Things I learn from women

Moving to Ottawa

2013-01-13T19:30:00.001-05:00

Moving to Ottawa

I am sitting amongst boxes, my bookshelves are empty, and my degrees are stacked on my desk in bubble wrap. I am moving to Ottawa where I will be taking an exciting new job as the CEO of the Society of Obstetricians and Gynecologists.(www.sogc.org)

I will be sorry to leave my many friends, and my patients at Sunnybrook, where I have practised for the past 13 years. I have certainly learned many things from the many women I have had the privilege to work with, and I will take those lessons with me. and special thanks to the web team at Sunnybrook who encouraged me to blog, then showed me the ropes and were always there if I had questions about the technology. It was a great learning experience.

I have had a chance to look at the stats on this blog, and thought you might be interested to know:
That I have had >20,000 page views, from countries all over the world, the most frequent:
Canada 10598
United States 4327
United Kingdom 605
Germany 375
Ukraine 277
Philippines 250
China 247
India 206
France 176
Turkey 152

The five most popular blogs were :
5. The kids are back
4. Vaccination: doing the right thing
3. A visit to the Gynecologist
2. Equal access to fertility treatment
1. Cosmetic labioplasty: is it OK

I am looking forward to working with the SOGC, an organization that makes such a difference to women’s health in Canada, and around the world. I hope you will visit our website and explore our many educational sites, sexualityandu.ca, hpvinfo.ca, endometriosisinfo.ca and menopauseandu.ca. I have long been a volunteer with SOGC and served the foundation, the Canadian Foundation for WOmen's HEalth ( www.cfwh.org) I expect to be blogging with the SOGC, so hope to keep in touch.

Well I have some more packing to do. Thank you for your reading and commenting on my blog. Wishing you all a happy healthy new year.
***
Note from Sunnybrook: Thank you, Dr. Blake, for your fabulous blogging and years of service. We’re wishing you all the best at the SOGC!

Menopausal hormone therapy

2012-07-25T08:56:00.001-04:00

Is the controversy over the safety of menopausal hormone therapy (HT) finally getting sorted out?

It appears so. Earlier this month, 15 respected medical organizations issued a joint statement on a set of conclusions about the benefits and safety of hormone therapy. This joint statement is, based on the accumulated evidence of the past decades of research.

The scary headline treatment that was given to the preliminary results of the Women’s Health Initiative resulted in a decade of frustration and confusion . Worse, research that demonstrated the benefits of hormone therapy was never given much coverage in the press. Women stopped taking hormone therapy, opted for compounded hormones and other so-called natural remedies in the unfounded hope that they would be safer. Many doctors were equally alarmed and advised women against hormones. But the data was telling a different story, and those who were more knowledgeable about hormone therapy continued to prescribe HT; more to the point, they continued to use hormone therapy themselves.

So what do we know now that we didn’t know before? The most important lesson is that all women are not alike (hello!), and nor are all hormones. Women who were prescribed menopausal hormones in the first few years after menopause had a 40% lower risk of dying. The evidence suggests that the benefits are many:reduced cardiovascular disease, reduced diabetes, reduced muscle loss, reduced abdominal fat, reduced risk of fracture, and potentially even reduced impact on memory and cognitive function.

If it were that simple this would be a slam-dunk. Unfortunately the breast is also more sensitive to hormones in the first few years of menopause transition, and the risk of beast cancer to women who are taking the combination of estrogen and progestin HT becomes detectable within three or four years.

So how can we get the benefits and lower the risks?

It turns out that for the great majority of women, a year or two of hormone therapy gets them through the worst of the symptoms, and that once hormone therapy is stopped, the risk returns to normal very rapidly. Estrogen by itself has much less impact on the breast - it can be taken for many years without raising the risk of breast cancer at aoo. It is the mix of estrogen and progesterone that elevates the risk profile.

Research is looking to see if it makes a difference which progestin a woman takes, and if it’s better to take them cyclically, rather than the continuous combined way that became popular in the 90s. As well, new research suggest that taking estrogen by mouth appears to slightly increase risk of blood clots, whereas estrogen taken into the body through a transdermal patch or gel does not seem to.

So 10 years after the WHI bombshell, the 15 leading medical societies focused on women’s health have agreed on these five statements*:
• Hormone therapy is an acceptable option for the relatively young (up to age 59 or within 10 years of menopause), as well as healthy women who are bothered by moderate to severe menopausal symptoms. Individualization is key in the decision to use hormone therapy.
• If women have only vaginal dryness or discomfort with intercourse, the preferred
treatment is low doses of vaginal estrogen.
• Women who still have a uterus need to take a progestogen (progesterone or a similar product) along with the estrogen to prevent cancer of the uterus. Women who have had their uterus removed can take estrogen alone.
• Both estrogen therapy and estrogen with progestogen therapy increase the risk of blood clots in the legs and lungs, similar to the kinds of risks associated with birth control pills, and other hormonal contraceptive patches and rings. Although the risks of blood clots and stroke increase with either type of hormone therapy, the risk is rare in women ages 50-59.
• An increased risk in breast cancer is seen when a woman has had five or more years of continuous estrogen with progestogen therapy, and its possible even earlier. Her risk of breast cancer goes back to normal levels after hormone therapy is stopped.

For all women the most important advice in menopause is the most basic - strive to achieve a healthy body weight through healthy choices, sensible portions (smaller than you might think!) and an active life style. Don’t smoke, check your blood pressure, and stimulate your mind. Stay up-to-date with your screening tests for cervical, colon and breast cancer. Menopause research is helping us to understand just how complex the few years after the last period really are. To keep up to date visit trustworthy websites such as www.http://menopauseandu.ca, or www.http://menopause.org. You will find a wealth of useful resources. The SOGC will be doing another series of public forums for women this fall; I expect to be helping out with that series, so watch for information on the SOGC websites, or in your local newspaper.

*The statement is being published in the journals of The North American Menopause Society, the American Society for Reproductive Medicine, and The Endocrine Society and has been endorsed by the Academy of Women’s Health, the American Academy of Family Physicians, the American Academy of Physician Assistants, thee American Association of Clinical Endocrinologists, the American Medical Women’s Association, the Asociación Mexicana para el Estudio del Climaterio, the Association of Reproductive Health Professionals, the National
Association of Nurse Practitioners in Women’s Health, the National Osteoporosis Foundation, the Society for the Study of Reproduction, the Society of Obstetricians & Gynaecologists of Canada, and the SIGMA Canadian Menopause Society.

What Are You Eating?

2012-06-01T12:14:00.000-04:00

France Gélinas has introduced a Private Member’s Bill in the Ontario Legislature. I heard her on the radio in heavily accented and careful English, asking which the listener thought had higher calorie count, a bran muffin or a Boston cream pie donut? The answer was the bran muffin — more calories, more salt, more fat. The legislation she is proposing would insist that the large fast food chains display nutritional value in the menu. Bill 86, Healthy Decisions for Healthy Eating Act, is posted on the website for the Ontario Legislature. There is plenty of support for this initiative.

Of course there is opposition, but I can’t come up with a single good argument against this idea.

It is not a new idea — last year we drove with the kids down to New York City, and stopped at a thruway plaza for lunch. Calories and fat content were displayed along with the price on all the overhead menu boards The kids were fascinated, and immediately searched out the worst possible choices at every restaurant, and marvelled that one could eat a full day's worth of calories in one misguided lunch. It led to a discussion of nutrition and fitness that lasted long into the next half of the trip.

It isn’t as simple as fat is bad; we need a certain amount of fat in our diet, it helps us absorb fat soluble nutrients from food, and the body uses fats to make many essential substances, such as estrogen. Estrogen is manufactured from cholesterol, our bodies make cholesterol in the liver and use it as a building block in the walls of cells, as well as to make all the steroid hormones: cortisol, estrogen, testosterone, and aldosterone. Aldosterone is the least well known of these, but crucial in managing salt and blood pressure.

Salt is the other substance Mme. Gélinas proposes should be disclosed — she is right on that count too. Salt makes food tasty, which is why it has long been such a prized substance. In times past it was restricted to the top end of the table — the rabble sat “below the salt”. There are times when we need salt, especially if exerting ourselves in hot conditions, but for the most part we live in a climate-controlled world, and we “add salt to taste”. That salting to taste is a key ingredient in a burgeoning health problem of hypertension. The problem with high blood pressure is the damage it does to the blood vessels of the sensitive organs in the body: the heart, kidneys and brain.

High blood pressure does the damage the same way a creek in spring-flood damages the banks of the river. Where there is damage done the body lays down plaque that narrows the blood vessels and reduces the oxygen supply to the organ. It also leads to the build-up of fatty material, in the same way flotsam piles up on a discarded tire or riverbank. When that debris breaks loose it can cause a blockage in the smaller vessels upstream. When those small vessels happen to be in the brain they cause a stroke; in the heart a heart attack… and all the while, if there is hypertension, the heart has to work harder which makes it thicker and less able to pump the blood around.

Reducing salt intake is an important step to reducing the risk of high blood pressure.

I am told that where the law requires posting nutritional information, most people ignore it. However, I am encouraged that a lot more people are taking a great awareness in what they eat, and I hope that this group will continue to grow in numbers and influence. We should all be able to know what we are eating.

This simple piece of legislation makes good sense to me. I wish this private member’s bill luck.

Avoiding the Pound of Cure

2012-05-06T22:15:00.001-04:00

It finally feels like spring, time to shake out the light and colourful wardrobe. Except those spring duds may not feel quite so light on. The “winter 5” can make the waist bands shrink.

Weight and obesity was on the agenda yesterday at the 29th Research Day for the Department of Obstetrics and Gynecology at U of t. It is always an interesting and thought-provoking day, as everyone from medical students to post doctoral PhD students present the results of their various research projects. The visiting professor, who delivered the Henderson lecture, was Dr Pat Catalano, from Cleveland. His topic was obesity in pregnancy.

We know that obesity is the health epidemic of our time, but it is sobering to see how it continues to grow. We are trying to keep up with the health consequences. One research article in every six that is submitted to our major Obstetrics and Gynecology journal is on the subject of obesity. It impacts a mother’s health risks in pregnancy, her risk of cesarean, and the health risk that her baby faces. Pregnancy can also contribute to worsening of obesity; extra pounds gained in pregnancy are not always shed, and if the meal habit of eating for two carries on after delivery, the consequences are rapid.

There is no simple fix to this problem. Through most of human history we have had a marginal food supply, we have not adapted well to a surplus. And for generations we were largely responsible for our own food, as an agricultural society. It all changes when our consumption represents someone else’s business proposition. All of these factors get mixed in with our family food culture, and our own metabolism. We are what we eat, and we need to be mindful of every bite. And I have no idea whey we don’t make nutrition and phys-ed mandatory all through school, it would sure help if we could instill the knowledge and the habits into everyone.

Foresight system obesity map

The data at research day presented showed that waiting until we are obese before taking action is waiting too long. Lifestyle modification may not be able to turn the ship around. That doesn’t mean that there is not point in adopting healthy diet and exercise habits. As the old saw goes: the first thing to do, if you find yourself in a hole is to stop digging. By the time you are obese, life style modification may not be enough may not be enough. An ounce of prevention is literally worth a pound of cure, especially if we don’t have a good cure.

Body weight , body fat and fat distribution are also influenced by our hormones. After menopause we have to reduce portion size to maintain weight, and in the absence of estrogen we are more inclined to put weight on in the abdominals — the “visceral fat’ that contributes to our risk of metabolic syndrome and cardiac disease. Stress hormones also contribute to the risk of obesity. A veritable vicious cycle.

We spend a lot of time worrying about our weight, but the literature shows us that not all fat is equal; we need to pull out the tape and measuring our waist line. In men, regardless of height, a waist measurement of 102 cm (40 inches) or greater increases risk of developing health problems. In women, it is a waist measurement of 88 cm (35 inches) or more. An apple-belly does not keep the doctor away, better to be a pear.

And for those who are light weight, important not to become one of the “skinny fat”. Body composition counts, we need muscle to be strong. And of course we want a healthy weight, fat is not bad in and of itself, it is excess fat that is the problem, women need a certain amount of fat for our reproductive cycle.

So what about those five pounds? It is worth keeping a watch on your weight and not letting it get away; a pound a year doesn’t sound like much, but over ten years it sure is. The best way to start is to be mindful of what you are eating, make nutritious choices and monitor volume. There are great resources out there. Eat Right Ontario is a resource anyone in Ontario should know about; you can get the free advice of a dietician, as well as many tips and tools. Weight watchers has been shown to be effective, and offers an online as well as an in-person program. There are other good and reputable programs; your doctor can help find one.

Here is a quick fix: Stand in the mirror, feet comfortably apart. Pull yourself up to your full height, level out your pelvis, nod your chin and be sure your ears are well apart from your shoulders. Chances are that you look like you just lost five pounds — chances are you won’t get back into those pants until you actually do, but if your posture is good and you are more active, it will be easier to lose the pounds.

We don’t need to join a gym to exercise, an active lifestyle is the key, the little labour-making alternatives like carrying instead of wheeling the (healthy) groceries to the car, or better yet, walking or biking them home — choices that we can take advantage of dozens of times each day. Or do something fun, anything that keeps your body active.

My parting thought is that if I am losing someone else should gain, so I will give ten dollars for every pound of the 5 I lost in my spring tune-up to one of my favourite charities. If we all did that then it would be quite a good spring all the way around.

Inheriting the Risk for Breast and Ovarian Cancer

2012-04-28T23:03:00.001-04:00

This past week I participated in a conference in Montreal, on hereditary breast and ovarian cancer. The majority of breast and ovarian cancer is not hereditary, but there are some families that are at risk because of a genetic mutation.

The meeting attracted scientists, oncologists, geneticists, genetic counselors, psychologists and epidemiologists from around the world. There were over 120 affected women who attended, women who knew that they were carrying the BRCA genetic mutation that put them at risk for developing cancer, and who knew that their children had a 50:50 risk of inheriting the gene. The Hereditary Breast and Ovarian Cancer Foundation sponsored the meeting

BRCA is a gene that helps the body repair damage to DNA. Think of all the times the cells in our body. Each time the cells divide the DNA has to be replicated. When something goes wrong in the replication of DNA, cancers can get started. The body has a whole other set of machinery in the cells to search out and destroy cells where the DNA is corrupted, they are called “tumor suppressors” BRCA is part of that housekeeping machinery. With either of the BRCA mutation there is not enough BRCA expressed, and the abnormal cells can slip by.

There are things women can do, but they are all choices that involve unwelcome side effects, or risks. Balancing those out is a decision that in the end, each woman must make for herself. Removing your ovaries can dramatically reduce the risk of ovarian cancer and of breast cancer, but at a cost of immediate menopause, increased bone and cardiac risks, and impairments in sexual feelings. Having a double mastectomy can reduce the risk of breast cancer, but how successful can the plastic surgical result be? There is new research looking at the effectiveness of MRI, to monitor for breast health, but will it be as safe?

Scientists have observed that even with the same mutation, the risk of breast cancer varies between countries; the risk of breast cancer in Poland, for example, is much less than it is Canada. Is that because of diet? A study is looking to find out.

From the session on diet, two welcome studies: one found that drinking coffee actually reduced the breast cancer risk in BRCA carriers, and the other looked at the benefit of cruciferous vegetables (cabbage family).

Who is at risk of carrying the gene? Only about 1% of the general population, but that number rises in people of Ashkenazi Jewish descent, or if you have more than one relative affected by breast or ovarian cancer, or if you have a male relative with breast cancer. There are web sites that help estimate the risk, such as Myriad, or BRCAPro, but the best advice if you believe you are at risk is to consult a genetic counselor, or a familial breast and ovarian cancer clinic in your community.

It is easy to say knowledge is power; sometimes knowledge feels burdensome. One strength that I saw in Montreal this week was women, some by themselves, some accompanied by their husband or a family member, helping one another learn to live with the knowledge of their genetic risk, and begin to come to terms with some of the decisions that need to be made.

The most enduring strength of the Montreal meeting was the opportunity for affected women to mingle with the scientists, doctors and counselors- the invaluable partnership that was formed so that the right research will be done to find answers to the questions that are important to the affected women. One couple I spoke to said it best.

"If this is what I have to face, so be it, but don't tell me that it will be the same for my daughter."

Surely a partnership, such as I saw in Montreal last week, is the way to find that better future.

A Farewell to Warts

2012-04-22T22:32:00.000-04:00

I don’t know what it is about warts, but nobody likes them, no matter where they are. We feel a bit embarrassed by them, hiding our hands, demurring about our feet. Folk legends on wart treatments abound. Dandelion milk? Really?? If only it were that easy- A gentle pouff.
Embarrassment doesn’t even begin to get at how people feel when they find a genital wart. Or many warts, because they travel in great big clusters. I decided against adding a picture; those who wish to can easily find images on the Internet. Man or woman, genital warts cause acute distress. And they don’t go away easily. Weeks of visits to the doctor or clinic for painful treatments. Avoiding sex. Feeling badly.

It’s is unlikely that we would bother with a vaccine just for genital warts, but one of the vaccines against the cancer causing HPV virus also protects against the two types of HPV (6 and 11) that cause 90% of genital warts, and so we have an added benefit of impacting a condition that, while it isn’t cancer, nobody wants. And it gives us an early indication of whether vaccination will be able to reduce the rate of cancer. The two HPV vaccines that we have available in Canada cover 70% or more of the types of HPV (types 16 and 18) that cause cancers of the cervix, and also cause cancers of the genital skin, the anus, the penis and throat.

The news out of Australia is exciting indeed (for the complete reference, see footnote). In April 2007 they started a broad programme of vaccination for all women aged 12-27. Within four years the rate of genial warts in girls under 21 fell from 18.6% to 1.9%. In young men, even though they were not vaccinated, the rate of genital warts fell by 90%- their partners were not exposing them to the virus. Men who were in same sex relationships showed no decline in the rate of genital warts, so it wasn’t because the wart virus was just going through some sort of a cycle.Nor did the rate drop in older women who were not part of the vaccination programme.

At this rate the scientists predict that genital warts could disappear entirely, there is not enough of it to be successfully passed around- it is something that infectious disease specialists call “herd-immunity”. In Canada we won’t be so lucky, we have a rather luke-warm vaccination programme, or maybe tepid is a better word. I see women all the time who have abnormal pap smears or warts. Most of them have no idea that they could have been protected by vaccination. Women who are vaccinated after they have an abnormal pap can still benefit; they are less likely to need treatments of the cervix- treatments that we would prefer to avoid doing, as they can increase the risks of premature labour in pregnancy.

Vaccine is not just for schoolgirls. The research shows also protection against HPV for older women, at least to age 45; there is a second spike in HPV that follows older men and women as they enter new relationships.
If we think women are unaware of the vaccine, try asking a man. The most recent vaccination guidelines for (footnote 2) Canada come out very clearly recommending vaccine for males, but most boys men do not know anything about it.

The reality is that none of us think anything bad will happen to us, and how could anyone we trust enough to have sex with, give us an infection? Well they can, and probably didn’t have any idea that they were passing it along.

What we have learned about vaccines over the years is this: left to our own devices, we aren’t very good about getting our shots. To really be effective, we need school-based programmes, or mandated vaccines. Governments haven’t launched vaccine programmes because they are that concerned about warts- although some economists argue that the reduction in warts alone could pay for the programme- it is the reduction in cancer that is most compelling. The impact on cancer reduction will take time, but already the Australians are seeing an impact on abnormal pap tests, the first step.

The most recent Canadian Guidelines (NACI) tell us that the vaccine is safe, that we don’t need to give boosters, and that we can offer it to many more men and women than we have to date.
The news from Australia tells us that the vaccines do work. Our own Canadian guidelines tell us we can be offering vaccine to more people, to older women, and to boys and men. It is time that we applied the rest of the lessons learned and started a truly comprehensive programme- the Aussies have shown us how to get the job done. To my Aussie colleagues: Thanks Mates.

Read TR, Hocking JS, Chen MY, Donovan B, Bradshaw CS, Fairley CK. The near disappearance of genital warts in young women 4 years after commencing a national human papillomavirus (HPV) vaccination programme. Sex Transm Infect. 2011 Dec;87(7):544-7. Epub 2011 Oct 4.

http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/12vol38/acs-dcc-1/assets/pdf/acs-dcc-1-eng.pdf

The Kids are Back

2012-04-15T22:53:00.003-04:00

“I’m just waiting for the kids to leave home, so we can retire”. I hear this over and over again from my patients. They like their kids and, for the most part, enjoy their company; they just hadn’t counted on having them still at home. These are often good bright kids, who have graduated, but are back living at home and trying to find a job. I see both sides of this problem in my office, the parents with their re-filled nests, and the young women, trying to find an opening, somewhere.

It is a common story. This is a generation of kids that have been labeled “boomerang” in the media, it not a bad label because it is true that they are coming back, and true that it isn’t their doing.

According to Stats Canada the percentage of adult children living with their parents has more than risen sharply between 1981 and 2006; 43.5% of young adults age 20-29 were living at home in 2006, and 30% of young men aged 24—29. These are substantial numbers.

The reasons for this seem complex. There are few jobs to be had, and with each succeeding year that goes by, the competition increases as anew wave of fresh graduates hits the pavement. I can count on one hand the number of would-be teachers who have been able to find work in Canada. Many have gone to teach English as a second language in Korea or other countries.

The boomers aren’t helping matters. As pensions and retirement funds shrivel, plans for retirement are evaporating. No one is talking about “Freedom 55” these days. Many boomers enjoy great health and don’t feel remotely inclined to retire, that isn't a bad thing, they are contributing to the economy, but we need to find a way for our kids to get in.

Perhaps we need to look at our workweek; I am part of a generation that has glorified the long workweek, but there may be better ways of balancing work and family. While visiting in the Netherlands I found my self the cause of much merriment; I would be asked how many hours a week I worked and my answer would trigger either a burst of laugher, or perhaps just a pitying smile. The average woman in the Netherlands works 25 hours. Working 3 or 4-days/ week is common for both men and women while their children are small. In Canada the average woman’s work week 33 hours, a day longer than a Dutch woman’s. A doctor in Ontario who works 40 hours a week is classified as working part-time.

The problem for our kids is made worse by the high cost of homes. In Toronto we are seeing perfectly nice homes being knocked down and multi million dollar homes built on the lot. It all translates to fewer affordable homes.

This is not a simple problem of inconvenience, nor is it laziness on the part of youth. Freud said that the tasks of adulthood were to work and to love. Like everything else that we do, there is a time when we are primed to be able to take on these developmental tasks. We need young people to have an adult role, to be committed to the development of our social fabric. The easiest time to take the risk of leaving home and starting something new is as a young adult. Failure to launch is not just a movie; it is a real risk for our children.

I am not worried about the 1%; I am worried about the 30% of a generation that is languishing, waiting in the wings. We cannot afford to waste their energy and talent; to have it dwindle as they become increasingly disenchanted, and disengaged. I don’t know what the solutions are; I am pretty sure that solving this will take some thought and creativity. But we cannot afford to ignore this, and we don't have time to waste. The first step is to agree that it is a problem.

As to our house? Our daughter is finishing up her final exams this week, and will be moving back home; she is going to be continuing her education. Selfishly, I am looking forward to having her home, but I hope for her sake that the day will come that she will be able to find her place in society.

Eggs, for sale or not

2012-04-08T13:20:00.001-04:00

Images of brightly coloured eggs abound, it is after all Easter. Timely for the Globe and Mail’s Andre Picard to have tackled the scrambled eggs (sorry, could not resist) of 2004 Assisted Human Reproduction Act. Parts of the Act were struck down by the Supreme Court in 2010, and the remaining sections range from the obvious (banning cloning) to the highly controversial. Developing and enforcing regulation has proven even more of a challenge, so not a huge surprise that the recent budget eliminated the ineffective agency, Assisted Reproduction Canada. http://www.theglobeandmail.com/life/health/new-health/andre-picard/canadas-fertility-law-needs-a-reset/article2389474/page2/ Bravo to Andre for having come down firmly on the side of couples who want nothing more than to be able to try to have a family. It is a pretty normal human aspiration.

One of the many stipulations of the Act is to prohibit the buying or selling of human gametes, sperm and eggs. At first pass this sounds reasonable enough; we do not wish to have young women being exploited, and a free market in gametes is fraught with ethical problems, but it is, as always, more complicated. For starters, we continue to allow sperm to be brought into Canada, for a price, from the USA, where a commercial market does exist. Eggs cannot be so easily shipped around the continent. Gender inequality is a part of the status quo.

The American Society for reproductive Medicine has arrived at a position where they state that reasonable compensation is ethical, but excessive compensation not- and they go so far as to suggest the amounts that would be deemed reasonable. We Canadians are usually the master of the compromise. The ethical discussion paper can be found on line http://ww.asrm.org/uploadedFiles/ASRM_Content/News_and_Publications/Ethics_Committee_Reports_and_Statements/financial_incentives.pdf

In Canada altruistic donation of oocytes is permitted, and donors can be compensated for legitimate expenses. These expenses are not insignificant; women who are donating eggs must go through an expensive medical treatment, a series of injections to stimulate a wave of mature eggs, blood tests and ultrasounds to monitor progress, and a surgical procedure to retrieve the eggs. There are risks for women who go through a stimulation cycle, hyper-stimulation of the ovaries, or complications of the retrieval process. There may be emotional risks too. Was she truly a volunteer? What if she doesn’t have children of her own? Should women be compensated for taking on these risks?

There is a range of what are deemed expenses in Canada. Should compensation cover time, or worry, or against future concerns that may arise? Under the Act it only covers receiptable expenses. Buying oocytes is not legal in Canada, but those who can afford it can go to the States where it is - is that fair?

Few women would go through this unless they felt a strong wish to help the unfortunate woman to whom the eggs are being donated, a friend or sister perhaps. Sisters have genetically identical oocytes, as they share the same parents and so might be seen as the ideal donors, but families can be complicated places. A known or family donor can be a wonderful solution, but it can also make parenting complex, with a more than interested party watching you, “That was my egg, it is my genetic child”. Anonymous donation is sometimes a better option, albeit not without its own set of problems. Anonymous donations might come from a woman who is undergoing IVF and decides to make any excess oocytes that she might have in a given cycle available for donation. Oocyte sharing at least ensures that the woman who is donating the eggs is also benefitting. Excess oocytes otherwise end up in deep freezers in fertility clinics, and may never be used.

Women who had donated or received eggs through an altruistic programme in one Canadian centre were interviewed about their views on compensation to donors. They were mixed in their views, reflecting the range of opinions that are likely to be found on this subject. They were agreed that they did not want a commercial market for eggs- to see ads recruiting young women as donors for cash, but opinions varied on how to compensate donors. Women who had been the altruistic donors were more in favour of compensation than the recipients. All these voices need to be heard.

Of course the best solution is to prevent the problem in the first place. What are the reasons that mean that a donated egg is the only chance? Well the most common is the age of the mother. All those celebrities that you see having babies in their mid forties? Chances are it was oocyte donation. Our natural fertility is not improved by moving to Hollywood. Other causes can be the unexpected early arrival of menopause—in 95% of women menopause comes after age 45- that means 5% of women it comes early. Premature ovarian failure happens to one woman in a thousand in the thirties, to one in ten thousand in the twenties, and to one in a hundred thousand teenaged women.

Add to those women who have surgical removal of their ovaries, or who undergo chemo or radiation therapy, or certain other medical illnesses and you have a picture of the women who make up most of the recipients of donated eggs. These are women who did not choose the predicament they find them selves in, and their suffering is real.

By far the majority of those seeking donated eggs are older would-be mothers. And in contrast to popular depictions, a very revealing study of Canadian women http://jogc.org/abstracts/full/201201_WomensHealth_1.pdf found that the most common reasons for women of any age to plan, or defer a pregnancy was the presence of a secure relationship. The number one reason for 98-99.5% of all women; it fell slightly for women over the age of 35, perhaps as they realized that a secure relationship might be out of reach, but it was still the most important reason for 95% in this age group. Career considerations, financial security, lifestyle wishes to travel etc. rank way, way down the list for women of any age. It brought to mind one of my patients last week, she is in her early forties, and asked me about her chances of being able to have a baby. She was single, and told me that there was no one on the horizon. Going it alone is not for everyone, but ironically, for women who make that decision while their eggs are still “good”, sperm can be legally purchased. What are the chances of being able to find the right partner and have a secure relationship before running out if time? I hope she does.

With the budget decision to scrap the Assisted Human Reproduction Canada it is an opportune time to reconsider what we are trying to achieve. The challenge is to balance the good of enabling women who wish to be mothers fulfill that deep human desire, with the protection of young women from financial coercion. It makes sense to allow reasonable compensation;, and to have it above board. There must be more creative ways of finding this balance than we have currently. While we are at it, let’s consider other types of coercion, such as emotional coercion, or family pressures on a sibling, where one sister may have lost her ovaries, and look at the legal protections needed by all parties.

There is a good reason why we are inundated with eggs at this time of year; they represent the beginning of life, something precious and beautiful. It is just about impossible to balance an egg; it seems our eggs are just as tricky.

Whether or not you celebrate the religious holiday, I wish you a very Happy Easter!

Fame: it's not all shallow

2012-04-01T22:26:00.001-04:00

Is there something un-Canadian about fame? Certainly the pursuit of fame, as a goal in itself, is more than a bit suspect to Canadians of established generations. To some others fame and personal-branding are a way of life. I have just read Maryann Sanati’s piece in Walrus on internet narcissism, so when I attended the Canadian Medical Hall of Fame Induction Celebration in Toronto last week, the contrast was vivid in my mind. Those honored that night are from the fame-is-suspect camp; none of the inductees sought fame or glory, instead they followed their passion, and in time were recognized for what they had achieved. In the case of four of the seven inducted last week in Toronto, that recognition came long after their deaths. In an era where everything is instant and virtual, fame can be fleeting indeed; it is all of the moment, the here and now. But we owe much to those who came before us, and taking a few of those moments to pay tribute is the right thing to do

The celebration of the newest inductees to the Canadian Medical Hall of Fame was the second to last event booked in the Toronto Four Seasons Hotel, before that memory-laden hotel closes the doors on Avenue Road and moves to its new home. Seven men were named for 2012. No women, that is true, but that should not take anything away from this group of men, and what they have given to us all.

Unlike some award ceremonies that I have attended, this one was marked by a sincerity and humility that was quintessentially Canadian. The stories and video clips can be found at http://www.cdnmedhall.org/ , but I would like to say a word or two on each.

John Dirks may not be a household name to those outside medicine, but he has made an indelible mark upon Canadian bio- medical research, through his efforts to make the Gairdner Awards http://old.gairdner.org/ not only an internationally renowned and coveted award, but more importantly, suing the award as a vehicle to inspire young people and potential researchers across the country, and establishing a nation wide lecture series to communicate the key advances in science to Canadians everywhere. He has succeeded in all of these objectives, and has galvanized a wide range of partners to make the awards a secure Canadian institution.

Terry Fox needs no introduction, but there are many Canadians who may not realize that he was the first person who had the idea that through his own personal action, in attempting to run across this country, he could attract aattention to a greater cause. Since his first run, and his premature death, more than 500 million dollars has been raised in his name for cancer research in runs held across Canada and around the world. His father accepted on his behalf.

Dr. Armand Frappier graduated from the Unviersity of Montreal in 1930. He founded a microbiology laboratory in Quebec City. The path of his life work was set when his mother died from tuberculosis. He studied at the Pasteur Institute ( the same Pasteur whose name we know from pasteurized milk) and dedicated his life to research in TB. He established a world class microbiology laboratory. His research innovations saved countless lives in the second world war. His legacy lives on in Quebec, annd now in our antinal Hall of Fame.

Dr. F. Clarke Fraser earned his PhD from McGill in 1945 and his MD in 1955. He brought these dual perspectives to his work and Montreal Children’s Hospital, and is credited with founding the field of medical genetics and genetic counseling. Now retired to the Maritimes, and unable to travel, his son delivered the acceptance speech he had written, full of verse and humour.

Dr. Peter Macklem was a lung doctor and researcher from McGill. His research on how cigarette smoke damages the lungs has provided the foundation for much of what we now know about the harms of smoking. . I can remember when none of this was known, when flat tins of 50 cigarettes were as common a gift as a box of chocolates.

Dr. J.J.R. McLeod was recognized because of his contribution to the discovery of insulin, one of the greatest advances of medicine for which Banting and Best received a Nobel prize, but the discovery is credited to four people, including J.J.R. McLeod and Bertram Collip. www.bbdc.org/News-InsulinExhibit.htm.

Dr. Lap-Chee Tsui was honored for his discovery of he gene that is responsible for cystic fibrosis. He spoke about the team-work and collaborations that made the discovery possible; his collaborators spoke about his leadership and tenacity, and devotion to excellence.

Devotion to work, duty, commitment, doggedness, rigor, mentorship, lasting legacy, humor.…these were the themes that underlay the speeches and celebrations. These are indeed the qualities we should be celebrating. Sometimes they will lead to great achievement, and sometimes they will lead to unsung achievements, the sort of work that is done by countless people everyday. Like the obstetrician from Alberta who flew to Toronto and invited seven medical students and trainees to join fher for dinner, young people she had never met, in order that they might be inspired by the people they met and the stories they heard. None of these are the qualities that will make anyone famous in the twitterverse, what they did can’t be told in 140 keystrokes.
I hope we continue to value these parts of our Canadian character, not just in halls of fame, but also in ourselves, in our workplaces and in generations to come.

How to Buy the Pill

2012-03-25T10:28:00.005-04:00

Birth control pills are an everyday part of life: 84% of us have used them at one time or another. It's not a surprise that we are now talking about making them available without a prescription, but it is surprising that it has taken us so long to have that debate. For that I thank Tim Rowe, a good friend and colleague, who caught Margaret Wente’s attention by uttering the word paternalism in the course of a discussion about requiring a prescription for the pill, and once Wente picked that up, the story was all over the news (see the overage on Global TV March 22 ). Good that we’re talking about it, not good to frame it in the language of paternalism; that just shuts down any serious discussion.

I am all in favour of reducing barriers to women who want to use the pill for birth control. So I called my favourite 21 year old reality checker, and floated the idea of over the counter birth control pills by her. “Really Mum?” she asked, “ Well you are entitled to your opinion, but really, you should think about it some more.” It was like holding up a mirror. Now I know how I sound as a mother. Never mind that I was thinking about it long before she was born, she was right, beware of the easy answer.

Birth control pills are available without prescription in many countries around the world, and it is nearly twenty years since the respected researcher David Grimes wrote a strong editorial in favour of over the counter (OTC ) availability of the pill, so ample time to get some answers. Unfortunately we don’t have any new answers. Let’s go through some of the issues.

Safety is the first consideration, and in that regard the pill is very safe, serious side effects are calculated on the number of events per million years of use. That doesn’t mean zero, and if we are that one person in a million, rare is cold comfort. The big factors that increase any one person’s risk are smoking cigarettes and age (being older than 40). Other risk factors are having high blood pressure, having an inherited risk, certain types of migraine, and being immobile, as in long flights or times of confinement to bed rest. The problem is that the risk with age doesn’t happen on your birthday, and doesn’t happen all at once, like an elevator opening on a new floor. It is gradual and we don’t see it. Still the pill is safe and if there is any doubt, your doctor can help to sort out the risk issues.

The pill is effective, which is why it is so popular. But it is not equally effective in all users. In adult women who use it perfectly, it is 99.8% effective, almost as good as the progestin IUD, which is the most effective method we have to offer. In teenagers that number drops to 89% or worse, for a whole lot of reasons. Sometimes it is because of ambivalence about being on the pill, or leaving the pills in a school locker, or not being all that regular about use, or stopping if she and her boyfriend break up -- temporarily.

There are many barriers to getting and using the pill, and they are different for each person. Cost is a big one. If the pill is prescribed it is covered by insurance, if it is over the counter it is not. All the costs now go to the woman to pick up.

The pill only works if you take it, and side effects lead many women to stop taking the pill. The younger you are the greater the chance that you will stop the pill, because the side effects don’t feel like nuisances, they make women nervous. Or totally frustrated. Spotting and break-through bleeding are only a minor problem if it is happening to someone else. I haven’t met too many women who don’t mind unexpected bleeding. When there are side effects or problems you need someone to come back and talk to, and that means someone who you are comfortable talking with about personal things, someone who knows you and that you trust. If that conversation doesn’t happen those pills are going to end up in the garbage (not good for the environment, please take unused medications back to the pharmacy). Side effects can lead a woman to conclude that the pill is no good for her, without knowing that there may have been a solution, or perhaps that here is an underlying problem that should have been addressed.

And finally there is the problem of the very young teen. If she needs birth control she needs it, but there may be a whole lot more going on that also needs to be addressed. And if she is not in a safe situation, whoever she is talking to needs to be able to help her

So should we take the pill off the prescription list? Maybe we should. I think it does need careful thought and some well-designed studies to see if, on balance, it reduces barriers while maintaining safety and effectiveness. We can certainly take some immediate steps to improve access; for instance to ensure that a woman who has forgotten her pills can get a package to tide her over, and then set about getting answers to some of the thornier questions. It isn’t about paternalism, it is about having good safe options to help us control when we get into maternalism.

Correction: I have completed my term as Chief of Obstetrics and Gynecology at Sunnybrook, the mast head and bio should soon be updated to reflect that.

P.S. It is nice to be back, work and other writing got in the way, I hope now to keep up with my regular postings.

On Becoming a Doctor

2011-06-16T16:33:00.005-04:00

There are few days in the life of a medical student more memorable than the day that they graduate.

Sure the speeches are often long and long and boring, and quite often forgettable.

In Alberta Dean Phillip Baker’s speech will not be forgotten, the story of his speech is front page news around the world, because it apparently wasn’t in fact his. It was in considerable part a speech by Dr. Atul Gawande, a well known physician and writer. It was so well crafted that it had been published . Students who recognized some key phrases were reportedly able to read along, word for word on their smart phones. (http://www.theglobeandmail.com/news/national/prairies/deans-plagiarized-speech-prompts-investigation/article2059535/)

I disagree with the Dean of Medicine at the University of Alberta, it is not a private event, it is a very public event; you are with your peers, who will be your life long colleagues, and most often your family is with you. We could not have done it with out our families, whether they provided financial or motional support, or just the odd hot meal, medicine takes everything you have to give, and it is our families who let us re-charge and go back to give some more.

And so I was very upset when I read that the Dean at the University of Alberta had not written a speech for the graduating class of 2011. Beyond the obvious issue of academic honesty ( and the only thing “beyond” honesty is dishonesty) is that it seems to say that he did not think the occasion warranted the time and effort it would take to write his own words, or share his own thoughts with his school’s graduating students. Is he not proud of their accomplishments? Does he not want to share some pieces of his advice that may help them through the difficult moments that inevitably lie ahead?

A few years ago I had the privilege of heading the MD programme at McMaster University, and so saw many classes of students through from admissions to graduation day. It is a very momentous occasion; the day that you receive the letters “MD” to go after your name. So I have written a few words for the graduating class of 2011, where ever you have studied, about graduation day.

Graduation changes you. It changes how others see you. It probably started the day you were accepted into medical school, when introductions would now go, “and this is…., he/ she is a medical student”. Medicine is more than a job, it changes who we are, and it starts with changing our name to Dr. .... .

Our interactions with patients are part of the therapeutic relationship. We use ourselves to help with healing and to the ease of suffering. We must live up to the trust that we receive. That sense of your changed role may start in medical school, or some time later, but from the day you first feel it, it is yours and will never go away. In my med school class and in every one I have seen follow, there was a perceptible shift, hair worn shorter, shirts buttoned up, and jeans replaced by dress pants. We start to dress in a way that shows respect for our patients. We start to govern ourselves differently, seeing ourselves through our patient's eyes. We get to live our work, we don’t just do medicine, we are doctors. To be a good doctor you will need to take good care of your own health. Be aware of how much the demands of work are taking out of you, and restore yourself with family, good friends, exercise, and time for contemplation.

We lose our anonymity. Where ever we go we may run into our patients. That can be the day care centre or the liquor store (“Did you see what she said to her child? what was in her shopping cart??”). From graduation day on, remember that the person who may be annoying you today may be in your waiting room tomorrow. You are now the person living in the glass house.

We are moving into a role where we will be asked to make decisions, and we will never have enough knowledge to be certain, 100%, because people are not 100% predictable in any way. As I was getting ready to graduate I spoke to Dr Bill Goldberg, then Chief of Medicine at St Joe’s in Hamilton, and told him I wasn’t ready, I didn’t know enough. He answered forcefully: “It is not how much you know, it is how much you care that really matters.” I was unconvinced. “You can never know all that you need to know, but if you care, you will always try to learn more, and when you still don’t know, you will get the help that you need."

I look at it this way. If you don’t know you will read all that you can, that is sort of like "eliminate two choices." If you are still in doubt you will probably go talk to your colleagues. That is always wise, kind of like “ask the audience." If they don’t know either, find out who the expert is and phone them. They will always be willing to help. That is how they got to be experts. It is like “calling a friend." It sound a bit like “who wants to be a millionaire” (http://www.dadt.com/millionaire/) and it works.

Three pieces of advice are more than enough for any commencement exercise. We are lucky that in Canada our medical schools prepare their students well, and although the first of July when the residencies (we used to call it internship) begin is looming large, we know that you are ready for the next step.

The Doctor and His Patient by Jan Steen

Until next week, keep well

Born a little early

2011-06-13T12:45:00.001-04:00

I am late for this blog, but with an excuse, the best excuse, a new baby. Our daughter-in-law and two year old grandson came to stay with us last week while her husband was away, they live in the country and she was expecting their second child in July. I think she knew something was up, it didn’t feel quite right, and sure enough the contractions started the first night that she arrived. At the hospital they confirmed that indeed this was premature labour. The best advice was to wait and rest and hope for the best, but this baby was not planning on waiting.

The realization that you are going to have the baby early is never easy, and the more so if you don’t know whether your husband will be able to be with you. She handled all the stresses incredibly well, was calm and composed during labour, and gave birth to a beautiful baby girl. Her husband made it back with 2 hours to spare. Mother and baby are home and doing well. At 35 weeks (40 weeks is full term) babies can mange quite well.

We are seeing an increase in premature deliveries, much of it is related to the increase in multiple pregnancies, and another factor is later maternal age, two topics that I have written about in the past. There is a lot of good news; we are doing much better with the tiniest premies, the “miracle” babies. NICUs can be very frightening environments to families, watching their babies, out of touch, inside incubators. Their babies are surrounded by high-tech equipment, beeping and regulating the environment, and teams of health care staff hurry in to respond as alarms sound. Babies can be weeks and months in the NICU before coming home, and that can be very hard on families. Parents can feel like the outsiders, wondering how they will ever manage.

Some of the things that make a difference in a neonatal intensive care unit (NICU) are so simple, like protecting tiny babies from noise and bright light. Some of the changes required a change in thinking.

Kangaroo care is one of the simple but profound changes in the neonatal intensive care units. Kangaroo care started in Bogota in 1978. They could not afford a fancy hi-tech ICU and had terribly high mortality rates, up to 70%. Dr Edgar Rey, wanting to reduce the number of babies dying, and to help lessen the impact on families came up with this simplest of all suggestions, .

One of the most important reasons a baby needs an incubator is to help regulate body temperature. That ability, so important to us, happens close to term. Dr Rey had the idea that perhaps being carried with the mother would do that, just as it does with kangaroos and other marsupials whose babies are born prematurely. And so it began. Mothers were asked to carry their babies on their chests, heads turned to be able to hear their mother’s heart, wearing only a diaper and a hat, to enable skin-to-skin contact. The babies were given breast milk. Rey and Martinez published the first scientific results in 1983. They found that neonatal death rate dropped from 70%to 30%, and that the babies were able to maintain temperature, and had fewer infections. No surprise, mothers bonded better with their fragile babies when they could be with them, hold them and care for them.

How the results of this experiment, borne of desperation, have been transmitted around the world is a remarkable story in itself. The best news is the amount of research that has followed, all reaching the same conclusion. Kangaroo care is associated with a decreased risk of hypothermia, infection, and death. There are improvements in growth, breast-feeding, and mother-infant attachment. You don't need a fancy NICU to save a tiny baby.

In the design of our NICU at Sunnybrook, we build space into each baby’s room for their parents, to enable their parents to stay with their baby and be part of the care team.

Our little grand daughter didn’t need to go to the NICU, but it is comforting to know, that it was there if needed, and that her mother would be a key part of care. They are both doing very well!

Living life as the Skipper not the Crew

2011-05-30T09:09:00.002-04:00

I heard a reference to Marshal McLuhan, "On spaceship earth there are no passengers. We are all crew". I rather like that, and want to talk about being the skipper of our lives. We don't get to control the sea, but we do have our boat.

I met many phenomenal women in the past week. To start I want to say hello to Lindsay, a remarkable and courageous woman who I had the opportunity to meet last week. She has blog about her experience with cancer of the cervix. When anyone suggests to me that we don’t need vaccination, that pap smears are sufficient, I will suggest that they read her blog. http:// Standing with cancer .blog.com.

Last night Lauran, one of the nurses from Share clinic, and I met with a group of young women with breast cancer. The piece I wrote about IVF was re-enforced for me. Many of these young women had not had their families before they were diagnosed; many were single when they learned they had cancer. Many lost their jobs because they could not work and be in hospital at the same time ( I know, it seems self-evident). Their only hope for a future pregnancy, if treatment goes well, is IVF, but in Ontario and in many other province and States, that takes money. They were not out to complain, this was a Live Laugh Learn event sponsored by Re-think Breast Cancer. We all did some learning.

But here is what I wanted to talk about this week. What would you think if your daughter, a grade 9 student who was not happy at her new high-school school, told you from time to time that she felt sick, or tired, and then was completely fine? I made the mistake of chalking it up to the fact that the adjustment to high school is never easy, and focused on trying to help with that. I made an appointment for her see our family doctor, because you should never try to be doctor to your own family. And we both missed the diagnosis.

The times when she felt sick got to be more often, and at times she would feel suddenly nauseated and throw up. It was not an eating disorder. It was only, after she had moved on to a school where she was happy, but she still was having episodes of feeling sick that I realized we had missed the boat, and something was definitely wrong. By then there were more symptoms, and a lot of bloating. It took 6 months for the specialists to come to a diagnosis, but then we finally understood what was going on. She had celiac disease. I still feel terrible that it took so long before we figured it out

May is celiac awareness month, (www.celiac.ca) so with my daughter’s permission I am sharing our story. Her symptoms were not “classic” she didn’t have chronic diarrhea or weight loss, and she had some unusual symptoms. The treatment of Celiac disease is both simple, don’t eat gluten, and difficult, gluten is everywhere. For a teenager it is a huge transition, as many favourite foods simply cannot be re-created gluten free.

It is a difficult diagnosis to really accept, and you have to do it for months before you truly feel better, all that while wondering what the point of it all is. Giving up your favourite foods, passing up on the foods that get served at parties. Trying to find food in the cafeteria that is safe to eat. Once you finally get feeling better, there is the frustration of getting accidentally “glutened” and feeling sick again.

It is an adjustment for the entire family I tend to be a “scratch” cook, which is lucky because prepared foods are a minefield, but even so, it was a learning curve to eliminate gluten entirely. It has gotten a lot easier in recent years, as more and more good tasting gluten free foods are available. Many restaurants today really understand how to accommodate food allergies.

Celiac disease is an allergic type reaction to gluten, a protein found in wheat, rye, barley, among other grains. It damages the lining of the intestine, so that it is unable to absorb nutrients, leading to malnutrition and anemia, depression and many other health problems. Women can have menstrual irregularity or no periods and may have fertility problems. Making the diagnosis and sticking to the diet can avoid all of these complications.

It does seem to be more common than ever before, although it may be that we are just diagnosing it more often. I certainly think about it more, and from time to time make a diagnosis, where before I would never have even looked for it.

My daughter is thriving now. Looking back she descries how when she was sick she couldn’t think well and certainly couldn’t remember well. Her marks leapt up once she was treated. She is enjoying university and looks after herself well. I thank her for letting me share this story and hope by telling it someone else will be helped.

Brent, thanks for your help with word spacing, I think it worked!

Until next time, keep well.

spacing problems

2011-05-22T09:48:00.000-04:00

For some reason words are running together when I post the blog. Spacing is correct in the editing pane so I am at a loss for how to fix this. If any of you reading this blog can advise me please do :)

Equal Access to Fertility Treatment

2011-05-21T08:50:00.003-04:00

There is a lot to learn, and keep learning in medicine. When I was in medical school we were told that half of what we were learning would be wrong in ten years, but they didn't know which half. Well that turns out to have been a wild over- statement, but it is true that there is a huge amount new every year, far more that anyone could ever be taught. The subject of our hospital rounds this week did not exist when I studied. Louise Brown was born in 1978 and since then millions of babies have been born using IVF. Dr. Robert Edwards was awarded a Nobel Prize in 2010 for this advance in medicine.

Dr. Marjorie Dixon gave rounds this week. She is a member of our department and a fertility specialist. She had the opportunity to serve on the Ontario Expert Panel (the chair of the panel, David Johnston, has recently been named Governor General), a panel that brought a wide range of people together to advise on how to help Ontarians build their families. The panel started with the problem that the basis of our future is families, but we have an aging population, and one family in six will have fertility issues. Anyone who knows people who have suffered with infertility knows that it really is suffering. Today I will be attending a birthday party; two of the young women who will be there have had fertility treatments, maybe more. This is not a rare problem, and it is a painful one. We do have good treatments available, but in Ontario access is limited.

The four key recommendations of the Ontario Expert Panel on infertility were:

All Ontarians should know how to protect their fertility.
Assisted reproduction services should be safe and meet the highest, evidence-based standards.
Ontario cannot afford to NOT fund assisted reproduction services.
All Ontarians who could benefit should have access to assisted reproduction services.

I have talked about the problems of age and delayed motherhood, but want to share some of the information on IVF.

IVF is one of the most effective and safe treatments that we have for infertility. The “octomom” (what a terrible term that is) didn’t have IVF. With IVF the ovaries are stimulated with fertility medications to develop an abundance of eggs, the eggs retrieved from the ovaries and fertilized in the embryology lab. (In vitro is Latin for “in glass”, meaning in the lab). Healthy embryos are then transferred back to the mother. You can control the number of fertilized embryos that have transferred back into the uterus. With fertility drugs alone the ovaries are stimulated to produce many eggs, but the ovary then releases the eggs and fertilization takes place naturally. It is cheaper, but can result in many more eggs being fertilized. IVF is more controlled, is a more complex process, and is costly.

The report talks about what cost means "Even for those who can afford IVF, the process can be financially devastating.The average cost of a single cycle of IVF is $10,000 including medications – almost 14% of the median family income in Ontario. " Bottom line? Many will never be able to have a child because they cannot afford the treatment."

IVF does lead to more twins and triplets than natural fertility. In Canada it results in more than ten times the rate of natural fertility. (27 5 vs 2%)

Why so many twins or triplets? Partly because the treatment is expensive, and not covered by OHIP. Women will try many other treatments first, so by they time they get to IVF time is running out. Every one feels the pressure to have the treatment succeed, and the risk of twins may seem better than the risk of failure. But twin pregnancies carry more risks, including the risk of premature delivery, and life long problems for the babies. Imagine going from all the hopes of pregnancy to the reality of two or more children with major disability. The costs to families and to society are huge

It need not be that way. In most European countries, and now in Quebec, IVF is covered by public health insurance. Everywhere this has happened the rate of multiple births has dropped, from 25% down to 5% of pregnancies. The cost of paying for IVF is quickly recovered by the reduced costs of caring for premature babies. Covering the cost of IVF means making an effective treatment available, correcting the injustice of fertility care being a luxury of those with means, and preventing the life long burden to the children born prematurely.

Both the women I will see later today did eventually have babies, but both lost pregnancies and had to find the courage to try again. IVF is not a cure-all, (it does not work as well as we get older, nothing can turn back the clock) but it is often the best we have to offer.

The report of the expert panel was released in August 2009. To date we have not heard what action will come of it. I certainly hope we will learn from others and fund and regulate IVF. I hope that with an election coming, this report gets the attention it deserves; it is in all of our best interest.

To read more about infertility, visit the website of Infertility Awareness Canada, http://iaac.ca/. You can find the expert panel report at http://www.children.gov.on.ca/htdocs/English/infertility/report/index.aspx

Enjoy the long weekend (What would Queen Victoria have said about all this?)

Response to HPV mail

2011-05-16T13:05:00.001-04:00

I have heard from women very concerned about the implications of HPV virus, enough that I thought a quick note might help:

Yes HPV can be transmitted to the mouth, or to the anus, and it can go from hand to genitals, but the most common means of transmission is genital to genital. Condoms do not give complete protection.

It sounds horrifying , but we have to not let those immediate reactions stick with us. HPV is as common as dirt. Estimates are that 70-80% of us are exposed at some point, and most often our body just deals with it.

Soemtimes it doesn't clear, and it can lead to an abnormal pap. Sometimes, rarely, the changes lead to a cancer.

We know cigarette smoke can increase the chance of an abnormal pap, or worse, and that chemicals from cigarette smoke come out through the cervix. That is a truly gross thought, in my mind.

Currently women who are 65, and who have had three normal pap smears within the past ten years, can stop going for pap testing. But still see your doctor for check ups.

I have been asked about how women who have had abnormal paps should check for anal cancer. Right now we don't have a good screening test, but talk to your doctor about any concerns you might have and let your doctor know if you develop and symptoms, such as skin irritation of the vulva or anus.

The HPV vaccination does appear to be of benefit to women who have had abnormal paps, and there was data presented that is very exciting about the vaccine's ability to prevent anal cancers. Stay tuned for more news on this.

News on HPV vaccination

2011-05-11T20:46:00.001-04:00

It really is a problem that “no news is good news”, when the news media are such an important source of health information. They have no duty to report balanced news, and it unfortunately leaves us with two types of news: miracle break-throughs and scary news. There is a lot more that goes on that the public never hears about.

The information that has been presented at his meeting is agood example. Lots of good news, but I can guess what, if anything, will make the news.

The good news is new safety data that came out of California. The Kaiser Permanente, a Health maintenance organization, has kept records of all the girls and women who have had HPV vaccination. 189,629 women and girls were vaccinated between 2006 and 2008. They found no increased risk of any health concern, other than sore arms after vaccination, and that some girls fainted.

Why is this particular helpful? Because this is a real world test of safety, not a formal research study. In formal studies a lot of women are not eligible for study, but in the real world is where most of us, and most of my patients live. The first rule of “evidence based medicine” is “how much do the patients in this study resemble my patients?”. As a doctor, that means that I have to take most research with a grain of salt. When Kaiser reports on real world data, I pay attention. This data provides the answer that many women, and their family doctors, were waiting for.

What else. Well let’s talk about anal cancer again. And no,this is not about kinky sex, this is about unfortunate anatomy that puts the anus and the vagina as very close neighbours. It turns out that proximity does place women at increased risk for anal cancer, and the rates of anal cancer although much lower than cervix cancer, are increasing, and it is showing up in women 10 years younger than traditionally seen. This is supposed to be a good news story and it is, the vaccine is protective against the HPV type that is responsible. Women who have had a previous abnormal pap smear are at increased risk for anal cancers.

For women who have had abnormal pap sears, and that is true for a lot of women, the evidence for both vaccines shows the there is a reduced risk of future trouble, specifically a reduced risk of needing to be referred for an abnormal pap, or needing a treatment to the cervix. We care about being able to avoid treatments for abnormal pap smears because we know that those procedures carry a risk of premature labour and delivery. It is a risk worth, taking if needed to prevent cancer, but it can largely be avoided by vaccination.

Women older than 26 might wonder if the vaccine is still something for them to consider. The answer is that we all respond well to it, and it does afford protection, though not as complete as for younger women, but better than no protection. The data show that we continue to be at risk of exposure to HPV vaccine. The percentage of us who get exposed does diminish, as we get older. Women who are not in settled relationships know that they might need some protection. For the rest? Well that is a good question, and the research doesn’t have those answers. If only we could see the future.

What did I hear that might attract the press? Well there was evidence today that the virus can be transmitted within a couple not just by intercourse, but on the hand. That is not the most common means, but oh my, that does make hand-washing seem a much more admirable habit than ever. Wash well, and wash often. Sing the happy birthday song while you wash with soap (it takes the right amount of time: “happy clean-hands to you…”). Never mind you, while HE washes HIS hands.

How are we doing in Canada with vaccination? Well at 50-55% we lag way behind the UK and Australia who are in the 85-90% range, about on par with many European countries, and ahead of may American states. Australia has already picked up a marked reduction in risk of genital warts in their population, because of vaccination, and reported early evidence of an impact on abnormal paps. Our vaccination rates in Ontario were very low to begin, but we seem to be doing a little better. We might get to a level where we can see an overall benefit, but we have a way to go.

There was much more, but my guess is that the fact that the hands can be the culprit might be more exciting to report.

This meeting was in Lisbon, this has been my first visit to Portugal, and I hope it will not be my last, what a beautiful hospitable and historically interesting country this is. Being in a country that dates itself back so deeply in history puts much in perspective. It lets me dream about the day when we will think of cervix cancer as we think of polio; historically.

This meeting is over so back to Canada and work as usual. I have had a few emails to my earlier blog on this topic, and thank you for those notes. Until next week, be well.

HPV, what's new?

2011-05-10T04:00:00.003-04:00

The idea that cervical cancer could be caused by a virus was quite shocking. That was thirty years ago. Everything pointed to an infectious cause, but it was a longtime before the story could finally be put together and we finally understood that it was the lowly human Papilloma virus, HPV, that was the culprit.

Once an infectious cause was established the wild hope was that a vaccine could be developed. Not only did we get vaccines against this virus, we got vaccines that work incredibly well. We have two vaccines, each with unique features, but both nearly 100% effective in preventing disease related to the two most common cancer-causing types of HPV; HPV 16 and 18. Both are available in Canada.

This week I am in Lisbon, attending Eurogin, an international conference on HPV and associated cancer and diseases. The HPV virus is responsible for 5.2% of all the cancers that afflict men and women, cervix, vagina, vulva, anal cancers, and, head and neck cancers. The data on the value of the HPV vaccines to protect us from these cancers, and on their safety, gets better each year. At a meeting like this we get to hear the latest research, before it gets published. We also get to hear what is going on in other countries.

So from the first day of the meeting the highlights were:

· Long-term safety. One of the questions that I hear is whether there are any long-term side effects from vaccination. The first trial of HPV were in the Nordic countries, starting in 2003, (four-years ahead of when we got the vaccine in Canada), and no serious adverse effects. The most common side effect of vaccination remains temporary soreness from the needle.

· Long-term efficacy. Seven years and counting, and so far there have been no cases of pre-cancer related to HPV 16 or 18 in vaccinated women. The good news for us is that if there is any weakening of the effect, or any need for a booster, we will know well in advance. So far there is no reason to think we will need boosters

· Anal cancer. There once was a time when no one mentioned the word breast, now “breast cancer” must be on found on almost any consumer item you can name. We remain squeamish about anal cancer, but it too is an HPV related cancer. Farah Fawcett died from it. Anal cancer is not common but it is rate is rising quite markedly. Any one can get it, but it is more common in women who have had other HPV related trouble, like abnormal pap smears. HPV vaccination can dramatically reduce that risk.

There is a lot more to learn. England and Australia have been very successful with their school based vaccination programmes, and there is some early data on whether they work. I will be back after today’s meeting with an update on these programmes and some more highlights.

Reflections on the royal marriage

2011-05-05T23:31:00.001-04:00

This week I missed posting my blog. Like most everyone I have been captivated by the news and images of the Royal wedding. No sooner was that done then we, in Canada, were into a historic federal election, and then refocused on terrorism. Blogging about women’s health just didn’t get to top of my mind.

On the other hand there was a lot to reflect on, that has a lot to do with our lives as women; our hopes, our fantasies, and the communal pleasure we take in seeing other’s happiness. On the morning of the royal wedding I was invited for a wedding breakfast party, we were to wear hats or fascinators, and treated to scones and cream and berries while we watched the wedding. I have never seen so much festive spirit at 5:30 in the morning!

Even the least sentimental of us have been had our imagination captured by the royal wedding. It was not a young girl who was thinking that this was going to be the best day of her life, wearing the to-die-for dress. Kate signaled loud and clear that she understood that this wedding day was as much, if not more about the job she was taking on, as it was the marriage she was entering into. As much about what she was giving up as it was what the mantle she was taking on.

Much has been written about her sister, suggesting that her sister “upstaged her”. I saw it differently; to me her sister was her alter-ego, wearing the dress that Kate could not wear, living the life that would not be hers, wearing the light and alluring dress, Kate’s dress, while beautiful, was not light, and it was heavy with history. She wore it with grace and dignity, and she entered into the role that will be hersfrom now on. She managed to do that and still look completely natural and at ease. Quite a feat. The relationship between the sisters was touching. Marriage is a letting go of one life and the taking up of another. Kate Middleton’s life change is extreme, but for each of us the choice of mate can change the course of our lives profoundly. I think it is the mixture of taking up and leaving behind that lends a poignancy to wedding days.

We are heading into wedding season and the press has led us to expect many look-a-like wedding dresses. I rather think they have missed the point. It was not the dress(es), it was their quiet confidence, their calm amidst the hoopla, that was so striking. Neither seemed in the least self-conscious. That can only come from being yourself, and knowing that you are entering into a rock-solid relationship. So that is what I hope for my patients, as we head into peak wedding season.

And did you notice that both sisters had absolutely perfect posture? There is a women's health issue here, as a lot of the pain that I see in women comes from poor core strength, poor posture, and poor mechanics. Our sedentary lives do not help, but simple core strengthening exercised do.

Sophia Loren has been quoted as saying that the secret to real beauty is perfect posture, kind eyes and a genuine smile. That puts beauty within all of our reach, fairy tale princess or not.

Well they are back to work, and life goes on. Until soon, be well.

Vaccination: Doing the right thing

2011-04-25T17:37:00.004-04:00

As a girl growing up, I remember that just about every winter there was some illness that came through, and there were two or three weeks that would be spent home with measles, mumps, chicken pox; rashes and fevers and swollen glands. Since we were a family of four it was also usual that we would come down in series with the season’s contagion. For my mother it would have been like running an infirmary. In those days few mothers worked, for those who did it would not have been easy.

The illness passed in a feverish blur, and then there were long days of quarantine to fill. We had two TV stations, CBC French and English, and books to read. That was when I learned all the traditional needle arts, sewing, embroidery, and knitting. It sounds pleasant, almost romantic to read about it, but that would be wrong. Polio season was a time of fear. We could not go to places where we might be exposed. There was one surprise and very brief trip to the Ex; we could go but not eat anything, nor touch anything. Other children were not so lucky, and ended up with paralysis or in iron lungs. We were glad to get many of these illnesses “out of the way" knowing they were far worse, with serious complications, if you were older. And they could be deadly serious. We lost a classmate, Jeffrey, to measles encephalitis.

abnormal pap smear,
image on waronwarts.com

Perhaps it is because of those memories that I am very grateful for vaccinations. This week is national immunization awareness week, www.immunize.ca Working in a hospital, it is a given, we must all keep our vaccinations up to date to protect our patients. As a society, we no longer “see” what these needles are protecting us from. Travelling to countries without these programmes is a stark reminder. I do not need to travel to see the affects of potentially preventable disease. As a gynaecologist I see dozens of women affected by HPV related illness every week. Some of them were “waiting to see” about the vaccine, others thought it could never happen to them. Some of them have a passing illness. Others have a lethal disease.

The HPV virus is commonplace. It cam be made to sound nasty, a ” sexually transmitted virus”, but since life itself is sexually transmitted I take that as a simply a factual description. 60-80% of us will be exposed to HPV, and we won't know it. In most people it will go away, like all those other infections went away, but for others it will hang around, and then cause changes that can lead to trouble: abnormal pap smears, vulvar or cervical cancer in women, throat papillomas in children, anal cancers, cancers of the mouth and throat in anyone.

Cancer of the cervix is the second most common cancer in Canadian women between the ages of 20 and 44. It is often, but not always curable. The cure can rob women of their fertility, and can affect sexual function. I hope the day will come when we can eradicate this cancer. www.hpvinfo.ca.

We are not there yet, but that day may come soon. The two vaccines we have in Canada are good for 70% of the cervical cancer. We have years of experience and millions of doses to tell us that it is safe. It is most effective when we are children and our immune system is at its peak. It is still effective right through adulthood- the studies go up to age 55. It also protects, and is indicated for boys and men. I will be attending an international scientific meeting about HPV next moth, so may have some news to share.

This week how about checking the status of all your vaccinations, and check on others in your family? Vaccines are no longer just for children, they have grown up to protect us from grown up illnesses.

Spring is a good time to turn over a new leaf, and get everything sorted out. Until next week, be well.

Menopause and Estrogen, why such confusion?

2011-04-18T21:29:00.002-04:00

My cousin just sent me a column from the New York Times, by Gail Collins. It is about the recent research report on estrogen in menopause. “Sometimes you really do want to tell the medical profession to just makeup its mind. We got word this week that estrogen therapy, which was bad, is good again. Possibly. In some cases.” (New York Times April 7, 2011)

I do get what she is saying, it can be very frustrating. Medicine depends on research, and research is based on proof. That often means proving something wrong, asking questions, creating doubt, challenging assumptions, and acknowledging uncertainty.

I think of science as being a rather slow paced argument, or a debate, that is being conducted through the scientific literature. If you only read the last article, you are no better off that if you walk into a room and hear the last thing one person said. If you read postings on an internet site, it is as if you only read the last post. To make sense of it, you need to have heard (or read) the whole conversation, and to really assess who is on the right track you also need background knowledge. The background knowledge required can be considerable.

To deal with science and research you need to be able to live comfortably with uncertainty. Sadly for newspapers, that hardly makes for an exciting headline. “the latest research shows that _______ might be good for you” . When a headline reports it as “who knows?” it is easy to decide no one does, you can’t believe anything you read, and chuck the whole thing.

Sometimes the path is not a straight line, and depending on where you are on that path it can look very different. Coming into Toronto last night on the Gardiner there was a beautiful moon rising right over Lake Ontario, we came around the bend and there it was again, only now it was straight ahead over the downtown skyline. Very confusing. The moon hadn't moved, we had. There is a good side to this. If you have ever used a sewing machine, you will know that you can be making zigzags and still be moving in the right direction. The zigzags actually make a stronger seam.

This is a lot of what has happened with the estrogen debate. It is a challenge to say it briefly; an office visit is so very brief. To really explain it properly takes time. A blog is supposed to be about one page. What can I say in only one page? I am sympathetic to that reporter. My solution is that this is a topic I will visit many times.

We are now arriving at a better understanding of when estrogen is good, and when maybe not so good. It is because of this that we don’t advise using hormones for their preventive values, unless you are having symptoms that are interfering with the quality of your life. So it would be nice to get this settled, as increasingly we are learning that there may be opportunities to benefit, for things like heart health, or brain (mood and memory) but that as we get older we lose the opportunity to benefit. Breast cancer risk may also be related to our age.

I have spent many years in the company of estrogens, to me they are familiar, and not particularly scary. To stay on hormones for five years is the same as if your menopause naturally had come five years later. It doesn’t matter if it is your body's own hormones. But I also look after many women with breast cancer, and do not want to see any extra cases. How to find the line between those?

If you are someone who has made a decision to take hormone therapy, there are three useful things we have learned: 1. the risk is less when women need only take estrogen. 2. The risk is from prolonged exposure; for the short amount of time that most women need to take hormones, it is not a worry, and 3. The risk goes right back down to where it started when you stop hormone therapy.

For any individual women it is always a more complicated decision. It is never quite so simple as magazine headlines, nor ever quite so complicated as trying to read through the scientific literature. Reputable websites like http://www. menopauseandu.ca, http://www. menopause.org, and http://www.menopausematters.co.uk/ are all sites where you can find a bit of useful perspective on the latest menopause research. The SOGC is about to start a cross Canada public lecture series, look out for one near you. Until next week, be well.

Is 60 the New 40?

2011-04-10T20:41:00.002-04:00

My Dad just bought a new car. What makes that special is that he is 91. His recent knee replacement had some complications, so he isn’t able to get out on his bike to enjoy the weather. He decided to get a car with a sunroof instead. He wondered if he was being foolish, buying a car at his age.

The literature would say that Dad is not being foolish, that 90 is the new 80, and 80 is the new 70. He has taken care of his health, and he is enjoying life. We are reaching advanced age with better health than ever before in history. Just look at all the birthday cards to celebrate 100^th Birthdays!

When I was asked to give a talk about menopause and aging, to address the question “Is 60 the new 40?” I thought of my parents, my aunt, my in-laws and all the wonderful people who at 80 and 90+ are going strong and putting us to shame, and I jumped into the research.

What I found was not so pretty. What is impressive about our seniors, may not hold true for the rest of us. In 2007, in partnership with Health Canada and the Public Health Agency of Canada, Statistics Canada conducted a survey of over 30,000 Canadians, living in 13,500 households, the Canadian Health Measures Survey (CHMS). It assessed fitness by questionnaire as well as by physical measure and fitness testing (aerobic fitness, flexibility, muscular endurance and muscular strength). In the report, our results are compared to the results from 1982.

Since 1982 Canadian adult women are 12 pounds heavier. Unfortunately we are not even half an inch taller. We are just heavier. We know that obesity is a major public health concern for our American Neighbours; it is for us too. In all age groups and in both men and women our mean weight was in the overweight category (BMI > 25).

We are less fit. One of the tests was to do 25 partial curl-ups — not a sit-up, just to lift your shoulder blades off the mat. More than one-third of females aged 20 to 39 years and the majority of those aged 40 years or older were unable to complete even one partial curl-up. Our back–health was poorer and our muscle strength is lower.

This isn’t about going to the gym (although that isn’t a bad idea). Our lives are so much less physical than those of our parent’s generation, and our children’s are less active than ours. Our parents walked, we rode our bikes and our kids get driven to wherever they are going. I cringe when I see healthy women push the handicapped button to open the doors. If we don’t want to end up handicapped we ought to open every heavy door we see. Skip the elevator lobby and climb the stairs, lift the groceries our of the cart and carry them to the car, walk the dog, rake the lawn, take the bike out for a spin.

One of the tests that was part of the survey was grip strength. It is easy to do: you just squeeze a little spring-loaded device as hard as you can. It just takes a few seconds. This simple test though, predicts our likelihood of being in good health 20 years form now, the risk of bone fracture, even the relative risk that we will still be alive. Our strength is a good measure of how robust we are. It is by no means the only predictor of our future health, but it is sobering to realize how it is the little things that add up to be so very important.

We need to build physicality back into our lives and our children’s way of life. Press for gym classes, for sports and active play. By being physically fit we can reduce our risk of fracture, not just be stronger bones, but by having better balance,better recovery, and less chance of falling like and breaking bones. Fear of falling shuts many senior women indoors. Frailty leads many to lose their independence.

If we are to live to be older, the one thing most people do want is to be able to maintain an independent lifestyle. My Dad has exercised every day of his life. It is easy to think we are too busy. I know that I go through times when I let other things get in the way. Or we might try to do too much and get injured. What is clear that if we want good quality in our life twenty or forty years from now, we need to take steps (real steps) today. And an even better idea is to bring a friend along.

It was time for me to replace my car yesterday. To take it for a drive we packed up the dog, headed down to Ashbridges Bay and took along walk on the boardwalk.

Thanks Dad, for being a good role model. I think a lot of us would like to be choosing new cars at 91!

Coming up: You may have seen in the news that the most recent report from the WHI (the study of menopausal hormone replacement) has found that after nearly nine years of follow up, the risk of breast cancer remains lower in the women who were prescribed estrogen, compared to women who were given placebo. (JAMA. 2011;305(13):1305-1314) What are we to make of this? I will try to pull the strands of research together in future blogs. It may take a few! Some challenge.

Until then be well…. and do something physical!

April: Spring, babies and cesarean sections

2011-04-03T09:11:00.009-04:00

April is cesarean section awareness month. I didn’t know that until yesterday, but it is a good idea to spend some time thinking about what is happening to childbirth. April is all about bunnies and babies and spring, a good time to think about birth.

In Ontario 28% of all births are by cesarean section, in women who have had one cesarean section that number rises to 84%, according to Echo's recently released POWER report.

The statistics may be a little off. We don’t count women who have home births in the hospital statistics, but we do count the cesarean sections of those who transfer to the hospital with complications in labour. But there is no doubt that the rate for cesarean birth is going up, way up.

I work in a hospital that cares for women with high risk pregnancies so our overall c-section rate is over 30%, and some months it is well over (our rate for healthy uncomplicated pregnancies is half of that). We track the rate every month, we watch the reason for performing a cesarean section, and we do our best to ensure that we do not subject women to unnecessary cesareans. We are trying to provide the best possible care and achieve the healthiest outcomes. There is no agreement on what the right rate of cesarean is. How would you define it?

There is a diversity of opinion. Earlier to day I was reading about how to avoid unnecessary cesarean. And a few weeks ago I was reading the arguments of women who wanted to be able to choose a cesarean delivery and avoid the uncertainties of a vaginal delivery.

We are all influenced by our own personal experience. I was lucky enough to have experienced an un-medicated natural childbirth, but I have seen and attended enough women in labour to know that every labour is different and every woman’s experience is unique. The goal is a healthy mother and baby, and it can be a wonderful life affirming experience. Sometimes it is, sometimes it is just not.

Eileen Hutton, a wonderful midwife based at McMaster, together with Jude Kornelson did an interesting research project in which they interviewed women who had requested a scheduled cesarean section. Many of these women feared the pain of labour, but for more it was the risk and the uncertainty. Some women, who have gone through long and difficult infertility treatments, or think that this may be their only chance to have a baby, might prefer elective surgery. In their assessment it gives more certainty that their baby will be OK. And the women who were making this choice strongly believed it was their right to choose the manner of birth.

Onatrio Niday database 2008

The POWER study “age adjusted” cesarean section rates. That may have helped them compare different parts of the province, but it hid an important truth. The older we are, the higher the likelihood of cesarean section. But why? Is it because as we get older we know that we may not have another chance at pregnancy? Probably not, all women want the healthiest baby. Does that knowledge influence the people looking after you in labour? Maybe. We do recognize the heightened concern when someone has tried for years to become pregnant. Is it because we are in not in prime physical condition, and so cannot do the work of “labour”? Maybe. Obesity and poor physical condition can affect labour.

Most women of any age would prefer not to have a cesarean, but the proportion who would choose a cesarean increases among older mothers. There is no question that we are different at 35 than we were at 20. Talk to anyone whose 35 year old is still living at home, it is a lot easier to leave home at 19. At 35 we don’t really want a lot of uncertainty and risk in our lives.

So what about “older” mothers? Frankly I am tired of hearing that women are “choosing to delay childbirth.” For some reason this whole issue of late maternal age is being portrayed as a problem of self-absorbed, career-obsessed women.

I see women every day who know just how little time they have, and who want nothing more that to be able to have a child. Sometimes they are not in a relationship, sometimes they are in one, but with a partner who is not about to commit to marriage and mortgages and babies, and sometimes they have had a failed marriage, but by the time they are clear of it their chance to have a baby has been diminished.

I have not met many women who say “life as a single women is so much fun”, “my career is so rewarding”, that I think “I will wait till I am 40 to try for a baby.” Few women have careers that are high-powered fast-lane; many more are working, like everyone else, to pay the bills. And yet the media continue to portray this as “women are choosing to delay childbirth.” It is not so simple.

When I started in medicine it was understood that as a woman, taking a coveted position in Medical school, I was depriving a man of his opportunity. The idea of "selfishly" getting pregnant was unthinkable. And if you did, your peers would have to pick up all of your work, while you were "off" having a baby (as if the first three months of a newborn baby aren’t the hardest three months you will ever put in). That thinking, in my specialty of Obstetrics and Gynecology has 100% changed. We now sit down with our young female students and trainees and talk seriously about their plans to start their families, to be sure that when they are ready, we are ready and able to help. Our specialty has long, long hours, and lots of night work, but we, more than any others, know how precious and short-lived our fertility is.

It is my hope that all work places could understand that it is in their best interest to help their employees achieve all their potential, at home and at work. It may require planning a few parental leaves to get there, but in the long run it will be worth it. We can look to the Netherlands, and other countries to see how they have succeeded, and we can look for other examples, closer to home.

Until we do that, we will continue to see women who, at last pregnant, would prefer to skip the risks of labour and just get to the main objective of a babe in arms. Other women will seek to minimize the risk of intervention, and want a natural birth experience. I understand both of these view points, (there are important pros and cons to consider) but are these are the concerns of the lucky ones.

Let us not lose sight of the many women who would love nothing more than to have the chance to worry about cesarean vs. vaginal birth. In order to have that worry they would need the chance to be pregnant.

So how about if this April Cesarean-section-awareness-month we turn our thoughts to what we are doing, in each of our work places, to help support our young employees start their families?

I found this image on hubpages.com

Until next week, be well.

Toxic chemicals in our homes, and our health.

2011-03-25T21:18:00.003-04:00

Does this topic sound unlikely for a gynecologist? You might have seen in the news this week that women with higher levels of the chemicals that are found in common household plastics, were more likely to have gone through menopause, more likely to have had a hysterectomy, and appear to have lower estrogen levels. http://www.globalnews.ca/video. The eggs I worry about are ours.

Does that mean those chemicals, perfluorocarbons, cause menopause and alter our hormones? Should I throw out my non-stick frying pan? Stop eating microwave popcorn? Good questions, and we need to know the answers, but the study that was done cannot tell us.

A foray into the medical literature can feel like gong into an unfamiliar city. There are lots of dead ends and opportunities to get lost. You can run into neighborhoods where you can’t understand a word that is being said. You may think you have arrived at something only to find that things are not at all as they seemed, and yet there is a certainty that the answers are there, somewhere.

One of my jobs is to be able to interpret the literature, to make sense out of the papers we read. On Wednesday, I came down to my office to get ready for a meeting and was asked if I could please review this particular article and comment on it for a journalist who was reporting the story. The reporter was on a tight deadline. The research we get asked to comment on has almost never been published in journals where we as doctors have a chance to read them; they are “embargoed” released to the press first and then everyone tries to make sense of the results them before the press deadline. So it was with this.

In a nutshell, the researchers in West Virginia did a very large and high quality study, of over 26,000 women, in whom they measured blood levels of these chemicals, they asked a lot of questions about their health, and then they measured the relationship between health outcomes, like menopause, and blood levels of the chemicals. (This research will be published in JCEM in June of this year.)

This sort of a study, a descriptive study of a large population cannot tell if the chemical caused the problems; to do that you can study a group of people before hand, expose them to the chemicals and the study them again afterwards. Better yet you can take two groups of equivalent people, expose one group to the chemicals and the others not, and then compare what happens to the two groups.

Neither of those is possible to do with toxic chemical (can you imagine!) But we can look to see how well this jibes with other studies that have been done, to see if it consistent, and we can look to see how it fits with what we know from the basic science of how the chemicals actually work. And there is enough evidence to make us take this study seriously.

The women in the study live near river where there is a large chemical plant in West Virginia, so, if we don’t live there, we might think we are ok. The trouble is that the chemicals that were associated with having an earlier menopause were not the ones that were found in the water, they were the ones that are found in all of us, everywhere. They are chemicals that are found in household plastics, Teflon, stain retardants, packaging and greenhouse gases.

Is earlier menopause a problem? Most would never know if we went through menopause a year or two earlier, because we don’t know when we are going to have menopause. (We don't have schedules for that.)

In 95% of women menopause happens after the age of 45, and the average age is 52. Apart from menopausal symptoms there are health consequences of early menopause, an increased risk of heart disease, osteoporosis, and long term there appear to be increased risks of dementia, and a shorter life span overall. Earlier menopause also means earlier loss of fertility. So any way you look at it, it isn’t good.

Is this likely to be a real relationship? There is already a great deal of research looking at the potential affect of these compounds on fertility, and on the growth and development of babies. The effect sizes all seem to be small, but they are there. Consistently. Clearly we need more research, and we need our public health agencies to be watching this carefully.

So what can we do? Well being aware is the first step, and then doing what we can to protect our homes and our environment. But the problem is that no one seems to know how they get into our system, the water, dust in the air we breathe, from food, or cooking methods, maybe all of the above. You can toss out the fry pan if the lining is chipping; if it is an old pan, it may be time to buy a new one. You can ask the questions to let you make choices about what you bring into your home.

But there may be a little good news in a Danish study that showed that diet can also make a difference. Women who ate more red meat and animal fats and snack foods had higher blood levels of these chemicals, women who ate more vegetables and lean meats were better off. (Environ Sci Technol. 2008 Dec 1;42(23):8971-7). And that is always good advice.

Thank you to everyone who commented on last week’s posting. We seem to be having trouble with comments posting, I hope that gets sorted out soon.

Of interest:
If you are in Toronto, please consider join us at Sunnybrook for an evening talk, Tuesday, March 29, 2011 6:30 – 8:30 P.M. Preventing Blood Clots in Women: from Pre-pregnancy to Post-menopause. The talk will be in the McLaughlin Auditorium, admission is free, parking is free in garage 1. You can find details on www.sunnybrook.ca. You might never have given blood clots much thought, but you will find this fascinating.

Until next week, be well

Cosmetic labioplasty: Snip Cut: is it OK to cut our labia?

2011-03-18T09:20:00.003-04:00

There are some things that I see in the course of my work that I find very troubling, most often a patient's story that I cannot get out of my mind, becuase there is something about it that just doesn't seem right. This is one of them.

A very distrressed woman in her mid thirties came to see me because of pain in the vulva that was relentless; she was never comfortable, and sexual relationships were totally impossible. It had all started when she had undergone cosmetic surgery to reduce the size of her labia, the thin and delicate wings of tissue that develop with puberty and make up part of the normal genitals.

We as Obs Gyne have been wrestling for years with the complex issues surrounding female genital cutting, otherwise called female genital mutilation, or female circumcision. It is not legal in Canada, and we are expected not to re create the procedure if it is disrupted by pregnancy. Are these procedures so different?

My colleague Gillian Einstein has been doing research on what happens to nerve endings when we cut them, especially in this very sensitive part of the body. Does it lead to pain (sometimes) reduced sensation, heightened sensation, or no difference? Wouldn’t you want to know before going under a knife? And what happens when you hit menopause?

It may be helpful to talk about what happens to the vulva normally. We don’t come with operating manuals, and no one is likely to have told you about these changes. As a child the labia are small and pale, and do not close over the vaginal opening. I always thought that was a bit of a pity, given it is little girls who are likely to be playing in sand boxes, running around in wet bathing suits, and otherwise have lots of reasons for needing some extra protection.

Then we hit puberty. Our vulva changes. Pubic hair develops. The inner lips, that were small and straight become larger, darker in colour, and wing-like in shape. They vary greatly in size. On either side we develop pads of fat, under the hair-bearing skin of the vulva. Until those pads are fully developed it can seem that the inner lips are overly large.

I have had young teenage girls come in with their mothers asking for surgery to reduce the labia, but what is really needed is patience, in time everything will get into proportion It is no different than the way, when kids are growing, that their ears can look too big, or their nose, and then they grow a little more and it all seems fine. It is not a good idea to be operating on young girls going through normal development!

At menopause these changes start again. The labia actually regress, and where there was once a clear lip, it can be gradually reabsorbed and flattened. This is not a good thing, as it reduces the elasticity of the tissues; it can feel like going from a gathered skirt into a straight skirt. And the skin gets thinner and more fragile

Many women who have undergone traditional female genital cutting speak with satisfaction of the smooth appearance of the results, and cannot imagine not having their daughters circumcised too. My colleague Dorothy Shaw, Past President of the International Federation of Obstetrics and Gynecology has explored the many deeply entrenched cultural beleifs and customs that sustain this practice. She commissioned an award winning film, The Cutting Tradition,together with Safe Hands for Mothers and narrated by Meryl Streep: http://www.safehands.org/index.php?option=com_content&task=view&id=94&Itemid=29 to draw awareness. Ironically, in other parts of the world , young women pull on their labia to stretch them, as long labia are associated with sexual desirability and prowess.

But let us talk about the west. So what of women requesting or choosing cosmetic surgery? Some women say it is a problem with their underwear or bathing suit. Is the problem with the garment, or our bodies? And is it anyone else’s business, these are adults making choices after all.

The troubles are many. First of all, some women will end up with pain. And then there is the problem that there is absolutely no research saying what will happen with aging. But once the tissue is gone, we cannot put it back. We are more or less agreed that girls should not be subjected to disfiguring circumcisions, because they did not make the decision, but what does it take to be a truly informed decision?

Even more troubling, to me, is where are we getting these ideas of normal. Some of it comes from pornographic literature, in which the pictures of women have been air-brushed . Some of it from websites advertising cosmetic surgery, suggesting to women how they should look (could there be a conflict of interest?) and maybe it is my problem, but I am not comfortable with a fashion that portrays the ideal woman’s genitals as those of a pre-pubertal girl. So perhaps the issue is that in the west women have for years been free to have their genitals just be, and now we are having some imposed notions of how we are supposed to look.

The operation to reduce labia is not a recognized medical procedure, and some of the surgical results are anything but good. No doubt there are cases where surgery does make sense, but in an informal poll of Ob Gynes from across the country, we overwhelmingly felt that this would be very rare indeed. I am not alone in my concerns about the reasons for, and long term consequence of, cosmetic labial surgery. The Royal College of Obstetricains and Gyencologists has expressed their concerns about the practice, http://www.rcog.org.uk/news/bjog-release-study-raises-concerns-about-cosmetic-labial-surgery, referencing

Liao L-M, Michala L, Creighton S. Labial surgery for well women: a review of the literature. BJOG 2010;117:20–25. http://www.bjog.org/

Gillian Einstein sent me a link to a thoughtful article about cosmetic surgery and female genital cutting, http://www.womenlobby.org/spip.php?article1184. the WHO website of FGM is http://www.who.int/topics/female_genital_mutilation/en/

The woman who I saw with pain bitterly regrets that she ever had the surgery. She cannot imagine what possessed her to do it, and to make matters worse, it was very expensive.

Not every woman who has this surgery will have pain, and I am sure that many are pleased with the result. I would be a lot happier if we really knew the long term consequences, and I wish I didn’t have this nagging sense that the desire for cosmetic surgery comes from someone else’s views of how women ought to look. So for my part I hope that this is a phenomenon that goes as quickly as it came.

Credits: The "caution" graphic came from http://www.livestrong.com/article/174213-vulvar-vestibulitis-symptoms/, the FGM graphic from http://middle-east-online.com/english/?id=40741