The study’s lead author, Melissa Bartick, M.D., an assistant professor of internal medicine at Harvard Medical School and an internist at Cambridge Health Alliance says via email that the bottom line of the analysis is this: “Women need to be supported to be able to breastfeed each child for at least a year — their health, and our economy depend on it.” She adds: “The CDC has found that 60% of women do not even reach their personal breastfeeding goals. Now we know this has a real cost, with thousands of women suffering needless disease and premature death.”

(Bartick also happens to be founder of the “Ban The Bags” campaign, a pro-breastfeeding advocacy group working to stop the common hospital practice of handing over free infant formula samples, or gift bags, to new moms after they give birth.)

Here’s more detail on the breastfeeding study from the Cambridge Health Alliance news release:

The analysis used sophisticated models to compare the effect of current breastfeeding rates in a simulated group of nearly two million U.S. women who turned 15 in 2002. The authors modeled this cohort of women across their lifetimes and estimated cumulative costs. They then compared these results to what would be expected if 90% of the women followed medical recommendations to breastfeed each child for one year. Currently, only about 25% of US children are still breastfeeding at one year of age.

The economic costs to society of premature death total $17.4 billion a year, due to an increase in heart attacks, hypertension, breast cancer, premenopausal ovarian cancer and type 2 diabetes in women who breastfeed less than recommended. In the study, premature death is defined as before age 70, or more than 10 years before the average U.S. woman is expected to die. The authors also found the increased burden of disease from suboptimal breastfeeding increased medical costs, incurring $734 million in direct costs and $126 million in indirect costs. The costs result from the increased rates of breast cancer, hypertension, and heart attacks, which are seen in women who breastfeed less than recommended…

Dr. Bartick previously led a similar cost analysis on the cost of excess pediatric disease due to low breastfeeding rates, which was published in 2010. That study showed that suboptimal breastfeeding cost the U.S. economy $13 billion a year, including the costs of 911 excess deaths in children per year.

Now, adding to the mounting data on the potential risks of prolapse surgery in general, a new study in the Journal of the American Medical Association finds that a common surgical treatment for prolapse — one considered the “gold standard” involving abdominal surgery — fails nearly 1 out of 3 women.

So why does prolapse surgery matter? As the JAMA study authors note, nearly 1 in 4 woman have at least one pelvic floor condition and “more than 225,000 surgeries are performed annually in the United States for pelvic organ prolapse.” So, any woman considering this surgery should be aware of the “long-term risks of mesh or suture erosion.”

(Just to be clear, the latest JAMA study is not about the more problematic vaginal mesh surgery that the FDA has flagged with two safety alerts in the last five years and more recently, requirements that manufactures conduct new testing in the mesh products. In these procedures, surgeons implant the mesh vaginally and use it as a scaffold for support. From 2005 to 2010, the FDA received nearly 4,000 reports of serious complications, including mesh erosion, severe pain, nerve damage, bleeding and other serious problems, some that required multiple hospitalizations and repeat surgeries.)

USA Today reports on the latest findings:

Doctors found that the “gold standard” prolapse surgery, a procedure called abdominal sacrocolpopexy, often fails to relieve symptoms of prolapse, which can cause discomfort and difficulty voiding, according to a study published in the Journal of the American Medical Association last week.

In this surgery, doctors use tissue or synthetic mesh to attach the top of the vagina to a ligament in the lower back, says Ingrid Nygaard, a professor of obstetrics and gynecology at the University of Utah School of Medicine and lead author of the new study, which followed 215 women for about seven years.

In that time, nearly one in three women saw their symptoms return or had their pelvic organs slip out of place again, the study says. About 17% needed additional pelvic surgery within seven years, either to treat the original prolapse, correct a new prolapse or treat complications related to the synthetic mesh, the study says.

In about one in 10 women, the mesh protrudes through tissue, which can cause inflammation and bleeding, Nygaard says.

Jessica McKinney is a physical therapist in Boston who specializes in women’s health and recently launched a new website for women and clinicians to talk about pelvic-related health issues. McKinney, also co-owner and Director of Women’s and Pelvic Health at Boston-area Marathon Physical Therapy and Sports Medicine, says that while surgery may be the best option for some women, there are several non-surgical measures — from pelvic floor massage to specific muscle exercises to work on breathing and posture — that can alleviate the
pain, discomfort and other symptoms associated with prolapse.

She says she can’t comment on the prolapse study with respect to specific surgical technique and procedure, but she still has these thoughts to share:

” “What stands out to me the most in these findings is that it documents a deterioration in effectiveness over time. It begs consideration of what are the women doing and how are they living in their bodies during the years following surgery, and are they doing so in a way that is protective of the repair or not. While it has long been standard of care to utilize physical therapy services pre-and post-operatively in orthopedics, this is not yet the current standard in female pelvic medicine and reconstructive surgery. The role of such interventions would be to comprehensively address “local” issues of pelvic floor muscle strength and endurance, but more importantly to address how the pelvic floor is functionally integrated with breathing, the deep abdominals, posture, alignment, whole body strength, and movement so that the effect of everyday stresses on the repair are minimized over time. Addressing toileting habits, weight management, lifting mechanics, and specific exercise activities falls under this umbrella, as well. From these findings, I am less convinced that the surgeries themselves are lacking, but rather that we have not yet applied the full spectrum of support, education, and exercise necessary to achieve optimal long-term outcomes. Achieving this level of care requires a multidisciplinary approach and patients who are equally engaged in the process, willing to modify behaviors or activities as necessary in order to achieve better outcomes.”

]]> 2013-05-23T16:07:51-04:00 http://commonhealth.wbur.org/2013/05/mothers-pressured-on-birth-interventions http://commonhealth.wbur.org/2013/05/mothers-pressured-on-birth-interventions#comments Thu, 09 May 2013 20:38:14 +0000 http://commonhealth.wbur.org/?p=30124 It’s Mother’s Day Sunday — a time for high-calorie brunches and pastel-colored bath products — but an even better time to do some listening.

So, just in time, here’s a new report that does just that. “Listening to Mothers III,” produced by the nonprofit Childbirth Connection, is an in-depth look at women’s pregnancy and birth experiences that covers a huge range of topics, from pregnancy weight gain, breast-feeding and postpartum depression to use of pain medication during birth and paying for maternity care.

The report, the third of its kind, is based on online surveys of 2,400 women who gave birth to a single baby from July of 2011 through June of 2012 in a U.S. hospital. There’s a lot to digest here, but for anyone interested in birth, it’s worth spending time wading through the material.

Here, as highlighted by authors of the report, are some of the more salient findings:

–A quarter of women surveyed experienced three or more of five major medical procedures such as labor induction, drugs to speed labor, and cesarean section, while only one in eight women had none of these interventions.

–Unnecessary interventions — such as inducing labor for convenience or routine repeat cesareans — exposed women and their babies to avoidable risk.

–Most of the women could not correctly identify risks of labor induction or cesarean section, revealing problems with prenatal education.

–One in four who had these procedures reported experiencing pressure from a care provider to do so.

–Mothers expressed a high degree of trust in maternity care providers, with nearly half rating them as “completely trustworthy.”

Maureen Corry, Executive Director of New York-based Childbirth Connection, said in an interview that a perfect storm of forces — including pressure on women and complete trust in their provider — could lead to unwanted outcomes.

“The pressure to have an induction or c-section, a lack of awareness about the risks of those interventions and an unqualified trust in their health care providers is a potent combination that could result in women and their babies being exposed to unnecessary risk and receiving care that isn’t based upon the evidence,” Corry said. “You can imagine if providers put a little bit of pressure on and the women don’t have all the facts, they might make decisions that aren’t good for them.”

In the survey, mothers were asked if they felt pressure from a health profesional to have one of three interventions and, according to the report, “notable proportions indicated that they had experienced such pressure. The proportions reporting pressure varied very slightly by intervention: labor induction (15%), epidural analgesia (15%), or cesarean section (13%).”

Here’s more detail from the survey:

We looked at these finding by whether or not mothers had the specific intervention, and there was significant difference in each case. In terms of induction, 25% of mothers who experienced an induction cited pressure compared to 8% who did not have an induction. Most notably, there was a difference in the case of cesarean sections. Of those mothers with a vaginal (not VBAC) birth, 7% indicated they felt pressure while among those who had a primary cesarean 28% said they felt pressure. For those with a prior cesarean, 28% of the mothers with a VBAC and 22% of those with a repeat cesarean indicated they felt pressure. Overall, 8% of mothers who did not have a cesarean experienced pressure for surgery versus 25% of mothers who had a cesarean.

The report also found that many effective pregnancy and birth-related practices that help women weren’t routinely used. From the news release:

In pregnancy, for example, these included help with smoking cessation. Around the time of birth, just a fraction received continuous labor support from a doula, though many would have liked to have had doula care. Half of the women were not exclusively breastfeeding a week after the birth, and many had not received help from a provider for notable symptoms of depression. Many women who would have liked the option of vaginal birth after a cesarean (VBAC) reported that their maternity care provider and/or hospital was unwilling to provide this option, and faced another cesarean and the range of risks associated with repeated surgeries.

“Underused maternity practices tend to be non-invasive, pose few if any risks, and use relatively few resources,” said Dr. Eugene Declercq, the survey’s lead investigator, and a professor of community-health sciences at the Boston University School of Public Health. “They offer many opportunities to improve the quality, outcomes and cost of maternity care, with benefits for mothers and babies, and those who pay for their care,” he said.

Readers, were you pressured by providers to have one or another intervention during childbirth? Or were there things you wished you could have had (like a doula or breastfeeding support) that were not available to you? Please comment and let us know.

]]> 2013-05-09T17:04:34-04:00 http://commonhealth.wbur.org/2013/04/pediatricians-aap-guidelines http://commonhealth.wbur.org/2013/04/pediatricians-aap-guidelines#comments Tue, 30 Apr 2013 19:27:05 +0000 http://commonhealth.wbur.org/?p=29596 Yesterday, the influential American Academy of Pediatrics issued, for the first time, a set of guidelines related to planned home births, a hotly debated practice (though not so much among women who do it) that has increased slightly in the past few years, mainly among highly educated white women.

Specifically, the guidelines are on caring for infants born via planned delivery at home. The first line of the guidelines underscores the fact that the new statement is hardly radical:

The American Academy of Pediatrics concurs with the recent statement of the American College of Obstetricians and Gynecologists affirming that hospitals and birthing centers are the safest settings for birth in the United States while respecting the right of women to make a medically informed decision about delivery.

Time Healthland reiterates that the guidelines, published in the journal Pediatrics yesterday, are pretty straightforward, including these recommendations:

“…at least one person at the birth should be responsible for tending to the newborn infant; that person should also be trained in infant CPR. Medical equipment should be tested before the delivery. A phone line should be available; while you’re at it, check the weather forecast too, in case complications arise and a trip to the hospital is necessary. In case of emergency, have a plan to transfer the laboring mom to a hospital. And do all the stuff that nurses do in the hospital to brand-new babies: monitor their temperature and heart rates, keep them warm and cozy, administer vitamin K and heel-prick newborn screening tests that are sent to outside labs for processing, among other things.

Still, Time says:

More controversial is the academy’s advice that pediatricians endorse only midwives who are trained and cleared by the American Midwifery Certification Board. Midwives accredited by this board typically attend deliveries at hospitals and birthing centers. That position has upset certified professional midwives, who deliver the majority of babies born at home in this country but are accredited by a different body — the North American Registry of Midwives (NARM).

Robin Hutson, executive director of the nonprofit Foundation for the Advancement of Midwifery, based in Boston, says these guidelines are only useful if consumers also have access to data on the risks of giving birth in other settings. In a hospital, for instance, Hutson notes there’s a higher likelihood of infections, unnecessary use of medical interventions and prolonged separation of mother and baby which can deter breast-feeding. “No method of birth is risk free,” Hutson says.

One local doula told me that even though the statement is certainly not a full-blown endorsement of home birth, just the fact that the AAP put it out somehow offers the practice added legitimacy in mainstream circles.

Of course it’s also pragmatic for the AAP to acknowledge that all babies, regardless of where they’re born, deserve the same level of care, particularly since home birth has been undergoing a mini-resurgence. (It ticked up a bit after actress and home-birth advocate Ricki Lake gave birth in a bathtub and then produced the film, The Business of Being Born.)

As we reported in 2011:

After a 15-year decline, home births in the U.S. rose 20 percent between 2004-2008. Though the actual numbers remain tiny — out of about 4 million births, 28,357 happened at home in 2008 — the reversal of the long downward trend is notable. So are the demographics: much of the increase was driven by highly educated white women.

Dr. Kristi Watterberg, a professor of pediatrics at the University of New Mexico and the lead author of the AAP statement, told The Huffington Post:

“There are standards for caring for babies who are born anywhere” Watterberg told The HuffPost. “This is to reiterate that the same standards should be met for” all of them….

Home birth “is an area that has high passion surrounding it on all sides,” Watterberg said. “I don’t think it does anyone any good to have such a fractured way of looking at things.”

But Eugene Declercq, a professor of community-health sciences at the Boston University School of Public Health who studies childbirth, wrote me in an email that he’s of two minds on the new statement:

On the one hand the section that calls for more integrated care that can smooth the transfer of births from home to hospital can be seen as a positive development and would be applauded by most everyone on both sides of this argument, with the exception of those so opposed to home birth that they would not approve of anything that might make them more popular (sort of like Congressional Republicans and Obama).

On the other hand the statement can be seen as another reflection of the increasingly polarized debate over home birth. One strategy in opposing a particular practice is to set up standards that sound reasonable on the face of them but if put into law or regulations can become very restrictive. For example, a requirement for a second attendant at birth to focus on the baby is something that is actually pretty common at home births (which are often attended by family members and friends as well as a midwife and assistant), but if put into regulations that required that person to be, say, a pediatric nurse practitioner or pediatrician the standard would be almost impossible to meet unless licensing laws permitted it and insurers would cover it.

I can’t speak to the intentions of the authors. I don’t know if they meant to be supportive or not, but they rely on the ACOG Guidelines, which are not supportive. These efforts are usually driven by a handful of members in these organizations who feel passionately about an issue that does after all, only involve 0.7% of U.S. births, but symbolizes a rejection of the medical model that was at the core of their training.

On Friday, a new study was released in the British Medical Journal showing that antidepressant use during pregnancy is associated with autism in the exposed children. This is now the second study within the last two years showing this link and it adds to the accumulating evidence of potential harm associated with the use of antidepressants during pregnancy.

The study was a case-control study from Sweden, which was fairly large: it looked at 4,429 cases of autism spectrum disorder and compared these cases to 43,277 matched controls. The researchers found that antidepressant use during pregnancy, with either SSRIs or nonselective monoamine reuptake inhibitors (another type of antidepressant) was associated with an increased rate of autism spectrum disorders in the offspring. The odds ratio was high at 3.34, which roughly means that antidepressant use was associated with more than a tripling of risk of autism in the children.

The study concludes:

In utero exposure to both SSRIs and non-selective monoamine reuptake inhibitors (tricyclic antidepressants) was associated with an increased risk of autism spectrum disorders, particularly without intellectual disability. Whether this association is causal or reflects the risk of autism with severe depression during pregnancy requires further research. However, assuming causality, antidepressant use during pregnancy is unlikely to have contributed significantly towards the dramatic increase in observed prevalence of autism spectrum disorders as it explained less than 1% of cases.

These results do not surprise those of us who have been following the scientific studies in this area over the past two decades.

Serotonin: a crucial neurotransmitter

Serotonin, the first neurotransmitter expressed in the developing embryo, plays a crucial role in brain formation. Serotonin is essential for the growth and development of certain areas of the brain. It is involved in such basic processes as cell division, differentiation, migration and synaptogenesis. In short, proper functioning of the serotonin system is essential for the brain to form and function normally. The SSRIs and other such antidepressants are believed to exert their effects by blocking the reuptake of serotonin into neurons—the basic cell of the brain. For a developing baby, such blockade is occurring throughout the body (including the brain) and throughout pregnancy development. It is now well-established scientifically that autism is characterized by changes in the serotonin system. Hyperserotonemia is the most consistent neurochemical change in autism.

Animal Studies

Most of the data we have on developmental effects of the SSRIs on the brain comes from animal studies on small mammals (mice and rats). The majority of these studies show significant changes in the brains and behavior of exposed animals and these results are very concerning. The two best-known studies were published in the world’s leading scientific journals, Science (2004) and in the Proceedings of the National Academy of Sciences (PNAS) (2011). But these are just two examples of the many animal studies that show changes in the brain and behavior that result when the serotonin system is altered during development by the use of the SSRI antidepressants. In the Discussion section of these manuscripts, again and again, the authors warn us that their findings of harmful effects should make us concerned with using them in humans.

Human Studies

Several human studies looking at the effects of SSRI exposure during pregnancy have shown brain and behavioral changes in exposed children. In 2009, Pawluski, et al published a landmark study showing decreased S100B protein levels in babies who were exposed to SSRIs in utero—similar to alcohol and cocaine-exposed pregnancies. In 2010, Pedersen, et al demonstrated that SSRI-exposed children sat up and walked later and that they had behavioral changes. In 2011, Bellisima, et al showed that babies exposed to SSRI antidepressants in utero have dramatically higher levels of the brain damage marker Activin A in their blood and amniotic fluid. In 2013 Hanley, et al showed that SSRI-exposed children scored lower on gross motor and social-emotional testing. And these are just four of many studies that show changes in exposed children.

As far as autism goes, the first study came out in 2011. Croen, et al showed that SSRI exposure during pregnancy was associated with a doubling of the risk of autism. For first trimester SSRI exposure, the risk was almost quadrupled. Importantly, her study looked at depressed women not on SSRIs, and in this group there was no increased risk of autism. It was the antidepressant use that was linked to the autism and not the depression.

The current study by Rai, just published April 19th , also shows an increased rate of autism in antidepressant-exposed children and this does not appear to be a result of depression, but rather of the medication. Thus, the only two studies in humans that have asked the question: “Is antidepressant use during pregnancy associated with autism?” have found the answer to be a clear “Yes.”

Public Confusion

The authors of the recent study concluded that they cannot declare whether the problem is with the antidepressants or the depression. Many readers find this confusing. The reason the authors state this is that their study was not a randomized controlled trial (RCT). Only a randomized controlled trial (where half the depressed women are given an antidepressant and the other half a placebo) can most accurately assess causation. However, this type of trial has never been done with antidepressants during pregnancy and many people feel that such a trial would not be ethical.

However, an RCT is not always needed to presume that an agent is causing harm (for example, we have never had an RCT on cigarettes, but we have concluded that they cause harm) and an RCT is not needed to caution the public. In this case, we see clearly from the animal studies that exposure to SSRIs during development leads to changes in the brain and behavior –that often mimic the findings in autism. Then, in the only 2 human studies to look at this area, we see increased rates of autism in the antidepressant exposed groups (and not in the depressed/nonmedicated group.)

Balancing Risks and Benefits

SSRI antidepressant use during pregnancy is linked to pregnancy complications and risks for the baby, including what may be an increased risk of autism. These complications might be considered tolerable if there was solid evidence of benefit with the use of antidepressants by pregnant women. Sadly, in 25 years of study, not a single study has ever shown improvements in pregnancy outcomes in the antidepressant-treated group. In studies of nonpregnant populations, there is little evidence of clinically significant benefit with the use of antidepressants (when compared with placebo) by most patients with depression.

This second study showing an increased risk of autism in the children who were exposed to antidepressants during pregnancy is concerning. The current evidence that the SSRI antidepressants can injure the developing brain is clear and consistent. Pregnant women suffering from depression need treatment and care. But, with good evidence that non-drug therapies, such as psychotherapy and exercise, may provide at least as much benefit in the treatment of depression (if not more), it makes sense to first use these approaches in women of childbearing age—approaches that have not been linked to autism.

Adam C. Urato, MD is a maternal-fetal medicine physician at Tufts Medical Center, Assistant Professor of Obstetrics & Gynecology at Tufts University School of Medicine and Chairman, Department of Obstetrics & Gynecology, MetroWest Medical Center in Framingham. He has written previously on this topic here.

For another perspective, see this piece by a psychiatrist specializing in women’s mental health issues.

Citing a recent JAMA study that found robotic hysterectomies cost more but aren’t really better, ACOG president, James T. Breeden, MD, in a statement said it’s “important to separate the hype from reality” when considering this type of robotic surgery.

Here’s the full ACOG statement:

Many women today are hearing about the claimed advantages of robotic surgery for hysterectomy, thanks to widespread marketing and advertising. Robotic surgery is not the only or the best minimally invasive approach for hysterectomy. Nor is it the most cost-efficient. It is important to separate the marketing hype from the reality when considering the best surgical approach for hysterectomies.

The outcome of any surgery is directly associated with the surgeon’s skill. Highly skilled surgeons attain expertise through years of training and experience. Studies show there is a learning curve with new surgical technologies, during which there is an increased complication rate. Expertise with robotic hysterectomy is limited and varies widely among both hospitals and surgeons. While there may be some advantages to the use of robotics in complex hysterectomies, especially for cancer operations that require extensive surgery and removal of lymph nodes, studies have shown that adding this expensive technology for routine surgical care does not improve patient outcomes. Consequently, there is no good data proving that robotic hysterectomy is even as good as—let alone better—than existing, and far less costly, minimally invasive alternatives.

Vaginal hysterectomy, performed through a small opening at the top of the vagina without any abdominal incisions, is the least invasive and least expensive option. Based on its well-documented advantages and low complication rates, this is the procedure of choice whenever technically feasible. When this approach is not possible, laparoscopic hysterectomy is the second least invasive and costly option for patients.

Robotic hysterectomy generally provides women with a shorter hospitalization, less discomfort, and a faster return to full recovery compared with the traditional total abdominal hysterectomy (TAH) which requires a large incision. However, both vaginal and laparoscopic approaches also require fewer days of hospitalization and a far shorter recovery than TAH. These two established methods also have proven track records for outstanding patient outcomes and cost efficiencies.

At a time when there is a demand for more fiscal responsibility and transparency in health care, the use of expensive medical technology should be questioned when less-costly alternatives provide equal or better patient outcomes. Hysterectomy is one of the most common major surgeries in the US and costs our health care system more than $5 billion a year.

At a price of more than $1.7 million per robot, $125,000 in annual maintenance costs, and up to $2,000 per surgery for the cost of single-use instruments, robotic surgery is the most expensive approach. A recent Journal of the American Medical Association study found that the percentage of hysterectomies performed robotically has jumped from less than 0.5% to nearly 10% over the past three years. A study of over 264,000 hysterectomy patients in 441 hospitals also found that robotics added an average of $2,000 per procedure without any demonstrable benefit.

If most women undergoing hysterectomy for benign conditions each year chose a vaginal or laparoscopic procedure—rather than TAH or robotic hysterectomy—performed by skilled and experienced surgeons, pain and recovery times would be reduced while providing dramatic savings to our health care system. Conversely, an estimated $960 million to $1.9 billion will be added to the health care system if robotic surgery is used for all hysterectomies each year.

Aggressive direct-to-consumer marketing of the latest medical technologies may mislead the public into believing that they are the best choice. Our patients deserve and need factual information about all of their treatment options, including costs, so that they can make truly informed health care decisions. Patients should be advised that robotic hysterectomy is best used for unusual and complex clinical conditions in which improved outcomes over standard minimally invasive approaches have been demonstrated.

There a number of non-medical interventions that can help fix the problem, such as pelvic floor physical therapy, which we’ve also written about here. Still, for some, medication may be called for, so it looks like a positive development that the FDA earlier this week approved a new drug to alleviate the pain that many post-menopausal women experience during intercourse.

MedPage Today reports that the newly approved “selective estrogen receptor modulator (SERM)” called ospemifene (Osphena) is taken as an oral tablet and “targets vulvar and vaginal atrophy resulting from menopause, which is the underlying cause of dyspareunia, or pain during sex.” There are risks, however:

The treatment, however, will come with a boxed warning stating that it may thicken the uterine lining, with the concern that unusual bleeding may be a sign of endometrial cancer or a condition that can lead to it.

The boxed warning also will caution about the risk of thrombotic and hemorrhagic strokes (occurring in 0.72 and 1.45 per 1,000 women, respectively), and the risk of deep vein thrombosis (occurring in 1.45 per 1,000 women).

These rates are considered low risks in relation to the increased risks of stroke and deep vein thrombosis seen with estrogen-only therapy, the FDA noted.

Still, the agency said the drug should be prescribed for the shortest duration possible.

The safety and efficacy of ospemifene were established in three clinical trials with a total enrollment of 1,889 postmenopausal women with vulvar and vaginal atrophy.

Two 12-week studies showed that those on the drug had significant improvements in dyspareunia compared with those on placebo. A third study vouched for its longer-term safety, though FDA did not note exactly how long the trial ran.

Here are a few more details from the LA Times:

Lubricants are not very effective for such women. And while estrogen-based medications have long been available in topical cream, suppository and insertable ring form, the makers of Osphena say that the new medication offers what for many will be a more convenient remedy for dyspareunia, and one that is not estrogen-based.

Unlike those creams and dissolving rings, the medication in Osphena is selective estrogen receptor modulators, or SERMs, which binds to estrogen receptors and activates many of the mechanisms that have shut down with menopause.

Estrogen-based medications for dyspareunia are thought to raise systemic levels of the hormone in a woman’s body only slightly, and there is no evidence that, like estrogen-only hormone replacement therapy, it raises breast cancer risk. But some women remain wary of taking them, said Dr. David J. Portman, director of the Columbus Center for Women’s Health Research in Ohio, who conducted some of the early safety and effectiveness trials of Osphena.

I asked a few local sex therapists and gynecologists not involved in the trials whether they were familiar with the drug and what they thought of it. No one I spoke to has prescribed it to patients yet (it’s just approved, after all) but a few had some thoughts.

Dr. Sharon Bober, a clinical psychologist and director of the Dana-Farber Cancer Institute’s Sexual Health Program said by email: “It is potentially great news to have another strategy in the pharmaceutical tool kit to address dyspareunia and painful intercourse but it seems like there are lots of questions that still need to be addressed. From my particular vantage point working with women after cancer, there are a number of specific questions that will need to be examined, for instance, I’d like to learn more about how it compares to use of vaginal estrogen.”

Eman Elkadry, MD, in the department of Female Pelvic Medicine and Reconstructive Surgury at Mt Auburn Hospital said in an email: “I have never used this drug so don’t know much about it. We tend to use vaginal estrogen for that issue — which comes in cream, suppository or long acting vaginal ring form. They tend to be less absorbed than oral estrogen and work locally quite well for atrophic and Irritative symptoms without as much systemic risks. It will be interesting to compare efficacy and tolerability of both.”

I’ll update as I hear more from the experts.

While homicide is one of the leading causes of death for pregnant women, The American College of Obstetricians and Gynecologists (ACOG) reports that many abused adolescent girls and women are also the subject of another, lesser-known form of abuse: “contraception sabotage,” the most common form of reproductive coercion.

In a just-released committee opinion ACOG notes that victims of such abuse have “male partners who intentionally sabotage their contraception, deliberately give them sexually transmitted infections, or force them into having unwanted pregnancies or abortions.” This type of “reproductive coercion” says ACOG, can even go as far as male partners “forcefully remove intrauterine devices (IUDs) and vaginal rings, poke holes in condoms, or destroy birth control pills.”

ACOG reports:

Sexual coercion includes a range of behavior that a partner may use related to sexual decision making to pressure or coerce a person to have sex without using physical force. This behavior includes repeatedly pressuring a partner to have sex, threatening to end a relationship if the person does not have sex, forcing sex without a condom or not allowing other prophylaxis use, intentionally exposing a partner to a sexually transmitted infection, including human immunodeficiency virus (HIV), or threatening retaliation if notified of a positive STI test result.

One quarter of adolescent females reported that their abusive male partners were trying to get them pregnant through interference with planned contraception, forcing the female partners to hide their contraceptive methods. In one study of family planning clinic patients, 15% of women experiencing physical violence also reported birth control sabotage. Among adolescent mothers on public assistance who experienced recent intimate partner violence, 66% experienced birth control sabotage by a dating partner. Compared with women not experiencing abuse, women experiencing physical abuse and women disclosing psychologic abuse by an intimate partner had an increased risk of developing an STI. Based on this information, health care providers should include reproductive and sexual coercion and IPV as part of the differential diagnosis when patients are seen for pregnancy testing or STI testing, emergency contraception, or with unplanned pregnancies because intervention is critical.

ACOG is calling for ob-gyns to routinely screen teens and women for sexual and reproductive coercion at annual exams, new patients visits, during prenatal visits, and postpartum. Some examples of screening questions may include the following, according to the report:

–Has your partner ever forced you to do something sexually that you did not want to do or refused your request to use condoms?

–Has your partner ever tried to get you pregnant when you did not want to be pregnant?

–Are you worried your partner will hurt you if you do not do what he wants with the pregnancy?

–Does your partner support your decision about when or if you want to become pregnant?

ACOG offers these recommendations:

–Participate in education events regarding reproductive and sexual coercion that covers birth control sabotage, pregnancy pressure and coercion, and the effect of IPV on patients’ health and choices.

–Routinely screen women and adolescent girls for reproductive and sexual coercion in a safe and supportive environment that respects confidentiality.

–Counsel patients on harm-reduction strategies and safety planning.

–Offer long-acting methods of contraception that are less detectable to partners, like IUDs and the contraceptive implant or injection.

–Include reproductive and sexual coercion and IPV as part of the differential diagnosis when patients are seen for pregnancy or STI testing, emergency contraception, or with unintended pregnancies.

For more information, or for help, here are several resources:

National Domestic Violence Hotline
1-800-799-SAFE (7233)

Rape Abuse & Incest National Network (RAINN) Hotline
1-800-656-HOPE (4673)

Futures Without Violence (previously known as Family Violence Prevention Fund)

According to the CDC news release:

…binge drinking puts women at increased risk for many health problems such as breast cancer, sexually transmitted diseases, heart disease, and unintended pregnancy. Pregnant women who binge drink expose a developing baby to high levels of alcohol, which can lead to fetal alcohol spectrum disorders and sudden infant death syndrome.

In addition, the report finds that about 1 in 8 women and 1 in 5 high school girls report binge drinking. Binge drinking was most common among women aged 18-34 and high school girls, whites and Hispanics, and women with household incomes of $75,000 or more. Half of all high school girls who drink alcohol report binge drinking.

Binge drinking is defined as consuming four or more drinks on an occasion for women and girls. Drinking too much, including binge drinking, causes about 23,000 deaths among women and girls in the United States each year.

On WBUR’s Cognoscenti, writer Judy Foreman posts here today:

Earlier this month, the American College of Obstetricians and Gynecologists, the country’s leading professional group for ob/gyn physicians, recommended that oral contraceptives — on the market for more than half a century now — finally be available over-the-counter.
It’s about time.

And also last week, the American Academy of Pediatrics recommended that doctors routinely counsel teenagers about emergency contraception — better known as Plan B or the morning-after pill — and prescribe it in advance, even if the teen is not sexually active. Currently, girls under 17 need prescriptions for the pills.

WBUR’s Here & Now discusses the issue here, and the segment elicited this cogent comment:

Well how about the boys? Isn’t it time we gave them a script for the morning-after-pill to give to their partners?

Readers? Interesting scenario, isn’t it? How might that dialogue in the steamed-up car go?