstrual syndrome (PMS) has been derided by some who are unwilling or unable to understand it and ignored by others who choose not to believe it exists. Let us be clear. It is a real disorder that can be a minor irritant for some women, a major handicap and impediment for others.

PMS is a chemically induced disorder. With each menstrual cycle the effect of changing hormone levels affects neurotransmitter levels in the brain responsible for mood. You cannot control your cycle.

These mood changes are identical to Major Depression. The difference is that while the depressed person remains so everyday, the PMS sufferer experiences it seven to 10 days per month. Some report feeling suicidal, aggressive, irritable or emotionally labile. The have difficulty concentrating and functioning at work. They pretend to others that they are happy but inside they feel rotten. Their husbands and children suffer along with her.

Many treatments have been proposed. Different vitamin concoctions, B6, B12, primose oil to name a few. Lets be frank; it is a chemical disorder. It is a variant of depression that is no one’s fault.

A patient of mine quipped when finally relieved of her PMS symptoms, “Better health through brain chemistry.”Many patients have been successfully treated by regarding this disorder as a physical illness like any other. The mainstay of treatment is antidepressant therapy. A medication is required to revers the effects of this chemical disorder.

If PMS interferes with your day to day activities and cause undue hardship, it becomes a quality of life issue. Avoid the stigma and get treatment. Do not deny yourself improved quality of life. Indeed the prerequisite to treat is based upon whether quality of life improves.

Would you deny yourself or others from treatment of Crohn’s disease, asthma or arthritis? These diseases can spontaneously enter remission and relapse. Medications are available to help prevent relapses so that people do not suffer and deteriorate. The brain is no different. It functions under the same physiologic principles like any other organ.

But we think we can control how it functions. Tell that to someone under the influence of a mind altering substance. Chemicals do influence behaviour. In this cae, it is the chemical effect of a woman’s menstrual cycle that alters mood and behaviour. The logic is consistent. The visceral reaction is not.

Do not be afraid to confront PMS if you suspect it. Do not needlessly suffer. Please talk to your doctor about it. Regain those three to four months of life lost for each and every year.

Obstetric complications

Dr. Barry Dworkin — Tue, 07 Aug 2001 22:49:55 +0000

Originally published in The Ottawa Citizen August 7, 2001

Some women can sail through pregnancy with nary a problem while others can have a difficult time. The basis for treating these conditions rests entirely upon individual circumstances. If these problems interfere with ones ability to function consult with your doctor. Ask about the available treatment options. It is important to have options and to be comfortable with the decision one makes when opting for a particular treatment.

Heartburn is a common problem occurring any time during pregnancy. It is caused by fetal growth. The enlarging uterus exerts pressure on the stomach forcing acid into the esophagus potentially causing ulcers within it. It tends to be more painful at night when acid production is greatest.

When the pain becomes more than just an irritant, there are several solutions. Frequent small meals can help absorb some of the acid. An antacid like TUMS can alleviate minor heartburn. It also provides much needed calcium. In moderate to severe cases, Zantac (Ranitidine) is used. Both medications are safe to use during pregnancy.

Nausea and vomiting tends to be most severe in the first 12 weeks of pregnancy. It can markedly reduce one’s food and water intake. In severe cases, the patient is hospitalized because of weight loss and dehydration. The only SOGC (Society of Obstetricians and Gynecologists of Canada) approved medication for the treatment of nausea in pregnancy is Diclectin.

The effect of one’s work environment at home or office should not be understated. Many pregnant women intend to work for as long as possible. However for some their physical stamina wanes. Back and hip pain makes it difficult to sit or stand for extended periods of time. Fatigue catches up to them earlier in the day. Left unchecked these problems can lead to exhaustion and for some, depression. I strongly suggest that patients pay close attention to what their body tells them. It is important to maximize one’s emotional and physical strength for delivery and the post-partum period.

When, where and how deliveries occur is another area of interest for many. One commonly hears that subsequent deliveries are always faster than the first. Not necessarily. Complications can slow labour. These include big shoulders, a large or poorly positioned head and ineffective contractions.

Complications can be unexpected. Last month, Ms. P. had a perfect delivery. However her placenta, usually delivered within five to 30 minutes after the baby, became stuck within the uterus. It prevented the uterus from contracting. Within 30 minutes about a litre of blood was lost. An adult has a blood volume of about 5 litres. Medication and manual removal of the placenta controlled the bleeding. Appropriate pain relief was used before its removal. Had she been at home, she may have bled to death before being able to reach the hospital.

Last month I attended another “normal” labour and delivery. Once the baby was delivered, he would not breathe. There were no warning signs that this would happen. He did not respond to normal stimulation. He was floppy and blue. You have four minutes before he suffers brain damage.

The neonatal team arrives within 30 seconds. They insert a tube into his airway to suction out secretions and to help him breathe. Silence envelops the room as time slows down. Everyone waits for the child to cry. The parent’s faces are frozen in fear. Within two minutes the baby starts to whimper, then cry. His skin turns pink and he moves his arms. A collective sigh, the mother and father cry. If he was born at home, he would have died.

I relate these events to you not to be a scaremonger. Labour and delivery can be unpredictable. We have one of the lowest infant and maternal mortality rates in the world. Modern obstetrical care has led parents to expect normal outcomes as a matter of fact. This is a fantastic turnaround in expectations. Seventy-five to 100 years ago, one hoped that some of their babies survived childbirth. Mr. B., a volunteer fireman and the father of Ms. P. commenting on her delivery stated, “Well, I would sooner fight a fire with a fire truck than use a bucket.” Indeed. The availability of rapid obstetric and neonatal backup that a hospital can offer is invaluable.

Home births carry an increased risk of morbidity and mortality if complications arise. Granted most home births are uncomplicated and indeed it is a more intimate and comfortable place to give birth. The degree of acceptable risk is an individual choice. But it is impossible to predict which of these normal deliveries will go wrong. Most times, you beat the odds practicing low-risk obstetrics. But the potential risk to the health of the mother and child is not to be gambled. The birth of one’s child is indeed a joyous occasion. One to two days in hospital to maximize the health and safety of the mother and child is a small inconvenience for the next 18 years raising a healthy child.

Post partum depression

Dr. Barry Dworkin — Thu, 21 Jun 2001 22:52:53 +0000

Originally published in The Ottawa Citizen, June 21, 2001

Post Partum Depression (PPD) is a severe debilitating illness. It occurs in about one in ten childbearing women. It can cause women untold and unnecessary suffering and guilt. It is important to keep in mind the difference between the “baby blues” and PPD. The “baby blues” usually shows up three to four days after delivery. Mothers may feel a little down, have lost their appetite, have difficulty concentrating or have problems sleeping even while the baby is sleeping. These symptoms usually resolve by the tenth day after delivery. These blues are considered normal.

When these symptoms persist for more than two weeks PPD has to be considered. The family and friends who support the new mother are essential in detecting PPD. Family members may observe that the new mom is “just not quite right” or “not like their usual selves”. This information helps the mom’s caregiver investigate the risk of PPD. Recent news events have brought to light how overlooking the early signs of depression can lead to disaster. PPD can show up as late as six months after the delivery but there are usually warning signs before the full blown illness occurs.

Depression comes in many forms. These are signs and symptoms that are commonly seen in PPD:

* Mood swings (depression, panic and anxiety) and agitation
* Fatigue and loss of energy
* Loss of enjoyment or interest participating in activities that were once enjoyed
* Feelings of guilt, shame and worthlessness
* Suicidal thoughts
* Difficulty concentrating and indecisiveness
* Lack of motivation and drive
* Difficulty falling or staying asleep
* Loss of appetite and weight loss
* Thoughts of harming the baby
* It is important not to overlook or minimize the symptoms that you are feeling or for that matter what one tells their doctor.

Some women are more at risk for PPD. These women have either had PPD before, have a history of depression not due to pregnancy, marital problems or severe premenstrual syndrome. Isolation from extended family or friends or lack family support structures can increase their risk. Life circumstances and stressors such as loss of a job, recent death of a friend or relative or financial pressures during and after the pregnancy should alert you to the risk of PPD.

If anything this brief outline of PPD should be remembered for this reason: PPD is a medical illness. The hormonal changes that a woman experiences after birth can have a tremendous impact upon their ability to function. They are not “going crazy” as some might say. They are experiencing a lack of brain chemicals (neurotransmitters) necessary for normal mood. They can no more be held accountable for their depression than someone with Diabetes or Thyroid disease. They cannot will themselves to make the necessary brain chemicals for normal mood anymore than someone can will their thyroid gland to make more thyroid hormone.

Think of it this way. When someone is drunk, can they sober-up immediately after drinking just because you have asked them to do so? Obviously they can’t because the alcohol affects brain function by temporarily altering brain chemistry. In the case of PPD it is the lack of certain chemicals that affects their mood and behavior. If you can accept how alcohol affects the brain then logically one has to accept how the lack of certain neurotransmitters can alter behavior. This illness must be aggressively and compassionately treated. It is important to listen and offer support to the mom who suffers from PPD. Medications available today can make the difference between needless suffering and a normal healthy post partum period. They can completely reverse the depression, are non-addictive and can give the mother her life back.

Do not feel afraid or embarrassed to talk about your concerns. Talk to friends, family and your doctor or caregiver. It may just save your life.